The term ‘developmental dysplasia of the hip’ (DDH) includes a wide spectrum of hip alterations: neonatal instability; acetabular dysplasia; hip subluxation; and true dislocation of the hip. DDH alters hip biomechanics, overloading the articular cartilage and leading to early osteoarthritis. DDH is the main cause of total hip replacement in young people (about 21% to 29%). Development of the acetabular cavity is determined by the presence of a concentrically reduced femoral head. Hip subluxation or dislocation in a child will cause an inadequate development of the acetabulum during the remaining growth. Clinical screening (instability manoeuvres) should be done universally as a part of the physical examination of the newborn. After two or three months of life, limited hip abduction is the most important clinical sign. Selective ultrasound screening should be performed in any child with abnormal physical examination or in those with high-risk factors (breech presentation and positive family history). Universal ultrasound screening has not demonstrated its utility in diminishing the incidence of late dysplasia. Almost 90% of patients with mild hip instability at birth are resolved spontaneously within the first eight weeks and 96% of pathologic changes observed in echography are resolved spontaneously within the first six weeks of life. However, an Ortolani-positive hip requires immediate treatment. When the hip is dislocated or subluxated, a concentric and stable reduction without forceful abduction needs to be obtained by closed or open means. Pavlik harness is usually the first line of treatment under the age of six months. Hip arthrogram is useful for guiding the decision of performing a closed or open reduction when needed. Acetabular dysplasia improves in the majority due to the stimulus provoked by hip reduction. The best parameter to predict persistent acetabular dysplasia at maturity is the evolution of the acetabular index. Pelvic or femoral osteotomies should be performed when residual acetabular dysplasia is present or in older children when a spontaneous correction after hip reduction is not expected. Avascular necrosis is the most serious complication and is related to: an excessive abduction of the hip; a force closed reduction when obstacles for reduction are present; a maintained dislocated hip within the harness or spica cast; and a surgical open reduction.Cite this article: EFORT Open Rev 2019;4:548-556. DOI: 10.1302/2058-5241.4.180019

Supracondylar fractures of the humerus are the most frequent fractures of the paediatric elbow, with a peak incidence at the ages of five to eight years.Extension-type fractures represent 97% to 99% of cases. Posteromedial displacement of the distal fragment is the most frequent; however, the radial and median nerves are equally affected. Flexion-type fractures are more commonly associated with ulnar nerve injuries.Concomitant upper-limb fractures should always be excluded. To manage the vascular status, distal pulse and hand perfusion should be monitored. Compartment syndrome should always be borne in mind, especially when skin puckering, severe ecchymosis/swelling, vascular alterations or concomitant forearm fractures are present.Gartland’s classification shows high intra- and inter-observer reliability. Type I is treated with casting. Surgical treatment is the standard for almost all displaced fractures. Type IV fractures can only be diagnosed intra-operatively.Closed reduction and percutaneous pinning is the gold standard surgical treatment. Open reduction via the anterior approach is indicated for open fractures, absence of the distal vascular flow for > 10 to 15 minutes after closed reduction, and failed closed reduction.Lateral entry pins provide stable fixation, avoiding the risk of iatrogenic ulnar nerve injury.About 10% to 20% of displaced supracondylar fractures present with alterations in vascular status. In most cases, fracture reduction restores perfusion.Neural injuries occur in 6.5% to 19% of cases involving displaced fractures. Most of them are neurapraxias and it is not routinely indicated to explore the nerve surgically.Cite this article: EFORT Open Rev 2018;3:526-540. DOI: 10.1302/2058-5241.3.170049

Lateral epicondylitis, also known as ‘tennis elbow’, is a very common condition affecting mainly middle-aged patients.The pathogenesis remains unknown but there appears to be a combination of local tendon pathology, alteration in pain perception and motor impairment.The diagnosis is usually clinical but some patients may benefit from additional imaging for a specific differential diagnosis.The disease has a self-limiting course of between 12 and 18 months, but in some patients, symptoms can be persistent and refractory to treatment.Most patients are well-managed with non-operative treatment and activity modification. Many surgical techniques have been proposed for patients with refractory symptoms.New non-operative treatment alternatives with promising results have been developed in recent years.Cite this article: Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev 2016;1:391-397. DOI: 10.1302/2058-5241.1.000049.

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

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

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Opioids have been widely used in the USA for pain control after total knee arthroplasty (TKA). However, adverse effects, especially the possibility of addiction, have increased interest in opioid-free pain management after surgery. We therefore sought to review current pain management protocols after TKA, focusing especially on opioid-free alternatives. We reviewed the literature on pain management after TKA using Medline (PubMed), through June 30, 2018, using the keywords BTKA^and Banalgesia.^We found 388 articles but chose to analyze the 34 that presented high-quality (levels I and II) evidence. Local infiltration analgesia (LIA) is a good option for reducing the use of post-operative opioids; many reports have compared LIA against a nerve block or studied the synergies between two protocols of loco-regional anesthesia. Multimodal blood-loss prevention is sometimes recommended in combination with opioid-free analgesia. In most studies, however, no differences are reported or contradictory results exist. Post-operative pain management protocols vary so much that it is difficult to strongly favor a determined pathway. Keywords knee. total knee arthroplasty. post-operative pain. opioids. local infiltration analgesia. opioid-free TKA

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