A single-centre experience of 29 total ankle replacement in haemophiliac patients: Therapeutic management, factor consumption and cost.

INTRODUCTION: In patients with haemophilia, repeated bleeding in large joints leads to chronic haemophilic arthropathy, a rare disease that can be managed surgically with ankle arthrodesis or with total ankle replacement (TAR). TAR has been reported to provide good surgical results in the medium/long-term and allow preservation of joint mobility but the medical therapeutic management of the patients has not been described. AIM: To describe the medical therapeutic management of TAR. METHODS: All patients with haemophilia A/B, with haemophilic ankle arthropathy, and who underwent TAR between April 2006 and October 2019 were retrospectively included. Factor consumption, perioperative and early complications, volume of blood lost, and orthopaedic data were collected. RESULTS: A total of 25 patients underwent 29 TAR (mean age was 44.7 years [range: 26-65]). In the 17 patients with HA without history of anti-FVIII inhibitor, the mean ± SD consumption the day of surgery was 116 ± 16 UI/kg when clotting factors were administered by continuous infusion, 106 ± 13 UI/kg when SHL factors were administered by bolus infusion, and 75 ± 22 UI/kg when EHL factors were administered by bolus infusion. During hospitalisation, the mean factor cost was €38,073 (83.7% of the total cost of surgery). Mean blood loss was significantly lower in patients treated with tranexamic acid (164 mL, range: 40-300) than in those not (300 mL, range: 70-800; p = .01). Six patients had haematoma. The 10-year survival free of any prosthesis removal/arthrodesis was estimated to be 92.2% (95% CI [83; 100]). CONCLUSION: The medical therapeutic management of TAR is complex, carried out by a multidisciplinary team but effective in avoiding the occurrence of complications.

Dual-mobility tripod cup for revision hip arthroplasty: long-term (five to fourteen years) evaluation of a new generation cementless implant.

PURPOSE: The aims of this study were to evaluate the survivorships of a new generation cementless DMC with tripod additional fixation in revision total hip arthroplasty and complications at a minimum five year follow-up. METHODS: One hundred and fifteen revisions (THA) treated with tripod DMC performed between 2009 and 2015 were included in this retrospective study. Acetabular defects were classified as Paprosky 1 (n = 38, 33%), 2 (n = 75, 65%) or 3 (n = 2, 2%). Unipolar or bipolar revision was performed for the following indications: aseptic acetabular loosening (63%), infection (14%), aseptic bipolar loosening (11%), instability (4%), aseptic femoral loosening (3%), ALVAL (3%) and iliopsoas impingement (2%). Mean follow-up was 9.4 years ± two (range, 5 to 14). RESULTS: At the final follow-up, a single episode of dislocation occurred within three months after the procedure (0.8%) with no revision. Three cases of aseptic loosening were diagnosed (2.6%). Four infections (3.5%) required reoperation: three required a two stage bipolar revision; one was treated by DAIR procedure. At the latest follow-up, the survivorship of the acetabular cup for aseptic loosening was 98% [95% CI (91.2-99.4)] and for any reasons was 94.4% [95% CI (90.1%-98.9%)]; the mean HHS improved from 60 points (range, 18-94 points) to 83 points (range, 37-100 points) (p < .001). CONCLUSION: This study reports a low complication rate in favour of the use of a tripod DMC in revision THA with a satisfactory survivorship at a ten year follow-up.

An anatomical study of the meniscal roots of the knee: landmarks for its surgical reconstruction and implications for knee surgeons.

PURPOSE: The aim of this anatomical study was to describe the anatomy of the meniscal roots and their relationships with respect to the main adjacent structures in order to improve their surgical reconstruction. METHODS: Fourteen knees were included. The mean age of the donors was 92 years (range 89-96). We studied the general characteristics of the anterior and posterior roots of the medial meniscus and lateral meniscus by measuring their widths at their base and area. We investigated the relations between anterior and posterior roots of the medial and lateral menisci with respect to the anterior and posterior cruciate ligaments (ACL and PCL). RESULTS: The mean width of the anterior root of the lateral meniscus was 10.5 ± 1.4 mm. The mean width of the anterior root of the medial meniscus was 10 ± 1.5 mm. The mean width of the posterior root of lateral meniscus was 11.4 ± 1.4 mm. The mean width of the posterior root of medial meniscus was 10.5 ± 1.0 mm. The mean distance between the anterior cruciate ligament and the anterior root of lateral meniscus was 9.8 ± 2.9 mm, for the medial meniscus it was 15.9 ± 3.4 mm. The mean distance between the posterior cruciate ligament and the posterior root of the lateral meniscus was 11.5 ± 2.7 mm, for the medial meniscus, it was 11 ± 2.6 mm. CONCLUSION: The anterior and posterior meniscal roots have precise landmarks, and this article contributes to define the location of the meniscal roots with respect to their adjacent anatomical structures: ACL, PCL and intercondylar tubercle. Having precise measures of the distances between the meniscus roots and these structures allows knee surgeons to perform ACL reconstruction, meniscal root repair and meniscal allograft transplantation.

Relationships of the superficial fibular nerve and sural nerve with respect to the lateral malleolus: implications for ankle surgeons.

PURPOSE: Superficial fibular nerve (SFN) and sural nerve are at risk during osteosynthesis of the lateral malleolus. The aim of this anatomical study was to describe the relationships of the superficial fibular and sural nerves with respect to the lateral malleolus. METHODS: Nine corpses (18 ankles) were dissected, using a direct lateral approach. Measurements were recorded between the fibula and the nerves, and the pattern variations of the SFN were recorded for both right and left side to assess intra-individual variability. RESULTS: Distance between the tip of the lateral malleolus and the piercing of fascia cruris was 111 ± 26 mm for type 1 pattern, and range was 46-161 mm all types included. 78% (14 SFN) were type 1 pattern, 17% (3 SFN) were type 2 pattern, and 5% (1 SFN) were type 3 pattern. 44% (4 specimen) had a type 1 pattern SFN on one ankle and another pattern on the other ankle. The sural nerve was always observed just posterior to the lateral malleolus. CONCLUSION: This study demonstrated a great inter-individual variability especially for the SFN, but also an intra-individual variability with frequent different patterns between right and left leg. It is important to know the anatomical variations of the SFN and sural nerve to decrease the risk of intra operative nerve injury during direct lateral approach of lateral malleolus.

97 HINTEGRA ankle prostheses: Results and survival at more than 5 years' follow-up.

BACKGROUND: In Europe, fixed-bearing implants predominate again in total ankle replacement (TAR). The present single-center single-surgeon study assesses the Hintegra® mobile-bearing implant (NEWDEAL). METHODS: Between November 2008 and November 2015, 97 Hintegra® were implanted in 94 patients: mean age, 62.4±10.9 years (26-83); 59% (57/97) male; normal mean body-mass index (BMI), 27.5 ± 4.3 kg/m2. Indications mainly comprised posttraumatic (40.2%), instability (29.9%) and primary osteoarthritis (16.5%). 17.5% of patients had prior surgery during the previous 6 months (9 fusions, 8 ligament reconstructions, and 4 osteotomies); in 59.8%, other procedures were associated to TAR. Functional, clinical and radiological follow-up was conducted at 1 year, 2 years and last follow-up (>5 years). RESULTS: Ninety-four TARs were analyzed at a mean 81 ± 21.6 months (19-124). Revision-free survival was 76% (95% confidence interval (95%CI): 0.66-0.8), and explantation-free survival 92% (95%CI: 0.85-1) with 10 cases of curettage and 5 explantations. Mean AOFAS score improved from 41.8 ± 12.5 (21-69) to 77.5 ± 16.5 (24-100) up (p < 0.001); 75% of patients had no or only mild pain (p < 0.001). Clinical ranges of motion were 8.0 ± 7.1° dorsiflexion (p < 0.001) and 35.1 ± 9.4° plantar flexion (preoperatively, 34.1 ± 7.9°) (p = 0.71). Radiologically, tibial components were well-positioned; 87% of talar components were well-centered. Global ankle range of motion was 23.5 ± 10.2° (5-48) (p = 0.17). 54.6% of TARs showed posterior tibial calcification at follow-up. Risk of severe cyst (>1 cm) on CT was 36% (95%CI: 23-47) at a mean 77 ± 21.9 months (18-123). CONCLUSION: Hintegra® TAR incurred a low risk of revision, and is a reliable option for ankle osteoarthritis. LEVEL OF EVIDENCE: IV.

Association Between Short-, Intermediate-, and Long-term Mortality and Myocardial Injury After Noncardiac Surgery After Hip Fracture Surgery: A Retrospective Cohort.

BACKGROUND: For more than 20 years, hip fracture 1-year mortality has remained around 20%. An elevation of the postoperative troponin peak within 72 hours (myocardial injury after noncardiac surgery [MINS]) is associated with a greater risk of short-term mortality in the general population. However, there seem to be conflicting results in the specific population who undergo hip fracture surgery, with some studies finding an association between troponin and mortality and some not. The objective of the present study was to investigate the association of MINS and the short- (before 28th day), intermediate- (before 180th day), and long-term (before 365th day) mortality after hip fracture surgery. METHODS: We conducted a single-center retrospective cohort of patients undergoing hip fracture surgery from November 2013 to December 2015. MINS was defined as postoperative troponin peak within the 72 hours >5 ng/L. Four MINS subgroups were defined according to the value of troponin peak (ie, ≥5-<20, ≥20-<65, ≥65-<1000, and ≥1000 ng/L). To document the association between the different mortality terms and the troponin peak, odds ratio (OR) and adjusted OR (aOR) associated with their 95% confidence interval (CI) with the log of the scaled troponin peak within 72 hours were estimated, with and without patients presenting a postoperative acute coronary syndrome (ACS). Cox proportional hazards modeling was used to estimate hazard ratio (HR) and adjusted HR (aHR) of death between the no MINS and MINS subgroups. The adjustment was performed on the main confounding factors (ie, sex, American Society of Anesthesiologists [ASA] physical status, dementia status, age, and time from admission to surgery). RESULTS: Among 729 participants, the mean age was 83.1 (standard deviation [SD] = 10.8) years, and 77.4% were women; 30 patients presented an ACS (4%). Short-, intermediate-, and long-term mortality were at 5%, 16%, and 23%, respectively. The troponin peak was significantly associated with all terms of mortality before and after adjustment and before and after exclusion of patients presenting an ACS. HR and aHR for each subgroup of troponin level were significantly associated with an increased probability of survival, except for the 5 to 20 ng/L group for which aHR was not significant (1.75, 95% CI, 0.82-3.74). In the landmark analysis, there was still an association between survival at the 365th day and troponin peak after the short- and intermediate-term truncated mortality. CONCLUSIONS: MINS is associated with short-, intermediate-, and long-term mortality after hip fracture surgery. This could be a valuable indicator to determine the population at high risk of mortality that could benefit from targeted prevention and possible intervention.

Articular Noise After THA Using Delta CoC Bearings Has Little Impact on Quality of Life.

BACKGROUND: To report clinical outcomes and survival at a minimum of 10 years of a consecutive series of uncemented total hip arthroplasty (THA) with fourth-generation ceramic-on-ceramic (CoC) bearings and determine the incidence of articular noises, their risk factors, and impact on quality of life (QoL). METHODS: From a series of 456 CoC THAs, there were 25 revisions, 38 deceased, and 36 lost to follow-up. The remaining 357 hips were assessed at 11.1 ± 0.7 years (range, 10-14) using the Forgotten Joint Score, Oxford Hip Score, and a questionnaire on articular noises. Kaplan-Meier survival was calculated, and multivariable analysis was performed to determine associations between articular noise and patient/surgical factors. RESULTS: The 10-year survival was 96.3% for the cup, 96.5% for the stem, and 94.2% for all components. The Forgotten Joint Score was 79 ± 26 (range, 0-100), and Oxford Hip Score was 16 ± 7 (range, 12-60). The mean impact of articular noises on QoL was 1.8 ± 2.9 (range, 0-9): considered negligible in 60 hips (16%), moderate in 27 hips (7%), and severe in only 13 hips (4%). Multivariable analyses revealed that the incidence of articular noise decreased with age (odds ratio [OR], 0.94; P = .001), body mass index (OR, 0.85; P = .001), and in hips implanted with 32-mm (vs 36 mm) heads (OR, 0.18; P = .030). CONCLUSION: Of 100 hips (28%) that reported some articular noises 10 years after CoC THA, the impact of articular noises on QoL was negligible for most patients. Although larger heads can improve mobility and reduce risks of dislocations, surgeons must be aware that increasing head size could also increase risks of articular noises, notably in young and active patients.

Mid-Term Clinical and Radiographic Outcomes of a Long Cementless Monobloc Stem for Revision Total Hip Arthroplasty.

BACKGROUND: For the past 2 decades, the authors have been using a long tapered cementless stem made of titanium and fully coated with hydroxyapatite for revision total hip arthroplasty. The purpose of this multicentric study is to assess clinical outcomes, radiographic outcomes, re-revision rates, and survival rates of this revision stem at a minimum 5-year follow-up. METHODS: The records of a multicentric continuous series of 335 adults undergoing revision total hip arthroplasty using the Corail revision stem (DePuy, Leeds, UK) between 2000 and 2012 were retrospectively reviewed. The Harris Hip Score, Oxford Hip Score, and Engh score were recorded. Survival was assessed using the Kaplan-Meier method and cumulative incidence function. RESULTS: Seventy-seven patients died with their revision stem in place, 47 could not be contacted, and 22 had stem re-revisions. This left a final cohort of 201 patients, aged 70 ± 12 years at revision surgery, with a body mass index of 26 ± 4. The Kaplan-Meier survival was 93.9% for re-revision of any component for any reason, 96.7% for re-revision of the stem for any reason, and 99.3% for re-revision of the stem for aseptic reasons. At last follow-up, the Harris Hip Score was 84.8 ± 13.1, the Oxford Hip Score was 21.0 ± 7.8, and the Engh score was 16.4 ± 6.7. CONCLUSION: The long tapered cementless revision stem had excellent clinical and radiographic outcomes at a minimum follow-up of 5 years. The revision stem enabled restoration of bone stock in femurs with pre-revision bone defects, confirming that the hydroxyapatite coating promotes osseointegration, even in femurs with extensive bone loss. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Rheumatoid Forefoot Reconstruction in Nonrheumatic Patients: Lesser Metatarsal Head Resection versus Osteotomy.

In the literature, first metatarsophalangeal joint arthrodesis with lesser metatarsal head resection seems to be a reliable procedure in rheumatoid foot deformity. Maybe this procedure could be proposed in nonrheumatoid severe forefoot deformity (hallux valgus angle >40° and lesser metatarsophalangeal dislocation). The aim of this study was to compare radiological and clinical outcomes between lesser metatarsal head resection and lesser metatarsal head osteotomy in nonrheumatoid patients. Thirty-nine patients (56 feet) suffering from well-defined nonrheumatoid severe forefoot deformity were retrospectively enrolled in our institution between 2009 and 2015. Metatarsal head resection and metatarsal head osteotomy represented 13 patients (20 feet) and 26 patients (36 feet), respectively. In this observational study, a rheumatoid population (21 patients) was included as the control. The clinical outcome measures consisted of American Orthopaedic Foot and Ankle Society score, Foot and Ankle Ability Measurement, and Short Form-36. The radiological outcomes were: intermetatarsal angle, hallux valgus angle, and metatarsophalangeal alignment. Mean follow-up was 24 months. Satisfaction rate was, respectively, 92% for resection, 91% for osteotomy procedure, and 80% for surgery in rheumatoid patients. Short Form-36 global score was, respectively, 80.7 (52.5-96.4), 76 (57.7-93), and 68.3 (22.6-86). No functional outcome difference was found between resection and osteotomy procedures, except that the metatarsal head resection group had poorer results in sports activities than the osteotomy group. Complications were similar between osteotomy and resection (p > .05). The radiological outcomes were improved significantly from preoperative to postoperative. First metatarsophalangeal joint arthrodesis with lesser metatarsal head resection in nonrheumatoid severe forefoot deformity might be a good therapeutic option.

No Differences in Midterm Sports Participation or Functional Scores After Total Hip Arthroplasty by Posterolateral Vs Anterolateral Approach.

BACKGROUND: Patients undergoing total hip arthroplasty (THA) frequently question surgeons on return to sports. We compared midterm sports participation and functional scores after THA by posterolateral approach (PLA) vs anterolateral approach (ALA). METHODS: Of 1381 patients who underwent uncemented ceramic-on-ceramic THA for primary osteoarthritis, 503 were excluded because of preoperative or postoperative lower limb surgery, leaving 594 operated by PLA and 284 by ALA. Forgotten Joint Score (FJS), Oxford Hip Score (OHS), satisfaction, as well as motivation, participation, and discomfort regarding 22 sports were collected. A 1:1 matching was performed to obtain 2 groups of PLA and ALA patients with similar age, gender, body mass index, and sports motivation. RESULTS: Matching yielded 2 equal groups of 259 patients. There were no significant differences in FJS (P = .057), OHS (P = .685), satisfaction (P = .369), or rates of participation in light (P = .999), moderate (P = .632), or strenuous sports (P = .284). Participation in strenuous sports was reported by 50 PLA (19%) and 61 ALA (24%) patients, with differences for downhill skiing (22 vs 39), running (10 vs 19), and cross-country skiing (18 vs 10). More than 50% of motivated patients practiced most of their sports. Severe discomfort was reported similarly in PLA and ALA patients, mainly during running (13 vs 11), team ball games (9 vs 7), and downhill skiing (7 vs 8). CONCLUSION: There were no significant differences between PLA and ALA patients in terms of OHS, FJS, satisfaction, or sports participation rates. There is little or no evidence to promote an approach based on sports participation or functional improvement. LEVEL OF EVIDENCE: Level III, comparative study.

Metasul vs Cerasul bearings: a prospective, randomized study at a mean eighteen years.

BACKGROUND: The aims of our study were to compare the clinical, radiographic outcomes and survivals between second-generation metal-on-metal (Metasul) and ceramic-on-ceramic (Cerasul) bearings at a very long-term follow-up. METHODS: A prospective, randomized study was originally performed on a consecutive series of 250 cementless, 28-mm head and primary total hip arthroplasties between 1999 and 2002. For each bearing (Metasul or Cerasul), 125 THAs were initially included. All cases were evaluated both clinically and radiographically, and survival was assessed, considering revisions for aseptic loosening or for any reason as the end points for failure. RESULTS: At a mean 18-year follow-up, clinical and radiographic outcomes were similar. Harris Hip Score increased 30% in the Metasul group and 32% in the Cerasul group (p = 0.6). Survival free of aseptic loosening was higher for Cerasul (100%), than for Metasul (94% [CI 88-99.9]) (p = 0.04). Survival free of any revision was 91% ([CI 84-98%]) for Cerasul and 91% ([CI 84-98%]) for Metasul. Fractures of Cerasul insert occurred in four cases (3%) at a mean 12.5 ± 3.3 years (range, 6 to 17 years). CONCLUSION: At 18 years, Cerasul demonstrated higher survivorship than Metasul considering aseptic loosening as an end point. However, Cerasul liners had high rate of fracture because of its sandwich design (thin ceramic liner into polyethylene). These implants are no more available on the market.

Subcutaneous suppressive antibiotic therapy for bone and joint infections: safety and outcome in a cohort of 10 patients.

BACKGROUND: Optimal treatment of prosthetic joint infection and chronic osteomyelitis consists of surgical removal of biofilm-embedded bacteria, followed by a 6-12 week course of antimicrobial therapy. However, when optimal surgery is not feasible, oral prolonged suppressive antibiotic therapy (PSAT) is recommended to prevent prosthesis loosening and/or relapse of infection. Since 2010, we have used infection salvage therapy using off-label subcutaneous (sc) injection of a ß-lactam as PSAT for patients in whom oral PSAT is not possible. METHODS: A single-centre prospective cohort study (2010-18) reporting treatment modalities, efficacy and safety in all patients receiving sc PSAT. NCT03403608. RESULTS: The 10 included patients (median age 79 years) had polymicrobial (n = 5) or MDR bacterial (n = 4) prosthetic joint infection (knee, n = 4; hip, n = 3) or chronic osteomyelitis (n = 3). After initial intensive therapy, seven patients received ertapenem, three patients received ceftriaxone and one patient received ceftazidime by sc injection (one patient received 8 days of ceftriaxone before receiving ertapenem). In one patient, sc PSAT failed with recurrent signs of infection under treatment. In three patients, sc PSAT had to be discontinued due to side effects; in only one of these was the sc route implicated (skin necrosis following direct sc injection and not gravity infusion). Median treatment duration was 433 days. In six patients, sc PSAT was successful with favourable outcome at the time of writing. Interestingly, three patients with MDR bacterial carriage at baseline lost this under PSAT during follow-up. CONCLUSIONS: As salvage therapy, sc PSAT delivered by gravity infusion is a safe and interesting alternative when an optimal surgical strategy is not feasible and no oral treatment is available.

Midterm Clinical and Radiographic Outcomes of a Contemporary Monoblock Dual-Mobility Cup in Uncemented Total Hip Arthroplasty.

BACKGROUND: The efficacy of contemporary monoblock dual-mobility (DM) cups to prevent dislocations in total hip arthroplasty (THA) is well reported, but there is little published data on their mid- to long-term outcomes. The authors aimed at reporting the 10-year survival of a contemporary DM cup as well as its clinical and radiographic outcomes. METHODS: From a retrospective consecutive multicentric series of 516 patients (541 hips) that received uncemented THA between June 2007 and June 2010, 6 patients (6 hips) had cup and stem revisions, 5 patients (5 hips) had isolated stem revision, and 2 patients (2 hips) had isolated insert revision. A total of 103 patients (111 hips) died with their original implants, and 41 patients (42 hips) were lost to follow-up. This left 358 patients (375 hips) for clinical assessment at a median follow-up of 8.7 years (range, 6.8-10.5 years), including 279 patients (290 hips) with postoperative radiographs. Implant survival was calculated using the Kaplan-Meier method, and multivariable analyses were performed to determine whether clinical outcomes are associated with patient or surgical factors. RESULTS: The 10-year survival considering revision for aseptic loosening as end point was 100% for the cup and 99.2% for the stem. No dislocations were observed, and radiographic assessment revealed 1 acetabular granuloma (0.3%), but no radiolucencies nor fractures. The Harris hip score improved from 49.6 ± 15.5 to 85.2 ± 14.5, and the postoperative Oxford hip score was 19.2 ± 7.6. Multivariable analyses revealed that improvement in Harris hip score increased with cup diameter (beta, 1.28; P = .039). CONCLUSION: Our data confirmed satisfactory midterm outcomes of uncemented THA using a contemporary DM cup, with no dislocations nor cup revisions due to aseptic loosening. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Long-term survivorship of a monoblock long cementless stem in revision total hip arthroplasty.

PURPOSE: The purpose of this study was to assess the clinical outcomes, complications, and survival of a long cementless titanium femoral stem in revision total hip arthroplasty (THA) at a minimum five year follow-up. METHODS: Between 2000 and 2010, 114 patients (116 hips), with a mean age of 68 ± 12 years, underwent revision THA using a KAR® stem (DePuy, Leeds, UK). The main reasons for revision were aseptic loosening (82%), periprosthetic joint infections (PJI) (11%), and periprosthetic fractures (6%). Mean follow-up was ten ± three years (range, 5-16). Harris Hip Score (HHS), Oxford Hip Score (OHS), and Postel-Merle d'Aubigné (PMA) score were recorded. Radiographic analysis assessed stem osseointegration and subsidence. Survival was analyzed using the Kaplan-Meier (KM) method and cumulative incidence function (CIF). RESULTS: Post-operative HHS was 83 ± 15 (range, 35-99) and OHS was 37 ± 8 (range, 8-48). PMA score significantly increased from 12 ± 2 (range, 5-18) pre-operatively to 14.6 ± 2 (range, 9-18) post-operatively (p = 0.0004). The radiographic Engh score was 15 ± 8 (range, 7-22). Stem subsidence was observed in two cases (3%). At ten years, five stems had been revised, three for infections and two for periprosthetic fractures. Using the KM method, ten year survival free of stem revision for aseptic loosening was 100%, free of revision for any reason 95%, and free of any re-operation 81%. CONCLUSIONS: The present study reported satisfactory outcomes and survival of a long tapered unlocked cementless femoral stem in revision THA at a minimum follow-up of five years.

A comparative study about the incidence of dislocation and peri-prosthetic fracture between dual mobility versus standard cups after primary total hip arthroplasty.

PURPOSE: Dislocation and peri-prosthetic fracture (PPF) are major reasons for revision THA (total hip arthroplasty). The main advantage of dual mobility (DM) cups is to minimize the incidence of dislocation compared to single mobility (SM) cups. We hypothesized that the use of DM would lead to an increased risk of PPF because of its greater stability. In contrast, standard cups would be at higher risk of dislocation. METHODS: A retrospective comparative study was performed in our institution including 126 revision THAs between January 2013 and December 2017. Collected data included gender, age, BMI, Parker score, ASA score, the etiology for primary THA, type of cup (SM or DM), cortical index, Noble index, and the stem fixation. RESULTS: Overall, 53 standard and 73 DM cups were included for study. In the dislocation group, 29 had standard cups (83%) and 6 had DM cups (17%). Dislocation was 12-fold higher in SM cups (p < 0.001). In the PPF group, 24 had standard cups (26%) and 67 had DM cups (74%). PFF was 12-fold higher for DM cups (p < 0.001). A higher Parker score and a higher cortical index had a protective effect on the risk of PPF (OR = 0.76 (p = 0.03), OR = 0.57 (p = 0.048)). CONCLUSION: The use of DM increased hip stability but led to a higher rate of PPF by load transfer on the femur. Further studies with larger cohort and follow-up are needed to confirm these findings and measure the incidence of these complications.

The history of anatomy teaching in Lyon University: in the footsteps of Rabelais, Petit, Lisfranc, Testut and Latarjet, and many others.

Anatomy and Lyon have a very long history together since the first hospital in France was set up on the banks of the Saône River in the fourteenth century. The Lyon school of Anatomy was originally in the Hôtel-Dieu, which later housed the "secondary" (1821) then "preparatory" (1841) schools. Only in 1877 was the Medicine and Pharmacy Faculty set up. The development of anatomy teaching followed the rise of printing in the fifteenth century. The rise of surgery was founded on knowledge of anatomy and the ability to teach it. Before the days of anesthesia, surgery required perfect anatomical skills, to keep operative time to a minimum. Correlation with anatomy accompanied the introduction of radiology and later of medical imaging in general; the science of Anatomy is nowadays enriched by robotics and information technology.

Radiographic and Clinical Comparison of Proximal Interphalangeal Joint Arthrodesis Between a Static and Dynamic Implant.

Hammertoe deformation is a frequent motive for consultation in forefoot surgery, and proximal interphalangeal joint arthrodesis is a classic treatment for fixed deformation, which tends to be achieved more and more thanks to specific implants. This work evaluated and compared clinical improvement, radiologic fusion, and complication rates between dynamic (Difuse®) and static (TinyFix®) implants from Biotech Ortho. A total of 95 patients (110 feet and 166 toes; 97 static and 69 dynamic implants) were included. Mean age was 63.6 (±12.6) years in the dynamic group and 62.3 (±14.01) years in the static group. Epidemiologic and intraoperative radiologic data were collected. Pain, toes deformity, complications, and radiologic findings (bone fusion and osteolysis) were recorded at 4 months postoperatively and at the last follow-up. Mean follow-up was 11.5 (range 4 to 28) months, and the position of the implants was more often satisfying in the dynamic group (p = .01). Fusion rates at 4 months were 67% and 80% in the dynamic and static groups, respectively (p = .05). Radiologic osteolysis occurred more frequently in the dynamic group (p = .05 at 4 months), and pain was still present in 3% in the dynamic group at the last follow-up compared with 7% in the static group. Complication rate was 7% in the dynamic group (implant fractures) and 4% in the static group. Revision was considered more often in the dynamic group (p = .01). The static titanium implant seems superior to the dynamic memory shape implant in Nitinol alloy with regard to fusion (p = .04), complications (p = .03), and revision rates (p = .01). The literature review seems to support the good results of static implants compared with the rest of the available arthrodesis implant solutions.

Prospective Cohort Study of the Tolerability of Prosthetic Joint Infection Empirical Antimicrobial Therapy.

The empirical use of vancomycin in combination with a broad-spectrum beta-lactam is currently recommended after the initial surgery of prosthetic joint infection (PJI). However, the tolerability of such high-dose intravenous regimens is poorly known. Adult patients receiving an empirical antimicrobial therapy (EAT) for a PJI were enrolled in a prospective cohort study (2011 to 2016). EAT-related adverse events (AE) were described according to the common terminology criteria for AE (CTCAE), and their determinants were assessed by logistic regression and Kaplan-Meier curve analysis. The EAT of the 333 included patients (median age, 69.8 years; interquartile range [IQR], 59.3 to 79.1 years) mostly relies on vancomycin (n = 229, 68.8%), piperacillin-tazobactam (n = 131, 39.3%), and/or third-generation cephalosporins (n = 50, 15%). Forty-two patients (12.6%) experienced an EAT-related AE. Ten (20.4%) AE were severe (CTCAE grade ≥ 3). The use of vancomycin (odds ratio [OR], 6.9; 95% confidence interval [95%CI], 2.1 to 22.9), piperacillin-tazobactam (OR, 3.7; 95%CI, 1.8 to 7.2), or the combination of both (OR, 4.1; 95%CI, 2.1 to 8.2) were the only AE predictors. Acute kidney injury (AKI) was the most common AE (n = 25; 51.0% of AE) and was also associated with the use of the vancomycin and piperacillin-tazobactam combination (OR, 6.7; 95%CI, 2.6 to 17.3). A vancomycin plasma overexposure was noted in nine (37.5%) of the vancomycin-related AKIs only. Other vancomycin-based therapies were significantly less at risk for AE and AKI. The EAT of PJI is associated with an important rate of AE, linked with the use of the vancomycin and the piperacillin-tazobactam combination. These results corroborate recent findings suggesting a synergic toxicity of these drugs in comparison to vancomycin-cefepime, which remains to be evaluated in PJI. (This study has been registered at ClinicalTrials.gov under identifier NCT03010293.).

Factors associated with Clostridium difficile infection: A nested case-control study in a three year prospective cohort.

BACKGROUND: Clostridium difficile infection (CDI) is a serious medical condition that is associated with substantial morbidity and mortality. Identification of risk factors associated with CDI and prompt recognition of patients at risk is key to successfully preventing CDI. METHODS: A 3-year prospective, observational, cohort study was conducted in a French university hospital and a nested case-control study was performed to identify risk factors for CDI. Inpatients aged 18 years or older, suffering from diarrhea suspected to be related to CDI, were asked to participate. RESULTS: A total of 945 patients were included, of which 233 cases had a confirmed CDI. CDI infection was more common in men (58.4%) (P = 0.04) compared with patients with diarrhea not related to C. difficile. Previous hospitalization (P < 0.001), prior treatment with antibiotics (P = 0.001) or antiperistaltics (P = 0.002), liver disease (P = 0.003), malnutrition (P < 0.001), and previous CDI (P < 0.001) were significantly more common in patients with CDI. Multivariate logistic regression analysis showed that exposure to antibiotics in the last 60 days (especially third generation cephalosporins and penicillins with ß-lactamase inhibitor), chronic renal or liver disease, malnutrition or previous CDI, were associated with an independent high risk of CDI. Age was not related with CDI. CONCLUSIONS: This study showed that antibiotics and some comorbid conditions were predictors of CDI. Patients at high risk of acquiring CDI at the time of admission may benefit from careful monitoring of antibiotic prescriptions and early attention to infection control issues. In future, these "high-risk" patients may benefit from novel agents being developed to prevent CDI.

Dual mobility cups in revision total hip arthroplasty.

AIM: The purpose of our study was to evaluate the dislocation and aseptic loosening rates of a dual mobility construct in revision total hip arthroplasty (THA). METHODS: Three hundred thirty-four revision THAs performed between 2006 and 2011, using a dual mobility cup, were included in this retrospective study. The indications for revision were aseptic loosening (70%), infection (21%) and recurrent instability (9%). The minimum follow-up was five years (mean 7 ± 2 years, maximum 10 years). RESULTS: At the latest follow-up, 11 episodes of dislocation occurred, seven of which were recurrent (1.3% for aseptic loosening, 2.8% for infection and 3.4% for recurrent dislocation). Ten cases of aseptic loosening occurred; in seven of them, a cemented cup into a reinforcement ring had been used (OR = 14, p = 0.0001). CONCLUSION: This study provided evidence of the advantages of dual mobility cups in all revision THA indications.