Staphylococcus aureus colonization and periprosthetic joint infection in patients undergoing elective total joint arthroplasty: a narrative review.

Peri-prosthetic joint infections (PJIs) following total joint arthroplasty (TJA) are associated with higher treatment costs, longer hospital admissions and increased morbidity and mortality. Colonization with Staphylococcus aureus is an independent and modifiable risk factor for PJIs and carriers of S. aureus are ten times more likely than non-carriers for post-operative infections. Screening and targeted decolonization, vs universal decolonization without screening, remains a controversial topic. We recommend a tailored approach, based on local epidemiological patterns, resource availability and logistical capacity. Universal decolonization is associated with lower rates of SSI and may reduce treatment costs.

The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are successful orthopaedic procedures with an ever-increasing demand annually worldwide, and persistent wound drainage (PWD) is a well-known complication following these procedures. Despite many definitions for PWD having been proposed, a validated description remains elusive.PWD is a risk factor for periprosthetic joint infection (PJI). PJI is a devastating complication of THA and TKA, and a leading cause of revision surgery with dramatic morbidity and mortality and a significant burden on health socioeconomics.Prevention of PJI has become an essential focus in THA and TKA. Understanding the pathophysiology, risk factors and subsequent management of PWD may aid in decreasing the rate of PJI.Risk factors of PWD can be divided into modifiable and non-modifiable patient risk factors, pharmacological and surgical risk factors. No gold standard treatment protocol to address PWD exists; however, non-operative options progressing to surgical interventions have been described.The aim of this study was to review the current literature regarding PWD and consolidate the risk factors and management strategies available. Cite this article: EFORT Open Rev 2021;6:872-880. DOI: 10.1302/2058-5241.6.200054.

Should we routinely prescribe proton pump inhibitors peri-operatively in elderly patients with hip fractures? A review of the literature.

Elderly hip fracture patients are at risk of stress-related gastric mucosal damage, and upper gastrointestinal bleeding is one of the underrecognized but devastating complications.Proton pump inhibitors (PPIs) offer effective prophylaxis against stress-related gastric mucosal damage.Systematic analysis of the literature revealed numerous articles on PPIs and hip fractures, but only three articles dedicated to the analysis of prophylactic use of PPIs in patients with a hip fracture.There is significant reduction in upper gastrointestinal bleeding following PPI prophylaxis and reduced 90-day mortality in elderly hip fracture patients on prophylaxis.PPIs are generally safe, cost-effective and based on available evidence. Their prophylactic use is justifiable in elderly patients with hip fractures.We suggest that PPIs be prescribed routinely peri-operatively in elderly hip fracture patients. Further level-one studies on the subject will allow for firmer recommendations. Cite this article: EFORT Open Rev 2021;6:686-691. DOI: 10.1302/2058-5241.6.200053.

The management of displaced intracapsular femoral neck fractures at a Sub-Saharan Academic Hospital.

BACKGROUND: Femoral neck fractures (FNFs) remain "the unsolved fracture" and optimal management is still controversial. The outcomes of hemiarthroplasty (HA) and total hip arthroplasty (THA) in the treatment of FNFs are inconsistent. As demand for management of FNFs continues to grow globally, evaluation of the appropriateness of treatment remains essential, particularly in resource-constrained settings. METHODS: We conducted a retrospective chart review of all patients presenting with isolated low energy intracapsular FNFs to an orthopaedic academic unit in Sub-Saharan Africa from January 2016 to April 2019. The decision regarding HA or THA was largely based upon the Sernbo score and ASA classification. The majority of patients with a Sernbo score of ≥15 and ASA class III or better received THA. RESULTS: There were 117 patients (33 male/84 female) 72 years (33-97 years) with FNFs who underwent 56 THA and 61 HA between January 2016 and April 2019. The mean Sernbo score was 15.99 overall (range 8-20) and was 18.95 (11-20) for THA patients compared to 14.46 (8-20) for HA patients (p = 0.042). Time taken from admission to the theatre was 8-19 days (1-22) and 7-61 days (2-31) for HA and THA respectively. The average length of stay (LOS) was 16.04 days and the main reason for same-day cancellations was the lack of post ICU/High Care beds. The 30-day mortality rates were 1.78% and 4.91% for THA and HA patients, respectively (p = 0.07). The mortality rate for patients with a Sernbo score < 15 was 15.38% overall, 8.93% for THA patients, and 21.31% for HA patients, respectively (p = 0.021). CONCLUSION: The 30-day mortality rate was comparable with published rates from developed countries. There were significant delays in time to theatre, high rates of same-day surgical cancellations, and increased LOS for both HA and THA. These factors play a cumulative role in inflating costs on a strained healthcare system in a developing country. A multidisciplinary approach including the care provision of a specialized geriatric unit is recommended. Retrospective Study, Level III evidence.

Pain and function deteriorate in patients awaiting total joint arthroplasty that has been postponed due to the COVID-19 pandemic.

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.

The management of displaced femoral neck fractures: a narrative review.

This article serves to review the existing clinical guidelines, and highlight the most recent medical and surgical recommendations, for the management of displaced femoral neck fractures (FNFs). It stresses the need for multi-disciplinary intervention to potentially improve mortality rates, limit adverse events and prevent further economic liability.Globally, the incidence of FNFs continues to rise as the general population ages and becomes more active. The annual number of FNFs is expected to exceed six million by 2050. The increased burden of FNFs exacerbates the demand on all services associated with treating these injuries.The management of FNFs may serve as an indicator of the quality of care of the geriatric population. However, despite escalating health costs, a significant 30-day and one-year mortality rate, increased rate of peri-operative adverse events and sub-optimal functional clinical outcomes, continued controversy exists over optimal patient care.Much debate exists over the type of surgery, implant selection and peri-operative clinical care and rehabilitation. FNF care models, systematized clinical pathways, formal geriatrics consultation and specialized wards within an established interdisciplinary care framework may improve outcomes, mitigate adverse events and limit unnecessary costs. Cite this article: EFORT Open Rev 2021;6:139-144. DOI: 10.1302/2058-5241.6.200036.

Good Functional Outcomes and Low Infection Rates in Total Hip Arthroplasty in HIV-Positive Patients, Provided There Is Strict Compliance With Highly Active Antiretroviral Therapy.

BACKGROUND: Patients with HIV are more likely to require a total hip arthroplasty (THA) because of an increase in life expectancy and complications with HIV. The purpose of this study is to describe the mid-term outcomes of THA in HIV-positive patients and risk factors for postoperative infections and poor outcomes. METHODS: This is a single-center retrospective review of nonhemophiliac HIV-positive patients who underwent THA. We reviewed the short- and mid-term readmission and complication rates. RESULTS: Eighty-seven patients underwent 102 THAs. The average age was 58 years (24-73 years). The average body mass index was 31.6 (18-55). The average CD4+ count was 569 cells per cubic millimeter (mm3) (51-1480), and the mean viral load was <40 copies/mL (undetectable-380 000). The mean follow-up time was 6.7 years (24 months- 8.3 years). Four patients had postoperative complications within 30 days. Seven patients had postoperative complications after 30 days; 5 of which had septic loosening of implants and had either not been initiated on or were noncompliant with their highly active antiretroviral therapy. The average postoperative Harris Hip Score was 81 (41-100) and Oxford Hip Score was 43.43 (34-48). There was no correlation the between CD4+ count and viral load with complications. CONCLUSION: Low rate of complications and revision is achievable in the HIV-positive, nonhemophilic arthroplasty population contrary to published literature. An important factor ensuring good long-term outcomes in HIV-positive patients undergoing THA was the initiation of highly active antiretroviral therapy before the procedure and ensuring patient compliance with therapy after joint arthroplasty.

Good long-term outcomes for Direct Anterior Approach Total Hip Arthroplasty in South Africa.

This study aims to assess long-term outcomes of Total Hip Arthroplasty (THA) through Direct Anterior Approach (DAA) in a developing country using traditional and novel Patient-Reported Outcomes. There were 522 patients (mean age, 56.5 years; 66.3% female) after mean follow-up 7.35 years. There were 13 revisions. Overall 5-year implant survival rate was 97.5%. Patient Joint Perception scores of 65.5% perceived a completely natural joint. Mean Hip Disability and Osteoarthritis Score was 89.1. Median Forgotten Joint Score-12 was 90 and modified Harris Hip Score was 88. Primary DAA THA in sub-Saharan Africa allows good clinical outcomes at minimum 5 years follow-up.

Human immunodeficiency virus in total hip arthroplasty.

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.

Prevalence of Staphylococcus aureus colonization in patients for total joint arthroplasty in South Africa.

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.

The seroprevalence of HIV in patients undergoing lower limb Total Joint Arthroplasty (TJA) in South Africa.

AIM: The aim was to assess the seroprevalence of Human Immunodeficiency Virus (HIV) in non-haemophilic patients undergoing primary Total Joint Arthroplasty (TJA) at an academic hospital in South Africa. METHODS: A retrospective review of all Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) patients from January 2017 to December 2018 was conducted. All patients awaiting TJA were offered HIV screening and their demographic data were recorded. Consenting patients were tested or the refusal of testing was documented. The CD4+ T-cell count (CD4+) and viral load (VL) was measured for all HIV-positive patients and newly diagnosed patients were initiated on Highly Active Antiretroviral Treatment (HAART). RESULTS: We included 1007 patients in the study. The TJA population HIV seroprevalence was 10.7% (n = 108). The seroprevalence for THA was 14.9% (n = 78) and that for TKA was 6.2% (n = 30). There were 93 patients (9.2%) who refused screening. There were 12 (15.4%) and 3 patients (10%) that were newly diagnosed in the THA and TKA seropositive populations, respectively. The average CD4+ for THA and TKA was 569 cells/mm3 (105-1320) and 691 cells/mm3 (98-1406), respectively. The VL was undetectable in 75.9% (n = 82) of HIV-positive patients. Overall 12 HIV-positive patients (11.12%) had CD4+ <200 cells/mm3, 8 of these patients (66%) were newly diagnosed. The average age of the seropositive population was 58 ± 6.5 years and 66 ± 8.5 years for THA and TKA, respectively (p = 0.03). Femoral head osteonecrosis was the underlying pathology for 65.38% (n = 51) of seropositive patients for THA. CONCLUSION: The seroprevalence of HIV in patients undergoing THA in our South African institution is greater than the seroprevalence in the general population. The seroprevalence of HIV in THA is significantly greater than that in TKA. This may reflect the association between HIV, HAART and hip joint degeneration. Our findings draw attention to the significant burden HIV has on TJA.

Post-operative oral chemoprophylaxis in patients undergoing hip arthroscopy mitigates VTE risk with a low side-effect profile.

Hip arthroscopy (HA) has increased exponentially over the last decade. A recent systematic review found that the risk of venous thromboembolism (VTE) is 2%. This was higher than previous reports which may have underestimated the true incidence of VTE in HA. Thus, protocols to mediate VTE may be more necessary than previously thought. The aim of this article is to present a VTE prevention protocol and evaluate its subsequent efficacy. This is a prospective study of 880 consecutive HA cases. All patients were treated according to a predetermined VTE protocol which classified patients as high (≥1 risk factors) or low (no risk factors) risk for post-operative VTE. In high-risk patients, the protocol followed that of low-risk patients but additionally included rivaroxaban for 2 weeks post-operatively. The incidence of VTE was recorded and analysed in this study. A total of 880 HA cases at an average age of 35.4 years were evaluated, with 76.6% (n = 674) undergoing labral repair and concomitant cam and/or pincer resection, 17.2% (n = 151) of cases for isolated labral tear repaired, and 6.1% (n = 55) classified as other. The overall incidence of VTE was 0.45%. The incidence of VTE was 1.2% and 0.16% in high- and low-risk groups, respectively. Oral VTE prophylaxis was not associated with post-operative complications. This study demonstrated a lower rate of VTE in both risk groups. It highlights the value of a predetermined risk-adjusted protocol to VTE prophylaxis. Rivaroxaban prophylaxis is safe and efficacious in HA with a low associated morbidity.

Improvements in Objectively Measured Activity Behaviors Do Not Correlate With Improvements in Patient-Reported Outcome Measures Following Total Knee Arthroplasty.

BACKGROUND: Activity monitors have added a new dimension to our ability to objectively measure physical activity in patients undergoing total knee arthroplasty (TKA). The aim of the study is to assess whether changes in the time spent sitting, standing, and stepping were associated with changes in patient-reported outcome measures (PROMs) before and after TKA. METHODS: Valid activPAL data (>3 days) and PROMs were obtained from 49 men and women (mean [SD] age, 62.8 [8.6] years; body mass index, 33.8 [7.1] kg/m2) who underwent primary TKA, before and at 6 weeks or 6 months after surgery. Patient-reported symptoms of pain, stiffness, and knee function were obtained using the Knee injury and Osteoarthritis Outcome Score and Oxford Knee Score questionnaires. RESULTS: Mean (SD) Knee injury and Osteoarthritis Outcome Score (80.1 [16.3] to 41.6 [6.5], P < .001) and Oxford Knee Score (12.0 [9.8] to 17.7 [22.8], P < .001) scores improved 6 months after TKA. Walking time (mean [95% confidence interval]; min/d) increased from before (79 [67-91]) to 6 months after TKA (101 [88-114], P = .006). Standing time (318 [276-360] to 321 [291-352], P = .782) and sitting time (545 [491-599] to 509.0 [459.7-558.3], P = .285) did not change from before to 6 months after TKA. Participants took more steps (2559 [2128-2991] to 3515 [2983-4048] steps/day, P = .001) and accumulated more steps (31 [30-34] to 34 [33-35] steps/min, P < .001) after TKA compared to before. There were no associations between changes in activity behaviors and changes in PROMs (P > .05). CONCLUSION: Despite improvements in self-reported knee pain and functional ability, these changes do not correlate with improvements in objectively measured light-intensity and sedentary activity behaviors.

The Role of One-Stage Exchange for Prosthetic Joint Infection.

PURPOSE OF REVIEW: In an era of increasing numbers of hip and knee replacements, strategies to manage prosthetic joint infection (PJI) that are effective at infection control with good patient-reported outcomes and cost containment for health systems are needed. Interest in single-stage exchange for PJI is rising and we assess evidence from the last 5 years related to this treatment strategy. RECENT FINDINGS: Only five series for total knee replacement and ten series for total hip replacement have been reported in the last five years. More review articles and opinion pieces have been written. Reinfection rates in these recent studies range from 0 to 65%, but a meta-analysis and systematic review of all studies showed a reinfection rate of 7.6% (95% CI 3.4-13.1) and 8.8% (95% CI 7.2-10.6) for single-stage and two-stage revisions respectively. There is emerging evidence to support single-stage revision in the setting of significant bony deficiency and atypical PJIs such as fungal infections. Prospective randomised studies are recruiting and are necessary to guide the direction of single-stage revision selection criteria. The onus of surgical excellence in mechanical removal of implants, necrotic tissue, and biofilms lies with the arthroplasty surgeon and must remain the cornerstone of treatment. Single-stage revision may be considered the first-line treatment for all PJIs unless the organism is unknown, the patient is systemically septic, or there is a poor tissue envelope.

Proximal hamstring tendinopathy: pathophysiology, diagnosis and treatment.

Proximal hamstring tendinopathy is a chronic degenerative disease associated with progressive morbidity and functional decline. There is a growing incidence of the disease process but diagnosis is commonly delayed as patients present with vague and indolent symptoms, often without a specific precipitating injury. Treatment is also challenging as the existing literature varies in the nomenclature used for proximal hamstring tendinopathy and clinical trials use different management protocols with variable follow-up times. This review explores the existing literature on proximal hamstring tendinopathy and discusses the relevant anatomy, pathology, medical history, differential diagnosis, clinical assessment, diagnostic imaging and treatment of patients with proximal hamstring tendinopathy. This structured approach to proximal hamstring tendinopathy will enable clinicians to better understand the pathophysiology of the disease process, improve referrals to diagnostic imaging, and follow a stepwise approach to medical treatment and surgical referral.

Iatrogenic Bone and Soft Tissue Trauma in Robotic-Arm Assisted Total Knee Arthroplasty Compared With Conventional Jig-Based Total Knee Arthroplasty: A Prospective Cohort Study and Validation of a New Classification System.

BACKGROUND: The objective of this study was to compare macroscopic bone and soft tissue injury between robotic-arm assisted total knee arthroplasty (RA-TKA) and conventional jig-based total knee arthroplasty (CJ-TKA) and create a validated classification system for reporting iatrogenic bone and periarticular soft tissue injury after TKA. METHODS: This study included 30 consecutive CJ-TKAs followed by 30 consecutive RA-TKAs performed by a single surgeon. Intraoperative photographs of the femur, tibia, and periarticular soft tissues were taken before implantation of prostheses. Using these outcomes, the macroscopic soft tissue injury (MASTI) classification system was developed to grade iatrogenic bone and soft tissue injuries. Interobserver and Intraobserver validity of the proposed classification system was assessed. RESULTS: Patients undergoing RA-TKA had reduced medial soft tissue injury in both passively correctible (P < .05) and noncorrectible varus deformities (P < .05); more pristine femoral (P < .05) and tibial (P < .05) bone resection cuts; and improved MASTI scores compared to CJ-TKA (P < .05). There was high interobserver (intraclass correlation coefficient 0.92 [95% confidence interval: 0.88-0.96], P < .05) and intraobserver agreement (intraclass correlation coefficient 0.94 [95% confidence interval: 0.92-0.97], P < .05) of the proposed MASTI classification system. CONCLUSION: There is reduced bone and periarticular soft tissue injury in patients undergoing RA-TKA compared to CJ-TKA. The proposed MASTI classification system is a reproducible grading scheme for describing iatrogenic bone and soft tissue injury in TKA. CLINICAL RELEVANCE: RA-TKA is associated with reduced bone and soft tissue injury compared with conventional jig-based TKA. The proposed MASTI classification may facilitate further research correlating macroscopic soft tissue injury during TKA to long-term clinical and functional outcomes.

Treatment of limb length discrepancy following total hip arthroplasty.

Limb length discrepancy is the leading cause of patient dissatisfaction following total hip arthroplasty and the most common reason for litigation in the field of orthopaedics. This article provides a systematic, stepwise approach for identifying the aetiology of limb length discrepancy following total hip arthroplasty and provides guidance on the treatment of this complication to optimize postoperative clinical and functional outcomes. This review discusses postoperative history taking, clinical examination, radiographic assessment, conservative treatment, and surgical intervention for the management of patients with established limb length discrepancy following total hip arthroplasty. A comprehensive understanding of the multifactorial nature and methods of managing postoperative limb length discrepancy is essential for optimizing patient satisfaction, clinical outcomes and long-term function following total hip arthroplasty.

Human Immunodeficiency Virus Infection and Hip and Knee Arthroplasty.

BACKGROUND: Modern management of human immunodeficiency virus (HIV) infection has afforded patients longevity while increasing the burden of arthroplasty procedures because of the increased risk of osteonecrosis, fragility fractures, and degenerative joint disease. Early publications on hip and knee arthroplasty in HIV-positive patients reported a high risk of complications, although some more recent publications demonstrated acceptable outcomes. Despite the widespread nature of the HIV pandemic, there is a paucity of literature addressing outcomes following joint arthroplasty in infected patients. We pooled available studies to obtain the best evidence regarding the safety of total hip and knee arthroplasty procedures in HIV-positive patients. The studies identified were heterogeneous, precluding a meta-analysis. However, we performed a review of the literature focusing on complications and outcomes. METHODS: Twenty-one published English-language articles involving 6,516,186 joints were identified by a systematic review as suitable for inclusion in the study. The articles were analyzed for complication and prosthesis survivorship rates and relative risks. RESULTS: An overall complication rate of 3.3% was found across the 19 articles that provided such data. HIV-positive patients had a significantly elevated risk of periprosthetic joint infection, at 7.6%, compared with HIV-negative patients, at 3.3% (relative risk = 2.28, 95% confidence interval = 2.14 to 2.43). Eleven articles were suitable for analysis of prosthesis survivorship, and survivorship rates did not differ significantly between HIV-positive and negative patients. CONCLUSIONS: Total hip and total knee arthroplasty appear to be safe procedures with acceptable outcomes in HIV-positive patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prevention of limb length discrepancy in total hip arthroplasty.

Total hip arthroplasty is a highly effective and cost-efficient procedure but postoperative limb length discrepancy is a common source of patient dissatisfaction and litigation. This article provides a systematic, stepwise approach for identifying and proactively managing risk factors associated with limb length discrepancy following total hip arthroplasty. This review explores preoperative history taking, clinical examination, radiological templating, implant positioning, soft tissue balancing, and intraoperative surgical techniques for minimizing leg length discrepancy while maintaining stability and restoring mechanical function following total hip arthroplasty. A comprehensive understanding of the multifactorial nature and methods for reducing postoperative limb length discrepancy is essential for optimizing patient satisfaction, clinical outcomes and long-term function following total hip arthroplasty.