[Performances of different types of airflow system in operating theatre]. / Performances en activité de différents types d'installation de traitement de l'air au bloc opératoire.

AIM: To compare the performance of various types of airflow system in operating theatre. METHODS: Besançon Hospital has three types of airflow system in operating theatre: laminar (unidirectional) flow, stabilized flow and turbulent flow. We have compared performances of these airflow systems during operations by evaluating several indicators: number of airborne particles, microbial contamination, kinetics of decontamination, rate of mixing and an index of functionality. RESULTS: At rest, performances of stabilized flow are close to these of laminar flow. On the other hand, during operations, the laminar flow is the single airflow system to reach the class B10. CONCLUSION: Our study suggest that laminar flow should be used for prosthetic orthopaedic surgery. However, clinical studies are needed to confirm the superiority of laminar airflow systems in operating theatre.

[Centromedullary nailing of the femur for bone metastasis: clinical and radiological evaluation using the Tokuhashi score in 24 patients]. / Métastase osseuse du fémur traitée par enclouage centromédullaire: évaluation clinique et radiologique par le score de Tokuhashi: a propos de 24 patients.

PURPOSE OF THE STUDY: Pluridisciplinary management of patients with metastasis to the femur is well defined, but the choice between palliative surgery or abstention must be decided on the basis of a few evaluated prognostic criteria. We report a series of 24 cases of metastasis to the weakened or fractured femur which was evaluated with the Tokuhashi score and treated by surgery. MATERIAL AND METHODS: Sixteen women and eight men, mean age 71 years (58-89) underwent centromedullary nailing of the femur. These patients had metastases from breast cancer (n = 13 of the 16 women). Twenty of the 24 patients also had other metastases. The Tokuhasi score was > 6 in 16/24 patients. Fourteen patients had pain which did not respond to morphine. Thirteen had fractures and eleven weakened femurs. Time to surgery was six days (1-15). A full nail was inserted in four patients and a reconstruction nail in twenty. RESULTS: Operative time was 93 minutes (57-123). Blood loss was 200 ml (150-350). There were no intraoperative complications (fat embolism) excepting increased comminution. Hospital stay was 23 days (8-55). Survival was 148 days (8-510) for patients with fractures and 272 days (12-730) for patients with weakened femurs. Eight patients with a fractured femur died (six within the first three postoperative weeks), two among those with preventive nailing. On average, weight bearing among the surviving patients with nailing for fracture was achieved on the 57th postoperative day (30-90). Only six patients required morphine early after surgery. Centromedullary nailing successfully relieved pain in all patients with an isolated metastasis. Mean survival in patients with a Tokuhashi score < 3 was 2.1 months. It was 17 months in those whose score was > 6. CONCLUSION: Centromedullary nailing for fractured or weakened femur due to metastasis is a useful therapeutic solution for patients with short life expectancy. With this technique, antalgesics can be reduced while preserving independence as long as possible. The Tokuhashi score is easy to establish. If it is less than 3, centromedullary nailing should not be attempted due to the short expected survival.

Modelling the usefulness of a dedicated cohort facility to prevent the dissemination of MRSA.

The aim of this retrospective study was to determine whether or not a surgical dedicated cohort facility, mainly dedicated to the care of orthopaedic patients, can control the risk of infection caused by methicillin-resistant Staphylococcus aureus (MRSA). We tested this hypothesis on the orthopaedic surgery ward of a university-affiliated public hospital with 1228 beds by determining whether there was a significant correlation between the colonization pressure exerted by MRSA and the number of cases of acquired MRSA. This was then used as a tool to predict the number of patients contaminated with MRSA in hospitals with and without dedicated cohort facilities. We found that the relative risk of MRSA acquisition increased with the colonization pressure exerted by MRSA imported cases. This statistical model enabled us to predict that the risk of MRSA acquisition would increase by 160% per year in the absence of a dedicated cohort facility. We conclude that these units are useful to control the spread of MRSA in hospitals.

The treatment of avulsion fractures of the tibial tuberosity in adolescent athletes.

Avulsion fractures of the tibial tuberosity occur mainly during sport activities and are closely related to the strains exerted on the anterior tibial tuberosity by the extension complex of the thigh. A knowledge of the mechanical aspects of these avulsions may improve understanding of the mechanisms of such injuries. In such avulsion fractures, tensile forces due to the contraction of the quadriceps complex overcome the cohesive forces within the apophyseal cartilage. A 1-month cast immobilisation on an extended knee gives good results in the management of nondisplaced fractures. In minor displacements, such immobilisations follow closed external reductions. Open reductions and stable screw fixations precede a 3-week immobilisation for displaced fractures. Long term results are regularly good in well-managed cases.

Avulsion fractures of the tibial tuberosity in the adolescent athlete. Risk factors, mechanism of injury, and treatment.

Based on a review of the literature and our study of six cases, we investigated avulsion fractures of the tibial tuberosity in the athletic adolescent. A study of the mechanism of this acute injury helps to explain the different types of avulsion fractures of the tibial tuberosity. An understanding of predisposing factors and the biomechanical conditions leading to this injury may help identify those young athletes at the highest risk and may help the surgeon determine the most effective treatment for such a fracture. No complications were experienced by the patients in our study. Displaced fractures underwent open reduction and fixation with screws. This method shortens the period during which athletic activities are restricted.

Trauma emergency unit: long-term evaluation of a quality assurance programme.

OBJECTIVE: Long-term evaluation of a quality assurance programme (after an assessment in 1993). DESIGN: Review of medical records. SETTING: Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon). SUBJECTS: 1187 consecutive ambulatory patients' records, from July 1995. MAIN MEASURES: Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event). RESULTS: 71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols). CONCLUSIONS: Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme.

Incidence and preventability of adverse events in the emergency room of an orthopaedic traumatologic surgery unit.

This paper reviews the nature and the frequency of adverse events in the everyday functioning of a French trauma emergency unit, and evaluates the feasibility of their detection by the means of a daily record review. A senior surgeon identified the adverse events by reviewing the complete record with a minimal 6-months follow-up for every patient attending the emergency unit during a 10-week period. To test the reliability of this review, a blind re-review of all records corresponding to the detected adverse events, mixed with an equal number of controls, was carried out by two independent experts. The review of the 2604 records identified 210 medical adverse events, most of them occurring early in the care process. Sixty-seven per cent of the adverse events involved prevention failure, mainly for tetanus but also for thrombosis and rabies. For the other 33% it was possible to determine two situations with a high risk of adverse event: body contusions following a traffic accident and metacarpo-phalangeal thumb sprains. The re-review evaluated the positive predictive value of the initial review to be 97.5% and its negative predictive value to be 96%. It is concluded that the review of the initial record by a single senior is effective in detecting the adverse events. Prevention of two-thirds of them could be possible by the implementation and monitoring of protocols.

Reconstruction of a complex defect of the dorsum of the hand.

A 37-year-old right-handed male truck driver was admitted with a severe injury of the dorsum of his right hand following a traffic accident. He had a large combined defect involving skin, tendons and bone. A complex reconstruction was performed using a large iliac crest allograft, a tendon graft and a free serratus anterior flap in one stage, 8 hours after the injury. A skin graft was performed later. 2 years later the functional and aesthetic result are good.

[Treatment of complex fractures of the ankle and their sequellae using trans-plantar intramedullary nailing]. / Traitement des fractures complexes du cou-de-pied et de leurs séquelles par enclouage transplantaire verrouillé.

UNLABELLED: Nine patients were treated for complex tibial pilon and talus fractures or non unions from 1990 to 1997 using intramedullary nails introduced through the calcaneus. All patients were followed until healing. The average follow-up was 14 months. Failure of the procedure was defined by the occurrence of complications or reintervention. We used a modified Seidel nail in 5 cases, a tibial shaft nail in 3 cases, and a special nail in one case. All nails but two were locked. CASES: These arthrodeses were performed for treatment of sequels from open talus fractures. Transplantar nailing was performed between 9 months and 3 years after arthrodesis, because of non union. In two cases fusion was obtained at 3 and 8 months postoperatively. In the third case non union occurred due to instability of fixation (the nail was unlocked). Replacement by an interlocked nail was performed through a proximal tibial approach, and healing was obtained in 6 months. PSEUDARTHROSES: 2 CASES: These two cases presented comminuted tibial pilon and open talus fractures in association with vascular and tendon lesions. They had previously undergone debridement and external fixation. Transplantar nailing was performed 8 and 10 months after trauma using a locked modified Seidel nail. Radiographic fusion was obtained in 5 months. PRIMARY SURGERY: 4 CASES: The first two cases were foot reimplantations after traumatic amputation. Skeletal stabilization was obtained using a transplantar locked tibial nail. Revascularization attempts failed and an amputation was performed on the fourth day in one case. The reimplantation succeeded in the second case. Radiographic fusion was obtained in 2 months. The third case was a distal tibial shaft fracture. The patient was an obese mentally deficient and invalid woman. Bone union was achieved in four months. The last case was a primary arthrodesis for post-trauma necrosis of the talus. Radiographic fusion was observed 45 days after operation. Transplantar locked nailing offers an optimal stabilization for complex ankle fractures. We had two failures not related with the principle of the technique. We think that transplantar nailing is best indicated to obtain tibiotalar or tibiocalcaneal arthrodesis and to treat compound ankle fractures. Another indication could be distal tibial shaft fractures in invalid or mentally deficient patients.

[Entrapment of the median nerve after dislocation of the elbow]. / Incarcération du nerf médian après luxation du coude.

Entrapment of the median nerve as a complication of a dislocation of the elbow has rarely been reported. The prognosis is worse in case of delayed diagnosis. Exploration surgery is indicated when neurological signs remain following reduction of a dislocation of the elbow.

[Costal osteosynthesis by plating]. / L'ostéosynthèse costale par plaque vissée.

The authors have utilised rib stabilization by plating in five patients. The sites at which such operations are indicated are discussed. The procedure is performed with the patient prone or in the lateral position. A solid fixation was always achieved. This surgical procedure was performed - not only on flail chests, but also on potentially unstable lesions.

[Inter-trochleo-bicondylar fracture of the femur. An unusually traumatic lesion. Mechanism. Therapeutic implications]. / La fracture inter-trochléo-bicondylienne du fémur. Une lésion traumatique exceptionnelle. Mécanisme. Implications thérapeutiques.

UNLABELLED: The authors present a curious type of fracture of the distal end of the femur. They discuss the mechanism and the factors responsible for that lesion. The treatment and results are finally presented. MATERIAL: A 65 years old female, submitted to a crash accident while driving a car, with a seat in maximaly low position. She presented a bilateral open transverse fracture of the patella associated in the right limb to a fracture line between condyles and the patellar surface of the femur. METHOD: Bilateral osteosynthesis of both patella had been realised in emergency through a transverse approach. Through the fractured right patella two anteroposterior screws had been used to fix the fractured femur. RESULT: A plaster cst had been used for three weeks. Full weight bearing was permitted after three months. Full range of motion of both knees was noticed after six months follow-up. DISCUSSION: The femoral fracture could have been fixed by another device like D.C.S. platescreen but it would be weaker. That type of fracture was produced because of flexed low position of the knee at the moment of the accident. Usually, supra-condylar femoral fractures are due to a force vector applied on the upper extremity of the tibia without any patellar fracture. In our case, the patella involved associated to a fracture line between the condyles and the patellar surface. The structural anatomy (noeud sutural de Chevrier) explains the solidarity of the two femoral condyles.

[Posterior fracture-dislocation of the shoulder. A study of 11 cases (author's transl)]. / Les luxations-fractures postérieures de l'épaule. Etude anatomo-pathologique et thérapeutique à propos de 11 observations.

The authors have observed 11 cases of posterior fracture-dislocation of the shoulder. All were recognised easily except one. The lesions are described and the mechanism of the lesion is considered. Treatment was conservative in most cases, and gave satisfactory results.

[Ball and socket ankle associated with congenital synostosis of the tarsus. Report of a case (author's transl)]. / Déformation en "cupule et dôme" de l'articulation tibio-tarsienne révélatrice d'une synostose congénitale du tarse.

The author describes a case of ball and socket ankle joint in a man aged 30 years. The deformity was associated with a congenital synostosis between the talus and calcaneus, absence of the fifth toe and 2 centimetres of shortening of the limb. The literature is reviewed.

[Osteosynthesis of the odontoid process by a clover-shaped plate]. / L'ostéosynthèse par la plaque en trèfle des fractures de l'apophyse odontoïde.

UNLABELLED: The goal was to design an osteosynthesis material able to stabilize after reduction a fracture of the odontoid process without C1-C2 arthrodesis. MATERIAL AND METHODS: The implant comprises a clover shaped plate which has to be applied on one hand on the anterior face of the dens (one leaf), and on the other hand on the anterior face of C3 (2 leaves are applied with a screw one screw for each leaf). A barrel fastened to the 3 leaves (implanted on the anterior face of the leaves, at their junction) gives way to a vertically oriented screw which will carry out dens fixation. The screw makes the compression possible. Placement through a pre-sterno-mastoid-approach, needs a special plate support and 18/10 Kirchner pins preparing the passage of the screw. RESULTS: This screw-plate designed for dens fractures (especially those with anterior displacement incompatible with a simple screwing) led to bone union in all cases. A C2-C3 subluxation operated on with the same technique was reduced and stabilized: a C2-C3 ankylosis was the consequence of a C2-C3 arthrodesis combined with the osteosynthesis. No complication was observed. DISCUSSION AND CONCLUSION: This technique is the only one able to perform dens osteosynthesis without implying postoperative immobilization. It is a significant advantage in elderly or multitrauma patients. A part from dens fractures, it can also help to manage dislocations, subluxations and serious C2-C3 sprains and even combinations as fractures of the odontoid process with axis pedicles fractures.

[Bilateral recurrent anterior dislocation of the hip (author's transl)]. / Luxation antérieure non traumatique récidivante et bilatérale de la hanche. Une observation.

The authors report a case of bilateral recurrent anterior dislocation of the hip in a child suffering from Seckel's disease (bird-headed dwarf). There were no neurological abnormalities. The dislocations appeared to relate to coxa valga and dysplastic acetabula. Femoral osteotomies together with a shelf procedure were performed. The dislocations had ceased when the child was reviewed in a two-year follow-up.

[Parosteal chondrosarcoma. A report of two cases]. / Le chondrosarcome juxta-osseux deux observations.

Parosteal chondrosarcoma is a tumour of the soft tissues different from juxta-cortical chondrosarcoma. It is extra-periosteal, has no attachment to bone and develops primary in the soft tissues. The authors review the literature and agree that the frequency of recurrence after local excision requires treatment by amputation.

[Pedal cutaneous island flap. Apropos of 6 case reports]. / Le lambeau cutané pédieux en îlot. A propos de 6 observations.

The authors report their experience using the dorsalis pedis island flap, described by MacCraw, for coverage of soft tissue defects of the heel, and both lateral and medial areas of ankle. The operative technique is recalled and six cases are presented. The authors analyse the several indications of the island flap. Its disadvantages are emphasized.

[Subungual glomus tumor. A case of unusual form]. / Tumeur glomique sous unguéale. Un cas de forme inhabituelle.

The authors report a case of glomus tumour developing beneath the nail of the ring finger in a 95 year old woman. In contrast with other similar cases, the pain was moderate and had been present for 20 years. The bony phalanx was deformed. Microscopic examination confirmed the diagnosis of a glomus tumour developing in the soft tissues. The phalanx was amputated.

[Injury rupture of flexors of the index finger complicating subcutaneous dislocations of the semilunar bone]. / Rupture traumatique des fléchisseurs de l'index compliquant une énucléation sous-cutanée du semi-lunaire.

A case is reported here of an unusual case of rupture of the flexor tendons of the index finger in the carpal tunnel complicating a subcutaneous displacement of a lunate bone. This was combined with a carpal tunnel syndrome with hypoaesthesia. The treatment, taking account of the age of the patient and the relative tolerance to the dislocation, consisted of a simple resection of the lunate to free the medial nerve together with a partial graft of the flexor digitorum profundus.