The value of suction drainage fluid culture during aseptic and septic orthopedic surgery: a prospective study of 901 patients.

There are no guidelines on the value of suction drainage fluid culture (SDC), and it is difficult to determine whether the organisms cultured from suction drainage fluid samples are pathogenic or simply contaminants. We performed 2989 cultures of suction drainage fluid samples obtained, during a 1-year period, from 901 patients who underwent aseptic or septic orthopedic surgery (946 operations). The culture results were analyzed to evaluate their ability to detect postoperative infection after aseptic operations or to detect either a persistent or new episode of sepsis in patients known to have infection. For aseptic operations, the sensitivity of SDC was 25%, the specificity was 99%, the positive predictive value was 25%, and the negative predictive value was 99%. For septic operations, the sensitivity of SDC was 81%, the specificity was 96%, the positive predictive value was 87%, and the negative predictive value was 94%. We conclude that, for aseptic orthopedic surgery, SDC is not useful in detecting postoperative infection. However, for septic orthopedic surgery, it is of clinical importance.

Outpatient parenteral antimicrobial therapy (OPAT) for the treatment of osteomyelitis: evaluation of efficacy, tolerance and cost.

OBJECTIVES: To evaluate the feasibility, efficacy, and cost of outpatient parenteral antimicrobial therapy (OPAT) in the treatment of osteomyelitis. SUBJECTS: 39 patients with an osteomyelitis requiring parenterally administered antibiotics for more than 4 weeks, and able to receive antibiotics at home. METHODS: All patients had a totally implanted catheter. Antibiotics were administered by continuous infusion using a portable elastomeric infusion system, which was changed every day by the patient or by the home-care nurse. Laboratory monitoring and surveillance were performed weekly. Clinical efficacy, adverse effects and quality of life were recorded. RESULTS: The most commonly used antibiotics were vancomycin (51%) and beta-lactam (44%) antibiotics. Thirty patients were available for follow-up for a minimum of 12 months after completion of therapy. Twenty-eight (93%) were considered cured of their infection with a mean of 24 +/- 4 months after completion of antibiotic therapy. Adverse effects among the study patients were rare. The 39 patients in our OPAT programme resulted in a potential saving of US $1 873 885 relative to conventional therapy. CONCLUSION: OPAT is practicable and effective and may be the best alternative treatment for patients suffering from osteomyelitis requiring intravenous therapy.

Combined injuries in the upper cervical spine: clinical and epidemiological data over a 14-year period.

Concomitant traumatic injuries in the upper cervical spine are often encountered and rarely reported. We examined the data concerning 784 patients with cervical spine injuries following trauma, including 116 patients with upper cervical spine injuries. Twenty-six percent of patients with upper cervical spine injuries (31 cases) were found to have combined injuries involving either the upper or the upper and lower cervical spine. The frequent patterns were combined type I bipedicular fracture of the axis and dens fracture, and combined dens fracture and fracture of the posterior arch of C 1. Other patterns posed specific problems, such as combined dens and Jefferson fracture and combined dens and C2 articular pillar fracture. Seventy percent of atlas fractures, 30% of C2 traumatic spondylolistheses and 30% of dens fractures were part of a combination. A total of 1.7% of patients with lower cervical spine injuries had a combined injury in the upper cervical spine. A comprehensive therapeutic schedule is outlined. Combined injuries in the upper cervical spine should be sought in any patient with a cervical spine injury.

[MacFarland fractures. A series of 24 cases]. / Fractures de Mac-Farland. Etude d'une série de 24 cas.

PURPOSE OF THE STUDY: MacFarland fracture is a joint fracture of the ankle in children. The fracture line passes through the medial part of the lower epiphyseal disk of the tibia. Prognosis is dominated by later risk of malalignment and osteoarthritis. MacFarland fracture usually occurs subsequent to adduction trauma. The aim of this study was to analyze prognosis in a retrospective series of children with MacFarland fractures. MATERIAL AND METHOD: The series included 24 cases (14 boys and 10 girls, mean age at the time of trauma 12.7 years, age range 10-15 years). The fractures were classed into two groups according to the Salter and Harris classification for epiphyseal detachment: Salter 3 (n=4) and Salter 4 (n=20). Surgical treatment was given in 17 cases (11 screw fixations, 4 pin fixations and 2 other ostheosynthesis combinations). Orthopedic care was given in 7 cases (mean immobilization=40 days). All 24 children were followed for a mean 3 years 2 months (3 months=12 years). Three outcome categories were used: good (no pain, stiffness or malalignment), fair (pain and/or stiffness, no malalignment), and poor (malalignment). RESULTS: Overall results were good in 15 cases, fair in 2 and poor in 7 (29 p. 100). Ankle malalignments (7 cases) required surgical correction: epiphysiodesis for varus<5, supramalleolar tibial valgization osteotomy for varus > 5 degrees. After these procedures, outcome was good with a normally aligned painless ankle at 13 months follow-up. Among factors predictive of malalignment (poor outcome), power of the initial trauma (traffic or sports accident in 5 of the 7 poor outcomes), crush injury (medial metaphyseal comminution in two cases which led to varus ankle despite well conducted treatment), fracture type (7 malalignments among the Salter 4 fractures versus none among the Salter 3 fractures), initially defective reduction or osteosynthesis material passing through the epiphyseal disk leading to epiphysiodesis. DISCUSSION: Careful radiologic and clinical surveillance is needed and should be continued to the end of growth (fusion of the tibial cartilage) in children with high risk fractures in order to detect epiphysiodesis early and avoid secondary malalignment. Surgical correction does remain possible and gives good results.

[Acute compartment syndrome in the thigh: 3 cases]. / Syndrome de loge aigü de cuisse. A propos de 3 cas chez 2 patients.

We report three cases of compartment syndrome in the thigh related to drug intoxications. Compartment syndrome is an uncommon condition often diagnosed late as it may occur in unconscious patients. The typical clinical presentation begins with pain of the lower limb refractory to major antagesics. The condition then progresses with sensoromotor involvement of the sciatic nerve. Rapid onset of acute renal failure in the setting of a crush syndrome may be life-threatening with a long-term risk of major sensoromotor sequelae. Surgical treatment with aponeurotomy is required rapidly to limit sequelae.

[Value and limits of determining serum cobalt levels in patients with metal on metal articulating prostheses]. / Intérêt et limite du dosage du cobalt sérique chez les patients porteurs d'une prothèse à couple métal-métal.

PURPOSE OF THE STUDY: The purpose of this study was to measure the serum cobalt levels and their correlation with clinical and radiological findings in patients with metal on metal hip articulating surfaces. METHOD: Forty-one patients with metal on metal hip arthroplasty were reviewed retrospectively at mean follow-up of 12.9 months. Serum cobalt levels were determined for each patient by atomic absorption spectrometry at the maximal follow-up and were compared to a control group (19 patients). Two patients and one control subjects also performed exercise on a treadmill in order to appreciate the influence of physical activity on serum cobalt levels. RESULTS: The metal on metal group presented higher serum cobalt levels than those of the control group (p < 0.0001). There was no correlation between serum cobalt and clinical and radiological findings at the exception of patient age (n = 40, r = 0.37). However, when the follow-up was greater than 18 months, mean serum cobalt was significantly higher compared to a follow-up less than 18 months. The physical exercise test led to a moderate elevation (around 10 p. 100) of cobalt in the two patients but not in the control subject. DISCUSSION AND CONCLUSION: The interpretation of an elevated cobalt serum level is difficult. Cobalt-containing drugs, other implants, excess of activity and diseases (renal failure) may influence serum cobalt level. In this study, the high serum cobalt levels seem not linked to a failure of the implant, mainly because of the short follow-up. They could rather be attributed to an increase of the patient activity beginning 18 months after the surgery. Because potential long-term cobalt toxicity and carcinogenicity is not well known, careful medical follow-up should be emphasized specially in young patients.

Effects of freezing on the biomechanics of the intervertebral disc.

Storage of anatomic specimens is possible only if there is a reliable method for preservation of the tissues. The establishment of such a procedure is thus of twofold importance: clinical (transplantation of segments of the vertebral column) and experimental (research and teaching programs). Simple freezing at -18 degrees C is the simplest and least expensive method for storing spinal specimens compared to other modes of storage such as cryo-preservation and lyophilization. Does this mode of storage affect the biomechanics of frozen anatomic specimens, in particular those of the intervertebral disc? This experiment dealt with the comparative biomechanical analysis before and after three months of freezing of 19 segments of the sheep vertebral column (4 functional C4-C5 units, 3 C7-T1 units, 6 T13-L1 units and 6 L5-L67 units). The results showed that there was no significant difference (risk of error 5%) between frozen and fresh segments of vertebral column in terms of amplitude and rigidity, except for the C7-T12 segment where the conditions of validity of the statistical tests were not met. The results of this experiment allowed us to validate a biomechanical model to assay the effects of freezing.

Reappraisal of pancreaticojejunostomy after pancreaticoduodenectomy: a report of 86 cases with particular reference to the rate of pancreatic fistulation.

OBJECTIVE: To report our experience of 86 patients who underwent pancreaticoduodenectomy followed by pancreaticojejunostomy, paying particular attention to the rate of fistulation. DESIGN: Retrospective study. SETTING: Two teaching hospitals, France. SUBJECTS: 86 patients (58 men and 28 women) who required pancreatic resection for adenocarcinomas of the head of the pancreas (n = 34), chronic pancreatitis (n = 21), cancer of the ampulla of Vater (n = 12), cancer of the distal bile duct (n = 6), or other causes (n = 13). INTERVENTION: Pancreaticoduodenectomy followed by pancreaticojejunostomy with mucosa to mucosa suture. RESULTS: 26 patients (30%) developed complications, 9 (10%) required reoperation, and 8 (9%) died postoperatively. Pancreatic fistulas developed in 2 (2%), one of whom was successfully treated conservatively. The other was reoperated on and died on day 40. CONCLUSION: Pancreaticojejunostomy after pancreaticoduodenectomy is safe, and the rate of fistulation compares favourably with that after pancreaticogastrostomy (2%).