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  • Author: E Carlos Rodríguez-Merchán x
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Elena Bravo, Raul Barco, and E. Carlos Rodríguez-Merchán

  • Musculo-skeletal complications of the hand in the haemophilia patient are rare, and they include synovitis, arthropathy, pseudotumours, carpal tunnel syndrome and vascular aneurysms and pseudoaneurysms.

  • The best way to prevent the aforementioned musculo-skeletal complications is early continuous haematological primary prophylaxis (intravenous infusion of the deficient coagulation factor, ideally from cradle to death).

  • There is a wide range of procedures that a hand surgeon treating these patients should be able to manage, including synovectomy, prosthetic replacement of small joints, removal or curettage of pseudotumours, release of carpal tunnel and, occasionally, vascular reconstruction of aneurysms.

  • The treatment of these patients should be made at an institution with close collaboration between haematologists and hand surgeons (all surgical procedures must always be performed under cover of the deficient coagulation factor).

Cite this article: EFORT Open Rev 2020;5:328-333. DOI: 10.1302/2058-5241.5.190078

Inmaculada Moracia-Ochagavía and E. Carlos Rodríguez-Merchán

  • It is essential to know and understand the anatomy of the tarsometatarsal (TMT) joint (Lisfranc joint) to achieve a correct diagnosis and proper treatment of the injuries that occur at that level.

  • Up to 20% of Lisfranc fracture-dislocations go unnoticed or are diagnosed late, especially low-energy injuries or purely ligamentous injuries. Severe sequelae such as post-traumatic osteoarthritis and foot deformities can create serious disability.

  • We must be attentive to the clinical and radiological signs of an injury to the Lisfranc joint and expand the study with weight-bearing radiographs or computed tomography (CT) scans.

  • Only in stable lesions and in those without displacement is conservative treatment indicated, along with immobilisation and initial avoidance of weight-bearing.

  • Through surgical treatment we seek to achieve two objectives: optimal anatomical reduction, a factor that directly influences the results; and the stability of the first, second and third cuneiform-metatarsal joints.

  • There are three main controversies regarding the surgical treatment of Lisfranc injuries: osteosynthesis versus primary arthrodesis; transarticular screws versus dorsal plates; and the most appropriate surgical approach.

  • The surgical treatment we prefer is open reduction and internal fixation (ORIF) with transarticular screws or with dorsal plates in cases of comminution of metatarsals or cuneiform bones.

Cite this article: EFORT Open Rev 2019;4:430-444. DOI: 10.1302/2058-5241.4.180076

Alfonso Vaquero-Picado and E. Carlos Rodríguez-Merchán

  • From the biomechanical and biological points of view, an arthroscopic meniscal repair (AMR) should always be considered as an option. However, AMR has a higher reoperation rate compared with arthroscopic partial meniscectomy, so it should be carefully indicated.

  • Compared with meniscectomy, AMR outcomes are better and the incidence of osteoarthritis is lower when it is well indicated.

  • Factors influencing healing and satisfactory results must be carefully evaluated before indicating an AMR.

  • Tears in the peripheral third are more likely to heal than those in the inner thirds.

  • Vertical peripheral longitudinal tears are the best scenario in terms of success when facing an AMR.

  • ‘Inside-out’ techniques were considered as the gold standard for large repairs on mid-body and posterior parts of the meniscus. However, recent studies do not demonstrate differences regarding failure rate, functional outcomes and complications, when compared with the ‘all-inside’ techniques.

  • Some biological therapies try to enhance meniscal repair success but their efficacy needs further research. These are: mechanical stimulation, supplemental bone marrow stimulation, platelet rich plasma, stem cell therapy, and scaffolds and membranes.

  • Meniscal root tear/avulsion dramatically compromises meniscal stability, accelerating cartilage degeneration. Several options for reattachment have been proposed, but no differences between them have been established. However, repair of these lesions is actually the reference of the treatment.

  • Meniscal ramp lesions consist of disruption of the peripheral attachment of the meniscus. In contrast, with meniscal root tears, the treatment of reference has not yet been well established.

Cite this article: EFORT Open Rev 2018;3:584-594. DOI: 10.1302/2058-5241.3.170059

Alfonso Vaquero-Picado and E. Carlos Rodríguez-Merchán

  • Isolated posterior cruciate ligament (PCL) tears are much less frequent than anterior cruciate ligament (ACL) tears.

  • Abrupt posterior tibial translation (such as dashboard impact), falls in hyperflexion and direct hyperextension trauma are the most frequent mechanisms of production.

  • The anterolateral bundle represents two-thirds of PCL mass and is reconstructed in single-bundle techniques.

  • The PCL has an intrinsic capability for healing. This is the reason why, nowadays, the majority of isolated PCL tears are managed non-operatively, with rehabilitation and bracing.

  • Recent studies have focused on double-bundle reconstruction techniques, as they seem to restore knee kinematics.

  • No significant clinical differences have been established between single versus double-bundle techniques, autograft versus allograft, transtibial tunnel versus tibial inlay techniques or remnant-preserving versus remnant-release techniques.

Cite this article: EFORT Open Rev 2017;2:89-96. DOI: 10.1302/2058-5241.2.160009

E. Carlos Rodríguez-Merchán, Primitivo Gómez-Cardero, and Carlos A. Encinas-Ullán

  • The treatment of small to moderate size defects in revision total knee arthroplasty (rTKA) has yielded good results with various techniques (cement and screws, small metal augments, impaction bone grafting and modular stems). However, the treatment of severe defects remains problematic.

  • Severe defects have typically been treated with large allograft and metaphyseal sleeves. The use of structural allograft has decreased in recent years due to increased long-term failure rates and the introduction of highly porous metal augments (cones and sleeves).

  • A systematic review of level IV evidence studies on the outcomes of rTKA metaphyseal sleeves found a 4% rate of septic revision, and a rate of septic loosening of the sleeves of 0.35%. Aseptic re-revision was required in 3% of the cases. The rate of aseptic loosening of the sleeves was 0.7%, and the rate of intraoperative fracture was 3.1%. The mean follow-up was 3.7 years.

  • Another systematic review of tantalum cones and sleeves found a reoperation rate of 9.7% and a 0.8% rate of aseptic loosening per sleeve. For cones, the reoperation rate was 18.7%, and the rate of aseptic loosening per cone was 1.7%.

  • The reported survival of metal sleeves was 99.1% at three years, 98.7% at five years and 97.8% at 10 years. The reported survival free of cone revision for aseptic loosening was 100%, and survival free of any cone revision was 98%. Survival free of any revision or reoperation was 90% and 83%, respectively.

Cite this article: EFORT Open Rev 2021;6:1073-1086. DOI: 10.1302/2058-5241.6.210007

E. Carlos Rodríguez-Merchán, Hortensia De la Corte-Rodríguez, Carlos A. Encinas-Ullán, and Primitivo Gómez-Cardero

  • The main complications of surgical reconstruction of multiligament injuries of the knee joint are residual or recurrent instability, arthrofibrosis, popliteal artery injury, common peroneal nerve injury, compartment syndrome, fluid extravasation, symptomatic heterotopic ossification, wound problems and infection, deep venous thrombosis, and revision surgery.

  • Careful surgical planning and execution of the primary surgical reconstruction of multiligament injuries of the knee joint can minimize the risk of the aforementioned complications.

  • Careful postoperative follow-up is required to detect complications. Early recognition and prompt treatment are of paramount importance.

  • To obtain good results in the revision surgery of failed multiligamentary knee reconstructions, it is crucial to perform a thorough and exhaustive evaluation to detect all the causes of failure.

  • Addressing all associated injuries during revision surgery will lead to the best possible subjective and objective results, although functional outcomes are often modest.

  • However, advanced age and high-energy injuries have been associated with the poorest functional outcomes after revision surgery of failed multiligament injuries of the knee joint.

Cite this article: EFORT Open Rev 2021;6:973-981. DOI: 10.1302/2058-5241.6.210057

Elena Gálvez-Sirvent, Aitor Ibarzábal-Gil, and E. Carlos Rodríguez-Merchán

  • In aseptic tibial diaphyseal nonunions after failed conservative treatment, the recommended treatment is a reamed intramedullary (IM) nail.

  • Typically, when an aseptic tibial nonunion previously treated with an IM nail is found, it is advisable to change the previous IM nail for a larger diameter reamed and locked IM nail (the rate of success of renailing is around 90%).

  • A second change after an IM nail failure is also a good option, especially if bone healing has progressed after the first change.

  • Fibular osteotomy is not routinely advised; it is only recommended when it interferes with the nonunion site.

  • In delayed unions before 24 weeks, IM nail dynamization can be performed as a less invasive option before deciding on a nail change.

  • If there is a bone defect, a bone graft must be recommended, with the gold standard being the autologous iliac crest bone graft (AICBG).

  • A reamer-irrigator-aspirator (RIA) system might also obtain a bone autograft that is comparable to AICBG.

  • Although the size of the bone defect suitable to perform bone transport techniques is a controversial issue, we believe that such techniques can be considered in bone defects > 3 cm.

  • Non-invasive therapies and biologic therapies could be applied in isolation for patients with high surgical risk, or could be used as adjuvants to the aforementioned surgical treatments.

Cite this article: EFORT Open Rev 2020;5:835-844. DOI: 10.1302/2058-5241.5.190077

Carlos A. Encinas-Ullán, Primitivo Gómez-Cardero, Juan S. Ruiz-Pérez, and E. Carlos Rodríguez-Merchán

  • The number of rotating-hinge total knee arthroplasties (RH-TKAs) is increasing. As a result, the number of complications related to these procedures will also increase.

  • RH-TKAs have the theoretical advantage of reducing bone implant stresses and early aseptic loosening. However, these implants also have complication rates that cannot be ignored. If complications occur, the options for revision of these implants are limited.

  • Dislocation of RH-TKAs is rare, with an incidence between 0.7% and 4.4%. If it occurs, this complication must be accurately diagnosed and treated quickly due to the high incidence of neurovascular complications.

  • If the circulatory and neurological systems are not properly assessed or if treatment is delayed, limb ischemia, soft tissue death, and the need for amputation can occur.

  • Dislocation of a RH-TKA is often a difficult problem to treat. A closed reduction should not be attempted, because it is unlikely to be satisfactory. In addition, in patients with dislocation of a RH-TKA, the possibility of component failure or breakage must be considered.

  • Open reduction of the dislocation should be performed urgently, and provision should be made for revision (that is, the necessary instrumentation should be available) of the RH-TKA, if it proves necessary.

  • The mobile part that allows rotation can have various shapes and lengths. This variance in design could explain why the reported outcomes vary and why there is a probability of tibiofemoral dislocation.

Cite this article: EFORT Open Rev 2021;6:107-112. DOI: 10.1302/2058-5241.6.200093

Carlos A. Encinas-Ullán, José M. Martínez-Diez, and E. Carlos Rodríguez-Merchán

  • The use of an external fixator (EF) in the emergency department (ED) or the emergency theatre in the ED is reserved for critically ill patients in a life-saving attempt. Hence, usually only fixation/stabilization of the pelvis, tibia, femur and humerus are performed. All other external fixation methods are not indicated in an ED and thus should be performed in the operating room with a sterile environment.

  • Anterior EF is used in unstable pelvic lesions due to anterior-posterior compression, and in stable pelvic fractures in haemodynamically unstable patients.

  • Patients with multiple trauma should be stabilized quickly with EF.

  • The C-clamp has been designed to be used in the ED to stabilize fractures of the sacrum or alterations of the sacroiliac joint in patients with circulatory instability.

  • Choose a modular EF that allows for the free placement of the pins, is radiolucent and is compatible with magnetic resonance imaging (MRI).

  • Planning the type of framework to be used is crucial.

  • Avoid mistakes in the placement of EF.

Cite this article: EFORT Open Rev 2020;5:204-214. DOI: 10.1302/2058-5241.5.190029

Elena Gálvez-Sirvent, Aitor Ibarzábal-Gil, and E Carlos Rodríguez-Merchán

  • Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis.

  • The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA.

  • Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection.

  • In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage).

  • Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.