Jean Bahebeck

Implant orthopaedic surgery in HIV asymptomatic carriers: management and early outcome.

BACKGROUND To the best of our knowledge, no reports currently exist on how to manage HIV infected patients in cases where they present with an absolute indication for implant surgery. The aim of this study was to compare the immediate and early outcome of implant orthopaedic surgery in HIV carriers with less than 500CD4/ml (group A) treated with a protective antiretroviral therapy and prolonged prophylactic antibiotic therapy in one group, and in the other group, HIV carriers with more than 500CD4/ml (group B) and non-HIV carriers (group C) treated conventionally. METHODS During a 36-month-period, a protocol of screening and subsequent management of HIV carriage was proposed to patients admitted for internal clean trauma or orthopaedic implant surgery in our department. The HIV screening, its confirmation and the CD4 count were carried out by conventional methods. All group A patients were treated with cefuroxime for 10 days and a fixed combination of antiretroviral tritherapy before or just after surgery. Group B and C patients solely underwent surgery with a conventional 1.5g of cefuroxime. The wounds in the three groups were later examined at days 2, 7, 14, 45 and at 3 months. The rates of clinical wound infection were compared using the Fisher exact test; the difference was considered significant if p<or=0.05. RESULTS Six hundred and forty-six patients were selected for this protocol, due to fresh fractures in 544 (84.21%) cases, non-union in 41 (6.34%), mal-union in 17 (2.63%), aseptic necrosis in 16 (2.47%) and osteoarthritis in 28 (4.33%). During surgery, IM nailing was performed in 351 (54.33%) patients, plating in 165 (25.54%), pinning or wiring in 31 (4.79%) and finally, arthroplasty in 99 (15.32%) among which 45 were total hip replacements. Regarding HIV carriage and immune status, 44 patients were of group A, 30 of group B and 572 of group C. Two cases of infection were observed in both group A (4.54%) and group B (6.66%), and 37 in group C (6.46%). The differences were statistically non-significant. CONCLUSIONS The authors conclude that if a prolonged prophylactic antibiotic therapy and systematic antiretroviral therapy are given to HIV immune-depressed carriers undergoing implant orthopaedic surgery, their post-operative infection risk may be close to that of non-HIV carriers.

Limb-threatening and Life-threatening Diabetic Extremities: Clinical Patterns and Outcomes in 56 Patients

Limb- and life-threatening hand and foot infections in diabetic patients account for a large proportion of amputations and a substantial number of deaths. Between August 2006 and the end of July 2008, we conducted a prospective cohort study of consecutive diabetic patients with serious hand or foot infections, in an effort to identify clinical patterns and outcomes related to the treatment of these infections. Infections were categorized as dry, gas, and wet gangrene; necrotizing fasciitis or cellulitis; acute extensive osteomyelitis; and any of these infections involving the hand. All of the patients underwent a standard examination and treatment protocol, although none of the patients received vascular surgical care. End points included healing following debridement or minor amputation, major (transtibial or more proximal) amputation, or death. A total of 56 patients were included in the final analyses, and their mean age was 70 (range 51 to 86) years. Of the patients, 17 (30.36%) had necrotizing cellulitis, 12 (21.43%) had wet gangrene, 9 (16.07%) had acute extensive osteomyelitis, 5 (8.93%) had dry gangrene, 5 (8.93%) had gas gangrene, 4 (7.14%) had necrotizing fasciitis, and 4 (7.14) had diffuse hand infections. Five (8.93%) patients died (2 after prior amputation), 26 (46.43%) underwent debridement and/or minor amputation, and 27 (48.21%) required major amputations. Based on our findings, we concluded that 7 patterns of serious limb- or life-threatening infection were identified and, in the absence of vascular surgical intervention, mortality can be reduced at the expense of more amputations.

Lésions concomitantes aux genoux flottants et gravité

Floating knee is caused by high-energy trauma, whose genesis is suggestive of extensive locoregional and general damages. Referring to multiple trauma. The aim of our study was to collect data on all concomitant floating knee injuries in our practice environment and to evaluate their severity. We conducted a descriptive and retrospective study over a period of 14 years and 9 months. Our sample consisted of 75 floating knees, the average age was 35 years. Sixty six patients had an ISS≥16 (classified as polytrauma). Head traumas, chest and abdominal injuries associated with floating knee injuries require adequate resuscitation.