BACKGROUND Elective total joint arthroplasty (TJA) procedures have been postponed as part of the coronavirus disease 2019 (COVID-19) response to avert healthcare system collapse. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures comprise the highest volume of elective procedures performed at health care facilities worldwide. AIM To determine the demand for TJA despite the pandemic and the impact of surgery postponement on physical and mental health. METHODS We conducted a prospective cross-sectional telephonic interview-based study on patients awaiting THA and TKA at an academic institution in South Africa. The questionnaire consisted of four sections. The first section recorded baseline demographic data and medical co-morbidities, the length of time spent awaiting TJA, and the patients’ desire to undergo elective surgery despite the COVID-19 pandemic. Section 2 and Section 3 assessed the patients’ current physical and mental health, respectively, as a consequence of deferred surgical intervention. The last section established the patients’ perception of the healthcare system’s response to the COVID-19 pandemic and necessity to postpone elective surgery. Patients received counseling and education on the current state of surgery during the COVID-19 pandemic and associated risks. Thereafter, patients were once again asked about their desire to undergo TJA during the COVID-19 pandemic. RESULTS We included 185 patients (65.95% female; mean age: 50.28 years) awaiting TJA for a mean of 26.42 ± 30.1 mo. Overall, 88.65% of patients wanted TJA despite the COVID-19 pandemic. Patients awaiting TJA for 1-3 years were 3.3-fold more likely to want surgery than those waiting < 1 year ( P < 0.000). Patients with comorbidities were 8.4-fold less likely to want TJA than those with no comorbidities ( P = 0.013). After receiving education, the patients wanting TJA decreased to 54.05%. Patients who changed their opinion after education had less insight on the increased morbidity ( P = 0.046) and mortality ( P = 0.001) associated with COVID-19. Despite awaiting TJA for shorter period (24.7 ± 20.38 mo), patients who continued to demand TJA had greater pain ( P < 0.000) and decreased function ( P = 0.043) since TJA postponement. CONCLUSION There is deterioration in health for patients, who have had elective procedures postponed during the COVID-19 pandemic. Waiting lists should be prioritized for urgency with the re-initiation of elective surgery.

Human immunodeficiency virus (HIV) is a pandemic affecting more than 35 million people worldwide. The aim of this review is to describe the association between HIV and total hip arthroplasty (THA) and assess patient risk factors to optimize functional outcomes and decrease rates of revision. Since the advent of highly active antiretroviral treatment (HAART), HIV-infected patients are living longer, which allows them to develop degenerative joint conditions. HIV and HAART act independently to increase the demand for THA. HIV-positive patients are also more predisposed to developing avascular necrosis (AVN) of the hip and femoral neck fractures due to decreased bone mineral density (BMD). Prior to the widespread implementation of access to HAART in homogenous cohorts of HIV-infected patients undergoing THA, reports indicated increased rates of complications. However, current literature describes equivocal functional outcomes and survival rates after THA in HIV-positive patients controlled on HAART when compared to HIV-negative controls. HIV-infected patients eligible for THA should be assessed for medical co-morbidities and serum markers of disease control should be optimized. Periprosthetic joint infection (PJI) is a leading cause of revision THA, and HIV is a modifiable risk factor. Importantly, the significance is negated once patients are placed on HAART and achieve viral suppression. THA should not be withheld in HIV-infected patients injudiciously. However, HIV is a burgeoning epidemic and all patients should be identified and started on HAART to avoid preventable peri-operative complications. Cite this article: EFORT Open Rev 2020;5:164-171. DOI: 10.1302/2058-5241.5.190030

Background Periprosthetic joint infections (PJIs) are a major source of morbidity and mortality for patients undergoing total joint arthroplasty (TJA). Staphylococcus aureus (S. aureus) colonization is an independent, modifiable risk factor for periprosthetic joint infections. Post-operative infections are reported to be ten times greater in S. aureus carriers than in non-carriers in developed countries though recorded data is lacking for the developing world. This study aims to determine the prevalence of S. aureus colonization in patients awaiting TJA in South Africa. Methods We prospectively assessed 119 patients awaiting total knee arthroplasty and total hip arthroplasty between May and October 2016. We screened three separate anatomical sites on each patient for S. aureus. Patients with positive cultures were treated with intranasal mupirocin ointment and chlorhexidine body wash. Univariate and comparative statistical analyses to determine risk factors for colonization was conducted using t tests, Fisher’s exact tests, and chi-square analyses. Results The overall prevalence of methicillin-sensitive S. aureus colonization was 31.9% (n = 38). There were no patients colonized with methicillin-resistant S. aureus. Nasal swabs returned a yield of 81.6% (n = 31), with groin swabs and axillary swabs at 39.5% (n = 15) and 28.9% (n = 11), respectively. Eradication was successful in 94.74% (n = 36) after 5 days treatment. All patients (100%) were decolonized after counseling and repeat eradication treatment. The overall complication rate was 7.6% (n = 9). The 30-day readmission rate in the S. aureus-colonized group was 7.9% (n = 3) as opposed to 7.4% (n = 6) in the non-colonized cohort. There were no 60- and 90-day readmissions and no cases were revised at a mean follow-up of 2.26 years. Conclusions The rate of S. aureus colonization in patients undergoing elective TJA in a developing country was 31.9% and is equivalent to reported rates in developed countries. Eradication treatment with combined intranasal mupirocin ointment and chlorhexidine body wash is a successful treatment modality. A larger cohort of patients is recommended to determine risk factors and post-operative septic sequelae in this population group.

Obesity is a modern-day epidemic with increasing prevalence that is directly impacting the global burden of primary total hip arthroplasty. The risk of requiring total hip arthroplasty for osteoarthritis increases incrementally with increasing obesity class. Surgical intervention in obese patients presents a set of unique challenges that should be recognized by the treating medical team. Although predominantly satisfactory outcomes have been reported, perioperative anaesthetic and surgical concerns require thorough patient assessment. There is an increased potential risk of thrombogenic and septic complications, but the body mass index cutoff level beyond which total hip arthroplasty should not be offered in the obese patient remains controversial. Preoperative medical optimization of the patient and appropriate intraoperative interventions are essential to mitigate the risk of complications.