VOL. 91-B, No. 3, MARCH 2009 341 Joint replacement in Malawi ESTABLISHMENT OF A NATIONAL JOINT REGISTRY N. Lubega, N. C. Mkandawire, G. C. Sibande, A. R. Norrish, W. J. Harrison From Beit Cure Hospital, Blantyre, Malawi  N. Lubega, MBChB, MMed(Ortho), FCS(ESSA), Orthopaedic Surgeon  G. C. Sibande, BSc, Matron  W. J. Harrison, MA(Oxon), FRCS(Trauma & Orth), Consultant Orthopaedic Surgeon Beit Cure Hospital, P. O. Box 31236, Chichiri, Blantyre 3, Malawi.  N. C. Mkandawire, BMBS, FCS(ESSA), MCh(Orth), FRCS, Associate Professor College of Medicine, PO Box 95, Blantyre, Malawi.  A. R. Norrish, LLM, PhD, FRCS(Orth), Consultant Orthopaedic Surgeon Beit Cure Hospital, PO Box 36961, Lusaka, Zambia. Correspondence should be sent to Dr N. Lubega; e-mail: drniclubega@yahoo.com ©2009 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.91B3. 21706 $2.00 J Bone Joint Surg [Br] 2009;91-B:341-3. Received 28 August 2008; Accepted 30 October 2008 In Africa the amount of joint replacement surgery is increasing, but the indications for operation and the age of the patients are considerably different from those in the developed world. New centres with variable standards of care and training of the surgeons are performing these procedures and it is important that a proper audit of this work is undertaken. In Malawi, we have pioneered a Registry which includes all joint replacements that have been carried out in the country. The data gathered include the age, gender, indication for operation, the prosthesis used, the surgical approach, the use of bone graft, the type of cement, pressurising systems and the thromboprophylaxis used. All patients have their clinical scores recorded pre-operatively and then after three and six months and at one year. Before operation all patients are counselled and on consent their HIV status is established allowing analysis of the effect of HIV on successful joint replacement. To date, 73 total hip replacements (THRs) have been carried out in 58 patients by four surgeons in four different hospitals. The most common indications for THR were avascular necrosis (35 hips) and osteoarthritis (22 hips). The information concerning 20 total knee replacements has also been added to the Registry. Africa is unique in many aspects of joint replacement. There are different indications for the procedure, the patients are younger and there are different factors in life style which may affect the longevity of the prosthesis. The long-term effect of the presence of HIV infec- tion requires further investigation. Patients infected with HIV may be at risk of late deep infection of the implant as their immune status deteriorates. 1 Harrison, Lewis and Lavy 2 have suggested removal of trauma implants soon after union of the fracture if infection occurs. However, these studies were carried out before the widespread use of highly active antiretroviral treatment (HAART) in sub-Saharan Africa. Implants cannot be removed without affecting function. A large retrospective multicentre study by Hicks et al 3 showed that there was an increased rate of sep- sis after joint replacement in HIV-positive haemophiliacs. We are uncertain about late sepsis in HIV-positive patients especially those given HAART and prophylactic cotrimox- azole. In Malawi the present criterion for start- ing patients on HAART is a CD4 count which is lower than 250 × 10 6 /l, but the question remains as to whether HAART reduces the risk of late sepsis, and, if so, whether this is simply by elevating the CD4 count. Long-term follow- up of all HIV-positive patients who have undergone joint replacement should ascertain whether deep infection occurs as immunity deteriorates. Patients and Methods The National Joint Registry was established in 2005 with ethical approval from the Research and Ethics Committee of the College of Medi- cine of Malawi (Table I). All patients who have had or are about to undergo total hip replace- ment (THR) in Malawi are approached to give consent to be included in the Registry. To date 73 THRs have been entered, together with 20 total knee replacements. An assessment is carried out one week before the operation by a senior nurse (GCS). This includes calculating the Harris hip score 4 (HHS) and obtaining informed consent from the patient for both the procedure and inclusion in the Registry. After counselling and consent, HIV testing is carried out, with determination of the CD4 level in those who test positive. Routine pre-operative tests include a full blood count and a blood slide for malaria parasites. All ques- tions pertaining to the procedure are answered and general counselling is given so that the