Aims. HIV predisposes patients to opportunistic infections. However, with the establishment of Highly Active Anti-Retroviral Therapy (HAART), patients’ CD4 counts are maintained, as is a near normal life expectancy. This study aimed to establish the impact of HIV on the bacteriology of spondylodiscitis in a region in which tuberculosis (TB) is endemic, and to identify factors that might distinguish between them. Patients and Methods. Between January 2014 and December 2015, 63 consecutive cases of spontaneous spondylodiscitis were identified from a single-centre, prospectively maintained database. Demographics, presenting symptoms, blood results, HIV status, bacteriology, imaging, and procedure undertaken were reviewed and comparisons made of TB, non-TB, and HIV groups. There were 63 patients (22 male, 41 female) with a mean age of 42.0 years (11 to 78; . sd. 15.0). Results. In total, 53 patients had tuberculous, nine bacterial, and one cryptococcal spondylodiscitis. There were 29 HIV-positive patients, 29 HIV-negative patients, and five patients with unknown HIV status. The local incidence of TB spondylodiscitis was 1.54/100 000 and that of non-TB spondylodiscitis was 0.29/100 000 per annum. TB patients were younger with similar clinical presentation and infective markers, but were more likely to have a paraspinal abscess. They were also less likely to have a hyperintense disc on MRI. There was no difference between the two HIV groups. Conclusion. In areas of endemic TB and HIV, TB remains the most common cause of spondylodiscitis at five times the rate of non-tuberculous causes. HIV managed with HAART increases the rate of infection but does not influence the bacteriology unless there is a low CD4. There was little to differentiate the groups. TB /HIV co-infected patients were younger than non-TB and HIV-negative patients. Non-TB patients were more likely to have disc hyperintensity on MRI and TB patients were more likely to have abscess formation, but as both groups exhibited these features, neither was diagnostic. Culture confirmation remains necessary. Cite this article: Bone Joint J 2019;101-B:617–620

Background. In 2011 Aird et al published their results of the effects of HIV on early wound healing in open fractures treated with internal and external fixation. The study was conducted between May 2008 and March 2009 and performed in semi-rural area of KwaZulu-Natal, South Africa. These results suggested that HIV is not a contraindication to internal or external fixation of open fractures, as HIV is not a significant risk factor for acute wound implant infection. We present a longer term follow up of this same cohort of patients from the original study. Methods. From March 2011 to January 2012 we attempted to contact all patients from Airds original study. A simple telephonic questionnaire was obtained from all the patients contacted, regarding possible late sepsis, non-union and implant removal. Patients were requested to visit the outpatient department for a clinical assessment, a repeat HIV test and new X-rays. Results. Of the initial 133 patients, 27 patients had external fixators, which were removed, leaving 106 patients with implants in situ at the time of follow up. Six patients had died, 4 of AIDS, 1 of a traffic accident and one of community assault. We were able to obtain telephonic questionnaires of 46 patients in total. Of these 46 patients, 31 were seen at a dedicated research clinic for re-assessment. In the initial study, 33 patients were HIV positive. We re-assessed 14 of these HIV positive patients and of these, 1 patient had metal removed for sepsis and 1 patient had a non-union. The remaining 12 patients had implants in situ without sepsis or non-union. Conclusion. This is the longest follow up to date of the effect of HIV on surgical implants following open fractures. Our results suggest HIV is not a contraindication for internal surgical fixation of open fractures in HIV positive patients with regards to long term sepsis and the risk of non-unions. THIS RESEARCH IS SUPPORTED BY A RESEARCH GRANT OF THE ROYAL COLLEGE OF SURGEONS

Background. The prevalence of immunocompromised patients undergoing Total Hip Arthroplasty (THA) is increasing worldwide as a consequence of advances in treatment. HIV is presenting in an older population group and concerns of higher rates of infection, early failures and dangers posed to healthcare workers exist. This study is imperative to predict future burden of THA and make subsequent provisions. Objectives. The objective was to determine the seroprevalence of HIV in patients presenting for THA in an academic institution in a developing country. Secondarily, the aim was to determine if there is any difference in the seroprevalence of patients undergoing THA and TKA and finally to assess the status of disease control in seropositive patients eligible for TJA on pre-existing HAART. Study Design & Methods. The seroprevalence of HIV in 676 non-haemophilic patients undergoing Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) at a single academic institution was prospectively assessed. All patients undergoing TJA from January 2016 – March 2018 were counselled and offered HIV testing pre-operatively. HIV ELISA tests were performed on all consenting patients awaiting TJA. The CD4+ count and viral load was measured for all HIV-infected patients. Viral load is a strong indicator of good viral suppression and is a positive prognostic factor for the long-term disease outcome. Results. There were 51 patients (14.4%) of 352 patients undergoing THA who were HIV-infected. The seroprevalence of 324 patients undergoing TKA was 5.86%. There were 56 patients (8.2%) who refused HIV testing. Young females (<45 years old) were 6.8 times more likely to refuse testing. Overall, 70 patients (10.3%) of awaiting TJA were HIV-positive Only 14 patients (2%) undergoing TJA were newly diagnosed with HIV-infection. All other patients were already on anti-retroviral therapy. The age of HIV-infected patients awaiting THA (54.56 years) was statistically significantly (p=0.036) younger than patients awaiting TKA (62.45 years). The Body Mass Index (BMI) was significantly lower in THA than TKA (p=0.021). The average CD4+ counts for THA and TKA was 286 (56–854) and 326 (185–1000) respectively. 67% of patients had a viral load less than lower than detectable level (LDL). Of the HIV-infected patients presenting for THA, 34 (67%) had evidence of avascular necrosis (AVN) and 4 (7.84%) with a neck of femur fracture. No HIV-infected patients presenting for TKA had evidence of AVN of the knee. Conclusions. The seroprevalence of HIV in patients undergoing THA is higher than those undergoing TKA and the reported average in the general population. This may reflect the high association between both HIV and HAART and AVN of the hip. Our findings predict a significant burden on arthroplasty services in the future

We assessed the rates of fracture healing in a number of patients in Southern Africa where the Human Immunodeficiency Virus (HIV) is highly prevalent. Our aim was to deduce whether rates of union were affected by HIV and its subsequent clinical stages, including the Acquired Immune Deficiency Syndrome (AIDS). We evaluated 2376 patients with Weber B ankle fractures without talar shift. All the patients included in the study were tested for HIV using the Western Blot system and classified according to the WHO classification (Stages I–IV). From the sample group, 829 patients were HIV negative. 729 were HIV positive belonging to Stages I–III, whilst 755 were HIV positive in stage IV of the disease. Patients were all treated conservatively in below knee casts for a minimum of six weeks. All the patients were aged between 20 and 30. All patients were all part of similar socioeconomic circumstances and were non-smokers who used no dietary supplements. From the sample of patients we reviewed, the results were as follows. In the HIV negative category, 56% of patients had fracture union at 4 weeks, 32% had fracture union at 6 weeks, 10.5% had fracture union at eight weeks and 1.5% of patients suffered non-union of the fractures. In the HIV positive group (WHO Stages I–III), 54.7% of patients had fracture union at 4 weeks, 33.7% had fracture union at 6 weeks, 10.2% had fracture union at 8 weeks and 1.26% of patients suffered non-union. From the HIV positive category (WHO Stage IV), 18.28% of patients had fracture union at four weeks, 32.72% had fracture union at 6 weeks, 36.56% had fracture union at 8 weeks and 12.45% of patients suffered non-union of the fractures. Healing and union were described as sufficient callous formation, no further displacement, and no malleolar tenderness at the time of cast removal. In addition to this, the patients must have been able to fully weight bear. There was no significant statistical difference in fracture union between patients who were HIV negative and the patients with HIV stages one to three. There were significant differences between the above mentioned groups and patients with Stage IV HIV/AIDS. In essence, the more progressive the disease, the higher the rates of non-union

There are 33 million people worldwide currently infected with human immunodeficiency virus (HIV). This complex disease affects many of the processes involved in wound and fracture healing, and there is little evidence available to guide the management of open fractures in these patients. Fears of acute and delayed infection often inhibit the use of fixation, which may be the most effective way of achieving union. This study compared fixation of open fractures in HIV-positive and -negative patients in South Africa, a country with very high rates of both HIV and high-energy trauma. A total of 133 patients (33 HIV-positive) with 135 open fractures fulfilled the inclusion criteria. This cohort is three times larger than in any similar previously published study. The results suggest that HIV is not a contraindication to internal or external fixation of open fractures in this population, as HIV is not a significant risk factor for acute wound/implant infection. However, subgroup analysis of grade I open fractures in patients with advanced HIV and a low CD4 count (< 350) showed an increased risk of infection; we suggest that grade I open fractures in patients with advanced HIV should be treated by early debridement followed by fixation at an appropriate time

Introduction and Aims: The rate of wound infection for HIV positive patients, range from 0–33% for closed fractures to 72–80% for compound fractures. For the outcome at our institute, I undertook to study the rate of surgical wound infection in HIV positive patients undergoing unreamed intramedullary fixation for acute fractures. Method: A prospective single blind study involving 45 patients, who sustained acute fractures of the femur and/or tibia were treated with unreamed intramedullary nails at Durban’s Metropolitan hospitals during April 2002 to June 2003. Eighteen patients were HIV positive with a mean age of 29 years (20–47) compared to 28.5 years (15–56) amongst the HIV negative. There were six and three females in HIV positive and negative groups respectively. Motor vehicle accidents involving pedestrians and gunshot injuries accounted for the majority of the fractures. Although all of the patients were asymptomatic prior to injury, fourteen had associated injuries. Results: The mean follow-up was 7.3 months (1–14). Following discharge from hospital, patients were seen at two and six weeks, three, six, nine, and 12 months post-operatively. Amongst patients with closed fractures, nine were HIV positive, seven with femur and two with tibia fractures and amongst the HIV negative group 12 patients had femur and seven tibia fractures. Three of the HIV positive patients had compound fracture tibia, each with a Gustilo type II, type IIIA and type IIIB fracture, while four HIV negative patients with, two each of grade II and grade IIIB fracture tibia. Amongst the six HIV positive patients who had compound fractures of the femur one had a grade I, two grade II, two grade IIIA and two grade IIIB fractures. Four HIV negative patients had compound femoral fractures, three with grade II and one grade IIIA. Two patients had wound infection, at one week a HIV positive male with a grade IIIA fracture of the femur and a HIV negative female at two weeks with a grade IIIB fracture of the tibia, resulting in an infection rate 5.5% and 3.7% for the HIV positive and HIV negative patients respectively. This difference was not statically significant (p=0.641). Conclusion: The results show that when asymptomatic HIV positive patients are treated operatively for acute long bone fractures, be they closed or compound, the rate of surgical wound infection is comparable to those of HIV negative patients

Introduction. The Human immunodeficiency virus (HIV) has changed all aspects of orthopaedic practice in Durban, South Africa. In our Arthroplasty unit, we have noticed a significant increase in HIV positive patients that required total hip arthroplasty (THR). Method. We conducted a retrospective, demographic chart review of all patients below the age of 55years undergoing primary THR in our unit from 2004 to 2011. Results. The results show a steady rise from 22 THR's in 2004, to 51 in 2011. There was a demographic change in patients presenting with avascular necrosis (AVN) as primary diagnosis, with a significant increase of HIV positive patients. The new demographic group that makes up 44% of our current practice are black Africans, particularly females (70% of all black patients). The majority of them (66%) have none of the previous risk factors for AVN (alcohol, smoking and steroids) and out of this group 52% are HIV positive on anti-retroviral medication (ARV's) with an average CD4 count of 516. All HIV positive patients, in this demographic study, were black African females. Discussion. In the past, the typical patient receiving a primary THR for AVN in Durban was a young Asian male. These patients had strong associations with alcohol, smoking and oral steroid use. This demographic group makes up 33% of our current practice. Demonstrated clearly is a change in demographics of patient population and this lead to a number of interesting questions. What caused this sudden increase in HIV related AVN in our unit? To what extend do ARV's contribute to this accelerated progression of AVN and HIV?. This paper focuses our attention on HIV and its affect in modern orthopaedics. The challenge is great, the question remains … how will we respond?. NO DISCLOSURES

Introduction. HIV is known to affect many of the processes involved in fracture healing. Recent work has suggested that CD4 cells may act as suppressor in the regulation of fracture healing. There are no clinical studies looking at fracture healing in patients with open fractures in these patients. Study question. Is there an association between HIV and risk of non union in open fractures treated with surgical stabilisation. Methods. This was a prospective observation cohort study. All open fractures treated with surgical fixation, presenting to the study hospital over a 9 month period, were included. Non union was the primary outcome. 133 patients (33 HIV positive) with 135 open fractures fulfilled the inclusion criteria. Results. Exposed and unexposed populations were broadly similar. The risk of non union was 15% in HIV positive patients and 4% in HIV negative patients (Risk Ratio= 4, p =0.04). Discussion. The data suggests that HIV may adversely affect fracture healing in open fractures treated with surgical stabilisation. Treatment of these patients needs to account for the high non union rate. This study population provides an interesting insight into how modulation of the immune system affects fracture healing

The study sought to compare infection and union rates in HIV positive patients sustaining severe open tibial fractures, with those in healthy controls. In a prospective study, consecutive adult patients with Gustilo grade 2 or 3 open tibial fractures who consented to enter the study were enrolled and treated according to a standard regime. The regime consisted of intravenous antibiotics, emergency wound excision and irrigation, wound left open, fracture stabilisation by external fixation, wound inspection at 48 hours and closure if clinically indicated. 27 patients with 28 fractures entered of whom 7 patients were HIV positive. At 3 months, 2 of the HIV positive cases had satisfactory wound healing, while 5 were infected. In the HIV negative controls, 17 had satisfactory wound healing while 4 were infected (p=0.020, Fishers exact test). At 6 months 4 HIV positive patients were united, 3 were ununited. At the same time, 16 HIV negative patients were united, 1 ununited, and 4 lost to follow-up (p=0.059, Fishers exact test). Open tibial fractures in HIV positive patients are prone to wound sepsis and may show a tendency to delayed or non-union

Background: The importance of HIV in trauma has been poorly investigated. There’re few reports in the literature on the effects of HIV on fracture healing, those that there are involve small numbers. Many surgeons have concerns about both internal and external fixation in these patients. Some of the most recent published studies have suggested a 4 fold increase in infection rates in internal fixation of open fractures (small series 39 patients, 12 of whom HIV positive). In our hospital we have prospectively reviewed the outcomes of our open fractures treated by internal fixation, to see if HIV is a significant risk factor for wound infection and non union. Methods: All patients undergoing internal fixation for open fractures were entered into a database. Patients were managed along predesigned protocols, under the care of one consultant to try and standardise care. Patients were followed up in a dedicated clinic. 96% 2 month follow up and 84% 3 month follow up was obtained. Results: Over a 9 month period 102 open fractures were treated with internal fixation. 23% of patients were HIV positive and 14% declined to be tested. CD4 counts ranged from 131–862, mean of 387. The superficial wound infection rate was 13% in HIV positive patients and 15% in HIV negative patients. Sub group analysis suggested that HIV positive patients with low CD4 counts and grade 1 injuries were significantly more likely to develop wound infections (50%) than controls (12%), p value=0.02. Grade 1 injuries were not managed with urgent debridement, under hospital guidelines, and had an average delay to theatre of 4 days. Rates of non union were 4% and 2% in the HIV positive/negative groups respectively. Conclusions: This series is the largest prospective study in the literature. Our data suggests that:. The risks of acute infection in open fractures fixed by internal fixation in HIV positive individuals may not be as high as some previous studies have suggested;. Open fractures in HIV positive patients can be managed to union with internal fixation;. That in may not be appropriate to leave grade 1 injuries in HIV positive patients for non urgent debridement/fixation, as previous studies have suggested. Discussion: We feel that the current dogma of denying such patients internal fixation, is no longer appropriate. Although this study does not provide a direct comparison between differing Methods: of fixation, it provides the strongest evidence available in the literature, that internal fixation should be considered as a treatment option in these patients. We are currently awaiting the result of long term follow up looking at rates of delayed sepsis in these patients

Methods. We conducted a single centre prospective observational study comparing post-operative infection rates in HIV positive and HIV negative patients presenting with tibial shaft fractures managed with surgical fixation. Results. Twenty eight patients were incorporated over a six month period and followed up for three months post operatively. 25 open fractures including 6 HIV positive patients and 3 closed fractures including 1 HIV positive patient were assessed for signs of wound sepsis assessed with the asepsis wound score. 21 patients treated with external fixation including 4 HIV positive patients were also assessed using Checkett's scoring system for pin site infection. There was no significant difference in post-operative wound infection rates between the HIV positive (mean wound score = 7.7) and HIV negative (mean = 3.7) patients (p=0.162). HIV positive patients were also found to be at no increased risk of pin site sepsis (p=0.520). No correlation was found between CD4 counts of HIV positive patients and wound infection rates. Conclusions. Our results show that HIV positive patients with tibial fractures are not significantly more at risk of wound infection postoperatively. External fixation has also been shown to be a safe effective treatment of open tibial fractures in HIV patients

A prospective study was undertaken of wound healing in HIV positive patients undergoing orthopaedic implant surgery. 175 implant operations were assessed. 40 operations (23%) were in HIV positive individuals. Wounds were scored using the Asepsis scoring system. Closed fractures in HIV positive patients had 1 (3. 5%) major infection. No correlation was seen between CD4 count and risk of wound infection. With regards to early wound sepsis, implant surgery can be undertaken safely in HIV positive individuals with closed injuries regardless of CD4 count. The risk of wound sepsis rises dramatically in implant surgery for HIV positive patients with open fractures

The increased prevalence of HIV has increased awareness and concern for the diagnosis and treatment of patients requiring total joint arthroplasty. Collective experience with HIV and arthroplasty at any institution is small and limited. This study evaluates the clinical outcome of arthroplasty in HIV infected patients. Between July 2000 and August 2001, we treated 14 patients (4 female) and with uncemented total hip replacement. (Mean age of 42 years). Informed consent was obtained before HIV testing and counselling was provided for all patients. Patients were classified according to the WHO and CDC classification. All patients were operated on by a single surgeon using the Hardinge approach. 14 Patients were followed up with a mean follow up 62 months. The pre-lymphycyte subset analysis was TLC-2.24, CD4 425, CD8 873, CD4/CD8-0.52. All patients were fully ambulant. One patient sustained a periprosthetic fracture following a high energy car accident which was treated non operatively. Three patients have dropped their CD4 count to below 200 and are presently receiving antiretroviral treatment. There was no loosening, infection or dislocation. The literature on complications associated with arthroplasty in HIV infected patients is inconsistent. A few authors have reported a 40% incidence of infection with total joint replacement. In this series there were no infections, and the outcome of total joint arthroplasty depends on the nutritional status of the patient, the stage of the under lying disease, as well as previous surgery and co-morbidities. Orthopaedic Surgeons should be aware of the increasing prevalence of HIV infection, and that arthroplasty in these patients can be safely performed with minimum complications

Introduction. The resurgence of TB worldwide has several underlying causes, but HIV infection has undoubtedly been a key factor in the current TB epidemic. Since TB is endemic in the developing world the influence of HIV is of concern, particularly with the emergence of multi-drug-resistant strains. The remarkable susceptibility of patients with AIDS to develop TB has shown the critical role of CD4 lymphocytes in protective immunity. In the absence of immunological surveillance by CD4 cells, 5-10% of persons with latent foci of TB reactivate each year. Aim. This paper highlights the presentation and outcome following treatment in HIV patients with spinal TB. Methods. 81 HIV+ve patients with spinal tuberculosis were prospectively evaluated between 2006 and 2007. The mean age was 31 years and 63% were females. The thoracic spine was affected in 45, lumbar (33) and cervical (3). Non-contiguous lesions were noted in six patients. Sixty-six (81%) patients had neurological deficit. The mean Hb was (10.1gm/dl), mean WCC 4.9, mean lymphocyte count was 1.8, mean ESR 79mm/h and the mean CD4 count was 268 cell/cumm. Co-morbidities were seen in 68% of patients. All patients were optimised prior to treatment. Posterolateral decompression was performed in 29 cases, anterior decompression (25), needle biopsy (13), incision and drainage 5 and 9 were treated non-operatively. Medication included ARV (72 patients) and anti-TB in all patients. Results. The mean follow-up was 21 months. Eleven (13.5%) patients developed wound infection and one child died. Complete recovery occurred in 23 patients (35%). The mean CD4 count was 341 cell/cumm. Conclusion. The short term results are encouraging. These patients are best managed by a multidisciplinary team to monitor potential complications from dual therapy, to ensure compliance and adequate nutrition

Introduction: There are no current estimates of the risk of transmission of HIV, HBV, HCV, or HTLV by musculoskeletal tissue transplantation. Such accurate data would be helpful to determine the effectiveness of current and proposed screening and processing procedures, and contribute to increased confidence in the use of musculoskeletal tissue products. Methods: The prevalence rates of HIV, HBV, HCV, and HTLV were determined from 12.245 musculoskeletal tissue donors from three bone tissue banks across Australia from the period 1993 to 2004. The incidence rates among tissue donors were estimated by comparing the data with age-specific incidence rates of first-time blood donors. We estimated the probability of a tissue donor was within the window period when infection was undetected by serological screening procedures by the modified incidence-window period model. Further we calculated the projected probability of viremia with the addition of nucleic-acid amplification testing (NAT). Results: The prevalence (per 100,000 persons) of confirmed positive tests among musculoskeletal tissue donors was 169.15 for HIV, 427.68 for HBV, 534.63 for HCV, and 121.66 for HTLV. This is greater than the prevalence among first-time blood donors during the same period (6.47 for HIV, 136.00 for HBV, 215.29 for HCV, and 3.46 for HTLV). The incidence rate among musculoskeletal donors were estimated to be 15.81, 0.68, 3.53, and 4.85 per 100,000 person-years, respectively. The estimated probability of viremia (per 100,000 persons) at the time of donation was 1.38 for HIV, 0.46 for HBV, 1.82 for HCV, and 0.85 for HTLV. These estimations would be even lower with the addition of NAT – 0.57, 0.23, and 0.20 respectively. Conclusions: The prevalence and incidence of HIV, HBV, HCV, and HTLV among musculoskeletal tissue donors, although low are significantly higher than those of first-time blood donors. Current screening and processing measures are effective, though the probability of viremia can be reduced further by nucleic-acid amplification testing

From May 2002 to April 2003, a prospective, non-randomised, blinded study was undertaken in 30 patients with fractures of the femur and tibia, all treated with unreamed intramedullary (AO) nail fixation. There were 17 (57%) femoral shaft fractures and 13 (43%) tibial shaft fractures. Most of the patients (23) had been injured in road findings accidents, 17 of them pedestrian. No patient had any known co-morbidities. Fourteen patients (47%) were HIV positive, nine with femoral fractures and five with tibial fractures. Three patients with compound femoral fractures were HIV positive, two HIV negative. The mean age of HIV-positive patients with femoral shaft fractures, two men and seven women, was 33 years (18 to 48). The mean age of the eight HIV-negative men with femoral shaft fractures was 28 years. Five tibial fractures were compound, three in HIV-positive patients and two in HIV-negative patients. The mean age of HIV-positive patients with tibial fractures, three men and two women, was 31 years (18 to 56). The mean age of the HIV-negative patients, seven men and one woman, was 28 years. All the fractures were Gustillo-Anderson grade- II. At 12 weeks, 29 fractures had united. In one HIV-positive patient with a compound tibial fracture there were no radiological signs of union at 12 weeks, but after bone grafting the fracture united uneventfully. An HIV-positive patient, who had sustained a gunshot femur injury, developed deep wound infection four months after fixation. In all other patients, the wounds healed uneventfully. In asymptomatic HIV-positive patients, wound healing and fracture union rates are comparable with those of HIV-negative patients

To determine whether HIV seropositivity is a significant risk factor for infection following open fractures of long bones, we undertook a prospective cohort-type analytical study. We obtained Ethics Committee approval and invited suitable patients (adults with open fractures of long bones) presenting to our institution to participate in the study. Written informed consent was obtained and the patient registered. Baseline blood tests were done (Hb, HIV, Albumin, CD4 count), after which treatment proceeded in the standard manner. At set intervals, patient records were accessed and information captured in a database. Patients were followed up until bony union had occurred. To date, 50 patients have been recruited to the study. Of these, 19 were followed up until bony union. All but one of these patients was male and the mean age was 34.5 years. Fractures included three femora, two humeri, two radii and 15 tibiae. There were five Gustilo-Anderson grade-I, seven grade-II, six grade-IIIa and three grade-IIIb open fractures. Three of the 19 patients tested positive for HIV (15.8%). Infection occurred in five patients (26.3%), none of whom was HIV-positive. The strongest predictor for infection was the time delay to wound inspection, with mean delays of 56.9 hours and 100.2 hours respectively in patients who did and did not develop infection. Although our study is small, it suggests that asymptomatic HIV seropositivity is not a significant risk factor for infection following open fractures of long bones. Delayed wound inspection puts patients at increased risk

Aims. The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures. Methods. A total of 120 PLWH with limb fractures, between January 2015 and December 2023, were included in this study. We established a multidisciplinary team to design and implement a standardized ERAS protocol. The demographic, surgical, clinical, and follow-up information of the patients were collected and analyzed retrospectively. Results. Compared with the control group, the ERAS group had a shorter operating time, hospital stay, preoperative waiting time, postoperative discharge time, less intraoperative blood loss, and higher albumin and haemoglobin on the first postoperative day. The time to removal of the urinary catheter/drainage tube was shortened, and the drainage volume was also significantly reduced in the ERAS group. There was no significant difference in the visual analogue scale (VAS) scores on postoperative return to the ward, but the ERAS group had lower scores on the first, second, and third postoperative days. There were no significant differences in the incidence of complications, other than 10% more nausea and vomiting in the control group. The limb function scores at one-year follow-up were similar between the two groups, but time to radiological fracture union and time to return to physical work and sports were significantly reduced in the ERAS group. Conclusion. The implementation of a series of perioperative nursing measures based on the concept of ERAS in PLWH with limb fracture can significantly reduce the operating time and intraoperative blood loss, reduce the occurrence of postoperative pain and complications, and accelerate the improvement of the functional status of the affected limb in the early stage, which is worthy of applying in more medical institutions. Cite this article: Bone Joint Res 2024;13(11):647–658

Tuberculosis (TB) remains endemic in many parts of the developing world and is increasingly seen in the developed world due to migration. A total of 1.3 million people die annually from the disease. Spinal TB is the most common musculoskeletal manifestation, affecting about 1 to 2% of all cases of TB. The coexistence of HIV, which is endemic in some regions, adds to the burden and the complexity of management. This review discusses the epidemiology, clinical presentation, diagnosis, impact of HIV and both the medical and surgical options in the management of spinal TB. Cite this article: Bone Joint J 2018;100-B:425–31