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.

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.

Late preterm delivery in women with preterm prelabour rupture of membranes.

OBJECTIVE: To estimate maternal and neonatal outcomes in women with preterm prelabour rupture of membranes (PPROM) who delivered at 34+0 to 36+6 weeks' gestation, particularly in those who had an obstetrically indicated delivery. METHODS: We conducted a population-based study of late preterm singleton births complicated by PPROM, using data from the Nova Scotia Atlee Perinatal Database from 1988 to 2006. The study cohort was categorized by type of labour (spontaneous, induced, no labour), and each group's characteristics prior to delivery, and their outcomes were compared after accounting for potential confounding variables. RESULTS: From a total population of 164 384 pregnancies, 2618 deliveries were identified as having PPROM. Among these, 2180 (83.3%) delivered between 34+0 and 36+6 weeks' gestation. Adjusted analyses showed no differences in risk between those women entering labour spontaneously (n = 1296) and those with obstetrically indicated delivery (labour induction or Caesarean section without labour, n = 698). Additional adjusted analyses evaluating only women with obstetrically indicated delivery showed that rates of chorioamnionitis (OR 0.27; 95% CI 0.08 to 0.93), composite perinatal morbidity/mortality (OR 0.39; 95% CI 0.25 to 0.62), neonatal depression at birth (OR 0.22; 95% CI 0.06 to 0.86), and respiratory distress syndrome (OR 0.17; 95% CI 0.06 to 0.47) were significantly lower in those delivering at 36 weeks (n = 458) than in those delivering at 34 to 35 weeks (n = 240). CONCLUSIONS: This large population-based study suggests that in pregnancies complicated by PPROM rates of adverse maternal and perinatal outcomes at 36 weeks' gestational age are at least comparable to those in pregnancies delivering at 34 to 35 weeks, and these rates may be further reduced by delivery after 36 completed weeks if spontaneous labour has not occurred.

Intramuscular stimulation vs sham needling for the treatment of chronic midportion Achilles tendinopathy: A randomized controlled clinical trial.

BACKGROUND: The insertion of filiform needles intramuscularly (a.k.a. intramuscular stimulation/dry needling) has been suggested as a possible treatment for various painful musculoskeletal conditions. Our aim was to answer the question, is intramuscular stimulation more effective than sham intramuscular stimulation/dry needling for the treatment of Achilles tendinopathy? METHODS: 52 participants with persistent midportion Achilles tendinopathy began and 46 completed one of three treatment protocols which were randomly assigned: (G3) a 12-week rehabilitation program of progressive tendon loading plus intramuscular stimulation (n = 25), (G2) the same rehabilitation program but with sham intramuscular stimulation (n = 19), or (G1) a reference group of rehabilitation program alone (as an additional control) (n = 8). The a priori primary outcome measure was change in VISA-A score at 12 weeks-VISA-A was also measured at 6 weeks, and at 6 and 12 months. Secondary outcome measures include the proportion of patients who rated themselves as much or very much improved (%), dorsiflexion range of motion (degrees), and tendon thickness (mm). RESULTS: The study retention was 94% at 12 weeks and 88% at 1 year. VISA-A score improved in all three groups over time (p<0.0001), with no significant difference among the three groups in VISA-A score at the start of the study (mean ± SD: G3 59 ± 13, G2 57 ± 17, G1 56 ± 22), at 12 weeks (G3 76 ± 14, G2 76 ± 15, G1 82 ± 11) or at any other timepoint. The percentage of patients who rated themselves as much or very much improved (i.e. treatment success) was not different after 12 weeks (G3 70%, G2 89%, G1 86% p = 0.94), or at 26 (p = 0.62) or 52 weeks (p = 0.71). No clinically significant effects of intervention group were observed in any of the secondary outcome measures. CONCLUSION: The addition of intramuscular stimulation to standard rehabilitation for Achilles tendinopathy did not result in any improvement over the expected clinical benefit achieved with exercise-based rehabilitation alone.

Mapping the stochastic sequence of individual ligand-receptor binding events to cellular activation: T cells act on the rare events.

T cell receptor (TCR) binding to agonist peptide major histocompatibility complex (pMHC) triggers signaling events that initiate T cell responses. This system is remarkably sensitive, requiring only a few binding events to successfully activate a cellular response. On average, activating pMHC ligands exhibit mean dwell times of at least a few seconds when bound to the TCR. However, a T cell accumulates pMHC-TCR interactions as a stochastic series of discrete, single-molecule binding events whose individual dwell times are broadly distributed. With activation occurring in response to only a handful of such binding events, individual cells are unlikely to experience the average binding time. Here, we mapped the ensemble of pMHC-TCR binding events in space and time while simultaneously monitoring cellular activation. Our findings revealed that T cell activation hinges on rare, long-dwell time binding events that are an order of magnitude longer than the average agonist pMHC-TCR dwell time. Furthermore, we observed that short pMHC-TCR binding events that were spatially correlated and temporally sequential led to cellular activation. These observations indicate that T cell antigen discrimination likely occurs by sensing the tail end of the pMHC-TCR binding dwell time distribution rather than its average properties.

3D Ultrasound Spine Image Selection Using Convolution Learning-to-Rank Algorithm.

3D Ultrasound imaging has become an important means of scoliosis assessment as it is a real-time, cost-effective and radiation-free imaging technique. However, the coronal images from different depths of a 3D ultrasound image have different imaging definitions. So there is a need to select the coronal image that would give the best image definition. Also, manual selection of coronal images is time-consuming and limited to the discretion and capability of the assessor. Therefore, in this paper, we have developed a convolution learning-to-rank algorithm to select the best ultrasound images automatically using raw ultrasound images. The ranking is done based on the curve angle of the spinal cord. Firstly, we approached the image selection problem as a ranking problem; ranked based on probability of an image to be a good image. Here, we use the RankNet, a pairwise learning-to-rank method, to rank the images automatically. Secondly, we replaced the backbone of the RankNet, which is the traditional artificial neural network (ANN), with convolution neural network (CNN) to improve the feature extracting ability for the successive iterations. The experimental result shows that the proposed convolutional RankNet achieves the perfect accuracy of 100% while conventional DenseNet achieved 35% only. This proves that the convolutional RankNet is more suitable to highlight the best quality of ultrasound image from multiple mediocre ones.

Apoptosis induced in HIV-1-exposed, resting CD4+ T cells subsequent to signaling through homing receptors is Fas/Fas ligand-mediated.

The hallmark of HIV-1 disease is the gradual disappearance of CD4+ T cells from the blood. The mechanism of this depletion, however, is still unclear. Evidence suggests that lymphocytes die in lymph nodes, not in blood, and that uninfected bystander cells are the predominant cells dying. Our and others' previous studies showed that the lymph node homing receptor, CD62 ligand (CD62L), and Fas are up-regulated on resting CD4+ T cells after HIV-1 binding and that these cells home to lymph nodes at an enhanced rate. During the homing process, signals are induced through various homing receptors, which in turn, induced many of the cells to undergo apoptosis after they entered the lymph nodes. The purpose of this study was to determine how the homing process induces apoptosis in HIV-1-exposed, resting CD4+ T cells. We found that signaling through CD62L up-regulated FasL. This resulted in apoptosis of only HIV-1-presignaled, resting CD4+ T cells, not normal CD4+ T cells. This homing receptor-induced apoptosis could be blocked by anti-FasL antibodies or soluble Fas, demonstrating that the Fas-FasL interaction caused the apoptotic event.

How many people have had a myocardial infarction? Prevalence estimated using historical hospital data.

BACKGROUND: Health administrative data are increasingly used to examine disease occurrence. However, health administrative data are typically available for a limited number of years - posing challenges for estimating disease prevalence and incidence. The objective of this study is to estimate the prevalence of people previously hospitalized with an acute myocardial infarction (AMI) using 17 years of hospital data and to create a registry of people with myocardial infarction. METHODS: Myocardial infarction prevalence in Ontario 2004 was estimated using four methods: 1) observed hospital admissions from 1988 to 2004; 2) observed (1988 to 2004) and extrapolated unobserved events (prior to 1988) using a "back tracing" method using Poisson models; 3) DisMod incidence-prevalence-mortality model; 4) self-reported heart disease from the population-based Canadian Community Health Survey (CCHS) in 2000/2001. Individual respondents of the CCHS were individually linked to hospital discharge records to examine the agreement between self-report and hospital AMI admission. RESULTS: 170,061 Ontario residents who were alive on March 31, 2004, and over age 20 years survived an AMI hospital admission between 1988 to 2004 (cumulative incidence 1.8%). This estimate increased to 2.03% (95% CI 2.01 to 2.05) after adding extrapolated cases that likely occurred before 1988. The estimated prevalence appeared stable with 5 to 10 years of historic hospital data. All 17 years of data were needed to create a reasonably complete registry (90% of estimated prevalent cases). The estimated prevalence using both DisMod and self-reported "heart attack" was higher (2.5% and 2.7% respectively). There was poor agreement between self-reported "heart attack" and the likelihood of having an observed AMI admission (sensitivity = 63.5%, positive predictive value = 54.3%). CONCLUSION: Estimating myocardial infarction prevalence using a limited number of years of hospital data is feasible, and validity increases when unobserved events are added to observed events. The "back tracing" method is simple, reliable, and produces a myocardial infarction registry with high estimated "completeness" for jurisdictions with linked hospital data.

Experimental validation of the GNRB® for measuring anterior tibial translation.

INTRODUCTION: The objective of this study was to validate the technique used to measure anterior tibial translation in cadaver knees using the GNRB® device by comparing it with the gold standard, the OrthoPilot® navigation system. HYPOTHESIS: Simultaneous measurement of anterior tibial translation by the GNRB® and the OrthoPilot® in the chosen experimental conditions will result in significant differences between devices. MATERIAL AND METHODS: Five fresh frozen cadavers were used. The knee was placed in 20° flexion. Four calibrated posterior-anterior forces (134N to 250N) were applied. For each applied force, the anterior tibial translation was measured simultaneously by both devices. Two conditions were analyzed: anterior cruciate ligament (ACL) intact and ACL transected. The primary criterion was anterior tibial translation at 250N. The measurements were compared using a paired Student's t-test and the correlation coefficient was calculated. Agreement between the two methods was determined using Bland-Altman plots. Consistency of the measurements was determined by calculating the intraclass correlation coefficient. RESULTS: For all applied forces and ligament conditions, the mean difference between the GNRB® and the navigation system was 0.1±1.7mm (n.s). Out of the 80 measurements taken, the difference between devices was less than ±2mm in 66 cases (82%). There was a strong correlation, good agreement and high consistency between the two measurement methods. DISCUSSION: The differences between the measurements taken by the GNRB® and the navigation system were small and likely have no clinical impact. We recommend using the GNRB® to evaluate anterior knee laxity. LEVEL OF EVIDENCE: II controlled laboratory study.

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.

Can a target zone safer than Lewinnek's safe zone be defined to prevent instability of total hip arthroplasties? Case-control study of 56 dislocated THA and 93 matched controls.

BACKGROUND: Various factors contribute to instability of total hip arthroplasty (THA), with implant orientation being a major contributor. We performed a case-control study with computed tomography (CT) data to determine whether: 1) orientation contributes to THA instability and 2) a safer target zone for stability than Lewinnek's classic safe zone can be defined. MATERIAL AND METHODS: We included prospectively 363 cases of THA dislocation that occurred during the calendar 2013 year in 24 participating hospitals. Of the 128 dislocations that occurred in patients who underwent THA at these centers, 56 (24 anterior, 32 posterior) had CT scans, thus were included in the analysis. The control group was matched 4:1 based on implant type, year of implantation, age, sex, bearing types and THA indication. Of the 428 matched control THA cases, 93 had CT scans. In all, the CT scans from 149 cases (56 unstable, 93 stable) were analyzed to determine the acetabular cup's inclination and anteversion, and the femoral stem's anteversion. RESULTS: In the unstable THA group, cup inclination was 46.9°±7.4°, cup anteversion was 20.4°±10.8° and stem anteversion was 14.2°±9.9°. In the stable THA group, cup inclination was 44.9°±5.3° (P=0.057), cup anteversion was 22.1°±5.1° (P=0.009) and stem anteversion was 13.4°±4.4° (P=0.362). The optimal total anteversion (cup+stem) of 40-60° was achieved in 16.5% of unstable THA cases and 13.9% of stable THA cases, thus this parameter does not predict stability (odds ratio [OR] of 0.40, P=0.144). The cup was positioned in Lewinnek's safe zone in 44.6% of patients in the unstable group and 68.2% of those in the stable group (OR 3.74, P=0.003). A target zone defined as 40-50° inclination and 15-30° anteversion was better able to distinguish between unstable cases (23.2%) and stable cases (71.6%) resulting in an OR of 13.91 (P<0.001). DISCUSSION: Implant positioning was the only risk factor for instability found in this study. Moreover, our findings reinforce the theory put forward by other authors that Lewinnek's safe zone is not specific enough to differentiate between stable and unstable THA implantations. The target zone for acetabular cups proposed here (40-50° inclination and 15°-30° anteversion) is related to a lower risk of instability. This orientation can be used as a guide, but must be combined with other technical elements to optimize stability. By balancing stability and biomechanics, the 40-50° inclination and 15°-30° anteversion target zone redefines the optimal positioning window. LEVEL OF EVIDENCE: III case-control study.

[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.

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.

Can the presence of an infection be predicted before a revision total hip arthroplasty? Preliminary study to establish an infection score.

INTRODUCTION: The diagnosis of periprosthetic joint infection can be challenging, in part because there is no universal diagnostic test. Current recommendations include several diagnostic criteria, and are mainly based on the results of deep microbiological samples; however, these only provide a diagnosis after surgery. A predictive infection score would improve the management of revision arthroplasty cases. The purpose of this study was to define a composite infection score using standard clinical, radiological and laboratory data that can be used to predict whether an infection is present before a total hip arthroplasty (THA) revision procedure. HYPOTHESIS: The infection score will make it possible to differentiate correctly between infected and non-infected patients in 75% of cases. MATERIAL AND METHODS: One hundred and four records from patients who underwent THA revision for any reason were analysed retrospectively: 43 with infection and 61 without infection. There were 54 men and 50 women with an average age of 70±12 years (range 30-90). A univariate analysis was performed to look for individual discriminating factors between the data in the medical records of infected and non-infected patients. A multivariate analysis subsequently integrated these factors together. A composite score was defined and its diagnostic effectiveness was evaluated as the percentage of correctly classified records, along with its sensitivity and specificity. RESULTS: The score consisted of the following individually weighed factors: body mass index, presence of diabetes, mechanical complication, wound healing disturbance and fever. This composite infection score was able to distinguish correctly between the infected patients (positive score) and non-infected patients (negative score) in 78% of cases; the sensitivity was 57% and the specificity 93%. DISCUSSION: Once this score is evaluated prospectively, it could be an important tool for defining the medical - surgical strategy during THA revision, no matter the reason for revision. LEVEL OF EVIDENCE: Level IV - retrospective study.

CD4 lymphocytes in the blood of HIV(+) individuals migrate rapidly to lymph nodes and bone marrow: support for homing theory of CD4 cell depletion.

The mechanism(s) by which human immunodeficiency virus (HIV) causes depletion of CD4 lymphocytes remains unknown. Evidence has been reported for a mechanism involving HIV binding to (and signaling) resting CD4 lymphocytes in lymphoid tissues, resulting in up-regulation of lymph node homing receptors and enhanced homing after these cells enter the blood, and induction of apoptosis in many of these cells during the homing process, caused by secondary signaling through homing receptors. Supportive evidence for this as a major pathogenic mechanism requires demonstration that CD4 lymphocytes in HIV(+) individuals do migrate to lymph nodes at enhanced rates. Studies herein show that freshly isolated CD4 lymphocytes labeled with (111)Indium and intravenously reinfused back into HIV(+) human donors do home to peripheral lymph nodes at rates two times faster than normal. They also home at enhanced rates to iliac and vertebral bone marrow. In contrast, two hepatitis B virus-infected subjects displayed less than normal rates of blood CD4 lymphocyte migration to peripheral lymph nodes and bone marrow. Furthermore, the increased CD4 lymphocyte homing rates in HIV(+) subjects returned to normal levels after effective, highly active antiretroviral therapy treatment, showing that the enhanced homing correlated with active HIV replication. This is the first direct demonstration of where and how fast CD4 lymphocytes in the blood traffic to tissues in normal and HIV-infected humans. The results support the theory that the disappearance of CD4 lymphocytes from the blood of HIV(+) patients is a result of their enhanced migration out of the blood (homing) and dying in extravascular tissues.

[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.

Post-arthroscopy septic arthritis: Current data and practical recommendations.

Septic arthritis develops after less than 1% of all arthroscopy procedures. The clinical symptoms may resemble those seen after uncomplicated arthroscopy, raising diagnostic challenges. The diagnosis rests on emergent joint aspiration with microscopic smear examination and prolonged culturing on specific media. Urgent therapeutic measures must be taken, including abundant arthroscopic lavage, synovectomy, and the concomitant administration of two effective antibiotics for at least 6 weeks. Preservation of implants or transplants is increasingly accepted, and repeated joint lavage is a component of the treatment strategy. After knee arthroscopy, infection is the most common complication; most cases occur after cruciate ligament reconstruction, and staphylococci are the predominant causative organisms. Emergent synovectomy with transplant preservation and appropriate antibiotic therapy ensures eradication of the infection in 85% of cases, with no adverse effect on final functional outcomes. After shoulder arthroscopy, infection is 10 times less common than neurological complications and occurs mainly after rotator cuff repair procedures; the diagnosis may be difficult and delayed if Propionibacterium acnes is the causative organism. The update presented here is based on both a literature review and a practice survey. The findings have been used to develop practical recommendations aimed at improving the management of post-arthroscopy infections, which are exceedingly rare but can induce devastating functional impairments.

Incomplete or absent acute phase response in some postoperative patients.

In a prospective study, 74 patients were admitted for an open fracture of the lower limb and treated by osteosynthesis. None of them presented infectious complication during the postoperative period. Among them, 67 exhibited a classical acute phase response. In 5 patients, the response was apparently incomplete since no serum C-reactive protein (CRP) rise was observed after the injury; i.e. CRP concentrations remained inferior to the detection limit of the assay used; in contrast, serum alpha-1 acid glycoprotein (AAG) concentrations were temporarily increased, a variation associated with a concomitant decrease of transthyretin (TTR) concentration. In 2 other patients, CRP and AAG levels were not significantly modified. The 7 patients did not suffer hepatic insufficiency or protein malnutrition. In our series, incomplete or absent acute phase response was not rare (prevalence 9%) and was not related to an increased risk of postoperative infection. In contrast to CRP, the TTR response, i.e. a transitory decrease, was observed in all the 7 patients.

Diagnostic value of C-reactive protein and transthyretin in bone infections of the lower limb.

In a prospective study, white and red blood cell counts, hematocrit, erythrocyte sedimentation rate (ESR), albumin, alpha-1 acid glycoprotein, C-reactive protein (CRP), and transthyretin (TTR) values were determined by serial measurements during 23 days in 80 patients with an open fracture of the lower limb. Postoperative reference profiles were defined in 74 patients without septic complications. In the six remaining patients, serum CRP and TTR concentrations were found efficient for the early diagnosis of postoperative infections: a CRP/TTR mass concentration ratio higher than 0.6 from the 8th day after surgery was sensitive (100%) and specific (93%). Variations of CRP and TTR concentrations often preceded the clinical diagnosis in patients with early infection. ESR was found unreliable with regard to postoperative infection because of its high dependence with respect to red blood cell count.

Comparison of reconstruction of the anterior cruciate ligament with and without a Kennedy ligament-augmentation device. A randomized, prospective study.

In a randomized, prospective study, sixty-four patients who were operated on for a torn anterior cruciate ligament were divided into two groups: thirty patients (the control group) had repair with the Marshall-MacIntosh technique alone, and thirty-four patients had repair with the same technique but with the addition of a Kennedy ligament-augmentation device. The preoperative characteristics were essentially identical in the two groups. The postoperative management, resumption of athletic activities, and occurrence of complications were also similar. All patients were followed for more than two years. No significant functional or clinical difference between the two groups was found with respect to residual laxity determined either from dynamic radiographs or with the KT-1000 arthrometer. There was no evidence that the addition of the Kennedy ligament-augmentation device gave results that were superior to those obtained with the Marshall-MacIntosh technique alone.