Cindy Bouvet

Is there any benefit in pre-operative urinary analysis before elective total joint replacement?

Whether patients with asymptomatic bacteriuria should be investigated and treated before elective hip and knee replacement is controversial, although it is a widespread practice. We conducted a prospective observational cohort study with urine analyses before surgery and three days post-operatively. Patients with symptomatic urinary infections or an indwelling catheter were excluded. Post-discharge surveillance included questionnaires to patients and general practitioners at three months. Among 510 patients (309 women and 201 men), with a median age of 69 years (16 to 97) undergoing lower limb joint replacements (290 hips and 220 knees), 182 (36%) had pre-operative asymptomatic bacteriuria, mostly due to Escherichia coli, and 181 (35%) had white cells in the urine. Most patients (95%) received a single intravenous peri-operative dose (1.5 g) of cefuroxime as prophylaxis. On the third post-operative day urinary analysis identified white cells in 99 samples (19%) and bacteriuria in 208 (41%). Pathogens in the cultures on the third post-operative day were different from those in the pre-operative samples in 260 patients (51%). Only 25 patients (5%) developed a symptomatic urinary infection during their stay or in a subsequent three-month follow-up period, and two thirds of organisms identified were unrelated to those found during the admission. All symptomatic infections were successfully treated with oral antibiotics with no perceived effect on the joint replacement. We conclude that testing and treating asymptomatic urinary tract colonisation before joint replacement is unnecessary.

Do Diabetic Foot Infections With Methicillin-Resistant Staphylococcus aureus Differ From Those With Other Pathogens?

There is controversy as to whether or not diabetic foot infections (DFIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) are associated with worse outcomes than DFIs caused by other pathogens. To address this issue we performed a nonsystematic literature search of published articles in English language journals seeking studies reporting on the outcomes of DFIs related to their microbiology. We retrieved 48 articles published from 1999 to 2013 that described a total of 7771 cases of DFI. The overall proportion of DFIs with an isolate of S aureus was about 30%; just over one third of these (11% of all cases) were MRSA strains. Among the DFI cases caused by MRSA 1543 were episodes of soft tissue infections and 113 of osteomyelitis, while non-MRSA organisms caused 5761 soft tissue infections and 354 cases of osteomyelitis. Only 5 of the included articles attempted a comparison between DFI caused by MRSA and those caused by other pathogens, with no clear differences noted. The median total duration of antibiotic therapy for DFI caused by MRSA was 26 days, of which a median of 10 days was given intravenously. Only a few articles reported the proportion of patients with a recurrence, but they often did not differentiate between MRSA and non-MRSA cases. Four publications reported a worse functional or microbiological outcome in MRSA, compared to non-MRSA, cases, but the findings were variable and differences did not seem to be significant. Many trials failed to adjust for case-mix or to definitively demonstrate a relationship between microbiology and outcomes. Few of the articles specifically commented on whether the MRSA isolates were health care- or community-acquired strains. Notwithstanding the substantial limitations of the available literature, there does not appear to be a need for any special treatment for DFI caused by MRSA. The current guidelines for treating according to established international recommendations seem appropriate.

No need to search for the source of haematogenous arthroplasty infections

QUESTIONS UNDER STUDY/PRINCIPLESnProsthetic joint infections (PJI) may be a potential sentinel event for an unknown neoplastic or infectious source in elderly patients. However, the value and cost-effectiveness of investigations to determine the origin of these infections is unknown.nnnMETHODSnRetrospective study at Geneva University Hospitals, evaluating associated medical examinations performed in search of the origin of all presumed surgical site and haematogenous arthroplasty infections.nnnRESULTSnA total of 182 PJI were found in 182 patients (median age 75 years). Seventy PJI (38%) were classified as probably haematogenous, occurring more than 2 years post-implantation, with 27 (15%) due to Gram-negative pathogens. Overall, the origin of PJI was found solely by admission history in 28 cases (15%). Among the remaining 154 cases, no remote origin could be detected despite 17 echocardiograms, 17 other sonograms, 49 chest x-rays, 23 computed tomograms, 107 urinary cultures, 11 endoscopies, 9 scintigraphies and 31 medical specialist consultations. The average cost of these exams was 675 Swiss francs (845 US

Staphylococcus aureus soft tissue infection may increase the risk of subsequent staphylococcal soft tissue infections

) per PJI. At long-term follow-up six patients were found to have developed a neoplasm, of which only one (hepatocellular carcinoma after PJI due to Streptococcus bovis) could eventually be attributed to prior infection.nnnCONCLUSIONSnFrom an epidemiologic point of view, patient history is the best way to predict the origin of PJI. Blind additional radiographic or endoscopic exams are costly, inconclusive and do not contribute to the management of these cases.

Aneurysms of the hand: Imaging and surgical technique

BACKGROUNDnStaphylococcus aureus is the most common cause of soft tissue infections. It is unknown, however, if a patient who has had such an infection is at greater risk for future soft tissue infections with S. aureus.nnnMETHODSnWe conducted an epidemiological survey of adult patients hospitalized in the only public hospital in Geneva for treatment (usually combined surgical and medical) of a soft tissue infection caused by S. aureus. By reviewing nursing and medical records from the emergency department and hospital wards, we assessed whether or not they developed any other soft tissue infections (excluding a recurrence) after or before the index one.nnnRESULTSnAmong 1023 index episodes of soft tissue infections, 670 (65%) were caused by S. aureus, of which 47 were caused by methicillin-resistant strains (30 healthcare-associated and 17 community-acquired). The patients median age was 51 years and 334 (34%) were immune-compromised. The median time span between the patients first and last consultation (for any reason) in our hospital was 21.4 years (interquartile range, 10-30 years). In addition to their index infection, 124 patients (12%) developed a new nosocomial or community-acquired soft tissue infection. Among the index cases with an S. aureus infection, 92 (14%) had another soft tissue infection, compared to 32 (9%) who had a non-staphylococcal index infection (Pearson-χ2-test; p=0.03). Similarly, patients with an index S. aureus infection, compared to those with a non-S. aureus infection, had a higher rate of another soft tissue infection caused by S. aureus (χ2-test; p<0.01). In multivariate analysis, an index infection due to S. aureus shows a high association to further S. aureus soft tissue infections (logistic regression; odds ratio 2.5, 95% confidence interval 1.4-4.6).nnnCONCLUSIONnAmong adult patients hospitalised for a soft tissue infection, those infected with S. aureus (compared with other pathogens) may be at higher risk of a subsequent soft tissue infection, particularly with S. aureus.

Recurrent Vasospastic Myocardial Infarctions and Hand Necrosis

Hand aneurysms are a rare entity only described as case reports in the literature. The aim of our study was to describe a series of four cases and the surgical technique using an arterial bypass. We also wanted to define an algorithm for the imaging of this pathology. We have operated on four patients with hand aneurysms in the past decade or so. One patient had an aneurysm in the thumb proper palmar digital artery, one in the superficial palmar arch and the two others in the ulnar artery. All patients had an excision surgery with direct arterial bypass; no patient had a venous graft. All patients were seen a few years after the surgery and underwent an ultrasonography to check the anastomosis permeability. All anastomoses were permeable 2 to 8 years after surgery. Through a review of the literature we discuss the best algorithm for imaging a hand aneurysm. Direct arterial suture by proximal and distal mobilization allows for long-term permeability. If a graft is necessary, a graft of arterial origin should be preferred. The additional first-line examination is ultrasonography, followed by arteriography if acute ischemia is present; otherwise, CT angiography or MR angiography is performed.

Radioscapholunate arthrodesis with distal excision of the distal scaphoid pole: Intraoperative measurement of range of motion and bone graft coming from a radial cortical flap

A 30-year-old male smoker presented to the emergency department with anterior ST-segment elevation myocardial infarction. Primary percutaneous coronary intervention performed via the right radial artery showed an ostial thrombotic subocclusion of the left anterior descending artery ([Figurexa01A][1

Prise en charge chirurgicale des anévrismes de la main

Objectives: In a series of 9 cases with radio-carpal arthritis from trauma that benefitted from a radioscapholunate arthrodesis with excision of the distal scaphoid pole, we desired to measure the perioperative range of motion to see if mobility was preserved after the operation. We also sought to describe our graft technique with a bone cover coming from the cortical distal radius. nMethods: We retrospectively collected data from nine patients that benefitted from this surgical technique and we documented the clinical and radiological information. nResults: With a mean follow-up of three years, we had the following perioperative results: flexion 44°, extension 41°, ulnar deviation 24° and radial deviation 17°. This range of motion was depressed at postoperative follow-up. We did not observe any pseudoarthrosis. We did find a high complication rate with three cases of mediocarpal arthritis, one tendon rupture and one radiotriquetral conflict. During the postoperative period, the pain was 0/10. nConclusions: Radioscapholunate arthrodesis in the case of radiocarpal arthritis with the use of a bone graft coming from the distal radius demonstrated robust results in terms of pain. The perioperative benefit on mobility was not found during postoperative period. A bone graft using a cortical cover from the distal radius yielded favorable results with regards to bone healing.

P197: Futility of perioperative urinary analysis before elective total joint arthroplasty

Introduction Les anevrismes de la main sont une pathologie rare faiblement decrite dans la litterature. Nous rapportons une serie de 5xa0cas pris en charge dans notre centre. Methode Nous avons revu 5xa0cas de facon retrospective operes durant les 10xa0dernieres annees. On retrouve 4xa0hommes et 1xa0femme, la moyenne d’âge etait de 49xa0ans. Les patients presentaient cliniquement une masse pulsatile a la face palmaire de la main. Un patient presentait simultanement une endocardite, et une patiente avait presente dans l’enfance une endocardite. Un patient presentait un anevrisme sur une artere digitale, 2xa0patients sur l’arcade palmaire superficielle et 2xa0patients sur l’artere ulnaire. Tous les patients ont eu un complement d’imagerie avec echographie puis angio-IRM. Chaque patient a beneficie d’une prise en charge chirurgicale avec excision de l’anevrisme. Resultats Tous les anevrismes ont ete reseques, les analyses pathologiques ont confirme 3xa0anevrismes d’origine mycotique. Un anevrisme etait d’origine traumatique sur le territoire de l’artere ulnaire dans un contexte de syndrome du marteau hypothenarien, un anevrisme etait d’origine idiopathique. La technique chirurgicale etait chez 4xa0patients une excision avec mobilisation des arteres de part et d’autre pour permettre une suture microchirurgicale directe termino-terminale. Cette technique a pu etre utilisee sur le territoire de l’artere ulnaire a 2xa0reprises, sur l’artere digitale et sur une arcade palmaire superficielle. Chez un patient du fait du defect arteriel trop important sur l’arcade palmaire superficielle (>xa02xa0cm) nous avons realise un pontage veineux provenant de l’avant-bras. Discussion La prise en charge des anevrismes a la main reste exceptionnelle et seuls quelques cas sont decrits dans la litterature. Notre serie represente bien le panel retrouve dans la litterature avec certains cas d’origine infectieuse, un cas d’origine traumatique. Dans tous les cas il faut privilegier la mobilisation arterielle pour realiser une suture directe, si la perte de substance est trop importante (>xa02xa0cm) il faut envisager un pontage. Les resultats de la litterature sur l’utilisation de greffons veineux au long terme presentent un taux de thrombose entre 20xa0et 50xa0%. Cela ne peut que nous encourager a suivre au long cours notre serie afin de suivre la permeabilite des sutures directes entre arteres et le suivi du pontage veineux a l’aide d’echo-Doppler.

Revue de cas sur la prise en charge de fractures comminutives de l’EDR avec plaque d’arthrorise pancarpienne provisoire

The search for asymptomatic bacterial urinary tract colonization (UTC) and its eradication before elective hip and knee arthroplasty surgery is controversial, but reflects widespread practice. The influence of perioperative antibiotic prophylaxis on the dynamics of UTC is unknown.