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ObjectivesIn a new experimental model of carbapenemase-producing Klebsiella pneumoniae osteomyelitis we evaluated the efficacy of colistin alone and in various combinations and examined the emergence of colistin-resistant strains and cross-resistance to host defence peptides (HDPs).MethodsKPC-99YC is a clinical strain with intermediate susceptibility to meropenem (MIC = 4 mg/L) and full susceptibility to gentamicin, colistin and tigecycline (MICs = 1 mg/L) and fosfomycin (MIC = 32 mg/L). Time–kill curves were performed at 4× MIC. Osteomyelitis was induced in rabbits by tibial injection of 2 × 108 cfu. Treatment started 14 days later for 7 days in seven groups: (i) control; (ii) colistin; (iii) colistin + gentamicin; (iv) colistin + tigecycline; (v) colistin + meropenem; (vi) colistin + meropenem + gentamicin; and (vii) colistin + fosfomycin.ResultsIn vitro, colistin was rapidly bactericidal, but regrowth occurred after 9 h. Combinations of colistin with meropenem or fosfomycin were synergistic, whereas combination with tigecycline was antagonistic. In vivo, colistin alone was not effective. Combinations of colistin with meropenem or fosfomycin were bactericidal (P ConclusionsIn this model, combinations of colistin plus meropenem, with or without gentamicin, or colistin plus fosfomycin were the only effective therapies. The combination of colistin and tigecycline should be administered with caution, as it may be antagonistic in vitro and in vivo.

Traumatic neurological lesions may lead to development of heterotopic ossification. These cases are classified as ‘neurogenic heterotopic ossifications’ (NHOs). The associated neurological lesions can be caused by cranial trauma or spinal cord injury and may sometimes include a local trauma. NHOs that form around the hip joints are of particular interest because they often cause the patient to avoid the sitting position or the resumption of walking. Whilst NHO can involve the knee, shoulder and elbow joints, hip-involving NHOs are more numerous, and sometimes develop in close contact with vascular or neurological structures. Multi-disciplinary clinical examination is fundamental to evaluate patients for surgical intervention and to define the objectives of the surgery. The best investigation to define an NHO mass is a computerized tomography (CT) scan. Resection is performed to liberate a fused joint to provide functionality, and this need not be exhaustive if it is not necessary to increase the range of motion. While recurrence does occur post-surgery, a partial resection does not pose a greater risk of recurrence and there are no adjuvant treatments available to reduce this risk. The greatest risks associated with NHO surgical resection are infection and haematoma; these risks are very high and must be considered when evaluating patients for surgery. Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180098

International audience; BACKGROUND: Heterotopic ossification (HO) is defined as the formation of endochondral bone within soft tissue. Non-genetic forms, mainly corresponding to a consequence of bone, brain or spinal cord injury, are the most common. ho leads to important functional limitations and alteration of quality of life. To our knowledge, the time between brain, bone, or spinal cord injury and clinical suspicion of HO has never been studied. By admitting patients with severe neurological disorders, we hypothesized that the prevalence of HO in neurological post-intensive care rehabilitation units (PICRU) might be significant as these patients have recognized risk factors for HO. AIM: This study aimed to investigate HO among patients admitted to a neurological PICRU with two objectives: 1) to describe the prevalence of HO in PICRU; 2) to assess the time between neurological disorder, clinical suspicion of HO and radiological diagnosis. dEsiGN: a monocentric retrospective cohort study. SETTING: PICRU in our public university teaching hospital. This inpatient referral department is specifically dedicated to the early discharge from Intensive Care Units (ICU) of patients with severe neurological impairment who need rehabilitation. POPULATION: We study all patients admitted between April 2016 and January 2019. One hundred twenty-five subjects were admitted for a rehabilitation program after neuro-trauma or stroke. We included all first-time stays in PICRU lasting 7 days or longer. METHODS: Retrospective data extraction using administrative data from an electronic patient management program was done to select eligible subjects. Included subjects were then identified by a retrospective review of electronic inpatient medical records after patient discharge. Data of interest were collected from these same medical records. RESULTS: Forty-four HO were diagnosed in 24 subjects (24/125; 19%), with a median number of 2 [1; 2] HO per subject. Neurological trauma was the main reason for admission to ICU (89/125; 71%) and half of patients had a traumatic brain injury (TBI) (67/125; 54%). The diagnosis of HO was made in PICRU in 75% of cases. Clinical suspicion of HO (autonomic dysfunction, local inflammatory signs, pain, or reduced joint range of motion) was made 6 [5; 7] weeks after admission to ICU. Radiological confirmation of clinical suspicion or fortuitous diagnosis by imaging (50% of the cases) occurred 8 [7; 12] weeks after admission to ICU. The median time of clinical suspicion or radiological diagnosis was 1 week after admission to PICRU. CONCLUSIONS: HO is a sub-acute complication which develops in patients admitted to ICU for severe central nervous system disorders as clinical suspicion or radiological confirmation of diagnosis was made within the first week after admission in neurological PICRU (i.e. 6 to 8 weeks after ICU admission). CLINICAL REHABILITATION IMPACT: As treatment for HO may at least partially improves rehabilitation and quality of life, we recommend a systematic screening in picru patients for ho by clinical examination supplemented by imaging in case of suspicion.

Neurogenic heterotopic ossification of the hip is secondary to neurologic lesions such as cranial trauma, stroke, medullary injury or cerebral anoxia. We shall not deal here with the other etiologies of heterotopic ossification. There are numerous locations within the hip, depending on etiology and relations with adjacent neurovascular structures are sometimes close. Preoperative work-up should include contrast-enhanced CT; scintigraphy is non-contributive. Indications for surgery are decided in a multidisciplinary team meeting, with a contract laying out expected functional gain. It is this contract that determines the extent of resection, without seeking complete resection, which would incur an increased risk of complications. The surgical approach and resection strategy depend on lesion location and any resulting neurovascular compression. The most common complications are infection and postoperative hematoma. No adjuvant treatments have demonstrated efficacy against recurrence.

Resume Background Les paraosteoarthropathies neurogenes (POAN) sont habituellement traitees par exerese chirurgicale, mais cette intervention peut se compliquer d’infection postoperatoire (IPO). Cependant, l’epidemiologie, l’ecologie bacterienne et les facteurs de risque de ces infections sont mal connus. Aussi, nous avons mene une etude retrospective afin de : (1) connaitre les facteurs de risque d’IPO apres resection de POAN de hanche ; (2) leur incidence ; (3) leur ecologie microbienne. Hypothese Il est possible de determiner les facteurs de risque d’IPO a la suite de l’exerese de POAN de hanche. Materiel et methodes A partir de la base de donnees BANKHO, colligeant les interventions sur POAN dans notre centre, nous avons etudie retrospectivement les facteurs associes a un sur risque d’IPO dans une etude cas (patients infectes)-temoins (patients non infectes). Le suivi postoperatoire a ete d’au moins 6 mois. Les odds ratio sur les differents criteres principaux etudies ont ete calcules (indice de confiance a 95 %) permettant l’identification de facteurs de risque. Resultats Quatre cent-onze interventions sur POAN de hanche ont ete recensees entre 1993 et 2013, compliquees d’une IPO dans 42 cas (10 %). Le score ASA (American Society of Anesthesiologists) etait ASA I pour 2/42 (5 %) patients infectes (contre 74/369 patients non infectes [20 %]), ASA II pour 30/42 (71 %) patients infectes (contre 258/369 patients non infectes [70 %]) et ASA III pour 10/42 patients infectes (24 %) (contre 37/369 patients non infectes [10 %]) (p Discussion Le score ASA eleve, l’âge jeune et l’etiologie medullaire a l’origine de la POAN de hanche sont des facteurs de risque identifies d’IPO. Il survenait 10 % d’IPO sur POAN conformement aux donnees de la litterature. Elles surviennent chez 22 % des blesses medullaires (5 % pour les autres etiologies). Les changements d’antibioprophylaxie et la mise en place d’un protocole precis de preparation cutanee n’ont pas change le taux d’IPO constatees. Une modification du pH cutane pourrait etre une piste de recherche a etudier pour diminuer ce taux d’IPO, en particulier chez les patients blesses medullaires. Niveau de preuve III : etude cas-temoins.

International audience; Guidelines for the management of carbapenemase-producing Enterobacterales (CPE) infections recommend a combination of two active agents, including meropenem if the minimum inhibitory concentration (MIC) is ≤8 mg/L. The therapeutic equivalence of meropenem generics has been challenged. We compared the bactericidal activity of meropenem innovator (AstraZeneca) and four generic products (Actavis, Kabi, Mylan and Panpharma), both in vitro and in vivo, in association with colistin. In vitro time-kill studies were performed at 4 × MIC. An experimental model of KPC-producing Klebsiella pneumoniae osteomyelitis was induced in rabbits by tibial injection of a sclerosing agent followed by 2 × 10 CFU of K. pneumoniae KPC-99YC (meropenem MIC = 4 mg/L; colistin MIC = 1 mg/L). At 14 days after inoculation, treatment for 7 days started in seven groups of ≥10 rabbits, including a control group, a colistin group, and one group for each meropenem product (i.e. the innovator and four generics), in combination with colistin. In vitro, meropenem + colistin was bactericidal with no viable bacteria after 6 h, and this effect was similar with all meropenem products. In the osteomyelitis model, there was no significant difference between meropenem generics and the innovator when combined with colistin. Colistin-resistant strains were detected after treatment with colistin + meropenem innovator (n = 3) and generics (n = 3). The efficacy of four meropenem generics did not differ from the innovator in vitro and in an experimental rabbit model of KPC-producing K. pneumoniae osteomyelitis in terms of bactericidal activity and the emergence of resistance.

Carbapenemase-producing Enterobacteriaceae (CPE) are emerging multidrug-resistant bacteria responsible for invasive infections, including prosthetic joint infections (PJIs). Local administration of colistin may provide bactericidal concentrations in situ. This study evaluated the efficacy of a colistin-impregnated cement spacer, alone and in combination with systemic antibiotics, in a rabbit model of CPE-PJI. Elution of 3 MIU of colistimethate sodium (CMS) in 40 g of poly(methyl methacrylate) cement was studied in vitro. In vivo, 5 × 108 CFU of KPC-producing Klebsiella pneumoniae (colistin and meropenem MICs of 1 mg/L and 4 mg/L, respectively) were injected close to a prosthetic knee. Surgical debridement and prosthesis removal were performed 7 days later, and rabbits were assigned to six treatment groups (11–13 rabbits each): drug-free spacer; colistin-loaded spacer; colistin intramuscular (i.m.); colistin i.m. + colistin spacer; colistin i.m. + meropenem subcutaneous (s.c.); and colistin i.m. + meropenem s.c. + colistin spacer. Systemic treatment was administered at doses targeting pharmacokinetics in humans, and rabbits were euthanised 7 days later to evaluate bacterial counts in infected bones. In vitro, CMS elution was low ( 20 × MIC). In vivo, combinations of local and systemic colistin, with or without meropenem, were the only regimens superior to the control group (P ≤ 0.05) in terms of viable bacterial counts and the proportion of rabbits with sterile bone, with no emergence of colistin-resistant strains. Colistin-loaded cement spacer in combination with systemic antibiotics were the most effective regimens in this CPE-PJI model.

Dear Editor, Neurogenic heterotopic ossifications (NHOs) are benign ectopic bones that develop within the muscle tissue surrounding extracapsular bone joints [1] after severe lesions of the central nervous system (CNS) such as spinal cord injury (SCI) or traumatic brain injury [2]. NHOs are often diagnosed late, thereby resulting in large ossifications causing joint pain and stiffness that often progress to partial or complete joint ankyloses. Complications such as nerve and blood vessel compression and skin bedsores occur further exacerbate patient morbidity. Occurrence of NHO delays recovery from injury, interrupts rehabilitation programs and lengthens the hospital stay [3]. There is no effective pharmacological treatment to reduce the burden of NHO. Surgical resection of troublesome NHO remains the only treatment and provides some benefit for mobility [3].

The clinical assessment of a hypertonic upper limb in central neurological diseases should be analytical, systematic (shoulder, elbow, extrinsic and intrinsic hand) and focused on the patient or caregiver’s wishes and on the expected objectives (esthetic, hygienic, functional). Nerve blocks can help to separate mixed contractures, show the existence of antagonist muscles or find a starter muscle in dystonia patterns. The etiology (especially the evolving nature of the disease), general health condition (especially in older adults), associated deficits (cerebellar, sensory and cognitive; hemineglect) are considered together to arrive at a contract with patients and/or caregivers.

International audience

Resume Introduction Les modeles animaux d’infections peri-prothetiques en orthopedie sont importants pour comprendre certains mecanismes ethio-pathogeniques et tester de nouvelles methodes therapeutiques, car les essais formalises restent difficiles devant l’extreme diversite des situations cliniques. Le cahier des charges de ces modeles experimentaux consiste a reproduire les caracteristiques des infections rencontrees en pratique clinique. Une des problematiques repose sur la voie d’inoculation (locale, intraveineuse ou intra-arterielle, per- ou postoperatoire). Cette voie varie pour simuler des modes de contamination differents, soit directs, soit de contiguite, soit hematogenes. Cependant, la voie d’inoculation peut aussi induire des taux et des degres de severite de l’infection variables selon les modeles et parfois eloignes des infections postoperatoires en clinique. Hypothese Le mode d’inoculation directe est plus efficace et moins iatrogene pour induire une infection locale sur materiel etranger articulaire. Methodologie Une analyse critique de la litterature a ete effectuee en evaluant chaque modele selon son type d’inoculation en fonction de trois criteres de jugement. Le critere principal etait le taux d’infection induite qui devait etre proche de 100 %. Les criteres secondaires etaient le taux de mortalite qui devait etre le plus faible possible et le taux de guerison spontanee. Vingt et un articles ont ete selectionnes. Resultats Les inoculations intra-articulaires et medullaires avaient des taux d’induction de 70 a 100 %, les inoculations intra-arterielles ou intraveineuses avaient des taux de 100 et de 47 a77 % respectivement. Les premieres induisaient aussi des taux de mortalite plus faibles (5 a 23 % pour les inoculations intra-articulaires et medullaires contre 37 % pour les inoculations intra-arterielles et 28 a 56 % pour les inoculations intraveineuses). Enfin, les taux de guerison spontanee etaient respectivement de 0 a 30 % pour les inoculations intra-articulaires et medullaires, 30 a 53 % pour les inoculations intraveineuses et 0 % pour les inoculations intra-arterielles. Conclusion Les modes d’inoculation directs sont les plus efficaces pour reproduire une infection chronique ne mettant pas en jeu la vie de l’animal et sans survenue de guerison spontanee. La simulation des infections hematogenes est plus aleatoire.

Introduction Because the extreme diversity of clinical situations makes formal clinical trials difficult to carry out, animal models of periprosthetic infection in orthopaedics are needed to understand the aetiology and pathology of these infections, and to test new treatment methods. These experimental models must reproduce the features of the infections encountered in clinical practice. One of the model variables is the method of inoculation: local (intra-articular), intravenous or intra-arterial. Another is the timing of the inoculation: intra-operative or postoperative. Together, these options simulate the different contamination methods: direct, by proximity or blood-borne. However, the chosen inoculation route can also affect the infection rate and severity in the various models, and in some cases do not accurately reproduce the postoperative infections encountered clinically. Hypothesis The direct inoculation method is the most effective for inducing a local infection on a foreign body in a joint, and the least iatrogenic. Methods A critical analysis of published studies was carried out to evaluate each model against three endpoints, according to the type of inoculation. The primary endpoint was the infection rate, which should be as close as possible to 100%. The secondary endpoints were the mortality rate and rate of spontaneous healing, both of which should be as low as possible. Twenty-one articles were reviewed. Results Intra-articular and intra-medullary inoculations had induction rates between 70 and 100%; intra-arterial inoculations had an induction rate of 100%, while intravenous inoculation had a rate of 47 to 77%. The mortality rates were lower with the intra-articular and intramedullary inoculations (5 to 23%) than for the intra-arterial inoculations (37%) and intravenous inoculations (28 to 56%). The spontaneous healing rate was 0 to 30% for intra-articular and intramedullary inoculations, 30 to 53% for intravenous inoculations and 0% for intra-arterial inoculations. Conclusion Direct inoculation methods are most effective at reproducing chronic periprosthetic joints infections, without putting the animal's life at risk or allowing for spontaneous healing. The simulation of blood-borne infections is more random.

Neuro-orthopedic complications of the upper limb affect all of its joints and lead to a multitude of clinical pictures. The clinical assessment, which should be multidisciplinary, will have to answer basic questions to define the goal(s) and the appropriate surgical strategy. What is the patient's and family's complaint? What is the possible utility of the deformities? What is the type of deformity? Is it reducible or not? What is the contribution of the upper limb deformities versus that of any associated injuries to the discomfort? Several difficulties exist in the clinical assessment: evaluation of the antagonists especially the wrist extensor muscles; the intrinsic deformity component, which can be masked by the extrinsic component when retracted, the muscles responsible for a wrist flexion contracture and the complex shoulder deformities. Many patients have multiple deformities, which creates a problem for the hierarchy of corrections depending on the objectives. The answer to these questions helps to define a clear objective that will be formalized in a contract with the patient and subsequently to define the surgical strategy. Surgery is based on a simple principle: relax the muscles on the side of the deformity, either by selective neurotomy if there is a simple hypertonia, or by a tendon procedure if the muscle is retracted; compensate for the antagonists if they are deficient, and potentially stabilize the joint. Conservative procedures are preferred to preserve the possibility of functional recovery in the future. The wide range of medical and surgical solutions allows the patient's care to be personalized. In the upper limb, the results are better for hygienic, positioning, and analgesic objectives. They remain more difficult to obtain for functional objectives, due to the biomechanical complexity of gripping.

Review of the literature.It is widely believed that the timing of surgery and the size of the initial Neurological Heterotopic Ossification (NHO) affect the recurrence risk of NHO after SCI. A large number of studies were published in the 80s and the 90s, mostly of poor quality despite the fact that they were carried out by experienced surgical teams. The aim of this study was to suggest recommendations relating to the timing of excision of heterotopic ossification after SCI following the analysis of a recent review of the literature.France.A systematic literature search was performed in the PubMed Embase from January 2002 until June 2014 using the MESH headings 'spinal cord injury', 'paraplegia', 'heterotopic ossification' and 'surgery'. Results were compared with results from epidemiological studies based on the BANKHO database (patients who underwent surgery for troublesome HO after central neurological system (CNS) lesions in our center (357 patients, 539 surgeries)).Few studies were found in the literature, results were sometimes contradictory and practices heterogeneous. Results from the BANKHO database showed that troublesome recurrence of NHO was not associated with 'early' surgery (before 6 months), and no association was found between recurrence and the size of the NHO around the joint (Brooker status).We suggest that surgical excision of the NHO should be carried out when it begins to be troublesome, as soon as comorbid factors are under control and the HO is sufficiently constituted for excision.

Introduction Patients with neurological disorders often exhibit dislocation or subluxation of the hip. Anterior dislocation is rare, little known, and often associated with deformities. Its surgical treatment has rarely been studied. Hypothesis Hip surgery (with open reduction, femoral and pelvic osteotomy, and adapted tenotomies) could provide a centered hip that is supple and painless. Materials and methods Ten hips (seven dislocated, three subluxated) in six patients with a mean age of 8.3 years were operated between 1995 and 2009 and revised with a mean follow-up of 6.5 years. The deformities comprised four cases of abduction, extension, and external rotation and six cases of adduction, extension, and external rotation. Four patients had lost the ability to walk or maintain the sitting position. Intraoperative findings were an increased neck-shaft angle, anterosuperior acetabular dysplasia, and in only one case increased femoral anteversion. In all cases of dislocation, open reduction was necessary, and all hips underwent pelvic and femoral osteotomy. Results At the longest follow-up, hips were centered on X-rays. Five patients could walk or sit as they had done before and hips were supple, with no deformities. Discussion The study of deformities and intraoperative findings is mandatory for surgical management, whose mid-term results are encouraging. Femoral anteversion does not seem to be excessive, but the increase of femoral valgus is constant, as is anterosuperior acetabular dysplasia. We propose a decision tree for the management of these patients. Design of study Retrospective. Level of scientific evidence IV.

Resume Introduction Les patients atteints d’affections neurologiques presentent souvent des luxations ou subluxations de hanche. Parmi elles, la luxation anterieure est rare, peu connue et souvent associee a des attitudes vicieuses. Son traitement chirurgical a rarement ete etudie. Hypothese La chirurgie de la hanche (avec reduction chirurgicale, osteotomies femorale et pelvienne, et tenotomies adaptees) permettrait d’obtenir une hanche recentree, souple et indolore. Patients et methode Dix hanches (7 luxees et 3 subluxees) chez 6 patients d’âge moyen de 8,3 ans ont ete operees entre 1995 et 2009 et revues avec un recul median de 6,5 ans. Les attitudes vicieuses etaient : quatre cas d’abduction, extension et rotation externe et six cas d’adduction, extension et rotation externe. Quatre patients avaient perdu la marche ou la station assise. Les constatations peroperatoires ont retrouve un angle cervico-diaphysaire excessif, une dysplasie acetabulaire antero-superieure et dans seulement un cas, une antetorsion femorale excessive. En cas de luxation, une reduction chirurgicale a toujours ete necessaire. Toutes les hanches ont eu une osteotomie pelvienne et une osteotomie femorale. Resultats Au recul maximum, les hanches etaient centrees sur les radiographies. Cinq enfants ont retrouve ou ameliore leur deambulation, ou la station assise preexistantes et leurs hanches etaient souples, sans attitude vicieuse. Discussion L’etude des attitudes vicieuses, et des constations peroperatoires est importante pour la strategie chirurgicale dont les resultats a moyen terme sont encourageants. L’antetorsion femorale ne semble pas excessive, mais l’exces de valgus femoral est constant ainsi que la dysplasie acetabulaire antero-superieure. Nous proposons un arbre decisionnel pour la prise en charge de ces patients. Type d’etude retrospective. Niveau d’evidence scientifique IV.

Neurogenic heterotopic ossification (NHO) is usually treated by surgical excision. Postoperative infection (POI) is a possible complication, whose epidemiology, causative organisms, and risk factors are poorly known. We therefore conducted a case-control study to (1) identify the risk factors for POI after surgical excision of NHO at the hip, (2) determine the frequency of POI, (3) and identify the causative organisms.Risk factors for POI after NHO excision at the hip can be identified.In this retrospective case-control study, the BANKHO database for patients with NHO at our centre was used to identify risk factors by comparing patients with and without POI after NHO excision at the hip. To this end, odds ratios (ORs) with their 95% confidence intervals (95%CIs) were computed for each main criterion. Postoperative follow-up was at least 6 months.Between 1993 and 2013, 411 hip NHO excisions were performed. Among them, 42 (10%) were followed by POI. The American Society of Anesthesiologists (ASA) score was I in 2/42 (5%) patients with vs. 74/369 (20%) patients without POI, II in 30/42 (71%) patients with vs. 258/369 (70%) patients without POI, and III in 10/42 (24%) patients with vs. 37/369 (10%) patients without POI (P0.01). Mean age was 31±11 years (range, 17-79years) in the group with POI and 39±14 years (range, 15-77years) in the group without POI (P0.01). The NHO was related to spinal cord injury in 26/42 (62%) patients with POI compared to 92/369 (25%) patients without POI (P0.01). ORs indicated a significant risk increase in patients with an ASA score of III (2.84; 95%CI, 1.28-6.31), age younger than 30 years (1.85; 95%CI, 1.03-3.32), and spinal cord injury as the cause of NHO (4.89; 95%CI, 2.67-8.98). The predominant organisms were staphylococci (skin flora) in the patients with spinal cord injury and bacteria commonly found in intensive care units in the other patients.A higher ASA score, younger age, and spinal cord injury as the cause of NHO at the hip are risk factors for POI. The proportion of patients with POI after hip NHO excision was 10%, in accordance with previous reports. POI was more common among patients with spinal cord injury (22% vs. 5% in the other patients). Neither changes in prophylactic antibiotic therapy regimens nor the institution of a detailed skin preparation protocol affected the frequency of POI. Skin pH alterations may deserve to be investigated with the goal of diminishing the risk of POI, most notably in spinal cord injury patients.III, case-control study.

Purpose Soft tissue surgery for upper extremity contractures can improve hygiene, pain, and appearance in adults with central nervous system lesions. The goal of such interventions is highly individual; thus, goal attainment scaling (GAS; a method of scoring the extent to which patient's individual goals are achieved [5 levels] in the course of intervention and using T score values) is pertinent to evaluate outcome. The objective of this study was to assess the effect of soft tissue surgery for upper extremity muscle contractures in patients with central nervous system lesions using GAS. Methods Retrospective data from 70 interventions were included (63 patients; 23 women). The mean age was 51.3 ± 16.2 years (range, 24.2–87.0 years). The primary goal was to improve hygiene (n = 58), pain (n = 10), or appearance (n = 2). The etiologies were stroke (n = 35), traumatic brain injury (n = 16), cerebral anoxia (n = 4), neurodegenerative disease (n = 6), and cerebral palsy (n = 2). The GAS score was calculated before surgery and 3 months after surgery. Results The T score (which took into account the weight of each goal) was 52.3 at 3 months (38.5 before surgery), corresponding to a "better than expected" outcome. The mean of the differences of the GAS score for each goal before and after surgery increased by 1.27 for hygiene, 1.06 for pain, and 1.00 for appearance. Conclusions Soft tissue surgery can safely and effectively improve hygiene, pain, and appearance in adults with cerebral damage. The preoperative evaluation should be multidisciplinary. The GAS is a useful tool to assess the effectiveness of orthopedic surgery for these patients. Type of study/level of evidence Therapeutic IV.

Objectif Elaborer une synthese des pratiques professionnelles concernant la prise en charge des fractures recentes des membres inferieurs chez le patient poliomyelitique adulte.

Introduction/Background Heterotopic ossification (HO) is a frequent complication after damage to the central nervous system (CNS), with an estimated prevalence of up to 76%. The primary site of HO is the hip joint (60,9%). The only effective treatment of troublesome HO is surgery. The main purpose of this study was to identify the relationship between the location of troublesome hip HO treated by surgery and the etiology of the cerebral damage. The secondary aim was to identify risk factor of sepsis and recurrences after the surgery. Material and method We retrospectively analyzed data from an anonymous prospective survey of patients undergoing surgery for troublesome HO from 1993 to 2016 (417 patients, 609 surgeries). Results The sites of HO on the hip joint were associated with its etiology (P Conclusion The sites of hip HO, their recurrences and sepsis were associated with its etiology. The patients with SCI will develop most frequently anterior hip HO, with a risk of sepsis that is more frequent than in the other etiologies.

Introduction/Background Raymond-Poincare hospital is a national rehabilitation center for disabled patients with orthopedic issues. Physical medicine and rehabilitator physicians and orthopedic surgeons have developed interdisciplinary neuro-orthopedic approach for treatment of patients, with over 30 years of experience. The framework of diagnosis and therapeutic treatment outcome decision making considers patient concerns and expectation. An initial selection consultation is performed to identify complex cases requiring interdisciplinary expertise, as approximately 60% of new patient referrals (1000 patients annually) present with a surgical indication; otherwise patients are reoriented to different departments. Material and method Patients are stratified into one of four consultation services, dedicated to conditions associated with: upper limb and geriatric/lower limb/cerebral palsy/heterotopic ossification, Charcot-Marie-Tooth, and poliomyelitis. Results Consultations are split into 4 phases. The primary phase is performed by a single physician and is dedicated to understand what the complaint is depending on the patients’ medical history. Phase 2 involves the entire interdisciplinary team, where there is time dedicated to clinical exam and an interactive discussion between doctors and patient and the best therapeutic options are debated. In the 3rd phase of consultation, the therapeutic options are presented to the patient with clear goals being established in a formal “agreement” with the patient. The 4th part of the consultation is done by one single doctor who stay with the patient to summarize, answer questions and precise the procedure. Discussion with patients is essential for identifying the unique pathological features of individual cases. The interdisciplinary team is comprised of experts in OS and PMR seniors and interns; who participate equally in the process. Conclusion The interaction between medico-surgical experts in this framework of consultation has developed a cooperative network of experts in PMR that spans French territory. Thus, diagnosis and consultation using this novel framework delivers ideal treatment strategies for the rehabilitation of patients.

Introduction/Background Neurogenic heterotopic ossification (NHO) of the hip is secondary to neurologic lesions such as cranial trauma, stroke, medullary injury or cerebral anoxia. Our practice of heterotopic ossification surgery has progressed during our experience, becoming better adapted to the pathology and to the patients, who are often fragile and show neurologic sequelae. We want to give a feedback of the lessons we learned in the Raymond-Poincare Hospital about NHO resection. Material and method In total, 377 first-line procedures were performed for heterotopic ossification of the hip between 1993 and November 2016. Surgery requires rigorous organization and planning, preferably in a rehabilitation department, by a multidisciplinary team experienced in this pathology. Preoperative work-up should include contrast-enhanced CT; scintigraphy is non-contributive. Indications for surgery are decided in a multidisciplinary team meeting, with a contract laying out expected functional gain. It is this contract that determines the extent of resection, without seeking complete resection, which would incur an increased risk of complications. Results The surgical approach and resection strategy depend on lesion location and any resulting neurovascular compression. In our own series, 3,5% of patients required revision for recurrence. The most common complications is infection: 10.3% in our experience, with wide variation according to location. No adjuvant treatments have demonstrated efficacy against recurrence. Conclusion Surgical treatment of heterotopic ossification of the hip is reliable when performed in an adapted center by an experienced multidisciplinary team. Clinical results are satisfactory. There remains, however, a risk of sepsis, especially with medullary injuries.

Possibilities for bone reconstruction in osteonecrosis of the femoral head in sickle cell hemoglobinopathies before the end of growth have not been assessed. The aim of our study was to evaluate the morphological and functional results in 11 osteonecrosis of the femoral head because of homozygous sickle cell disease. Surgical treatment consisted of a triple acetabular osteotomy in seven cases, femoral varus osteotomy in two cases and a combination of both in two cases. The severity of the osteonecrosis was evaluated on radiographs and magnetic resonance imaging (MRI), pre- and postoperative, and function of the hip joint was assessed by Harris and Postel Merle d'Aubigné scores. The anesthetic part (pre- and postoperative) and eventual complications were collected and analyzed. The maximum follow-up was between 1 to 9.6 years. All patients were considered to be satisfactory at maximum follow-up. The severity of the initial damage was not associated with any morphological or functional outcome at maximum follow-up. All patients had an objective functional gain. We found no general complications. We proposed a decision tree for the patient's management of avascular necrosis of the femoral head in sickle cell hemoglobinopathies before bone maturity, and with an Arlet and Ficat's stage of 3 or 4. The results of this study confirmed the interest of conservative surgical treatment in children with homozygous sickle cell anemia in case of osteonecrosis of the femoral head.IV (cases series of our department).

International audience; INTRODUCTION: In bone and joint infections (BJIs), bacterial toxins are major virulence factors: Panton-Valentine leukocidin (PVL) expression leads to severe local damage, including bone distortion and abscesses, while α-hemolysin (Hla) production is associated with severe sepsis-related mortality. Recently, other toxins, namely phenol-soluble modulins (PSMs) expressed by community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strain USA300 (LAC WT) were shown to have ex vivo intracellular cytotoxic activity after S. aureus invasion of osteoblasts, but their in vivo contribution in a relatively PVL-sensitive osteomyelitis model remains poorly elucidated. MATERIALS AND METHODS: We compared the outcomes of experimental rabbit osteomyelitises induced with pvl+hla+psms+ LAC WT and its isogenic Δpsm derivatives (LAC Δpsmα and LAC Δpsmαβhld) using an inoculum of 3 \texttimes 108 CFUs. Mortality, hematogenous spread (blood culture, spleen and kidney), lung and bone involvements were assessed in two groups (non-survivors of severe sepsis and survivors sacrificed on day (D) 14). RESULTS: Severe sepsis-related mortality tended to be lower for Δpsm derivatives (Kaplan-Meier curves, P = .06). Non-survivors' bone LAC-Δpsmα (6.9 log10 CFUs/g of bone, P = .04) or -Δpsmαβhld (6.86 log10 CFUs/g of bone, P = .014) densities were significantly higher than LAC WT (6.43 log10 CFUs/g of bone). Conversely, lung Δpsmαβhld CFUs were significantly lower than LAC WT (P = .04). LAC Δpsmα, Δpsmαβhld and WT induced similar bone damage in D14 survivors, with comparable bacterial densities (respectively: 5.89, 5.91, and 6.15 log10 CFUs/g of bone). Meanwhile, pulmonary histological scores of inflammation were significantly higher for LAC Δpsmα- and Δpsmαβhld-infected rabbits compared to LAC WT (P = .04 and .01, respectively) but with comparable lung bacterial densities. CONCLUSION: Our experimental results showed that deactivating PSM peptides significantly limited bacterial dissemination from bone during the early phase of infection, but did not affect local severity of USA300 rabbit osteomyelitis.

Objective Soft tissue surgery for upper extremity contractures is uncommon or under evaluated, however can improve hygiene, pain and appearance in adults with central nervous system lesions. The goal of such interventions is highly individual, thus goal attainment scaling (GAS) is pertinent to evaluate outcome. The objective of this study was to assess the effect of soft tissue surgery for upper extremity muscle contractures in patients with CNS lesions using GAS. Material/Patients and methods Retrospective data from 70 interventions were included (63 patients, 23 women). Mean age was 51.3 ± 16.2 years (24.2 to 87.0). The primary goal was to improve hygiene ( n = 58), pain ( n = 10) or appearance ( n = 2). Aetiologies were stroke ( n = 35), traumatic brain injury ( n = 16), cerebral anoxia ( n = 4), neurodegenerative disease ( n = 6) and cerebral palsy ( n = 2). The GAS Score was calculated before and 3 months’ post-surgery. Results Mean GAS score increased by 1.27 for hygiene, 1.06 for pain and 1.00 for appearance. Mean total GAS score increased by 1.18. The T-score (which took into account the weight of each goal) was 52.29 at three months, corresponding to a “better than expected” outcome. Discussion/Conclusion Soft tissue surgery can effectively improve hygiene, pain and appearance in adults with cerebral damage. The preoperative evaluation should be multidisciplinary. GAS is a useful tool to assess the effectiveness of surgery for these patients. Surgery does not necessarily mean the end of treatment for patients with CNS lesions – post-surgical changes allow new objectives to be determined, which can then be attained through further pharmacologic treatment and rehabilitation.

Clindamycin, a lincosamide antibiotic with a good penetration into bone, is widely used for treating bone and joint infections by Gram-positive pathogens. To be active against Staphylococcus spp, its concentration at the infection site, C, must be higher than 2× the minimal inhibitory concentration (MIC). The aims of the work were to study the determinants of plasma clindamycin trough concentration, C min, especially the effect of co-treatment with rifampicin, and the consequences on clinical outcome. An observational study was performed, involving patients hospitalized for a bone and joint infection who received clindamycin as part of their antibiotic treatment. Target C min was 1.7 mg/L, to reach the desired bone concentration/MIC >2, assuming a 30 % diffusion into bone and MIC = 2.5 mg/L. Sixty one patients (mean age: 56.8 years, 57.4 % male) were included between 2007 and 2011. 72.1 % underwent a surgery on a foreign material, and 91.1 % were infected by at least a Gram-positive micro-organism. Median C min value was 1.39 mg/L, with 58 % of the values below the threshold value of 1.7 mg/L. Median C min was significantly lower for patients taking rifampicin (0.46 vs 1.52 mg/L, p = 0.034). No patient with rifampicin co-administration reached the target concentration (maximal C min: 0.85 mg/L). After a median follow-up of 17 months (1.5–38 months), 4 patients relapsed, 2 died and 47 (88.7 % of the patients with known outcome) were cured, independently of association with rifampicin. This study shows the high inter-variability of plasma clindamycin concentration and confirms that co-treatment with rifampicin significantly decreases clindamycin trough concentrations.

Ceftaroline (CPT), the active metabolite of the prodrug ceftaroline-fosamil (CPT-F), demonstrates in vitro bactericidal activity against methicillin-resistant Staphylococcus aureus (MRSA) and is effective in rabbit models of difficult-to-treat MRSA endocarditis and acute osteomyelitis. However, its in vivo efficacy in a prosthetic joint infection (PJI) model is unknown. Using a MRSA-infected knee PJI model in rabbits, the efficacies of CPT-F or vancomycin (VAN) alone and combined with rifampin (RIF) were compared. After each partial knee replacement with a silicone implant that fit into the tibial intramedullary canal was performed, 5 × 10 7 MRSA CFU (MICs of 0.38, 0.006, and 1 mg/liter for CPT, RIF, and VAN, respectively) was injected into the knee. Infected animals were randomly assigned to receive no treatment (controls) or CPT-F (60 mg/kg of body weight intramuscularly [i.m.]), VAN (60 mg/kg i.m.), CPT-F plus RIF (10 mg/kg i.m.), or VAN plus RIF starting 7 days postinoculation and lasting for 7 days. Surviving bacteria in crushed tibias were counted 3 days after ending treatment. Although the in vivo mean log 10 CFU/g of CPT-treated (3.0 ± 0.9, n = 12) and VAN-treated (3.5 ± 1.1, n = 12) crushed bones was significantly lower than those of controls (5.6 ± 1.1, n = 14) ( P < 0.001), neither treatment fully sterilized the bones (3/12 were sterile with each treatment). The mean log 10 CFU/g values for the antibiotics in combination with RIF were 1.9 ± 0.5 (12/14 were sterile) for CPT-F and 1.9 ± 0.5 (12/14 were sterile) for VAN. In this MRSA PJI model, the efficacies of CPT-F and VAN did not differ; thus, CPT appears to be a promising antimicrobial agent for the treatment of MRSA PJIs.

Introduction Les infections peri-prothetiques sont responsables de morbidite et couts financiers importants. Parmi ces infections, les infections a Klebsiella pneumoniae resistantes aux carbapenemes (KPC) commencent a emerger, et imposent de nouveaux defis therapeutiques. Apres avoir mis au point un modele d’infection periprothetique de genou chez le lapin a KPC, nous avons voulu tester des antibiotherapies systemiques et locales, seules ou en association, par colimycine. Materiel et methodes La souche KPC99YC, issue d’une hemoculture chez un patient bacteriemique, et resistante a la gentamicine (CMI, 8 mg / L) intermediaire a l’imipeneme (CMI, 4 mg / L) sensible a la colimycine (CMI, 0,25 mg / L), et a la fosfomycine (CMI, 12 mg / L). Notre modele d’infection periprothetique consistait en le remplacement partiel de l’articulation du genou chez des lapins Neo-Zelandais femelles par un implant en silicone. Immediatement apres la fermeture de l’articulation, 1,2, 109 UFC de KPC99YC etait injecte dans l’articulation ? Les animaux etaient euthanasies a j14, et des echantillons de rate, de rein etaient preleves pour compte bacterien. Des hemocultures etaient egalement realisees le lendemain de l’inoculation. Quatre bras de traitement ont ete realises : 12 lapins temoins, 12 lapins traites par colimycine dans un espaceur en ciment (colimycine locale 3 MUI dans 40 g de ciment), 12 lapins traites par colimycine systemique (12 MUI kg 3 fois par jour pendant 7 jours) et 12 lapins traites par colimycine systemique et locale (aux memes doses que precedemment). Resultats Tous les lapins temoins etaient infectes. Au moment du sacrifice, la moyenne d’UFC g d’os retrouvait 4,62 log10 dans le groupe temoin, 3,99 log 10 dans le groupe colimycine locale, 4,56 log 10 dans le groupe colimycine systemique et 2,62 log 10 dans le groupe association colimycine locale et systemique. Aucun lapin n’etait sterile dans le groupe temoin, 3 dans le groupe colimycine locale, 3 dans le groupe colimycine systemique et 7 dans le groupe colimycine locale et systemique. Conclusion Le modele cree est un modele fiable et reproductible. La colimycine, surtout en association en traitement systemique et local dans un espaceur en ciment est un traitement qui semble prometteur pour les infections a KPC.

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