Impact of smoking cessation on healing after foot and ankle surgery

INTRODUCTION: Perioperative smoking is the main risk factor for the development of postoperative cutaneous wound healing complications. We require that all patients undergoing elective foot and ankle surgery stop smoking (6 weeks before and 3 months after) and this abstinence is monitored with a preoperative cotinine test. We therefore wanted to understand how this impacted wound healing in elective foot and ankle surgery: do wounds heal differently in patients who quit smoking for surgery, former smokers and nonsmokers? HYPOTHESIS: Our hypothesis was that patients who stopped smoking for an upcoming surgery had the same wound healing complications as nonsmokers and former smokers.MATERIALS AND METHODS: This was a historical, single-center, single-surgeon cohort study of adult patients who underwent an elective ankle or foot surgery between June2016 and July2017. Patients were divided into 3 groups: group 1 smokers who stopped for surgery, group2 former smokers, and group3 nonsmokers. The primary endpoint was the occurrence of wound healing complications during the wound care consult scheduled 3 weeks after surgery. RESULTS: A total of 256 patients with a mean age of 58±14.2 years (range, 18-88) were included. Group3 had more women and a lower BMI than the other groups, but all the other demographic characteristics were similar. Smoking cessation was achieved in group1 on average 2.5±1.3 months (range, 1-6) before surgery. There were a total of 20 wound healing complications or 7.5% of the cohort: 13% in group1, 11.1% in group2 and 6.4% in group3. The univariate analysis found that the odds ratio was 2.3 when comparing Group1 to Group3 and 1.85 when comparing group2 to group3 (p=413). No significant risk factors for wound healing complications were found.DISCUSSION/CONCLUSION: Smoking cessation for foot and ankle surgery seems to limit the risk of wound healing complications, with results close to those of former smokers and nonsmokers. Mandatory smoking cessation before surgery could be one of the solutions to prevent this frequent complication. LEVEL OF EVIDENCE: III

Fewer complications after UKA than TKA in patients over 85 years of age: A case-control study

INTRODUCTION: Implanting a knee prosthesis in patients aged over 85 years is not without risk. Unicompartmental knee arthroplasty (UKA) is reputed to show lower morbidity and mortality than total knee arthroplasty (TKA). Elderly patients with isolated unicompartmental osteoarthritis without specific contraindications are thus good candidates for this procedure. The present retrospective case-control study compared complications rates in elderly patients receiving UKA versus TKA. The study hypothesis was that UKA incurs fewer complications, with equivalent functional results. MATERIAL AND METHODS: Five hundred and forty-four UKAs were performed between 1987 and 2015; all patients aged 85 years or over (n=30) were included, and age-matched at a rate of 1 UKA for 3 TKAs in our database of 4,216 TKA procedures. Mean age was 87.5 years (range, 85-92 years). The main endpoint was complications rate; secondary endpoints comprised satisfaction, IKS function and knee scores, and implant survival. RESULTS: Mean follow-up was 32 months (range, 12-118 months) for UKA and 34 months (range, 12-100 months) for TKA. The medical complications rate was significantly lower with UKA (6.7% versus 25.6%; P=0.02), with no early mortality. IKS scores were identical between UKA and TKA groups at last follow-up: knee, 93.8 (95% CI [89.7-98.0]) versus 89.5 (95% CI [85.6-93.4]), P=0.06; function, 63.8 (95% CI [53.1-74.5]) versus 67.0 (95% CI [61.3-72.7]), P=0.62. Satisfaction rates were likewise identical: 96% and 97%, respectively (P=0.77); and implant survivorship was identical (P=0.54). DISCUSSION: Early medical complications were fewer after UKA than TKA in a population aged ?85 years, with comparable clinical outcome. These results argue in favor of UKA in elderly patients with comorbidities. LEVEL OF EVIDENCE: III, case-control study

Influence of operative technique on anterior cruciate ligament reconstruction in patients older than 50 years

International audienceBackground: A consequence of the steady growth in the worldwide population of elderly individuals who remain in good health and continue to engage in sports is an increase in the incidence of anterior cruciate ligament (ACL) rupture occurring after 50 years of age. ACL reconstruction was formerly reserved for young athletes but now seems to produce good outcomes in over 50s. The type of graft and graft fixation method were selected empirically until now, given the absence of investigations into potential relationships of these two parameters with the outcomes. The objective of this study was to assess associations linking the type of graft and the method of femoral graft fixation to outcomes in patients older than 50 years at ACL reconstruction. Hypothesis: The operative technique is not associated with the clinical outcomes or differential laxity. Material and methods: A multicentre retrospective cohort of 398 patients operated between 1 January 2011 and 31 December 2015 and a multicentre prospective cohort of 228 patients operated between 1 January 2016 and 30 June 2017 were conducted. Mean follow-up was 42.7 months in the retrospective cohort and 14.2 months in the prospective cohort. The primary evaluation criterion was the clinical outcome as assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Tegner Activity Score (TAS). Differential laxity was the secondary evaluation criterion. The Wilcoxon rank sum test and Kruskal-Wallis test were used to compare groups, and p-values < 0.05 were considered significant. Results: In the retrospective and prospective cohorts, hamstring tendons were used in 269 (67.6%) and 197 (86.4%) patients and extensor apparatus tendons in 124 (31.2%) and 31 (13.6%) patients. Femoral fixation in the retrospective cohort was cortical in 81 (20.4%) cases, by press-fit in 112 (28.1%) cases, and by interference screw in 205 (51.5%) cases; corresponding figures in the prospective cohort were 135 (59.2%), 17 (7.5%), and 76 (33.3%). The multivariate analysis of the retrospective data identified no significant associations of graft type or femoral fixation type with the KOOS, TAS, or differential laxity values. In the prospective cohort, hamstring grafts were associated with 0.6 mm of additional laxity (p = 0.007); compared to cortical fixation, press-fit fixation of patellar tendon grafts was associated with 0.3 mm of additional laxity (p = 0.029) and a 0.5-point lower TAS value (p = 0.033), with no difference in KOOS values. None of these differences were clinically significant. Discussion: The various ACL reconstruction techniques used in patients older than 50 years produce similar outcomes. The technique can be chosen based on surgeon preference without regard for patient age. Level of evidence: IV

Female gender and medial meniscal lesions are associated with increased pain and symptoms following anterior cruciate ligament reconstruction in patients aged over 50 years

PURPOSE: Several studies report satisfactory clinical outcomes following ACLR in older patients, but none evaluated the effects of meniscal and cartilage lesions. The aim was to evaluate the influence of meniscal and cartilage lesions on outcomes of ACLR in patients aged over 50years. METHODS: The authors prospectively collected records of 228 patients that underwent primary ACLR, including demographics, time from injury to surgery, whether injuries were work related, and sports level (competitive, recreational, or none). At a minimum follow-up of 6months, knee injury and osteoarthritis outcome scores (KOOS), International Knee Documentation Committee (IKDC) score and Tegner activity level were recorded, and differential laxity was measured as the side-to-side difference in anterior tibial translation (ATT) using instrumented laximetry devices. Regression analyses were performed to determine associations between outcomes and meniscal and cartilage lesions as well as nine independent variables. RESULTS: A total of 228 patients aged 54.8?±?4.3years at index ACLR were assessed at a follow-up of 14.3?±?3.8months. KOOS subcomponents were 85?±?13 for symptoms, 91?±?10 for pain, 75?±?18 for daily activities, 76?±?18 for sport, and 88?±?12 for quality of life (QoL). The IKDC score was A for 84 (37%) knees, B for 96 (42%) knees, C for 29 (13%) knees, and D for 8 (4%) knees. Tegner scores showed a decrease (median 0, range -4 to 4) and differential laxity also decreased (median - 4, range - 23.5 to 6.0). KOOS symptoms worsened with higher BMI (p?=?0.038), for women (p?=?0.007) and for knees that had medial meniscectomy (p?=?0.029). KOOS pain worsened with higher BMI (p???0.001), for women (p?=?0.002) and for knees with untreated (p?=?0.047) or sutured (p?=?0.041) medial meniscal lesions. Differential laxity increased with follow-up (p?=?0.024) and in knees with lateral cartilage lesions (p?=?0.031). CONCLUSION: In primary ACLR for patients aged over 50years, female gender and medial meniscal lesions significantly compromised KOOS symptoms and pain, while lateral cartilage lesions significantly increased differential laxity. Compared to knees with an intact medial meniscus, those with sutured or untreated medial meniscal lesions had worse pain, while those in which the medial meniscus was resected had worse symptoms. These findings are clinically relevant as they could help surgeons with patient selection and adjusting expectations according to their functional demands. LEVEL OF EVIDENCE: III

Population pharmacokinetics of daptomycin in patients with bone and joint infection: minimal effect of rifampicin co-administration and confirmation of a sex difference

International audienceBackground Daptomycin is increasingly used in the treatment of bone and joint infection (BJI), but its pharmacokinetics (PK) and dosage requirements have not been thoroughly investigated in this indication. Daptomycin may be co-administered with rifampicin, which raises questions about a potential drug interaction. Objectives To investigate the population PK and dosage requirements of daptomycin in patients with BJI, and examine the influence of rifampicin co-administration. Methods A population approach was used to analyse PK data from patients who received daptomycin in our regional reference for BJI. We examined the influence of available covariates, including rifampicin co-administration on daptomycin PK. Simulations performed with the final model investigated the influence of dosages and covariates on PTA for both efficacy and safety. Results A total of 1303 daptomycin concentrations from 183 patients were analysed. A two-compartment model best described the data. Significant intra-individual variability was observed. Daptomycin clearance was influenced by renal function and sex, with females having a 26% lower typical clearance than males. Central volume of distribution (V1) was influenced by body weight, age, sex and rifampicin co-administration. Typical V1 was 11% lower in patients who were co-administered rifampicin. In PK/PD simulations, sex influenced the probability of AUC24/MIC target attainment, while rifampicin had a marginal effect. Conclusions A daptomycin dosage of 8 mg/kg/24 h in women and 10 mg/kg/24 h in men should optimize efficacy but may lead to excessive trough concentrations in many patients, especially in women. Therapeutic drug monitoring appears necessary for precision dosing of daptomycin

Coxiella burnetti prosthetic joint infection in an immunocompromised woman: iterative surgeries, prolonged ofloxacin-rifampin treatment and complex reconstruction were needed for the cure

International audienceAbstract Background Q fever is a zoonotic disease caused by the bacterium Coxiella burnetii , a strictly intracellular pathogen that can cause acute and chronic infection. Chronic Q fever can occur in immunocompetent as well as in immuno-compromised hosts, as a persistent localized infection. The main localizations are endocardial, vascular and, less frequently, osteoarticular. The most frequent osteoarticular form is spondyliscitis. Recommended treatment is combined doxycycline and hydroxychloroquine for 18 months, with cotrimoxazole as another option. Coxiella burnetti infection has been implicated in rare cases of prosthetic joint infection (PJI), and the medical and surgical management and outcome in such cases have been little reported. Case presentation We report an unusual case of chronic Q fever involving a hip arthroplasty in an immunocompromised woman treated with tumor necrosis factor (TNF)-α blockers for rheumatoid arthritis. Numerous surgical procedures (explantation, “second look”, femoral resection and revision by megaprosthesis), modification of the immunosuppressant therapy and switch from doxycycline-hydroxychloroquine to prolonged ofloxacin-rifampin combination therapy were needed to achieve reconstruction and treat the PJI, with a follow-up of 7 years. Conclusions Coxiella burnetti PJI is a complex infection that requires dedicated management in an experienced reference center. Combined use of ofloxacin-rifampin can be effective

Necrotizing external otitis: analysis of relapse risk factors in 66 patients managed during a 12 year period

International audienceAbstract Background Necrotizing external otitis (NEO) is a severe infection of the skull base that occurs generally in the elderly and/or in diabetic recipients. There are few data in the literature about the therapeutic management of this complex bone infection. Objectives To analyse relapses after NEO treatment completion, and to describe the clinical features of NEO. Methods We performed a retrospective cohort study in the Lyon regional reference centre for the management of complex bone and joint infections. Consecutive cases of NEO from 1 January 2006 to 31 December 2018 were included. The primary outcome was the relapse of NEO. Variables were analysed using Cox regression survival analysis with adjusted hazard ratio (aHR) and Kaplan–Meier curve. Results Sixty-six patients were included. Median age was 75 (IQR 69–81) years and 46 (70%) patients were diabetic. Eleven patients (17%) had temporomandibular arthritis, 10 (15%) cranial nerve paralysis, 2 (3%) cerebral thrombophlebitis, and 2 (3%) contiguous abscess. Microbiological documentation was obtained in 56 patients and revealed Pseudomonas aeruginosa in 44/56 patients (79%). Nine (14%) cases had no microbiological documentation. Antibiotic therapy was dual for 63 (95%) patients. During a median follow-up of 27 (IQR 12–40) months, 16 out of 63 (25%) patients experienced a relapse. Fungal infection was significantly associated with relapse [aHR 4.1 (95% CI 1.1–15); P = 0.03]. Conclusions NEO is a severe bone infection, mainly (but not exclusively) caused by P. aeruginosa, which occurs in elderly and diabetic recipients. Fungal infections at baseline significantly impact the outcome

Evaluation of intraosteoblastic activity of dalbavancin against Staphylococcus aureus in an ex vivo model of bone cell infection

International audienceAbstract Objectives Long-acting lipoglycopeptides are promising therapeutic options in Staphylococcus aureus bone and joint infections (BJIs). This study evaluated the ability of dalbavancin to eradicate the intraosteoblastic reservoir of S. aureus, associated with BJI chronicity. Methods Osteoblastic cells were infected with a standardized inoculum of the S. aureus reference strain HG001 and incubated for 24 h with dalbavancin, vancomycin or rifampicin using the MIC, 10×MIC, 100×MIC and/or the intraosseous concentrations reached using standard therapeutic doses (i.e. vancomycin, 10 mg/L; rifampicin, 2 mg/L; and dalbavancin, 6 mg/L). The remaining intracellular bacteria were quantified by plating cell lysates. Results MICs of dalbavancin, vancomycin and rifampicin were 0.125, 1 and 0.004 mg/L, respectively. Dalbavancin significantly reduced the intracellular inoculum of S. aureus starting at a concentration equal to the MIC, with a significant dose effect, ranging from a reduction of 31.4% (95% CI = 17.6%–45.2%) at MIC to 51.6% (95% CI = 39.8%–63.4%) at 100×MIC compared with untreated cells. Of note, dalbavancin was the only molecule to significantly reduce the intraosteoblastic inoculum at low concentration (MIC). At intraosseous concentrations, dalbavancin reduced the intracellular inoculum by 49.6% (95% CI = 45.1%–54.1%) compared with untreated cells (P &lt; 0.001), with no significant difference compared with vancomycin (38.1%; 95% CI = 19.2%–57.0%; P = 0.646), and was less efficient than rifampicin (69.0%; 95% CI = 63.2-74.8; P &lt; 0.001). Conclusions Dalbavancin was able to decrease the intraosteoblastic S. aureus inoculum by 50% at intraosseous concentrations reached during standard human therapeutic dosing, with no difference compared with vancomycin, and remained less efficient than rifampicin. However, it was the only molecule significantly active at low concentration