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.

Reducing the cervical flexion tear-drop fracture with a posterior approach and plating technique: an original method.

Flexion tear-drop fractures (FTDF) in the cervical spine constitute a highly unstable condition with a high incidence of neurological complications due to posterior displacement of the fractured vertebra in the spinal canal. The widely accepted surgical management for this condition includes complete excision and grafting of the vertebral body through an anterior approach. Thorough radiological and CT analysis of FTDF shows that the vertebral body is often separated into two parts by a sagittal plane fracture, but remains continuous through the pedicle and anterior arch of the vertebral foramen with the lateral mass and the articular processes. We therefore hypothesized that reduction would be possible by acting on the articular process through a posterior approach with a particular plating technique. Eight patients with FTDF were operated on with the technique we describe. Three had complete tetraplegia, four had incomplete tetraplegia and one was normal. A preoperative CT scan was made in all patients. Local kyphosis, posterior displacement of the vertebral body, and general lordosis in the cervical spine were recorded. In all cases, a satisfactory reduction was achieved on the postoperative radiographs and at the mean follow-up of 18.6+/-12.1 months, with residual posterior displacement being less than 1 mm. No complication occurred. Out of seven neurologically impaired patients, five showed some motor recovery at the latest follow-up. The posterior technique is described, and the rationale and pros and cons are discussed. The study showed that posterior reduction and fixation of flexion tear-drop fracture is not only possible, but permits an accurate restoration of the anatomy of the fractured cervical spine.

Traumatic total axial reversal of the thoracic vertebral body.

Numerous vertebral fracture patterns have been reported in the literature. We present the case of a patient who sustained severe trauma to the back that resulted in a very unusual and not previously reported rotational injury consisting in complete 180 degrees rotation of the T6 vertebral body along a vertical axis, with only limited anteroposterior and lateral displacement. An unsuspected aortic tear resulted in severe evolution with fatal outcome following surgical attempt. The aetiology of such displacement is unknown. The possibility of late vascular complications should be kept in mind while treating thoracic spine fractures with rotational displacement.

[Prevention of deep venous thrombosis in arthroplastic surgery of the hip by the combination of heparinotherapy and the antithrombosis stocking]. / Prévention des thromboses veineuses profondes lors de la chirurgie arthroplastique de hanche par l'association héparinothérapie-bas antithrombose.

Two hundred and eighty-six patients were divided into two groups according to the presence or absence of major risk factors. The so-called "at risk" patients were treated with continuous post-operative heparin therapy combined or not with anti-thrombosis stockings. The patients regarded as not at risk were divided into 3 subgroups allocated at random to different treatments based on subcutaneous heparin in effective or sub-anticoagulant doses with and without stocking. All patients underwent phlebography before and 7 days after the operation. The incidence of post-operative thrombosis was significantly lower in the 137 patients treated with heparin and stocking (10.22 per cent) than in the 131 patients treated with heparin alone (19.85 per cent).

[Posterior approach to the elbow preserving the extensor apparatus. Its value in the osteosynthesis of humerus plate fractures]. / Voie d'abord postérieure du coude respectant l'appareil extenseur. Son intérêt dans la synthèse des fractures de la palette humérale.

The authors describe a median posterior approach of the elbow with preservation of the triceps mechanism in continuity. Such an approach provides an excellent exposure of the elbow and of the lower part of the humeral shaft which can be used for the osteosynthesis of complex supra and intercondylar fractures. This approach can also be extended to the midshaft of the humerus, the radial head and the ulnar shaft. The repair is easy and strong enough to allow a rapid rehabilitation.

[Treatment of recurrent anterior dislocations of the shoulder by the technic of pre-glenoid stapling. Study of a series of 48 cases]. / Traitement des luxations récidivantes antérieures de l'épaule par la technique de l'agrafage pré-glénoïdien. Etude d'une série de 48 cas.

Preservation of local muscular structures, and closure of the capsulo-periosteum detachment, are the two essential principles observed, when treating recurrent anterior shoulder dislocation by pre-glenoid stapling and also afford satisfactory results. This technique is used for capsulo-ligamentar lesions without alterations of the anterior edge of the glenoid cavity. If the strict technique is followed when placing the staple excellent stability result. If physiotherapy is started early, functional recovery is rapid. Sporting activities can be resumed within the third month after the operation.

Fractured odontoid with fractured superior articular process of the axis. Report of three cases.

We report three patients in whom a fractured odontoid process was associated with a fracture of the superior articular process of the second cervical vertebra. Although there were no signs of neurological disorder, damage to the C1-C2 joint in all three patients made fusion necessary. Forced lateral flexion is suggested as the possible mechanism of injury.

[Technic of C1-C2 fixation by posterior screwing]. / Technique de fixation C1-C2 par vissage postérieur.

A posterior screw fixation technique for C1-C2 is described which respects strict anatomical relations and allows associated posterior arthrodesis limited to C1-C2, using a single approach route. This method of posterior fixation can be used even when anomalies of the posterior arch of C1 or C2 exist, of whatever origin, as well as in the presence of a laminectomy. Four patients were operated upon using this method without any postoperative complications.