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Resume Introduction La checklist (C/L) securite au bloc operatoire a montre son efficacite pour reduire les complications chirurgicales. Apres l’avoir mise en place autoritairement dans le cadre de la certification des etablissements, la Haute Autorite de Sante a realise une enquete, en 2010, afin d’analyser le ressenti des chirurgiens vis-a-vis de cette procedure. Nous presentons les reponses obtenues aupres de 559 chirurgiens orthopedistes engages dans l’accreditation et membres d’Orthorisq. Resultats Quatre-vingt-sept pour cent des chirurgiens estiment qu’il s’agit d’un outil utile a la securite des patients, 28,4 % n’y participent jamais et deux sur trois demandent que la C/L soit modifiee en raison de l’imprecision des questions. Trente pour cent estiment ne pas avoir recu le soutien necessaire pour sa mise en place et 40 % soulignent les difficultes qu’ils rencontrent pour reunir l’ensemble des acteurs au moment du « temps de partage ». Si aucune de ces difficultes n’a pu etre rapportee statistiquement au mode d’exercice (liberal ou public) ou au mode d’activite (sur une ou plusieurs salles), le manque d’implication du chirurgien est apparu comme un facteur majeur dans la demobilisation des equipes (p Discussion Bien que son utilite soit reconnue par les chirurgiens pour la securite des patients, l’utilisation de la C/L reste encore limitee. Son contenu doit s’adapter aux conditions de travail et au type de chirurgie. Cette reflexion doit etre orchestree par la commission medicale d’etablissement a qui le legislateur a donne un role majeur dans la conduite de la politique de gestion des risques.

Resume La chirurgie orthopedique et traumatologique est une des chirurgies les plus exposees aux plaintes des patients. Une etude retrospective de 791 declarations de plaintes aupres d’une meme assurance survenues a une cohorte de 794 chirurgiens sur une periode de cinq ans (2002–2007) fournit un cadre d’analyse des dimensions du risque de l’exercice professionnel. Dans la base consideree, 6,8 % des chirurgiens concentrent 46,8 % des declarations de plaintes ; ils en ont eu cinq ou plus en cinq ans, et representent 64,1 % du cout a charge pour l’assurance. Inversement 65 % des chirurgiens n’ont eu aucune declaration dans cette periode. Le « sur-risque » concerne particulierement la chirurgie du rachis et de la hanche alors que la chirurgie du membre superieur est au contraire sous-representee. La discussion analyse les limites de l’etude et propose une comprehension des causes profondes de ces sinistres selon trois dimensions du risque : le type de chirurgie, le type d’exercice professionnel (etablissement, organisation de l’activite) et des facteurs personnels (competence a communiquer, traces de vie, etc.).

Resume Introduction L’antibiotherapie prophylactique est un des atouts majeurs a la pratique securisee de l’implantation de tout dispositif medical implantable, mais les differentes enquetes de pratique montrent une observance faible. Materiel et methode Ce travail est fonde sur l’etude de 153 grilles d’« analyse approfondie » adressees aux chirurgiens orthopedistes ayant declare un evenement porteur de risque (EPR) cible concernant l’antibioprophylaxie au cours de l’annee 2008 dans le cadre de leur « bilan d’accreditation » via l’organisme agree Orthorisq. Resultats Un protocole d’antibioprophylaxie existe dans 95 % des etablissements mais n’est pas disponible aux endroits adequats dans 14 % des cas. Quatre-vingt-huit pour cent des chirurgiens orthopedistes considerent qu’il est adapte a leurs pratiques. La majorite des declarations fait suite a une decouverte fortuite par le chirurgien d’un dysfonctionnement perioperatoire immediat. Les causes humaines ont ete retrouvees dans 92 % des declarations, les causes organisationnelles generales dans 50 % et les causes materielles dans 28 % des cas. Quant aux actions de recuperation, si 65 % des declarants disent avoir mis en place une procedure degradee, seuls 20 % ont pu reinstaurer une procedure d’antibioprophylaxie vraiment conforme. Conclusion La principale cause d’une antibioprophylaxie mal ou non realisee reste « l’oubli de l’administration par negligence ou inadvertance », dans 56 % des declarations. Les axes d’amelioration proposes sont : la revision des protocoles d’antibioprophylaxie en precisant « qui fait quoi ? » ; la verification de la bonne connaissance de ces protocoles par les nouveaux arrivants, vacataires ou remplacants ; l’implication du patient dans la collection des informations medicales le concernant et l’institution de la pratique d’une « check list » conformement aux recommandations de l’Organisation mondiale de la sante et de la Haute Autorite de sante. Ces propositions d’amelioration ont ete prises en consideration lors de l’actualisation du consensus sur l’antibioprophylaxie en cours de redaction par la Societe francaise d’anesthesie reanimation. Niveau de preuve Niveau IV, etude d’analyses de decision.

Resume Des anomalies du retrocontrole des reflexes medullaires ont ete mises en evidence dans les phenomenes d’instabilite au niveau de differentes articulations (genou, cheville, epaule), mais aucune etude n’a etabli leur implication dans le fonctionnement de la hanche. Le but de cette etude etait de mettre en evidence et de comparer les reflexes intervenant au niveau de l’articulation coxo-femorale naturelle et prothetique. Deux groupes de sujets ont ete etudies. Le premier comprenait 11 sujets indemnes d’affection neurologique ou d’atteinte du membre etudie, le second, 10 sujets ayant eu une arthroplastie totale de hanche et, a cette occasion, une capsulectomie etendue. Pour chaque sujet, en plus d’une etude de la latence de la contraction volontaire, l’etude a porte sur les caracteristiques electromyographiques de la reponse musculaire du droit anterieur et du tenseur du fascia lata (ipsi et controlateraux) lors d’une modification de la position articulaire. Trois series de 10 essais, realisees dans un ordre aleatoire, ont permis de mesurer la latence de la reponse musculaire lors de chutes libres, accelerees du membre decontracte et lors de chutes accelerees associees a une contraction calibree du quadriceps. Pour chaque serie d’essai, a ete calculee la latence moyenne de la reponse musculaire. Il n’y avait pas de difference significative entre les caracteristiques temporelles des reflexes intervenant au niveau d’articulations coxo-femorales saines ou prothetiques. Les modifications dues au remplacement articulaire et a la capsulectomie ne semblent pas influencer les reflexes de stabilisation de l’articulation coxo-femorale.

The menisci and the anterior cruciate ligament (ACL) are two essential structures responsible for antero-posterior stability of the knee. Meniscal and ligamentous lesions often co-exist, either because of the initial trauma or as a consequence of chronic instability, and their treatment is interrelated. It is the ACL reconstruction which is the key to the treatment of the meniscal lesion. The technique of ligament reconstruction is not altered as such by the co-existence of a meniscal lesion. The aim of the treatment of meniscal lesions is to spare as much of the meniscus as possible. Meniscectomy is only justified if the meniscal tear is symptomatic and irreparable. On the other hand, when meniscal repair is feasible, it is imperative that the ACL be reconstructed in order to restore stability. The results of these repairs are then comparable to those in stable knees. When a meniscal lesion is a consequence of chronic instability, the joint cartilage status needs to be assessed prior to performing functional restoration or continuing with the treatment of an arthritic deterioration.

Because of medical and administrative difficulties that we had been encountering in France, we organized and standardized meniscal allografting, taking advantage of the international experience in this field. We encouraged orthopaedic departments interested in developing this technique to join the French Meniscal Transplantation Group. After establishing the standards and indications of deep-frozen meniscal allografting with bone plug fixation during arthroscopic surgery and defining the technique of this procedure, the meniscal transplantations performed at the 17 participating departments will be analysed in the first prospective and randomized study ever. We hope that the administrative steps that have already been accomplished will allow the diversification and the diffusion of this technique in France, based on our results and experience.

Summary Introduction Antimicrobial prophylaxis is one of the main safety measures to be enforced when implanting any medical device; surveys of practice, however, have found poor compliance. Material and methods This study is based on analysis of 153 dedicated in-depth analysis forms sent to orthopedic surgeons who had reported an antimicrobial prophylaxis-related near-miss event (NME) during the year 2008 as part of their certification report to the official organization, Orthorisq (orthopaedic Patient safety risk management agency). Results Antimicrobial prophylaxis guidelines exist in 95% of French centers, but in 14% are not available in the right place. 88% of orthopedic surgeons consider them well-adapted to their practice. Most declarations follow fortuitous discovery by the surgeon of an immediate peri-operative malfunction. Human causes were found in 92% of declarations, general organizational causes in 50% and material causes in 28%. Regarding corrective action, 65% of respondents reported implementing a second-order procedure, and only 20% were able to resume truly regular antimicrobial prophylaxis. Conclusion The main reason for poor or non-performance of antimicrobial prophylaxis was “omission by negligence or oversight”, reported in 56% of declarations. Proposals for improvement were: revised antimicrobial prophylaxis guidelines specifying “who does what”; guideline awareness checks on new, temporary and locum-tenens staff; patient involvement in personal data collection; and implementation of a check-list in line with WHO and French Health Authority recommendations. These improvement proposals were taken on board in the antimicrobial prophylaxis consensus update currently being drawn up by the French Society for Anesthesia and Intensive Care. Level of evidence Level IV, Decision Analyses Study.

Injury to infrapatellar branches of the medial saphenous nerve are incriminated in disorders of the anterior aspect of the knee, particularly following bone-tendon-bone reconstruction. We demonstrated in prior anatomic work the usefulness of using a double-incision minimal approach for harvesting the patellar transplant in order to spare the nerve branches.The patellar transplant is harvested via two vertical incisions, one on the apex of the patella and the other along the protrusion of the anterior tibial tubercle. After harvesting the bony transplant from the patella, discision of the patellar tendon fibers is advanced subcutaneously towards the anterior tibial tubercle, allowing extraction of the patellar graft via the tibial incision using a small forceps and respecting the peritendon. The tibial bone is then harvested. The standard anterolateral and anteromedial approaches are used for the ligament reconstruction.We have conducted a case control study between this harvesting technique using the double-incision technique (42 knees) versus the conventional single incision harvesting technique. We studied the influence of the harvesting technique on anterior knee pain, the surface area of the sensorial disorders involving the anterior aspect of the knee, and kneeling problems.Our technique has enabled a significant decrease in the surface area of sensorial disorders (7.4 cm2 versus 17.4 cm2) and problems kneeling compared with the conventional method.

We present here the preliminary results obtained with arthroscopic tightening of the anterior cruciate ligament. Six patients underwent the technique. Four had had prior ligamentoplasty, two had sequelae of tibial spine fractures. Laxity persisted in all cases. The transplant or the ligament were continuous and insertion points were well-positioned. The procedure consisted in using a trephine to bore the tibial bone at the "foot" of the ligament or transplant in order to tighten the ligament. There was no evidence of instability after the arthroscopic tightening procedure. Mean pre- and postoperative differential anterior drawer values were successively 9.2 and 3.9 mm. For native or reconstructed anterior cruciate ligaments, which are continuous and well-positioned but not loose, arthroscopic tightening spares the need for ligament transplant and appears to be free of specific morbidity.

Patellar malposition is a well-recognized patellar complication after total knee arthroplasty. Such residual malposition is particularly frequent when the knee presents lateral femoropatellar arthrosis. We compared the radiological position of the patella after total knee arthroplasty in degenerative knees with lateral femoropatellar arthrosis performed via a medial or lateral approach with elevation of the anterior tibial tuberosity.Twenty-six total knee arthroplasties were reviewed retrospectively. Thirteen prostheses had been inserted via a medial approach and thirteen via a lateral approach. A posterior stabilized implant was used with an original technique for insertion of the patellar implant. The only difference between the groups was the approach. In the "lateral" group, the lateral approach was used to raise the tibial tuberosity and perform lateral marginal patellectomy. The tibial tuberosity was reinserted in all cases without transposition. Preoperative and 3-month postoperative radiographs (weight-bearing, AP, lateral, femoropatellar 30 degrees flexion) were reviewed. Preoperative patellar displacement was at least 5 mm. There was no difference between the two groups for age, gender, weight, height, joint motion, pre- and postoperative mechanical alignment (HKA), or preoperative patellar gliding (7.6 mm in the "medial" group and 9.7 mm in the "lateral" group).Recurrent patellar dislocation occurred in one patient in the "medial" group and one patient in the "lateral" group had an anterior impaction of the tibial plateau following a fall. Patellar gliding was corrected in both groups: 0.7 +/- 1.8 mm in the "medial group" and 0.0 +/- 0 in the lateral group (p0.05). Residual patellar tilt was +4.2 +/- 3 degrees in the medial group (lateral tilt) and -3.3 +/- 5.4 degrees in the lateral group (medial tilt) (p = 0.003).Pateller gliding was corrected irrespective of the approach. Conversely, the medial approach did not allow effective correction of patellar tilt. The lateral approach with elevation of the anterior tibial tuberosity did not increase morbidity compared with the medial approach. It enabled avoiding residual lateral patellar tilt which can be a source of patellar complications. We prefer this approach for arthroplasty on degenerated knees with lateral femoropatellar arthrosis.

The purpose of this retrospective analysis was to study the parameters having an effect on blood loss during or after total hip arthroplasty. We examined a series of 350 procedures for primary degenerative hip disease with a normal course (n = 100), rapidly destructive degenerative disease (n = 100), and secondary joint degeneration due to atraumatic osteonecrosis of the femoral head (n = 100) or rheumatoid disease (n = 50).All arthroplasties were performed via the transtrochanteric approach using Charnley-Kerboull implants. The volume of blood loss was calculated by noting compensated blood loss (transfusion during the procedure and shortly thereafter), and estimated non-compensated loss using the Nadler and Mercuriali and Inghilleri formula. We examined the influence of age, gender, obesity, and surgeon experience. Data were analyzed with the Student-Fisher reduced deviation method was used for quantitative and qualitative variables and the coefficient of correlation for quantitative variables.Blood loss, calculated in ml packed red blood cells (hematocrit 100%), was 573 ml for arthroplasties with a normal course, 713 for arthroplasties secondary to osteonecrosis of the femoral head, and 950 ml for rapidly destructive degenerative disease and finally 609 ml for patients with rheumatoid arthritis. Considering 35% as normal for hematocrit, total estimated blood loss was 1,640, 2,040, 2,710, and 1,740 ml respectively in the different groups. Compared with the group of patients who had a normal course, total blood loss was significantly higher when arthroplasty was performed for osteonecrosis and rapidly destructive degenerative disease (p0.001). Age, obesity, and duration of the intervention had no effect on blood loss. Female gender and operator experience had a favorable influence in the group of patients who underwent hip surgery for primary degenerative disease. Blood loss occurring during or shortly after total hip arthroplasty was greater in men, when the procedure was performed for osteonecrosis, and most importantly for rapidly destructive diseases.In clinical practice, the influence of gender is not significant enough to require specific preoperative transfusion plans. Conversely, certain etiologies of the joint disease impose transfusion in all such patients, using a blood volume which usually exceeds the possibilities of auto-transfusions.

Treatment of recent laxity of the posterior cruciate ligament is not standardized. The purpose of this work was to analyze results of reconstruction with adjunction of a synthetic ligament for major recent isolated or combined laxity of the posterior cruciate ligament (triades, pentades or dislocations). Our hypothesis was that the synthetic ligament acts like a tutor for healing of the torn ligament.This retrospective analysis included 14 patients (1 woman and 13 men), mean age 27 years. All were competition athletes except one who did not practice sports. Three quarters of the patients were traffic accident victims. The series included three isolated posterior ligament tears, six combined laxities, and five knee dislocations. Average posterior laxity was 24 mm preoperatively. The procedure was performed 7 to 53 days after the accident. Arthroscopic reconstruction was performed for six patients and arthrotomy for eight. All associated lesions were repaired during the same procedure except for two cases (one anterior cruciate ligament and one popliteal tendon). Posterior cruciate ligament repair was achieved with the adjunction of a polyester ligament (LARS) using a one or two strand technique. Patients were reviewed at 36 months mean follow-up (10 - 88 months). The IKDC score was determined. A posterior drawer was measured manually with Telos at 70 degrees.Five stiff knees required either mobilization under anesthesia or arthrolysis. One tear occurred late after the accident during a new trauma. Subjectively, two patients were very satisfied, eight satisfied and three disappointed. Mean knee motion measurements were 6/0/130 degrees . A differential posterior drawer persisted in twelve knees. The Telos measurement of posterior drawer changed from a mean 24 mm to a mean 8 mm. The overall IKDC score was A: 0, B: 7, C: 3, and D: 2. Persistent posterior laxity was the predominant cause of poor scores. Outcome was less satisfactory for all items of posterolateral laxity. There was no difference between the 2- and 4-strand techniques. There were no cases of morbidity (synovitis, spontaneous tear) directly related to the synthetic ligament.The gain in posterior laxity was substantial. Results depended on associated lesions, particularly lateral involvement (stiffness, IKDC score) rather than the repair technique. The synthetic ligament appeared to play the role of a tutor: a single strand measuring 6 mm in diameter is sufficient. This technique spares tendon stock and could be proposed for major posterior cruciate ligament laxity. A longer follow-up will be necessary to confirm the durable stability.

The purpose of this prospective study was to develop and evaluate a method for measuring the femorotibial joint space and to assess the effect of meniscectomy.This study was conducted in a consecutive series of 36 patients undergoing arthroscopic meniscectomy for lesions of the medial meniscus on a stable knee. The height of the joint space was measured on x-rays taken in the morning before the operation then ten days later. X-rays were obtained for both knees in complete extension and in the 30 degrees flexion position. The height of the joint space was measured on the digital version of the x-rays midway between the vertical tangents of the posterior limits of the medial condyle.Readings were not reader dependent and demonstrated no significant difference between the pre and postmeniscectomy height of the medial femorotibial space (30 degrees flexion view, 5.2 +/- 1 and 5.2 +/- 1 before meniscectomy for reader 1 and 5.2 +/- 1 and 5.2 +/- 1 for reader 2 (p=0.05 for Student-Fisher test for paired values). The heights measured by the two readers were correlated (correlation coefficient test).The height of the medial femorotibial joint space can be measured reproductibly on plain x-rays of the knee in the standard flexion position. We were unable to demonstrate any significant difference in joint space between measures taken before and after meniscectomy.

Ligamentoplasty using an autologous transplant provides an effective and long-lasting solution for anterior instability of the knee. The most widely used transplant is the mid third of the patellar tendon. The short- and long-term stability has been proven, but there are reports of morbidity at the donor site affecting the extensor system. Different attitudes have been proposed. Certain authors leave the site open, only suturing the peritendon. Others suture the two peripheral thirds together, either directly or after combing. This different therapeutic options may modify patellar height and affect the tissue at the donor site that some authors suggest can provide transplants for repeated ligamentoplasties. The purpose of this work was to assess the influence of closing the donor site of the patellar tendon on patellar height.Two groups of 40 patients were compared. These patients underwent arthroscopic ligamentoplasty for anterior instability of the knee, excluding all other knee pathology. In the first group, the pretendon fibrous plane was closed alone at the end of the procedure without bringing together the edges of the tendon donor site. In the second group, the peripheral thirds of the patellar tendon were sutured together directly. Patellar height was assessed according to Caton, to Blackburn and to Insall and Salvati on lateral views (20 degrees flexion) of the knee six months after arthroscopy.Irrespective of the method used to measure patellar height, there was no statistical difference between post-operative patellar heights between the two groups (Caton=1.002 +/- 0.176/1.023 +/- 0.215; Blackburne=0.844 +/- 0.183/0.882 +/- 0.196; Insall and Salvati=1.118 +/- 0.213/1.184 +/- 0.146 for group 1 "open tendon" and group 2 "closed tendon" respectively). Pre- and post-operative heights were not different for either group (Student t - Fisher, p=0.05).Patellar height is not significantly changed after ligamentoplasty using the mid third of the patellar ligament with or without closing of the donor site.

Rapidly progressive destruction of the hip joint occurs in approximately 5 to 10% of patients with degenerative hip disease. The cause and natural history remain unclear, but total hip arthroplasty is almost always necessary. We performed a retrospective analysis to determine the particular clinical and radiological features of this condition and to assess long-term outcome after total hip arthroplasty.One hundred total hip arthroplasties were performed between 1984 and 1988 in patients with rapidly progressive hip destruction (67 women and 11 men, mean age 71 years). The transtorchanteric approach was used in all cases to implant cemented Charnley-Kerboull prostheses. Mean follow-up was 7 years 10 months.There were seven complications: two nonunions of the trochanter, three extensive periprosthetic ossifications, one case of recurrent dislocation, and one late hematogenous infection. At last follow-up, the Merle d'Aubigné classification showed an excellent or very good functional result in 95 hips. Stable fixation was observed for 94 acetabular implants and 97 femoral implants. Six acetabular implants showed signs of loosening: certain=1, probable=4, potential=1. Three femoral implants showed signs of loosening: certain=1, potential=2. All the femoral loosenings were associated with acetabular loosening. Four hips required revision surgery: one for nonunion of the trochanter, one for septic loosening, two for aseptic loosening.This series confirmed the radiological and clinical definitions of rapidly progressive hip destruction and demonstrated the reliability of pathological examination of the femoral head and joint capsule. Among the different hypotheses put forward to explain this condition, neither overloading nor use of antiinflammatory drugs would appear to be operating in this series. We were unable to confirm or infirm the micro-crystalline or vascular origin of this condition. Nevertheless, the vascular phenomena observed in the femoral head could be compared with those observed in ischemic joint disease. Arthroplasty led to major blood loss (2706 ml, hematocrit 35). This appears to be higher than observed for arthroplasty performed with the same technique in patients with the usual form of degenerative hip disease. Excepting this fact, the complications observed and the clinical results as well as the longevity of these implants suggest that arthroplasties performed for rapidly degenerative hips are not substantially different from those performed for common degenerative hip disease.

Extensive loss of femoral bone subsequent to implant loosening raises an unsolved problem. The purpose of this work was to examine mid-term results of 18 iterative total hip arthroplasties with femoral reconstruction using massive allografts performed between 1986 and 1997.Using the Vives classification, the femoral bone lesions were grade 3 (n =2) and grade 4 (n =16). The reconstruction was achieved with radiated massive allografts measuring 11 to 35 cm implanted in a split host femur. Charnley-Kerboull implants with a long stem were cemented in the reconstructed femurs.Mean follow-up was 4 years 10 months (range 2 to 9 years). Nine complications in 7 hips were observed: 6 trochanter nonunions, two recurrent prosthesis dislocations and 1 femoral fracture. At last follow-up, the functional result was excellent or very good in 12 hips (Merle d'Aubigné classification). A stable fixation persisted for 15 implants and 3 had loosened. Graft-host femur consolidation was achieved in all cases except 1. There were 3 cases with extensive resorption of the graft including 2 associated with loosening of the femoral component.Reconstruction of the femur after extensive bone loss using a massive allograft appears to be a useful method for restoring bone tissue and providing immediate mechanical support for the femur.

The authors report 4 cases of rapid lateral femoro-tibial chondrolysis following arthroscopic lateral meniscectomy. All patients were young athletes. At the time of meniscectomy, the cartilage of the lateral compartment was normal. Only one meniscectomy was done with the Ho Yag laser. Clinical symptoms were always identical: pain and important swelling, persisting despite intra articular injections of corticosteroids. A second-look arthroscopy was performed after a mean delay of 6 months (5 to 8), showing numerous cartilaginous debris floating in the joint (like in a chondromatosis disease) and a severe cartilaginous damage in the lateral compartment (grade 3 or 4). Swelling disappeared after arthroscopic lavage followed in two cases by a non weight bearing period of one to two months. But X-rays always demonstrated a narrowing of the lateral joint line on flexion-full weight bearing AP views. Rapid chondrolysis is a rare and severe complication of lateral meniscectomy. The etiology, which is mechanical, is not known. It probably represents an acute form of chronic, slow chondrolysis which is frequent after lateral meniscectomy. Rapid chondrolysis should be treated urgently by the following protocol: arthroscopic lavage, intra articular injections of corticosteroids and non weight bearing period.

Introduction Risk prone events (RPE) related to orthopaedic devices may compromise the achievement and/or the result of a surgical procedure. Their analysis to prevent any further incidents is crucial for orthopaedic surgeons. The aim of this work, based on the analysis of targeted RPE declared to the ORTHORISQ organism over a year, is to analyse the circumstances of their occurrence and their causes. Materials and methods For each RPE analysis included the study of the circumstances of the event, the existence of protocols within the institution, and the conditions of recovery. The incidents were classified into three groups: non-available medical devices, non-sterile medical devices and non-functional medical devices. Results The RPE related to medical devices accounted for 35% of all the declarations to Orthorisq (424 cases in 1500). The distribution in the three groups was respectively 55% for non-available medical devices, 29% for non-sterile medical devices 16% for non-functional medical devices. The event “non-available medical devices” concerned primarily casually loaned implantable devices (implants, prostheses). In 20% cases, the device was used occasionally in the institution. In 30% cases, the order was too late with a deadline less than 48 h. In 35% cases, there was no checking procedure of the implants in immediate pre-operative time and 17% of the institutions concerned seem not to have any procedure to deal with expired sterilisation. The event “non-sterile medical devices” mainly concerned cases of perforation of packaging paper and wet sterilisation containers. These events have resulted in recovery periods of about 82 min on average. In 58% cases, the transport containers are used as containers for sterilisation. The existence of a quality manager for the sterilisation department is reported only in 79% of cases. The ‘non-functional medical devices’ group is dominated by the preoperative breakage as well as compatibility problems between the ancillary available and the device to remove. Discussion Perioperative issues with orthopaedic devices are frequent. They are mainly due to organisation or procedural planning problems, and malpractice is frequently involved. Those issues could be avoided with respect to existing protocols, for example, the use of a minimum deadline in ordering devices before the surgical procedure, checking protocol of ordered devices, and checking conformity of devices to the order. We did not find any link between the distance of sterilisation department to operating room and the occurrence of RPE, but we emphasise and remind that existing sterilisation procedures must be applied. Sterilisation of urgently needed devices is a recovery mode which can significantly increase the operative time, but with increased theoretical risk of infection. Conclusion Following this work, five preventive measures can be proposed. We recommend: to develop loan agreements between institutions, to respect minimum deadline order of ancillaries and devices to companies, to have double set of implantable devices available, to have checking procedures of implants and finally to have a universal ablation ancillary equipment available. Introduction Les EPR lies a un probleme de materiel orthopedique peuvent compromettre la realisation et/ou le resultat de l9intervention projetee. Leur analyse dans le but de prevenir tout nouvel incident est donc capitale pour les chirurgiens orthopedistes. Le but de ce travail, base sur l9analyse des EPR cibles declares a l9organisme ORTHORISQ sur une periode de un an, est d9analyser leurs circonstances de survenue et leurs causes. Materiel et methodes Pour chaque EPR, l9analyse comportait l9etude des circonstances de l9evenement, l9etat des procedures au sein de l9etablissement, ainsi que les conditions de recuperation. Les incidents ont ete classes en trois groupes : dispositifs medicaux non disponibles, dispositifs medicaux avec sterilisation non conforme, dispositifs medicaux non fonctionnel. Resultats Les EPR en rapport avec le materiel representaient 35% des declarations totales (424 cas sur 1500). La repartition dans les trois groupes etait respectivement 55% pour les dispositifs medicaux non disponibles, 29% pour les dispositifs medicaux avec sterilisation non-conforme et 16% de dispositifs medicaux non fonctionnels. L9evenement « dispositifs medicaux non disponibles » concernait principalement les dispositifs medicaux implantables (implants, protheses) en pret occasionnel. Dans 20 % des cas, le dispositif etait utilise occasionnellement dans l9etablissement. Dans 30 % des cas, la commande etait trop tardive avec un delai inferieur a 48heures. Dans 35 % des cas, il n9y avait pas de procedure de verification des implants en pre operatoire immediat et 17 % des etablissements interesses ne disposaient pas de procedure de gestion des perimes. L9evenement sterilisation non conforme concernait majoritairement des cas de perforation d9emballage papier ainsi que les charges de sterilisation mouillees. Ces evenements ont entraine des delais de recuperation de l9ordre de 82 minutes en moyenne. Dans 58% des cas, les containers de transport sont utilises comme containers de sterilisation. L9existence d9un responsable qualite en sterilisation pour l9etablissement n9est declaree que dans 79% des cas. Les dysfonctionnements de materiel sont domines par les ruptures per operatoire de materiel ainsi que par les problemes de compatibilite entre le materiel a enlever et l9ancillaire disponible Discussion Les problemes de materiel peri-operatoire en chirurgie operatoire sont frequents. Ils sont lies majoritairement a des problemes d9organisation ou de planification des interventions avec un non respect frequent des bonnes pratiques. Ces problemes pourraient etre evites par le respect des procedures deja en vigueur, notamment le respect d9un delai de commande suffisant avant l9intervention et la verification a la reception de la conformite de la commande. Si nous n9avons pas trouve de lien entre l9eloignement eventuel du lieu de sterilisation et la survenue de dysfonctionnements, la necessite du respect des procedures de sterilisation en vigueur doit etre soulignee et rappelee.La sterilisation en urgence du materiel necessaire, est un mode de recuperation possible qui augmente de facon significative le temps operatoire, avec une augmentation theorique des risques infectieux. Conclusion A l9issue de ce travail, 5 mesures preventives peuvent etre proposees. Il s9agit de la necessite de developper des conventions de pret inter-etablissements, de respecter les delais de commande aux laboratoires, de disposer du materiel implantable en double, de disposer de procedures de verification de la conformite des implants et enfin de disposer d9ancillaires universels d9ablation du materiel.

Background and objectives Antibiotic prophylaxis is a major tool for the safe implantation of any medical device. The ‘Societe Francaise d9Anesthesie et Reanimation’ (SFAR) produced the first French guidelines for antibiotic prophylaxis back in 1992 but, since then, several practice surveys have shown that compliance is low. Our objective was to develop recommendations for improving compliance. Programme We reviewed 153 analytical questionnaires that had been completed by all the orthopaedic surgeons who had reported a risk event related to antibiotic prophylaxis during their 2008 ‘accreditation programme’. Reporting was to Orthorisq, a certified organisation. The questions explored four fields directly related to the circumstances and professional conditions prompting the report: (1) characteristics of the institution9s antibiotic prophylaxis protocol, (2) circumstances leading up to the discovery of the event, (3) search for human and organisational causes, and (4) recovery actions, if carried out. The questionnaires reflected the experience of orthopaedic surgeons, most of whom were discovering risk management procedures for the first time. Results An antibiotic prophylaxis protocol existed in nearly all institutions, but was not available at the appropriate site in 15% of cases. Most orthopaedic surgeons considered that the protocol was suited to their practice, but over 10% did not know its exact content. Most reports were the result of an immediate peri-operative dysfunctional event that the surgeon had discovered by chance. Most risk events were discovered after skin incision. A systematic prospective (use of checklist) or retrospective (audit) analysis was very seldom performed. The causes of the event were material (28%), human (92%) and/or organisational (50%). The main cause of inappropriate antibiotic prophylaxis was ‘omission of administration through negligence or inadvertence’ (56% of reports). Overall, 65% of surgeons reported a low-grade recovery procedure, but only 20% of them were able to reinitiate an appropriate antibiotic prophylaxis procedure. Discussion and conclusion Our results have highlighted the risks related to the cross-disciplinary and cross-professional (‘transversal’) aspects of the prescription and administration of antibiotic prophylaxis, thus raising the issue of the practitioner9s responsibility in the case of a nosocomial infection. Because of the high rate of omissions, 40% of surgeons spontaneously suggested routine use of a checklist. The following improvement axes were proposed: (1) updating protocols for antibiotic prophylaxis by indicating ‘who does what?’; (2) routine checks of protocol knowledge by all new arrivals (resident practitioners, temporary staff, and locums); (3) involving patients in data collection for their medical records; (4) encouraging use of a checklist in line with WHO and HAS recommendations. These conclusions should be taken into account when SFAR next updates its guidelines on antibiotic prophylaxis. They could also be used as an information source for medical professional liability insurance purposes in order to define professional malpractice profiles better. Contexte, objectifs L9antibiotherapie prophylactique est un des atouts majeurs a la pratique securisee de l9implantation de tout dispositif medical implantable. La Societe Francaise d9Anesthesie et Reanimation (SFAR) a edicte en 1992 les premieres recommandations en antibioprophylaxie, mais les differentes enquetes de pratique montrent une observance faible. Programme Ce travail est base sur l’etude de 153 grilles d9 « analyse approfondie » ciblee adressees aux chirurgiens orthopedistes ayant declares un evenement porteur de risque (EPR) concernant l9antibioprophylaxie au cours de l9annee 2008 dans le cadre de leur « bilan d9accreditation » via l9organisme agree Orthorisq. Les questions proposees exploraient quatre domaines interessant directement les circonstances et l9environnement professionnel ayant conduit a la declaration du dysfonctionnement: (1) les caracteristiques du protocole d9antibioprophylaxie de l’etablissement, (2) les circonstances de decouverte de l’evenement, (3) la recherche de causes humaines et organisationnelles et (4) les actions de recuperation menees quand elles existaient. Ces questionnaires representent un retour d9experience des chirurgiens orthopedistes decouvrant, dans leur grande majorite, la demarche de gestion de risques. Resultats Un protocole d9antibioprophylaxie existe dans quasiment tous les etablissements mais n9est pas disponible aux endroits adequats dans environ 15% des cas. La majorite des chirurgiens orthopedistes considere qu9il est adapte a leurs pratiques mais plus de 10% ne savent pas ce qu9il contient. La majorite des declarations provient de decouvertes fortuites par le chirurgien d9un dysfonctionnement peri-operatoire immediat. Une analyse systematique, prospective (check list) ou retrospective (audit), reste anecdotique. Des causes humaines ont ete retrouvees dans 92% des declarations, des causes materielles dans 28% et des causes organisationnelles generales dans 50% des declarations. Quant aux actions de recuperation, si 65% des declarants disent avoir mis en place une procedure degradee, seuls 20% ont pu reinstaurer une procedure d9antibioprophylaxie conforme. Discussion Les resultats de cette enquete mettent clairement en evidence les risques lies au caractere transversal de la prescription et de l9administration de l9antibioprophylaxie, soulevant le probleme de la responsabilite des praticiens en cas d9infection nosocomiale. La majorite des EPR ont ete decouverts une fois l9incision deja realisee. La principale cause d9antibioprophylaxie mal ou non realisee reste « l9oubli de l9administration par negligence ou inadvertance » (56% des declarations): dans cette optique, l9institution d9une « check list » etait spontanement proposee par 40% des declarants. Conclusions Les axes d9amelioration proposes sont: (1) la redaction de protocoles d9ATBP precisant « qui fait quoi? »; (2) la verification de la bonne connaissance de ces protocoles par les nouveaux praticiens, vacataires ou remplacants; (3) l9implication du patient dans la collection des informations medicales le concernant; (4) l9institution de la pratique d9une « check list » conformement aux recommandations de l9OMS et de la HAS. Ces conclusions meriteraient d’etre prises en compte lors de l9actualisation des recommandations sur l9antibioprophylaxie prevue par la SFAR. Enfin, elles pourraient participer a l’etablissement de recommandations susceptibles d9intervenir dans l’evaluation des profils de sinistralite des praticiens.

Plantar fracture-dislocation of the tarso-metatarsal joint (Lisfranc plantar fracture-dislocation) is rather unusual. The authors described a case sustained in a 39 years old man injured in a motorcycle road traffic accident. Mechanism was recognized as plantar hyperflexion combined with an axial foot compression. Open reduction, and K-wires fixation were performed. An anatomical feature was restored. In an additional anatomical study on 8 cadavers, the plantar direction of a fracture-dislocation of the tarso-metatarsal joint was observed when the injury axis followed the scapho-cuneiform joint of the inner border of the foot and the cuboïdo-metatarsal joint on the lateral border, so that both tibialis muscles were fixed on the distal fragment. As tibialis posterior muscle is more powerful, the direction of the dislocation will be plantar. This type of injury is different from plantar fracture-dislocation of the tarso-metatarsal joint secondary to direct load bearing on the dorsum of the foot with severe skin and vessels injuries.