Daptomycin > 6 mg/kg/day as salvage therapy in patients with complex bone and joint infection: cohort study in a regional reference center

Background: Even if daptomycin does not have approval for the treatment of bone and joint infections (BJI), the Infectious Diseases Society of America guidelines propose this antibiotic as alternative therapy for prosthetic joint infection. The recommended dose is 6 mg/kg/d, whereas recent data support the use of higher doses in these patients.Methods: We performed a cohort study including consecutive patients that have received daptomycin >6 mg/kg/d for complex BJI between 2011 and 2013 in a French regional reference center. Factors associated with treatment failure were determined on univariate Cox analysis and Kaplan-Meier curves.Results: Forty-three patients (age, 61 ± 17 years) received a mean dose of 8 ± 0.9 mg/kg/d daptomycin, for a mean 81 ± 59 days (range, 6-303 days). Most had chronic (n = 37, 86 %) implant-associated (n = 37, 86 %) BJI caused by coagulasenegative staphylococci (n = 32, 74 %). A severe adverse event (SAE) occurred in 6 patients (14 %), including 2 cases of eosinophilic pneumonia, concomitant with daptomycin Cmin >24 mg/L. Outcome was favorable in 30 (77 %) of the 39 clinically assessable patients. Predictors for treatment failure were age, non-optimal surgery and daptomycin withdrawal for SAE.Conclusions: Prolonged high-dose daptomycin therapy was effective in patients with complex BJI. However, optimal surgery remains the cornerstone of medico-surgical strategy; and a higher incidence of eosinophilic pneumonia than expected was recorded

Case report: Continuous infusions of ceftazidime-avibactam and aztreonam in combination through elastomeric infusors for 12 weeks for the treatment of bone and joint infections due to metallo-β-lactamase producing Enterobacterales

Among carbapenem-resistant Enterobacterales, metallo-beta-lactamase producing strains represent a growing therapeutic challenge. While the association of aztreonam and ceftazidime-avibactam has been investigated in recent years for the treatment of infections involving these strains, little to no clinical data support the use of this association for the treatment of bone and joint infections. We report two cases of complex bone and joint infections involving metallo-beta-lactamase-producing Enterobacterales, successfully treated at our referral center with aztreonam and ceftazidime-avibactam for 12 weeks in continuous infusions through elastomeric infusors

Coronal alignment after total knee arthroplasty

Recent studies have challenged the long-held notion that neutral mechanical alignment after total knee arthroplasty leads to optimal function and survivorship.The ideal alignment for function and survivorship may actually be different.Kinematic alignment, where components are implanted to re-create the natural flexion/extension axis of the knee, may lead to improved functional results. Residual varus alignment may not adversely impact survivorship provided the tibial component is implanted in neutral alignment

Reconstruction du MFPL avec ou sans section de l'aileron externe: étude prospective randomisée

SFA 2017 - Congrès annuel de la Société Francophone d'Arthroscopie, MARSEILLE, FRANCE, 06-/12/2017 - 09/12/2017La reconstruction du ligament fémoro-patellaire médial (MPFL) est la technique de choix dans le traitement de la luxation épisodique de la rotule (LED). La section de l'aileron externe (SAE) est un geste associé, réalisé au gré du chirurgien. L'objectif de ce travail préliminaire est de montrer la non-infériorité de l'option sans SAE lors d'une reconstruction du MPFL par rapport à l'option avec SAE en termes de score subjectif IKDC à 12 mois et de résultat objectif de bascule rotulienne (BR) quadriceps décontracté et contracté (BRQDC et BRQC). Dans cette étude randomisée prospective, étaient inclus des patients agés de 18 à 45 ans avec une indication de reconstruction isolée du MPFL. Étaient exclus les révisions et les indications de gestes associés (TTA, trochléoplastie). La SAE était réalisée sous arthroscopie. Un délai de suivi de 1 an minimum était respecté. Les critères d'évaluation pré- et postopératoire étaient un score IKDC, une mesure de la BR sur un scanner. La randomisation était réalisée la veille de la chirurgie, pour réalisation ou non de la SAE. Entre novembre 2011 et mars 2015, 44 patients ont pu donc être inclus dans l'étude. 28 patients (16 avec SAE, 12 sans SAE) ont été analysés avec un recul médian de 24,0±15,4 (12-60) mois, sans aucune complication retrouvée. Le score IKDC à 1 an était de 86,21±20,69 (28,74-94,25) dans le groupe SAE, et 83,34±14,00 (52,87-95,40) dans le groupe sans SAE (p =0,76, NS). La BRQDC était de 22,0±6,5° (13-30) dans le groupe SAE, versus 21,0±11,2 (4-30) dans le groupe sans SAE. La BRQC était de 25,5±10,1° (12-40) dans le groupe SAE, versus 27,0±13,4 (5-45) dans le groupe sans SAE. Aucune différence significative n'a été mise en évidence pour la BR, avec respectivement p =0,76 (NS) et p =0,74 (NS). De plus, aucune différence significative n'a été retrouvée entre les 2 groupes dans l'amélioration du score IKDC entre pré- et postopératoire. Dans cette étude préliminaire à un an de recul, aucune différence significative n'a été retrouvée entre SAE et pas de SAE lors de la reconstruction du MPFL, en termes de score IKDC et de bascule rotulienne, à 12 mois de recul minimum. Associée au MPFL, la SAE n'a donc pas montré de bénéfice dans cette étude par rapport à la reconstruction isolée du MPFL

How to optimize patellar tracking in knee arthroplasty?

Good patellar tracking is needed for functionally successful total knee arthroplasty (TKA), and depends on several factors. The aim of the present Instructional Lecture is to identify the main factors and how to control them so as to optimize patellar tracking: more or less "patella-friendly" prosthetic trochlea design, requiring precise assessment and choice of model; patellar component design; type of tibial implant; surgical approach and management of peripatellar structures, and any lateral release; distal and posterior femoral bone cuts, determining femorotibial alignment, femoral component rotation and patellar height; tibial implant rotation with respect to the anterior tibial tubercle; patellar cut characteristics in resurfacing. In case of instability or patellar maltracking despite correct implant positioning, there are 2 main surgical techniques: medial patellofemoral ligament reconstruction, and anterior tibial tubercle medialization. To obtain optimal patellar tracking, correction of other factors should be associated: trochlear component design, distal and posterior femoral bone cuts, tibial implant positioning, patellar component shape and positioning, etc

Similar postoperative patient-reported outcome in both second generation patellofemoral arthroplasty and total knee arthroplasty for treatment of isolated patellofemoral osteoarthritis: a systematic review

INTRODUCTION: Due to inconsistent results and high failure rates, total knee arthroplasty (TKA) is more often used to treat isolated patellofemoral osteoarthritis (PFOA) despite the theoretical advantage of patellofemoral arthroplasty (PFA). It is perceived that second-generation PFA may have improved the outcomes of surgery. In this systematic review, the primary aim was to compare outcomes of second-generation PFA and TKA by assessment of patient-reported outcome measures (PROMs). METHODS: A systematic search was made in PubMed, Medline, Embase, Cinahl, Web of Science, Cochrane Library and MeSH to identify studies using second-generation PFA implants or TKA for treatment of PFOA. Only studies using The American Knee Society (AKSS), The Oxford Knee Score (OKS) or The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to report on PROMs were included. RESULTS: The postoperative weighted mean AKSS knee scores were 88.6 in the second-generation PFA group and 91.8 in the TKA group. The postoperative weighted mean AKSS function score was 79.5 in the second-generation PFA group and 86.4 in the TKA group. There was no significant difference in the mean AKSS knee or function scores between the second-generation PFA group and the TKA group. The postoperative weighted mean OKS score was 36.7 and the postoperative weighted mean WOMAC score was 24.4. The revision rate was higher in the second-generation PFA group (113 revisions [8.4%]) than in the TKA group (3 revisions [1.3%]). Progression of OA was most commonly noted as the reason for revision of PFA, and it was noted in 60 cases [53.1%]; this was followed by pain in 33 cases [29.2%]. CONCLUSION: Excellent postoperative weighted mean AKSS knee scores were found in both the second-generation PFA group and in the TKA group, suggesting that both surgical options can result in a satisfying patient-reported outcome. Higher revision rates in the second-generation PFA studies may in part be due to challenges related to patient selection. Based on evaluation of PROMs, the use of second-generation PFA seems to be an equal option to TKA for treatment of isolated PFOA in appropriately selected patients. Hopefully, this can be considered by physicians in their daily clinical work. LEVEL OF EVIDENCE: IV

Coronal alignment in total knee replacement: historical review, contemporary analysis, and future direction

Substantial healthcare resources have been devoted to computer navigation and patient-specific instrumentation systems that improve the reproducibility with which neutral mechanical alignment can be achieved following total knee replacement (TKR). This choice of alignment is based on the long-held tenet that the alignment of the limb post-operatively should be within 3° of a neutral mechanical axis. Several recent studies have demonstrated no significant difference in survivorship when comparing well aligned versus malaligned TKRs. Our aim was to review the anatomical alignment of the knee, the historical and contemporary data on a neutral mechanical axis in TKR, and the feasibility of kinematically-aligned TKRs. Review of the literature suggests that a neutral mechanical axis remains the optimal guide to alignment