Poor performance of microbiological sampling in the prediction of recurrent arthroplasty infection

During a two-stage revision for prosthetic joint infections (PJI), joint aspirations, open tissue sampling and serum inflammatory markers are performed before re-implantation to exclude ongoing silent infection. We investigated the performance of these diagnostic procedures on the risk of recurrence of PJI among asymptomatic patients undergoing a two-stage revision. A total of 62 PJI were found in 58 patients. All patients had intra-operative surgical exploration during re-implantation, and 48 of them had intra-operative microbiological swabs. Additionally, 18 joint aspirations and one open biopsy were performed before second-stage reimplantation. Recurrence or persistence of PJI occurred in 12 cases with a mean delay of 218days after re-implantation, but only four pre- or intraoperative invasive joint samples had grown a pathogen in cultures. In at least seven recurrent PJIs (58%), patients had a normal C-reactive protein (CRP, <10mg/l) level before re-implantation. The sensitivity, specificity, positive predictive and negative predictive values of pre-operative invasive joint aspiration and CRP for the prediction of PJI recurrence was 0.58, 0.88, 0.5, 0.84 and 0.17, 0.81, 0.13, 0.86, respectively. As a conclusion, pre-operative joint aspiration, intraoperative bacterial sampling, surgical exploration and serum inflammatory markers are poor predictors of PJI recurrence. The onset of reinfection usually occurs far later than reimplantatio

Noninfectious Wound Complications in Clean Surgery: Epidemiology, Risk Factors, and Association with Antibiotic Use

Background: Noninfectious wound complications are frequent and often are confused with and treated as infection. Methods: We assessed the epidemiology, impact, risk factors, and associations with antibiotic use of noninfectious wound complications in clean orthopedic and trauma surgery. We report a single-center, prospective, observational study in an orthopedic department. Results: Among 1,073 adult patients, 630 (59%) revealed clinically relevant postoperative noninfectious wound complications, leading to a significant prolongation of hospital stay (14 vs. 12days; Wilcoxon rank-sum test; p<0.02) compared with patients without complications. The most frequent and severe complications were discharge with dehiscence (n=437; 41%) and hematoma (n=379; 35%). Forty-seven patients (47/630; 7%) underwent reoperation for dehiscence (n=39) or hematoma (n=8). These patients made up 4.3% of the entire study population (47/1,073). In multivariate analysis, an ASA score ≥2 points, age≥60years, surgery duration for ≥90min, implant-related surgery, and poor compliance toward nurses' recommendations were pronounced risk factors for these complications, whereas antibiotic-related parameters had no influence. Staple use was significantly associated with wound discharge but not with hematoma. Conclusions: Wound complications, such as dehiscence with discharge or hematoma after clean orthopedic and trauma surgery, are frequent with an overall incidence of 60%. Although they lead to few surgical reinterventions, they prolong hospital stay by 2days. Few clinical parameters show association with wound complications. Among them, improvements of patient compliance and avoidance of staples use for skin closure are the most promising actions to decrease complication ris

No need for broad-spectrum empirical antibiotic coverage after surgical drainage of orthopaedic implant infections

Purpose: Empirical broad-spectrum antibiotic treatment for orthopaedic implant infections after surgical lavage is common practice while awaiting microbiological results, but lacks evidence. Methods: This was a single-centre cohort study from 1996 to 2010 with a follow-up of twoyears. Results: We retrieved 342 implant infections and followed them up for a median of 3.5years (61 recurred, 18%). Infected implants were arthroplasties (n = 186), different plates, nails or other osteosyntheses. The main pathogens were S. aureus (163, 49 methicillin-resistant) and coagulase-negative staphylococci (60, 45 methicillin-resistant). Median duration of empirical antibiotic coverage after surgical drainage was threedays before switching to targeted therapy. Vancomycin was the most frequent initial empirical agent (147), followed by intravenous co-amoxiclav (44). Most empirical antibiotic regimens (269, 79%) proved sensitive to the causative pathogen, but were too broad in 111 episodes (32%). Cephalosporins and penicillins were used only in 44 and ten cases, respectively, although they would have covered 59% of causative pathogens identified later. Multivariate Cox regression analysis showed that neither susceptible antibiotic coverage (compared to non-susceptible; hazard ratio 0.7, 95% confidence interval 0.4-1.2) nor broad-spectrum use (hazard ratio 1.1, 0.8-1.5) changed remission rates. Conclusions: Provided that surgical drainage is performed, broad-spectrum antibiotic coverage does not enhance remission of orthopaedic implant infections during the first threedays. If empirical agents are prescribed from the first day of infection, narrow-spectrum penicillins or cephalosporins can be considered to avoid unnecessary broad-spectrum antibiotic us

Les fractures du fémur proximal chez les seniors aux hôpitaux universitaires de Genève

Les Fractures du Fémur Proximal (FFP) sont une pathologie fréquente et qui touche le sujet âgé dont l'état de santé est fragile. Ces fractures sont responsables de complications médicales, perte d'autonomie et de décès. Dans ce contexte, une approche multidisciplinaire entre orthopédistes et gériatres basée sur des protocoles est reconnue comme étant bénéfique dans la littérature et peut actuellement être considérée comme le « gold-standard ». Notre travail prospectif descriptif a récolté les données démographiques et indicateurs de qualité lors de la trajectoire intra et extra hospitalière des FFP afin d'établir l'adéquation de ce type d'approche avec la population genevoise et de poser les fondations sur laquelle les projets d'amélioration de la qualité pourront reposer à l'avenir. Notre travail conclu que notre cohorte est comparable à celles décrites jusqu'à présent dans la littérature et l'instauration d'un itinéraire protocolé multidisciplinaire serait potentiellement bénéfique aux Hôpitaux Universitaires de Genève

Osteosynthesis of non-displaced femoral neck fractures in the elderly population using the femoral neck system (FNS): short-term clinical and radiological outcomes

Femoral neck fractures (FNF) are frequent in the elderly population, and surgical management is indicated in the vast majority of cases. Osteosynthesis is an alternative to arthroplasty for non-displaced FNF. Triple screw construct (TS) and the dynamic hip screw system (DHS) are considered gold standards for osteosynthesis. The newly available femoral neck system (FNS) currently lacks evidence as to whether it is a valid alternative to TS and DHS. The purpose of this study was to evaluate the short-term clinical and radiological outcomes after non-displaced (Garden I and II) FNF osteosynthesis using TS, DHS, and FNS

Idiopathic scoliosis: etiological concepts and hypotheses

Scoliosis is diagnosed as idiopathic in 70 % of structural deformities affecting the spine in children and adolescents, probably reflecting our current misunderstanding of this disease. By definition, a structural scoliosis should be the result of some primary disorder. The goal of this article is to give a comprehensive overview of the currently proposed etiological concepts in idiopathic scoliosis regarding genetics, molecular biology, biomechanics, and neurology, with particular emphasis on adolescent idiopathic scoliosis (AIS). Despite the fact that numerous potential etiologies for idiopathic scoliosis have been formulated, the primary etiology of AIS remains unknown. Beyond etiology, identification of prognostic factors of AIS progression would probably be more relevant in our daily practice, with the hope of reducing repetitive exposure to radiation, unnecessary brace treatments, psychological implications, and costs-of-care related to follow-up in low-risk patients

Transient synovitis of the hip: which investigations are truly useful?

To assess the usefulness of several laboratory and radiological investigations for the limping child with suspected transient synovitis of the hip

Wound dehiscence and stump infection after lower limb amputation: risk factors and association with antibiotic use

Optimal duration of antibiotic prophylaxis following major lower limb amputation in preventing adverse stump outcomes is controversial

Which Orthopaedic Patients Are Infected with Gram-negative Non-fermenting Rods?

Background : 1st and 2nd generation cephalosporins used for perioperative prophylaxis in orthopaedic surgery do not cover non-fermenting Gram-negative rods (NFR). Methods: Epidemiological cohort study of adult patients operated for orthopedic infections between 2004 and 2014 with perioperative cefuroxim or vancomycin prophylaxis. Exclusion of polyneuropathic ischemic foot infections and septic bursitis cases. Results: Of the total 1840 surgical procedures in the study, 430 grew Gram-negative pathogens (23%), of which 194 (11%) were due to NFR and 143 (8%) to Pseudomonas aeruginosa. Overall, 634 episodes (35%) involved orthopaedic implants (321 arthroplasties, 135 plates, 53 nails, and others). In multivariate analysis and group comparisons, especially preoperative antibiotic use (124/194 vs. 531/1456; p<0.01) was significantly associated with NFR. Conclusions: Overall proportion of NFR oscillated between 9% and 13% among our orthopaedic infections. Variables associated with NFR were antibiotic use prior to hospitalization. The low infection rate of NFR following elective surgery and the community-based epidemiology, has led us to keep our standard perioperative prophylaxis unchanged

Native septic arthritis is not an immediate surgical emergency

Acute native joint septic arthritis is generally considered a surgical emergency, requiring drainage within hours, including during night, weekend or holiday shifts. However, there are few data supporting the need for the disruption caused by this degree of urgency