Highly active anti-retroviral therapy has transformed HIV into a chronic disease with a long-term asymptomatic phase. As a result, emphasis is shifting to other effects of the virus, aside from immunosuppression and mortality. We have reviewed the current evidence for an association between HIV infection and poor fracture healing.

The increased prevalence of osteoporosis and fragility fractures in HIV patients is well recognised. The suggestion that this may be purely as a result of highly active anti-retroviral therapy has been largely rejected. Apart from directly impeding cellular function in bone remodelling, HIV infection is known to cause derangement in the levels of those cytokines involved in fracture healing (particularly tumour necrosis factor-α) and appears to impair the blood supply of bone.

Many other factors complicate this issue, including a reduced body mass index, suboptimal nutrition, the effects of anti-retroviral drugs and the avoidance of operative intervention because of high rates of wound infection. However, there are sound molecular and biochemical hypotheses for a direct relationship between HIV infection and impaired fracture healing, and the rewards for further knowledge in this area are extensive in terms of optimised fracture management, reduced patient morbidity and educated resource allocation. Further investigation in this area is overdue.

Achilles tenotomy is a recognised step in the Ponseti technique for the correction of idiopathic congenital talipes equinovarus in most percutaneous cases. Its use has been limited in part by concern that the subsequent natural history of the tendon is unknown. In a study of 11 tendons in eight infants, eight tendons were shown to be clinically intact and ten had ultrasonographic evidence of continuity three weeks after tenotomy. At six weeks after tenotomy all tendons had both clinical and ultrasonographic evidence of continuity.

We examined 204 children (137 boys and 67 girls) aged 12 years and under with septic arthritis. Their mean age was 31.1 months (1 to 144; SD 41.6). The most common joints affected were the knees and shoulders. Joints in the upper limb were affected more often in younger children and in the lower limb in those who were older. The mean age for an infection was 12 months in the shoulder and 73 months in the hip. The most common organisms cultured were species of Salmonella.

25 cases of closed fractures around the distal femoral growth plate were analysed prospectively over a one-year period. There were 22 males and 3 females. Mean age was 16 years (range 7 to 22).

According to the classification of Salter and Harris there were 6 cases (24%) of type 1 fracture, 12 (48%) type 2 fractures, 3 (12%) type 3, and 4 (16%) type 4. Mechanism of injury was football in 13 (59%), simple fall in 4 (18%), crush in 2 (9%), RTA in 2 (9%), and fall from height in 1 (5%); in 3, the mechanism was not recorded. The average time from injury to hospital admission was 5 days (range 0 to 17 days).

Management was conservative in 4 and operative in 21. The medial parapatellar approach was used in 16. Post-surgically plaster cylinders were used for a mean of 3 weeks (range 0 to 6 weeks). No patient received physiotherapy.

In the operative cases, sepsis was observed in 1 case (5%). This was a crash injury with a skin ulcer that became septic postoperatively and later required knee fusion.

Of the remaining 20 operative cases, 17 cases were reviewed, 4 to one year, 9 to six months, and 4 to three months. There were no cases of deformity, nor wound complications. Those reviewed at one year had an excellent range of movement averaging 0 to 117 degrees (range 0–100 to 0–140). At six months the average range of movement was 1–98 degrees (range 5–70 to 0–140) and at three months 2–62 degrees (range 10–50 to 0–95).

In conclusion, we believe that these difficult fractures should usually be managed operatively where expertise allows. Preliminary results suggest that the medial parapatellar approach provides excellent access but may inhibit initial rehabilitation.

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.

Accepted treatment for acute septic arthritis in children involves drainage of the pus and systematic antibiotics. Review of published studies show that there is a tendency for paediatricians and physicians to drain pus by aspiration and for surgeons to drain the pus by arthrotomy and surgical lavage. There is however no published prospective study comparing the two methods of drainage.

201 consecutive children under 13 (134 boys and 67 girls) presenting to our hospital with acute septic arthritis were entered into a prospective study and randomised to either aspiration of the joint with a 14g needle or arthrotomy and lavage. Both groups had systematic antibiotics for six weeks. All patients were followed up with clinical examination and x-rays at 2, 6, 12, 24 and 52 weeks.

There were 102 patients in the aspiration group and 99 in the lavage group. Both groups were similar in respect to mean age (2 yrs 5m and 2 yrs 10m respectively) and both groups had had symptoms for a mean of 6. 5 days. The commonest joint involved in both groups was the knee, followed by the shoulder, and the commonest organism involved was salmonella, followed by staphylococcus aureus.

Aspiration failed in 9/102 patients who then underwent arthrotomy. Aspirated cases were discharged at a mean of 7. 9 days compared to 9. 8 days in the lavage group. There is no published method of measuring clinical improvement in septic arthritis so we devised the Blantyre septic joint score (BSJS) which measures pain, swelling, range of motion and function. Using the BSJS we found significant difference in scores between the aspirated and the lavage groups at any stage of follow up.

We could not demonstrate any difference in clinical outcome between aspiration and arthrotomy with lavage in the treatment of septic arthritis.

We undertook a prospective study of 61 children in Malawi with septic arthritis of the shoulder. They were randomised into two groups, treated by aspiration (group 1, 31 patients) or arthrotomy (group 2, 30 patients). Both received antibiotics for six weeks. We studied the results of blood tests, microbiology, and the clinical and radiological outcome one year after diagnosis. Only one patient was sickle-cell positive and three were HIV-positive. Non-typhoidal Salmonella species accounted for 86% (19/22) of the positive joint cultures in group 1 and 73% (16/22) in group 2. Of the 33 radiographs available for review at follow-up at six months, 23 (70%) showed evidence of glenohumeral damage. There was no statistical difference in radiological outcome for the two groups. We devised and validated a scoring system, the Blantyre Septic Joint Score, for the assessment of joints based upon swelling, tenderness, function and range of movement. Despite the radiological changes only one of the 24 joints examined at one year had any deficit in these parameters. There was no statistical difference in the clinical outcome for the two treatment groups at any stage during the period of follow-up.

We performed a prospective, blind, controlled study on wound infection after implant surgery involving 41 procedures in patients infected with the human immunodeficiency virus (HIV) and 141 in HIV-negative patients. The patients were staged clinically and the CD4 cell count determined. Wound infection was assessed using the asepsis wound score. A risk category was allocated to account for presurgical contamination.

In HIV-positive patients, with no preoperative contamination, the incidence of wound infection (3.5%) was comparable with that of the HIV-negative group (5%; p = 0.396). The CD4 cell count did not affect the incidence of infection (r = 0.16). When there was preoperative contamination, the incidence of infection in HIV-positive patients increased markedly (42%) compared with that in HIV-negative patients (11%; p = 0.084).

Our results show that when no contamination has occurred implant surgery may be undertaken safely in HIV-positive patients.

The atlas of Greulich and Pyle for skeletal maturity and epiphyseal closure is widely used in many countries to assess skeletal age and to plan orthopaedic surgery. The data used to compile the atlas were collected from institutionalised American children in the 1950s.

In order to determine whether the atlas was relevant to subSaharan Africa, we compared skeletal age, according to the atlas, with chronological age in 139 skeletally immature Malawian children and young adults with an age range from 1 year 11 months to 28 years 5 months. The height and weight of each patient were also measured in order to calculate the body mass index.

The skeletal age of 119 patients (85.6%) was lower than the chronological age. The mean difference was 20.0 ± 24.1 months (t-test, p = 0.0049), and the greatest difference 100 months. The atlas is thus inaccurate for this group of children.

The body mass index in 131 patients was below the normal range of 20 to 25 kg/m².

The reasons for the low skeletal age in this group of children are discussed. Poor nutrition and chronic diseases such as malaria and diarrhoea which are endemic in Malawi are likely to be contributing factors. We did not find any correlation between the reduction in body mass index in our patients and the degree of retardation of skeletal age.