Low prevalence of tissue detection of cefepime and daptomycin used as empirical treatment during revision for periprosthetic joint infections: results of a prospective multicenter study.

Data demonstrating that antibiotics administered intraoperatively in patients with surgical revision for periprosthetic joint infection achieve concentrations exceeding minimal inhibitory concentrations of the identified bacteria at the surgical site when the new implant is inserted are lacking. We prospectively included patients with periprosthetic joint infection operated with one- or two-stage replacement during which cefepime (2g)-daptomycin (10mg/kg) combination was administered intravenously as intraoperative empirical antibiotic treatment. Three biopsies (two bones and one synovial membrane) were taken from each patient just before the insertion of the new implant. Eighteen adults of median age 68 years were included. Knee was involved in 10 patients (55.6%) and surgery consisted in one-/two-stage replacement in 11/7 patients. A tourniquet was used during the intervention in the 10 patients with knee prosthesis. Among 54 tissue samples, cefepime and daptomycin were detected respectively in 35 (64.8%) and 21 (38.9%) cases (P=0.01). A total of 17 bacteria dominated by staphylococci (n=14) were identified in 10 patients; tissue inhibitory quotient calculated in 51 samples was >1 in 22 cases (43.1%) for cefepime and in 16 cases (31.4%) for daptomycin. The proportion of tissue samples with detectable antibiotic was significantly higher in hip versus knee prosthesis (P=0.03). The present study suggests that intraoperative empirical administration of cefepime-daptomycin combination during septic prosthetic joint replacement results in a high proportion of tissue samples in which at least one of the two antibiotics was not detected or at a low concentration despite satisfactory concomitant blood serum concentrations.

Impact of rifampicin dose in bone and joint prosthetic device infections due to Staphylococcus spp: a retrospective single-center study in France.

BACKGROUND: Prosthetic joint infections (PJI) are a major cause of morbidity and mortality burden worldwide. While surgical management is well defined, rifampicin (RIF) dose remains controversial. The aim of our study was to determine whether Rifampicin dose impact infection outcomes in PJI due to Staphylococcus spp. METHODS: single-center retrospective study including 411 patients with PJI due to Rifampicin-sensitive Staphylococcus spp. Rifampicine dose was categorized as follow: < 10 mg/kg/day, 10-20 mg/kg/day or > 20 mg/kg/day. The primary endpoint was patient recovery, defined as being free of infection during 12 months after the end of the initial antibiotic course. RESULTS: 321 (78%) received RIF for the full antibiotic course. RIF dose didn't affect patients recovery rate with 67, 76 and 69% in the < 10, 10-20 and > 20 mg/kg/day groups, respectively (p = 0.083). In univariate analysis, recovery rate was significantly associated with gender (p = 0.012) but not to RIF dose, or Staphylococcus phenotype (aureus or coagulase-negative). In multivariate analysis, age (p = 0.01) and treatment duration (p <  0.01) were significantly associated with recovery rate. CONCLUSION: These data suggest that lower doses of RIF are as efficient and safe as the recommended high-dose French regimen in the treatment of PJI.

Medical versus surgical treatment in native hip and knee septic arthritis.

OBJECTIVE: Antibiotic treatment and arthroscopic or open drainage is the gold standard for septic arthritis. Full recovery takes time after surgery and hospital stay is longer than for arthrocentesis at the bedside. We aimed to evaluate the effectiveness of arthrocentesis (medical approach) versus a surgical approach. METHOD: We retrospectively included 97 cases of native joint arthritis (hip and knee) between 2010 and 2017. The primary outcome was treatment failure of medical and surgical approaches (defined as surgical intervention within 7 days following diagnosis). Risk factors of failure were identified by univariable and multivariable logistic regression. RESULTS: We included 72 cases of knee arthritis, of which 43 and 29 were treated medically and surgically, respectively; 25 cases of hip arthritis, of which 8 and 17 were treated medically and surgically, respectively. Failure was observed in 39.2% of cases in the medical group and in 30.4% in the surgical group (P=0.2) (37.5% vs. 52.9% and 39.5% vs. 17.2% for hip and knee, respectively). The univariate analysis identified age and male sex as risk factors for failure (P=0.048 and P=0.02, respectively), but only age was independently associated with failure (P=0.04). Hospital length of stay was 12 days shorter in the medical group (21 vs. 33 days, P=0.02), sequelae were less frequent and less important in the medical group (31.7% vs. 60%). CONCLUSION: The medical treatment seems to be as effective as the surgical treatment for native joint septic arthritis with a shorter hospital stay and better functional outcome. Further prospective studies are warranted.

Total hip arthroplasty revision by dual-mobility acetabular cup cemented in a metal reinforcement: A 62 case series at a minimum 5 years' follow-up.

INTRODUCTION: Total hip arthroplasty (THA) requires bone reconstruction in case of severe acetabular injury, with risk of dislocation, especially postoperatively. Dual-mobility cups have proved effective in preventing dislocation in THA revision for instability, but their behavior when cemented in a metal reinforcement has been little studied. OBJECTIVES: The present study assessed results for a dual-mobility cup cemented in a metal reinforcement, in terms of aseptic loosening and postoperative instability. MATERIAL AND METHODS: A single-center continuous series of 62 patients receiving such an assembly in THA revision was assessed retrospectively at a minimum 5 years' follow-up. Failure due to aseptic loosening or instability and implant survival at last follow-up were analyzed. RESULTS: Radiological and clinical analysis was performed at a mean 77 months' follow-up. Mean Merle-d'Aubigné-Postel score was 14, Harris score 73 and Oxford-12 score 23.9 at last follow-up. Complications comprised 5 cases of loosening and 2 of dislocation. Loosening risk was significantly greater in case of<2mm cement thickness between cup and reinforcement. Eight-year infection-free survival was 91.9%. DISCUSSION: The present clinical results were comparable to those in series using the same kind of assembly; the dislocation rate was low, but the rate of aseptic loosening was higher than reported elsewhere. Cement thickness between cup and reinforcement was a determining factor for stability. Cup design may also be relevant to loosening. This technique seemed to be a good option in THA revision with severe bone loss. LEVEL OF EVIDENCE: IV, retrospective study.

Outcome of patients with streptococcal prosthetic joint infections with special reference to rifampicin combinations.

BACKGROUND: Outcome of patients with streptococcal prosthetic joint infections (PJIs) is not well known. METHODS: We performed a retrospective multicenter cohort study that involved patients with total hip/knee prosthetic joint (THP/TKP) infections due to Streptococcus spp. from 2001 through 2009. RESULTS: Ninety-five streptococcal PJI episodes (50 THP and 45 TKP) in 87 patients of mean age 69.1 ± 13.7 years met the inclusion criteria. In all, 55 out of 95 cases (57.9 %) were treated with debridement and retention of the infected implants with antibiotic therapy (DAIR). Rifampicin-combinations, including with levofloxacin, were used in 52 (54.7 %) and 28 (29.5 %) cases, respectively. After a mean follow-up period of 895 days (IQR: 395-1649), the remission rate was 70.5 % (67/95). Patients with PJIs due to S. agalactiae failed in the same proportion as in the other patients (10/37 (27.1 %) versus 19/58 (32.7 %); p = .55). In the univariate analysis, antibiotic monotherapy, DAIR, antibiotic treatments other than rifampicin-combinations, and TKP were all associated with a worse outcome. The only independent variable significantly associated with the patients' outcomes was the location of the prosthesis (i.e., hip versus knee) (OR = 0.19; 95 % CI 0.04-0.93; p value 0.04). CONCLUSIONS: The prognosis of streptococcal PJIs may not be as good as previously reported, especially for patients with an infected total knee arthroplasty. Rifampicin combinations, especially with levofloxacin, appear to be suitable antibiotic regimens for these patients.

No improvement in the post-TKA infection prognosis when the implant is not reimplanted: Retrospective multicentre study of 72 cases.

INTRODUCTION: For the surgeon and patient, permanent removal of an infected knee prosthesis is an unwelcome decision taken out of necessity because unfavourable local or general conditions may increase the likelihood of mechanical or infectious failure upon prosthesis reimplantation. The purpose of this study was to determine if permanent removal of an infected total knee arthroplasty (TKA) implant controls the infection and prevents above-the-knee amputation when reimplantation turns out to be too risky. It was hypothesized that removal without reimplantation contributes to eradicating the infection and helps to avoid amputation. PATIENTS AND METHODS: Seventy-two consecutive patients who underwent TKA removal between 2000 and 2010 at 14 hospitals were reviewed. The TKA removal was followed by knee fusion in 29 cases or implantation of a permanent cement spacer in 43 cases. RESULTS: If failure is defined as clinically obvious recurrence of the infection, the survival rate was 65 ± 5% at 2 years; 44% of patients had a recurrence of the infection, 8% had undergone amputation and 19% presented with nonunion at the last follow-up. The male gender and the presence of multiple co-morbidities were predisposing factors for failure. DISCUSSION: Control of the infection is not guaranteed upon TKA implant removal; the success rate is lower than in cases of two-stage reimplantation. The outcomes in this study are worse than those of other published studies. This is likely due to the heterogeneity in the patient population and treatments, along with the presence of co-morbidities. This treatment option should be the last recourse before amputation.

Unicompartmental knee arthroplasty modes of failure: wear is not the main reason for failure: a multicentre study of 418 failed knees.

BACKGROUND: This study originated from a symposium held by the French Hip and Knee Society (Société française de la hanche et du genou [SFHG]) and was carried out to better assess the distribution of causes of unicompartmental knee arthroplasty (UKA) failures, as well as cause-specific delay to onset. HYPOTHESIS: Our working hypothesis was that most failures were traceable to wear occurring over a period of many years. MATERIALS AND METHODS: A multicentre retrospective study (25 centres) was conducted in 418 failed UKAs performed between 1978 and 2009. We determined the prevalence and time to onset of the main reasons for revision surgery based upon available preoperative findings. Additional intraoperative findings were analysed. The results were compared to those of nation wide registries to evaluate the representativeness of our study population. RESULTS: Times to revision surgery were short: 19% of revisions occurred within the first year and 48.5% within the first 5 years. Loosening was the main reason for failure (45%), followed by osteoarthritis progression (15%) and, finally, by wear (12%). Other reasons were technical problems in 11.5% of cases, unexplained pain in 5.5%, and failure of the supporting bone in 3.6%. The infection rate was 1.9%. Our results were consistent with those of Swedish and Australian registries. DISCUSSION: Our hypothesis was not confirmed. The short time to failure in most cases suggests a major role for surgical technique issues. Morbidity related to the implant per se may be seen as moderate and not greater than with total knee prostheses. The good agreement between our data and those of nationwide registries indicates that our population was representative. A finer analysis is needed, indicating that the establishment of a French registry would be of interest.

Treatment of recurrent THR dislocation using of a cementless dual-mobility cup: a 59 cases series with a mean 8 years' follow-up.

INTRODUCTION: Instability is one of the most feared complications following total hip replacement (THR). In France, dual-mobility cups are widely used in acetabular revision for instability; few studies, however, have focused on this type of implant. HYPOTHESIS: The gain in stability provided by the dual-mobility implant allows the risk of dislocation to decrease by the sole revision of the acetabular component in case of recurrent instability. OBJECTIVES: This hypothesis was tested over medium-term follow-up of a series of cementless dual-mobility cups implanted during isolated acetabular revision for recurrent dislocation. PATIENTS AND METHODS: A series of THR revision for instability was analyzed retrospectively. Inclusion criteria were: recurrent THR dislocation treated by cementless dual-mobility cup, between 1995 and 2001. Radiological analysis used Imagika™ software. Fifty-nine patients were included; nine died before radioclinical follow-up could be performed; none of the survivors were lost to follow-up. Mean follow-up was 8 years (range, 6-11 years). RESULTS: There was one early dislocation without recurrence; the dislocation rate was 1.7%. At follow-up, mean PMA score was 16.5 (12-18) and mean Harris score 86.7 (49-99). Radiologically, there was no loosening or migration, but 19% of X-ray views showed less than 1mm wide peri-acetabular radiolucency. With dislocation as censoring criterion, 8-year survivorship was 98% (95% CI: 95-100%). DISCUSSION: The dislocation rate (1.7%) and clinical results were better than in most series of revision by constrained cup for recurrent dislocation. The high rate of peri-acetabular radiolucency would seem to relate to the external coating of the cup: aluminum oxide in the Novae-1 implant and aluminum oxide/hydroxyapatite in the Novae-E. CONCLUSION: The use of dual-mobility cups to treat THR instability gave satisfactory results. We recommend dual-mobility cups with hydroxyapatite surface treatment over a porous metallic substrate, rather than with an aluminum oxide or an aluminum oxide/hydroxyapatite bilayer coating. LEVEL OF EVIDENCE: Level IV. Retrospective Study.

[Ileocecal herniation through the foramen of Winslow: a case report]. / A propos d'un cas de hernie de l'angle iléocaecal à travers l'hiatus de Winslow.

A case of ileocecal herniation through the foramen of Winslow is presented. This is an uncommon type of internal hernia and the diagnosis is difficult. From this case, clinical signs, imaging procedures and treatment options are discussed.