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P Vichard

Publications and source records attributed to P Vichard.

At least 19 recordsLinked to original sources
PubMed2003

Modelling the usefulness of a dedicated cohort facility to prevent the dissemination of MRSA.

The aim of this retrospective study was to determine whether or not a surgical dedicated cohort facility, mainly dedicated to the care of orthopaedic patients, can control the risk of infection caused by methicillin-resistant Staphylococcus aureus (MRSA). We tested this hypothesis on the orthopaedic surgery ward of a university-affiliated public hospital with 1228 beds by determining whether there was a significant correlation between the colonization pressure exerted by MRSA and the number of cases of acquired MRSA. This was then used as a tool to predict the number of patients contaminated with MRSA in hospitals with and without dedicated cohort facilities. We found that the relative risk of MRSA acquisition increased with the colonization pressure exerted by MRSA imported cases. This statistical model enabled us to predict that the risk of MRSA acquisition would increase by 160% per year in the absence of a dedicated cohort facility. We conclude that these units are useful to control the spread of MRSA in hospitals.

Cohort Studies↗
PubMed2001

[Osteosynthesis of distal radius fractures by doral plate: advantages and disadvantages].

Distal radius fractures remain a challenge. No one osteosynthesis procedure can solve all the problems. A method of analysis is necessary in order to choose the best tools. Open treatment of the fracture is logical but rarely performed. A review of the literature and the experience of the authors are reported in order to analyse the correct place of dorsal plating in distal radius fracture with dorsal displacement. The learning curve of the operative procedure and the design of the implants can explain the occurrence of several complications. The dorsal plate is effective against secondary dorsal displacement. This demanding procedure must be compared with other reported procedures (pining and external fixator) to define the advantages and disadvantages.

Bone Nails↗
PubMed2001

[Occult fractures of the carpal navicular. Detection by quantitative radioscintigraphy. Social and medico-legal repercussions].

Fractures of the scaphoid of the wrist are not easily diagnosed and when they are eventually recognized due to late complications, the prognosis is much poorer than it would have been at injury. Medical negligence and poorly-performed or interpreted x-rays are frequently cited as reasons for non-diagnosis. Often these fractures are trabecular, so-called occult, and they cannot be seen on a conventional exam, even if well-performed. Tomography and tomodensitometry have yielded poor results. Quantitative radioscintigraphy (QRS), the exam we are proposing, is a modification of scintigraphy, which is a very sensitive exam (100%) but has little specificity. The first step in QRS is to quantify the fixation of the tracer on the injured side and compare it to that of the uninjured side. If the injured side fixation is double that of the uninjured side, a fracture (often scaphoid) is present. MRI is our reference. In the second step in QRS, a computer-assisted fusion is made of the scintigraphic image and the x-ray (quantitative scintigraphy has the same diagnostic value as MRI). The center of the fracture is localized, thus yielding a specificity of nearly 100% for this exam. Out of a prospective series of 154 patients who had a conventional examination: 41% were diagnosed to have a scaphoid fracture using QSR, therefore a number higher than supposed. Rare carpal fractures were also detected. The cost of this exam is low. The exam climinates non-diagnosed fractures which can lead to non-union and arthrosis. Due to the frequency of carpal trauma, this exam should have a significant effect on the individual, on social security costs and litigations.

Adolescent↗
PubMed1999

[A turning point in the therapeutic history of open leg fractures: osteosynthesis coupled to the immediate dressing in the presence of major damage to the soft tissues].

A brief history of the treatment of open leg fractures (OLF) points out the problems posed by the present therapy with regard to the soft tissues in the most serious cases (type III from cauchoix, Duparc, type III A and B from Gustilo). Which strategy should be foremost, knowing that the debridement, stabilization and cover are the three essential procedures? Rigorous debridement certainly carries unanimous approval but some are opposed to this procedure during the first few days. Also widely recognized is the beneficial aspect of early cover when regarding aseptic evolution, consolidation, low rate of complications, rehabilitation and the patient's helplessness. However, despite the well demonstrated results of BYRD [14] and GODINA [15] and because of the debridement concept and logistical insufficiencies, thorough treatment in a true emergency has not achieved full acceptance. In general, the majority of surgeons first clear, stabilize with the use of an external fixator in true emergency situations and cover several days later. For the past ten years, in real emergencies, in the Department of Orthopedics, Traumatology and Plastic Surgery at the Besançon University Hospital Center we have subscribed to a radical treatment which simultaneously combines debridement, osteosynthesis (locked centro-medullary nailing) and cover with the use of free flaps in the same operating period. A study based on 27 wounded patients seeks to validate the advantages of looked centro-medullary nailing over the use of an external fixator and the use of free flaps rather than local flaps in the most serious cases.

Adult↗
PubMed1998

[Hand replantation: long-term functional results (apropos of 8 cases)].

STUDY AIM: The aim of this study was to report the long term functional results after replantation of the hand in eight patients. MATERIALS AND METHODS: Between 1977 and 1995, hand replantation was performed in eight cases (six males and two females). Mean age at the time of injury was 31 years (24-47 years). The dominant hand was amputated in half of the cases. In two cases, the soft tissue lesions were severe; in the six other cases, the wound was clean-cut. The level of amputation was transmetacarpal (n = 2), carpal (n = 2), wrist (n = 2), distal part of the forearm (n = 2). RESULTS: The mean convalescence time was 16 months (from 6 months to 2 years). The degree of disability ranged from 40 to 65%. Patient follow-up lasted 2 to 20 years (mean: 11 years). The return of discriminative sensitivity of the digits was noted in six cases. The active motion of the fingers was satisfactory in all cases, but intrinsic muscle function was weak or absent. Pinch and grasp strength was reduced from 10 to 60% (when compared to the non-damaged hand). One patient resumed his prior occupation, and another resumed his occupation part-time. The six other patients found new occupations. CONCLUSION: All the patients achieved a useful function of their replanted hand in their daily, spare-time and professional activities.

Adult↗
PubMed1998

Trauma emergency unit: long-term evaluation of a quality assurance programme.

OBJECTIVE: Long-term evaluation of a quality assurance programme (after an assessment in 1993). DESIGN: Review of medical records. SETTING: Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon). SUBJECTS: 1187 consecutive ambulatory patients' records, from July 1995. MAIN MEASURES: Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event). RESULTS: 71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols). CONCLUSIONS: Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme.

France↗
PubMed1997

[Functional treatment of isolated fractures of the ulnar diaphysis in adults. A prospective study apropos of 10 cases and review of the literature].

In this prospective study, ten consecutive isolated fractures of the ulna were treated by short-arm plaster cast (an average of 16.8 days) with immediate mobilization in our institution since January 1995. The minimum follow-up was eight months and the longest was two years. All fractures were closed. The median age of the patients was 36.7 years (17 to 61), the male to female ratio was 7 to 3. The patients were seen and radiographed every two weeks until bridging external callus was detected by same surgeon. Monteggia fractures-dislocation, open fractures, fractures with elbow or wrist dislocation and gunshot fractures were also excluded. The fracture involved the distal third in 5 cases, the distal quarter in 4 cases and the middle third in one case. Seven fractures were displaced between 2.5 and 6 mm, but no fracture needed reduction. All patients returned to work a mean of 4 months after the accident. Some angulation was found in most cases, but it rarely exceeded 10 degrees. In this study, the average healing time was 8 weeks and there were no non-unions. We did not encounter any synostosis between the radius and ulna in our patients. Motion at the wrist and elbow was always restored. All patients were satisfied by the functional method. The method that we have described can be safely recommended as treatment of choice for these fractures. Completely displaced, Monteggia fractures, comminuted or gunshot fractures of the ulna should be treated by other methods.

Adolescent↗
PubMed1997

[Recent, closed trapezio-metacarpal luxation, treated by pinning.Apropos of 7 cases with a median follow-up of 8 years].

Seven cases of acute and closed traumatic dislocation of the trapezio-metacarpal joint treated by percutaneous pinning adapted by Wiggins are reported with an average follow-up of eight years. Seven patients (five men and two women) aged 18 to 62 were treated. The injury was due to a road traffic accident in four cases. The dominant hand was injured in six cases. The metacarpal base was always dislocated dorsally and closed reduction always remained unstable. All cases consisted of closed dislocation but in two cases dislocation was associated with upper limb fractures. On the initial radiographs no patients had degenerative changes. All patients were treated as an emergency or the following during the days injury by reduction and stabilization by one or two percutaneous kirschner wires followed by a scaphoid cast for three to six weeks. All patients were followed and reviewed for this study between two and thirteen years (mean eight years) after injury. Enquiries were made about return to work, pain, stability, range of movement, key-pinch and grasp compared with the uninjured side. The joint was examined radiographically with particular attention to the presence of subluxation and degenerative changes. 2 patients with associated complex injury of the upper limb developed reflex sympathetic dystrophy. 2 patients had moderate pain, 2 patients had limitation of joint movement, 1 patient presented a reduction of strength (pinch and grasp) but none had subluxation, instability, or degenerative changes. Closed reduction and stabilization by percutaneous pinning is a simple method and gives good or excellent results in the treatment of acute traumatic dislocation of the trapezio-metacarpal joint.

Accidents, Traffic↗
PubMed1997

[Treatment of complex fractures of the ankle and their sequellae using trans-plantar intramedullary nailing].

UNLABELLED: Nine patients were treated for complex tibial pilon and talus fractures or non unions from 1990 to 1997 using intramedullary nails introduced through the calcaneus. All patients were followed until healing. The average follow-up was 14 months. Failure of the procedure was defined by the occurrence of complications or reintervention. We used a modified Seidel nail in 5 cases, a tibial shaft nail in 3 cases, and a special nail in one case. All nails but two were locked. CASES: These arthrodeses were performed for treatment of sequels from open talus fractures. Transplantar nailing was performed between 9 months and 3 years after arthrodesis, because of non union. In two cases fusion was obtained at 3 and 8 months postoperatively. In the third case non union occurred due to instability of fixation (the nail was unlocked). Replacement by an interlocked nail was performed through a proximal tibial approach, and healing was obtained in 6 months. PSEUDARTHROSES: 2 CASES: These two cases presented comminuted tibial pilon and open talus fractures in association with vascular and tendon lesions. They had previously undergone debridement and external fixation. Transplantar nailing was performed 8 and 10 months after trauma using a locked modified Seidel nail. Radiographic fusion was obtained in 5 months. PRIMARY SURGERY: 4 CASES: The first two cases were foot reimplantations after traumatic amputation. Skeletal stabilization was obtained using a transplantar locked tibial nail. Revascularization attempts failed and an amputation was performed on the fourth day in one case. The reimplantation succeeded in the second case. Radiographic fusion was obtained in 2 months. The third case was a distal tibial shaft fracture. The patient was an obese mentally deficient and invalid woman. Bone union was achieved in four months. The last case was a primary arthrodesis for post-trauma necrosis of the talus. Radiographic fusion was observed 45 days after operation. Transplantar locked nailing offers an optimal stabilization for complex ankle fractures. We had two failures not related with the principle of the technique. We think that transplantar nailing is best indicated to obtain tibiotalar or tibiocalcaneal arthrodesis and to treat compound ankle fractures. Another indication could be distal tibial shaft fractures in invalid or mentally deficient patients.

Adolescent↗
PubMed1997

[Complex injuries of the dorsum of the hand. Therapeutic reflections apropos of 2 cases].

UNLABELLED: We report 2 similar cases of severe injury of the dorsum of the hand, both treated in emergency. FIRST CASE: A 37-year-old right handed male truck driver was admitted with a complex severe injury of the dorsum of his right hand following a traffic accident. He had a combined large defect involving skin, tendons and bone. A complex reconstruction was performed using a massive iliac crest allograft, a tendon graft and a free serratus anterior flap in a one stage procedure, eight hours after the injury. A skin graft was done later. Two years later the functional and esthetic results are good. SECOND CASE: A 37-year-old woman was admitted with a severe injury of the dorsum of her right hand following a traffic accident. She had a large combined defect involving skin, tendon and bone. A complex reconstruction was carried out using a large iliac crest autograft, a multiple tendon graft and a free latissimus dorsi flap, in one stage 6 hours after the trauma. Eight months later the functional result is partial but useful for the daily activities of the patient.

Adult↗
PubMed1997

[Reflections on recent ruptures of the diaphragm. Apropos of 45 cases].

Trauma-induced ruptures of the diaphragm are very exceptional but are regularly encountered in trauma surgery units. Closed ruptures occur in 60 to 80% of diaphragm lesions in European series, 9 times out of 10 after traffic accidents. Large American trauma centers however, have had more experience with stab of firearm wounds. The diagnosis raises many problems and requires further exploration after the standard chest x-ray. We discuss the different explorations which can be contributive in both emergency and non-emergency situations. The most appropriate therapeutic approach is also discussed. Should thoracotomy or laparotomy be used? What precautions are required prior to surgery? Can laparoscopy be useful?

Adult↗
PubMed1997

[Value of the surgical approach through the patellar tendon for intramedullary nailing of the tibia and the femur].

The goal of this study was to propose a new approach of the upper tibia for intramedullary nailing. Since two years, the authors performed a transversal skin incision superior to the distal end of the patella. The patellar tendon is dissociated and the tibia is perforated through the anterior intercondylar area. The advantages of this approach versus classical techniques are discussed. This approach allows isolated tibial or femoral nailing but also both nailings during the same procedure.

Bone Nails↗
PubMed1996

[Kienböck's disease treated by shortening osteotomy of the radius. Analysis of the results apropos of 13 cases].

A series of 13 cases of Kienbock's disease, treated by shortening of the radius, operated between 1975 and 1995, is presented. This series consisted of 7 males and 6 females with a mean age of 27.5 years (range: 17 to 37 years). The dominant hand was affected in 12 cases. 6 men and 5 women performed heavy work. The mean period between the first symptoms and the operation was 18 months (range: 3 months to 6 years). In 10 cases, pain was severe and limited activities; in 3 cases, pain was moderate with partial limitation of activity. 8 cases had a mobility greater than 75% compared to the healthy side. 5 cases had a mobility of approximately 50%. None of the cases had a mobility less than 25%. Strength was not measured preoperatively with the JAMAR dynamometer. The standard radiographic assessment included an AP palm-plate film (raised palm) and a true profile on a small board. This radiographic assessment established, for each case: the Decoulx and Lichtmann classification, the radioulnar index, the angle of the radial slope and the lunate fossa, collapse of the carpus according to Youm and McMurtry. There were two stage 1, three stage 2, eight stage 3 (six stage 3A, and two stage 3B) and no stage 4. The radioulnar index was negative in 10 cases, zero in 1 case, and positive in 2 cases. The mean angle of the radial slope was 23 degrees, the mean angle of the lunate fossa was 10.8 degrees, the mean height of the carpus was 0.476. The incision was anterior in 7 cases, and posterolateral in 6 cases. The mean shortening was 5 mm (range: 4 to 6 mm). Patients were reviewed with a mean follow-up of 5 years (range: 10 months to 12 years). The analysis according to Michon's criteria revealed 3 excellent results, 9 good results, 1 moderate result and no poor results. All patients were able to resume their previous occupation. Five no longer had any pain, 6 had moderate and rare pain, 2 patients presented pain limiting activity. 10 patients presented a mobility greater than 75% compared to the healthy side. In 2 cases, the mobility was greater than 50%. In 9 cases, the strength was greater than 75% compared to the healthy side, and in 4 cases, it was greater than 50%. Radiological assessment, all stages combined, showed 4 improvements, 7 stabilizations, 2 deteriorations. There was no correlation between the height of the carpus (which varied only very slightly postoperatively) and the clinical or radiological course. In this series of 13 patients; shortening osteotomy gave results on all stages of the disease. There was no correlation between the clinical and radiological course of the lunate, and the following factors: age, preoperative radiographic stage, instability of the carpus, position of the plate. On the basis of the results of our series, it appears important to increase the angle of the lunate fossa and to obtain an angulation greater than 12 degrees 5 and to maintain a negative radioulnar index. The 2 cases of radiological deteriorations corresponded to a positive postoperative radioulnar index, while the index remained negative in the 4 cases of improvement; all cases in which the angulation of the lunate fossa was greater than 12 degrees stabilized or improved radiologically, regardless of the preoperative stage. Despite contradictory theories, we believe, in the light of our series, that an angulation of the lunate fossa greater than 12 degrees and that a negative radioulnar index appear to be decisive criteria in the course of Kienböck's disease treated by shortening of the radius.

Adolescent↗
PubMed1996

Incidence and preventability of adverse events in the emergency room of an orthopaedic traumatologic surgery unit.

This paper reviews the nature and the frequency of adverse events in the everyday functioning of a French trauma emergency unit, and evaluates the feasibility of their detection by the means of a daily record review. A senior surgeon identified the adverse events by reviewing the complete record with a minimal 6-months follow-up for every patient attending the emergency unit during a 10-week period. To test the reliability of this review, a blind re-review of all records corresponding to the detected adverse events, mixed with an equal number of controls, was carried out by two independent experts. The review of the 2604 records identified 210 medical adverse events, most of them occurring early in the care process. Sixty-seven per cent of the adverse events involved prevention failure, mainly for tetanus but also for thrombosis and rabies. For the other 33% it was possible to determine two situations with a high risk of adverse event: body contusions following a traffic accident and metacarpo-phalangeal thumb sprains. The re-review evaluated the positive predictive value of the initial review to be 97.5% and its negative predictive value to be 96%. It is concluded that the review of the initial record by a single senior is effective in detecting the adverse events. Prevention of two-thirds of them could be possible by the implementation and monitoring of protocols.

Aftercare↗
PubMed1996

[Additional supra-malleolar osteotomy].

This old operation is rarely practiced and it appeared interesting to precise its technique and indications from a short series. In the majority of our cases, a valgus type osteotomy by medial graft addition was performed. One or more prismatic triangular graft are taken from the full thickness of the iliac crest. The respect of the fibula protects the periostal hinge on the other side of the surgical approach; so the graft under pressure will have rapid and constant consolidation. Tibial osteosynthesis is facultative. We can distinguish major indications of that type of osteotomies: supramalleolar malunion, while the fracture of the fibula associated to the tibia is a contra-indication for that operation. The other indications are the distortion of the pilon articular surface and old ligamentous lesions leading to osteoarthritis. In some cases, it is appropriate to realise valgisation of the articular surface, with an overcorrection to harmonise the pressure on articular surfaces; on that condition, an osteotomy of the fibula has to be discussed. The rapid and constant good results obtained with those iliac crest grafts interposed between the two fragments of the tibia contrast with those hazardous results of inlay or onlay grafts, free from all mecanical sollicitations.

Adult↗