Lower limb long bone IM nail fixation in South Africa: outcomes and the influence of HIV on fracture-related infection

Listen to Andrew Duckworth, Simon Graham, Maritz Laubscher and Sithomobo Maqungo discuss the papers 'Late fracture-related infections in HIV-positive patients' and 'Outcomes following lower limb long bone intramedullary nail fixation in South Africa' published in the February 2025 and May 2025 issues, respectively, of The Bone & Joint Journal.

Click here to read the paper  'Late fracture-related infections in HIV-positive patients'.

Click here to read the paper 'Outcomes following lower limb long bone intramedullary nail fixation in South Africa'.

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Transcript

[00:00:00] Welcome everyone to our BJJ podcast for the month of May. I'm Andrew Duckworth and a warm welcome back to you all from your team here at The Bone and Joint Journal. As always, we'd like to thank you all for your continued comments and support as well as a big gratitude to our many authors and colleagues who take part in the series that highlights just some of the great work published by our authors each month.

So today for our podcast, I have the pleasure of being joined by three authors from two papers, one published in the February edition of the BJJ entitled 'Late fracture-related infections in HIV-positive patients', and the other published in the May edition of the BJJ entitled 'Outcomes following lower limb, long bone intramedullary nail fixation in South Africa'.

So firstly, I'm very pleased to be joined by Simon Graham, who is an academic orthopaedic trauma surgeon based in Oxford and Liverpool along with strong links to Cape Town as well. Simon, it's great to have you with us. No thanks for inviting me and the team to talk about the paper today. That's great, Simon.

And secondly, joining. Simon is one of Simon's colleagues in South Africa, Maritz Laubscher, who's a consultant, orthopaedic trauma and limb recon surgeon in Cape Town. Maritz, it's great to have you with us as well. Hi, thank [00:01:00] you very much. It's so honoured to be on the podcast. Thank you. Thanks. And finally joining.

Simon and Maritz is a senior author for both papers, Sithomobo Maqungo, who is a consultant, orthopaedic trauma surgeon based in Cape Town. Sithomobo it's great to have you with us. Thanks so much taking the time to join us. Hi Andrew. Yeah. Thank you for the opportunity to join the podcast. Sithomobo, I think we kick off with yourself and I was hoping you could maybe as a background to the work you've done, maybe give us a brief overview of the current impact of ortho orthopaedic trauma in lower- and middle-income countries, particularly in relation to the impact of lower limb long bone fractures and how these are currently being managed.

Hi. Yeah, thanks. Thanks Andrew. So basically, you know lower- to middle-income countries have a very high burden of of traumatic injuries. And you know, and then looking at our region in particular Africa, you know, we are the least motorised of the regions of the world, but we have the highest burden of you know, of road traffic injuries.

So, [00:02:00] you know. Who is typically affected by the traumatic injuries young males, you know, between the ages of about 16 to, to late forties or maybe up to age 50. And those are in many instances or, you know, on the continent are the most economically active individuals. They are the breadwinners in their families.

Mm-hmm. So any injury that affects them and that takes them off work, you know, is a big burden for, you know, for the family as well. Then also, you know, for, for the healthcare systems as well, because, you know, often in, in some of these regions, you know, hospital systems are not well developed and even treatment protocols within some of the hospitals are not well developed.

So there's a huge disproportion of musculoskeletal injuries. That are emanating from from all the traumatic injuries that that come through to the hospitals and and tend to overwhelm the, you know, the local trauma systems. Mm. And then there are also [00:03:00] variations within, you know, the certain, for the three countries we're looking at Malawi, Cape Tanzania, and, in South Africa, in you know, in that some of the or other, sorry, we're looking at South Africa only, but geographically within South Africa, you know, there are, you know, more rural parts of the country where, you know, it takes a few days for a patient to get to the hospital. And so those ones tend to present with late.

Late late injuries and those that tend to leave within the urban centres around Cape Town, which is the focus of the two papers, then they tend to have earlier access to, to healthcare and and often you know. Better, better outcomes in terms of infection. And then lastly, of course, there is a, you know, a problem that is not uniquely South African, but definitely much more common in Cape Town, which is gunshot injuries.

We have a high burden of civilian gunshot injuries that that we see. And they also form part of. Part of this cohort. Yeah, that, that's a really lovely [00:04:00] overview you've given there. And actually, I think, without going onto the, the results of your paper too soon, but I think that was one of the things that just struck me was the, the injury characteristics and the mechanism of injury.

This in this patient population compared to what we see, for example, here in the UK. I mean, it's just completely different. And I think you've described it really nicely there, and particularly the motor vehicle accidents and the, and the, and the gunshot wounds, which we'll come on to. So Maritz maybe if I could come to yourself, you know, that's sort of the lower limb trauma burden that, you know, Sithomobo really gives a nice overview of.

Obviously the other paper is related to HIV infection, you know, what's the current burden for yourselves regarding this and how is it impacting on sort of trauma and fracture care? So HIV is a a leading course of morbidity and mortality around the world. And just a little bit similar to injury.

This is, disproportionately affect low- and middle-income countries who have sort of 80% of the world's HIV positive population living in low- and middle-income countries, and the epicentre sort of in [00:05:00] South Saharan Africa and South Africa has the largest. Living population of HIV positive patients on antiretrovirals.

Now if you look in South Africa, we, we work the population average HIV positivity rates around 10%, but trauma specifically affecting more younger males, that's sort of a higher risk taking group. Now trauma population up to one fifth. So up to 20% of patients are HIV positive. Now, HIV, just like diabetes affect, affect your immune system and could potentially lead to more complications like infection.

So even though it's a large burden historically, there's very. Low levels of evidence guiding our treatment. And there was a lot of anecdotal treatment of HIV positive patients in a different way just based on perceived you know, perceived risk of infection. So, so we've done a lot of focus on, on showing that, you know both healing rates after the surgery for injury and as well, an infection rate is [00:06:00] not that different and not enough certainly to justify treating HIV positive patients different than any other, other patient that, that's really interesting reason I think like you, like, like you say. Is like, it's, it's really interesting about that, that burden in that lower sort of, particularly the more deprived patients, that higher rate of, of HIV infection, how you've gotta deal with that, but also that linked with the more complex injury often as well, which I think is a really interesting thing that you, you highlight there.

So Simon, maybe if I come to yourself, you know you know, there's sort of two papers here, but based on, on one study. So there was a paper looking at the lower limb long bone nailing and that aim to evaluate the outcomes of lower limb nailing for long bone fracture in South Africa and, and, and look at predictors of outcomes.

And then you've got the fracture-related infection paper that aim to look at whether a HIV infection is associated with FRI. In patients that undergo nailing for their lower limb fractures, and these were both part of the HOST study. So maybe for our listeners, can you give us maybe some background about the HOST study and what it entailed?

Yeah, sure. So the HOST study stands for the [00:07:00] HIV in Orthopaedic Skeletal Trauma Study. So it was a group of studies that was funded by the Wellcome Trust, who a big foundation based in the UK. And it came about, I was, I was working not in South Africa, actually in Malawi as a junior registrar.

Before I travelled to Malawi, I wanted to look at basically the cohort of patients I'd be seeing. And at the time there was quite a lot of information in and around HIV and as as Maritz said, a lot of it was anecdotal. So there's quite a lot of evidence published by different people, including The Bone & Joint Journal that said that people with HIV, this is sort of over ten years ago.

Don't heal up their bones and essentially get nonunions and also have a high rate of infections. And it was all anecdotal, but obviously 'cause we're orthopaedic surgeons, all the anecdotal evidence actually gets printed in textbooks. So if you looked up in Miller until 2015, it said the HIV's a risk factor for nonunion.

And if you went on Orthobullets, [00:08:00] the same would be said. But I was in Malawi and I was basically managing patients with HIV and they all seemed to be doing okay. So I did some research out there on, on bone infection. And again, it didn't show too much difference between the HIV positive negative patients, and I just thought, well, this is something that's unique.

Mm-hmm. I was interested in research, so I applied to a big funder, luckily got some money, and that formed the basis of, of the HOST study. And the main, the main focus of the HOST study was actually, was actually on non union. Okay. And produced a big study. Published it in a, in a, in a HIV journal actually, so a bit odd getting orthopaedic surgeons publishing information in the HIV journal, but it basically showed that that patients with HIV have no problem with bone healing.

And it changed the textbook. So if you look up on Orthobullets have just done, actually, it's been removed. And Millers again. You know it's been removed as well. So it's actually, you know, a relatively small [00:09:00] piece of work which has made a, a big impact. And through that funding that's what formed the basis of these two patients.

So the, the cohort of patients aren't identical, but it's the, the data collection processes were all funded through, through that through that stream. That's fantastic. Simon. I think, like you said, just being able to. Debunk some myths that are out there is, is, is absolutely awesome. I think that's, that's brilliant.

And so for the HOST study itself, just maybe to give our listeners, a bit of insight, you know, what, what was sort of the inclusion exclusion criteria for this, the studies and what were the interventions? And yeah, we had to think quite long and hard about it 'cause lots of the, lots of the studies in the past have looked at lots and lots of different injuries, but we wanted to be very focused to see if we could actually answer the question more accurately.

So we collected the information between September, 2017 and December, 2018 initially, and then it was extended for some of these studies and we decided to only include. Patients who'd undergone intramedullary [00:10:00] nailing of their femur and tibia. Mm-hmm. Mostly 'cause that was probably the best type or the most accurate type of fracture we could determine union accurately, accurately using x-rays patients over the age of 18.

So essentially adults, I. Exclusion wise, we excluded pathological fractures. Mm-hmm. Obvious reasons around healing. Yeah. intertrochanteric fractures of the femur, mostly due to issues assessing union of those fractures, brain injuries, burns, presurgical site infection, and any open fracture that basically presented over 24 hours, mostly due to issues of infection and also, patients who essentially we knew were never gonna come back. Yeah. Which was actually quite a small number of patients and that formed the, sort of the inclusion exclusion criteria. Yeah. And then the intramedullary nailing study that we're talking about, the data collection period was just extended a little bit longer to March, 2021.

That's, that's really interesting. And I think actually same that gives you that good insight into the, what Sithomobo was saying before about [00:11:00] actually that, that delay. So those patients who maybe had a delayed presentation, they're not. They're not part of the, the study cohort, is that correct? That's correct, yeah.

Which is, it's difficult, isn't it? When you're trying to design any form of study, ideally you'd, you'd include them, but the likelihood is. They'd have a higher chance of developing infection. So therefore it may, it may influence your, your results, but we had to, we had to basically have some form of cutoff and that was the decision we made at the time.

Yeah. But agree, it would've been ideal to, to, to include everyone on everyone, but you know, it's not always absolutely possible in these types of studies. Makes complete sense. So maybe Maritz, if I could sort of. Come to you. Sorry. Sorry Sithomobo, I'll come to you first. You know, in terms of what data you collected, what was the baseline, collective collected for the study in these papers in particular?

Right, so I mean, for the two papers we went quite broad with our, with our data collection, so I. We basically looked at, you know, patient demographics. Mm-hmm. We looked at injury characteristics that in terms of outcomes, looked at, you know, surgery [00:12:00] outcome and in, and infection outcomes specifically.

So for the demographics, you know, specifically we look at, at the patient's sex patient's age and whether or not they use alcohol. We look at smoking history and and whether they use steroids, which of course are the things that may affect fracture union. And we look at their HIV status and this was whether they're HIV positive or HIV negative, and if they're HIV positive, were they diagnosed.

During this particular hospital stay or do they know beforehand if they were HIV positive or not? And those were positive also whether they were on antiretroviral therapy or not. And importantly, we looked at the viral load. And we looked also at at the CD4 count. Mm-hmm. Then we looked again at things like patients' body mass index.

And also because, you know, we were looking at a cohort from a low- to middle-income country. We also, you know, have an interest on like just the, the [00:13:00] social side of the, of, of, of their history. And we sort of use the crowding index to determine where where they where they fit in. And that looks at the number of people that.

Number of people per room in the household. Yeah. Then we looked at the also functional scores like the the EQ-5D-3L . So we used that as well, where, and then looked up also looked at injury characteristics you know, mechanism of injury. Was it a fall from a high standing height?

Was it a blank fall from a height, high energy versus low energy? Was it a gunshot injury? And if it was assault it was assault with a blunt object or assault with a sharp object. I spoke about it earlier over said the gunshot injuries. If it was a motor vehicle crash, was it a pedestrian? Yeah, passenger or a driver.

And we know that I did allude to it earlier on that, you know, Africa has a low is the least motorised region in the world. So [00:14:00] you know, the few cars that are available, you know, tend to transport large number of people. So there are lots of passengers, far more than drivers. And also, I suppose as a function of a low- to middle-income country, we have a lot of.

Pedestrians that walk on the highways, and they also get knocked down by cars. So with the, so that's where the high proportion of tibia and femur injuries come from. And then we look at no other injuries sustained by the patient and if they have also other orthopaedic injuries. And then looking at, injury severity score. If it was lower than 16 or or above 16. Then we look at the open fracture characteristics, you know, how it was managed was it washed out, you know, and cluster cast applied. Was it washed and ex-fixed or washed? And and intramedullary nail. Then we look at the antibiotics, whether they were administered.

Preoperatively or only afterwards. And then lastly, we [00:15:00] look at the surgical outcomes there in terms of union, nonunion and malunion. And then also for infection outcomes. We collected data on whether it was early or late structurally related infection and whether it was superficial or deep infection.

So as you can see, we, we were quite comprehensive with our, with our data collection. And but. Yeah, a hundred percent. I mean, the, the, the, the baseline data, particularly like everything that's collected there is incredible, and you, you've touched briefly on the outcomes, but maybe Maritz, if I come to you just a bit more about the details of the outcomes that you guys collected and how they were sort of defined.

So first if we look at the outcomes of the lower limb long bone intramedullary lower nail fixation study we mainly looked at union rates and rates of infection. And when it comes to union, we looked at delayed union as in defined as, as not united in six months for a lower limb long bone fracture and.

nonunion is not united in nine months. Then we also looked at [00:16:00] infection rate. And infection was separated into early surgical site infection, which was before 90 days. And late infection after 90 days, basically using the CDC definitions, which was probably, you know, at the time of the study collection was the sort of standard definitions.

Definitions for these. So basically in the outcomes study we found, delayed union rates of around 18% and and nonunion rates of just under 6% and overall infection rate close. And open fractures combined earlier and later around 6%, which showed that in, in this population that was equivalent to sort of study populations published from high income settings.

In the, specifically looking at HIV we look, you know, we compared the early, late, and overall, infection rates [00:17:00] in the HIV positive and the HIV negative group. Of all the patients, I said just around 20% were HIV positive. And there was no significant difference in the early infections between the two groups.

But Interesting. And, and you know, contrary to. Sort of most recent literature, there was an increase in the late infection rate in the HIV study population, which sort of makes sense because, you know, HIV is a disease that affects your immune system just like diabetes. It, it. The degree to which it affects your immune suppression depends on how well it's controlled.

So, in other words, poorly controlled or poorly suppress, HIV, just like poorly controlled diabetes will have a greater effect. So that will lead you to think that you know, it might differ over time if patients compliance to treatment changes. So. It was quite a interesting and a little bit unexpected finding that it showed an increased late infection rate in the HIV positive [00:18:00] population.

Yeah. Thanks Maritz. And, and I think that that leads us in nicely to those sort of results and give those sort of headline overviews. Simon, if I could sort of maybe come back to you, 'cause obviously. Those are the sort of over sort of headline findings that, you know, Maritz has just highlighted. Is there any other particular findings in the, in the results that you'd want to highlight in any of the thing, particularly the analysis you performed?

'cause you did some regression analysis, didn't you as well? Yeah, I mean, everyone loves not really knowing what regression analysis is. Don't but essentially we use univariate and multivariate regression analysis. So univariate analysis, essentially you take an outcome, which we. You know, took as infection and then you compare it with a predictor, which you know could be HIV and just compare C of HIV as a risk factor for basically developing union.

The problem is that doesn't take into account lots and lots of other different confounding factors. So that's when you bring in multivariate analysis where you basically add in all the confounders and see if that predictor still impacts the [00:19:00] outcome and the outcome being for the HIV paper infection.

Mm-hmm. So that's what we did. The problem with regression analysis, you can only include a certain number of confounders before the whole thing explodes. So you can include sort of six or seven. So that's the problem with it. Yeah. What, one of the things, the analysis probably important to note is when you go through particularly the, not the HIV paper, but the, the outcome IM nail paper is that some of the, the, the, the.

The numbers, the, the number of missing data is reported in the, in the paper. But some of the figures don't add up essentially 'cause some of the patients just didn't have the data for. Yeah. So when you're reading it the reason why some of the figures were obviously up and down is because there, there was some missing data because these are an extremely difficult.

Patient group to follow up and we could maybe talk about the, the, the follow-up the follow-up right next potentially. Yeah, no, that, that'd be, that. That's exactly right. And I was hoping like you just sort of talk about how you did follow them up and then what, what was the data collection like, because obviously you collected outcomes scores as well.

Did you in [00:20:00] terms of PROMs as well. Yeah, so the, the data collection was, was hinged on, on, on people. So we, we basically had to employ really good people, and we had with two really good nurses, Nosipho and Nomsa. And they went above and beyond to actually follow these patients. So following patients up, I, I in, in, in a challenging environment.

Is is not easy. And it's very different to the UK where in all the trials we do in the UK, we get someone in an office to send them a message and they fill in a text message and give them a PROM and that's it. The, the nurses phone the patients several times a week, you know, several times over the weeks.

Yeah. They we paid them for their time. It was only a small payment, but we did, we reimburse their time. But in patients who essentially couldn't find you know, on some occasions the nurses got into taxis went to I. The region where patients were essentially homeless and physically found them on the street and brought them in a taxi to the outpatient appointments.

So that's sort of the, the length that [00:21:00] the nurses went to basically, you know, to follow up these patients. And because of the hard work of individuals that still work with us there, some of them are still research with nurses working in Cape Town now. The follow-up, the lost to follow-up rate, even after a year was, was less than 10%.

So it's pretty amazing. Really incredible. Certainly wouldn't get that in the UK. No, no. And that's amazing. And in terms of, just to highlight from, from the, the long bone paper that sort of, that finding of the overall health-related quality of life was comparable between the open and closed fractures.

I found that at the nine-month follow-up anyway, that was what, what was your sort of interpretation of that? I found that quite, quite interesting. 'cause obviously the nature of these open injuries is quite different than what we see here in the UK as well. Yeah. So it is interesting. So it could mean that basically they're all sort of okay.

Or it could mean the tool that we're using. Is isn't working or could be a, a, a bit of both. One of the challenges when you're filling out the forms is that, you know, if you ask if someone's okay, which essentially is what the EQ-5D is, [00:22:00] the majority of people say, say they're okay. So it could be the fact that these patients are recovering well, yeah.

It could be the fact that the tool isn't, doesn't work quite as good in this setting or it could be a combination of both. Yeah. But also if people don't recover, I. And if people don't go to work, yeah. The health system around them isn't as supportive as it is in the UK. So essentially they're not, they're not getting paid.

No. They can't feed their family. They can't feed themselves. So there's good motivation to essentially get better. Yeah. And maybe Maritz and Sithomobo could comment on that, but that could potentially be something which basically means that to a degree. Maybe patients do a little bit better because there's slightly more motivation to, to, to recover.

I dunno. Yeah. That's very interesting, isn't it, Simon? And that sort of takes me back to you Sithomobo maybe if I could actually, you know, sort of drawing all that data together from the two papers, you know, what do you feel the key take home clinical messages o of the studies are and, and the, and the real strengths of it, which are clear to me.

[00:23:00] Yeah. So look, and I think, you know, firstly, you know, it's important that the, the, these papers. Highlight the fact that, you know, high quality and high impact research can be performed in a low to middle income country. And and I mean this is like these are part of the largest studies that have been performed that look at clinical outcomes and and look at PROMs, you know, in patients with long bone fractures and that, you know, despite the challenges faced by low- to middle-income countries, the results are actually comparable to, you know, to what achievable in a higher income setting. And then secondly, you know, we've also, you know, provided new information and also, you know, added onto the existing body of knowledge for some of the known of a known science.

Mm-hmm. We've shown that, you know, HIV, you know, is a risk factor for late know, fractured-related infection. But we've also shown once again that, you know, whether you have HIV or not doesn't affect your rate of early, you know, fracture-related [00:24:00] infection. And also that, you know, if you look at, you know, gunshot injuries versus, open fractures from blunt trauma that gunshot injuries have a lower infection rate compared to co, compared to, to blunt trauma. And yeah, so I mean, I, I think probably the, the, for us, like the main highlight is that we've shown that HIV, you know, despite I think Maritz did allude to it earlier on, but despite previously published data, that the presence of HIV is a risk factor for late fracture-related infection.

And that's very good. So that leads me to you Maritz in terms of, you know, how do, how do you overall feel this data does fit with the current literature? And I suppose it's importantly, you know, how do you feel it fits with your practice? Is this what you sort of expected to see? I.

Yeah. So I think as I said, the results was a little bit unexpected and, and again, sort of other recent published literature. But it, I mean, it does make sense. If you think about it. I think it, it, it confirms with no, a difference in the early infection rate that there's [00:25:00] definitely not enough evidence to treat, to treat someone that's HIV positive different in the, in the acute setting.

So, you know, you can treat the fracture on its merit. It is something to be aware of than if you follow patients up that they might be more prone to late infections and, and may maybe help you to have a, you know to, to always keep it in mind. You see the patients in the future and, and, and, and treat accordingly.

So I don't think it's, it's sort of strong enough evidence to change practice. But it just sort of helps and forms our current practice, which we have as to in the acute setting. Certainly. It is something that we use to risk stratify a patient. But we don't treat any differently than an, than another patient.

Yeah, I totally agree, Maritz and I think that's the thing, isn't it? Is you, you can just, you how can, you can carry on and treating it as you would do normally, but just with that in the back of your mind, I, I think that's exactly how I interpret it. And so, Simon, if I can maybe sort of come to yourself now. And maybe sort of two questions just sort of to finish [00:26:00] up.

What do you, you know, as you said, you know, you designed this quite some time ago now. Do you any sort of limitations to you or anything you would want to change now? And then what does the sort of future hold? I. 'Cause this is such an amazing achievement, I think, in terms of what's been produced.

And it, and I think it gives us such valuable data that we just often don't, don't get. I think it's just such an amazing achievement. 'cause it's a very different patient population, very different mechanism of injury in all these things compared to what we see in, in sort of the, you know, the higher income countries.

Yeah, so, so I think that, I mean, I think it's a, isn't this a good question? I think it's from the, the two papers, you know, we've already spoke about what they show, but I think it's important to think about where the, the setting, you know, South Africa has, has amazing surgeons, amazing resources. But when you think about, you know, there's nearly 600 patients in the intramedullary paper.

Half of them were done. Outside of working hours. Yeah, a lot of them were done at nighttime. Yeah. And almost every single [00:27:00] one of them was done by a resident, or as we'd say, a registrar in the UK. And what the paper shows that the burden of injury is very high. A lot of these are, these are, these injuries are managed out of hours by trainees.

But actually when you look at the outcomes of the closed injuries, you look at the outcome of the open injuries, even in. That setting. The outcomes are basically the same as a high-income country. So that's something that's really positive. 'cause it sort of gives a benchmark for other countries and other institutes to show how, how well these, these injuries you know, can be managed in that setting.

Mm-hmm. And maybe it gives us something to think about in the UK that if the results are so. Similar you know, how are we managing them you know, in our country. Yeah. Yeah, absolutely. And the, with the HIV paper, I think it is probably important to highlight 'cause, you know, we are gonna come [00:28:00] across and manage patients with HIV in, in, in a trauma population, is that if you look into the results.

The, the late infection rate was higher, but actually a lot of those patients weren't on antiretrovirals. So if you look at late infection in particular if you are on antiretrovirals, it looks like your infection rate was probably actually similar to HIV negative patients. Mm-hmm. If you look at the cohort overall, so basically your risk of developing any infection, be that early or late HIV still showed an increased rate of infection.

An antiretroviral therapy wasn't actually protective for overall infection. Yeah, but certainly for late, if you are on antiretroviral therapy, you were probably okay. Whereas if you weren't your risk of getting an infection. You're not definitely gonna get an infection, but it's just higher. Yeah. Yeah. So I think for overall, for patients, 'cause essentially patients may listen to this, patients may read the paper.

You know, if you, if you and also surgeons [00:29:00] managing these injuries is gonna read the paper. If you are a patient with HIV or a surgeon managing h. Patient with HIV you know, you test their viral load, which shows how well the virus is being controlled. You test the CD4 count to see how their immune response is.

If they're on, if they're not on therapy, start them on therapy. If they're not on, if they are on therapy, just continue with therapy. Yeah. And then just treat them in a similar way to HIV negative patients. And just be aware of, of the risks moving forward. I think that's probably, yeah. Sort of an overall summary of the two papers.

Yeah. And then, and then moving forward as a group we're doing lots and lots of work in and around trauma. So we've, we've got a, large amount of funding from NIHR to establish a global injury group with, which is an NIHR Global Health Group. So the first global health group in orthopaedic trauma, which Maritz and Sithomobo are the lead investigators for and that's [00:30:00] looking at trauma across Tanzania, Malawi and South Africa.

Mm-hmm. Focusing on the burden of injury healthcare resources. How patients have managed their outcomes and looking at introducing feasibility trials. So we think about sort of the way forward with regards to trauma itself over the coming years. It's very exciting with the establishment in the global injury group.

So anyone can get in touch with, with with us about that. You can contact me, Sithomobo or Maritz and with regards to HIV, you know. There's been a lot of work in and around union. I think union question has probably been answered. There's lots of work around elective surgery, particularly on hip replacements, and I think, you know, again, you can manage HIV positive patients the same as HIV negative with regards to infection, the probably is an unanswered question there.

The problem with, to answer it. You're gonna need a lot of patience. Yeah, I totally agree. I totally agree. And you're gonna need a lot of money. Yeah, absolutely. Well, that's a really nice nice time place to wrap it [00:31:00] up, but, you know, congratulations to all three of you and, and the whole team, I mean.

What an amazing collaboration actually, the, the, the, the way that you're moving it forward as well with the NIHR Global Injury Group. And I think that's just such a positive thing and I think there's so much we can learn from that and actually so much positivity that can come out of it. And, and congratulations on two, two great studies that were published in the Journal and it was so nice to have you all with us.

And to our listeners, we do hope you've enjoyed joining us and we encourage you to share your thoughts and comments alike through our social media platforms. Feel free to post about anything we've discussed here today. And thanks again for joining us. Everyone. Take care.