Infection recurrence factors in one- and two-stage total knee prosthesis exchanges.

PURPOSE: Revision of infected total knee replacements (TKR) is usually delayed for a period in which the joint space is filled with an antibiotic-loaded acrylic spacer. In contrast, one-stage re-implantation supposes immediate re-implantation. Formal comparisons between the two methods are scarce. A retrospective multi-centre study was conducted to investigate the effects of surgery type (one-stage vs. two-stage) on cure rates. It was hypothesised that this parameter would not influence the results. METHOD: All infected TKR, treated consecutively between 2005 and 2010 by senior surgeons working in six referral hospitals, were included retrospectively. Two hundred and eighty-five patients, undergoing one-stage or two-stage TKR, with more than 2-year follow-up (clinical and radiological) were eligible for data collection and analysis. Of them, 108 underwent one-stage and 177 received two-stage TKR. Failure was defined as infection recurrence or persistence of the same or unknown pathogens. Factors linked with infection recurrence were analysed by uni- and multi-variate logistic regression with random intercept. RESULTS: Factors associated with infection recurrence were fistulae (odds ratio (OR) 3.4 [1.2-10.2], p = 0.03), infection by gram-negative bacteria (OR 3.3 [1.0-10.6], p = 0.05), and two-stage surgery with static spacers (OR 4.4 [1.1-17.9], p = 0.04). Gender and type of surgery interacted (p = 0.05). In men (133 patients), type of surgery showed no significant linkage with infection recurrence. In women (152 patients), two-stage surgery with static spacers was associated independently with infection recurrence (OR 5.9 [1.5-23.6], p = 0.01). Among patients without infection recurrence, International Knee Society scores were similar between those undergoing one-stage or two-stage exchanges. CONCLUSION: Two-stage procedures offered less benefit to female patients. It suggests that one-stage procedures are preferable, because they offer greater comfort without increasing the risk of recurrence. Routine one-stage procedures may be a reasonable option in the treatment of infected TKR. LEVEL OF EVIDENCE: III.

Unicompartmental knee arthroplasty modes of failure: wear is not the main reason for failure: a multicentre study of 418 failed knees.

BACKGROUND: This study originated from a symposium held by the French Hip and Knee Society (Société française de la hanche et du genou [SFHG]) and was carried out to better assess the distribution of causes of unicompartmental knee arthroplasty (UKA) failures, as well as cause-specific delay to onset. HYPOTHESIS: Our working hypothesis was that most failures were traceable to wear occurring over a period of many years. MATERIALS AND METHODS: A multicentre retrospective study (25 centres) was conducted in 418 failed UKAs performed between 1978 and 2009. We determined the prevalence and time to onset of the main reasons for revision surgery based upon available preoperative findings. Additional intraoperative findings were analysed. The results were compared to those of nation wide registries to evaluate the representativeness of our study population. RESULTS: Times to revision surgery were short: 19% of revisions occurred within the first year and 48.5% within the first 5 years. Loosening was the main reason for failure (45%), followed by osteoarthritis progression (15%) and, finally, by wear (12%). Other reasons were technical problems in 11.5% of cases, unexplained pain in 5.5%, and failure of the supporting bone in 3.6%. The infection rate was 1.9%. Our results were consistent with those of Swedish and Australian registries. DISCUSSION: Our hypothesis was not confirmed. The short time to failure in most cases suggests a major role for surgical technique issues. Morbidity related to the implant per se may be seen as moderate and not greater than with total knee prostheses. The good agreement between our data and those of nationwide registries indicates that our population was representative. A finer analysis is needed, indicating that the establishment of a French registry would be of interest.

[Dissociation of the acetabular metallic inlay of a metal-on-metal total hip arthroplasty]. / Dessertissage de l'insert métallique acétabulaire d'une prothèse totale de hanche à couple de frottement métal-métal.

Total hip arthroplasty was performed in November 2001 in a 30-year-old active patient with degenerative hip disease. A metal-on-metal bearing was used. Follow-up was considered excellent until the development of pain and squeaking at hip mobilization, leading to revision in March 2006. The acetabular metallic inlay of the metal-on-metal insert was found detached from the polyethylene insert; half of the diameter of the neck of the femoral stem was sectioned. Complete revision was performed with an acetabular graft. At one year follow-up, anatomic and functional outcome has been excellent. To our knowledge, this is the first report of this kind of mechanical failure of a metal-on-metal total hip arthroplasty.

Contribution of climate-driven change in continental water storage to recent sea-level rise.

Using a global model of continental water balance, forced by interannual variations in precipitation and near-surface atmospheric temperature for the period 1981-1998, we estimate the sea-level changes associated with climate-driven changes in storage of water as snowpack, soil water, and ground water; storage in ice sheets and large lakes is not considered. The 1981-1998 trend is estimated to be 0.12 mm/yr, and substantial interannual fluctuations are inferred; for 1993-1998, the trend is 0.25 mm/yr. At the decadal time scale, the terrestrial contribution to eustatic (i.e., induced by mass exchange) sea-level rise is significantly smaller than the estimated steric (i.e., induced by density changes) trend for the same period, but is not negligibly small. In the model the sea-level rise is driven mainly by a downtrend in continental precipitation during the study period, which we believe was generated by natural variability in the climate system.

Sea level rise during past 40 years determined from satellite and in situ observations.

The 3.2 +/- 0.2 millimeter per year global mean sea level rise observed by the Topex/Poseidon satellite over 1993-98 is fully explained by thermal expansion of the oceans. For the period 1955-96, sea level rise derived from tide gauge data agrees well with thermal expansion computed at the same locations. However, we find that subsampling the thermosteric sea level at usual tide gauge positions leads to a thermosteric sea level rise twice as large as the "true" global mean. As a possible consequence, the 20th century sea level rise estimated from tide gauge records may have been overestimated.

Mammographic pattern due to residual Lipiodol after galactography.

The purpose of this pictorial essay is to describe the different mammographic aspects of residual Lipiodol ultra fluid (LUF) after galactography, and to define some specific patterns, because it may in some cases mimic microcalcifications and give diagnostic problems. The mammograms of 14 patients, aged 32-63 years, presenting LUF residues related to previous galactography, were analyzed retrospectively. In 12 cases the diagnosis was easy because the patients presented a typical pattern on mammography and came with their initial galactography. In 2 cases the diagnosis was more difficult because the patients did not remember the previous injection and the progressive resorption mimicked perfectly intraductal calcification. Benign duct ectasia with inflammatory reaction to foreign bodies were found in 3 cases in which surgery was performed. Lipiodol ultra fluid is no longer used for galactography, but it may persist in breast ducts or cysts for years and seems to still be used in some countries. There are in most cases specific signs enabling the diagnosis.

[Malignant angular cheilitis]. / Queilitis angular malignizada.

A case of chronic angular cheilitis is reported. Candida albicans was isolated repeatedly and the process developed into epitheliomatous carcinoma. The etiopathogenic role of Candida albicans and possible mechanism of action are discussed.

[Reconstruction of the anterior cruciate ligament with artificial ligament (Ligastic). Clinical results in 72 patients]. / Reconstruction du ligament croisé antérieur avec un ligament artificiel (Ligastic). Résultats cliniques de 72 patients.

INTRODUCTION: The purpose of the study was to evaluate the anatomical and functional results of Anterior Cruciate Ligament reconstruction with the synthetic ligament Ligastic. MATERIAL AND METHODS: 72 patients have been reviewed clinically and radiologically and their functional abilities have been evaluated with Lysholm and Arpege score. 46 have been operated for recent ruptures (group A) and 26 for chronic ACL tears (group B). Follow up was 2 to 4,5 years. RESULTS: The results showed in group A a Lachman test > 3 mm in 57 per cent cases, a positive pivot shift in 29 per cent and ruptures of the ligament in 22 per cent. In group B, the Lachman test was > 3 mm in 47 per cent of the cases the pivot shift was positive in 54 per cent and the rupture of the ligament occurred in 35 per cent. The functional evaluation showed that only one third was stable but painful, and one third was unstable and painful. DISCUSSION: As many authors, we found an increase of bad anatomical and functional results with time. The ligament can't be considered as a scaffold for ingrowth tissue. Two thirds of the patients had painful knees at effort. CONCLUSION: The high percentage of ruptures of the ligament, and the non satisfactory functional results led us not to recommend the ACL reconstruction with a Ligastic implant.

[Recent ruptures of the anterior cruciate ligament. Suture technique on a reinforcement ligament. Results of a 5 years' experience]. / Ruptures récentes du ligament croisé antérieur. Technique de suture sur ligament de renfort. Résultats après cinq ans d'expérience.

225 patients with acute rupture of the anterior cruciate ligament were operated upon with a knitted polyester synthetic ligament (Ligastic) reinforced by a suture of the anterior cruciate ligament remnant. Five technical points must respected during the implantation of the ligament: isometry, direction of the femoral and tibial tunnels, absence of abrasion of the ligament in the notch, tensioning of the synthetic ligament equal to the natural cruciate ligament, careful suture of the remnants of the ruptured anterior cruciate around the synthetic ligament replacement. The functional results, according to the rating system of ARPEGE, demonstrated 8.6 on the stability scale, 8.1 for pain, 8.7 for mobility; 87 per cent of the competitors were able to return to their sport at the same level. There were no cases of acute synovitis. The patients were separated into three groups for evaluation: Group I--More than three years follow-up. Group II--More than two years follow-up. Group III--Less than two years follow-up. An anterior drawer test of less than 5 mm was observed in 85 per cent of Group I, 88 per cent of Group II, and 87 per cent of Group III. A negative jerk test was noted in 92 per cent of Group I, 95 per cent of Group II and 95 per cent of Group III. These differences were not statistically significant. On follow-up, a Lachman test of less than 5 mm was found respectively in 37 per cent, 70 per cent and 79 per cent; this difference was statistically significant. The relatively mediocre results of the Lachman test in Group I led us to follow a more precise isometric method. Postoperative cases were reexamined and demonstrated that the artificial ligament had become covered with an oriented fibrous tissue. The long-term outlook also depended on a successful restoration of proprioception in the repaired remnant of the anterior cruciate.

[Post-traumatic hemarthrosis of the knee and arthroscopy. Review of 161 cases]. / Hémarthroses post-traumatiques du genou et arthroscopie. Revue de 161 cas.

In a prospective study, 161 traumatic hemarthrosis of the knee had clinical, radiological and arthroscopic examination. The anatomical lesions were diagnosed clinically and radiologically in 78%, but was incomplete every other time. Arthroscopy allowed us to confirm, to complete or to do the exact diagnosis in 98%. Anatomical lesions were never benign: ligaments ruptures (65%), patella dislocations (20.5%), chondral lesions (41%), meniscal lesions (31%). The main interest of arthroscopy is to precise associated lesions and thus, to use these data for a rational treatment program. Most often, the treatment has been performed by arthroscopic techniques, avoiding arthrotomy and shortening post operative rehabilitation. No complication due to arthroscopy has been noted. This study confirms: (1) that a traumatic hemarthrosis indicates a serious knee injury, and (2) the important contribution of arthroscopy for diagnosis and treatment of these traumatic knees.

[Reconstruction of the anterior cruciate ligament. Determination of the pre- and peroperative femoral isometric point]. / Recontruction isométrique du ligament croisé antérieur. Détermination pré et per-opératoire du point fémoral.

This study attempted to determine the femoral isometric site by a simple, reliable and easily reproducible technique for the reconstruction of a torn anterior cruciate ligament (A.C.L.). Anatomoradiological studies showed that the posterior border of the lateral condyle corresponded with the third of a circle and that the center of this circle was named the "isometric point" (F). The variations of the intra-articular length of a ligament between the point F and the center of the A.C.L. tibial attachment did not exceed 2 mm. A radiological study on 50 normal patients knees X-Rayed at 0 degree and 90 degrees of flexion showed a length dependence of 1.5 mm in 84% and 2 mm maximum in 98%. Twenty patients with acute or chronic A.C.L. rupture were operated on; the isometric point F was determined by superimposing a template of circles on the posterior border of the condyle. An original guide allowed to drill a bony tunnel with a pin emerging at the exact previous point F. A per-operative X-Ray studied the good reliability of this guide. The measurements of the variations of length of the ligament between 0 degree and 110 degrees of flexion varied less than 5% in 18 patients, which confirms the good isometry of the reconstruction. On the basis of these data, we propose to improve the implantation of autogenous or synthetic ligament in A.C.L. reconstruction by the use of a pre-operative determination of the isometric femoral point and the use of a guide able to drill easily a bony tunnel at this exact pre-determined point.