Duration of rifampin therapy is a key determinant of improved outcomes in early-onset acute prosthetic joint infection due to Staphylococcus treated with a debridement, antibiotics and implant retention (DAIR): a retrospective multicenter study in France.

Introduction: In patients undergoing a « debridement, antibiotics, and implant retention ¼ (DAIR) procedure for acute staphylococcal prosthetic joint infection (PJI), post-operative treatment with rifampin has been associated with a higher probability of success.(1,2) However, it is not known whether it is the total dose, delay of introduction or length of therapy with rifampin that is most strongly associated with the observed improved outcomes. Methods: A multicentric, retrospective cohort study of patients with acute staphylococcal hip and knee PJI treated with DAIR between January 2011 and December 2016. Failure of the DAIR procedure was defined as persistent infection, need for another surgery or death. We fitted logistic and Cox regression multivariate models to identify predictors of DAIR failure. We compared Kaplan-Meier estimates of failure probability in different levels of the 3 variables of interest - total dose, delay of introduction or length of therapy with rifampin - with the log-rank test. Results: 79 patients included (median age 71 years [63.5-81]; 55 men [70%]), including 54 (68%) DAIR successes and 25 (32%) DAIR failures. Patients observed for a median of 435 days [IQR 107.5-834]. Median ASA score significantly lower in DAIR successes than in DAIR failures (2 vs. 3, respectively p = 0.011). Bacterial cultures revealed 65 (82.3%) S. aureus and 16 (20.3%) coagulase negative staphylococci, with 2 patients being infected simultaneously with S. aureus and CNS. Among S. aureus isolates, 7 (10.8%) resistant to methicillin; 2 (3.1 %) resistant to rifampin. Median duration of antimicrobial therapy was 85 days [IQR 28.5-97.8]. Fifty-eight patients (73.4%) received rifampin at a median dose of 14.6 mg/kg/day |IQR 13-16.7], started at a median delay of 8.5 days [IQR, 4-7.5] after debridement surgery. Twenty-one patients (26.6%) developed a drug-related adverse event, leading to rifampin interruption in 6 of them (7.6% of total cohort). Determinants of DAIR failure were rifampin use (HR 0.17, IC [0.06, 0.45], p-value <0.001), association of rifampin with a fluoroquinolone (HR 0.19, IC [0.07, 0.53], p-value = 0.002) and duration of rifampin therapy (HR 0.97, IC [0.95, 1], p-value = 0.022). We did not observe a significant difference between DAIR successes and failures in rifampin use, dose and delay of introduction. In a multivariate Cox model, only duration of rifampin therapy was significantly associated with DAIR failure. Kaplan Meier estimate of DAIR failure probability was significantly higher in patients receiving less than 14 days of rifampin in comparison with those receiving more than 14 days of rifampin (p = 0.0017). Conclusion: Duration of rifampin therapy is a key determinant of improved outcomes in early-onset acute prosthetic joint infection due to Staphylococcus treated with DAIR.

Should we expand the indications for the DAIR (debridement, antibiotic therapy, and implant retention) procedure for Staphylococcus aureus prosthetic joint infections? A multicenter retrospective study.

To evaluate factors associated with failure in patients treated with DAIR (debridement, antibiotic therapy, and implant retention) for Staphylococcus aureus prosthetic joint infections (PJIs). We retrospectively analyzed consecutive patients with stable PJI due to S. aureus treated with DAIR at six hospitals between 2010 and 2014. Cox proportional hazards regression was used to study factors associated with treatment failure at 2 years. Of 154 eligible patients, 137 were included (mean age 73 ± 13 years; male 56%). The estimated success rate according to the Kaplan-Meier method was 76.2 [95% CI 68-83] at 2 years of follow-up. In multivariate analysis, longer duration of treatment (hazard ratio (HR) 0.78 [0.69-0.88]; p < 0.001) and combination therapy including rifampin (HR 0.08 [0.018-0.36]; p = 0.001) were independently associated with success, whereas active smoking was independently associated with failure (HR 3.6 [1.09-11.84]; p = 0.036). When the analysis was restricted to patients with early infection onset (< 3 months), early acute infection was also predictive of a better prognosis (HR 0.25 [0.09-0.7]; p = 0.009). Failure was not associated with time from prosthesis insertion to debridement, nor with duration of symptoms > 3 weeks and type of prosthesis (hip or knee). These results remained unchanged when the 14 patients under immunosuppressive therapy were removed from analysis. These data suggest that DAIR can be performed even if infection and symptoms are delayed but reserved to patients who are able to follow rifampin-based combination therapy for a prolonged duration that should not be different for hip and knee PJI.

[Computer-assisted knee arthroplasty: comparison with a conventional procedure. Results of 50 cases in a prospective randomized study]. / Mise en place des prothèses totales du genou assistée par ordinateur : comparaison avec la technique conventionnelle.

PURPOSE OF THE STUDY: The aim of this work was to compare the radiographic findings after two techniques for total knee arthroplasty, one using a computer-assisted approach and the other a conventional approach. MATERIAL AND METHODS: Between January 1998 and April 1999, we conducted a prospective study randomizing 25 patients for conventional surgery (group A) and 25 for computer-assisted surgery (group B). All patients volunteered to participate in this study and gave their written informed consent. There were 35 women and 15 men, mean age 69.5 years (range 47-85). The two groups were comparable for age, gender, height, weight, orthopedic history, etiology and preoperative mobility. The preoperative hip-knee angle (HKA) was also comparable between the two groups. Mean HKA was 175 degrees, i.e. 5 degrees varus (range 162 degrees (18 degrees varus) to 210 degrees (30 degrees valgus)). Genu varum was found in 80 p. 100 of the patients in group A and in 76 p. 100 in group B, genu valgum in 16 p. 100 in group A and 24 p. 100 in group B. The same operator performed all the procedures) with the same type ok prosthesis for all patients. The goal of the operation was to position the prosthesis to produce an HKA of 180 +/- 3 degrees, a femoral angle of 90 degrees (from the mechanical axis), a tibial angle of 90 degrees and a posterior tibial slope of 0 degrees (tibial plateau at 90 degrees to the lateral tibial axis). Statview 5 PC was used for the statistical analysis. Comparisons between groups were made with the Student's t test to compare means when the validity conditions were met. RESULTS: The patients were reviewed by two surgeons, independently of the operator and the designers of the computer-assistance program. Mean duration of the procedure was longer in group B (102 mn versus 70 mn, p<0.001). There was no statistically significant difference in mean postoperative bleeding (group A=380 cc, group B=480 cc). The postoperative HKA was 181.2 +/- 2.72 degrees in group A and 179.04 +/- 2.53 degrees in group B (p > 0.05). The HKA was between 177 degrees and 183 degrees in 75 p. 100 of the patients in group A and in 84 p. 100 of those in group B. Implantation of the femoral component showed a mean angle of 91.12 +/- 2.07 degrees in group A and 89.56 +/- 1.61 degrees in group B (p=0.048). The mean tibial angle was 90.167 +/- 1.61 degrees in group A and 89.5 +/- 1.34 degrees in group B (p=0.11). On the lateral view, the femoral component was at 90 degrees to the mechanical axis in 16/21 patients in group B. These data were missing in group A. The posterior tibial slope was 90.76 +/- 2.19 degrees in group A and 89.44 +/- 2.14 in group B (p=0.18). CONCLUSION: Computer-assisted surgery for total knee arthroplasty was found to provide remarkably reliable results. Once the "growing pains" of this new material have been mastered, all surgeons should be able to expect an improvement in the positioning of prosthetic implantations.

Surgical treatment of bi- and trimalleolar ankle fractures: should the medial collateral ligament be sutured or not?

In Weber type A, B, and C fractures there is no census or whether or not to suture the ruptured medial collateral ligament. From May 1990 to December 1994, operations were performed on 48 patients with such lesions. Thirty-three cases were reviewed, 29 males and four females, with an average age of 39 years (range, 15-73 years). In 22 cases there was an isolated fracture of the lateral malleolus, and in 11 cases the fracture was associated with a posterior malleolus fracture. There were tibiotalar dislocations in nine cases. Fifty-eight percent of the injuries were caused by sports activities and 27% by an ordinary fall. After a preoperative external reduction, the lateral and posterior (if necessary) fractures were anatomically and rigidly fixed (plate, pins, and wire) without any suture of the medial ligament. Medial tibiotalar and tibiofibular diastasis were totally reduced as shown during intraoperative radiographs. The follow-up at time of review was 27 months on average (range, 9 months-5 years). Functional results were excellent and good in 82.5% of cases, with a return to sports activities at a mean time of 4.3 months. X-rays were considered as normal in 73% of cases, with an anterior impingement syndrome in 15% and calcifications of the medial collateral ligament in 12%. Stress radiographs in valgus talar tilt (n = 24) were normal in all cases. The authors suggest new surgical guidelines in ankle fractures with a medial collateral rupture, based on fracture stabilization, with ligament tears left unexplored (medial, tibiofibular, and syndesmotic ligaments), and early mobilization.

[Anatomo-clinical consequences of the vertical sectioning of the subscapular muscle in Latarjet intervention]. / Conséquences anatomo-cliniques de la section verticale du muscle sub-scapulaire dans l'intervention de Latarjet.

UNLABELLED: The goal of this study was to assess the effects of the vertical section of the subscapularis muscle (internal rotation and muscular degeneration) during Latarjet procedure. MATERIAL AND METHODS: From October 1st, 1990, to June 30th, 1991, 40 patients were operated according to Latarjet for chronic anterior shoulder instability. A vertical section of the subscapular muscle was performed. Except for one female patient, all of them practiced sports. Preoperative delay between first dislocation and surgery averaged 59 months. Postoperative rehabilitation was aimed at external rotation, recovery began 48 hours after surgery, without specific indications as far as internal rotation was concerned. Sports activity was resumed 90 days after surgery. 38 were reviewed after 4 years. Clinical review was made according to Constant's score and by measuring strength, and amplitude of internal rotation. Radiological assessment of the shoulders was made with standard x-rays and CT. RESULTS: For global results, we noted absence of recurrence, a weighted Constant score of 88 per cent, 87 per cent of patients satisfied or very satisfied, 55 per cent of the osteoplastic ridge were on level, 16 per cent were retracted, and 29 per cent overlapped, 19 per cent non union or ridge lysis, 21 per cent glenohumeral osteophytosis. As far as clinical results are concerned, no significant difference was noted associated to osteoplastic ridge position. Internal rotation was assessed by measuring the distance hand to back (lift-off test). On the operated side it averaged 6 cm (0-18 cm), on the other side 13 cm (2-21 cm). The difference between each side was statistically very significant (p = 0.0001). Strength in internal rotation on the operated side averaged 3 kg (0-8 kg), on the other side, 6 kg (2-10 kg). The difference between each side was statistically very significant (p < 0.0001). CT was carried out on thickness and degeneration of the subscapular muscle (n = 29). Thickness of the subscapular muscle (operated side) average 10.5 (5-17 mm) after surgery, and 14.6 mm before surgery. It was thimer than on the contralateral shoulder 21 mm (10-33 mm). In both cases (shoulder before and after surgery, operated and contralateral shoulder), the difference was statistically significant. Degeneration of the subscapular muscle showed 4 stage 0, 13 stage 1, 5 stage 2, 6 stage 3, and 1 stage 4. A non statistical correlation was noted, between muscle degeneration and functional result, strength in internal rotation, distance hand to back. DISCUSSION: This series confirms efficiency and low morbidity of Latarjet procedure. Nevertheless, assessment of the subscapular muscle shows that 50 per cent of its strength and 50 per cent of its thickness were lost, 4 years after surgery. A significant degeneration (stages 2.3.4) was found in 41 per cent of the patients. This limitation is related to the trans-subscapular approach and to the absence of internal rotation postoperative rehabilitation. CONCLUSION: A randomized study comparing the vertical trans-subscapular approach to the horizontal trans-subscapular one would determine the better procedure.

Reconstruction of the lateral ankle ligaments using an inferior extensor retinaculum flap.

The aim of this study was to assess the results of 32 cases of chronic ankle instability. These were treated by ligament shortening and reinforced with an inferior extensor retinaculum flap. All patients complained of persistent functional instability unrelieved with proprioceptive exercises. Results were assessed clinically (pain, instability, recovery of sports activity, mobility) and radiologically (correction of laxity on stress x-rays). This enabled us to draw up a revision score on a scale of 100 points. We obtained a mean score of 86.7 points (45-100 points), and subjective results showed that 88% of the patients were satisfied with the surgery.

[A morphometric study of the femoro-patellar joint from lateral x-ray view]. / Etude morphométrique de l'articulation fémoro-patellaire à partir de l'incidence radiologique de profil.

PURPOSE OF THE STUDY: The goal of this study was to specify criteria of femoro-patellar joint normality on lateral view. MATERIAL: This study was based on radiological examination of 102 knees in 51 adults (average age 26.1 years). It concerned 29 women and 22 men that had never suffered from their knee and were supposed healthy. METHODS: The radiological protocol was the following: a lateral view at 45 degrees of flexion, two lateral views in extension, with and without quadriceps contraction. The analysis was focused on patellar surface aspect, its height, its depth and covering measurement. RESULTS: We found 83.7 per cent of so-called "normal" patellar surface, and 12.7 per cent of "abnormal" patellar surface (dysplasia) in the absence of pain. DISCUSSION: We have confirmed figures advanced in others series of the literature concerning patellar height and patellar surface, as well as patellar surface depth and covering. We have underlined the interest of lateral views; in extension with quadriceps contracted and relaxed. Finally, we have defined a trochleo-patellar sign that allows to correlate patellar height to patellar surface height (ITP = 0.35 to 0.84). CONCLUSION: This study insists on the interest of radiological lateral views of the knee and determine criteria for normalities.

[Pseudotumor manifestation of metallosis in a hip prosthesis]. / Manifestation pseudo-tumorale d'une métallose sur prothèse de hanche--à propos d'un cas.

A pseudo-tumour due to metallosis is described in association with an iso-elastic hip replacement. This is a relatively rare lesion which may be difficult to diagnose. Scintigraphy and radiography may be helpful in distinguishing the lesion from a primary or secondary neoplasm, but the presence of osteolysis adjacent to the prosthesis will suggest the true nature of the lesion.

Iatrogenic hallux varus surgical procedure: a study of 14 cases.

Hallux varus occurs most frequently as a result of excessive surgical correction of musculoligamentous imbalance around the metatarsophalangeal (MTP) joint of the great toe (lateral release and medial capsuloligamentous tensioning). If untreated, the condition may lead to motion loss and degenerative arthritis. In this series, 14 cases of hallux varus were treated. Medial arthrolysis was done in each case. In five cases, reconstruction of the lateral ligament (with a 1.5-mm Ligapro suture), using a new technique, accompanied the medial release. Arthrodesis of the MTP was done in nine cases treated when there was already stiffness and arthrosis. According to a 100-point scoring system, the results were excellent in 56% and good in 44% of the MTP joint arthrodesis cases. Results were excellent in 100% of the mobilizing technique cases using Ligapro suture.

[Isolated rupture of the tendon of the supra spinatus muscle. Results of 49 surgical repair]. / Les ruptures isolees du tendon du muscle supra-epineux. Resultats de 49 reparations chirurgicales.

PURPOSE OF THE STUDY: The purpose of this study was to assess the results of surgical repairs in 49 << isolated >> tears of the supra- spinatus in 49 patients, 32 males and 17 females. MATERIAL AND METHODS: The average age at operation was 54,2 years (35 to 72) and the dominant side was injured in 30 patients (12 opposite side and 5 unknown). According to Constant's score the pain was permanent in 23 patients, it occurred at moderate exertion in 21 patients and at important exertion in 5. The average pain duration was 43,4 months (0 to 360 months). The range of motion was normal (40 points) in 24 patients, diminished in 15 (30 points), very diminished (10 points) in 7 and the shoulder was stiff in one patient (2 files were uncomplete). All the patients were disturbed in daily living activity and the strength assessment was disturbed because of the pain. In all cases we performed an anterior acromioplasty. At operation, 39 patients had an isolated tear of the supra-spinatus and 10 an associated tear of the long head of the biceps (7 tendinities, 1 dislocation and 2 ruptures). The size of the rupture was less than 2 cm2 in 21 cases comprised between 2 and 5 cm2 in 27 and greater than 5 cm2 in one case. The surgical procedure was a Neviaser's technique in 4 cases, a single suture in 19, a transosseous suture in 19 and a deltoid muscular flap in 7 cases (large retracted tear), in addition we performed 14 resections of the distal end of the clavicle and 4 tenodesis of the long head of the biceps. RESULTS: The results were assessed according to Constant's score on 46 patients (3 lost to follow-up), the average follow-up was 31,5 months (12 to 86). The average scores were: pain 12,3 points (3 to 15), range of motion 35,5 (14 to 40), daily living activity 17,4 (8 to 20), and strength 11,4 (<> side = 14,8 points). The total Constant's scores were 75,7 per cent (actual score) and 88,3 per cent (weighted score), according to the weighted score 24 patients had 100 per cent; 9 were comprized between 85 and 100, 5 between 65 and 85, and 8 were less than 65 per cent. The average post-operative acromio-humeral height was 9,84 mm (pre-operative height = 11 mm). DISCUSSION - CONCLUSION: If we compare the results in terms of surgical procedure the difference was not statistically significant although the transosseous suture was not so good: single suture 91,5 per cent, deltoid muscular flap 90,9 per cent, Neviaser's technique 87 per cent, and transosseous suture 79,1 per cent. Nevertheless the results are not so good (p = 0,01) if it is an industrial injury and if the post operative acromio-humeral height is diminished. On the other hand, age, sex, duration of the pain, occupation, tenodesis of the long head of the biceps and resection of the distal end of the clavicle don't have any pejorative influence on the results.

[Osteosynthesis of forearm fractures using a P.C.D. "Small fragments" plate from A.O instruments. Apropos of 283 screwed plates]. / L'ostéosynthèse des fractures de l'avant-bras par plaque P.C.D. "Petits fragments" de l'instrumentation A.O. A propos de 283 plaques vissées.

The authors report the results of using 283 P.C.D. "petits fragments" plates by A.O. instruments, inserted between 1980 and 1989 for internal fixation of 207 forearm fractures. These included 97 double forearm fractures, 34 isolated ulnar fractures, 30 isolated radial fractures, 24 Monteggia fractures, 13 Galeazzi fractures and 9 pseudoarthroses of the radius or ulna. The mean delay to consolidation was 3.3 months with a range of 2 to 15 months. Complications included 1 hypertrophic callus of the ulna; 3 pseudoarthroses, 7 cases of sepsis (6 ulnar, 1 radius i.e. 2.5%); no plate ruptures occurred in this series. 125 plates were removed after consolidation (after 18 months); the fracture recurred in only one case where the plate was removed after 8 months. Results are based on 203 operated patients (4 lost to follow up). Before treatment of the complication, results showed 150 very good results (73.2%), 44 good results (21.5%) 1 moderate (0.5%) and 10 poor results (4.8%). After treatment of the complications there were 156 very good results (77%), 46 good results (22.5%) and 1 moderate result. In summary, forearm fractures are no longer a problem in traumatology. The P.C.D. "petits fragments" plate of A.O. instruments would appear to be particularly adapted and a bulkier implant (4.5 screw) is not required.