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Metacarpophalangeal joint stiffness. Still a challenge for the hand surgeon?
Rigideces metacarpofalángicas en extensión. ¿Un desafío para el cirujano de mano?
I. Jiménez
Corresponding author
isidro_jimenez@hotmail.com

Corresponding author.
, G. Muratore-Moreno, A. Marcos-García, J. Medina
Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In 1956 Sterling Bunnell observed that in hand surgery the fingers have a tendency to become rigid&#44; and furthermore that they do so in a non-functional position&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> It is fundamental to understand that the hand is an extremely complex organ in which modification of one of its parts will affect its overall working&#46; This is so to the extent that a single rigid finger may disturb the working of the whole hand and therefore the professional future of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Finger mobility requires bone stability&#44; mobile joints&#44; muscular integrity&#44; the sliding of tendons&#44; sensitivity and a suitably elastic skin&#46; This means that practically all lesions of the fingers and hand may lead to rigidity&#44; regardless of whether joints are directly affected by the lesion or not&#46; Additionally&#44; other lesions at different levels of the arm and even systemic pathologies may lead to this restriction in mobility&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The metacarpophalangeal joint &#40;MCPH&#41; is of the condylar type and permits movements involving flexion-extension and radial and cubital deviation&#44; together with a certain amount of rotational movement&#44; chiefly when it is in extension&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> The main characteristic that differentiates this joint is that its stability varies depending on its position&#44; so that in extension there is less bone contact and the ligaments and capsule are relaxed&#44; so that the joint is less stable&#46; Moreover&#44; when extended intra-joint capacity is maximum&#44; so that an oedema resulting from trauma makes the joint adopt this position&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Due to its multiple causes&#44; complex anatomy and postoperative results that are often disappointing&#44; suitable treatment of metacarpophalangeal joint stiffness in extension is still a challenge for hand surgeons&#46; Our aim is to analyse the results obtained in the treatment of metacarpophalangeal joint stiffness using dorsal tenoarthrolysis in our hospital&#44; and to revise the results published in the literature&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0020" class="elsevierStylePara elsevierViewall">We present a retrospective study of 21 MCPH stiffness in extension in ten patients operated surgically in our hospital during the period from 2004 to 2011&#46; Their clinical histories were revised and they were evaluated once again&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The inclusion criteria were patients diagnosed with MCPH stiffness in extension &#40;reduction of normal mobility leading to patient functional disability&#41; that had not improved clinically following at least three months of rehabilitation treatment&#46; They also had to be motivated and involved&#44; demanding greater hand mobility for their professional or recreational activities&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Surgery was carried out on an outpatient basis&#44; under locoregional anaesthesia &#40;the axillary plexus&#41;&#44; using a preventive ischaemia tourniquet at the root of the arm and placing the patient&#39;s hand on a hand surgery table&#46; When the elasticity of the skin was affected &#40;three cases&#41;&#44; we made an arched incision that centred on the MCPH joint &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; preserving the dorsal vein return&#46; In those cases where the skin retained its normal elasticity&#44; and when several adjacent fingers were affected&#44; we preferred to make a longitudinal dorsal incision between both affected MCPH joints &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; We performed surgery in three successive stages&#44; gently flexing the joint between them&#46; We first carried out tenolysis of the extensor tendon&#44; freeing adherences present in its path&#46; We then performed a dorsal capsulectomy&#44; approaching the joint capsule proximally and the sagittal band distally&#44; respecting the extensor tendon as well as the sagittal band itself&#44; so as not to cause instability of the extensor tendon &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; When necessary we also freed the collateral ligaments&#46; And lastly&#44; when complete mobility was not achieved passively &#40;a flexion&#8211;extension range of 0&#8211;90&#176;&#41;&#44; the palmar plate was freed using a blunt spatula through the same dorsal approach&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The skin was closed using absorbable 4&#47;0 suture while keeping the MCPH joint flexed and rotated&#44; and moving the skin flap forwards when necessary &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">A plaster splint was kept in place for the first ten days after the operation&#44; with the MCPH at the maximum flexion achieved&#46; This was then replaced by a passive MCPH flexion orthesis and rehabilitation commenced&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The results were recorded and preoperative active mobility together with postoperative active mobility were evaluated &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; as well as the time taken to return to work&#44; a postoperative upper limb self-reporting <span class="elsevierStyleItalic">DASH questionnaire</span><a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> and a satisfaction survey about the result of surgery&#44; in which each patient had to classify the result of the operation as excellent&#44; very good&#44; good&#44; mediocre or poor&#46; The values of the preoperative DASH questionnaire were not available to us&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">70&#37; of the patients were men&#46; Their average age at the time of the operation was 36&#46;5 &#40;24&#8211;58&#41; years old&#44; and the average postoperative follow-up lasted for 6&#46;5 &#40;3&#8211;10&#41; years&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The fingers were one index finger&#44; three middle fingers&#44; eight ring fingers and nine little fingers&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Stiffness aetiology was metacarpian fracture and subsequent immobilisation of the same in 52&#46;4&#37; of cases &#40;11 cases&#41;&#44; of which one was a Gustilo and Anderson grade II open fracture &#40;9&#37;&#41;&#46; Three cases &#40;27&#46;2&#37;&#41; had been operated on&#44; two by percutaneous surgery and one by open reduction and osteosynthesis&#46; In four cases &#40;19&#37;&#41; the rigidity was due to complex forearm trauma with a grade IIIA open fracture&#46; In three cases &#40;14&#46;3&#37;&#41; the aetiology was parting of the extensor tendon followed by surgical treatment and immobilisation&#46; In the remaining three cases &#40;14&#46;3&#37;&#41; the cause was a type I complex regional pain syndrome &#40;CRPS&#41; following entrapment of the hand under the patient&#39;s body&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Intraoperatoratively a passive mobility of at least 0&#8211;90&#176; was achieved in 17 of the 21 cases &#40;81&#37;&#41;&#46; Nevertheless&#44; at the end of follow-up the average improvement in the mobility of our patients was 30&#46;5&#176;&#44; with a standard deviation of 34 and an IC of 95&#37; &#40;14&#46;8&#8211;46&#46;1&#41;&#46; This improvement stabilised after four months of postoperative treatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">When the patients are divided into subgroups according to their aetiology&#44; we found that when rigidity is caused by a fracture&#44; the average improvement in mobility was 44&#46;5&#176; &#40;5&#176;&#8211;85&#176;&#41;&#46; When the cause was complex trauma of the arm&#44; active postoperative mobility did not improve&#46; When the aetiology was parting of the extensor tendon&#44; active postoperative mobility improved by an average of 35&#176; &#40;5&#176;&#8211;70&#176;&#41; while lastly&#44; when the cause was CRPS&#44; active postoperative mobility increased by an average of 15&#176; &#40;0&#176;&#8211;45&#176;&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">On the other hand&#44; if the patients are divided according to the finger affected&#44; when it was the index finger no improvement was achieved&#59; in the middle fingers &#40;three cases&#41; active mobility increased by an average of 26&#46;7&#176; &#40;0&#176;&#8211;45&#176;&#41;&#59; in the case of the ring finger &#40;eight cases&#41; it improved by an average of 45&#176; &#40;0&#176;&#8211;80&#176;&#41;&#59; and for the little finger &#40;nine cases&#41; active mobility increased by an average of 22&#46;3&#176; &#40;0&#176;&#8211;85&#176;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Lastly&#44; when the results are analysed according to the number of fingers affected&#44; when one or two fingers were affected by rigidity &#40;eight patients&#41;&#44; the average improvement in active mobility was 42&#46;5&#176;&#44; while when three or four fingers were affected &#40;two patients&#41;&#44; it only improved by 6&#46;4&#176;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In terms of their return to work&#44; 60&#37; of our patients were able to return to the same job they performed prior to their injury&#46; 30&#37; of the patients returned to work but had to do a different job from the one they had before their injury&#46; These patients &#40;90&#37;&#41; started work again after an average time of 3&#46;8 &#40;3&#8211;4&#41; months following surgery&#46; The remaining 10&#37; of our patients did not return to work&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In the DASH questionnaire&#44; the patients in this series obtained an average score of 36&#46;9 &#40;4&#46;5&#8211;70&#46;4&#41; points&#46; When they were asked about their level of satisfaction with the result of the operation&#44; 10&#37; described it as excellent&#44; 30&#37; of the patients considered it to be good&#44; 40&#37; stated that it was mediocre and the remaining 20&#37; described it as poor&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In terms of complications&#44; two cases &#40;9&#46;5&#37;&#41; developed type I CRPS after the operation&#44; and three &#40;14&#46;3&#37;&#41; a situation of &#8220;extrinsic finger&#8221; arose&#44; characterised by hyperextension of the MCPH joint that could not be actively reduced &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; We believe that this was due to excessively aggressive liberation&#44; with injury to the intrinsic musculature&#46; These patients refused further surgical treatment&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The aim of treatment in cases of stiffness is to achieve a stable&#44; mobile and painless joint&#46; The ideal treatment is prevention following any trauma or surgery&#44; preventing pain and the oedema and placing the hand in a suitable position&#44; on condition that this is possible following the procedure used&#46; That is&#44; with the wrist in 10&#176; extension and the MCPH joints flexed at 90&#176; with the interphalangeal joints in extension&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;6</span></a> Up to 66&#37; of cases have been estimated to be iatrogenic&#44; and they are therefore potentially avoidable&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> Moreover&#44; this lesion often affects young patients and therefore has a major impact on their working life&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Once stiffness has been established&#44; conservative treatment using different types of orthesis is effective&#44; achieving resolution of the clinical symptoms in 63&#46;9&#8211;87&#37; of cases&#44; according to different authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;8&#44;9</span></a> There are four types of orthesis&#58; continuous static&#44; discontinuous static&#44; progressive static and dynamic splints&#44; all of which have been proven to be effective&#44;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;4</span></a> although the exact pressure that they should apply has not been determined&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> or how long the patient should wear them every day&#44; as has been determined for proximal interphalangeal joint flexion stiffness&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Surgical treatment should only be considered when conservative treatment is not effective&#46; There is currently no available evidence that would make it possible to know when surgery is indicated&#46; However&#44; some authors recommend it when correctly applied conservative treatment has attained a plateau without further improvement and the mobility arch is unacceptable<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> after at least three months&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Surgical treatment should be indicated when joint surfaces are intact&#44; although this is not indispensible&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;4</span></a> It is also indicated when joint motors work properly<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> and&#44; most importantly&#44; when the patient is aware of his lesion and is motivated&#44; given that surgery is only the first step in a long and difficult process of recovery that he must understand and accept&#46; Additionally&#44; it is not rare for rigidity to reappear in spite of having a cooperative patient&#44; suitable surgery and a correct rehabilitation team&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;4</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">There are not many works in the literature on the results of surgical treatment for MCPH extension rigidity&#46; The published series do not contain a large number of cases&#44; and moreover most of them are from the last century&#44; so that they are less relevant in terms of improvements in the prevention and physiotherapeutic treatment of stiffness&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Weeks et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> showed that a volar approach is superior to a dorsal one in terms of joint movement improvement&#46; In spite of this&#44; the majority of authors and we ourselves prefer a dorsal approach&#44; as it is direct and permits suitable exposure dorsal structures and the MCPH joint itself&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#8211;4&#44;11&#44;12</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Buch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> published their results of operating on 27 hands&#44; achieving an active mobility of at least 30&#176; flexion&#46; They emphasise the importance of early mobility after surgery&#46; Young et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> published their results using dorsal tenoarthrolysis with a Kirschner needle to keep the MCPH flexed for two weeks after surgery&#59; with this technique they achieved a passive MCPH mobility of 48&#176;&#46; Gould and Nicholson<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> published the largest series in the literature&#44; with 105 dorsal MCPH capsulotomies in which they achieved an intraoperative mobility of 0&#176;&#8211;90&#176; and an average increase in mobility at the end of the follow-up period of 21&#176;&#46; This falls to 18&#176; when the cause is a fracture or crush injury&#44; in spite of which the authors conclude that the surgery is worthwhile&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Wiznicki et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> publish a work describing their treatment of 65 cases of MCPH and interphalangeal rigidity with a 28&#176; improvement in mobility&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In the 1990s Mansat et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> published the series showing the greatest increase in active mobility&#44; with an average of 40&#176;&#44; while Foucher<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> published a 38&#176; improvement in mobility&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The average improvement in active mobility in our series was 30&#46;5&#176;&#44; which is similar to the improvement shown in the literature consulted&#46; The results were far superior in the cases with rigidity of one or two fingers than they were when three or four fingers were affected &#40;a 42&#46;5&#176; improvement vs&#46; 6&#46;4&#176;&#41; while the mobility of the fourth finger improved the most&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">We use a proximal approach to the MCPH joint and a distal approach to the sagittal bands to prevent cutting the tendon or the bands themselves&#44; thereby avoiding the need for suture of the extensor apparatus&#44; which should be protected by keeping the hand immobilised&#46; Based on findings in the literature&#44; this would be a theoretical advantage&#44; and we do not know whether it would really affect the final result&#44; given that our results are similar to those published by other authors who part the sagittal band<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">11&#44;13</span></a> or divide the extensor tendon longitudinally&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;12</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In the series of Gould and Nicholson&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> like ours&#44; the discord between the passive mobility obtained intraoperatively and the active mobility at the end of follow-up stands out&#46; The cause may be the delay in starting rehabilitation treatment and pain following aggressive surgery which hinders postoperative mobilisation&#46; We believe coordination with the rehabilitation services to be fundamental to start therapy early&#44; as well as coordination with the Anaesthesiology&#47;Pain Unit to control postoperative pain&#44; with catheters to aid mobilisation&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">On the other hand&#44; the <span class="elsevierStyleItalic">Wide Awake Local Anaesthesia No Tourniquet</span> technique is of interest&#46; This was recently described by Lalonde&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> and it makes it possible to evaluate active mobility during the operation&#44; guiding the different surgical actions and directly instructing the patient&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">To conclude&#44; it seems clear that the ideal treatment is to prevent stiffness and&#44; once it has commenced&#44; to make full use of conservative treatment&#46; When surgery is necessary&#44; it is fundamental to correctly select a motivated patient who has received good advice&#44; as they will have to understand that the recovery process will be long and arduous&#44; and that surgery is only the first step&#46; We believe that dorsal tenoarthrolysis is a reproducible technique in terms of the published results in the literature and those obtained by us&#46; The final situation stabilises about four months after the operation and the results that may be expected are generally not very satisfactory&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">We therefore believe that surgical treatment for metacarpophalangeal stiffness in extension is still a challenge for hand surgeons&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Level of evidence</span><p id="par0175" class="elsevierStylePara elsevierViewall">Level of evidence IV&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of human and animal subjects</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work centre on the publication of patient data&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2015-08-05"
    "fechaAceptado" => "2016-03-10"
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          "clase" => "keyword"
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            0 => "Joint"
            1 => "Extension"
            2 => "Metacarpophalangeal"
            3 => "Stiffness"
            4 => "Treatment"
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            0 => "Articular"
            1 => "Extensi&#243;n"
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            3 => "Rigidez"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to analyse the outcomes of the surgical treatment of metacarpophalangeal stiffness by dorsal teno-arthrolysis in our centre&#44; and present a review the literature&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This is a retrospective study of 21 cases of metacarpophalangeal stiffness treated surgically&#46; Dorsal teno-arthrolysis was carried out on all patients&#46; A rehabilitation programme was started ten days after surgery&#46; An evaluation was performed on the aetiology&#44; variation in pre- and post-operative active mobility&#44; complications&#44; DASH questionnaire&#44; and a subjective satisfaction questionnaire&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean age of the patients was 36&#46;5 years and the mean follow-up was 6&#46;5 years&#46; Of the 21 cases&#44; the most common cause was a metacarpal fracture &#40;52&#46;4&#37;&#41;&#44; followed by complex trauma of the forearm &#40;19&#37;&#41;&#46; Improvement in active mobility was 30&#46;5&#176;&#44; despite obtaining an intra-operative mobility 0&#8211;90&#176; in 80&#37; of cases&#46; Mean DASH questionnaire score was 36&#46;9 points&#46; The outcome was described as excellent in 10&#37; of our patients&#44; good in 30&#37;&#44; poor in 40&#37;&#44; and bad in the remaining 20&#37;&#46; There was a complex regional pain syndrome in 9&#46;5&#37; of cases&#44; and intrinsic muscle injury in 14&#46;3&#37;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Because of its difficult management and poor outcomes&#44; surgical treatment of metacarpophalangeal stiffness in extension is highly complex&#44; with dorsal teno-arthrolysis being a reproducible technique according to our results&#44; and the results reported in the literature&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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          2 => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar los resultados obtenidos en el tratamiento quir&#250;rgico de la rigidez metacarpofal&#225;ngica en extensi&#243;n mediante tenoartr&#243;lisis dorsal en nuestro centro y revisar la literatura al respecto&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de 21 rigideces metacarpofal&#225;ngicas intervenidas&#46; En todos los pacientes se realiz&#243; tenoartr&#243;lisis dorsal de forma ambulatoria&#44; comenzando la rehabilitaci&#243;n a los diez d&#237;as postoperatorios&#46; Se registr&#243; etiolog&#237;a&#44; variaci&#243;n de la movilidad activa tras la cirug&#237;a&#44; complicaciones&#44; cuestionario DASH y una encuesta de satisfacci&#243;n con el resultado&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El seguimiento medio fue de 6&#44;5 a&#241;os y la edad media de 36&#44;5 a&#241;os&#46; La causa m&#225;s frecuente fue la fractura de un metacarpiano &#40;52&#44;4&#37;&#41; seguida de los traumatismos complejos de antebrazo &#40;19&#37;&#41;&#46; A final del seguimiento la mejor&#237;a en la movilidad activa fue de 30&#44;5&#176; pese a obtener una movilidad intraoperatoria de 0-90&#176; en m&#225;s del 80&#37; de los casos&#46; En el cuestionario DASH la puntuaci&#243;n media fue de 36&#44;9&#44; calificando el resultado como excelente el 10&#37; de nuestros pacientes&#44; bueno el 30&#37;&#44; regular el 40&#37; y malo el 20&#37; restante&#46; En el 9&#44;5&#37; de los casos se produjo un s&#237;ndrome de dolor regional complejo y en el 14&#44;3&#37; lesi&#243;n de la musculatura intr&#237;nseca&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Por su dif&#237;cil abordaje y pobres resultados&#44; el tratamiento quir&#250;rgico de la rigidez metacarpofal&#225;ngica en extensi&#243;n es de gran dificultad mostr&#225;ndose la tenoartr&#243;lisis dorsal como una t&#233;cnica reproducible en relaci&#243;n con nuestros resultados y a los resultados publicados en la literatura&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Jim&#233;nez I&#44; Muratore-Moreno G&#44; Marcos-Garc&#237;a A&#44; Medina J&#46; Rigideces metacarpofal&#225;ngicas en extensi&#243;n&#46; &#191;Un desaf&#237;o para el cirujano de mano&#63;&#46; Rev Esp Cir Ortop Traumatol&#46; 2016&#59;60&#58;215&#8211;220&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">FMc&#58; metacarpian neck fracture&#59; FMd&#58; metacarpian diaphysis fracture&#59; CRPS&#58; complex regional pain syndrome&#59; CT&#58; cut tendon&#59; CTr&#58; complex trauma&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Finger&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aetiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Active preop&#46; mobility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Active postop&#46; mobility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Active improvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">1</td><td class="td" title="table-entry  " align="left" valign="top">D3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">d</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">d</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">d</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">2</td><td class="td" title="table-entry  " align="left" valign="top">D4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">d</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">c</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">4</td><td class="td" title="table-entry  " align="left" valign="top">D4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">d</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">6</td><td class="td" title="table-entry  " align="left" valign="top">D4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">d</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">d</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">7</td><td class="td" title="table-entry  " align="left" valign="top">D3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">c</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">9</td><td class="td" title="table-entry  " align="left" valign="top">D4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">d</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FM<span class="elsevierStyleInf">c</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">10</td><td class="td" title="table-entry  " align="left" valign="top">D2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CTr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CTr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CTr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CTr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1112511.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Pre- and postoperative mobility in the series&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:17 [
            0 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Surgery of the hand"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "S&#46; Bunnell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:5 [
                        "edicion" => "3rd ed&#46;"
                        "fecha" => "1956"
                        "paginaInicial" => "712"
                        "editorial" => "JB Lippincott"
                        "editorialLocalizacion" => "Philadelphia"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The stiff finger"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;Y&#46; Shin"
                            1 => "P&#46;C&#46; Amadio"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Green&#39;s operative hand surgery"
                        "paginaInicial" => "355"
                        "paginaFinal" => "388"
                        "serieFecha" => "2011"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of the stiff finger&#58; evidence and outcomes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Yang"
                            1 => "E&#46;P&#46; McGlinn"
                            2 => "K&#46;C&#46; Chung"
                          ]
                        ]
                      ]
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es en pt

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