Functional recovery after total hip/knee replacement in obese people: A systematic review.

OBJECTIVE: Several studies have investigated the influence of body mass index (BMI) on functional gain after total hip replacement (THR) or total knee replacement (TKR) in osteoarthritis, with contradictory results. This systematic literature review was conducted to ascertain whether obesity affects functional recovery after THR or TKR in the short (<1 year), medium (<3 years) and long term (>3 years). METHODS: The study was registered with PROSPERO and conducted according to the PRISMA guidelines. A systematic literature search was conducted across Medline and EMBASE databases for articles published between 1980 and 2020 that investigated patient-reported measures of functional recovery after THR and TKR in participants with osteoarthritis and obesity (defined as BMI ≥30 kg/m2). RESULTS: Twenty-six articles reporting on 68,840 persons (34,955 for THR and 33,885 for TKR) were included in the final analysis: 5 case-control studies, 21 cohort studies (9 for THR only, 10 for TKR only and 2 for both). The average minimum follow-up was 36.4 months, ranging from 6 weeks to 10 years. Most studies found significantly lower pre-operative patient-reported functional scores for participants with obesity. After THR, there was a small difference in functional recovery in favor of those without obesity in the short term (<6 months), but the difference remained below the minimal clinically important difference (MCID) threshold and disappeared in the medium and long term. After TKR, functional recovery was better for those with obesity than those without in the first year, similar until the third year, and then decreased thereafter. CONCLUSIONS: Although there is a paucity of high-quality evidence, our findings show substantial functional gains in people with obesity after total joint replacement. Functional recovery after THR or TKR does not significantly differ, or only slightly differs, between those with and without obesity, and the difference in functional gain is not clinically important. PROSPERO NUMBER: CRD42018112919.

Gluteus maximus tendon transfer for chronic abductor insufficiency: the Geneva technique.

INTRODUCTION: The treatment options of chronic abductor insufficiency in the setting of muscle degeneration, are limited and technically demanding. We present the outcomes of a salvage technique for unreconstructable, chronic abductor tears performed by a single surgeon. METHODS: We retrospectively evaluated 38 patients who were surgically managed for chronic abductor insufficiency. Patients without hip implants and patients following primary or revision total hip arthroplasty (THA) were involved. All patients had a Trendelenburg gait, impaired muscle strength of abduction (⩽M4) and fatty degeneration of muscles (Goutallier ⩾3). They underwent transfer of a flap of the anterior third of gluteus maximus to the greater trochanter that was sutured under the slightly mobilised vastus lateralis. The level of pain, functional scores, muscle strength and Trendelenburg gait were re-evaluated at 12 postoperative months. RESULTS: The mean age of patients was 70.2 years. 10 patients received the tendon transfer on a native hip, 6 following primary THA and 22 after revision THA. The mean pain level (3.2 vs. 7, p < 0.001) and Harris Hip Score (80.2 vs. 41.6, p < 0.001) and the median abductor strength (4 vs. 3, p < 0.001) was significantly improved compared to the preoperative scores. 26 patients demonstrated negative and 12 positive Trendelenburg sign at 12 postoperative months. No serious complications were reported. CONCLUSIONS: This salvage technique improved the strength of abduction and functional results and reduced the level of pain in 80% of patients with chronic abductor tears. The short-term outcomes of the procedure were favourable; however, further evaluation is needed.

Enterococci in orthopaedic infections: Who is at risk getting infected?

Some orthopaedic patients might be at risk for enterococcal infections and might benefit from adapted perioperative prophylaxis. METHODS: We performed a single-center cohort of adult patients with orthopaedic infections. RESULTS: Among 2740 infection episodes, 665 surgeries (24%) involved osteosynthesis material, including total joint arthroplasties. The recommended perioperative prophylaxis was cefuroxime (or vancomycin in case of documented MRSA body carriage). Patients had received antibiotic therapy before surgery in 1167 episodes (43%); among them with potential anti-enterococcal activity (penicillins, glycopeptides, imipenem, linezolid, daptomycin, aminoglycosids, tetracyclins) in 725 (62%) cases. Overall, enterococci were identified in intraoperative samples of 100 different infections (3.6%) (Enterococcus faecalis, 95; Enterococcus faecium, 2; and other enterococci, 3). However, only 15/100 (15%) enterococcal infections were monomicrobial and 19 were nosocomial (19/2740; 0.7%), of which 15 had previous cephalosporin perioperative prophylaxis without other antibiotic exposure. This association to prior cephalosporin use was significant (Pearson-χ2-test; 148/2640 vs. 15/100, p < 0.01). By multivariate analysis, the presence of diabetic foot infection (odds ratio 1.9, 95% confidence interval 1.2-2.9), and polymicrobial infection (OR 6.0, 95%CI 3.9-9.4) were the main predictors of enterococcal infection, while sex, age, and type of material were not. CONCLUSIONS: Community-acquired or nosocomial enterococcal infections in orthopaedic surgery are mostly polymicrobial, rare and very seldom attributed to a nosocomial origin. Thus, even if they are formally associated with prior cephalosporin use, we do not see a rational for changing our antibiotic prophylaxis.

Are antibiotic-resistant pathogens more common in subsequent episodes of diabetic foot infection?

BACKGROUND: After antibiotic therapy of an initial diabetic foot infection (DFI), pathogens isolated from subsequent episodes might become more resistant to commonly prescribed antibiotics. If so, this might require a modification of the current recommendations for the selection of empiric antibiotic therapy. This study investigated whether the Infectious Diseases Society of America (IDSA) DFI guideline recommendations should be modified based on the number of past DFI episodes. METHODS: This was a single-centre retrospective cohort survey of DFI patients seen during the years 2010 to 2016. RESULTS: A total 1018 episodes of DFI in 482 adult patients were identified. These patients were followed-up for a median of 3.3 years after the first DFI episode. The total number of episodes was 2257 and the median interval between recurrent episodes was 7.6 months. Among the recurrent DFIs, the causative pathogens were the same as in the previous episode in only 43% of cases (158/365). Staphylococcus aureus was the predominant pathogen in all episodes (range 1 to 13 episodes) and was not more prevalent with the increasing number of episodes. DFIs were treated with systemic antibiotics for a median duration of 20 days (interquartile range 11-35 days). Overall, there was no significant increase in the incidence of antibiotic resistance to methicillin, rifampicin, clindamycin, or ciprofloxacin over the episodes (Pearson's Chi-square test p-values of 0.76, 1.00, 0.06, and 0.46, respectively; corresponding p-values for trend of 0.21, 0.27, 0.38, and 0.08, respectively). CONCLUSIONS: After the successful treatment of a DFI, recurrent episodes are frequent. A history of a previous DFI episode did not predict a greater likelihood of any antibiotic-resistant isolate in subsequent episodes. Thus, broadening the spectrum of empiric antibiotic therapy for recurrent episodes of DFI does not appear necessary.

Comparison of dual-mobility cup and unipolar cup for prevention of dislocation after revision total hip arthroplasty.

Background and purpose - Revision total hip arthroplasty (THA) is associated with higher dislocation rates than primary THA. We compared the risk of dislocation within 6 months and all-cause re-revision during the whole study period using either the dual-mobility cup or the unipolar cup. Methods - We used a prospective hospital registry-based cohort including all total and cup-only revision THAs performed between 2003 and 2013. The cups used were either dual-mobility or unipolar; the choice was made according to the preference of the surgeon. 316 revision THAs were included. The mean age of the cohort was 69 (25-98) years and 160 THAs (51%) were performed in women. The dual-mobility group (group 1) included 150 THAs (48%) and the mean length of follow-up was 31 (0-128) months. The unipolar group (group 2) included 166 THAs (53%) and the mean length of follow-up was 52 (0-136) months. Results - The incidence of dislocation within 6 months was significantly lower with the dual-mobility cup than with the unipolar cup (2.7% vs. 7.8%). The unadjusted risk ratio (RR) was 0.34 (95% CI: 0.11-1.02) and the adjusted RR was 0.28 (95% CI: 0.09-0.87). The number of patients needed to treat with a dual-mobility cup in order to prevent 1 case of dislocation was 19. The unadjusted incidence rate ratio for all-cause re-revision in the dual-mobility group compared to the unipolar group was 0.6 (95% CI: 0.3-1.4). Interpretation - Use of a dual-mobility rather than a unipolar cup in revision THA reduced the risk of dislocation within 6 months.