EULAR/EFORT recommendations for management of patients older than 50†years with a fragility fracture and prevention of subsequent fractures.

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Radiographic evaluation of posttraumatic osteoarthritis of the ankle: the Kellgren-Lawrence scale is reliable and correlates with clinical symptoms.

OBJECTIVE: To assess reliability and construct validity of the Kellgren-Lawrence (K&L) scale in posttraumatic ankle osteoarthritis (OA); additionally evaluate the validity of including tibiotalar tilting in the scale. METHOD: One-hundred and fifty ankle radiographs (75 patients, unilateral malleolar fractures) evaluated at average of 18 years after surgery. American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot (HF) score and pain (visual analog scale) were recorded. Grading of OA according to K&L criteria and identification of OA features was performed on standardized radiographs by four physicians. Minimal joint space width, sclerosis, and talar tilt angle were quantified by digital measurements. A modified K&L scale including talar tilting is presented. Validity of original and modified scale was evaluated and expressed as ability to (1) Identify those with clinical symptoms of ankle OA; and (2) Distinguish between different degrees of fracture severity. RESULTS: Inter- and intra-observer reliability of OA assessment according to K&L were good (ICC 0.61 and 0.75). Original and modified K&L grades significantly increased with decreasing AOFAS ankle-HF scores and greater pain. A talar-tilt angle > 2° compared with ≤ 2° in grade 3 was associated with significantly higher pain levels (VAS pain 4.2 vs 1.4, respectively; mean difference 2.8, 95% CI 0.5-5.1). More severe fracture patterns at time of surgery were more often in patients with the highest K&L grades. CONCLUSIONS: The K&L scale is a valid and reliable radiographic grading system for assessment of ankle OA. Inclusion of the talar tilt angle might allow for better differentiation with respect to clinical outcomes.

[Shoulder arthroplasty: the situation in 2014]. / Arthroplastie de l'épaule: le point en 2014.

Evolution of shoulder arthroplasty has led to mainly three types of implants: hemiarthroplasty, total shoulder arthroplasty and reverse shoulder arthroplasty. There is yet no clear consensus about indications for the different existing types of prothesis. The aim of this article is therefore to bring together and clarify the indications found in the current literature. Hemiarthroplasty, historically the first widely used implant, has lost much ground to total shoulder arthroplasty, and keeps its place only for specific situations. Total shoulder arthroplasty is mainly used for centered glenohumeral osteoarthritis, whereas reverse shoulder arthroplasty is indicated for most situations in which the rotator cuff or tuberoties are deficient.

[Incidence of major lower limb amputation in Geneva: twenty-one years of observation]. / Incidence de l'amputation majeure des membres inférieurs à Genève: vingt-et-un ans d'observation.

Between 1990 and 2010 the incidence of major lowerlimb amputations (by definition any level of amputation above the foot) in the canton of Geneva was 10.02 per 100,000 inhabitants/ year. The analysis of various population groups revealed that the presence of diabetes increased the relative risk of amputation by a factor of 20, and age 65 years or older by a factor of 9. During this 21 years period we observed a gradual decline in the incidence of amputation and an increased age at the time of amputation, despite the increasing prevalence of diabetes and an aging population. This was a reflection on the efforts of primary and secon- dary prevention, initiated in the 1980s in which Geneva was a pioneer.

[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.

[Pit falls in the emergency walk-in clinic: the spine]. / Pièges en orthopédie ambulatoire: rachis (3).

Spine is always a great deal in tramatology. Complete clinical exam associated to plain Xray is the best challenge. CT-scan is preferred when there is osteoarthritis. IRM is used to check ligaments ("coup du lapin") or for medullar contusion.

[Measures against surgical site infections in orthopaedic surgery]. / Prévention des infections postopératoires en orthopédie.

Orthopaedic surgery has low healthcare-associated infection incidences compared to other surgical disciplines. However, whenever they occur, these infections are associated with substantial morbidity, prolonged hospital stay, high costs, and difficulties of eradication with life-long recurrence risks. Among the many measures to prevent orthopaedic surgical site infections, only few are based on strong evidence, and there is insufficient evidence to ascertain which element is superior to any other. This highlights the need for multimodal approaches involving active post-discharge surveillance, as well as measures at every step of the care process; from the individual patient to department-wide interventions targeting all infections, and including antibiotic stewardship.

Socioeconomic and living conditions are determinants of hip fracture incidence and age occurrence among community-dwelling elderly.

UNLABELLED: In this prospective, 10-year study in community-dwelling elderly aged 50 years and over, hip fracture incidence and accordingly age at hip fracture were inversely associated with the area-level income, independently of the geographical area. Age at hip fracture also depended of marital status but in a gender-specific way. PURPOSE: The purpose of this study is to investigate the impact of socioeconomic and living conditions on hip fracture incidence and age occurrence among community-dwelling elderly. METHOD: Between January 1991 and December 2000, 2,454 hip fractures were recorded in community-dwelling adults aged 50 years and over in the Geneva University Hospital, State of Geneva, Switzerland. Median annual household income by postal code of residence (referred to as area-level income) based on the 1990 Census was used as a measure of socioeconomic condition and was stratified into tertiles (< 53,170; 53,170-58,678; and ≥ 58,678 CHF). Hip fracture incidence and age occurrence were calculated according to area-level income categories and adjusted for confounding factors among community-dwelling elderly. RESULTS: Independently of the geographical area (urban versus rural), community-dwelling persons residing in areas with the medium income category presented a lower hip fracture incidence [OR 0.91 (0.82-0.99), p = 0.049] compared to those from the lowest income category. Those in the highest income category had a hip fracture at a significant older age [+1.58 (0.55-2.61) year, p = 0.003] as compared to those in the lowest income category. Age at hip fracture also depended on marital status but in a gender-specific way, with married women fracturing earlier. CONCLUSIONS: These results indicate that incidence and age occurrence of hip fracture are influenced by area-level income and living conditions among community-dwelling elderly. Prevention programs may be encouraged in priority in communities with low income.

[Posterior dislocation of the shoulder, challenges in diagnosis and management]. / Luxation postérieure de l'épaule, défis diagnostiques et thérapeutiques.

Posterior glenohumeral dislocation is rare, accounting for less than 3% of all shoulder dislocations. Main etiologies are direct or indirect trauma, seizure and electrocution. The diagnosis is missed in 50 to 80% of the cases on initial presentation because of the rather subtle clinical signs compared to anterior dislocation and inadequate imaging. An unreduced posterior dislocation can lead to severely impairing complications such as recurrent instability, arthritis or avascular necrosis, requiring open reduction and complex surgery with a lower rate of success. The purpose of this article is to highlight and clarify the challenges when confronted with posterior dislocation in order to avoid misdiagnosis. Furthermore it aims to propose an adequate and comprehensible management from the initial diagnosis to the treatment.

[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.

[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.

[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%).

Risk factors for treatment failure in orthopedic device-related methicillin-resistant Staphylococcus aureus infection.

The purpose of this study was to determine the clinical and microbiological risk factors for treatment failure of methicillin-resistant Staphylococcus aureus (MRSA) orthopedic device-related infection (ODRI). A retrospective cohort study of patients with MRSA ODRI who were treated at Geneva University Hospitals between 2000 and 2008 was undertaken. Stored MRSA isolates were retrieved for genetic characterization and determination of the vancomycin minimum inhibitory concentration (MIC). Fifty-two patients were included, of whom 23 (44%) had joint arthroplasty and 29 (56%) had osteosynthesis. All 41 of the retrieved MRSA isolates were susceptible to vancomycin (MIC

[Antibiotic prophylaxis before dental procedures in arthroplasty patients]. / Utilité de la prophylaxie antibiotique avant un geste dentaire pour tes porteurs de prothèses totales du genou ou de la hanche.

Antibiotic prophylaxis is commonly prescribed to patients with total arthroplasties before a dental intervention. This attitude is not evidence-based for several reasons: 1) the usual pathogens of prosthetic joint infections are not of oral origin; 2) even if given, systemic antibiotic do not completely suppress the occult bacteraemia occurring during dental intervention and 3) humans may have up to twelve episodes of occult bacteraemia of dental origin per day. Routine antibiotic prophylaxis should be clearly distinguished from the antibiotic treatment required in case of established oral cavity infection. A constant optimal oral and dental hygiene is more important in terms of prevention and should be routinely recommended to every patient carrying a joint arthroplasty.

Partial atlE sequencing of Staphylococcus epidermidis strains from prosthetic joint infections.

Partial atlE sequencing (atlE nucleotides 2782 to 3114 [atlE(2782-3114)]) was performed in 41 Staphylococcus epidermidis isolates from prosthetic joint infections (PJIs) and 44 isolates from skin as controls. The atlE(2782-3114) allele 1 (type strain sequence) was significantly more frequent in PJI strains (38/41 versus 29/44 in controls; P = 0.0023). Most PJI strains were positive for mecA, icaA/icaD, and IS256, and most belonged to the sequence type 27 subgroup, suggesting the involvement of few related clones.

[Is hardware removal a necessity?]. / Ablation du matériel d'ostéosynthèse: un mal nécessaire?

Hardware removal should be decided only after careful examination of the medical and economic implications. Current literature fails to offer systematic guidelines. Infected hardware, non-union after surgery or obvious mechanical problems are straightforward indications for implant removal. However, when motivated by pain alone, the procedure can have disappointing results, and patients' expectations should be consequently moderated. Protection against toxicity, allergy, carcinogenesis or possible implant failure should not prompt systematic removal. Hardware removal in children should be considered separately, since metallic implants can interfere with normal growth patterns. Overall, implant removal should not be considered a routine procedure, and indications for surgery should reflect the thorough examination of the risks and the benefits.

[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.

Reversal of the hip fracture secular trend is related to a decrease in the incidence in institution-dwelling elderly women.

UNLABELLED: In this prospective 10-year study in elderly aged 60 years and over, there was a 1.3% per year reduction in the standardized incidence of hip fracture in women but not in men. This decrease was mainly due to changes in the standardized incidence of hip fracture in institution-dwelling women. INTRODUCTION: A decrease in age-adjusted hip fracture incidence has been recently demonstrated in some countries. Since a large proportion of hip fractures occur in nursing homes, we analyzed whether this decreasing trend would be more detectable in institution-dwelling elderly compared with community-dwelling elderly. METHODS: All hip fracture patients aged 60 years and over were identified in a well-defined area. Incidence of hip fracture, age- and sex-adjusted to the 2000 Geneva population, was computed in community- and institution-dwelling elderly. RESULTS: From 1991 to 2000, 1,624 (41%) hip fractures were recorded in institutionalized-dwelling elderly and 2,327 (59%) in community-dwelling elderly. The standardized fracture incidence decreased by 1.3% per year in women (p = 0.039), but remained unchanged in men (+0.5%; p = 0.686). Among institution-dwelling women, hip fracture incidence fell by 1.9% per year (p = 0.044), whereas it remained stable among community-dwelling women (+0.0%, p = 0.978). In men, no significant change in hip fracture incidence occurred among institution- or community-dwelling elderly. CONCLUSIONS: The decrease in the standardized hip fracture incidence in institution-dwelling women is responsible for the reversal in secular trend. Future research should include stratification according to the residential status to better identify the causes responsible for the trend in hip fracture incidence.