Purpose: Prevention of post-trauma infections is basically aimed at streptococcal, staphylococcal and anaerobic germs. An increasing number of open fractures are however contaminated with Bacillus cereus leading to a multidisciplinary discussion involving infectious disease specialists, orthopaedic surgeons, and bacteriologists concerning the appropriate management. Bacillus is an ubiquitous genus of sporulated telluric Gram positive germs found in soil and plants. B. cereus can lead to local wound infection. This environmental (including hospital) bacterium is often a temporary host of the skin flora and its isolation can be taken as a simple contamination with no therapeutic consequence. B. cereus is sensitive to fluoroquinolones.

Material and methods: Between August 1995 and December 2000, B. cereus was isolated in 41 patients from surgical specimens taken from deep muscle and bone tissues. Ordinary medium was used for culture. Genomic analysis was used to type the Bacillus. Statistical analysis was conducted in cooperation with the epidemiology unit.

Results: In our unit, isolation of B. cereus was significantly associated with severe open leg fractures (Gustilo grades IIA and IIIB) with soil contamination. Samples were taken due to fever, wound discharge, elevation of C reactive protein despite antibiotic prophylaxis beyond 48 hours using the standard protocol of aminopenicillin + betalactamase inhibitor, constantly inactive against B. cereus. The strains identified presented different genomic types ruling out nosocomial contramination. One amputation, one chronic osteitis and one anteriolateral leg compartment necrosis resulted from B. cereus infection in this series.

Conclusion: Arguments developed here allow us to recall the importance of careful surgical debridement of open fractures and to emphasise the requirement for bacteriological samples and appropriate antibiotic therapy for 48 hours, combining, in agreement with the 1998 Consensus Conference, aminopenicillin + betalactamase inhibitor and gentamycin which is active against B. cereus. Severe open leg fractures which follow an unfavourable course should suggest possible B. cereus infection requiring early antibiotic therapy using a regimen with good bone diffusion including a fluoroquinolone which is always active against B. cereus.

Purpose of the study: In accordance with the conclusions established at the SOFCOT symposium in 1988, we propose surgical treatment of displaced fractures of the calcaneus with screw fixation after reduction. We developed an original classification system of 3D computed tomography images which allows a precise description of the fractures and guides joint and calcaneal body reconstructions. The purpose of this work was to provide a precise analysis of operated fractures in order to identify prognostic factors and validate use of exclusive screw fixation for calcaneal fractures.

Materials and methods: This series included 60 operated articular fractures of the calcaneus. The Uthéza classification was: 12 vertical, 7 horizontal with 1 fracture line, 3 horizontal with 2 fracture lines, 23 mixed with 1 fracture line and 15 mixed with 2 fracture lines. 3D computed tomography evidenced the fundamental fracture lines and their anterior extension. Fixation was achieved with one screw inserted in a transverse position under the posterior facet and one oblique screw from the greater tuberosity to the sustentaculum tali.

The medial and lateral Böhler angles were measured on plain x-rays. The analysis included search for a double line on the posterior talocalcaneal facet, secondary body displacement, the position of the oblique screw and the degree of posttraumatic subtalar wear. The clinical criteria established in the 1988 SOFCOT guidelines were recorded. Analysis of variance, Pearson and Spearman coefficients, and RIDITS analysis (the most powerful method available for evidencing a relationship between two qualitative variables one of which is ordinal) were used to search for prognostic elements and correlations.

Results: No severe complications were encountered with the wide lateral access. A negative medial Böhler angle was significantly correlated with an additionnal posterior facet line. A mean 80 p. 100 reduction in the lowering of the medial part of the posterior facet and an 87 p. 100 reduction in lateral pivoting were achieved irrespective of the type of fracture. Minimal secondary body displacements were significantly related to anchorage of the oblique screw outside the sustentaculum tali. Functional outcome was satisfactory (very good + good + average) in 75 p. 100 of the cases and physical outcome in 50 p. 100 (very good + good) irrespective of the type of fracture. Outcome was significantly correlated with reduction in the Böhler angle, double lines on the posterior facet, secondary displacement and osteoarthritis.

Discussion: The 3D analysis of posterior facet fractures using our classification was useful in guiding reconstruction with correction of the medial lowering and the lateral pivoting. A negative medial Böhler angle was a factor of poor prognosis: more posterior facet lines, joint wear and deterioration of the functional and physical outcome. Good outcome required good reduction of the Böhler angle and good anchorage of the oblique screw in the sustentaculum tali. Good subtalar mobility was associated with pain relief. Uniform anatomic and pathologic classifications and precise analysis criteria are needed for pertinent comparison between series and proper definition for indications for first-line reconstruction-arthrodesis.

Conclusion: Measurement of the medial Böhler angle improves the sensitivity of revision criteria for articular fractures of the calcaneus. Screw fixation has proven its reliability.