Between September 2004 and December 2005 we carried out a prospective study of all cases of sepsis of the hip in childhood at a South African regional hospital with a large local population, and which also took referrals from nine rural hospitals. The clinical, radiological, ultrasound and bacteriological features were assessed. All the hips were drained by arthrotomy and the diagnosis was confirmed microbiologically and histologically. Hips with tuberculosis were excluded. The children were reviewed in a dedicated clinic at a mean follow-up of 8.1 months (3 to 18). There were 40 hips with sepsis in 38 patients. Two patients were lost to follow-up. Nine (24%) had multi-focal sepsis. Overall, 13 hips (34%) had a full and uncomplicated clinical and radiological recovery and 25 (66%) had complications. All patients treated by arthrotomy and appropriate antibiotics within five days of the onset of symptoms had an uncomplicated recovery. Initial misdiagnosis was associated with a delay to arthrotomy. However, 'deprivation', consultation with a traditional healer, maternal educational attainment and distance to a primary health-care facility were not associated with delay to arthrotomy. The early correct diagnosis of this condition, common in the developing world, remains a significant factor in improving the clinical outcome.

We compared early post-operative rates of wound infection in HIV-positive and -negative patients presenting with open tibial fractures managed with surgical fixation. The wounds of 84 patients (85 fractures), 28 of whom were HIV positive and 56 were HIV negative, were assessed for signs of infection using the ASEPIS wound score. There were 19 women and 65 men with a mean age of 34.8 years. A total of 57 fractures (17 HIV-positive, 40 HIV-negative) treated with external fixation were also assessed using the Checkett score for pin-site infection. The remaining 28 fractures were treated with internal fixation. No significant difference in early post-operative wound infection between the two groups of patients was found (10.7% (n = 3) vs 19.6% (n = 11); relative risk (RR) 0.55 (95% confidence interval (CI) 0.17 to 1.8); p = 0.32). There was also no significant difference in pin-site infection rates (17.6% (n = 3) vs 12.5% (n = 5); RR 1.62 (95% CI 0.44 to 6.07); p = 0.47). The study does not support the hypothesis that HIV significantly increases the rate of early wound or pin-site infection in open tibial fractures. We would therefore suggest that a patient's HIV status should not alter the management of open tibial fractures in patients who have a CD4 count > 350 cells/μl.

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.

Although the distribution of polyps in the colon in cases of familial polyposis coli may be variable', it is generally supposed that the rectum is never spared in this disease'. We report a case of familial polyposis coli, with a strong family history, in which the rectum was spared. Case reportW.M., a 55-year-old housewife was admitted with a history of 24 hours of severe abdominal pain. She complained of 1 month of alteration of bowel habit, but there was no other history of bowel dysfunction. Examination showed diffuse peritonitis, and at laparotomy she was found to have faecal peritonitis due to a perforated carcinoma of the mid sigmoid colon. The sigmoid colon was resected and a Paul-Mickulicz double-barrelled colostomy was fashioned. The resected sigmoid colon contained a Dukes' C1 adenocarcinoma and 38 adenomatous polyps. A diagnosis of familial polyposis coli was made. Three weeks later, when she had recovered from this operation, she underwent sigmoidoscopy which showed that there were no polyps in the rectum to 15cm. Colonoscopy was later performed through both limbs of her doublebarrelled colostomy. In the distal limb this confinned the absence of rectal polyps, but showed five polyps in the residual lower sigmoid adjacent to the stoma. The proximal colon had multiple polyps from the hepatic flexure to the stoma. She therefore underwent subtotal colectomy and ileo-rectal anastomosis 2 months after her initial operation. She recovered well, but died of carcinomatosis 5 months later.Other members of her family have been subsequently investigated and her family history is illustrated in Figure 1.