Purpose of the study: Management of bone and joint infections is a recognised public health concern recently labellised by the establishment of Reference Centres and associated Reference Centres. Among other objectives, these Centres are designed to develop pluridisciplinary expertise in the form of recommended clinical practices (French Health Ministry directive DHOS, May 2008).

Material and methods: In response to this tender, a weekly pluridisciplinary meeting was instituted in March 2008 with an orthopaedic surgeon, an infectious disease specialist, an anaesthetist, a pharmacist, microbiologists, a rheumatologist and a diabetologist. The activity and impact on antibiotic consumption in the functional unit of septic surgery was evaluated over a one-year period.

Results: From March 2008 to March 200, 35 pluridisciplinary meetings were held and analysed 243 files concerning 133 patients. This consensual approach led to a decrease in the antibiotic consumption in the functional unit. This consumption was 1222 DDJ/1000 days hospitalisation during the last semester of 2007 and 1069 DDJ/1000 days during the last semester of 2008 (p=0.005). During this same period, the activity in the unit increased from 37 patients with infected material (CIM 10 T 84) in 200 to 58 in 2008 and from 27 patients with septic arthritis (codeM00) to 42 in 2008. Similarly the number of indexed pathological conditions in this unit increased from 447 to 548 in 2008 with a fall in the mean duration of the hospital stay from 11 days in 2007 to 9.6 in 2008. The improvements provided by the process of intraoperative sampling provided bacteriological documents in 85% of cases. The analysis of antibiotics prescribed in the functional unit showed a decline in the consumption of antibiotics with week or unknown distribution in bone (amoxicillin + clavulanic acid: −13%; pristinamycin: −72%) and an increase in the prescription (before adaptation to documented bacteriological results) of the association cefotaxime+fosfomycin (5-fole increase in one year).

Discussion: This study clearly shows how important regular pluridisciplinary discussion is needed to optimise the management of bone and joint infections and that this approach improves the antibiotic prescription and shortens the hospital stay.

Conclusion: This experience proves the pertinence of the Reference Centres and the associated Reference Centres, both economically and medically.

Purpose of the study: Locked centromedullary nailing has proven efficacy for the treament of tibial shaft fractures but its use remains controversial for the most distal fractures. The purpose of this work was to assess clinical and radiological outcome of nailing procedures used to treat fractures of the lower quarter of the leg.

Material and methods: Fifty-eight fractures of the lower quarter of the leg were treated by locked centromedul-lary nailing between 1999 and 2002. All patients were included in the analysis. Twenty-four patients aged 44 years on average (range 18–68 years) were reviewed by an independent operator at mean 43.2 months follow-up (range 18–70). Four types of nail were used, on an orthopedic table for 47 procedures and with a hanging leg for 11. The fibula was not fixed.

Results: Early complications were: compartment syndrome (n=2) and infection (n=3). Postoperative alignment was anatomic or good in 86%. Mean time to weight bearing was 66 days (range 0–180). Nonunion occurred in six patients who required revision. Secondary displacement was noted in ten patients. Knee motion was normal in all patients and ankle motion was normal in 80%. Mean time to resumed occupational activity was 5.7 months (range 1–18). At last follow-up, bone healing had been achieved in all patients.

Discussion: As compared with data in the literature, we found that locked centromedullary nailing allows early weight bearing with less risk of infection for radiological results comparable with those obtained with plate fixation. The secondary displacements resulted from defective locking of inappropriately adapted materials (holes insufficiently distal).

Conclusion: Locked centromedullary nailing is a treatment of choice for fractures of the distal quarter of the leg. Use of new nails with more distal holes should improve outcome by allowing distal locking with at least two screws in all cases.

Purpose of the study: 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).

Material and methods: 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 extra-focal pînning [22 patients mean age 55.6 years (range17–83 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.

Results: Mean operative time was equivalent for the two plate 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, 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 supination pronation 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.

Discussion: While posterior plate fixation is logical (approach on the side of the injury), the technique is difficult and can lead to nerve and tendon complications. For these extra-articular fractures, pinning like anterior plating can provide good functional results. Pinning is a rapid procedure and anterior plates do not have to be removed, allowing more rapid recovery of total independence.

Purpose: Fractures o the distal radius remain a problem difficult to resolve. A post-operative displacement is observed in about half the cases. The displacement is generally a secondary shortening with mis- or unrecognized metaphyseal comminution. In the United State, autologous bone graft is widely used, which, like bone substitutes also used in France, allows appropriate filling of the metaphyseal comminution which always remains open after pin withdrawal. We present a prospective series of 30 patients with a fracture of the distal radius treated by pin or plate fixation in combination with Norian to fill the substance loss subsequent to metaphyseal comminution.

Material and methods: Thirty patients were treated between November 1998 and March 1999 for fracture of the distal radius with posterior displacement. The inclusion criterion was comminution > 2 according to the Laulan classification. All were treated by osteosynthesis with plate or pin fixation and insertion of Norian. There were 26 women and 4 men. Twenty-two patients had an articular fracture. Plate fixation was used in ten patients and pin fixation in 19.

The fracture involved the dominant side in 21 cases. The fracture was closed in all cases. Norian was injected after osteosynthesis following the recommendations of the manufacturer (impaction of the cavity rims created by the comminution, no motion for 10 min after injection). All patients were reviewed at 1, 3 and 6 months and at last follow-up. The flexion-extension and pronation-supination amplitudes were measured, as was the muscle force.

Results: All patients were reviewed with a minimum follow-up of at least 2 years. Mean age was 65 years (545–82). All fractures had consolidated. There were three defective calluses in patients aged over 80 years with osteoporosis; the clinical outcome was better than the radiological image. Three patients developed reflex dystrophy. Mean amplitudes were: flexion 43.6°, extension 52.3°, pronation 63°, supination 70°. The mean wrist force was 52 kpa. No complications related to Norian were observed. Two biopsies were made and showed, in one case at six months, early signs of osteointegration. The product disappeared progressively after 2 years but not in all patients. The immediate postoperative ulnar variance was unchanged at last follow-up. In seven patients the ulnar variance was modified with impaction of the fracture line but with no effect on pronation-supination.

Discussion: Metaphyseal comminution after fracture of the distal radius is a classical observation. It may be located posteriorly or anteriorly and leads to secondary impaction before or after pin withdrawal. To avoid this problem, and the inversion of the ulnar variance, the bone defect must be filed at the initial surgical procedure. Solutions include bone grafts (autograft, allograft, xenograft) and injection of methylmethacrylate. Bone substitutes can now be used to fill the gap without the theoretical or real risk of bacterial contamination. The first studies in animal models were published in 1995. Kopylov and Jupiter demonstrated the contribution of Norian for fractures of the lower end of the radius to avoid impaction and improve pronation-supination.

Conclusion: Metaphyseal comminution of fractures of the distal radius is a real problem. If the gap is not filled during the initial surgical treatment, impaction with inversion of the ulnar variance can lead to pronation-supination insufficiency. Norian SRS can be used to fill the bone defect producing mechanical results as good as or better than compression cancellous grafts. The produce is resorbed slowly and is easy to use. Its high cost is undoubtedly an inconvenience limiting its use to “young” patients with fractures of the distal radius. After 70 years, the absence of a strong correlation between the radiological and clinical result suggests a less “aggressive” therapeutic approach.