Prosthetic joint infection (PJI) due to We performed a retrospective, observational multinational study with support of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Patients diagnosed with PJI due to Aim
Method
To evaluate the place of the massive prostheses in the most complex periprosthetic infections cases (PJis). Between 2011 and 2017, 516 hip and knee revisions for periprosthetic infections had been performed in our hospital by the same senior surgeon. We report a prospective series of 58 patients treated between 2011 and the end of 2017. 26 males and 32 females with on average 69,4 years old (38–86). Infection involved TKA in 39 cases (26 TKA revisions, 11 primary TKA), THA in 18 cases (10 revisions, 7 primary THA), a femoral pseudoarthrosis with posttraumatic gonarthrosis in one case and a septic humeral pseudoarthrosis in one case. We used one stage procedures in 38 cases (14 hips, 23 knees, 1 shoulder) and 20 two stages surgeries (16 knees and 4 hips). Additional technics used with massive prostheses, all for TKA PJis: 4 massive extensor systemallografts performed two times in a one stage procedure, two local flaps (medial gastronecmienmuscle). Two perioperative hyperbaric procedures used to limit the risks of wound complications.Aims
Method
The aim of our study was to identify pathogens involved in septic knee arthritis after ACLR and to describe clinical features, treatment and outcome of infected patients. We conducted a retrospective observational study including all patients with ACLR infection in 3 orthopedic centers sharing the same infectious disease specialists.Aim
Methods
The functional and anatomical results of TKA revisions are less good than a primary TKA. The TKA revision frequency increases and we must improve our surgeries and prepare the next standard of these surgeries. The aim of this study was to evaluate the CAOS / one stage strategie to treat the knee PJIs. In this prospective study, between September 2011 and December 2014, 41 patients treated for chronic knee PJI in a one stage revision. For all of them, an imageless CAOS system (ExactechGPS, Blue- Ortho, Gieres) was used. A personalised profile of revision was created. All surgeries were performed with the same protocole and by using the same Optetrak CC knee components (Exactech, Gainesville, FL). All operations were performed by a single senior surgeon. Indications for the revision TKA were (1) revision of a primary TKA or unicondylar knee arthroplasty ( The measurement of the HKA angle, the Oxford score and the ROM were evaluated pre and post- operatively.INTRODUCTION
MATERIALS
In private healthcare facilities, the access to a specialized infectious disease (ID) advice is difficult. More, the lack of traceability is problematic and harmful for treatment and follow-up. We have tested an information technology (IT) application to improve medical transmission and evaluate an interdisciplinary ID activity. In November 2015, three ID physicians (IDP) created an interdisciplinary activity, visiting patients and giving phone advices among ten private healthcare facilities. They are members of the complex bone and joint infection unit of the community hospital where they are attached. Since September 2016, each advice was prospectively recorded on a protected online information system. These data are available for consultation and modification by the three IDP. It is the first descriptive analysis of this database.Aim
Methods
Pre-operative distinction between prosthetic joint infections (PJI) and non-infectious causes of joint failure is particularly challenging, especially in chronic situations. Guidelines propose different algorithms using numerous preoperative tests. We evaluated place of serology. During a 9 month period, we included consecutive patients undergoing arthroplasty revision for a suspected chronic hip or knee infection. Serologies were sampled at the same day than the other blood tests. Results were compared with the final diagnosis, determined with peroperative bacteriological and histological results. Serology was performed using a multiplex antibody detection*. This multiplex antibody detection assay detects antibodies against Aim
Method
European population is ageing concurrently with an increase number of arthroplasties. Prosthetic joint infection (PJI) in the elderly is considered more severe. The aim of this study is to describe PJI's management of patients over 79 years of age. We conducted a retrospective study including all patients aged over 79 years old consulting for a suspected hip or knee PJI in our community hospital where a complex bone and joint unit is present.Aim
Methods
Ceftobiprole, a broad-spectrum cephalosporin, could be used for post-operative treatment of bone implant-associated infections. The aim of the study is to evaluate the in vitro susceptibility of bacteria isolated from bone implant-associated infections to ceftobiprole. We conducted an in vitro, retrospective and comparative study between July 2013 to April 2017 including patients with bone implant-associated infections (prosthesis joint infection (PJI) and osteosynthesis material (OM)). To evaluate MIC distribution of ceftobiprole against Gram positive and Gram negative strains and to compare activity of ceftobiprole to vancomycin for Gram positive and ceftriaxone or ceftazidime for Gram negative strains, we tested all strains (stored in Cryobank storage system) for minimal inhibitory concentrations (MIC) determination by E-test bandelet for ceftobiprole and comparator antibiotics.Aim
Method
Prosthetic joint infections (PJI) due to We conducted a retrospective and a monocentric study in an orthopedic unit where complex bone and joint infections are managed. From 2012 to 2016, we included patients with PJI which perioperative samples were positive with Aim
Method
When a prosthetic joint infection (PJI) is suspected, guidelines recommend performing periprosthetic samples, at least one for histopathological examination and 3 to 6 for microbiological culture. The diagnosis of infection is based on the presence of neutrophil granulocytes whose number and morphology can be variable, resulting in definition of “acute” inflammation. The acute inflammation of periprosthetic tissue is supportive of infection. Since 2007, in our hospital, for all patients with suspected PJI who underwent surgery, from each sample taken by the surgeon, one part has been sent to the pathologist and the other one to the microbiologist. Our aim was to compare histopathological to microbiological results from samples taken intraoperatively at the same site. We conducted a retrospective study including all surgeries for which at least one couple “histopathology-culture” was found. Exclusion criterion was a history of antimicrobial treatment 2 weeks prior the surgery.Aim
Method
To introduce and promote a new technic and a new component using the 3D technology in the extreme acetabular revisions. Since 2012, 13 patients, nine women and four men, were treated, 12 for a chronic complex PJI and one for an aseptic loosening. The average age was 75 years old (60 -90 years), the average follow-up 18,6 months (7–36 months). The revisions were bipolar in 12 cases and unipolar in one case for the oldest patient. For the septic cases, we performed 7 one stage procedure and 5 two stages. The femoral components were in 7 cases a modular stem, in 5 cases a massive component and a total femur. All these massive components were combined with a cemented double cup. The bone loss was evaluated with the AAOS, the Praposky and the Saleh classifications. A preoperative and postoperative Oxford score was used.Aim
Method
Total knee arthroplasty (TKA) is a common procedure with good success rates. The literature shows resection accuracy plays a crucial role in device longevity1. Computer guidance is used by some surgeons to enhance accuracy. This study reports on a continuous series of Optetrak knee prostheses (Exactech Inc., FL, USA) implanted by three senior surgeons between October 2010 and December 2013. 324 TKA were implanted at the Joseph Ducuing Hospital, Toulouse, France (Site 1), the Cleveland Clinic, Cleveland, OH, USA (Site 2) and the Riverview Hospital, Noblesville, IN, USA (Site 3) using Exactech GPS (Blue-Ortho, Grenoble, FR), a new computer-assisted guidance system. Each centre in this study used different surgical profiles defined specifically for their surgeical preferences. Planned tibial and femoral cuts were compared to actual cuts digitised using GPS. Operating time was analyzed and post-operative leg alignment was compared to pre-operative. The mean error between planned and digitised proximal tibial cuts was 0.06°±0.89 of valgus and 0.53°±0.90 of anterior slope for Site 1, 0.18°±0.85 of varus and 0.25°±1.18 of posterior slope for Site 2, and 0.02°±0.51 of valgus and 0.60°±1.15 of anterior slope for Site 3. The mean error between planned and digitised femoral distal cuts was 0.14°±0.85 of valgus and 0.49°±0.93 of flexion for Site 1, 0.15°±0.96 of varus and 0.04°±1.54 of extension for Site 2, and 0.09°±0.54 of varus and 0.48°±1.21 of extension for Site 3. Average operating time was 29 minutes for Site 1, 39 minutes for Site 2, and 33 minutes for Site 3. Post-operative Hip-Knee-Ankle angle (HKA) varied between 172° and 184° with an average of 179° for Site 1, 177° to 183° with an average of 179° for Site 2, and 177° to 185° with an average of 180° for Site 3. Pre-operative HKA ranged from 162 to 189°. Site 1 was already reporting in the series presented at ISTA 20132. Sites 2 and 3 were added later and could therefore benefit from the early feedback the analysis of site 1 cases provided. The use of the computer guidance at the new sites was associated with promising results and it did not take long to the surgeons to reach a reproducibility equivalent to the one of site 1. Average surgical time was similar in all three sites. GPS guidance added an average of 10 minutes to standard surgical times. All surgeons agreed the increased accuracy justified the additional time. Average post-operative HKA was 179°. HKA scores were within 3° of perfect alignment in 96% of the cases of Site 1, 99% of Site 2 and 97% of Site 3. According to the literature1, HKA between 177° and 183° is linked with high implant survival. Participating surgeons still associated Exactech GPS with satisfactory immediate post-operative results.
To evaluate the value of the use of massive prostheses in periprosthetic infections both in one stage and two stages procedures Between 2008 and 2014, 236 revisions for PJI had been performed in our hospital by the same surgeon. For the most complex cases, we decided to introduce megaprostheses in our practice in 2011. We report a prospective series of 33 infected patients treated between 2011 and the end of 2014, 14 male and 19 female with on average 67.9 years old (38–85) Infection involved TKA in 22 cases (17 TKA revisions, 4 primary TKA), THA in 9 cases (6 revisions, 3 primary THA), a femoral pseudo-arthrosis with posttraumatic gonarthrosis in one case and a septic humeral pseudoarthrosis in one case. We used a total femoral component for two patients: the first one for a hip PJI with extended diaphyseal bone loss and multiples sinus tracks, and the second one for a massive infected knee prosthesis used in a knee reconstruction for liposarcoma. We used one stage procedures in 20 cases (8 hips, 12 knees, 1 shoulder) and two stages in 13 cases (12 knees and 1 hip). Additional technics included 3 massive extensor system allografts, two local flaps. Perioperative hyperbaric treatment was used for 2 patients. The average follow up is 19.8 months (6–48 months). The most frequent complications were wound swelling and delayed healing in 8 cases;). In 3 cases of one stage surgery a complementary debridement was necessary in the three weeks after the surgery with always a good local and infectious evolution. VAC therapy was used in four cases with good results. We report one early postoperative dead. In summary, the use of massive prostheses in PJI is a good option for complex cases. It can be a good alternative to knee arthrodesis. These components must be used preferentially for older patients, in cases of extreme bone loss or extensive osteomyelitis to secure the bone debridement and the quality of the reconstruction. In our series, the one stage procedure is a validated option even by using complementary technics as bone allografts, extensor system allografts or flaps. We believe the two stages surgery is a secondary option, particularly when soft tissues status is compromised before or after the debridement, and mostly for the knees. The longevity of the implantation must be evaluate by a long term follow up.
Tc 99m labelled leukocytes scintigraphy (LLS) could be useful for the diagnosis of bone and joint infections. The aim of our study was to evaluate its performances specifically in the diagnosis of prosthetic joint infection (PJI). We conducted a multicenter -7 year- retrospective study including 164 patients with suspected PJI who underwent surgical treatment. In each case, 5 intraoperative samples were taken. Diagnosis of infection was confirmed if two or more samples yielded the same microbial agent. LLS was considered as « positive » if an accumulation of leukocytes was observed in early stage and increased in late stage (24 hours). Among these patients, 123 had also a bone scintigraphy. A total of 168 PJ were analyzed: 150 by in vitro polymorphonuclear labelled leukocytes scintigraphy (PLLS) and 18 by anti-granulocytes antibodies labelled leukocytes scintigraphy (LeukoScan®). Location of PJ were: hip (n = 63), knee (n = 71), miscellaneous (n = 4). According to microbiological criteria 62 hip prosthesis and 48 knee prosthesis were considered as infected. Sensitivity (Se), Specificity (Sp), Positive Predictive Value (PPV) and Negative Predictive Value of PLLS were: 72%, 60%, 80% and 47%. Se of LLS was higher for knee PJI (87%) than for hip PJI (57%) [p = 0.002]. Although Sp was higher for hip PJI (75%) than for knee PJI (52%) [p = 0.002]. The lowest Se was found for coagulase negative staphylococci (70%) and the highest for streptococci (87.5%). However the difference of Se between bacteria was not significant. Regarding bone scintigraphy, Se, Sp, PPV and NPV were: 94%, 11%, 65% and 50%. In our study, performances of LLS were rather low and varied according to the location of infection. Differences of LLS Se between bacteria was not significant. Bone scintigraphy has a high Se but lacks Sp.
To evaluate a innovate one stage procedure of the PJI knee treatment using computed assisted guidance. Our objectives; to increase the functional results by optimizing the anatomical joint reconstruction and to verifie if CAS help to simplifie and standardize these complex surgeries It's a prospective, single surgeon study. Since septembre 2011, 41 patients treated for chronic knee PJI in a one stage revision (one of them had a ipsilateral chronic knee arthritis). For all of them, a computed assisted guidance, the ExactechGPS® system was used. This system offers the possibility to define specific profiles to performe primary TKA surgeries. A personnalized profile of revision was created. All surgeries were performed with the same protocole; independently of the type of germ, with no use of tourniquet, no drainage by performing the same debridement procedure step by step and by using the same knee components 27 males, 14 female with 26 PJI of primary TKA, one infected unicompartimental prosthesis and 15 PJI of first revised TKA has been treated. The average age was 71 years old (55–87). The time of surgery was on average 135 mn (120 – 195 mn). The average time of hospitalization was 10 days (7–16). The average follow up was 20,9 months (6–47 months). The ROM were on average 114,7% (90°–130°), None post operative HKA outliers were reported. 3 patients presented a failure of the PJI treatment (one after a local open traumatism, one diabetic patient, one after a early revision for mechanical complication). None specific CAS complications and no failure of the CAS procedures are reported. As surgeon, CAS simplified the management of the bone loss after debridement and the control of the differents parameters (HKA, external femoral rotation, ligamentary balancing, lign joint…) by a real time feedback. we changed our practise by using more constraint condylar component instead hinge prostheses With a rate of success of 92,7% at this follow up, the one stage option appears to be valided. Using CAS is a safe option with no specific complication. It increases the quality of the ROM, a earlier functional recovery and a better middle term clinical result. Both combined, It should be a optimal medicoeconomical solution. compared revision using mechanical ancillary.
The objective was to compare susceptibility testing of all coagulase negative species (CNS) found in periprosthetic joint infections (PJI). We conducted a multicentre retrospective study in a same area from 2011 to 2014, including 215 CNS strains. Diagnosis of PJI was based on clinical, radiological and biological criteria. Microbiological criterion was at least 2 per-operative deep positive cultures with the same species of CNS. Identification and susceptibility testing were performed on automated Vitek2 (Biomérieux, France). PJI localizations were 54% knees, 39% hips, 7% other sites. CNS found in our study were by dicreasing order: S. epidermidis (SE) 60%, S. capitis 11%, S. lugdunensis (SL) 10%, S. caprae 5%, S. warneri (SW) 4%, S. hominis (SHo) 3%, S. haemolyticus (SHa) 3%. Fifty two percent of CNS strains were meticillin (oxacillin) resistant and 31%, 33%, 41%, 20% were also resistant to clindamycin (CLI), trimethoprim-sulfamethoxazole (SXT), ofloxacin (OFX), rifampicin (RMP) respectively. Regarding CNS species, meticillin resistance was detected for 70% SE, 71% SHo and 71% SHa. SE was the most resistant species, with 34% of the strains resistant to CLI, SXT, OFX and RMP simultaneously. Half of SE and SHa were resistant to the reference treatment levofloxacin+rifampicin. Thirteen percent of CNS were resistant to teicoplanin and only 1% to vancomycin. Susceptibility testing profiles are presented in table field. In our study, S. epidermidis was the main species found in PJI. Emerging species like S. lugdunensis or S. caprae were found, with more susceptible antibiotic profiles. The most active antibiotics in vitro were daptomycin, linezolid, vancomycin and teicoplanin.
PJI du to Enterobacter cloacae are rare and often severe. The aim of our study is to define the history of patients with such infections and their outcome. We conducted a retrospective monocentric study in an orthopedic unit where complex bone and joint infections are supported. From 2011 to 214 we selected patients with E. cloacae PJI based on data from the microbiology laboratory. In their files we collected information on their background, their medical and surgical history, antibiotics they received in the year before infection, the suspected portal of entry, the management and the outcome. Twelve patients were included, 7 male and 5 female. PJI was located to the hip in 8 cases, the knee in 3 cases and the ankle in one case. The average time between the placing of the first prosthesis and infection was 3 years. Eleven patients had one or more surgery for previous PJI. The average time elapsed since the last surgery was 30 days. Eleven patients had been treated with antibiotic combinations for at least 6 weeks, in the year before E cloacae infection. A portal of entry was identified only two times: urinary tract infection in one patient and catheter-related infection in one patient. Antibiotics the more often prescribed were carbapenems (n = 5) and cefepime (n = 4), each combined with quinolones (n =4) or fosfomycin (n = 3). Two patients required an additional debridement within an average of 18 days. Infectious outcome was favorable in 8 cases (67%) with a median duration of follow-up of 26 months. Two patients had a recurrent infection, one due to Streptococcus oralis and one to Candida albicans. One patient had a relapse of E cloacae infection. One patient died from unknown cause. PJI infections due to E.cloacae usually occur early after prosthetic surgery, typically in patients with complex surgical history. Despite a high rate of multi-resistance to antibiotics, outcome may be favorable in a large majority of patients.
Total knee arthroplasty (TKA) is a common procedure with good success rates. The literature shows resection accuracy plays a crucial role in device longevity1. Computer guidance is used by some surgeons to enhance accuracy. This study reports on a continuous series of Optetrak knee prostheses (Exactech Inc., FL, USA) implanted by three senior surgeons between July 2010 and April 2013. 259 TKA were implanted at the Haguenau Hospital, Haguenau, France (Site 1), Joseph Ducuing Hospital, Toulouse, France (Site 2) and Saint Michaels Medical Center, Newark, NJ, USA (Site 3) using Exactech GPS (Blue-Ortho, Grenoble, FR), a new computer-assisted guidance system. Surgeons can use the unique Exactech GPS profiler to define steps to be computer-assisted during surgery. Each centre in this study used different surgical profiles. Planned tibial and femoral cuts were compared to actual cuts digitised using GPS. Operating time and external femoral rotation were analyzed and post-operative leg alignment was compared to pre-operative. The mean error between planned and digitised proximal tibial cuts was 0.26° ± 1.11 of valgus and 0.06° ± 0.99 of posterior slope for Site 1, 0.07° ± 0.89 of varus and 0.53° ± 0.90 of anterior slope for Site 2, and 0.19° ± 0.73 of varus and 0.10° ± 1.17 of posterior slope for Site 3 (see Fig. 1). The mean error between planned and digitised femoral distal cuts was 0.03° ± 0.99 of varus and 0.67° ± 1.36 of extension for Site 1, 0.14° ± 0.85 of varus and 0.49° ± 0.94 of extension for Site 2, and 0.26° ± 0.86 of varus and 0.09° ± 1.22 of flexion for Site 3. Average operating time was 38 minutes for Site 1, 29 minutes for Site 2, and 34 minutes for Site 3. External femoral component rotation ranged from 0° to 18° with an average of 3.7° degrees for Site 1 and from −3° to 8° with an average of 3.0° for Site 2. External rotation was fixed at 3° for Site 3. Post-operative Hip-Knee-Ankle angle (HKA) varied between 177° and 182° with an average of 179° for Site 1, 172° to 184° with an average of 179° for Site 2, and 178° to 185° with an average of 180° for Site 3. Pre-operative HKA ranged from 162 to 191°. Despite different techniques and teams, all surgeons experienced similar results. Cuts were aligned in the frontal plane, while guidance was harder to follow in the sagittal plane, possibly due to saw blade bending during resection. Average surgical time was similar. GPS guidance added an average of 10 minutes to standard surgical times. All surgeons agreed the increased accuracy justified the additional time. Regardless the site, all average femoral rotations were close to the accepted 3° standard. Average post-operative HKA was 179°. HKA scores were within 3° of perfect alignment in all Site 1 cases and 96% of Site 2 and Site 3 cases. According to the literature1, HKA between 177° and 183° is linked with high implant survival. Participating surgeons associated Exactech GPS with satisfactory immediate post-operative results.
We have shown in a previous study that patients with combined lesions of the anterior cruciate (ACL) and medial collateral ligaments (MCL) had similar anteroposterior (AP) but greater valgus laxity at 30° after reconstruction of the ACL when compared with patients who had undergone reconstruction of an isolated ACL injury. The present study investigated the same cohort of patients after a minimum of three years to evaluate whether the residual valgus laxity led to a poorer clinical outcome. Each patient had undergone an arthroscopic double-bundle ACL reconstruction using a semitendinosus-gracilis graft. In the combined ACL/MCL injury group, the grade II medial collateral ligament injury was not treated. At follow-up, AP laxity was measured using a KT-2000 arthrometer, while valgus laxity was evaluated with Telos valgus stress radiographs and compared with the uninjured knee. We evaluated clinical outcome scores, muscle girth and time to return to activities for the two groups. Valgus stress radiographs showed statistically significant greater mean medial joint opening in the reconstructed compared with the uninjured knees (1.7 mm (
Traumatic anterior shoulder dislocation and sub-luxation are common injuries. But few studies have compared arthroscopic and open stabilization of the shoulder at long-term follow up. The purpose of our study is to show whether an arthroscopic approach to repair Bankart lesion can obtain the same results at long follow up as an open procedure. We analyzed 110 non-randomized consecutive shoulders in 110 patients who underwent a surgical repair of recurrent anterior shoulder instability between 1990 and 1999. Eighty-two patients were available at long term follow up (74,5% retrieval rate). In particular, 49 patients (59.8%) (group A) were treated with arthroscopic transglenoid suture (modified Caspari) between 1990 and 1995 (mean 15,7 year FU), whereas, 33 patients (40.2%) (group B) were treated with open repair between 1995 and 1999 (mean 12,7 year FU). We evaluated the patients in terms of failure rates, Rowe and UCLA scores. The failure cases in the forty-nine patients treated with arthroscopic suture were 13, six dislocations and seven subluxations. The group A had also a Rowe score: function 24.2+8.2, stability 42.4+13.9, range of movement 18.6+3.8, total score 85.0+22.46. The UCLA score was: pain 8.8+1.7, function 8.6+2.1, muscle power 9.2+1.6, total score 26.4+4.8. Of the thirty-three patients treated with open repair, three had at least one post-op dislocations and four felt sometimes subluxations. The Rowe score in group B was: function 23.6+9.7, stability 41.2+14.9, range of movement 18.3+3.9, total score 83.2+24.4. Moreover the UCLA score was: pain 8.8+1.9, function 8.8+1.9, muscle power 9.2+1.2, total score 26.9+4.2. We showed that both techniques were fairly good in treatment of shoulder instability. In our series no significant difference was observed in redislocation rate and in Rowe and UCLA scores between the two groups. The recurrence rate (subluxations and dislocations) was high in both groups: the arthroscopic group had 26.5% and the open one had 21.2%. Our recurrence rate following open repair was higher than in many studies, while the rate after arthroscopic transglenoid procedure was almost equivalent. We hypothesize that one of the reasons for these higher recurrence rates may be the long term follow up. Another cause could be our decision to include subluxation as a failure value, even if there is no agreement about. In fact we believe it to be an important disability factor in sport as in life activities. After surgery, most of the patients returned to their preinjuried activities. But at long term follow up almost all patients have stopped high level sport activity. Moreover, at this long term follow up, some patients told us a feeling of muscle weakness in the last years. In conclusion patients had good impressions about their shoulders thanks to surgery, but also because of lower functional demand.
