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AIM : The treatment of a chronic prosthetic joint infection (PJI) is a combination of the bacteria's identification, a «carcinological» surgery and an appropriate antibiotherapy. In case of gram positive cocci infection, rifampicin is often used. The aim of this study is to determine which factors are responsible for the development of resistance to rifampicine. METHOD : All patients had a total hip (THA) or knee (TKA) arthroplasty with a chronic infection. They were treated with a two-time surgery. All of them received a bi-antibiotic treatment. In case of gram positive cocci infection, and according to the susceptibility test, they received rifampicin. The 221 patients were operated from July 1997 to November 2013 in 3 university centers (one Belgian and two French) and were retrospectively analysed. The demographical, clinical and bacterial data as well as the antibiotic treatment were collected. The healing was defined as the absence of recurrence during the 2 years following surgery. RESULTS : Among the 221 patients (from 22 to 91 years old, median age: 67), 133 (60%) had a THA infection. 22% of the peroperative samples collected during the first time surgery were sterile. 64% were mono-microbial and 14% were poly-microbial. For 69% of them, gentamycin-impregnated spacers were used and for 26% of them vancomycin and gentamycin-impregnated spacers were used. The median delay for the second time surgery was 52 days (15 to 221 days). The healing was higher for the patients treated by an antibiotic combination with rifampicin than the others (86 vs 72%; p=0.02). In the same way, the healing rate was higher in patients where the delay between the two surgeries was less than one month (91 vs 77%; p=0.09). There were more recurrence in TKA than in THA (30% vs 13%, p=0.006). 12 % of the patients showed a persistence of the germ or the emergence of a new microorganism with a comparable antibiogram. A resistance to rifampicin during the second surgery appears in 9 % of cases. CONCLUSIONS : Theses study results suggest the benefit of the use of rifampicin for the treatment of gram positive cocci prosthetic joint infections treated by a two time surgery. In all cases, intravenous antibiotic therapy was maintained until the wound was closed to decrease the emergence of resistance.

Introduction La prise en charge des infections bacteriennes prothetiques chroniques repose sur l’identification du(des) pathogene(s), une chirurgie « carcinologique » ainsi qu’une antibiotherapie ciblee. Il est largement admis que la rifampicine est un antibiotique cle dans le traitement de ces infections. Materiel et methodes Les patients selectionnes avaient une infection chronique de prothese de hanche (PTH) ou de genou (PTG) et avaient beneficie d’une chirurgie en 2 temps associee a une antibiotherapie adaptee. Une cohorte de 221 patients suivis durant la periode juillet 1997–novembre 2013 dans 3 centres universitaires (un belge et deux francais) a ete analysee de maniere retrospective. Les donnees demographiques, cliniques et bacteriologiques ont ete colligees ainsi que les traitements antibiotiques administres. La remission de l’infection a ete definie par l’absence de recidive infectieuse durant le suivi d’au moins deux ans. Resultats Parmi les 221 patients d’âge moyen de 67 ans (22 a 91 ans), 133 (60 %) avaient une infection de PTH. Les prelevements peroperatoires lors du premier temps chirurgical etaient steriles dans 22 % des cas, monomicrobiens dans 64 % des cas et polymicrobiens dans 14 % des cas. L’espaceur en ciment utilise comportait de la gentamicine dans 69 % des cas et une association gentamicine-vancomycine dans 26 % des cas. Le delai median pour le deuxieme temps operatoire est de 52 jours (15 a 211 jours). Le taux de remission etait plus eleve chez les patients traites durant l’intertemps par une combinaison comportant de la rifampicine par rapport aux autres patients (86 versus 72 %, p = 0,02). Le taux de remission des patients dont la duree de l’intertemps ne depassait pas un mois etait plus eleve que celui des autres patients (91 vs. 77 %, p = 0,09). Le taux de guerison a deux ans est plus eleve chez les patients porteurs d’une PTH que chez les porteurs d’une PTG (87 vs. 70 %, p = 0,006). L’analyse microbiologique lors de la chirurgie de repose montre une persistance bacterienne ou l’emergence d’une nouvelle bacterie mais avec un profil d’antibiogramme identique dans 12 % des cas. Dans 9,5 % des cas, les prelevements mettaient en evidence une bacterie avec un nouveau profil de resistance (apparition de resistances non liee au traitement recu). Une resistance a la rifampicine au deuxieme temps operatoire etait notee chez 9 % des patients traites par cet antibiotique. Discussion Les resultats de ce travail suggerent l’effet benefique de l’utilisation de la rifampicine en combinaison dans le traitement des infections de prothese osteoarticulaires a cocci a Gram positifs traitees par remplacement en deux temps.

Recommendations for the management of chronic and bilateral total hip arthroplasty (THA) infection are lacking. However, this type of infection involves medical problems concerning the management of the antibiotic therapy. We report two cases of such infections operated as one-stage revision. For each case, both hips were infected with the same bacteria (Staphylococcus caprae for one patient and methicillin-sensitive Staphylococcus aureus for the other). The probabilistic antibiotic treatment started during the first side (after harvesting intraoperative samples) did not prevent the culture of the bacteriologic harvested during the intervention of the second side. Cultures were positive for the same bacteria for both sides in the two cases presented herein. After results of intraoperative cultures, patients received culture-guided antibiotic therapy for three months and were considered cured at the end of a two-year follow-up. Our results suggest one-stage bilateral change of infected THA is a viable option and that early intraoperative antibiotic, started during the first-side exchange, does not jeopardize microbiological documentation of the second side. This work brings indirect arguments, in favor of the use of prophylactic antibiotics during revision of infected THA.

In the 20-50-year age group, hip pain usually indicates dysplasia. Chronic mechanical pain is the usual pattern, although acute pain caused by avulsion or degeneration of the labrum may occur. The morphological characteristics of the dysplastic hip should be evaluated, and the link between the dysplasia and the osteoarthritis should be confirmed. Three factors indicate a favorable prognosis: joint space preservation, age younger than 40 years, and correctable femoral and acetabular abnormalities. Reconstruction is highly desirable, as it delays the need for joint replacement by 20 years. After 15 years, good outcomes are seen in 87% of patients after shelf arthroplasty and 85% after femoral varus osteotomy with or without shelf arthroplasty. Chiari acetabular osteotomy can be performed in patients with osteoarthritis but is followed by prolonged limping. Periacetabular osteotomy should be reserved for patients with moderate dysplasia and no evidence of osteoarthritis. Shelf arthroplasty and femoral osteotomy require 5-8 months off work (compared to 5 months after hip replacement surgery) but subsequently permits a far more active lifestyle. Hip replacement, which is required 20 years or more after biologic reconstruction, carries the same prognosis as first-line hip replacement (good results in 80% of patients after 15 years). Acute sharp pain related to anterior hip derangement also occurs in primary femoroacetabular impingement (FAI). The most common pattern is cam impingement, which is due to a decrease in head-neck offset and manifests as pain during flexion and adduction of the hip. Cam impingement can be corrected by anterolateral osteoplasty, which is often performed arthroscopically. Pincer-type impingement is contact between the anterior acetabular rim and the femoral neck due to retroversion of the proximal acetabulum. The imaging study strategy is discussed. Coxometry, computed tomography, and arthrography can be used. Primary FAI, which occurs as a result of geometric abnormalities, should be distinguished from secondary impingement. Causes of secondary impingement include exaggerated lumbar lordosis with pelvic tilt and to hip osteophytosis (sports or posterior hip osteoarthritis). Osteoplasty is rarely appropriate in patients with secondary impingement. The features of acute anterior hip derangement are now better defined. They can be used to guide palliative treatment, which is effective, in the medium term at least. Experience acquired over the last two decades has established the efficacy of surgery for hip dysplasia.