Short stem total hip arthroplasty with the direct anterior approach demonstrates suboptimal fixation.

PURPOSE: Short stems use has increased substantially despite variable results reported in the literature. The purpose of this study was to report the rate of complications using a short stem implanted through the direct anterior approach (DAA), and to evaluate mid-term clinical and radiological results focusing on femoral stem fixation. METHODS: Between April 2009 and November 2014, 698 elective total hip arthroplasties (THAs) were performed using a fully hydroxyapatite-coated short stem (AMIStem-H®). The mean age was 65.7 years (SD 12.6). Patients were invited for clinical and radiological evaluation, and to complete patient-reported outcomes questionnaires at two and five years after surgery. The mean follow-up was 6.2 years (range 2-9.73 years). RESULTS: During the study period, 59 (8.5%) patients died and 24 (3.4%) were lost to follow-up. There were six (0.9%) dislocations and 12 (1.7%) fractures, seven occurred intra-operatively. Twenty-nine (4.2%) THAs required revision surgery. Eleven THAs were revised for aseptic loosening of the stem at a mean 4.9 years (1.2-7.3 years). Five years after surgery, radiographs of 324 THAs (324/425 eligible = 76.2%) were available. Stem subsidence ≥ 2 mm was present in 42 cases (12.9%), proximal radiolucencies in 101 hips (31.5%), cortical thickening in 52 (16.0%), and a pedestal in 219 (67.6%). An Engh score between - 10 and 0 was associated with lower HHS pain subscore (p = 0.005), a higher risk of stem revision for aseptic loosening (18.8% vs. 2.7%; p = 0.008), and was more frequent in younger patients with ASA score 1. CONCLUSION: Patients presenting radiological alterations at five years had an increased risk of revision for aseptic stem loosening and also inferior clinical results. Our study warrants further continued scrutiny of mid- and long-term survivorship of the AMIStem-H®, with radiological results at five years indicating suboptimal fixation of the stem in younger and active patients.

[Lessons learned from 25 years of an institutional hip and knee arthroplasty registry]. / Leçons apprises par 25 ans d'un registre institutionnel des prothèses de hanche et de genou.

Since 1996, the Geneva Arthroplasty Registry at the University Hospitals of Geneva (HUG) has been collecting, archiving and disseminating relevant high-quality information on primary total hip and knee arthroplasties and revision procedures performed at the Division of Orthopaedics and Traumatology. Patients are followed throughout their lifetime with the prosthesis. The registry has been essential to better understand and subsequently improve the care of patients with hip and knee replacements. It will continue to fulfil its mission and to work towards an even more effective transfer of the knowledge obtained to all stakeholders and as well as towards its implementation.

Depuis 1996, le registre genevois des arthroplasties aux HUG recueille, archive et diffuse des informations pertinentes de haute qualité concernant les arthroplasties primaires de la hanche et du genou ainsi que les procédures de révision réalisées au Service de chirurgie orthopédique et traumatologie de l'appareil moteur. Les patients sont suivis pendant toute leur vie avec la prothèse. Le registre a été essentiel pour mieux comprendre et ensuite améliorer la prise en charge de patients avec arthroplastie de hanche et de genou. Il continuera à remplir sa mission et à assurer une transmission encore plus efficace des connaissances obtenues vers tous les groupes concernés (stakeholders) et à leur implémentation.

Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures: a retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate the association between epidemiological, clinical and radiographic factors of patients with tibial shaft fractures and the occurrence of acute compartment syndrome. METHODS: 270 consecutive adult patients sustaining 273 tibial shaft fractures between January 2005 and December 2009 were included in this retrospective cohort study. The outcome measure was acute compartment syndrome. Patient-related (age, sex), fracture-related (high- vs. low-energy injury, isolated trauma vs. polytrauma, closed vs. open fracture) and radiological parameters (AO/OTA classification, presence or absence of a noncontiguous tibial plateau or pilon fracture, distance from the centre of the tibial fracture to the talar dome, distance between tibial and fibular fracture if associated, and angulation, translation and over-riding of main tibial fragments) were evaluated regarding their potential association with acute compartment syndrome. Univariate analysis was performed and each covariate was adjusted for age and sex. Finally, a multivariable logistic regression model was built, and odds ratios and 95% confidence intervals were obtained. Statistical significance was defined as p < 0.05. RESULTS: Acute compartment syndrome developed in 31 (11.4%) cases. In the multivariable regression model, four covariates remained statistically significantly associated with acute compartment syndrome: polytrauma, closed fracture, associated tibial plateau or pilon fracture and distance from the centre of the tibial fracture to the talar dome ≥15 cm. CONCLUSIONS: One radiological parameter related to the occurrence of acute compartment syndrome has been highlighted in this study, namely a longer distance from the centre of the tibial fracture to the talar dome, meaning a more proximal fracture. This observation may be useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients). However, larger studies are mandatory to confirm and refine the prediction of acute compartment syndrome occurrence. Radiographic signs of significant displacement were not found to be correlated to acute compartment syndrome development. Finally, the higher rate of acute compartment syndrome occurring in tibial shaft fractures associated to other musculoskeletal, thoraco-abdominal or cranio-cerebral injuries must raise the level of suspicion of any surgeon managing multiply injured patients.

Improvement in mental health following total hip arthroplasty: the role of pain and function.

BACKGROUND: Mental health has been shown to improve after total hip arthroplasty (THA). Little is known about the role of pain and function in this context. We assessed whether change in mental health was associated with improvement in pain and function 1 year post-surgery. METHODS: This prospective study included patients enrolled in a THA registry from 2010 to 2014. We examined the mental component score (MCS) before and 1 year post-surgery, and 1-year change, in association with Western Ontario McMaster Universities (WOMAC) pain and function scores. All scores were normalized, ranging from 0 to 100 (larger score indicating better outcome). Analyses were adjusted for potential confounders. RESULTS: Our study included 610 participants, of which 53% were women. Descriptive statistics are as follows: the average (SD) for age (years) was 68.5 (11.8), and for BMI was 26.9 (4.9). In addition, the MCS average (SD) at baseline was 44.7 (11.2), and at 1-year after THA was 47.5 (10.5). The average change from baseline to 1-year post-THA in MCS was 2.8 (95% CI: 1.9, 3.6), for an effect size of 0.26. As for the WOMAC pain score, the average change from baseline to 1-year post-THA was 44.2 (95%CI: 42.4, 46.0), for an effect size of 2.5. The equivalent change in WOMAC function was 38.1 (95% CI: 36.2, 40.0), for an effect size of 2.0. Results from multivariable analysis controlling for covariates showed that an improvement of 10 points in the 1-year change in pain score resulted in a 0.78 point (95%: CI 0.40, 1.26) increase in the 1-year change in MCS, whereas a 10-point improvement in the 1-year change in function was associated with a 0.94 point (95% CI: 0.56, 1.32) increase. CONCLUSIONS: Mental health significantly improved from baseline to 1-year post-THA. Greater improvement in pain and function was associated with greater improvement in mental health 1 year post-THA.

Is There an Association Between Smoking Status and Prosthetic Joint Infection After Primary Total Joint Arthroplasty?

BACKGROUND: Recent reports highlighted the association between smoking and higher risk of postsurgical infections. The aim was to compare the incidence of prosthetic joint infection after primary total joint arthroplasty (TJA) according to smoking status. METHODS: A prospective hospital registry-based cohort study was performed including all primary knee and hip TJAs performed between March 1996 and December 2013. Smoking status preoperatively was classified into never, former, and current smoker. Incidence rates and hazard ratios (HRs) for prosthetic joint infection according to smoking status were assessed within the first year and beyond. RESULTS: We included 8559 primary TJAs (mean age 69.5 years), and median follow-up was 67 months. There were 5722 never, 1315 former, and 1522 current smokers. Incidence rates of infection within the first year for never, former, and current smokers were, respectively, 4.7, 10.1, and 10.9 cases/1000 person-years, comparing ever vs never smokers, crude and adjusted HRs were 2.35 (95% confidence interval [CI] 1.39-3.98) and 1.8 (95% CI 1.04-3.2). Beyond the first year, crude and adjusted HRs were 1.37 (95% CI 0.78-2.39) and 1.12 (95% CI 0.61-2.04). CONCLUSION: Smoking increased the infection risk about 1.8 times after primary hip or knee TJA in both current and former smokers. Beyond the first year, the infection risk was similar to never smokers.

Important patient characteristics differ prior to total knee arthroplasty and total hip arthroplasty between Switzerland and the United States.

BACKGROUND: Outcomes after total knee (TKA) and hip (THA) arthroplasty are often generalized internationally. Patient-dependent factors and preoperative symptom levels may differ across countries. We compared preoperative patient and clinical characteristics from two large cohorts, one in Switzerland, the other in the US. METHODS: Patient characteristics were collected prospectively on all elective primary TKAs and THAs performed at a large Swiss hospital and in a US national sample. Data included age, sex, education level, BMI, diagnosis, medical co-morbidities, PROMs (WOMAC pain/function), global health (SF-12). RESULTS: Six thousand six hundred eighty primary TKAs (US) and 823 TKAs (Swiss) were evaluated. US vs. Switzerland TKA patients were younger (mean age 67 vs. 72 years.), more obese (BMI ≥30 55% vs. 43%), had higher levels of education, more cardiac disease. Swiss patients had lower preoperative WOMAC pain scores (41 vs. 52) but pre-operative physical disability were comparable. 4,647 primary THAs (US) and 1,023 THAs (Swiss) were evaluated. US vs. Switzerland patients were younger (65 vs. 68 years.), more obese (BMI ≥30: 38% vs. 24%), had higher levels of education, more diabetes. Swiss patients had lower preoperative WOMAC pain scores (40 vs. 48 points). Physical disability was reported comparable, but Swiss patients indicated lower mental health scores. CONCLUSION: We found substantial differences between US and Swiss cohorts in pre-operative patient characteristics and pain levels, which has potentially important implications for cross-cultural comparison of TKA/THA outcomes. Reports from national registries lack detailed patient information while these data suggest the need for adequate risk adjustment of patient factors.

Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial plateau fractures: a retrospective cohort study.

BACKGROUND: The aim of the study was to evaluate the relation between demographic, injury-related, clinical and radiological factors of patients with tibial plateau fractures and the development of acute compartment syndrome. METHODS: All consecutive adult patients with intra-articular tibial plateau fractures admitted in our urban academic medical centre between January 2005 and December 2009 were included in this retrospective cohort study. The main outcome measurement was the development of acute compartment syndrome. RESULTS: The charts of 265 patients (mean age 48.6 years) sustaining 269 intra-articular tibial plateau fractures were retrospectively reviewed. Acute compartment syndrome occurred in 28 fractures (10.4%). Four patients presented bilateral tibial plateau fractures; of them, 2 had unilateral, but none had bilateral acute compartment syndrome. Non-contiguous tibia fracture or knee dislocation and higher AO/OTA classification (type 41-C) were statistically significantly associated with the development of acute compartment syndrome in multivariable regression analysis, while younger age (<45 years), male sex, higher Schatzker grade (IV-V-VI), higher tibial widening ratio (≥1.05) and higher femoral displacement ratio (≥0.08) were significantly associated in the analysis adjusted for age and sex. CONCLUSIONS: Two parameters related to the occurrence of ACS in tibial plateau fractures were highlighted in this study: the presence of a non-contiguous tibia fracture or knee dislocation, and higher AO/OTA classification. They may be especially useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients), and should rise the suspicion level of the treating surgeon. In these cases, regular clinical examinations and/or intra-compartmental pressure measurements should be performed before and after surgery, even if acute compartment syndrome seemed unlikely during initial assessment. However, larger studies are mandatory to confirm and refine both factors in predicting the occurrence of acute compartment syndrome.

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.

Reducing a Shoulder Dislocation Without Sweating. The Davos Technique and its Results. Evaluation of a Nontraumatic, Safe, and Simple Technique for Reducing Anterior Shoulder Dislocations.

BACKGROUND: Anterior shoulder dislocation is a well-known injury for people working in emergency departments (EDs). Throughout the years, the focus has been shifted onto more gentle reduction techniques with less risk of iatrogenic injury, fracture displacement, and less pain for the patient. We present the results of one such technique, the Davos reduction maneuver, also known as the Boss-Holzach-Matter technique, as well as its advantages, disadvantages, and a few practical tips. DISCUSSION: We evaluated, retrospectively, 100 patients presenting with an anteroinferior shoulder dislocation, who were treated in the ED of the university hospital of Geneva, Switzerland, in a time period of 18 months. In every case, the Davos technique was used for shoulder reduction. The detailed technique is described. Successful reduction was achieved in 86 patients. There were no neurological complications. Greater tuberosity fracture malreduction was noted in one case. Eighteen patients received no analgesia. Our results were comparable or superior to other reduction techniques. CONCLUSION: We concluded that the Davos technique is an easy, nontraumatic, very well-tolerated, and most of all, safe way to reduce a shoulder. It is complication free and easy to apply, giving reproducible and comparable or superior results to other reduction techniques. At the same time, it is well tolerated by a compliant patient, which makes it an ideal first-time reduction technique for anterior shoulder dislocations.

Influence of body mass index on revision rates after primary total knee arthroplasty.

PURPOSE: Studies demonstrate that revision rates after primary total knee arthroplasty (TKA) tend to be higher in obese patients. However, the existence of a body mass index (BMI) threshold remains unexplored. METHODS: We conducted a prospective cohort study of 2442 primary TKAs in 2035 patients (69.1 % women; mean age 72 years; mean follow-up 93 months, range 38-203). We evaluated the influence of BMI in five categories on all-cause revision after TKA using incidence rates (IR), hazard ratios (HR), and Kaplan-Meier survival analysis. Adjustment for baseline imbalances was performed using Cox regression analysis. RESULTS: Over the study period, 71 revisions occurred. Revision rates were 3.2 cases/1000 patient-years for patients of normal weight, 3.4/1000 for overweight patients and 3.0/1000 for patients classified as obese class I. At BMI ≥ 35, a significant increase in revision was noted. Comparing BMI ≥ 35 vs. < 35, there were 6.4 vs. 3.2 /1000. Crude HR was 2.0 [95 % confidence interval (CI) 1.2-3.3, p = 0.009], and the adjusted HR was 2.1 (95 % CI 1.2-3.6, p = 0.008). CONCLUSION: All-cause revision rates after primary TKA doubled in patients with a BMI of 35 but were similar in those with a BMI <35.

Body mass and weight thresholds for increased prosthetic joint infection rates after primary total joint arthroplasty.

BACKGROUND AND PURPOSE: Obesity increases the risk of deep infection after total joint arthroplasty (TJA). Our objective was to determine whether there may be body mass index (BMI) and weight thresholds indicating a higher prosthetic joint infection rate. PATIENTS AND METHODS: We included all 9,061 primary hip and knee arthroplasties (mean age 70 years, 61% women) performed between March 1996 and December 2013 where the patient had received intravenous cefuroxime (1.5 g) perioperatively. The main exposures of interest were BMI (5 categories: < 24.9, 25-29.9, 30-34.9, 35-39.9, and ≥ 40) and weight (5 categories: < 60, 60-79, 80-99, 100-119, and ≥ 120 kg). Numbers of TJAs according to BMI categories (lowest to highest) were as follows: 2,956, 3,350, 1,908, 633, and 214, respectively. The main outcome was prosthetic joint infection. The mean follow-up time was 6.5 years (0.5-18 years). RESULTS: 111 prosthetic joint infections were observed: 68 postoperative, 16 hematogenous, and 27 of undetermined cause. Incidence rates were similar in the first 3 BMI categories (< 35), but they were twice as high with BMI 35-39.9 (adjusted HR = 2.1, 95% CI: 1.1-4.3) and 4 times higher with BMI ≥ 40 (adjusted HR = 4.2, 95% CI: 1.8-9.7). Weight ≥ 100 kg was identified as threshold for a significant increase in infection from the early postoperative period onward (adjusted HR = 2.1, 95% CI: 1.3-3.6). INTERPRETATION: BMI ≥ 35 or weight ≥ 100 kg may serve as a cutoff for higher perioperative dosage of antibiotics.

Evidence showing the relationship between sagittal balance and clinical outcomes in surgical treatment of degenerative spinal diseases: a literature review.

The measure of radiographic pelvic and spinal parameters for sagittal balance analysis has gained importance in reconstructive surgery of the spine and particularly in degenerative spinal diseases (DSD). Fusion in the lumbar spine may result in loss of lumbar lordosis (LL), with possible compensatory mechanisms: decreased sacral slope (SS), increased pelvic tilt (PT) and decreased thoracic kyphosis (TK). An increase in PT after surgery is correlated with postoperative back pain. A decreased SS and/or abnormal sagittal vertical axis (SVA) after fusion have a higher risk of adjacent segment degeneration. High pelvic incidence (PI) increases the risk of sagittal imbalance after spine fusion and is a predictive factor for degenerative spondylolisthesis. Restoration of a normal PT after surgery is correlated with good clinical outcome. Therefore, there is a need for comparative prospective studies that include pre- and postoperative spinopelvic parameters and compare complication rate, degree of disability, pain and quality of life.

[Clinical gait analysis: user guide]. / Analyse quantifiée de la marche: mode d'emploi.

Clinical gait analysis has become an indispensable medical examination for the management of patients with complex gait disorders. As its name suggests, the purpose of this examination is to assess patients whilst they are walking in a laboratory setting. Measurements include: 3 dimensional joint motion, forces applied to joints, and electromyographic muscle activity. This quantitative data allows identification of walking deviations and to deduce the likely causes of these deviations thanks to the clinical data available for each patient.

Treatment challenges associated with bone echinococcosis.

OBJECTIVES: In this literature review, we concentrate on epidemiology and therapy of osseous echinococcosis, with an emphasis on the recurrence risk. METHODS: Literature review 1930-2012. RESULTS: We retrieved 200 publications based upon single case reports or case series, mostly from resource-poor settings. Among the 721 rural patients (22% females; median age 37 years), 60% of all reported cases were from the Mediterranean region and almost all patients were immune competent. Echinococcus granulosus was identified as the most frequent species. Most infections involved a single bone (602/721; 83%) and often the spine (321 cases; 45%). In eight cases (8/702; 1%), a secondary bacterial surgical site infection was reported. Surgical intervention was performed in 702 cases (97%), with single intervention in 687 episodes (95%). Complete excision of the lesion was possible in only 117 episodes (16%). Albendazole was by far the most frequently used agent in monotherapy with various dosages, while mebendazole in monotherapy was less frequent (32 cases). The median duration of antihelminthic therapy was 6 months (range 0.7-144 months). There were 124 recurrences (17%) after a median delay of 2 years (range 0.4-17 years). In multivariate analysis, the presence of visceral organ involvement increased the odds of recurrence by 5.4 (95% CI 3.1-9.4), whereas the number of surgical interventions, the duration of antihelminthic therapy or the use of hypertonic saline did not influence recurrence. CONCLUSIONS: Bone echinococcosis is a rare parasitic disease. While treatment modalities vary considerably, combined surgical and medical approaches are the standard of care with a 17% risk of recurrence.

Primary open anterior shoulder stabilization: a long-term, retrospective cohort study on the impact of subscapularis muscle alterations on recurrence.

BACKGROUND: Post-traumatic anterior shoulder instability patients may present histopathologic lesions within the subscapularis muscle compatible with a scarring process associated with disuse atrophy. We hypothesized that such lesions identified on intraoperative biopsy at the time of primary anterior shoulder stabilization would predict a higher risk of postoperative instability recurrence. METHODS: Of 52 eligible patients (52 shoulders) who had undergone subscapularis muscle biopsy during primary anterior open labral repair and capsulorrhaphy, 35 (mean age at surgery, 27.2 years; male sex, 71.4%) were retrospectively evaluated (mean follow-up, 12.9 years; range, 10.9-14.5 years). Primary outcome was shoulder instability recurrence. Secondary outcomes included shoulder range of motion, functional scores, and radiological analysis of glenohumeral joint degenerative changes. RESULTS: Overall five patients (14.3%) presented shoulder instability recurrence. Twelve patients with histopathologic lesions had significantly more instability recurrence than 23 without histopathologic changes (33.3% vs. 4.3%; risk difference, 29% [95% CI 1; 57]; p = 0.038). Patients without histopathologic changes had significantly reduced external rotation with arm at side (ER1; -11.9°; p = 0.001) and with shoulder abducted to 90° (ER2; -14.9°; p = 0.001) on the operated side when compared to the contralateral side. Patients with histopathologic lesions had only ER2 significantly reduced (-8.9°; p = 0.031). There was no substantial difference regarding functional and quantitative radiological scores between both patients' groups. CONCLUSIONS: Histopathologic changes within the subscapularis muscle at the time of primary open labral repair and capsulorrhaphy were associated with an increased risk of shoulder instability recurrence. Further investigations are needed to assess the impact of dedicated postoperative rehabilitation programs for patients presenting these lesions. Their recognition on preoperative magnetic resonance imaging should also be investigated; non-anatomical repairs could be an option in these cases.

Sexual activity after total hip arthroplasty: a motion capture study.

Relative risk of impingement and joint instability during sexual activities after total hip arthroplasty (THA) has never been objectively investigated. Hip range of motion necessary to perform sexual positions is unknown. A motion capture study with two volunteers was performed. 12 common sexual positions were captured and relevant hip joint kinematics calculated. The recorded data were applied to prosthetic hip 3D models to evaluate impingement and joint instability during motion. To explore the effect of acetabular component positioning, nine acetabular cup positions were tested. Four sexual positions for women requiring intensive flexion (> 95°) caused prosthetic impingements (associated with posterior instability) at 6 cup positions. Bony impingements (associated with anterior instability) occurred during one sexual position for men requiring high degree of external rotation (> 40°) combined with extension and adduction at all cup positions. This study hence indicates that some sexual positions could be potentially at risk after THA, particularly for women.

Adipokines correlate with pain in lower limb osteoarthritis: different associations in hip and knee.

PURPOSE: Our aim was to investigate whether serum and synovial-fluid (SF) concentrations of interleukin-6 (IL-6), leptin, adiponectin, resistin or visfatin are associated with joint pain in hip and knee in end-stage osteoarthritis (OA). METHODS: A cross-sectional study assessing patients with hip and knee OA undergoing total joint arthroplasty between January and December 2010 was conducted at a large university hospital. Serum and SF cytokine and adipokine concentrations were determined in samples obtained on the day of surgery. The main outcome was pain severity measured pre-operatively using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and visual analogue scale (VAS) pain scores. RESULTS: A total of 206 patients were involved (112 with hip and 94 with knee OA). Median age was 72 years [interquartile range (IQR) 66-79], 59% were women. All adipokine levels were significantly higher in the SF of hip joints than in that of knee joints, except for leptin, which tended to be higher in the knee. In both hip and knee OA, median serum concentrations of leptin, adiponectin, resistin and visfatin exceeded those in SF, whereas for IL-6, median concentrations were much higher in SF than in serum. In hip OA, worse pain was significantly associated with high SF concentrations of IL-6, visfatin and leptin; in knee OA, it was associated with high SF leptin and low SF adiponectin concentrations and a low adiponectin-leptin ratio. CONCLUSION: Our findings support a connection between intra-articular concentrations of several adipokines and severity of preoperative OA pain. However, the specific adipokines differed by joints: in hip OA, pain was associated with IL-6 and visfatin and in knee OA with adiponectin; leptin played a role in both hip and knee OA.

Are there clinical variables determining antibiotic prophylaxis-susceptible versus resistant infection in open fractures?

PURPOSE: In Gustilo grade III open fractures, it remains unknown which demographic or clinical features may be associated with an infection resistant to the administered prophylactic agent, compared to one that is susceptible. METHODS: This was a retrospective case-control study on patients hospitalized from 2004 to 2009. RESULTS: We identified 310 patients with Gustilo-III open fractures, 36 (12%) of which became infected after a median of ten days. In 26 (72%) of the episodes the pathogen was susceptible to the prophylactic antibiotic agent prescribed upon admission, while in the other ten it was resistant. All antibiotic prophylaxis was intravenous; the median duration of treatment was three days and the median delay between trauma and surgery was one day. In multivariate analysis adjusting for case-mix, only Gustilo-grade-IIIc fractures (vascular lesions) showed tendency to be infected with resistant pathogens (odds ratio 10; 95% confidence interval 1.0-10; p = 0.058). There were no significant differences between cases caused by antibiotic resistant and susceptible pathogen cases in patient's sex, presence of immune suppression, duration and choice of antibiotic prophylaxis, choice of surgical technique or materials, time delay until surgery, use of bone reaming, fracture localization, or presence of compartment syndrome. CONCLUSION: We were unable to identify any specific clinical parameters associated with infection with antibiotic resistant pathogens in Gustilo-grade III open fractures, other than the severity of the fracture itself. More research is needed to identify patients who might benefit from a broader-spectrum antibiotic prophylaxis.

Gram and acridine orange staining for diagnosis of septic arthritis in different patient populations.

PURPOSE: The sensitivity of Gram staining is known to be suboptimal for the diagnosis of native joint septic arthritis. We lack information about the accuracy of Gram compared to other microscopic staining techniques for predicting infection in different patient populations. METHODS: This was a cohort study with cost evaluations at the Orthopaedic Service of Geneva University Hospitals (January 1996-October 2012). RESULTS: Among 500 episodes of arthritis (196 with immunosuppression, 227 with underlying arthroplasties and 69 with gout or other crystals in synovial fluid), Gram staining revealed pathogens in 146 episodes (146/500, 29 %) or in 146 of the 400 culture-positive episodes (37 %). Correlation between the Gram and acridine staining of the same sample was good (Spearman 0.85). Overall, the sensitivity, specificity, positive predictive value and negative predictive value of Gram stain for rapid diagnosis of septic arthritis was 0.37, 0.99, 0.99 and 0.28, respectively, compared to microbiological cultures. Quite similar values were recorded across the different patient subpopulations, in particular for sensitivity values that were 0.33 for patients with prosthetic joint infections, 0.40 for immunosuppressed patients, 0.36 for patients under antibiotic administration and 0.52 for patients with concomitant crystalline disease. CONCLUSIONS: The sensitivity of Gram or acridine orange staining for a rapid diagnosis of episodes of septic arthritis is suboptimal compared to microbiological culture, regardless of underlying conditions, immunosuppression or antibiotic therapy. The sensitivity in the presence of synovial fluid crystals is moderate. Acridine orange and Gram stains are equivalent.