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  • Author: E Carlos Rodríguez-Merchán x
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E. Carlos Rodríguez-Merchán

  • Possible indications for a rotating hinge or pure hinge implant in primary total knee arthroplasty (TKA) include collateral ligament insufficiency, severe varus or valgus deformity (> 20°) with relevant soft-tissue release, relevant bone loss, including insertions of collateral ligaments, gross flexion-extension gap imbalance, ankylosis and hyperlaxity.

  • The use of hinged implants in primary TKA should be limited to the aforementioned selected indications, especially for elderly patients.

  • Potential indications for a rotating hinge or pure hinge implant in revision TKA include infection, aseptic loosening, instability and bone loss.

  • Rotating hinge knee implants have a 10-year survivorship in the range of 51% to 92.5%.

  • Complication rates of rotating hinge knee implants are in the range of 9.2% to 63%, with infection and aseptic loosening as the most common complications.

  • Although the results reported in the literature are inconsistent, clinical results generally depend on the implant design, appropriate technical use and adequate indications.

  • Considering that the revision of implants with long cemented stems can be challenging, in the future it would be better to use shorter stems in modular versions of hinged knee implants.

Cite this article: EFORT Open Rev 2019;4:121-132. DOI: 10.1302/2058-5241.4.180056

E. Carlos Rodríguez-Merchán

  • Some authors have reported that outpatient total knee arthroplasty (TKA) is a successful, safe and cost-effective treatment in the management of advanced osteoarthritis.

  • The success obtained has been attributed to the coordination of the multidisciplinary team, standardized perioperative protocols, optimal hospital discharge planning and careful selection of patients.

  • One study has demonstrated a higher risk of perioperative surgical and medical outcomes in outpatient TKA than inpatient TKA, including component failure, surgical site infection, knee stiffness and deep vein thrombosis.

  • There remains a lack of universal criteria for patient selection. Outpatient TKA has thus far been performed in relatively young patients with few comorbidities.

  • It is not yet clear whether outpatient TKA is worth considering, except in very exceptional cases (young patients without associated comorbidities).

  • Outpatient TKA should not be generally recommended at the present time.

Cite this article: EFORT Open Rev 2020;5:172-179. DOI: 10.1302/2058-5241.5.180101

E. Carlos Rodríguez-Merchán

  • It is clear that the stiff total knee arthroplasty (TKA) is a multifactorial entity associated with preoperative, intraoperative and postoperative factors.

  • Management of the stiff TKA is best achieved by preventing its occurrence using strategies to control preoperative factors, avoid intraoperative technical errors and perform aggressive, painless postoperative physical medicine and rehabilitation; adequate pain control is paramount in non-invasive management.

  • Careful attention to surgical exposure, restoring gap balance, minimizing surgical trauma to the patellar ligament/extensor mechanism, appropriate implant selection, pain control and adequate physical medicine and rehabilitation (physiotherapy, Astym therapy) all serve to reduce its incidence.

  • For established stiff TKA, there are multiple treatment options available including mobilization under anaesthesia (MUA), arthroscopic arthrolysis, revision TKA, and combined procedures.

Cite this article: EFORT Open Rev 2019;4:602-610. DOI: 10.1302/2058-5241.4.180105

E. Carlos Rodríguez-Merchán

  • The musculoskeletal problems of haemophilic patients begin in infancy when minor injuries lead to haemarthroses and haematomas.

  • Early continuous haematological primary prophylaxis by means of the intravenous infusion of the deficient coagulation factor (ideally from cradle to grave) is of paramount importance because the immature skeleton is very sensitive to the complications of haemophilia: severe structural deficiencies may develop quickly.

  • If primary haematological prophylaxis is not feasible due to expense or lack of venous access, joint bleeding will occur. Then, the orthopaedic surgeon must aggressively treat haemarthrosis (joint aspiration under factor coverage) to prevent progression to synovitis (that will require early radiosynovectomy or arthroscopic synovectomy), recurrent joint bleeds, and ultimately end-stage osteoarthritis (haemophilic arthropathy).

  • Between the second and fourth decades, many haemophilic patients develop articular destruction. At this stage the main possible treatments include arthroscopic joint debridement (knee, ankle), articular fusion (ankle) and total joint arthroplasty (knee, hip, ankle, elbow).

Cite this article: EFORT Open Rev 2019;4:165-173. DOI: 10.1302/2058-5241.4.180090

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 and Primitivo Gómez-Cardero

  • An age younger than 60 years, a body weight of 180 lb (82 kg) or more, performing heavy work, having chondrocalcinosis and having exposed bone in the patellofemoral (PF) joint are not contraindications for unicompartmental knee arthroplasty (UKA).

  • Severe wear of the lateral facet of the PF joint with bone loss and grooving is a contraindication for UKA.

  • Medial UKA should only be performed in cases of severe osteoarthritis (OA) as shown in pre-operative X-rays, with medial bone-on-bone contact and a medial/lateral ratio of < 20%.

  • The post-operative results of UKA are generally good. Medium-term and long-term studies have reported acceptable results at 10 years, with implant survival greater than 95% for UKAs performed for medial OA or osteonecrosis and for lateral UKA, especially when fixed-bearing implants are used.

  • When all implant-related re-operations are considered, the 10-year survival rate is 94%, and the 15-year survival rate is 91%.

  • Aseptic loosening is the principal failure mechanism in the first few years in mobile-bearing implants, whereas OA progression causes most failures in later years in fixed-bearing implants.

  • The overall complication rate and the comprehensive re-operation rate are comparable in both mobile bearings and fixed bearings.

  • The survival likelihood of the all-polyethylene UKA implant is similar to that of metal-backed modular designs for UKA.

  • Notable cost savings of approximately 50% can be achieved with an outpatient UKA surgery protocol. Outpatient surgery for UKA is efficacious and safe, with satisfactory clinical results thus far.

Cite this article: EFORT Open Rev 2018;3:363-373. DOI: 10.1302/2058-5241.3.170048

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

E. Carlos Rodríguez-Merchán and Inmaculada Moracia-Ochagavía

  • Tarsal tunnel syndrome (TTS) is a neuropathy due to compression of the posterior tibial nerve and its branches.

  • It is usually underdiagnosed and its aetiology is very diverse. In 20% of cases it is idiopathic.

  • There is no test that diagnoses it with certainty. The diagnosis is usually made by correlating clinical history, imaging tests, nerve conduction studies (NCSs) and electromyography (EMG).

  • A differential diagnosis should be made with plantar fasciitis, lumbosacral radiculopathy (especially S1 radiculopathy), rheumatologic diseases, metatarsal stress fractures and Morton’s neuroma.

  • Conservative management usually gives good results. It includes activity modification, administration of pain relief drugs, physical and rehabilitation medicine, and corticosteroid injections into the tarsal tunnel (to reduce oedema).

  • Abnormally slow nerve conduction through the posterior tibial nerve usually predicts failure of conservative treatment.

  • Indications for surgical treatment are failure of conservative treatment and clear identification of the cause of the entrapment. In these circumstances, the results are usually satisfactory. Surgical success rates vary from 44% to 96%.

  • Surgical treatment involves releasing the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Ultrasound-guided tarsal tunnel release is possible.

  • A positive Tinel’s sign before surgery is a strong predictor of surgical relief after decompression.

  • Surgical treatment achieves the best results in young patients, those with a clear aetiology, a positive Tinel’s sign prior to surgery, a short history of symptoms, an early diagnosis and no previous ankle pathology.

Cite this article: EFORT Open Rev 2021;6:1140-1147. DOI: 10.1302/2058-5241.6.210031

E Carlos Rodríguez-Merchán

  • The current applications of the virtual elements of artificial intelligence (AI), machine learning (ML), and deep learning (DL) in total knee arthroplasty (TKA) are diverse.

  • ML can predict the length of stay (LOS) and costs before primary TKA, the risk of transfusion after primary TKA, postoperative dissatisfaction after TKA, the size of TKA components, and poorest outcomes. The prediction of distinct results with ML models applying specific data is already possible; nevertheless, the prediction of more complex results is still imprecise. Remote patient monitoring systems offer the ability to more completely assess the individuals experiencing TKA in terms of mobility and rehabilitation compliance.

  • DL can accurately identify the presence of TKA, distinguish between specific arthroplasty designs, and identify and classify knee osteoarthritis as accurately as an orthopedic surgeon. DL allows for the detection of prosthetic loosening from radiographs.

  • Regarding the architectures associated with DL, artificial neural networks (ANNs) and convolutional neural networks (CNNs), ANNs can predict LOS, inpatient charges, and discharge disposition prior to primary TKA and CNNs allow for differentiation between different implant types with near-perfect accuracy.