Traumatismes de l'articulation sternoclaviculaire chez le joueur de rugby

Traumatisms of the sternoclavicular area are rare but not exceptional in rugby players. Sprains or fracture of the medial fourth of the clavicule are easy to treat and do not alter the ability to play. Posterior sternoclavicular dislocations are rare; usually stable after orthopedic reduction but the close proximity of vascular structures or the respiratory tract may be responsible for severe lesions, sometimes letal. Anterior dislocations are usually unstable and should not be operated on, if possible, in the rugby player. In patients under 23 years of age, it is usually a fracture through the epiphyseal plate and prognosis is good with conservative treatment.     

Conséquences de l'épidémie de SRAS sur le système hospitalier de l'Ontario

In March 2003 the healthcare system of Toronto had to respond to an outbreak of severe acute respiratory syndrome. This infectious disease due to a novel coronavirus spread rapidly because this infectious agent was highly contagious and contaminated many caregivers. The increase in the demand in critical care beds with concomitantly a decrease in the number of caregivers sick or in quarantine, deeply disorganized the emergency and critical care system. Lack of preparedness, absence of coordination and leadership, poor communication were identified as factors amplifying the impact of this outbreak. Rapidly, however a disaster plan was implemented allowing for better organizing the response of hospitals, allowing the control of the outbreak. During the second phase of the outbreak in April 2003, a coordinated network of hospital is designed to isolate the patients and provide best evidenced care with optimal protection of the caregivers. Several recommendations resulted from the retrospective analysis of these events. These were used to develop a transformation of the healthcare system in Ontario, with creation of local health integrated networks, reorganization of the acute care system with increased capacity, development of infectious disease control. In preparation of a new outbreak, provincial and local task forces have been implemented to provide recommendations in collaboration with the newly created Public Health Agency of Canada.     

Évaluation à moyen terme d'une intervention type hémi-Castaing dans le traitement de l'instabilité chronique de cheville

Introduction

The purpose of this study is to evaluate the functional and subjective results of hemi-Castaing replacement ankleplasty associated with articular cleaning in the treatment of chronic instability of the ankle.

Material and method

The study is retrospective, monocentric and continuous. Fifty patients (50 ankles) underwent surgery by hemi-Castaing ligamentar ankleplasty associated with articular cleaning. An independent investigator on the basis of a radioclinical examination and an ankle scoring system made the assessment.

Results

After a period of 37 months, 44 patients were seen again. Ninety-one percent of them were satisfied; the average ankle score was 87.5%. Four patients had relapsed, 26 still had pain. Seventy percent had returned to sport activities, 97% had gone back to work. The main complications were: 6 cases of tendinitis (Achilles tendon), 6 algodystrophies, 3 nevromes of the external saphene nerve and 3 dysesthesis of the external side of the foot. No sign of arthrosis was found on the radiological records.

Discussion

The treatment of chronic instability of the ankle by hemi-Castaing ankleplasty associated with articular cleaning is a satisfactory intervention for the surgeon as well as for the patient. It makes possible the recovery of a stable and functional ankle. The pain, however, will not totally disappear, which the patient should be told before the operation. Mastering the tension of the plasty is the main difficulty of this intervention, which may fail, but not necessarily as a result of the plasty's being too loose. The cause for the failure should also be sought in other factors related to the region of this pathology (deltoidian ligament, neurologic trouble, proprioceptive).     

Ruptures traumatiques de la coiffe des rotateurs chez le rugbyman

Rotator cuff tears are one of the shoulder lesions that can occur during modern Rugby. They are present in 3–10% of the traumatic lesions of the shoulder in this population and is this figure is expected to continue increasing because of the growth in popularity of the sport and the intensity of the game. The physician should be aware of the clinical signs in order to guide the correct imagery for this type of lesion to be correctly identified. The study of 29 rotator cuff tears in professional Rugby players from the French Rugby championships from 1996 to 2006 allowed us to clarify the epidemiology of these lesions and to specify the therapeutic indications. The surgical treatment, especially arthroscopic repair, proved to be efficient for the partial and full-thickness tears. Eighty-three percent of the patients were able to play Rugby at their presymptomatic competitive level with a delay of 5.5 months with a strictly normal clinical exam in more of 75% of the cases.     

Apport des techniques de biologie moléculaire dans le diagnostic des endocardites infectieuses

There is no doubt that molecular biological techniques have dramatically altered the diagnostic procedures for infectious diseases and in particular for blood culture-negative endocarditis (BCNE), the diagnosis of which remains difficult and is often established only with delay. These molecular techniques have been developed mainly for the detection and identification of pathogens that are difficult to culture or non cultivable under standard conditions, or non viable due to previous antibiotic treatment. With the exception of some specific tests that can be carried out with serum or blood, the molecular techniques for the diagnosis of BCNE are most often carried out using cardiac tissue samples. Because of their current limitations, the molecular techniques have to be considered as adjunct procedures and care has to be taken with respect to the interpretation of the results. Also, the more or less conventional (serological, histopathological, cell and cell-free culture-based) tests must not be neglected. Future efforts should aim at the improvement of the sensitivity of the molecular techniques and also of the early (serum-based) diagnosis of BCNE, using molecular techniques as well as antigenic microarrays.     

Laxité chronique antérieure du genou chez le sportif. À propos de 118 cas

The chronic anterior laxity of the knee is an evolutive disease owing to a rupture of the anterior crossed ligament which engages the functional prognosis of the lower member and compromise sportive activity. Many techniques of ligamentous plasty were described. Our study is about 118 sportsmen suffering from chronic anterior laxity treated by the modified Kenneth-Jones procedure between 1998 and 2002. After a main following-up of 25 months, we tried to value our results and determine the real place of ligamentous plasty using patellar tendon in the treatment of sportsmen chronic anterior laxity.     

L'ostéotomie tibiale chez le rugbyman professionnel. À propos de six cas

We report our experience of tibial osteotomy on 6 professional Rugby players. At revision, one was lost because he lived too far from our center, but still plays rugby. Five experienced a functional IKDC score (International Knee Documentation Committee) between 86/100 and 99/100 (versus 55/100 to 71/100 pre operative) and all returned to their sport at the same level. Modification of HKA angle (Hip-Knee-Ankle) didn't modify the impulsions during playing. Chondromalacia seems to go on despite the procedure. In all cases, pre-op washing arthroscopies (± viscosupplementation) failed. In conclusion, tibial osteotomy appears to be a quite simple procedure in the management of symptomatic chondromalacia for high level sportmen. Because of a quite short term follow up, it's impossible to preview long-term results of these osteotomies on arthro evolution.     

Instabilité antérieure récidivante de l'épaule chez le rugbyman. Résultats d'une série de 85 épaules opérées par la technique de Latarjet avec un recul moyen de sept ans

The stabilization of an unstable chronic shoulder is a difficult challenge in the contact sportsman especially the rugby player. We report our experience of the modified Latarjet procedure with a retrospective series of 85 shoulders (79 rugbymen at 75 months follow-up). It acted all young men with a prevalence of dominant shoulder, occupying all the stations (over-representation of the third lines). Eighty percent presented osseous lesions; the first luxation was traumatic during a tackle. We describe our technique and our postoperative protocol. Seven percent experienced recurrence of their instability after a new traumatism and 67% returned to rugby within 8 months by keeping for some of them a sport practice functional embarrassment (16 patients). Only two mechanical complications were observed, 93% of the patients were satisfied with their intervention.     

Rupture haute des tendons ischiojambiers chez le sportif. À propos d'une série de neuf cas opérés

Objectives

Muscular pathology of the hamstring is frequent among athletes. On the other hand, complete rupture with avulsion at the proximal bone-tendon junction is a rare injury. Functional treatment of this injury gives no successful results. This study aims at providing information on the results of operations on 9 athletes.

Methods

Between 2002 and 2006, 9 male patients with an average age of 36.4 years (from 20 to 59) were operated on for a complete rupture of the hamstring at the proximal bone tendon junction due to sporting accidents — 4 rugby accidents, two soccer, one fencing and one aikido accident — and one domestic accident. Emergency magnetic resonance imaging was systematically employed. All nine were operated on using the same technique: by reinserting the tendons into the bone with several Mitek GII^® anchors (3.6 on average). A specific rehabilitation programme was set up. An isokinetic Biodex™test was done after 6 months.

Results

All 9 patients were reviewed after a mean period of 33 months (from 9 to 64). At the last review, all patients were satisfied with their functional results. Eight patients out of 9 had gone back to their sporting activities at the same level, a mean 5 months after the operation (from 4 to 7 months). The isokinetic tests related to the unimpaired member show a muscular deficit of less than 8% after the 6th month.

Conclusion

Complete rupture of the hamstring at the proximal bone tendon junction is a rare but serious injury. With an early diagnosis and rapid surgical treatment, normal functions can be recuperated with a rapid return to high level sporting activity.     

Perfusions intraveineuses dans le sepsis

Intravenous fluids play a fundamental role in the resuscitation of patients with sepsis, not only to compensate for liquid losses, but also to augment plasma volume and contribute to reach an hyperkinetic state. Each intravenous fluid has its advantages and disadvantages. Crystalloids can be associated with the development of considerable edema. Albumin is expensive. Among the synthetic colloids, gelatins are the least effective and can cause anaphylactoïd reactions, while hydroxyethyl starches can accumulate in the organism, alter hemostasis, and compromise renal function. Ultimately, it must be accepted that all solutions have drawbacks, especially when used in large quantities, so that it is often better to use several types of fluid.     

Le rôle dévolu aux centres de référence dans le plan national maladies rares

The national plan on orphan diseases has been elaborated to improve access to care (diagnosis and treatments) in rare diseases. It includes 10 strategic axes including improvement of access to care, effectiveness of the global management and communication with patients. This review highlights these axes and offer potentially relevant information for intensivists.     

L'infection à cytomégalovirus chez le patient immunocompétent de réanimation : fièvre banale ou maladie grave ?

Cytomegalovirus (CMV) infection is a current pathology but complex and rather unknown. Primary infection occurs in 60 to 100% of the developed countries population, generally during childhood and often causes little or no symptoms, unlike exceptional cases. Like other herpesviridae, CMV remains in the organism and can be responsible for serious infections in immunocompromised patients. Several studies performed last decade have been also observed that CMV reactivation could occurred in the Intensive Care Unit (ICU) settings in patients who were immunocompetent at time of the admission. Trigger factors, currently present in ICU, would be inflammation or sepsis, associated or not to an immunity decrease. Cytomegalovirus reactivation could represent a biological marker because it could be associated with a higher morbidity and mortality. Pathogenic properties of CMV could interfere with pathological pattern of the complex ICU patient because of direct tissue injury or immunity and inflammation disequilibrium. Hence, CMV infection should be checked in ICU patients after several days of hospitalisation, developing a prolonged fever without other causes, or in the case or ARDS, MOF or every suggestive end-organ disease (interstitial pneumonia, inflammation of the digestive tract, hepatitis…). Further studies are needed to determine the utility of an antiviral treatment and the level of antigenemia necessary to treat.     

La lésion traumatique des tendons extenseurs en zone 5 chez le boxeur ou le boxer's knuckle

Sagittal bands of the extensor tendons can be injured by a direct trauma on flexed metacarpophalangeal joints. It's the boxer's knuckle, which consists on a bursitis or a dislocation of the extensor tendon between the metacarpal heads. This lesion is often misdiagnosed especially for the boxer. There are few publications on this subject in the medical literature. Diagnosis depends on clinical exam, plain X rays eliminates fractures and ultrasonnography or RMI, if necessary, visualize the lesion of the sagittal band. Treatment is essentially surgical and followed by an immobilization of 3 weeks. It gives generally good functional results and an early recover of function for sport activities.     

Physiopathologie de l'œdème pulmonaire

Pulmonary edema is defined by an abnormal increase in extravascular lung water. There is a physiologic liquid flux from the capillary to the interstitium, which is evacuated by the lymphatic vessels. Edema results from the imbalance between the increase in transudation or exsudation and the mechanisms of protection such as the lymphatic drainage or the resorption of alveolar liquid through the epithelium. Alveolar flooding occurs if interstitial space is saturated or in case of failure of the blood-gas barrier due to a major increase in microvascular pressure or due to an alveolar distension. The absorption of alveolar liquid is an active process following an osmotic gradient through the epithelium.     

Intérêt d'une curarisation systématique précoce de 48 heures sur le pronostic des patients présentant un syndrome de détresse respiratoire aiguë. Étude ACURASYS. Présentation du protocole

Acute respiratory distress syndrome (ARDS) is associated with a mortality of 40% to 60%. Numerous sophisticated treatments have been evaluated. However, the use of neuromuscular blocking agents (NMBA) remains poorly studied in this indication. In a recently published study (Gainnier et al., Crit Care Med 2004), our group reported a persistent oxygenation improvement in ARDS patients paralyzed during the first 48 h after the onset of ARDS as compared with ARDS patients who did not receive NMBA. One plausible explanation would be that tidal volume is much more homogenously distributed when patients are paralyzed. In a very recently published study, we have shown that NMBA use is associated with a significant reduction of pro-inflammatory cytokines in BAL and blood samples (Forel et al., Crit Care Med 2006). When the patients included in these two studies are considered together, we found a significant reduction in the mortality rate. These data have not been published because these two studies were not designed to study the outcome. However, we decided to perform a multicenter double-blind, placebo-controlled prospective trial in order to demonstrate that the early use of a short period of paralysis is associated with a better outcome of ARDS patients. A total of 340 patients need to be included in the twenty ICUs participating in this trial.     

Spécificités de la pratique du rugby chez l'enfant

The knowledge of the specificity of the child compared to the adult and his reactions regarding the exercise will make it possible to answer parents questions as well as possible and to accompany the child and the teenager in their sporting practice. Five essential concepts govern the practice of Rugby in the child: 1) the child is not an adult in miniature. It is an organization in constant evolution towards its physical and psychic statute of adult. He has a free will depending on the others; 2) Rugby must remain for him a ludic space, where the motivation must be the first condition; 3) the child is a mosaic of growth cartilages. Traumatic pathology is preferentially a pathology of this structure in the acute traumatisms (epiphysium separation rather than distorsion, muscular apophyse avulsion rather than tear) and under the effect of chronic microtraumatisms (osteochondrosis rather than tendinitis); 4) overtraining will result in a disturbance of one of the factors of the general balance of the organization which it acts of a pain, of against performance, an abnormal tiredness, of a demotivation, a relational disorder (mood, affectivity), of lower school output of which it will be necessary to establish a relationship to the sporting practice; 5) the execution of a sporting gesture must always be modulated as of the appearance of a pain, true alarm.