Management of established pressure ulcer infections in spinal cord injury patients.

OBJECTIVES: Pressure ulcers are frequently observed in spinal cord injury (SCI) patients. They can be life-threatening and are a major medico-economic burden. Despite their frequency, their pathophysiology and optimal management are still poorly understood. Most available data comes from non-comparative studies, especially in terms of antimicrobial use. METHODS: We performed a critical review of the literature and opinions of infectious disease specialists based in a French expert center for this disease. We mainly focused on antimicrobial treatments prescribed in this situation. RESULTS: These infections are usually clinically diagnosed. Microbiological samples are not the gold standard for this assessment. Furthermore, reliable microbiological identification is a major challenge but should help select antimicrobial treatment. Imaging technique could be helpful but cannot replace the physical examination. The choice of antimicrobials must consider the potential ecological collateral damages in this vulnerable population. Antimicrobial therapy should be as short as possible, adapted to the microbiological identification, and must have suitable bioavailability. CONCLUSION: Management of infected pressure ulcers is a major concern in disabled patients already highly exposed to antimicrobial treatment and multidrug-resistant organisms colonization. Extensive data is required.

Treatment of infected non-unions of the femur and tibia in a French referral center for complex bone and joint infections: Outcomes of 55 patients after 2 to 11 years.

INTRODUCTION: An infected non-union is a major complication following bone fracture. While bone union can be obtained in 70% to 100% of cases, treatment of osteomyelitis is less predictable, with reported healing rates ranging from 40% to 100%. The primary aim of this study was to assess the success rate of treating infected non-unions of the tibia and femur by a team specializing in complex bone and joint infections. MATERIAL AND METHODS: This single-center retrospective study included all patients operated between 2002 and 2012 due to an infected non-union of the femur or tibia using standardized surgical methods. The procedure was typically done in two phases: excision of the infected site and stabilization, followed by bone reconstruction after a waiting period. Additional procedures (lavage and/or bone grafting) were performed in some cases. A minimum 6-week course of antibiotic therapy was given. The primary endpoint was successful medical and surgical treatment after a minimum 2 years' follow-up defined as healing of the infection (no local clinical signs of infection, ESR≤20mm and CRP≤10mg/L, no mortality attributed to the infection) and radiological and clinical bone union, with the lower limb spared. RESULTS: Fifty-five patients (39 men, 16 women) were included with an average age of 37±11 years. There were 40 tibial fractures and 15 femur fractures. A polymicrobial infection was present in 47% of cases. Repeat surgery was required in 56.4% of patients. At an average of 4±2 years from the first surgical procedure, the treatment was successful in 49 patients (89%): 36 tibia (90%) and 13 femur (87%). The mean time to union was 9±4 months. There were six failures: 3 amputations at 5, 6 and 16 months; 1 mechanical and infection-related failure; 2 failed union. CONCLUSION: This study found that 89% of patients with an infected tibial or femoral non-union treated by a team specialized in complex bone and joint infections using a standardized surgical protocol had bone union and healing of the infection in an average of 9 months. LEVEL OF EVIDENCE: IV, retrospective study.

Diagnosis of prosthetic joint infection by beadmill processing of a periprosthetic specimen.

We report a microbiological process for the documentation of prosthetic joint infection (PJI). Intraoperative periprosthetic tissue samples from 92 consecutive patients undergoing revision surgery for PJI were submitted to mechanized beadmill processing: specimens were aseptically collected in polypropylene vials, filled with sterile water and glass beads and submitted to mechanized agitation with a beadmill. The documentation rate of PJI following culture on solid and liquid media was 83.7% and the contamination rate 8.7%. Final documentation was obtained after overnight culture for 51.9% of cases and with 7 days of broth culture for all documented cases.

Arthroplasty following a septic arthritis history: a 53 cases series.

INTRODUCTION: The most feared complication of arthroplasty after septic arthritis (active or quiescent) on a degenerative joint is septic failure, but this risk is difficult to assess. The aim of the present study was to analyze the results of arthroplasties after septic arthritis of native knee and hip joints, in terms of functional results and infection control and to seek eventual risk factors of failure. PATIENTS AND METHODS: Fifty-three cases of septic arthritis treated by arthroplasty (31 knees and 22 hips) were retrospectively included. In case of evolutive septic arthritis (30 cases: 17 knees and 13 hips) failing to react to conservative treatment, arthroplasty was performed in a 2-stage procedure (a mean interval of 6 weeks between stages, and an associated antibiotic therapy for a mean 3 months were routinely respected). In case of previous arthritis considered to be cured (23 cases: 14 knees and nine hips), arthroplasty was performed with a 1-stage procedure, observing a mean interval of 5 years after the initial septic arthritis, and antibiotic therapy maintained until definitive microbiological results were obtained from joint cultures samples at surgery. No patients were lost to follow-up; minimum follow-up was 2 years, for a mean of 5 years. The final results were assessed in terms of functional outcome (on PMA functional score for hips and IKS score for knees) and successful eradication of infection. RESULTS: Two-stage arthroplasty was successful in 26 of the 30 cases of evolutive septic arthritis (87%), while the 1-stage procedure was successful in 22 of the 23 cases of quiescent septic arthritis (95%) (NS). Functional results were very good. No significant difference in functional outcome or successful eradication of infection was found between the 1- and 2-stage procedures. No significant difference in final outcome in terms of infection eradication was found between knees and hips. No clinical, microbiological or treatment-related criteria emerged as risk factors for septic failure. DISCUSSION: Arthroplasty after septic arthritis of the knee or hip using the present protocol (2-stage implantation in case of evolutive septic arthritis and a 1-stage procedure in case of quiescent septic arthritis) achieved very good functional results with a success rate of 87% for sepsis control in evolutive septic arthritis and of 95% in quiescent septic arthritis. LEVEL OF EVIDENCE: Level IV retrospective or historical series.

First metatarsophalangeal joint percutaneous arthrodesis.

UNLABELLED: The aim of this work is to describe a percutaneous technique of first metatarsophalangeal (MTP1) joint fusion and to assess its preliminary results. Thirty-two percutaneous MTP1 joint arthrodeses were analysed in a prospective continuous series including 30 patients of mean age 66 years old. The indications for arthrodesis of the MTP1 joint were symptomatic hallux rigidus or hallux rigido-valgus in most of the cases. All patients underwent the same percutaneous procedure, as a one-day surgery for 26 cases. Clinical results were assessed using the functional AOFAS forefoot scoring system both preoperatively and at last follow-up. Radiographical analysis was focused on positioning and quality of the arthrodesis. No patient was lost to follow-up and the mean follow-up was 18 months. The functional AOFAS score improved in all cases from a mean 36/100 preoperatively to a mean 80/100 postoperatively (p=0.02). In 30 cases, patients were satisfied or very satisfied with their final outcome, one patient was disappointed and one was dissatisfied. Satisfied or very satisfied patients could wear normal shoes after a mean 50-day period. Fusion was radiographically obtained in 31 cases out of 32. The mean postoperative dorsi flexion of the MTP1 joint arthrodesis was 21° (min: 15°, max: 35°). One patient developed a deep surgical site infection, 3 weeks after the procedure. Percutaneous MTP1 joint fusion is a simple surgical technique that can achieve similar results to open techniques for MTP1 fusions, with very simple postoperative care requirements. Indications for percutaneous MTP1 joint arthrodesis are large and only major bone defects or severe osteoporosis can be considered as contraindications. LEVEL OF EVIDENCE: Level IV.

Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy.

INTRODUCTION: The present study assessed 2-year clinical and radiological results of percutaneous correction of hallux valgus by Reverdin-Isham osteotomy and sought to clarify indications for the technique. PATIENT AND METHODS: A continuous prospective single-center series of 104 cases of medium-to-moderate hallux valgus was managed by the same percutaneous technique, with a median 2 years' clinical and radiological follow-up (with no loss to follow-up). Uni- and multivariate analysis determined predictive factors for the mobility and degree of correction obtained. RESULTS: American Orthopedic Foot and Ankle Society (AOFAS) functional score rose from a preoperative median of 49/100 to 87.5/100 postoperatively (p<0.05); 89% of patients were satisfied or very satisfied with their result at end of follow-up. Hallux valgus and distal metatarsal articular angle (DMAA) were significantly reduced (30 and 15 degrees to 15 and 7 degrees, respectively; p<0.05). Associated lateral ray surgery significantly increased the postoperative risk of MTP1 joint incongruence (p=0.009). DISCUSSION: Percutaneous correction by Reverdin-Isham osteotomy seemed effective in isolated medium-to-moderate hallux valgus, but involves a learning curve and lacks precision in case of associated lateral metatarsal osteotomy, with a risk of DMAA hypercorrection and increased risk of MTP1 joint incongruence. Indications for percutaneous Reverdin-Isham osteotomy seem to be limited to isolated medium-to-moderate hallux valgus (M1M2 angle <15 degrees, M1P1 angle around 30 degrees) with elevated DMAA and congruent MTP1 joint. LEVEL OF EVIDENCE: Level IV. Therapeutic study.

Influence of posterior condylar offset on knee flexion after cruciate-sacrificing mobile-bearing total knee replacement: a prospective analysis of 410 consecutive cases.

The range of motion of the knee joint after Total Knee Replacement (TKR) is a factor of great importance that determines the postoperative function of patients. Much enthusiasm has been recently directed towards the posterior condylar offset with some authors reporting increasing postoperative knee flexion with increasing posterior condylar offset and others who did not report any significant association. Patients undergoing primary total knee replacement were included in a prospective multicentre study and the effect of the posterior condylar offset on the postoperative knee flexion was assessed after adjusting for known influential factors. All knees were implanted by three senior orthopedist surgeons with the same cemented cruciate-sacrificing mobile-bearing implant and with identical surgical technique. Clinical data, active knee flexion and posterior condylar offset were recorded preoperatively and postoperatively at a minimal one year follow-up for all patients. Univariate and multivariate linear models were fitted to select independent predictors of the postoperative knee flexion. Four hundred and ten consecutive total knee replacements (379 patients) were included in the study. The mean preoperative knee flexion was 112°. The mean condylar offset was 28.3mm preoperatively and 29.4mm postoperatively. The mean postoperative knee flexion was 108°. No correlation was found between the posterior condylar offset or the tibial slope and the postoperative knee flexion. The most significant predictive factor for postoperative flexion after posterior-stabilized TKR without PCL retention was the preoperative range of flexion, with a linear effect.

Joint infection after knee arthroscopy: medicolegal aspects.

INTRODUCTION: Septic knee arthritis following arthroscopy is a rare but dreaded complication: it might compromise patients' functional prognosis and engage surgeon's liability. This study analyzes the context of such infection occurrences, their management as well as their medicolegal consequences. PATIENTS AND METHODS: Twenty-two cases of knee septic arthritis following arthroscopy were examined during the medicolegal litigation process and collected for assessment from a medical liability specialised insurer. Half of the patients were manual workers who worked on their knees, and seven knees had a previous surgical history. The procedures performed at arthroscopy included seven ligamentoplasties, nine meniscotomies, three arthroscopic lavages, one arthrolysis, one chondroma removal and one plica resection. Seven patients, to some point, received corticosteroids: three preoperative joint injections, three intraoperative injections, and one oral corticotherapy. RESULTS: Clinical signs of septic arthritis appeared after a median interval of 8 days (0-37), twice after a hemarthrosis and once after an articular burn. The median delay before treatment initiation was 4.2 days, and in 10 cases this therapeutic delay exceeded 3 days. On average, 3.5 additional procedures (1-9) were required to treat the infection and its residual sequels. Two total knee prostheses were implanted. Only two patients were free of disabling sequellae, and in five patients these sequels affected their livelihood. The medicolegal consequences were a partially permanent disability averaging 5% (0-20), a total temporary work incapacity of 120 days (40-790), a suffering burden averaging 3 out of 7 (0-4.5) points on the scale conventionally used in France. Twelve of these legal claims led to court ordered patient compensation. DISCUSSION: Some risk factors of articular infection are known and well-identified. They can be linked to the patient's condition (addiction to smoking, surgical history, professional activity) or to medical management (intra-articular corticoid injections, interventions under oral anticoagulants, inadvertently overheated irrigation fluid). When infection is suspected, it is often the needle-aspirated fluid's inappropriate handling (such as absence of bacteriological testing or defective waiting time for the results), which delays the diagnostic or therapeutic management of this complication. All failures of infection diagnosis or treatment heavily contribute to malpractice claims against the surgeon. Early and appropriate management of postoperative infections helps limiting the risk of functional sequellae for the patient and reduces the risk of malpractice litigation for the practitioner. LEVEL OF EVIDENCE: Level IV; economic and decision analysis, retrospective study.

Partial atlE sequencing of Staphylococcus epidermidis strains from prosthetic joint infections.

Partial atlE sequencing (atlE nucleotides 2782 to 3114 [atlE(2782-3114)]) was performed in 41 Staphylococcus epidermidis isolates from prosthetic joint infections (PJIs) and 44 isolates from skin as controls. The atlE(2782-3114) allele 1 (type strain sequence) was significantly more frequent in PJI strains (38/41 versus 29/44 in controls; P = 0.0023). Most PJI strains were positive for mecA, icaA/icaD, and IS256, and most belonged to the sequence type 27 subgroup, suggesting the involvement of few related clones.

[Marjolin's ulcer in chronic osteomyelitis: seven cases and a review of the literature]. / Ulcère de Marjolin sur ostéite chronique: diagnostic et résultats du traitement: 7 cas.

PURPOSE OF THE STUDY: Malignant degeneration of chronic wound inflammation is a rare complication which almost always develops late. Unstable wounds and scar tissue related to chronic osteitis can degenerate after a long period of chronic inflammation. We report seven cases. CASE REPORTS: Seven patients presented squamous-cell carcinoma of the skin which had developed on wounds related to deep bone infections. Three patients had chronic bone infections subsequent to posttraumatic osteitis, two after hematogenous osteomyelitis, one after osteitis which developed on a zone of radiation-induced necrosis, and one after a deep burn was complicated by osteitis. The skin lesions developed over a period of 43 years on average before the diagnosis of malignant degeneration was established. Most of the lesions presented as budding malodorous ulcers. The pathological diagnosis was spinocellular squamous-cell carcinoma in five cases and verrucous squamous-cell carcinoma in two. Conservative treatment with wide resection and flap cover was attempted in all seven patients. RESULTS: Treatment failed in four patients and three required amputation. One patient died two years after amputation with local recurrence and metastatic dissemination to the brain. DISCUSSION: The diagnosis of malignant degeneration requires pathological proof. Biopsy material should be obtained whenever there is a modification leading to the development of a fistula or the formation of a scar tissue over a focus of chronic osteitis. Prevention requires adapted treatment of chronic bone infections, avoiding directed wound healing which can lead to fragile unstable scar tissue subject to degeneration.

[Infection on continuous bone of lower limb: 127 cases]. / Infection osseuse sur os continu au niveau du membre inférieur: a propos de 127 cas.

PURPOSE OF THE STUDY: Infection on continuous bone is a specific diagnostic and therapeutic entity. Treatment requires debridement of infected and necrotic soft tissue and bone, dead space management, effective antibiotic therapy in the bone and good skin coverage with well-vascularized tissues. Results of treatment of infection on continuous bone of the lower limb are presented in this series. MATERIAL AND METHODS: This retrospective series included 127 cases of osteomyelitis affecting continuous bone of the lower limb (tibia or femur). Septic nonunion and infected arthroplasties were excluded. All patients underwent surgery. The therapeutic protocol was based on debridement, filling of the osteomyelitic cavity as needed (flap, bone grafting, foreign material) and skin cover (by direct closure or flap). Antibiotics were given systematically. Patients were reviewed at minimum two years follow-up. RESULTS: Osteomyelitis was located on the tibia in 66% and was posttraumatic in 75% of cases. Localized osteomyelitis (type III of the Cierny-Mader anatomic classification) was found in 50% of patients. Staphylococcus aureus was the causal agent in 66% of cases. Flaps were performed in more than half of cases and most of them were local flaps. Systematic antibiotic therapy was given for an average three months. With an average four years follow-up, eradication of the infection was obtained in 80% of patients. Ten patients were lost to follow-up. No statistical difference was noted for final outcome according to the physiological hoste class, the anatomic localization (tibia or femur), bacteriological findings, duration of antibiotics, use of flaps, or filling of the osteomyelitic cavity. Treatment of type I and II osteomyelitis was more successful than type III or IV infection (NS). Failure rate increased with the number of previous surgical procedures (p=0.02). DISCUSSION: Infection on continuous bone is a characteristic entity, rarely clearly separated from other bone infections in reported series that combine these infection with septic nonunions and infected arthroplasties. Surgery is essential and is based on quality debridement. The use of flaps (for both dead space management and skin coverage) improves the results for the treatment of such infections but long-term follow-up is needed for a more accurate assessment of success rate.

[Results of reimplantation for infected total knee arthroplasty: 107 cases]. / Résultats des changements de prothèse de genou pour infection: à propos de 107 cas.

PURPOSE OF THE STUDY: The purpose of this study was to assess the results of reimplantations of total knee arthroplasties complicated by infection. Outcome was assessed in terms of eradicated infection and function. MATERIAL AND METHODS: This retrospective multicentric study included 107 cases of infected total knee arthroplasties treated by changing the implants. Seventy-seven patients had a two-stage revision and thirty had a one-stage procedure. Patients were reviewed with a minimal 2-year and an average 52-month follow-up. RESULTS: Revision arthroplasty (one- or two-stage) eradicated infection in two out of three patients. With a two-year follow-up, revision arthroplasty was successful in 77% of patients without any sepsis risk factor, in 65% of patients with one risk factor and in 33% of patients with at least two risk factors. After reimplantation for total knee arthroplasty infection, overall function outcome was good (KS knee score: 74.8 after two-stage revision and 75.5 after one-stage revision, NS). After two-stage procedures, the knee outcome was excellent in one-third of patients, good in another third and fair or poor in the final third. After one-stage reimplantation, 40% of the knees had an excellent outcome, 30% a good outcome and 30% a fair or poor outcome. Regarding functional outcome, overall results were fair (KS function score 62.5 for one-stage and two-stage revisions). Functional outcome was fair or poor in 42% of patients with a two-stage procedure and in 55% of patients with a one-stage revision (NS). DISCUSSION: Our study was unable to disclose any difference between one-stage and two-stage revision for eradicating infection. Unfavorable systemic and local conditions decreased the rate of success after revision total knee arthroplasty for infection. Length of infection before reimplantation, number of surgical procedures and bacterial virulence or resistance were not, in our series, predicting factors for failure of septic revision total knee arthroplasty. No difference was found for the clinical and functional results between one-stage and two-stage procedures. Functional outcome was fair or poor for half of the patients after septic revision total knee arthroplsty. The use of an external device between the two procedures for two-stage revision significantly decreased the functional outcome compared with the use of a spacer. Articulated spacers did not offered any advantage compared with a static spacer for functional outcome.

Polymorphism of the cell wall-anchoring domain of the autolysin-adhesin AtlE and its relationship to sequence type, as revealed by multilocus sequence typing of invasive and commensal Staphylococcus epidermidis strains.

We sequenced the adhesin-cell wall-anchoring domain of the atlE gene of 49 invasive and commensal Staphylococcus epidermidis strains. We identified 22 alleles, which could be separated into two main groups: group 1 (alleles 1 and 6 to 16, 32/49 strains) and group 2 (alleles 2 to 5 and 17 to 22, 17/49 strains). Allele 1 (the type strain sequence) was by far the most prevalent (21 of 49 strains). Multilocus sequence typing showed a clear relationship between the atlE allele and the sequence type (ST), with the "nosocomial" ST27 clone and closely related STs expressing group 1 alleles.

Pasteurella multocida infection of a total knee arthroplasty after a "dog lick".

The patient we report here underwent a total knee arthroplasty (TKA) which got infected with P. multocida after her dog had licked a small wound at the third toe of the same foot. Despite a correct treatment comprising synovectomy and cleansing, and an active antibiotic treatment for 3 months, the patient was readmitted for persistent infection of the same knee 2 weeks after the end of the antibiotic treatment. Sampling during surgery allowed for the growth of a P. multocida isolate proven by a molecular method to be identical to the previously isolated strain. This recurrent P. multocida infection was treated by a two-step change of the TKA comprising a 2-month period of antibiotic treatment between the two surgical interventions.

[Geriatric intervention team in an academic orthopedic surgery department: activity at the Ambroise-Paré Hospital in Boulogne, France]. / L'équipe d'intervention gériatrique dans un service de chirurgie orthopédique adulte: Bilan de la première année d'activité à l'hôpital Ambroise-Paré de Boulogne.

To respond to increasing demand resulting from population aging, a geriatric intervention team was created at the Ambroise-Paré hospital in February 2004. The main activity of the team is to improve medical and social care of elderly patients who are regularly frail with multiple morbid conditions and taking multiple medications. During the first year of activity, 23% of requests came from the orthopedic surgery department which annually cares for 720 patients aged over 75 years. Physicians and nurses from this department need to adapt their practices to the specific features of geriatric care. The geriatric intervention team provides advice, support, and suggestions as well as professional training.

[Knee septic arthritis]. / L'arthrite septique du genou.

The development of antibiotics and arthroscopic treatment have been two major turning points in the management of septic arthritis of the knee joint. We report a retrospective review of 78 patients managed in three surgery units and one rheumatology unit. Management practices varied between the units. Joint aspiration was proposed for all patients seen by rheumatologists. Certain surgeons proposed arthroscopy systematically at admission while others preferred a more selective approach. Arthroscopic wash-out was proposed as the first-line procedure for only 33 patients. All were given systemic antibiotics using a variety of protocols. The course under antibiotic treatment confirmed the potential gravity of septic arthritis of the knee joint since two patients died and 34 required surgery, half of which had more than one operation. The functional outcome at mean 19 months was rather poor. Only 65 knees were free of any implant and only 40 (62%) were pain free. Mean flexion was 116 degrees and 11 patients (17%) had significant flexion contracture. Factors of poor prognosis were initially high sedimentation rate, advanced stage according to Gächter, presence of specific germs (meti-R S. aureus, Gram-negative bacilli), and failure of first-line treatment. A management algorithm was proposed: initial aspiration for evacuation, medical treatment alone if there is no synovitis, and reduction synovectomy otherwise. The key to success is early well adapted treatment.

Use of genotypic identification by sodA sequencing in a prospective study to examine the distribution of coagulase-negative Staphylococcus species among strains recovered during septic orthopedic surgery and evaluate their significance.

A total of 212 coagulase-negative Staphylococcus strains recovered prospectively during 119 surgeries for proven or suspected bone and joint infection (BJI) were identified by sodA sequencing. These strains were identified as 151 Staphylococcus epidermidis isolates, 15 S. warneri isolates, 14 S. capitis isolates, 9 S. hominis isolates, 6 S. lugdunensis isolates, 5 S. haemolyticus isolates, 4 S. caprae isolates, 4 S. pasteuri isolates, 3 S. simulans isolates, and 1 S. cohnii isolate. Only S. epidermidis, S. lugdunensis, S. capitis, and S. caprae were found to be infecting organisms and were involved, respectively, in 35 (81.4%), 3 (7.0%), 3 (7.0%), and 2 (4.6%) cases of BJI.

Drop foot after high tibial osteotomy: a prospective study of aetiological factors.

Drop foot is not uncommon after high tibial osteotomy for genu varum. The authors report their results of a prospective study of 16 patients operated on between May 1990 and May 1991. All patients had medial femoro-tibial osteoarthritis with a constitutional genu varum. They all had a subtraction valgus high tibial osteotomy fixed by a blade plate. The experimental protocol included clinical review, antero-lateral compartment pressure measurements, intra- and post-operative electromyography, assessment of the post-operative drainage, serum estimation of muscle enzymes and post-operative arteriography. From their own results and a literature review, the authors consider successively the different aetiological factors for post-operative drop foot. Certain deficits occur due to direct trauma on the nerve during high osteotomy of the fibula, by local high pressure due to poor haemostasis or ineffective drainage. In addition, there are several related phenomena. The pneumatic tourniquet sensitises the nerve to trauma, and stretching of the nerve during correction of the deformation depends on the local anatomical factors and their marked variation. In order to diminish the frequency of these post-operative complications, the authors suggest limiting the surgical approach, and limiting as far as possible the traumatic manoeuvres on the nerve by using a tibial resection jig, which allows correction without forced manoeuvres. Finally, the authors discuss the benefits of using a pneumatic tourniquet.