Aim

Periprosthetic joint infection (PJI) is a major complication of prosthetic implantation and needs a combined surgical and antimicrobial treatment. One-stage revision results usually in similar cure rate than two-stage (around 85–92%), but antibiotic therapy duration is not well established. The aim of study was to evaluate the efficacy of a short six-weeks antibiotic course in hip and knee PJIs after one-stage replacement arthroplasty (RA).

Purpose of the study: Plurimicrobial infections account for 4 to37% of all infections of total hip arthroplasties (THA). According to data in the literature, they are the source of failure, contraindicating one-phase replacement procedures. The purpose of our study was to evaluate the results of our management practices in this group of patients and also to identify factors of risk associated with multimicrobial infection.

Material and methods: A prospective study included 116 patients with an infected THA from November 2002 to December 2006. Sixteen patients (13.8%), mean age 68±12.7 years had a plurimicrobial infection defined by having at last two interoperative bacteriological samples positive for two or more germs. Surgical treatment consisted in a single-phase replacement in seven cases, a two-phase replacement in seven, resection of the head and neck in one, and wash-out resection in one. Mean duration of the antibiotic therapy ws 91±6 days, including 46±14 days intravenously. Anaerobic germs were isolated more commonly in plurimicrobial infections than monomicrobial infections (50% versus 11%). Patients were assessed with prospectively collected data. Mean follow-up was 34±13 months, with none lost to follow-up. The main outcome was apparent cure rate of the initial infection at minimum two years follow-up, defined by the absence of clinical, biological and radiographic signs of infection, and absence of death attributable to infection or its treatment. If infection was suspected, a hip puncture or intraoperative samples confirmed the relapse (same germs) or reinfection (different germs).

Results: The cure rate was 100% for plurimicrobial infections and 97% for monomicrobial infections. There were however four reinfections in the monomicrobial group. In this series, the risk factor statistically associated with plurimicrobial infections was the presence of a fistula with an odds ratio of 5.4.

Discussion: A larger number of patients would probably enable identification of other risk factors associated with plurimicrobial infections.

Conclusion: The cure rate of plurimicrobial infections was higher than reported in the literature but for a small group of patients. The presence of a fistula was strongly associated with these plurimicrobial infections.

Purpose: During the second half of the 80s, Grammont, Trouilloud and Guichet developed a centromedullary nail for progressive limb lengthening. We analysed retrospectively twenty lengthenings, studying the clinical and radiological results to examine the quality of callus formation.

Material and methods: This study included eighteen patients, thirteen men and five women, who underwent lengthening procedures between 1991 and 2000. The patient’s clinical files were analysed in addition to the results of a physical examination. A standardised x-ray protocol was used to analyse bone regeneration.

Results: Mean follow-up was 4.55 years (1.5–10.5). Mean lengthening was 46 mm (30–80) achieved at a mean rate of 1.28 mm/d. The Bastiani index was 26 j/cm. Complications were: one progressive external popliteal sciatic palsy, one persistent knee flexion, one premature callus consolidation, and two callus fractures after nail removal. All patients maintained their activity level. The quality of regenerated bone was better in the dorsal and medial segments exposed to more stress. The callus was cortical and remodelled after removal of the nail.

Discussion: Like all lengthening techniques, the Albizzia nail requires careful preoperative planning, particularly to determine the level of the endomedullary osteotomy. The clinical results in this series were globally satisfactory. The callus was similar to cortical bone and quite different from the callus obtained with external lengthening methods, but our study demonstrated the excellent quality of the regenerated bone. The Albizzia nail can also be left in place until a solid reliable callus has formed, an advantage compared with external fixation which is less well tolerated.

Purpose: Patellar instability raises serious clinical and therapeutic problems in children. We present our results with the “soft baguette” technique used since 1974.

Material and methods: Sixty-four patients (50 girls and 14 boys) (85 knees) treated between 1974 and 2000 were reviewed. Mean follow-up was 140 months (14–234). For eight knees, section of the lateral wing of the patella was associated. The five types of patellar instability, from permanent dislocation to potential instability, were represented.

Results: At last follow-up, 84% of our patients were satisfied with significant improvement in pain, instability and patellar track. We had minor complications in 23.5% of the knees (haematoma, effusions) and eleven recurrences (9.5%) at mid- or long-term which were considered failures. There were no cases of epiphysiodesis. A neoTTA developed in eight cases, proving the efficacy of realignment of the medialised patellar ligament. Following changes in the mechanical axis of these knees revealed a clear trend towards increased valgus.

Discussion: The soft baguette technique has fulfilled expectations: stabilisation of the extensor system without injuring the growth cartilage, and trochlear remodelling for the younger patients. The trend towards increased valgus raises a problem. Because of this risk, if the initial valgum is greater than 5° we emphasise the theoretical importance of temporary medial epiphysiodesis associated with the soft baguette to control this potential source of recurrence and therapeutic failure.

Purpose: The purpose of this study was to analyse the results and morbidity of video-assisted minimally invasive thoracoctomy for anterior arthrodesis of thoracolumbar fractures treated with a two-stage procedure and to evaluate mid-term outcome.

Material and methods: This retrospective series included 6 patients with an unstable thoracolumbar fracture who underwent surgery between November 1997 and June 2002. A two-stage procedure was used: posterior reduction osteosynthesis and anterior arthrodesis with a tricortico-cancellous graft via video-assisted minimally invasive thoracotomy. The cohort included six women and eighteen men, mean age 34.5 years. Fractures were located at: L1 (n=4), T12 (n=10), T11 (n=2). At initial assessment the Franckel classification was: A (n=3), B (n=1), C (n=1), D (n=3), 3 (n=18). Time between the posterior procedure and the anterior thoracotomy was 30.2 days (range 6–86). Postoperative results as well as the time to fusion were recorded. Mean follow-up was 21 months (range 6–45) for functional and radiological assessment. No patient was lost to follow-up.

Results: Mean operative time was 188 min (range 80–240). Mean blood loss was 235 ml (range150–1000) with no intraoperative event requiring conversion to open thoracotomy. Mean duration of morphine administered postoperatively was 2.2 days, the same as for thoracic drainage. Residual pleural effusion was observed in one patient and residual pneumothorax in two; all resolved spontaneously. Mean hospital stay was 12 days (range 6–27). Twenty-five patients had achieved fusion at four months. One patient developed a radiological non-union which was asymptomatic at one year. At last follow-up, the Oswestry function score was 22.6% for the entire series, 18% for Franckel D or E patients (n=21) and 42% for Franckel A, B and C patients (n=5). Loss of angular correction of the spinal kyphosis and regional traumatic angulation between the postoperative films and the last follow-up films was 2 (mean).

Discussion: This series of complementary anterior arthrodesis by video-assisted minimally invasive thoracotomy confirmed the minimally invasive nature of this approach in comparison with thoracophrenolaparotomy and its complications. At mid term, this technique has provided satisfactory functional and radiographic results. Applied for thoracolumbar fractures, this combined surgical option can limit intraoperative morbidity and assure good mid-term results.

Purpose: We report results of management of infected total knee arthroplasty (TKA). Our aim was to analyse the different therapeutic options and identify factors predictive of cure.

Material and methods: This retrospective multicentric analysis included a consecutive series of 179 cases of infected TKA. Revision TKA was performed for 77 knees in two operative times, 30 in one operative time. Synovecetomy was performed for 26 knees, arthrodesis for 36 and amputation for nine. Minimum follow-up was two years. For each case, we assessed cure of infection and functional outcome. Non-parametric statistical tests were used to compare outcome.

Results: Mean follow-up was 41.2 months. There was a 17% death rate during the first two years after management of infected TKA. Cure was achieved in two-thirds of the revised cases (in one or two operative times) and in 54% of the synovectomy cases. Arthrodesis yielded cure in 50%. Staphylococci was identified in 65%. The functional outcomes of revised prostheses (two times) was less satisfactory if the anterior tibial tubercle was removed, if the extensor system was involved, or if a flap cover was necessary (p< 0.05). There was no significant difference in functional outcome for one-time and two-time operations. Cure was achieved in 95% of the synovectomies performed before 16 days. Relapse occurred in 95% of those performed after 56 days. Arthrodesis performed in patients with major bone loss failed. Among the arthrodesis failures, 50% were related to mechanical failure and the other 50% to recurrent infection.

Discussion: We discuss these results and indications for different treatments of infected total knee arthroplasty. For each therapeutic option, we analysed factors allowing hope for cure and good functional outcome.

Conclusion: The objective of treatment of an infected TKA is to achieve cure and maintain satisfactory function, often a difficult goal to reach. Major mutilating surgery can be avoided by early adapted care.