Treatment outcomes of patients with Cutibacterium acnes-positive cultures during total joint replacement revision surgery: a minimum 2-year follow-up.

INTRODUCTION: Periprosthetic joint infection (PJI) is a devastating complication following total joint replacement (TJR). Cutibacterium acnes (C. acnes) is a low virulent skin commensal, commonly found during TJR revision surgery for "aseptic" causes. The purpose of the present study was to report the treatment outcomes of patients with C. acnes contamination or infection in the presence of a TJR treated with a revision surgery ± implant exchange ± prolonged (≥ 8 weeks) postoperative antibiotics. METHODS: Medical records of patients with at least one positive C. acnes culture in intraoperative tissue samples or sonication fluid from a TJR revision surgery between January 2005 and December 2014 were retrospectively evaluated. The primary endpoint was infection eradication according to Delphi criteria. The diagnostic accuracy of preoperative TJR aspiration regarding the diagnosis of C. acnes PJI was also investigated. RESULTS: A total of 52 TJR (28 shoulders, 17 hips, 7 knees) in 52 patients (35 males, 17 females) with an average age of 63 ± 11 (33-86) years were included. At an average follow-up of 67 ± 33 (24-127) months, the infection eradication of C. acnes PJI was 97% regardless of the surgical treatment or administration of prolonged postoperative antibiotics. The incidence of unsuspected C. acnes PJI was 28.8%. The sensitivity and specificity of preoperative joint aspiration in detecting C. acnes PJI were 59% and 88%, whereas the PPV and NNV were 83% and 67%, respectively. CONCLUSION: Infection eradication of C. acnes PJI was very high at a minimum follow-up of 24 months, suggesting that C. acnes PJI could be adequately treated with a combination of revision surgery and prolonged postoperative antibiotics. The preoperative diagnosis of C. acnes PJI might be challenging with more than one-quarter of patients presenting without suspicion of C. acnes PJI. The appropriate treatment of patients with a single positive culture remains still unclear. A negative TJR aspiration should not rule out a C. acnes PJI, especially in the presence of clinical correlates of infection. LEVEL OF EVIDENCE: Retrospective case-control study, Level III. IRB APPROVAL: Kantonale Ethikkommission Zürich, BASEC Nr.:2017-00567.

[Dental ankylosis diagnosed by CT with tridimensional reconstructions]. / L'ankylose dentaire: diagnostic par tomodensitométrie et reconstruction tridimensionnelle.

The etiology of unerupted teeth often is difficult to establish. It may relate to abnormal orientation of the tooth bud, an anatomical obstacle, pathology of the dental sac or ankylosis. The ankylosis process and diagnosis are analyzed in this clinical series. Ankylosis and its underlying physiological process are abundantly described in the literature. Nonetheless, diagnosis remains difficult to achieve. Clinical evaluation and complementary radiographic techniques such as dental radiographs and orthopantomogram are considered by some authors as poorly reliable. These clinical examinations based on a series of subjective criteria cannot be performed on unerupted teeth. In a series of patients with unerupted or retained teeth of undetermined etiology or with traction failure, 15 were diagnosed with ankylosis. The diagnosis of ankylosis could not be achieved based on clinical or radiographic evaluation and required CT imaging. Source images along with tridimensional reconstructed images were evaluated using the MVS software (Hospices Civils of Lyon). The radicular volume involved by ankylosis could be measured and its exact location on the tooth could be demonstrated. This imaging technique with tridimensional reconstruction provided positive diagnosis of ankylosis.

Diffusion-weighted MR imaging for evaluation of pediatric recurrent cholesteatomas.

OBJECTIVE: To compare the efficiency of diffusion-weighted MR imaging (MRI) vs. high resolution CT in predicting recurrent or residual cholesteatoma in children who underwent prior middle ear surgery. DESIGN: Prospective study. SETTING: Tertiary care university hospital. PATIENTS: Seventeen patients (4 with 2 recurrences) aged 5-17 years (mean 11.4) previously surgically treated for a cholesteatoma of the middle ear, were included for follow-up with systematic CT scan and MRI, between 2005 and 2007. METHODOLOGY: CT scan was performed on a Siemens Somaton 64 (0.5/0.2 mm slices reformatted in 0.5/0.3 mm images), parallel and perpendicular to the lateral semi-circular canal for each ear (100 mmx100 mm FOV). MRI was undertaken on a Siemens Avanto 1.5 T unit, with an adapted protocol for young children. Diagnosis of recurrent cholesteatoma was based on the evidence of a hyperintense image at B1000 on diffusion-weighted images. Results of CT scan and MRI were compared with operative diagnosis. RESULTS: Nine patients had a positive MRI, among which 8 had cholesteatoma confirmed during revision surgery. In the 12 negative MRI cases, 5 were positive on revision surgery. None of these lesions was over 3mm. Two of them were diagnosed on the CT scan. CT scan alone had a positive predictive value of 75%, and a negative predictive value of 58%. CONCLUSION: Diffusion-weighted MRI is associated with a high positive predictive value for the detection of recurrent cholesteatoma. CT scan remains the first choice imaging technique. In case of doubtful CT scan, diffusion-weighted MRI could confirm a recurrence or, when negative, avoid second-look surgery.

[Evaluation of 3D imaging software to study computed tomography images of middle ear defects]. / Evaluation d'un logiciel de reconstruction 3D à l'étude TDM des malformations de l'oreille moyenne.

OBJECTIVE: Evaluate the contribution of original 3D reconstruction software based on the principle of region growing segmentation of CT images to diagnosis of ossicular malformations of the middle ear. METHOD: Prospective study on a population of ten patients presenting uni- or bilateral transmission deafness. Twenty ears were studied using multislice CT. All the data were treated using original software segmentation based on the principle of region growing segmentation. The 3D images were compared with the original CT slices to judge the software's potential contribution to the management of these patients. RESULTS: All the images obtained were deemed of sufficient diagnostic quality. The two normal ears on the CT slices were also found to be normal on the 3D images. Typical CT images of otospongiosis found in two patients were not visible on the 3D images. The 18 ossicular malformations were well analyzed on the images obtained, which also provided better visualization of the abnormalities and associated lesions (particularly the anomalies in facial nerve position), thus providing quality surgical planning as judged by the surgeon. CONCLUSION: The image reconstruction method studied, using region growing segmentation seems to be, in this limited sample, a useful complement to classical CT images in the study of constitutional abnormalities of the middle ear.

[Osteonecrosis of the jaw and biphosphonates: imaging features]. / Ostéonécrose de la machoire sous biphosphonates: aspects radiologiques.

PURPOSE: 1) To review the pathophysiology of osteonecrosis of the jaw in patients receiving biphosphonates. 2) To review the imaging findings of osteonecrosis of the jaw and attempt to define pathognomonic imaging features. Materials and methods. Retrospective study of 15 patients with metastatic disease treated with biphosphonates. All available imaging studies including orthopantomograms, CT and bone scans were reviewed simultaneously by two radiologists (FO, DB). RESULTS: The most frequent imaging finding was osteolysis. Signs of biphosphonate impregnation were frequently observed: areas os osteosclerosis or heterogeneous demineralization due to abnormal bone remodeling. The outer cortex appeared duplicated in one case. Complications including fracture, sequestra, oroantral fistula and sinusitis may also occur. CONCLUSION: The imaging features of osteonecrosis remain fairly non-specific. Drug-related osteonecrosis of the jaw should nonetheless be suggested in the appropriate clinical setting in the presence of osteolysis associated with osteosclerosis. Imaging is helpful to assess the extent of the disease and detect complications for improved patient management.

Management of haemophilic arthropathy.

Despite the tremendous benefit offered by primary prophylaxis, recurrent joint bleeding with progression to chronic synovitis and haemophilic arthropathy is still a daily concern for the multidisciplinary health care teams managing patients with severe haemophilia or haemophilia complicated by inhibitor development. Advanced stages of arthropathy could be prevented by regular assessment of musculoskeletal status and thus early detection of symptoms, daily rehabilitation exercises at home, and implementation of appropriate physiotherapy and medical training. Patient's education and psychological counselling are crucial. New tools such as magnetic resonance imaging are promising for the monitoring of these patients and might promote early detection of arthropathy and thus appropriate preventive measures to avoid further joint deterioration can be implemented. Medical synovectomy such as radionucleide synoviorthesis is a simple and non-invasive procedure that often delays the need for surgery which despite considerable improvement in techniques and postoperative rehabilitation remains a high-risk strategy in patients with severe haemophilia, especially those with inhibitors. In these high risk patients, availability of specific clotting factors such as activated prothrombin complex concentrate (FEIBA, Baxter, Vienna, Austria) and more recently, recombinant factor VIIa (rFVIIa, NovoSeven, Bagsvaerd, Denmark) has allowed to perform effective and safe orthopaedic procedures. The on-going EUREKA study will undoubtedly provide additional information about the optimal use of rFVIIa in this context.

Three-dimensional modeling system for unilateral mandibular bone distraction: a clinical case.

Facial hemiatrophies are anomalies of the first branchial arch and affect one in 4000-5000 newborns. Bone distraction is the technique of choice for the treatment of these dysmorphoses. Mandibular osteodistraction requires prior determination of the characteristics of the distraction vector whose three components will serve to activate the distractor. The patient, aged 5 years, presented with a right facial hemiatrophy, Grade IB according to the classification of Pruzansky. Tomodensitometric acquisition was obtained with a CT scanner. Software specifically designed for this application allows segmentation of the anatomical elements by a region-growing algorithm. The 3D representation of each element is added to a 3D scene, in which are placed the built-up landmarks necessary for the surgical simulation after 3D cephalometric analysis. The surgical cleavage plane is oriented according to the surgeon's requirements while preserving the predominant anatomical elements. The software allows performance of rotations and translations of the bone segments rendered independently from the cleavage plane. The distances and angles covered during the virtual movement are measured at its conclusion. The aim of moving the bone segments is to render the mandibular occlusion plane parallel to the reference occlusion plane. The vertical growth of the maxilla is realized by secondary recuperation. The distractor used was of an external multidirectional type allowing elongation of the mandibular ramus and mandibular corpus, closure of the goniac angle, and lateralization or medialization of the ramus. On the 15th day, the mandibular angle was reduced by 10 degrees, which allowed closure of the anterior gap and recentering of the incisive areas by a half-cuspid. The patient presented with a complex bone deficit in the three spatial directions, which allowed the development of software for modeling the distraction. Other clinical cases will be necessary to validate this 3D imaging-based technique.

Case report 801: Osteoid osteoma of the coccyx.

In summary, a typical osteoid osteoma in the coccyx in a 13-year-old boy has been presented-a unique location. The clinical, radiological, and pathological aspects of osteoma are summarized. The relationship of osteoid osteoma to osteoblastoma is stressed; it is also stressed that the occurrence of osteoid osteoma in the coccyx is most unusual.

[Diagnosis of acute infectious epidural inflammation. Role of magnetic resonance imaging]. / Diagnostic des épidurites aiguës infectieuses. Place de l'imagerie par résonance magnétique.

External pachymeningitis, usually caused by Staphylococcus aureus, is a rare pathological entity which is difficult to diagnose at an early stage, has a poor functional prognosis and often requires an emergency surgical treatment. We report three cases in which magnetic resonance imaging provided an early diagnosis of the epidural space infection before severe neurological deficits, such as paraparesis and/or paraplegia, set in. Following an anti-staphylococcal treatment with fluoroquinolone and beta-lactamase-resistant beta-lactam antibiotics with good bone penetration administered intravenously during 4 to 6 weeks, then orally for 5 to 6 months cure without functional sequelae was obtained in all three patients.

Haemorrhagic complications of intracerebral cavernomas: value of MRI.

The authors report a retrospective series of 10 cases of intracerebral haematomas consecutive to cavernomas and studied with MRI. The factors that led to the MRI study were the patients' age and clinical history, the site of the haematoma, the persistence of CT images and a negative arteriography. MRI showed that the haematoma was in contact with the cavernoma in 4 cases and at a distance from it in one case. In 5 cases only the cavernoma was seen at the site of the haematoma. Three patients had multiple cavernomas. In all cases, the diagnosis of cavernoma was confirmed at surgical excision.

MRI and CT in a case of pituitary abscess.

We report the case of a woman admitted for hypopituitarism of sudden onset, in whom conventional radiography, CT and MRT suggested a pituitary tumour with supra- and intrasellar extensions. The surgical findings and the clinical course under antibiotic therapy transformed this diagnosis into one of pituitary abscess by a pyogenic micro-organism. Pituitary abscess is an exceptional lesion. Despite the advent of CT and MRI, its preoperative diagnosis remains difficult. However, the presence of an intrasellar expansive process with liquid centre and contrast-enhanced outline should suggest the possibility of an abscess, particularly when the pituitary lesion is associated with a sphenoidal sinus effusion.

Osteoid osteoma: CT-guided percutaneous treatment.

Seven patients with presumed osteoid osteoma were treated with percutaneous destruction or drill resection with computed tomographic (CT) guidance. The diagnosis of osteoid osteoma was made on the basis of findings in the clinical history and results at plain radiography, bone scintigraphy, and CT. In four patients, histologic confirmation was obtained. Hospital stay lasted from 1 to 3 days. After 11-38 months of follow-up examinations, all patients were asymptomatic. The authors report this simple procedure as an alternative to the more traditional open surgery technique.

[A rare bone abnormality: intra-bone synovial cyst. Apropos of a case]. / Une anomalie osseuse rare: le kyste synovial intra-osseux. A propos d'un cas.

One case of intraosseous ganglion is reported and compared with a review of the literature. The clinical findings, the physiopathological and radiological patterns are discussed as well as the differential diagnosis.

[Dural fistula of the lateral sinus. Apropos of 2 recent cases]. / Fistule durale du sinus latéral. A propos de deux observations récentes.

On the basis of two recent cases of dural fistula of the lateral sinus, the authors review the literature relating to this type of arteriovenous fistulae. The development of selective arteriographic techniques has allowed better knowing them, ensurgin the diagnosis and also treating them with embolization techniques. The role of the ENT specialist is no less important: during the clinical stage, it for him to recognize the pulsatile character of a tinnitus and to demonstrate it in order to establish the diagnosis.

[2 cases of neurinoma of the mastoidal portion of the facial nerve: diagnostic contribution of MRI]. / A propos de deux cas de neurinomes de la portion mastoïdienne du nerf facial: apport diagnostic de l'IRM.

The authors report 2 cases of patients presenting a neurinoma of the 3rd portion of the facial nerve. In the 2 cases, the surgical observations correlated perfectly with the results of the radiological examinations (scanner and MRI). The clinical and paraclinical presentation of this rare tumor is recalled, emphasizing the additional contribution of imaging techniques: the scanner is indeed indispensable for evaluating the osseous destructions on the intrapetrous trajectory of the facial nerve, whereas MRI (in particular with injections of gadolinium) evaluates the exact tumoral limits as best as possible.

[Magnetic resonance imaging in the evaluation of malignant melanoma of the choroid and ciliary body]. / Apport de l'imagerie par résonance magnétique dans l'évaluation des mélanomes malins de la choroïde et du corps ciliaire.

We evaluated 16 patients with malignant melanomas of the choroid (11) or the ciliary body (5) by magnetic resonance imaging (MRI), using a 0.5 T magnet and a surface coil. The tumor was seen in all cases, hyperintense in T1-weighted images, and hypointense in T2-weighted sequences (80%). These images reflected the short T1 and T2 relaxation times caused by the presence of melanin in those tumors. This non-invasive method was superior to computed tomography (70%), and sometimes superior to fundoscopy (2 cases), angiofluorography (3 cases) or echography (1 case). MRI also proved valuable for differentiating uveal melanoma from associated subretinal effusion.