Organisation fonctionnelle de l'articulation fémorotibiale

The knee joint is composed of two articular systems: the femorotibial and femoropatellar joints. The femorotibial joint appears quite instable, with its two convexe femoral condyles on the planar tibial surface. Actually, a muscular and tendinous organization ensures stability during motion. The muscular extensor system, with quadriceps patella and patellar tendon, controls the forward sliding of the femoral condyles and provides the knee stability in the sagittal plane. The posterior internal/external capsular and muscular reinforcements, also called posterolateral/posteromedial corner, ensures stability during rotation in the frontal and horizontal planes. Nonetheless, it is necessary to add to this muscular organization, a powerful informative system where the cruciate ligaments of the knee assume the major role. Those ligaments still remain in tension and inform the nervous system in any motion of the knee. This functional organization allows both large flexion-extension and stability. This article shows as an example the functional organization of the femorotibial joint.     

La prise en charge rééducative globale de patients présentant un syndrome fémoro-patellaire : la lutte contre l’effondrement du membre inférieur par le renforcement du moyen fessier

The patellofemoral pain syndrome (PPS) is characterized by anterior knee pain and poor patellar kinetics. In this review, we focus on primary PPS. Several local factors are known to provoke knee pain (subchondral bony disorders, retraction of the lateral retinaculum, inflammation of the infrapatellar adipose pad). Furthermore, proximal factors involving the hip and pelvis as well as distal factors involving the ankle and foot explain the impact on lower limb mechanics, for instance on single-stance squat. In the 1980s, the gold standard management strategy for PPS was to strengthen the vastus medialis in order to counter lateral subluxation of the patella during knee flexion. More recently, with improved techniques for neuromuscular biomechanical investigations, several publications propose reinforcing the hip abductor muscles for PPS. This offers a more global approach by correcting the posture of the entire lower limb to provide relief from this difficult-to-treat complex syndrome. Strengthening the hip abductors (gluteus medius) appears to be the best way to eliminate the single-stance lower limb postural failure leading to several musculoskeletal disorders. This new approach to rehabilitation is a validated evidence-based therapeutic strategy.     

Accident hypoxique en anesthésie pédiatrique dû à un réglage inadapté du respirateur

A 3-year-old child was anesthetized for ENT examination and surgery. After induction and tracheal intubation, the patient was ventilated (controlled mode). The respirator screen showed information compatible with a failure of intubation: no expired CO₂, no expired flow, no alarm of high pressure limit, and no respiratory chest movement. A fall of SpO₂ appeared rapidly which recovered after extubation and manual ventilation through a face mask and reintubation. The expiratory CO₂ was present when the patient was ventilated manually and disappeared under controlled ventilation. The increase in the value of the maximal insufflation pressure allowed efficient ventilation with an expiratory CO₂ curve and showed high ventilation pressure compatible with a bronchospasme. This case report shows that in case of bronchospasme, if the value of the maximal insufflation pressure is low, this may lead to an erroneous diagnosis of failure of intubation.     

Durée de l’antibiothérapie lors du traitement des pneumopathies acquises sous ventilation mécanique : comparaison entre sept jours et dix jours. Étude pilote

Objective

To compare the efficiency of a 7-day antibiotics regimen with a 10-day regimen for ventilator-associated pneumonia (VAP).

Study design

Prospective randomized study.

Patients and methods

Adults patients ventilated for more than 48 hours in the intensive care unit (ICU) with a clinical diagnosis of VAP documented by positive quantitative cultures of tracheal aspiration were included in this study. All included patients were randomized in two groups. Ten-day group: 10 days antibiotic therapy, and 7-day group: 7 days antibiotic therapy. Primary judgment criteria were 14- and 28-day mortality, the number of days without antibiotics. Secondary judgments criteria were rate of recurrent pulmonary infection, the evolution of the clinical pulmonary infection scores (CPIS), the length of ICU stay and the length of mechanical ventilation.

Results

Thirty patients were included in this study (16 in the 10-day group and 14 in the 7-day group). The demographic and clinical characteristics of the groups assigned to receive antibiotic therapy for 7 or 10 days were generally similar. The 14-day and 28-day mortality rate following VAP onset were 31.2 and 37.5% in the 10-day group and 7.1 and 35.7% in the 7-day group. The difference was not significant. The number of day without antibiotics and without mechanical ventilation turned out: 1.75 and 2.06 days versus 4.14 and 3.43 days in the 10-day group and 7-day group respectively, the recurrent rate of pulmonary infection (12.5% versus 14.3%, p = 0.6), the length of stay in the ICU (27.7 days versus 26.0 days, p = 0.8) and the evolution of the CPIS were no different in the two groups.

Conclusion

In patients with microbiologically confirmed VAP who received appropriate empirical antibiotic therapy, a 7-day antibiotic regimen was as efficient clinically and microbiologically as a 10-day antibiotic regimen with a reduction of antibiotic use.     

Timing of tracheostomy and outcome of patients requiring mechanical ventilation

Objectives

To assess the impact of tracheostomy timing on outcome of critically ill patients requiring mechanical ventilation (MV).

Study design

Retrospective clinical study in a twelve beds intensive care unit (ICU).

Patients and methods

From January 2001 to June 2005, patients under MV who received tracheostomy were divided into 2 groups: early tracheostomy group when tracheostomy was performed before or on day 7 and late tracheostomy group when it was performed thereafter. We compared prevalence of nosocomial pneumonia, length of sedation, lengths of MV, length of stay in ICU, weaning from MV and mortality rates between the 2 groups.

Results

During this period of 4 years and half, 112 patients underwent tracheostomy, 62 of whom had early tracheostomy and 50 had late tracheostomy. Early tracheostomy was associated with significant reduction of length of sedation (10 ± 3 vs 17 ± 5 days, P < 0.001), length of MV (21 ± 19 vs 29 ± 17 days, P = 0.02) and length of stay in ICU (33 ± 22 vs 42 ± 18 days, P = 0.042). There were no differences in prevalence of pneumonia (21% for early tracheostomy group vs 31% for late tracheostomy group, P = 0, 13), weaning from MV (50 vs 36%, P = 0.19), and mortality rates between the 2 groups (38 vs 54%, P = 0.15).

Conclusion

This study demonstrated that early tracheostomy (≤ 7 days), was associated with shorter length of sedation, shorter duration of MV and shorter ICU length of stay, without affecting weaning from MV, prevalence of nosocomial pneumonia or survival.