Purpose: Operative site infections can have catastrophic consequences after orthopaedic surgery. Prevention is particularly difficult due to the large number of factors involved. We describe here an exceptional epidemic of meti-R Staphylococcus aureus (MRSA) operative site infections whose source was successfully identified and eradicated.

Material and methods: The epidemic affected seven patients who underwent orthopaedic surgery during a thirteen-month period. All patients developed acute MRSA operative site infection. The epidemic nature of the infections was confirmed by the bacteriological study which identified the causal germ as a specific MRSA strain very different from strains generally identified in hospital infections. The causal strain was sensitive to quinolones and resistant to amikacin. Antibiotic therapy prescribed in all cases was combined with surgical lavage in four patients. Search was undertaken to identify an environmental or human source. An audit of the operating theatre was performed and nasal swabs were obtained from all personnel present at the last operation complicated by operative site infection. One non-medical assistant was found to be a carrier of the same MRSA strain incriminated as the cause of the epidemic. Nasal application of mupirocin successfully eradicated the carrier-state. No new case of operative site infection was noted for more than fourteen months.

Discussion: Operative site infections in orthopaedic surgery led to longer inpatient care and can compromise functional outcome. These nosocomial infections have a significant impact on mortality and constitute a major cost burden for hospitals. Prevention, control and treatment of MRSA nosocomial infections is a major challenge in hospitals throughout the world. Most operative site infections are caused by direct contamination during the operation. This epidemic highlights the importance of strict application of rigorous preventive measures not only by the surgical team but also by all healthcare workers and hospital personnel in general.

Conclusion: The specific antibiotic susceptibility pattern of a Staphylococcus aureus strain incriminated in several operating site infections enabled identification of the source of the epidemic and its eradication.

Purpose: We report our expeience with the medial and posteromedial approach to the humerus for plate fixation of fractures of the distal two-thirds of the humerus.

Material: Fifteen patients (eleven men and four women) were treated for fractures (n=13) or nonunion (n=2) situated below the proximal third of the humerus without radial nerve involvement.

Methods: Eight patients were installed in the supine position for median approach between the humerus bundle and the median nerve anteriorly and the ulnar nerve posteriorly. The posteriomedian approach, with the ulnar nerve posteriorly and the brachial triceps anteriorly, was used for seven other patients installed in the prone position. The fixation plate applied to the medial aspect allowed at least six corticals on either side of the fracture line. The patients were immobilised for 45 days. Passive rehabilitation exercises involved the elbow and the shoulder without external rotation. Clinical and x-ray follow-up data were available for all patients.

Results: One patient was lost to follow-up two months after surgery: at this time the x-ray had demonstrated bone healing. Function could not be assessed as the fracture had occurred on the same side as the hemiplegia also caused by the initial trauma. For the fourteen other patients, mean follow-up was 12 months (range 6 – 36). Three patients operated via the median approach presented paraesthesia in the median nerve territory which was regressive in two. There were no neurological complications in the posteromedian approach group. Function was good for elbow and shoulder except for two patients. Bone healing was achieved in all cases.

Discussion: These approaches allowed avoiding dissection of the radial nerve and provided a more aesthetic scar. Several difficulties were encountered with the median approach and reduction was difficult to control. In such cases it is advisable to widen the exposure to avoid stretching the median nerve. These approaches are contraindicated if radial nerve injury is identified preoperatively.

Conclusion: Osteosynthesis of the humerus via a median approach avoids the need for radial nerve dissection. Reduction appears to be easier via the posteromedian approach with less risk than with the median approach.

A 55-year-old man developed a pseudoaneurysm of the popliteal artery after tibial valgization osteotomy performed for degenerative genu varum. A tourniquet was used for the procedure. A wedge osteotomy was performed two centimeters under the joint line; the correction angle was ten degrees. Immediately after the end of the procedure, the distal pulses disappeared for ten minutes. Doppler exploration of the arterial network did not demonstrate any anomaly. Ten days postoperatively, the patient complained of sudden onset pain in the knee and tension in the popliteal fossa. Arteriography demonstrated a pseudo-aneurysm of the popliteal artery. The lesion caused an interruption of arterial flow and was successfully treated by emergency resection and suture.

There is ambiguity concerning the nomenclature and classification of fractures of the ring of the second cervical vertebra (C2). Disruption of the pars interarticularis which defines true traumatic spondylolisthesis of C2, is often wrongly called a pedicle fracture. Our aim in this study was to assess the influence of asymmetry on the anatomical and functional outcome and to evaluate the criteria of instability established by Roy-Camille et al. We studied the plain radiographs and CT scans of 24 patients: 13 were judged to be asymmetrical, ten were considered unstable and 14 stable.

Treatment was with a Minerva jacket in 15 fractures and by operation in nine. Surgery was undertaken in patients with severe C2 to C3 sprains. One patient with an unstable lesion refused operation and was treated conservatively with a poor radiological result.

Our study showed that asymmetry of the fracture did not affect the outcomes of treatment and should not therefore influence decisions in treatment. The criteria of Roy-Camille seem to be reliable and useful. We prefer the posterior approach to the cervical spine, which allows both stabilisation of the fracture and correction of a local kyphosis.