We examined the effectiveness and safety of the combination of rifampin plus ofloxacin given orally for treating prosthetic orthopedic implants infected with staphylococci. The prospective cohort study was conducted in a referral public hospital with ambulatory care services between 1985 and 1991. Consecutive patients from whom Staphylococcus organisms susceptible to the study drugs were isolated from their orthopedic implants and who had no contraindication to the treatment were eligible for the study. All patients were treated orally with rifampin, 900 mg/day, plus ofloxacin, 600 mg/day. Patients with hip prosthesis infection were treated for 6 months, with removal of any unstable prostheses after 5 months of treatment; patients with knee prosthesis infection were treated for 9 months, with removal of the prosthesis after 6 months of treatment; and patients with infected bone plates were treated for 6 months, with removal of the plate after Infection complicates 0.5 to 1% of hip prostheses (13,14) and 1 to 2% of knee prostheses (6, 13). Staphylococcus species are the cause of 45 to 55% of these infections (1, 7), regardless of the type of implant. The functional prognosis for these types of infections remains poor, despite long-term intravenous antibiotic therapy combined with a one-or two-stage replacement of the orthopedic implant. The availability of fluoroquinolones prompted physicians to propose treatment protocols that included those drugs as alternatives to conventional intravenous treatment. Encouraging preliminary data regarding these trials and data from animal models were published as the present study was being conducted (2). We report herein the results of a prospective study carried out by a single protocol that included rifampin and a fluoroquinolone. The present study included the largest series of Staphylococcus species-infected orthopedic implants that has been known to be treated.

Dual mobility cups provided a dislocation rate of only 3.7% in revision THA, comparable to the one reported with standard implants for primary THA. This kind of cup design is especially suited to deal with high instability risk revision cases, where constrained components are generally recommended. It can also be indicated in cases of aseptic loosening, where it resulted in a 2.9% dislocation rate and only two impending failures of fixation. In terms of mechanical failure rate, these numbers compare well to the ones pertaining to tripolar and constrained implants. These later alternatives remain possible options but are not fully efficient in terms of long-term stability and fixation longevity. LEVEL OF STUDY: Level IV, retrospective or records-based.

We examined the effectiveness and safety of high-dose oral co-trimoxazole (trimethoprim-sulfamethoxazole) for the treatment of orthopedic implants infected with multidrug-resistantStaphylococcus species. The prospective study was conducted between 1989 and 1997 in a university medical center with ambulatory-care services. Patients eligible for the study consisted of those from whom multidrug-resistant Staphylococcus spp. organisms susceptible only to glycopeptides and co-trimoxazole were isolated from their orthopedic implants and for whom there was no contraindication to the treatment. All patients were treated orally with high-dose co-trimoxazole (trimethoprim, 20 mg/kg of body weight/day; sulfamethoxazole, 100 mg/kg/day). Patients with prosthetic hip infections were treated for 6 months, with removal of any unstable prosthesis after 5 months of treatment; patients with prosthetic knee infections were treated for 9 months, with removal of any unstable prosthesis after 6 months of treatment; and patients with infected osteosynthetic devices were treated for 6 months, with removal of the device after 3 months of treatment, if necessary. Monthly clinical evaluations were conducted until the completion of the treatment, and follow-up examinations were conducted regularly for up to 6 years. The overall treatment success rate was 66.7% (26 of 39 patients), with success rates of 62.5% for patients with prosthetic knee infections, 50% for those with prosthetic hip infections, and 78.9% for those with other device infections. Seventeen of the 28 (60.7%) patients who did not have any orthopedic material removed were cured. Eight patients stopped the treatment because of side effects, and one patient was not compliant. In three patients treatment failed because of the appearance of a resistant bacterium. Long-term oral ambulatory treatment with co-trimoxazole appears to be an effective alternative to the conventional medicosurgical treatment of chronic multidrug-resistantStaphylococcus-infected orthopedic implants which includes long-term intravenous antibiotic therapy combined with surgical debridement and removal of foreign material or its subsequent one- or two-stage replacement.

Eight cases of pigmented villonodular synovitis of the foot and ankle are reported. The purpose of this study was to analyze the manifestation of pigmented villonodular synovitis in the foot and to evaluate treatment options. There were four cases in the ankle and hindfoot, one in the first tarsometatarsal joint, and three in the toes. In seven of eight cases, diagnosis was confirmed by magnetic resonance imaging (MRI) scans. The tenosynovial form was found in the toes and the articular form in the hindfoot and ankle. Surgical treatment was performed in all cases: one arthroscopically assisted synovectomy in the ankle joint, two talocrural arthrodeses, one subtalar arthrodesis, one tarsometatarsal arthrodesis, and tumor removal on the toes with arthrodesis of the distal interphalangeal (DIP) joint in two cases. Average follow-up was 4 years. Recurrence occurred in one toe and led to partial amputation. Malunion in one ankle arthrodesis was operated on again with no sign of recurrence. In the toes, the lesion had a tumoral feature; the bone was infiltrated by soft tissue, and the surgical procedure was local removal of the tumor. In the hind-foot, the lesions were intra-articular and required synovectomy, usually with an arthrodesis. In the midfoot, there was a large extraosseous tumor surrounding tendons with destructive articular lesions.

Ezrin is a cytoskeleton linker protein that is actively involved in the metastatic process of cancer cells. We have searched for a prognostic value of ezrin and some of its partners: alpha-smooth muscle actin and CD44H in 37 patients with an osteosarcoma. Automate immunohistochemistry (IHC) with anti-ezrin, alpha-smooth muscle actin and CD44H antibodies was performed in 66 specimens: 37 biopsies before chemotherapy, 16 resected tumours of "poor" responders and 13 metastases. The messenger RNA (mRNA) levels of ezrin of 13 frozen biopsies and 4 metastases were evaluated by real-time quantitative reverse transcriptase polymerase chain reaction (RT-PCR). All results were correlated to the following clinical data. Ezrin expression by IHC was found in 62% of 37 biopsies in the different histological subtypes. A good correlation was found between positive or negative samples by IHC and mRNA levels. Ezrin expression was recorded in 84.5% of metastastic samples. The mean expression of ezrin was higher in metastases than biopsies (p = 0.024). In multivariate analysis, ezrin was an independent prognostic marker for event-free survival and overall survival (OS) with p < 0.001 and p = 0.003, respectively, and alpha-smooth muscle actin for OS only (p = 0.024). Our findings suggest that ezrin and alpha-smooth muscle actin are predictive IHC prognostic markers for patients with an osteosarcoma.