[Skin and osteoarticular bacterial infections of the diabetic foot. Ulcers of the diabetic foot: epidemiology and physiopathology]. / Infections bactériennes cutanées et ostéo-articulaires du pied diabétique. Les ulcères du pied diabétique: épidémiologie et physiopathologie.

EPIDEMIOLOGY: There are more than 2 million diabetics in France. Fifteen percent have suffered at one time or another from a foot ulcer. This condition accounts for 20% of all admissions of diabetic patients and for 50% of corresponding hospitalization stays. Fifteen to 25% of diabetic foot ulcers lead to an amputation, the patients being in the 45-65 year age range. Fifty percent of the amputated patients will have a contralateral amputation within the next 5 years. PATHOPHYSIOLOGY: Diabetic foot ulcers result from damage caused by diabetic neuropathy and micro- or macroangiopathy. Ulceration is favored by usually minimal trauma and secondary infection. The neuropathy causes deformations and sensorial disorders. Repair is hindered by the often precarious vascular supply. Reduced antibacterial defense related to high serum glucose levels and impaired diapedesis favor superinfection. MANAGEMENT: Careful physical examination and appropriate explorations are required for proper care giving the patient the best chances for cure.

[Skin and osteoarticular infections of the diabetic foot. Role of infection]. / Infections bactériennes cutanées et ostéo-articulaires du pied diabétique. La place des phénomènes infectieux.

A MAJOR PROBLEM: Two-thirds of all amputations involve infection. Infection is favored by dysfunction of the antibacterial defense systems due to high blood glucose and vascular disorders. DIAGNOSIS: General signs of infection are usually not found. A careful exploration is required to rule out or confirm osteitis in order to guide surgery and plan the antibiotic regimen. A history of chronic and/or recurrent ulceration or direct signs at inspection may be suggestive of osteitis. Radiographic signs are late and nonspecific. Scintigraphy scans are difficult to interpret. Magnetic resonance imaging can be quite helpful in difficult cases. BACTERIOLOGICAL PROOF: Staphylococcus aureus and to a lesser extent streptococci account for almost all of the superficial infections in the diabetic foot. In case of deep ulceration, it is important to obtain deep specimens at surgical cleansing as more superficial samples are easily contaminated. Nevertheless, if Staphylococcus aureus is isolated from pus coming from a deep zone fistulizing to the skin, it is likely the causal agent since 80% of all bone infections involve S. aureus. Other germs besides staphylococci and streptococci include enterobacteria (40%), enterococci (26%) and pseudomonas (7%). Several germs are involved in about 70% of cases with a probable synergetic effect between the different bacterial colonies within the infected tissues.

[Skin and osteoarticular bacterial infections of the diabetic foot. Treatment]. / Infections bactériennes cutanées et ostéo-articulaires du pied diabétique. Traitement.

MULTIDISCIPLINARY CARE: A multidisciplinary approach is essential. General measures include immobilization of the focus, controlling blood glucose, anticoagulation, and anti-tetanus vaccination. Topical application of growth factors is currently under evaluation. ANTIBIOTIC THERAPY: The antibiotics chosen should diffuse well into bone tissue. Combinations with synergetic or additive effects against Staphylococcus aureus are best. Treatment duration depends on the depth of the ulceration. Two weeks is generally advised for superficial ulcers. For deep ulcers, treatment duration depends on the presence or not of osteitis and the quality of surgical debridement. In case of osteitis, after amputation with a healthy margin, antibiotics can generally be discontinued 2 weeks after surgery. Six weeks are required if the amputation margins do not lie in healthy zones. Finally, if no surgery is attempted, the antibiotic regimen should be continued for 3 months, or even longer, with a risk of failure greater than 50%. The best criterion for successful treatment is the absence of late recurrence. SURGERY: Surgery is an indispensable element in the overall treatment of deep infections and/or osteitis. The operation should be performed as early as possible to improve prognosis. Well-conducted early surgical debridement can prevent the infection from spreading and avoid the need for much more mutilating "salvage" procedures. Vascular surgery can help maintain sufficient blood supply for wound healing and antibacterial defense. Plastic surgery can be very helpful. PREVENTION: A certain number of simple measures help reduce the risk of diabetic foot ulcers. However, many patients, and practitioners, are insufficiently aware of their effectiveness. Prevention and treatment can best be accomplished by a multidisciplinary approach calling upon the endocrinologist and the vascular and orthopedic surgery teams. A carefully planned rehabilitation program using adapted soles, orthesis, orthopedic shoes or prostheses as needed can considerably reduce the frequency of recurrence. The risk of recurrence in a patient wearing adapted footwear is only 26% at 5 years compared with 83% in other cases.

[Fracture of the femoral neck complicating algodystrophy of the hip during pregnancy. Apropos of 2 cases]. / Fracture du col du fémur compliquant une algodystrophie de hance au cours de la grossesse. A propos de 2 observations.

The authors report 2 cases of fracture of the femoral neck in pregnant women. This is a serious complication of a poorly understood disease, algodystrophy of the hip during pregnancy (transient osteoporosis of the hip of pregnancy, as referred by Anglo-saxon practitioners), whose main clinical, paraclinical and course characteristics are reported. The risk of subcapital fracture is maximal during the period of term, justifying recumbency in painful forms. In spite of the phantom appearance of the femoral head and neck, this type of fractures should not be confused with tumoral osteolysis, since they always unite within usual intervals.

[Results of surgical treatment of patellar disequilibrium. Apropos of 311 cases]. / Résultats du traitement chirurgical des déséquilibres rotuliens. A propos de 311 cas.

Three hundred eleven operations for patellar instability were reviewed after 2 to 10 years. Best results were obtained with surgical procedures on the quadriceps, especially with plasty of the vastus medialis and occasional transposition of the tibial tuberosity. If the procedure was limited to the patellar cartilage or the tibial tuberosity only, the results were not as good. Good results were achieved in 84 per cent of 269 patients: 14 per cent were satisfactory and 2 per cent were failures.

[Outcome, treatment and prognosis of Horton's disease]. / Evolution, traitement et pronostic de la maladie de Horton.

Precise information was obtained by a computerized analysis of the treatment, prognosis and clinical outcome of 108 representative cases selected from a series of 160 patients with Horton's disease (HD) diagnosed between 1970 and 1981. At the end of the study, 18 patients had died (16,6 p. 100), the commonest cause of death being a cerebrovascular accident. Death occurred during the first two years of the illness in half these cases. Despite these early complications of the disease, from a statistical point of view, the patients did not die of HD or the complications of its treatment. The 5 years survival rate 80,1 p. 100 (actuarial analysis). Most deaths were from natural causes; an intercurrent disease was often implicated; the lower probability of survival for men (69,9 p. cent at 5 years, compared to 85,4 p. cent for women) is compatible with the lower life expectancy which is well established. The roles of intercurrent disease and sex were statistically significant. On the other hand, there was no difference in the probability of 5 year survival when the different presenting of the disease, the terrain (HLA-DR4) and choice of corticosteroid therapy were compared. The initial dose of prednisone or prednisolone should exceed 0,5 mg/kg/day, if relapse is to be avoided. No additional benefits were observed with doses in excess of 1 mg/kg/day except in cases with complications from the onset (ocular, coronary insufficiency, stenosis of the main large arteries, without being able to prejudge their mechanism).(ABSTRACT TRUNCATED AT 250 WORDS)