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.

The aim of this study was to assess the incidence of low-grade infections in total hip arthroplasty revisions and the clinical outcomes after two-time revision surgery.

Retrospective study of total hip arthroplasty revision surgery between January of 2012 and December of 2013. Inclusion criteria: two-time revision surgery, PCR (pre and post-op) white blood cells count and microbiological culture. The diagnosis of low-grade infection was based on the Academy of Orthopedic Surgeons’ (AAOS) guidelines. All patients were evaluated with the Harris Hip Score (HHS).

Between this period were revised a total of 79 hips, none of them bilateral, of these fourteen full-filled the inclusion criteria, eight women and six men. The mean time between primary arthroplasty and revision surgery was 4.5 years. The interface was metal-on-polyethilene in thirteen and metal-on-metal in one. All patients had at least three episodes at the urgency department with permanent hip pain in the last six months. Ten have done a course of antibiotics previous to surgery. Intra-articular pus was present in four patients. The agent isolated was S. Aureus in five and S. Epidermidis in two. An elevated PCR and leucocytosis was present in all patients. The mean PCR was 18.1 and leucocytes countage 7600. The HHS was good in four patients, fair in seven patients and poor in three. These three patients with poor had another surgical intervention due to recurrent dislocation.

Periprosthetic joint infection is a common complication after total hip arthroplasty (THA). The incidence is approximately 1% after primary replacement and about 4% revision arthroplasty. As stated by Hanssen successful treatment outcomes require precise assessment of the infecting organism, the immune status of the patient, and the condition of the bone and soft tissues around the joint. With this study we tried to establish a protocol in our service: patient with a THA, interface metal-on-polyethilene, persistent coxalgia and elevated PCR will be diagnosed with low-grade infection, however we need further revision of our experience.

Introduction

The sliding hip screw is the implant of choice for the operative treatment of stable trochanteric femur fractures. Surgeons have been using widely the four-hole side plate DHS (Dynamic Hip screw) with four bicortical screws, which allows adequate weight bearing after operation. However, there is lacking of scientific studies that support the use of such long plate and we question ourselves if we can accomplish the same results with the use of a smaller plate. The objective of this study is to compare the results accomplished with a four-hole and a two-hole DHS side plate in the treatment of transtrochanteric fractures.

Introduction: Acute Achilles tendon rupture is very much associated with sports practice and it’s a common lesion between young people. Despite of much Discussion: in the literature, the correct treatment of the complete ruptures of this tendon in the acute phase remains controversial.

The objective of this work is to accomplish a comparative analysis between the results obtained with both techniques: open versus percutaneous.

Materials and Methods: This work included 81 patients (6 women e 75 men) with acute rupture of the Achilles tendon between January of 1999 and December of 2008 and that were submitted 51 to surgical treatment with open technique and 30 with the percutaneous with the technique of Ma and Griffith modified. This patients had medium age of 35,6 years with a greater incidence between 30 and 39 years and with medium time follow-up of 1,9 years.

The diagnostic of the lesion was based in clinic criteria and when there was a doubt an ecography was realized.

In both Methods: was used posteoperative cast immobilization with 20° of plantar flexion during 6 weeks. The patients were analysed according to clinical e functional evaluations and the American Orthopaedic Foot and Ankle Society scale and the Holtz score.

Results: The patients included in the percutaneous group had better functional results with more precocious weight bearing, better ankle range of movement e more earlier return to sports practice (p< 0,001). In the open technique there were more complications in comparison with the percutaneous one (15,7% vs 6,7%). In the open technique there were no rerupture and in the percutaneous technique there were 6.

The results in both scales were better in the percutaneous group but it wasn’t statistically significative.

Discussion: Good functional results and a low percentage of complications recommend the use of surgical techniques in the treatment of this disease. Better functional and aesthetic results were obtained in the percutaneous group but at expense of a more percentage of reruptures. Open surgery is indicated in the reruptures after the utilisation of the percutaneous technique.