Coalitions du tarse ou « fausses entorses » de l’enfant et de l’adolescent. À propos d’un cas

Tarsal coalitions, also called synostoses, are a cause of pain and gait disturbance in children and adolescents. They are often diagnosed as tarsal sprains, leading to an inappropriate functional prognosis. This is the case of an 8-year-old child with talo-calcaneum synostosis, presenting pain, hind-foot stiffness and marked disability in daily life activities and sports.     

Fixation des reconstructions du ligament croisé antérieur aux ischiojambiers par un « crosspin » unique (étude biomécanique)

Introduction

Postoperative reeducation and the retaking of precocious activities after the reconstruction of the anterior cruciate ligament (ACL) require a primary fixation to the adequate mechanic characteristics. The aim of the study is to determine the fixation properties with a unique RigidFix^® crosspin of the tendinous transplants in tiny diameter tunnels simulating a double bundle reconstruction.

Material and methods

On six adult fresh frozen cadavers (12 femurs and 12 tibias dissected), 48 bone tunnels were prepared in which were fixed with a single “crosspin” RigidFix^® a tendon with adequate diameter to tunnels (5, 6, 7 and 8 mm). Two types of tests were performed: cyclic test (sinusoidal load between 50 N and 150 N for 500 cycles) and ultimate load test (increasing load with a controlled speed 5 mm/min).

Results

The mean lengthening after 500 cycles was 1,89 ± 0,84 mm. The yield load was 262 ± 60 N with a lengthening of 4,61 ± 1,68 mm. The stiffness of the whole mounting was 61 ± 16 N/mm and the max load is 295 ± 79 N. The resistances (yield load and max load) were more important in the femur than in the tibia.

Discussion

The stress supported by the femoral fixation is less important than the tibia, in view of the application angle when the knee is extended. The yield load result fulfilled the specifications in the femur. At the tibia, the ultimate strength is not enough to allow intensive rehabilitation.

Conclusion

The use of a single “crosspin” in an anatomic reconstruction of anterior cruciate ligament is possible at the femur with diameters of the transplant greater than or equal to 6 mm, but not desirable in the tibia.     

Épicondylites : « les nouveautés en 2007 »

What news for 2007 concerning sportsmen lateral epicondylitis? Concerning biomechanics, we will evaluate the role of the supinatus at the same time we will talk about the complex characteristics of the functionnel unit. An anatomic work has showed in some cases, the involvment of ligment structure that could explain the atypical side of the pain and sometime the failure of the treatment. As for rehabilitation, we will insist on the importance of excentric work. The braces conserve a certain importance. We insist on new therapeutics and mostly on the interest of trinitrine patches. Botulinium toxic is still discussed and the recent study of Hayton does not show any significant difference with placebo injection. An original autologue blood injection in the epicondylitis tendon demonstrates good results and specially in the cases that resist to the corticoid therapeutics. We will talk about our experience. Considering corticoide injections a Crowther publication reveals a significant result compared to choc waves therapy. At last, we will criticize the Smidt study because we believe that the use of fluorite corticoid induce iatrogenic effects. We will conclude this article by our 2007 propositions about the local corticoid indication.     

Intérêt des infiltrations du « mur méniscal » par les corticoïdes dans les douleurs méniscales du genou. À propos de 214 cas

Femorotibial pain is a common manifestation of meniscal injury or microtrauma. In this situation, meniscectomy does not appear to accelerate joint degeneration. Meniscal wall steroid injections have been proposed for consenting patients suffering from degenerative or post-traumatic meniscal pain. The technique consists in injecting corticosteroids into a juxtameniscal zone after identification of the painful area by palpation of the joint space and radiographically. We conducted two non comparative studies: a first retrospective analysis of 178 patients aged 44 years on average and a second prospective series of 36 patients aged 39 years on average who were treated with one to three injections for meniscal pain. The main outcome assessment combined pain relief and return to prior activities at 60/90 days. Results were favorable in the retrospective series: 106 responders versus 46 non-responders (26 lost to follow-up) and also for the prospective series: 28 responders versus six non-responders (two lost to follow-up). Neither series yielded a clinical or radiographic finding predictive of outcome. The pattern of a “good” responder to treatment could not be identified. It was noted, however, that meniscal pain associated with a blocked knee appeared to be a poor indication for corticosteroid injections and that injections of hyaluronic acid should be associated in cases with cartilage damage. Meniscal wall injections thus appear to be a new perspective for the medical treatment of meniscal pain. Comparative studies versus arthroscopy will be needed to determine the role of this method in our therapeutic armamentarium.     

13 Knowledge Translation Shift

Health care providers have demonstrated difficulty in adopting the latest information into their clinical practice patterns. This gap in "Knowledge Translation" (KT) is currently under broad discussion within the medical community and was the focus of SAEM's Consensus Conference in 2007. In an effort to bridge this gap, we implemented a novel "KT shift" for our PGY-2 residents. PGY-2 emergency medicine (EM) residents are required to work a nine hour KT shift during their scheduled EM rotation at one of two large urban training emergency departments (EDs). This shift has reduced patient responsibilities to allow for the development of clinical queries that are answered by searching for the best evidence to be applied to patient care. This process is summarized on a "KT Shift Log" that records the PICO question, databases searched, and level of evidence found to answer clinical questions. KT shift log sheets and search strategies are reviewed by EM faculty with expertise in evidence-based medicine and KT principles. We believe that the implementation of a KT shift will improve residents' ability to obtain high quality evidence to answer real-time clinical questions. This may serve as an important measure in closing the knowledge to practice gap.     

11 Dawn Patrol Patient Follow-up Protocol

Follow-up of patients after their emergency department course provides a rich educational experience for residents, but due to time and logistical constraints, is infrequently performed in a scheduled and rigorous manner. The Dawn Patrol initiative was added to our residency curriculum to facilitate and protocolize patient follow-up for education and feedback on patient care. It also strives to improve communication with inpatient services, and provides a means of collection for morbidity / mortality and risk management cases. Our process functions by charging the clinical senior resident who is going off-shift, with reviewing the admission record for the past 24 hours. Interesting, clinically important, or cryptic case presentations are selected via our electronic medical record for review at the end of Morning Report. Generally, 1-3 new cases are selected for review each weekday morning. These cases are then recorded on a dry erase board in the Morning Report room, and the cases are followed until inpatient discharge, or are no longer of clinical interest. Visits to the inpatient wards are encouraged. Patient callbacks of outpatients are also eligible for inclusion. The cases are updated daily, and generally 5-10 cases are reviewed per day in approximately 10 minutes. The staff member attending Morning Report is responsible for providing bulleted teaching points on each case. The Dawn Patrol patient follow-up initiative seeks to improve emergency medicine resident education by facilitating and protocolizing patient follow-up, and provides real-time feedback on patient care performed in the emergency department.