Covering of wound infection in hip arthroplasty with local cutaneous flaps.

Total hip arthroplasty is a very common procedure to treat osteoarthritis. One of the complication is the infection which occurs in about 1% of the cases. The manifestation of infection can be poor wound healing with dehiscence and exposition of bone or prosthetic components. Hip arthroplasty infections are difficult to treat. It required an associated multidisciplinary approach with infectiology, orthopedic and plastic surgeries. The study included five patients with hip wound dehiscence after total hip arthroplasty. Coverage after orthopedic surgery was provided by local cutaneous flap. These cutaneous flaps were either a deep inferior epigastric perforator flap (DIEP) or a transposition flap. The orthopedic and the plastic treatment were done at the same time. Two deep inferior epigastric flaps were performed for patients with a deep defect with bone or prosthesis exposure. Four transposition flaps were done in three patients with wound dehiscence but without direct contact with the prosthesis. Three transposition flaps were done from the abdominal wall and one from the posterior thigh. The mean follow up was 18 months, ranging from 10 to 24months. After healing, there was no recurrence of the infection. In all cases, the coverage was obtained. The prosthesis was salvage and the gait was possible. Cutaneous flaps are easy and safe to cover the hip. They are reliable flaps even in patients with multiple co-morbidities. They do not cause sequelae on the recipient site. This study is the first about cutaneous flap for covering hip defects in hip arthroplasty infections.

[A pedicled deep inferior epigastric flap to cover a hip arthroplasty infection]. / Couverture d'une prothèse de hanche infectée par un lambeau perforant épigastique inférieur profond pédiculé.

The deep inferior epigastric perforator (DIEP) flap is a reliable flap mostly used in skin resurfacing after signifiant resection for sarcoma or correction contour deformities. This case is about a pedicled DIEP flap covering the trochanteric region after a total hip arthroplasty infection. A 62years old woman with a BMI at 42kg/m2 presents an infected total hip arthroplasty with a cutaneous defect. The hip prosthesis is changed and covered with a pedicled DIEP flap. This original case reports the used of pedicled DIEP flap in hip coverage. This local fasciocutaneous flap covered the hip osteoarticular infection. The limb is salved and the patient can walked again. The success of this surgery is the collaboration between infectious disease specialist, orthopedic surgeon and plastic surgeon.

Agreement between pre-operative and intra-operative bacteriological samples in 85 chronic peri-prosthetic infections.

BACKGROUND: Whether pre-operative microbiological sampling contributes to the management of chronic peri-prosthetic infection remains controversial. We assessed agreement between the results of pre-operative and intra-operative samples in patients undergoing single-stage prosthesis exchange to treat chronic peri-prosthetic infection. HYPOTHESIS: Agreement between pre-operative and intra-operative samples exceeds 75% in patients undergoing single-stage exchange of a hip or knee prosthesis to treat chronic peri-prosthetic infection. MATERIAL AND METHODS: This single-centre retrospective study included 85 single-stage prosthesis exchange procedures in 82 patients with chronic peri-prosthetic infection at the hip or knee. Agreement between pre-operative and intra-operative sample results was evaluated. Changes to the initial antibiotic regimen made based on the intra-operative sample results were recorded. RESULTS: Of 149 pre-operative samples, 109 yielded positive cultures, in 75/85 cases. Of 452 intra-operative samples, 354 yielded positive cultures, in 85/85 cases. Agreement was complete in 54 (63%) cases and partial in 9 (11%) cases; there was no agreement in the remaining 22 (26%) cases. The complete agreement rate was significantly lower than 75% (P=0.01). The initial antibiotic regimen was inadequate in a single case. DISCUSSION: Pre-operative sampling may contribute to the diagnosis of peri-prosthetic infection but is neither necessary nor sufficient to confirm the diagnosis and identify the causative agent. The spectrum of the initial antibiotic regimen cannot be safely narrowed based on the pre-operative sample results. We suggest the routine prescription of a probabilistic broad-spectrum antibiotic regimen immediately after the prosthesis exchange, even when a pathogen was identified before surgery. LEVEL OF EVIDENCE: IV, retrospective study.

Core needle biopsy for the assessment of unilateral male breast lesions.

The importance of preoperative histological diagnosis in the assessment of breast lesions in women is widely established, but in men with breast lesions histological diagnosis is obtained in a limited number of cases. The aim of this study was to report our single-center experience in a large series of 131 CNB performed for suspicious male breast lesions. Our data confirmed that CNB is an effective method in distinguishing between benign and neoplastic lesions in the male breast, thus validating the few published data. CNB should be a routine part of the unilateral male breast swelling diagnostic assessment, being precious tool for the clinicians for surgery planning or avoidance.

Impact of molecular subtypes classification concordance between preoperative core needle biopsy and surgical specimen on early breast cancer management: Single-institution experience and review of published literature.

BACKGROUND: Core needle biopsy (CNB) plays a crucial role as diagnostic tool for breast cancer (BC). The characterization of biomarkers status before surgical treatment is crucial when primary systemic therapy is a therapeutic option. The aim of this analysis was to report concordance between preoperative CNB and surgical specimen (SS) in evaluating biomarkers and molecular subtypes. METHODS: Data have been collected from a cohort of 101 patients affected by early BC treated at Careggi Florence University Hospital, between January 2014 and March 2015. The conformity between molecular subtype classification was tested using kappa (κ) test. RESULTS: Mean age was 57.5 years (range 29-86). There was concordance between the estrogen receptor (ER) assessment on CNB and SS in 95 cases (94.1%). Concordance of the progesterone receptor (PgR) assessment was observed in 89 cases (88.1%). Concordance for detecting immunohistochemistry-assessed BC molecular subtypes was 87.1% (κ = 0.78). Concerning Ki-67 evaluation, we report a concordance rate of 88.1% (κ = 0.68). The evaluation of luminal A plus luminal B/HER negative subgroup showed a κ-value of 0.65. CONCLUSIONS: CNB showed good accuracy in evaluating hormonal receptors status, HER2, and BC molecular subtypes. Evaluation of Ki67 status was less accurate than other biomarkers; therefore, we recommend that it should be detected both on CNB and SS samples, especially in hormonal positive HER2 negative tumors, in order to avoid a misclassification of tumor subtypes that could lead to an omission of potential effective systemic therapy.

May one-stage exchange for Candida albicans peri-prosthetic infection be successful?

UNLABELLED: Fungal infection of a total joint arthroplasty has a low incidence but is generally considered as more difficult to cure than bacterial infection. As for bacterial infection, two-stage exchange is considered as the gold standard of treatment. We report two cases of one-stage total joint exchange for fungal peri-prosthetic infection with Candida albicans, where the responsible pathogens was only identified on intraoperative samples. This situation can be considered as a one-stage exchange for fungal peri-prosthetic infection without preoperative identification of the responsible organism, which is considered as having a poor prognosis. Both cases were free of infection after two years. One-stage revision has several potential advantages over two-stage revision, including shorter hospital stay and rehabilitation, no interim period with significant functional impairment, shorter antibiotic treatment, better functional outcome and probably lower costs. We suggest that one-stage revision for C. albicans peri-prosthetic infection may be successful even without preoperative fungal identification. LEVEL OF EVIDENCE: Level IV-Historical cases.

Diagnostic accuracy of intra-articular C-reactive protein assay in periprosthetic knee joint infection--a preliminary study.

BACKGROUND: Periprosthetic joint infection often raises diagnostic challenges, as the published criteria are heterogeneous. New markers for predicting periprosthetic infection have been evaluated. Here, we assessed one of these markers, C-reactive protein (CRP), in joint fluid. HYPOTHESIS: We hypothesised that intra-articular CRP levels would perform better than serum CRP concentrations in diagnosing knee prosthesis infection. PATIENTS AND METHODS: We prospectively included 30 patients including 10 with native-knee effusions, 11 with prosthetic-knee aseptic effusions, and 11 with prosthetic-knee infection defined using 2011 Musculoskeletal Society criteria. Serum CRP was assayed using turbidimetry or nephelometry and intra-articular CRP using nephelometry. Appropriate statistical tests were performed to compare the three groups; P values < 0.05 were considered significant. RESULTS: Serum and intra-articular CRP levels were 5- to 16-fold higher in the group with periprosthetic infection than in the other two groups. Although the areas under the ROC curves were not significantly different, the likelihood ratios associated with the selected cut-offs suggested superiority of intra-articular CRP: a value > 2.78 mg/L suggested possible infection (100% sensitivity and 82% specificity) and a value > 5.37 mg/L probable infection (90% sensitivity and 91% specificity). DISCUSSION: Our findings suggest a possible role for intra-articular CRP assay in diagnosing knee prosthesis infection and perhaps periprosthetic infection at any site. LEVEL OF EVIDENCE: Level III, diagnostic study, development of a diagnostic criterion in consecutive patients comparatively to a reference standard.

Phyllodes tumours of the breast diagnosed as B3 category on image-guided 14-gauge core biopsy: analysis of 51 cases from a single institution and review of the literature.

AIMS: Image-guided 14-gauge (G) core biopsy (CB) has been shown to be an accurate method providing histological diagnosis of breast lesions. The purpose of this study was to evaluate the reliability of image-guided 14-G CB in the diagnosis of phyllodes tumours (PT) reported as B3 category and its accuracy in distinguishing this lesion from fibroadenomas (FA). MATERIALS AND METHODS: The records of 10 000 image-guided 14-G CB of the breast performed from January 2001 to August 2011 at the Diagnostic Senology Unit of Careggi University Hospital were reviewed; 2554 (25.5%) were fibroepithelial lesions: 56 of them (2%) were diagnosed as PT and reported as B3 category. The database of the Pathological Anatomy Unit of Careggi University Hospital was then searched to verify the histological diagnosis after surgical excision. Fifty-one cases of PT diagnosed as B3 category in 51 women were included in the present study. RESULTS: Of the 51 cases of PT diagnosed as B3 category on 14-G CB, 39 (76.5%) lesions were confirmed as PT on SE (30, 4 and 5 as benign, borderline and malignant PT respectively) with a PPV of 76.5%. Twelve lesions (23.5%) were diagnosed as FA after surgical excision. CONCLUSIONS: Our study shows that 14-G CB is a valuable tool, in a preoperative setting, in diagnosing PT.

Radial scar without associated atypical epithelial proliferation on image-guided 14-gauge needle core biopsy: analysis of 49 cases from a single-centre and review of the literature.

The purpose of this study was to evaluate the reliability of image-guided 14-gauge needle core biopsy in the diagnosis of radial scar without associated atypical epithelial proliferation, by comparison with definitive histological diagnosis on surgical excision. The records of 8792 consecutive image-guided 14-gauge needle core biopsy of the breast performed from January 1996 to December 2009 were reviewed. Forty-nine cases of radial scar without associated atypical epithelial proliferation were identified and compared with definitive histological diagnosis on surgical excision. The definitive histological diagnosis on surgical excision confirmed the results of image-guided 14-gauge needle core biopsy in 36 of 49 cases (73.5%), in 9 cases (18.3%) radial scar was associated with atypical epithelial proliferation, while 4 cases out of 49 cases were upgraded to carcinoma (3 cases of ductal carcinoma in situ and one case of invasive lobular carcinoma), with an underestimation rate of 8.2%. A diagnosis of radial scar without associated atypical epithelial proliferation on image-guided 14-gauge needle core biopsy does not exclude a malignancy on surgical excision; consequently during the multidisciplinary discussion further assessment by surgical excision or vacuum-assisted excision, as recently reported, needs to be considered to obtain a definitive histological diagnosis.

Comparison of microbiological results of needle puncture vs. superficial swab in infected diabetic foot ulcer with osteomyelitis.

AIM: To study prospectively two methods for the bacteriological diagnosis of osteomyelitis related to diabetic foot ulcer: needle puncture performed across normal skin surrounding the foot ulcer and superficial swabbing of the ulcer. PATIENTS AND METHODS: Diabetic patients with a foot ulcer complicated by bone or joint infection, as detected by X-ray imaging, were included in the study. Ulcer swabbing and needle puncture were performed in each patient. To reach the tissue nearest the bone surface, needle puncture was guided by X-ray imaging and the drop of fluid obtained by aspiration was used for both aerobic and anaerobic bacterial culture. RESULTS: Twenty-one diabetic patients were included. The mean number of microorganisms isolated by needle puncture was significantly lower compared with that obtained by superficial swabbing: 1.09 vs. 2.04 (P < 0.02). Three bacterial species were isolated by needle puncture only in one patient while three or more bacterial isolates were obtained by superficial swabbing in six patients. No bacterial isolate was detected in five patients by needle puncture and in two patients by superficial swabbing. Staphylococcus aureus accounted for 70% of cases (seven patients) when a single bacterial species was obtained by needle puncture. After needle puncture, no wound complication or infection was observed. CONCLUSION: Culture of samples obtained by needle puncture revealed one or two bacterial isolates in two-thirds of diabetic patients with osteomyelitis following foot ulcer. Given the lack of complications, this invasive diagnostic technique should be considered for deep direct sampling in diabetic patients with osteomyelitis related to foot ulcer when surgical debridement is contraindicated or delayed.

[Difficulties and reproducibility of radiological measurement of the proximal tibial axis according to Lévigne]. / Difficultés et reproductibilité de la mesure radiographique de l'axe épiphysaire proximal du tibia selon la technique de Lévigne.

PURPOSE OF THE STUDY: The angle between the anatomic axis of the tibia and the tangent to the superior borders of the tibial plateaus is, on average, tilted 3 degrees in the varus position. If there is no bone wear, this angle measures the constitutional epiphyseal axis of the proximal tibia. When degenerative joint disease modifies the aspect of the tibial plateaus, this angle measures the sum of the constitutional varus and the bone wear, without distinguishing between the two. It is known however that the respective contribution of these two deformations can have therapeutic implications, particularly when tibial osteotomy for valgus correction or implantation of a unicompartmental prosthesis is proposed. Lévigne proposed a radiographic measurement of the proximal tibial axis to distinguish between these two sources of tibial deformation. We studied the intra- and interobserver reproducibility of these measurements. MATERIAL AND METHODS: Fifty volunteers free of knee disease were chosen at random among a population of patients undergoing upper limb surgery. All patients provided their informed consent for participation in the study. Full-limb radiographs of one lower limb (chosen at random) were obtained using a standardized technique. The proximal tibial axis was measured according to the Lévigne technique using a manual goniometer graduated in degrees. One operator performed two series of measures independently on the same films. Two other operators performed a series of measurements on each film. The intra- and inter-observer reproducibility was determined with the interclass coefficient of correlation (rho). RESULTS: The proximal epiphyseal axis of the tibia could not be determined on 7 to 18 films, depending on the operator. All three operators were able to make the all measurements (four per film) for only 25 patients. The mean epiphyseal axis varied from 2.5 degrees to 4.7 degrees for the four series of measurements. Intra-observer reproducibility was considered good (rho=0.62). Inter-observer reproducibility was considered moderate (rho=0.41). DISCUSSION: The Lévigne technique is to our knowledge the only method described in the literature distinguishing the relative contribution of constitutional varus and bone wear of the proximal tibia. According to the advocates of this method, the angle between the epiphyseal axis linking the center of the tibial plateaus and the center of the proximal growth cartilage scare, and the anatomic axis of the tibia is a measurement of constitutional varus. The average is 3 degrees . The angle between a line perpendicular to the epiphyseal axis and the tangent of the superior borders of the tibial plateaus measures the deformation related to bone wear. In the present work, we found that this technique enables acceptable intra-observer reproducibility but that inter-observer reproducibility is low. The differences observed are certainly related to uncertain identification of the growth cartilage scar. This illustrates the difficulty in generalizing this technique for measuring healthy knees. Such difficulties would be even greater for degenerative knees. CONCLUSION: The Lévigne technique does not appear to be a reliable method for defining indications for different surgical procedures according to the morphology of the proximal tibia.

[Total hip replacement prosthesis infected by Mycobacterium tuberculous]. / Prothèse totale de hanche infectée à Mycobacterium tuberculosis.

We examined the diagnostic and therapeutic approaches used for two patients with loosened total hip prostheses who developed Mycobacterium tuberculosis infection. Revision total hip arthroplasty (THA) was performed in one patient. The prosthesis was left in situ in the second patient due to lack of sufficient bone stock. Medical treatment was given. The diagnosis was established on direct examination of bacteriological samples and culture on specific media. Polymerase chain reaction identified the Mycobacterium tuberculosis complex. Non-specific granulomas were observed on the histology sections. For us, management of overt tuberculosis involving a THA depends on the quality of the fixation. If the prosthesis remains stable, medical treatment can be sufficient. If the prosthesis loosens, definitive ablation must be considered with possible revision THA later. Exceptionally, a loosened implant may be left in situ if the remaining bone stock is insufficient. Minimal duration of anti-tuberulosis treatment is six months.

No drainage does not increase complication risk after total knee prosthesis implantation: a prospective, comparative, randomized study.

Sixty patients were operated on for primary gonarthrosis by means of a cemented, posterior cruciate preserving total knee and were randomly allocated to postoperative drainage or nondrainage. The primary criterion was duration of hospital stay. Secondary criteria included serial evaluation of knee pain, knee flexion, knee circumference, calculated blood loss after 7 days, complications, reoperations, and the need for blood transfusions. There was no difference between the two groups in any of the criteria during the entire follow-up. There was a nonsignificant trend to a decreased calculated blood loss in the nondrained group and significantly less transfused blood units in the nondrained group. Lack of drainage does not increase complication risk after total knee prosthesis implantation. We therefore recommend using no routine drainage after this procedure.

[Navigated implantation of total knee endoprostheses--a comparative study with conventional instrumentation]. / Navigiert implantierte Knietotalendoprothesen--Eine Vergleichsstudie zum konventionellen Instrumentarium.

OBJECTIVE: A navigation system should improve the quality of a total knee prosthesis implantation in comparison to the classical, surgeon-controlled operative technique. METHODS: The authors have implanted 40 knee total prostheses with an optical infrared navigation system (Orthopilot AESCULAP, Tuttlingen--group A). The quality of implantation was studied on postoperative long leg AP and lateral X-rays, and compared to a control group of 40 computer-paired total knee prostheses o the same model (Search Prosthesis, AESCULAP, Tuttlingen) implanted with a classical, surgeon-controlled technique (group B). RESULTS: An optimal mechanical femorotibial angle (3 degrees valgus to 3 degrees varus) was obtained by 33 cases in group A and 31 cases in group B (p > 0.05). Better results were seen for the coronal and sagittal orientation of both tibial and femoral components in group A. Globally, 26 cases of the group A and 12 cases of the group B were implanted in an optimal manner for all studied criteria (p < 0.01). CONCLUSIONS: The used navigation system allows a significant improvement of the quality of implantation of a knee total prosthesis in comparison to a classical, surgeon-controlled instrumentation. Long-term outcome could be consequently improved.

[Histologic microbiopsy with 14 G needle in the diagnosis of breast lesions. Experience with 1000 cases]. / La microbiopsia istologica con ago da 14 Gauges nella diagnosi delle lesioni mammarie. Esperienza su 1000 casi.

PURPOSE: We report our experience with large core biopsy (LCB: 14-Gauge needles) of questionable or suspicious breast lesions detected at mammography and/or US. All biopsies were performed under instrumental guidance. We also report on technique, costs, time, advantages and disadvantages of the method and, finally, give precise indications on when and why large core biopsy is needed. MATERIAL AND METHODS: From january 1996 to may 2000 we performed 1000 microhistologic biopsies on breast lesions at the Unità Integrata di Senologia, Azienda Ospedaliera Careggi, Florence; 650 (65%) were non palpable lesions. Large core needles were used (14-Gauge caliber). In the majority of cases (70%) we used US guidance, in the others a stereotactic guidance was employed. RESULTS: Microhistologic biopsy allowed accurate characterization in most cases. Inadequate samples were obtained in 15 cases. The false negative rate was 6%. Surgery was needed to characterize the lesion unquestionably in 13 cases only. CONCLUSION: In agreement with literature reports, our results confirm large core biopsy as an adequate alternative to surgical biopsy and, to some extent, to FNAC, thanks to its moderate invasiveness, low costs, short execution time, little patient discomfort and high sensitivity (93.98%) and specificity (99.7%).

[Trapezometacarpal ligamentoplasty: personal technique]. / Ligamentoplastie trapézométacarpienne: technique personnelle.

We describe a new procedure of trapeziometacarpal ligamentoplasty. This ligamentoplasty is both passive and active. The operation is performed in three stages: (1) Transfert of part of the abductor pollicis longus in a posterior and distal direction; (2) Transfert of the radial part of the extensor carpi radialis longus into the proximal first metacarpal; (3) Forming a loop around the flexor carpi radialis tendon with a distally inserted slip of abductor pollicis longus.

Computer-assisted implantation of total knee prostheses: a case-control comparative study with classical instrumentation.

A navigation system should improve the quality of a total knee prosthesis implantation in comparison to that obtained with the classical, surgeon-controlled operative technique. The authors implanted 30 total knee prostheses with an infrared navigation system (Orthopilot, Aesculap, Tuttlingen, Germany). The quality of implantation was studied on postoperative long-leg coronal and lateral X-rays, and compared to a control group of 30 matched-paired total knee prostheses of the same type (Search prosthesis, Aesculap, Tuttlingen, Germany) implanted with a classical, surgeon-controlled technique. An optimal mechanical femorotibial angle (177 to 183 degrees) was obtained in 25 cases in the study group and 21 cases in the control group (p > 0.05). Similar differences were seen for the coronal and sagittal orientations of both tibial and femoral components. Globally, 23 cases in the study group and 8 cases in the control group were implanted in an optimal manner for all studied criteria (p < 0.001). The navigation system used allows a significant improvement in the quality of implantation of a total knee prosthesis in comparison to that obtained with a classical, surgeon-controlled instrumentation, and long-term outcome could consequently be improved.

[Computer-assisted implantation of a total knee arthroplasty: a case-controlled study in comparison with classical instrumentation]. / Implantation d'une prothèse totale de genou assistée par ordinateur.

PURPOSE OF THE STUDY: The quality of total knee arthroplasty (TKA) implantation is an essential factor determining long-term outcome. Computer-assisted implantation could improve quality compared with conventional manual instrumentation. MATERIAL AND METHODS: We studied the radiographic quality of TKA implantation in 100 patients with primary degenerative knee disease who underwent a computer-assisted procedure guided by an informatic navigation system without imagery (group A) or a conventional manual procedure (group B). The two groups were matched for age, sex, initial frontal mechanical tibiofemoral angle and severity of the degenerative lesions. Postoperative telemetry was used in accordance with the Knee Society guidelines to measure the frontal mechanical tibiofemoral angle and the frontal and sagittal tilt of the tibial and femoral components. The number of optimal implantations for the five measured criteria was chosen as the main study criterion. The two groups were compared using the chi-squared test with statistical significance set at 5% and power at 80%. RESULTS: Globally, implantation of the prosthesis was considered to be optimal in 33 patients in group A and in 15 in group B (p<0.001). Mean angles were not different between the two groups, except for sagittal tilt of the femoral piece. The frontal mechanical tibiofemoral angle was considered optimal in 47 patients in group A and in 39 in group B (p<0.05). A significant improvement in the quality of the implantation was also found in group A for frontal tilt of the femoral piece (p=0.05), frontal tilt of the tibial piece (p<0.05) and sagittal tilt of the tibial piece (p<0.001). No particular peroperative difficulty or complication was related to the navigation system. DISCUSSION AND CONCLUSION: The navigation system allowed a significant improvement in the quality of implantation of TKA compared with conventional instrumentation controlled by the surgeon's hand and eye. Only minimal changes in the operative technique are necessary and standard preoperative investigations remain unchanged. Long-term survival of prostheses implanted with this system could thus be improved compared with manually implanted TKA. The system used here does not involve preoperative imaging and allows a precision to the order of 1 degree for angles and 1 mm for lengths.