[Future of interprofessional primary care in time of crisis]

The world is facing a crisis with several dimensions, economical, moral, social, epidemiological and scientific. This crisis is likely to have an impact on organisation of Primary Care, and on interprofessional collaboration. Several issues are raised by this situation: who will arbitrate rationalisation or rationing of care? Which professions will be called upon to collaborate? How will professionals take side between justice based on redistribution, and justice based on recognition? What will be the cost of reorganizing the work of the various professionals, particularly regarding the modification of the range of skills? How will collaboration among professionals be organized, vertically or horizontally? How will research evolve? This paper tries to reflect on this issues.

Bioabsorbable versus stainless steel screw fixation of the syndesmosis in pronation-lateral rotation ankle fractures: a prospective randomized trial

Thirty-two patients who had pronation-lateral rotation (PLR) fractures occurring four centimeters or more proximal to the ankle joint or lower if the talus was displaced greater than one centimeter laterally were enrolled in this study. Seventeen patients were randomized to fibular plate fixation with a 4.5 ml polylactic acid (PLA) bioabsorbable syndesmotic screw, and fifteen patients randomized to fibular plate fixation with a 4.5 mm stainless steel syndesmotic screw. All thirty-two patients had uncomplicated healing of their fibular fracture without loss of reduction. There was neither evidence of osteolysis nor sterile effusion in the patients who were treated with the PLA screw. There were no wound complications in either group. No difference in range of motion or subjective complaints was noted in either group. Use of the PLA syndesmotic screw at short-term follow-up was well tolerated and avoided the need for subsequent screw removal.

Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP)

A group from the European Working Party on Quality in Family Practice (EQuiP), working with over 20 European colleges of primary care, has assessed what, in their view, is needed to improve the quality of care at the interface between general practice and specialists. Experiences and ideas from a wide range of people were gathered through focused group discussions. From these it was clear that, for real improvement at the interface of care, changes are needed in the system of care and in the ways that doctors view their roles and their performance. All providers of care need to be able to see the care system from the patients' perspective if they are to help their patients make sense of and benefit from an increasingly complex system. This paper outlines the EQuiP recommendations on how cooperation between general practitioners and specialists might be improved. This includes strategic perspectives and both targets for improvement and methods for teaching, training and development that are all independent of country and health care system. The 10 targets for development identified by the group are: leadership, initial shared care approaches, task division, mutual guidelines, patient perspective, informatics, education, team building, quality monitoring systems, and cost effectiveness. Working towards these targets could provide an effective approach to improving the cooperation between the interfaces of care. Getting effective leadership is a necessary first step as implementation of such a strategy will involve significant change. Responsibility lies primarily with the medical profession.

The effects of knee reconstruction on combined anterior cruciate ligament and anterolateral capsular deficiencies

We tested the effect of intraarticular reconstructions of the anterior cruciate ligament alone and in combination with extraarticular reconstructions in 10 cadaveric knees. These knees had anterior cruciate ligament deficiency alone or in combination with anterolateral capsuloligamentous deficiencies. In the knees with combined injury, intraarticular reconstruction returned anterior stability to levels not significantly different from levels found for the knees deficient in the anterior cruciate ligament alone and treated with this procedure. After intraarticular reconstruction, rotational stability of the knee with combined injuries failed to return to the levels seen in the knee with isolated anterior cruciate ligament deficiencies that underwent the same treatment. When a tenodesis with either 0 N or 22 N of tension was added to the intraarticular reconstruction in the knee with combined injuries, we found that excessive internal rotation significantly decreased at all angles of flexion, except at full extension with 0 N of tension. In addition, the extraarticular reconstruction with 22 N of tension in the tenodesis overconstrained the knee in internal rotation between 30 degrees and 90 degrees of knee flexion. The tenodesis with 0 N of tension overconstrained the knee at only 60 degrees and 90 degrees of flexion. These results suggest extraarticular reconstruction as an adjunct to the intraarticular operation for the knee with anterior cruciate ligament and anterolateral structural injuries. The results also suggest that the surgeon can affect anterior and rotational laxity by adjusting the tension in the tenodesis.

Grip lock injuries to the forearm in male gymnasts

We performed an epidemiologic survey to estimate the number of grip lock injuries occurring among male high school and college gymnasts. These injuries occur when dowel grips used by the gymnast become locked on the bar as the gymnast's momentum carries him through the skill being performed. We also questioned injured gymnasts to obtain details of their injuries. Thirty-eight high school coaches reported 17 injuries and 32 college coaches reported 21 injuries for a 10-year period; 36% of the coaches responding reported at least one such injury in their program. Of the 23 injured gymnasts who returned detailed questionnaires, 20 had sustained fractures and 9 required surgery. The distal forearm or wrist were the areas injured most often. Fourteen gymnasts had residual pain, seven had functional limitations, and eight had limited motion in the wrist. Fifteen of the 23 athletes were using a cubital (hyperpronated) grip at the time of injury and 19 were using dowel grips. Among the reasons cited for the injury, 18 gymnasts thought that their grips were either too large, worn, or stretched; 8 said the grips slid up their wrists, and 7 cited technical errors.

An in vitro study of an intraarticular and extraarticular reconstruction in the anterior cruciate ligament deficient knee

The biomechanical effectiveness of an extraarticular ACL reconstruction, an intraarticular ACL reconstruction, and the combination of these on both anterior stability and internal rotational stability of the ACL deficient knee was investigated in six cadaver knees. The extraarticular reconstruction consisted of the Müller anterolateral femorotibial ligament iliotibial band tenodesis, and the intraarticular reconstruction used the middle third of the patellar tendon in the manner of Clancy. The extraarticular reconstruction was found to overconstrain internal tibial rotation of the ACL excised knee between 30 degrees and 90 degrees (P less than 0.05). While the isolated extraarticular reconstruction did not return normal anterior stability to the ACL deficient knee (P less than 0.05), it did significantly reduce the anterior laxity of the ACL deficient knee between 30 degrees and 90 degrees of knee flexion (P less than 0.05). For the combined reconstruction, the intraarticular procedure was performed and then only enough tension was applied to the extraarticular reconstruction to take up slack in the tenodesis without shifting the rotatory position of the tibia from that produced by the intraarticular procedure alone. Neither the intraarticular reconstruction nor the combined procedure resulted in any significant shifts from normal (P less than 0.05) in the rotatory position of the unloaded tibia; during loading neither resulted in rotational displacements significantly different from normal; and both of these procedures reduced the increased anterior laxity of the ACL deficient knee to a level not statistically different from normal. Because the extraarticular reconstruction shared the load when performed with the intraarticular reconstruction as part of a combined procedure, we concluded that it would be useful as an adjunctive procedure in appropriate clinical situations.