Surgical treatment of distal tibia fractures is usually associated with extensive soft tissue compromise and high complication rates (infection, delayed or non-union, ankle stiffness and osteoarthritis). Wound infection is one of the most common complication (deep infection rates up to 15%) and can develop into an infected non-union.

In 1973, Papineau described a staged technique for treating infected non-union of long bones, consisting of (1) surgical debridement of necrotic tissue, temporary splinting, specific antibiotic treatment, postoperative wet-to-dry wound dressing changes; (2) packing of the bone defect with cortico-cancellous autograft; (3) closure of the soft-tissue wound by a flap or secondary intent.

The authors aim to report a clinical case of a successful treatment of a distal tibia infected non-union with the Papineau technique and negative-pressure wound therapy.

Woman, 56 years-old, referred to Orthopaedic consultation on October 2013 for wound dehiscence and infection with a methicillin-resistant Staphylococcus aureus, one month after open reduction and internal fixation of an open distal tibia fracture.

On November 2013 she underwent surgical debridement, removal of osteosynthesis material, osteotaxis with external fixator, negative-pressure wound therapy and antibiotic treatment with intravenous vancomycin 1g 12/12h (1st stage of Papineau procedure)

On December, she underwent autologous iliac crest cancellous bone grafting and wound care, daily irrigated with saline solution (2nd stage).

On February 2014, she underwent a partial thickness skin graft for wound closure (3rd stage).

On April, the external fixator was removed and there was still no evidence of union. She had pain, disuse osteoporosis, ankle and midfoot stiffness, and was sent to physical therapy.

On April 2015, she can full weight bear with mild pain, the soft tissue envelope is in good condition, the fracture has united and she has an Ankle AOFAS Score of 83.

The Papineau technique has been used for the management of infected non-unions with bony defects, with high success rates. Complete necrotic tissue debridement and targeted antibiotics are fundamental for obtaining a viable and healthy tissue, able to receive the bone graft. Negative-pressure wound therapy is important in reducing the bacterial load, improving the microcirculation and enhancing the granulation tissue.

In the present case, the combination of the two techniques probably acted together in achieving successful eradication of the infection, reconstruction of the bone defect and soft tissue closure.

Triple arthrodesis is the most effective treatment resource for restoring shape and stability to the hind-foot. It is used in order to achieve a plantigrade foot, aligned, stable and painless, in the treatment of various pathologies. However, it has the effect of changing the dynamic mobility of the foot and diminishes the adapting ability to uneven ground, influencing the outcome. Opinions differ on the necessity of internal fixation to maintain the proper alignment of the hind-foot and improve consolidation, influencing the results.

The authors reviewed the patients who underwent triple arthrodesis between 01/01/1998 and 31/12/2008. Of a total of 46 patients 28 were reviewed, corresponding to 29 feet that underwent 36 interventions (7 recurrences).

Patients were divided into two groups according to whether or not the placement of internal fixation. They were evaluated according to the AOFAS ankle and hindfoot score and correlated with the radiologic result.

The most frequent indications for surgery were osteoarthrosis of the tarsus and sequelae of fractures of the calcaneus.

In the group without fixation 68% had radiological signs of consolidation. 24% required revision for non consolidation. In the group with internal fixation there was 72.7% consolidation and 9.1% required revision surgery. Bone graft was more often used in internal fixation group (72.7% vs 40%).

Group without fixation vs group with internal fixation:

AOFAS mean score: 74.5% vs 61.6%, patients without pain: 50% vs 20%; plantigrade foot with good alignment: 66.7% vs 40% without pain: 50% vs 20%; tibiotarsal arthritis: 48% vs 63.6%; Lisfranc arthrosis: 44% vs 63.6%.

There is a higher rate of consolidation in the group setting. However, the functional outcome seems to be better in the group without fixation.

Fixation seems to be associated with better consolidation. The functional outcome is related to a plantigrade and well aligned foot.

Slipped capital femoral epiphysiolysis (SCFE) is a rare condition with a unknown aetiopathogenesis. An early diagnosis and treatment is essential to minimize premature degeneration of the joint. The authors reviewed the cases treated between 1980 and 2005 in our institution. This study was aimed at evaluating patients with hip epiphysiolysis surgically treated by canullated screws or pinning and previously controlled by short-term follow-up, in order to evaluate radiographic medium/ long term evolution, looking for evidence of degenerative arthritis or femoroacetabular impingement.

We performed a retrospective review of the clinical notes and radiographs of all patients with slipped upper femoral epiphysis who were surgically treated at our institution between January 1980 and December 2005. These patients performed radiographs to detect evidence of osteonecrosis, chondrolysis, degenerative arthritis or femoroacetabular impingment. To grade the radiological osteoarthritic changes the grading system of Kellgren and Lawrence was used. These changes were correlated with the existence of femoroacetabular impingement. The radiological results were correlated with the Loder'sclassification of stability and the morphological classification.

43 patients were reviewed, corresponding to 47 treated hips. AP and Lowenstein x-ray views were taken in all patients. The alfa angle and the head-shaft angle were measured in the Lowenstein view (frog-leg).

Of 16 patients with impingement only 1 patient didn't present pistol grip deformity. 4 contralateral hips also presented the deformity. The mean alfa angle was 99,4.

43% of the patients with unstable hips have impingment. In stable hips this percentage is of 35%.

The Patrick test was positive in 30% of the hips with SCFE and only 17% of the unafected hips. The Kellgren and Lawrence scale was very diferent between trhe SCFE and control groups, with 43% grade 2, 17% grade 3 and 6% grade 4, versus 30% grade 2, 6% grade 3 and 0% grade 4.

Some patients show bilateral pistol grip deformity and clinical signs of impingment, despite only having one hip with SCFE

It appears that double bundle anterior cruciate ligament reconstruction can reproduce the original anatomy of the ligament, restoring normal kinematics and rotational control of the tibia. But an anatomical single bundle reconstruction may present very similar results, with minor technical difficulties and lower costs.

We compared two groups of 25 patients each, that underwent ACL reconstruction by the same surgeon, with a follow-up of 12–36 months. One group had double bundle reconstruction with hamstring and the other had single bundle anatomical reconstruction with patellar tendon.

Patients underwent a subjective evaluation and clinical testing with instrumented laxity with Rolimeter, and the data entered in the IKDC 2000 scale Double tunnel hamstring Vs bone-tendon-bone: Functional outcome of 85.6% Global Class A and B vs. 82.1% Class A and B. The subjective outcome (IKDC 2000) was 90.93 vs. 91.47. Pivot-shift test with 87% patients in class A and class B at 9.7% Vs 75% patients in class A, 21.4% for class B. The Rolimeter gave an average Lachman value of 2,56 and anterior drawer test of 2,88 Vs average Lachman value of 3.59 and anterior drawer test of 2.92. One leg hop test showed 85.7% knees class A, 9.5% knees class B vs. 90.4% knees class A and, 2.8% knees class B.

The subjective score was slightly higher in the single bundle anatomical reconstruction with patellar tendon, despite the overall functional outcome being higher in the double tunnel technique with hamstrings. The average Lachmann in the patellar tendon group was 1 mm higher. The rotational stability in the double tunnel was higher.

The same surgeon had better results in the double tunnel hamstrings technique, despite less experienced with this technique, which is more demanding, probably reflecting objective advantages over the single bundle reconstruction with patellar tendon

The median nerve compression in the carpal tunnel is the most common compression syndrome of the upper limb. In most cases it is idiopathic but may also occur from anatomical, traumatic, endocrine, rheumatic or tumoral causes.

Chow's endoscopic technique was initially used to treat this disease and then modified to a mini-open approach through a single palmar incision. This incision is similar to the one used in endoscopic release by Agee. After exposing the proximal part of the transverse carpal ligament a meniscus knife is advanced until there is a complete section of the ligament, without endoscopic equipment.

Between 2004 and 2006, 200 hands in 179 patients with a diagnosis based on clinical and electromyographic criteria were operated by this mini-open technique. The mean follow-up was 49 months (minimum of 34 months and a maximum of 70 months).

50 randomly selected patients were submitted to the self-administered Boston questionnaire. 50 patients treated by the minimal-incision decompression during the same period were also given the questionnaire. The aesthetic satisfaction was registered as well as if they would have surgery on the other hand or would recommend the procedure.

This mini-open technique is another technique available to the surgeon that allows very similar functional results to endoscopic surgery, without use of specific material and with a shorter surgical time.