Woodworking injuries: a comparative study of work-related and hobby-related accidents.

The primary objective of this study was to describe the injury characteristics and demographics of patients injured during woodworking activities, upon their arrival to the emergency department in a regional of France where this industry is prevalent. The secondary objective was to compare patient and injury characteristics for work-related and hobby-related accidents. A cohort of 87 patients who had suffered a woodworking accident over a two-year period was evaluated; 79 were available for follow-up. The context and circumstances of the accident, nature and location of the injuries and patient demographics were recorded. Hobby-related accidents accounted for two-thirds of the accidents (51/79). Most of the injured workers were either loggers (35%) or carpenters (46%). The hand was injured in 53 cases (67%). Work-related accidents resulted in significantly more serious consequences in terms of hospital stay, work stoppage, resumption of work or retraining than hobby-related accidents. For the workplace accidents, 86% occurred on new machines; more than 25% of the machines involved in accidents at home were over 15 years. Sixty-eight per cent of workers were wearing their safety gear, while only 31% of those injured during recreational woodworking wore the appropriate gear. Several elements of prevention should be improved: information about the need to maintain the equipment, protect the worker with suitable clothing, and learn which maneuvers are considered hazardous. Safety gear should be regularly inspected in the workplace.

Penetration of daptomycin into bone and synovial fluid in joint replacement.

Daptomycin exhibits clinical activity in the treatment of infections with Gram-positive organisms, including infections due to methicillin-resistant Staphylococcus aureus. However, little is known about its penetration into bone and synovial fluid. The aim of our study was to assess the penetration of daptomycin into bone and synovial fluid after a single intravenous administration. This study was conducted in 16 patients who underwent knee or hip replacement and received a single intravenous dose of 8 mg of daptomycin per kg of body weight prior to surgery. Plasma daptomycin concentrations were measured 1 h after the end of daptomycin infusion and when bone fragments were removed. Daptomycin concentrations were also measured on bone fragments and synovial fluid collected at the same time during surgery. All samples were analyzed with a diode array-high-performance liquid chromatography (HPLC) method. After a single-dose intravenous infusion, bone daptomycin concentrations were above the MIC of daptomycin for Staphylococcus aureus in all subjects, and the median bone penetration percentage was 9.0% (interquartile range [IQR], 4.4 to 11.4). These results support the use of daptomycin in the treatment of Staphylococcus aureus bone and joint infections.

Bacterial contamination of the hospital environment during wound dressing change.

INTRODUCTION: The hospital environment plays a role in the cross-transmission of multidrug-resistant bacteria. The aim of this study was to evaluate the bacterial contamination of the hospital environment during chronic wound dressing change. PATIENTS AND METHODS: This study was performed from July 2010 to May 2011. Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae were counted in environmental samples (air and surfaces) that were obtained in the rooms of patients with wounds colonized (cases, n=9) or not (controls, n=15) during or not during wound dressing change. Bacterial contamination was compared to that found in the rooms of patients without colonized wounds. RESULTS: The environment was frequently contaminated during wound dressing change (38% of the sampled series were positive). In comparison, the contamination was less frequent in the environment of patients with colonized wounds when the wounds were not being dressed (14.3%) and in controls (3.8%). S. aureus was the most frequent species identified in positive samples. DISCUSSION: These results suggest that previously recommended measures such as hand hygiene after contact with the environment and wearing a mask are justified. Moreover, other measures should be suggested, in particular cleaning the room before and after dressing change of colonized wounds. LEVEL OF EVIDENCE: Level III: case control study.

[Distal radius fracture with dorsal displacement: correlation between functional score, reduction quality and fixation]. / Fractures du radius distal à déplacement dorsal: corrélation entre scores fonctionnels, qualité de réduction et type de fixation.

Appropriate treatment for fractures of the distal radius with dorsal displacement remains a subject of debate. Intrafocal pinning is the most widely used technique in France. Plate fixation has been developed to avoid secondary displacement and stiffness sometimes observed after pinning. We compared three osteosynthesis techniques for the same type of fracture (extra-articular with dorsal displacement). Sixty-two consecutive patients underwent osteosynthesis using the following techniques successively: posterior plates (20 patients mean age 59.9 years [range 25-87 years]), intra- and extrafocal pinning (22 patients mean age 55.6 years [range 17-83 years]), the anterior plate (20 patients mean age 57.1 years [range 17-78 years]). An independent operator evaluated all patients using the Herzberg, Gartland and Werley and Dash scores. The radial slope in the frontal plane, sagittal tilt, and ulnar variance were measured and compared between the preoperative and last follow-up values. Kruskall-Wallis or ANOVA were applied as appropriate for continuous variables and the Chi-square test for non-continuous variables. P<0.05 was considered significant. Mean operative time was equivalent for the two plates fixation techniques and twice as long as for pinning. There were more complications in the posterior plating group (32%) and less satisfactory function score despite a two-fold longer follow-up and a smaller number of operators. The best results were obtained with the anterior plating group in terms of range of motion (flexion-extension), DASH score, preservation of ulnar variance and presence of a largest number of excellent and very good outcomes according to Gartland. The pinning group provided the best results in terms of sagittal slope. The pinning and anterior plating groups had equivalent range of motion for pronation-supination and the same rate of complications (5%). Irrespective of the treatment arm, the Herzberg scores and the Gartland and Dash scores were better: in men, in patients aged less than 30 years, in patients with an associated fracture of the apex of the ulnar syloid process rather than its base. For these extra-articular fractures, pinning can provide good functional results like anterior plating but each treatment has advantages that functional analysis detected.

Distal quarter leg fractures fixation: The intramedullary nailing alone option.

INTRODUCTION: Intramedullary (IM) nailing is the classical treatment for diaphyseal fractures of the tibia. Stabilizing fractures of the distal quarter is recognized as being delicate. We report a continuous, multicenter prospective study of distal tibia-fibula fractures treated with anterograde intramedullary nailing. HYPOTHESIS: The working hypothesis was to identify the problems encountered with IM nailing alone of distal leg fractures. PATIENTS AND METHODS: From May 2007 to November 2008, 51 fractures in 51 patients (19 females and 32 males; mean age, 46.2 years [range, 17-93 years]) were treated with IM nailing. The fractures were classified according to the association pour l'ostéosynthèse (AO) classification, with most type A1 (29/51). Thirteen fractures presented a distal articular extension treated with screws in five cases. Fixation consisted in intramedullary nailing, reamed in all cases, performed on a standard or orthopaedic surgery table. Nailing was static and distally locked (50/51). The patients were evaluated clinically and radiologically, with AP and lateral images of both legs and the Olerud score. RESULTS: We report one death and eight patients lost to follow-up, providing 42 cases to reviewing at 1 year. The bone union rate was 97.6% in a mean 15.7 weeks. Immediately after surgery, 14 axial deviations greater than 5° were observed, mainly valgus, with only one greater than 10°. The absence of fibular fixation was the only identifiable risk factor for appearance of an initial axial deviation as well as fracture instability over time. Two infections were observed and at 6 months four secondary displacements, one of which can be explained by changing the distal locking due to infection. Four dynamizations were performed. No other risk factor was found. The mean Olerud functional score at 12 months was 83.5 points. DISCUSSION: The clinical results are comparable to those reported in the literature. From a radiological point of view, the rates and times to bone union were identical. However, the rates of malunion were clearly higher. The risk factors for malunion found in the literature are metaphyseal enlargement, fracture comminution, a too distal location of fracture site, young patient age, patient installation on a standard operating table, and technical errors. The absence of supplementary fibular fixation, the subject of debate in the literature, was the only statistically significant point found in the present study. Nailing distal fractures of the leg provides good clinical results. However, with regard to the malunion rates, the technique must be precise and rigorous. We recommend systematic fibular fixation and use of an orthopaedic table. LEVEL OF EVIDENCE: Level IV; cohort type prospective study.

Bilateral Persistent Pharyngo-Stapedial Arteries Revealed during Evaluation of a Carotid-Cavernous Fistula. 3 Tesla MR Angiographic Aspects.

SUMMARY: A 33-year-old woman was evaluated for a right carotid-cavernous fistula revealed by a proptosis and chemosis of the right eye. The initial angiogram showed a left persistent pharyngo- stapedial artery (Ph-SA). A temporal bone CT suggested bilateral pharyngo-stapedial artery persistence. The right Ph-SA was not opacified in the first angiogram because of the high degree of shunting in the fistula. Four months later the patient was admitted for treatment of the carotid-cavernous fistula. In the meantime, the fistula had altered, with spontaneous thrombosis of the ophthalmic vein, and decrease of the vascular steal, explaining that the right Ph-SA was clearly visible on the angiogram performed during the procedure. The carotid-cavernous fistula was completely occluded with five detachable coils. The followup included 3 Tesla MR angiography that showed complete closure of the fistula with preservation of the right ICA and bilateral persistent pharyngo-stapedial arteries.

[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.

[Reinsertion of the flexor tendon using a suture anchor: prospective study using early active motion]. / Réinsertion du tendon fléchisseur par ancre de suture: étude prospective continue avec mobilisation active précoce.

INTRODUCTION: The aim of this study was to evaluate subjective and functional results of a prospective continuous series of immediate tendon-to-bone repair of the F.D.L. using a miniaturized anchor. METHOD: Seven patients have been operated by the same surgeon in emergency for a section of the FDL in zone one. Distal tendon-to-bone re-attachment has been realized using a mini-G II Mitek anchor suture. Five of the patient were male, four of them being manual workers. Only one had a work accident. According to Leddy and Packer's classification one patient had a stage 1 lesion and the six others had stage two lesions. The injured fingers showed associated lesions in four cases. Rehabilitation consisted of early active mobilization protected by a Duran-type splint. All the patients had been examined by an independent surgeon at 10 months follow-up. Mean age at that time was 32 years. RESULTS: One patient was very satisfied with his results while the six others were satisfied. Two minor complications were encountered, one of them being directly in relation to the implant. Total Active Motion (TAM) summed up to 92% of the arch of motion of the normal controlateral finger. Pinch-force reached 81% compared to that of the controlateral finger. Two patients described no pain. Mean eviction from work was 70 days. DISCUSSION: Tendon-to-bone repair of the FDL using an anchor seems to give good results on pain, TAM and on force. The only complication due to the implant did not have any functional incidence. The series of Marin Braun on 77 cases of such repairs using a barb-wire show similar results compared to the implant used in our series. However, anchor sutures have several advantages compared to a transcutaneous device: they reduce the risk of infection, of nail dystrophy and they offer a better comfort to the patient.

One-stage emergency treatment of open grade IIIB tibial shaft fractures with bone loss.

The purpose of this study was to report the authors' experience with emergency reconstruction of severe tibial shaft fractures. Five male patients were admitted to the emergency room with a grade IIIB open tibial shaft fracture with bone loss (average age, 33 years; age range, 18-65 years). Injuries were the result of motorcycle accidents (N = 2), pedestrian accidents (N = 1), gunshot wound (N = 1), and paragliding fall (N = 1). Primary emergent one-stage management for all patients consisted of administration of antibiotics, debridement, stabilization by locked intramedullary nailing, bone grafting from the iliac crest, and coverage using free muscle flaps (four latissimus dorsi and one gracilis). The average follow-up was 21 months (range, 8 months-3.5 years). Partial weight bearing with no immobilization was started at 3 months, and full weight bearing began 5 months after trauma. No angular complications and no nonunions were observed. There was one case of superficial infection without osteitis. All fractures healed within 6 months in 4 patients and within 10 months in 1 patient. At the last follow-up examination, ankle and knee motion was normal and no pain was noted, except for 1 patient who had associated lesions (ankle motion reduced by 50%). Aggressive emergency management of severe open tibial fractures provides good results. It improves end results markedly, not only by reducing tissue loss from infection, but also reducing healing and rehabilitation times.

Introduction.

The number of femoral fractures after hip arthroplasty has increased proportionally to the number of hip arthroplasties. Eleven university-orthopaedic centers in eastern France co-operated to review 250 femoral fractures in relation to hip prothesis. This is the largest published review. The aims of this retrospective study were: - an epidemiologic study of the predisposing factors of these fractures, - to define a protocol of therapeutic indications.

[Materiel and method]. / Matériel et méthode.

This retrospective, multicentre study has collected 250 cases of fractures of the femur following arthroplasty of the hip and covers a 20 year period from the 25/01/73 to the 30/05/93 (51 peroperative fractures and 199 fractures at some time after arthroplasty). There were 157 women and 93 men whose average age was 73 years for the 199 post operative fractures. The average period between arthroplasty and the fracture is 5 years. A common questionnaire was used by all the centres involved in this study in order to codify conditions of surgery, pre and post fracture X ray examinations and the different treatments and their complications.

Conclusions.

The main objectives of this retrospective multicentric study were to define the predisposing factors and methods of treatment. The common predisposing factor is the femoral fragilization due to loss of "bone stock" (secondary to osteopathies or tumor, or especially prosthetic loosening). More specific factors are iatrogenic. For intraoperative fractures we found reoperation, excessive mobilisation of the femur and excessive diaphyseal reaming. For postoperative fractures we found coticotomy and screw hole distal from the tip of the stem, or a gap between another implant wich induced a gradient of elasticity. The therapeutic indications follow the Johansson classification:Type I fractures: If the stability of the prothesis is good: - with a transverse fracture line: functional treatment (off-loading for 45 to 60 days), - with a spiral fracture line: internal fixation using a rigid plate or cerclage wire. If prosthesis loose:- revision arthroplasty with a long stem prothesis is the ideal, - if the general status is too poor, orthopaedic treatment is indicated.Type II fractures: If good stability of the prothesis: internal fixation using a rigid plate. Bone grafting is not necessary. If prosthesis loose: revision arthroplasty with long stem prothesisType III fractures: Altought the ideal seems revision arthroplasty using long stem prothesis, we think that internal fixation by plate with perfect operative technique is indicated for these old and vulnerable patients. Considering the therapeutic indications we suggest a modification of the Johansson's classification:Type I fracture: - Ia: stability of the prothesis, - Ib: loosening prothesis.Type II fracture: - IIa: stability of the prothesis, - IIb: loosening prothesis.Type III fracture: - IIIa: proximal fracture, - IIIb : distal fracture.