[Management of an infection associated with a prosthetic arthroplasty: the necessity of collaboration between surgeon and infectiologist]. / Prise en charge des infections d'arthroplasties prothétiques une collaboration entre chirurgiens et infectiologues.

The total number of total knee and hip joint arthroplasties is constinuously rising, due to an increasing population of physically active elderly patients. For primary elective arthroplasties, the infection risk ranges between I and 2%, but equals to a high morbidity, costs and complications for the individual infected patient. Diagnosis and management of prosthetic joint infections are improving. We review the latest consensus on the diagnosis and management of these infections and reveal some insight in still debated issues.

[Community-acquired bacterial septic arthritis in adults: diagnosis and treatment]. / Arthrite septique bactérienne communautaire chez l'adulte: du diagnostic au traitement.

The diagnosis of acute native joint bacterial infection can be difficult, because of its non- specific clinical and biological manifestation. Its management is often an emergency. Following a joint puncture, early joint lavage is performed, either by surgical drainage or by repeated arthrocentesis; and accompanied by systemic antibiotics, of which the ideal duration and route of administration remains unknown. The postoperative care is characterized by joint mobilization to avoid joint stiffening.

[Deep soft tissue infections]. / Infections profondes des tissus mous.

The clinical presentations of deep soft tissue infections can, initially, mimicry superficial skin infections such as erysipelas. However, a rapidly deteriorating health status, the spreading of the lesions and the lack of clear visual limitation of the infection on the skin are hallmarks of a more severe underlying infection, which may endanger patients' life. An immediate adequate multidisciplinary approach to therapy within a few hours is mandatory. The first step is surgical exploration with debridement of all infected tissues, accompanied by antibiotic therapy and additional supportive measures. Despite progress in the understanding of the physiopathology, the delay between suspicion of diagnosis and surgical exploration remains critical. Because of the low incidence of such severe infections, only multicenter studies might reveal deeper insights of optimal therapeutic strategies in the future and for possible improved patients' survival.

Short duration of antibiotic prophylaxis in open fractures does not enhance risk of subsequent infection.

We undertook a retrospective case-control study to assess the clinical variables associated with infections in open fractures. A total of 1492 open fractures were retrieved; these were Gustilo and Anderson grade I in 663 (44.4%), grade II in 370 (24.8%), grade III in 310 (20.8%) and unclassifiable in 149 (10.0%). The median duration of prophylaxis was three days (interquartile range (IQR) 1 to 3), and the median number of surgical interventions was two (1 to 9). We identified 54 infections (3.6%) occurring at a median of ten days (IQR 5 to 20) after trauma. Pathogens intrinsically resistant to the empirical antibiotic regimen used (enterococci, Enterobacter spp, Pseudomonas spp) were documented in 35 of 49 cases (71%). In multivariable regression analyses, grade III fractures and vascular injury or compartment syndrome were significantly associated with infection. Overall, compared with one day of antibiotic treatment, two to three days (odds ratio (OR) 0.6 (95% confidence interval (CI) 0.2 to 2.0)), four to five days (OR 1.2 (95% CI 0.3 to 4.9)), or > five days (OR 1.4 (95% CI 0.4 to 4.4)) did not show any significant differences in the infection risk. These results were similar when multivariable analysis was performed for grade III fractures only (OR 0.3 (95% CI 0.1 to 3.4); OR 0.6 (95% CI 0.2 to 2.1); and OR 1.7 (95% CI 0.5 to 6.2), respectively). Infection in open fractures is related to the extent of tissue damage but not to the duration of prophylactic antibiotic therapy. Even for grade III fractures, a one-day course of prophylactic antibiotics might be as effective as prolonged prophylaxis.

[Where are we in the treatment of chronic osteomyelitis?]. / Où en est-on dans le traitement médical des ostéomyélites chroniques?

Chronic osteomyelitis is a multifaceted bacterial infection with common features, which requires surgery for remission. The duration and modality of concomitant administration of antibiotic agents for adult patients is still based on expert opinions. The traditional recommendation of 6 to 12 weeks of antibiotic therapy with intravenous administration for at least the first 2 weeks is more and more challenged in favor of an oral antibiotic treatment with selected agents from the start. There is no evidence that the total duration of antibiotic therapy for more than 6-12 weeks improves outcome, when compared with shorter regimens. External advice from an expert team with combined surgeons and infectious disease physicians may help to reduce antibiotic consumption in a cost-effective way.

Associations between gait and clinical parameters in patients with severe knee osteoarthritis: a multiple correspondence analysis.

BACKGROUND: Given the complexity of the gait of patients with knee osteoarthritis, a multiple correspondence analysis may be helpful to optimise the extraction of relevant gait and clinical information. Therefore, the aims of this study are to identify the main associations with clinical and gait biomechanical parameters and to evaluate whether there are more specific knee osteoarthritis groups with different gait profiles. METHODS: Ninety patients with severe knee osteoarthritis and twenty-six healthy individuals participated in this study. Pain and function were assessed with the WOMAC Index; knee joint deformity was assessed by the hip-knee-ankle angle on full-limb radiography; and full body gait analysis was performed with a motion analysis system and force plates. FINDINGS: Using multiple correspondence analysis, two categories of gait parameters that best explain the gait variance of patients with knee osteoarthritis were highlighted. The forward displacement category is composed of the parameters speed, stride length, hip flexion and knee flexion. The frontal category is composed of the parameters thorax obliquity and knee adductor moments. Moreover, based on these parameters, four distinct gait profiles were identified: two gait profiles were associated with knee varus deformities, increased thorax obliquity and different forward displacements, while two gait profiles were associated with valgus deformities and different forward displacements. INTERPRETATION: These gait parameters can be used to simplify the characterisation of the gait of the knee osteoarthritis population. Patients in varus profiles increase thorax obliquity on the stance limb and may reduce forward displacement. Patients in valgus profiles, however, only reduce forward displacement.

[From aviation to surgery: the challenge of safety]. / De l'aviation à la chirurgie: le défi de la sécurité.

Medical errors result in 44,000 to 98,000 deaths per year in the United States of America. Within the surgical specialties, half of these errors occur in the operating room. The origin of these errors is multifactorial, and is generally associated with problems in communication and teamwork. In order to improve safety in the operating room, many hospitals now propose to the medical staff "crew resource management" (CRM) training programs inspired by the aviation industry. This approach favors a better utilization of surgical checklists, improves efficiency during chirurgical interventions, and reduces patient mortality. In October 2009 we introduced a CRM course within the department of surgery at the Geneva University Hospitals. We are presenting this program as well as the first results following its application.

[Patient information and informed consent in orthopaedic surgery: is it possible?]. / Information et consentement éclairé des patients en orthopédie: mission (im)possible?

Informed consent of the patient is a prerequisite for all surgical intervention. However, there is no consensus as to the quantity, manner and type of information that must be transmitted to the patient before an operation. Traditionally the patient receives information orally, but it is estimated that half of the information given by the physician is forgotten after 6 weeks. More and more complementary written documents have been proposed, but often they are beyond the understanding of the patient. Thus, other approaches are necessary. The models of communication that favor the partnership offer the best compromise between the principles of patient autonomy and that which benefits the treatment, allowing the patient to make the best decision.

[Open fractures of the tibia in the adult: surgical treatment and complications]. / Fractures ouvertes de la diaphyse tibiale chez l'adulte: prise en charge chirurgicale et complications.

Open tibial shaft fractures represent high-energy trauma and are associated with a substantial risk of complications. Management is an emergency, and the first steps in treatment include antibiotic prophylaxis, tetanus booster, surgical debridement, irrigation of the wound and stabilization of the fracture. The Gustilo and Anderson classification helps to guide definitive treatment. Intramedullary nailing is the surgical technique of choice. An indirect approach utilizing external fixation is recommended for Gustilo IIIB and IIIC fractures. The most prevalent complications are compartment syndrome (10%), infection (2%-40% without antibiotics according to Gustilo grading, most notably in the presence of vascular lesions), aseptic nonunion (23%), venous thromboembolism (60% without prevention) and anterior knee pain (>50%).

[Dislocation of a total hip prosthesis: etiology and treatment]. / Luxation d'une arthroplastie totale de la hanche: étiologie et prise en charge.

Dislocation of a total hip prosthesis is a substantial burden in terms of morbidity and health care costs. The incidence of dislocation is highest during the first postoperative months but the risk persists throughout the entire life of the patient. The first dislocation is treated by an emergency closed reduction of the hip undergeneral anaesthesia, following which about three out of four patients will have a stable hip. In cases of recurrent dislocation the treatment is difficult, depending upon the time between surgery and dislocation, the identification of an etiologic factor, and the general status of the patient. Patients in which a specific cause can be identified have better results after surgical revision. When no causal factor is detected several surgical options are possible, but the results are less consistent.

Primary motor cortex involvement in Alzheimer disease.

In Alzheimer disease (AD) the involvement of entorhinal cortex, hippocampus, and associative cortical areas is well established. Regarding the involvement of the primary motor cortex the reported data are contradictory. In order to determine whether the primary motor cortex is involved in AD, the brains of 29 autopsy cases were studied, including, 17 cases with severe cortical AD-type changes with definite diagnoses of AD, 7 age-matched cases with discrete to moderate cortical AD-type changes, and 5 control cases without any AD-type cortical changes. Morphometric analysis of the cortical surface occupied by senile plaques (SPs) on beta-amyloid-immunostained sections and quantitative analysis of neurofibrillary tangles (NFTs) on Gallyas-stained sections was performed in 5 different cortical areas including the primary motor cortex. The percentage of cortical surface occupied by SPs was similar in all cortical areas, without significant difference and corresponded to 16.7% in entorhinal cortex, 21.3% in frontal associative, 16% in parietal associative, and 15.8% in primary motor cortex. The number of NFTs in the entorhinal cortex was significantly higher (41 per 0.4 mm2), compared with those in other cortical areas (20.5 in frontal, 17.9 in parietal and 11.5 in the primary motor cortex). Our findings indicate that the primary motor cortex is significantly involved in AD and suggest the appearance of motor dysfunction in late and terminal stages of the disease.

[An unknown after surgical lengthening of the femur in children: spontaneous postoperative parasitic lengthening]. / Une inconnue après allongement chirurgical du fémur chez l'enfant: l'allongement parasite spontané post-opératoire.

The authors have studied overgrowth or diminished growth seen in 54 femora lengthened surgically by a one-stage procedure between 1963 and 1979. Thirty six cases were of poliomyelitis. An overgrowth was regularly seen of the order of 2.5 p. 100- that is 11 mm on average. This stimulation of growth by lengthening was not related to age. It was more marked where there was severe involvement. In contrast, in 13 cases of congenital femoral abnormalities and 5 cases of miscellaneous diseases (Ollier's disease, neurofibromatosis, sequelae of septic arthritis) overgrowth or diminished growth have been observed. This phenomenon was not constant and could not be predicted.