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Luke Turley, Ian Barry, and Eoin Sheehan


  • Open tibial shaft fractures comprise almost 45% of all open fractures and are frequently the result of high-energy trauma. Due to contamination, limited soft tissue coverage of the tibial shaft and poor tibial blood supply, open tibial shaft fractures are associated with high rates of complication including malunion, non-union and infection. Intramedullary nailing (IMN) is a mainstay of treatment. This study aims to determine the frequency of the various complications in this cohort.


  • A systematic review of papers published on Embase, PubMed and Cochrane databases pertaining to the use of IMN to fix open tibial shaft fractures were included. The available evidence was collated in regard to the incidence of union, malunion, non-union and infection seen in this cohort.


  • A total of 2767 citations were reviewed, and 17 studies comprising 1850 patients were included in the analysis. There was a delayed union rate of 22.4%, malunion rate of 8.3%, non-union rate of 9.7% and infection rate of 8.1% (95% CI: 5.7%–10.8%) in this patient cohort. Subgroup analysis showed a 3-fold increase in non-union and a 2-fold increase in deep infection among Gustilo III injuries compared to Gustilo I and II.


  • IMN for open tibial shaft fractures results in high rates of union and low rates of infection, comparable to figures seen in closed injuries and superior to those seen with alternative methods of fixation. There is a substantially increased risk of complication associated with Gustilo III injuries, reinforcing the significance of the soft tissue injury in these patients.

Paulo Diogo Cunha, Tiago P Barbosa, Guilherme Correia, Rafaela Silva, Nuno Cruz Oliveira, Pedro Varanda, and Bruno Direito-Santos

  • Patient positioning on the surgical table is a critical step in every spine surgery. The most common surgical positions in spine surgery are supine, prone and lateral decubitus.

  • There are countless lesions that can occur during spine surgery due to patient mispositioning. Ulnar nerve and brachial plexus injuries are the most common nerve lesions seen in malpositioned patients. Devastating complications due to increased intraocular pressure or excessive abdominal pressure can also occur in prone decubitus and are real concerns that the surgical team must be aware of.

  • All members of the surgical team (including surgeons, anesthesiologists and nurses) should know how to correctly position the patient, identify possible positioning errors and know how to avoid them in order to prevent postoperative morbidity.

  • This work pretends to do a review of the most common positions during spine surgery, alert to errors that can happen during the procedure and how to avoid them.

Stavros Tsotsolis, Eustathios Kenanidis, Vasileios F Pegios, Michael Potoupnis, and Eleftherios Tsiridis


  • This comprehensive systematic review aims to assess the literature regarding the risk of postoperative complications in patients undergoing total joint arthroplasty (TJA) with concomitant thyroid dysfunction.


  • Studies were identified by searching PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and (end of search: May 2022).

Inclusion criteria

  • Randomized control and case-control studies, cohort and observational clinical studies were included, which focused on postoperative complications and outcomes of patients undergoing TJA operations of major joints (knee, hip, ankle, elbow). All studies were assessed according to their level of evidence, the number and age of patients, and treatment complications.


  • Nine studies were included in this review that demonstrated a higher risk of postoperative anemia, perioperative blood loss, hemoglobin decrease, and transfusion rates in hypothyroid patients after TJA.


  • Hypothyroidism has been identified as a potential but modifiable risk factor for increased rates of deep venous thrombosis, acute kidney injury, pneumonia, and non-specified cardiac complications among hypothyroid patients who underwent TJA as well as increased rates of periprosthetic joint infection. No significant differences in the prosthesis-related mechanical complication rates have been calculated when comparing hypothyroid and euthyroid patients.

Michiel Vande Kerckhove, Henri d'Astorg, Sonia Ramos-Pascual, Mo Saffarini, Vincent Fiere, and Marc Szadkowski


  • This study aimed to systematically review the literature for comparative and non-comparative studies reporting on clinical outcomes of patients with lumbar foraminal stenosis treated by either endoscopic foraminotomy or fusion.


  • In adherence with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, a literature search was done on January 17, 2022, using Medline and Embase. Clinical studies were eligible if they reported outcomes following fusion or endoscopic foraminotomy, in patients with primary lumbar foraminal stenosis. Two independent reviewers screened titles, abstracts, and full-texts to determine eligibility; performed data extraction; and assessed the quality of eligible studies according to the Joanna Briggs Institute (JBI) checklist.


  • The search returned 827 records; 266 were duplicates, 538 were excluded after title/abstract/full-text screening, and 23 were eligible, with 16 case series reporting on endoscopic foraminotomy, 7 case series reporting on fusion, and no comparative studies. The JBI checklist indicated that 21 studies scored ≥4 points. When comparing endoscopic foraminotomy to fusion, pooled data revealed reduced operative time (69 vs 119 min, P < 0.01) but similar Oswestry disability index (19 vs 20, P = 0.67), lower back pain (2 vs 2, P = 0.11), leg pain (2 vs 2, P = 0.15), complication rates (10% vs 5%, P = 0.22), and reoperation rates (5% vs 0%, P = 0.16). The proportions of patients with good/excellent MacNab criteria were similar for endoscopic foraminotomy and fusion (82–91% vs 85–91%).


  • There were high heterogeneity and no significant differences in clinical outcomes, complication rates, and reoperation rates between endoscopic foraminotomy and fusion for the treatment of lumbar foraminal stenosis; although endoscopic foraminotomy has reduced operative time.

Patrick Ziegler, Christian Bahrs, Christian Konrads, Philipp Hemmann, and Marc-Daniel Ahrend

  • The present narrative review provides a summary of current concepts for the treatment of ankle fractures in elderly patients.

  • Despite a high complication rate, open reduction and internal fixation is the gold standard for operative care. However, individual patient-based treatment decision considering the soft-tissue status, the fracture pattern, as well as the patient’s mobility and comorbidities is mandatory to achieve sufficient patient outcomes.

  • Due to high complication rates after surgery in the past, techniques such as fibular nails or minimal invasive techniques should be considered.

Richard N de Steiger, Brian R Hallstrom, Anne Lübbeke, Elizabeth W Paxton, Liza N van Steenbergen, and Mark Wilkinson

  • Recent concerns surrounding joint replacements that have a higher than expected rate of revision have led to stricter controls by regulatory authorities with regards to the introduction of new devices into the marketplace.

  • Implant post-market surveillance remains important, and joint replacement registries are ideally placed to perform this role. This review examined if and how joint replacement registries identified outlier prostheses, outlined problems and suggested solutions to improve post-market surveillance.

  • A search was performed of all joint replacement registries that had electronic or published reports detailing the outcomes of joint replacement. These reports were examined for registry identification of outlier prostheses. Five registries publicly identified outlier prostheses in their reports and the methods by which this was performed, and three others had internal reports.

  • Identification of outlier prostheses is one area that may improve overall joint replacement outcomes; however, further research is needed to determine the optimum methods for identification, including the threshold, the comparator and the numbers required for notification of devices.

  • Co-operation of registries at a global level may lead to earlier identification of devices and thereby further improve the results of joint replacement.

A Prkić, N P Vermeulen, B W Kooistra, B The, M P J van den Bekerom, and D Eygendaal

  • Purpose: Total elbow arthroplasty (TEA) is rarely performed compared to other arthroplasties. For many surgical procedures, literature shows better outcomes when they are performed by experienced surgeons and in so-called ‘high-volume’ hospitals. We systematically reviewed the literature on the relationship between surgical volume and outcomes following TEA.

  • Methods: A literature search was performed using the MEDLINE, EMBASE and CINAHL databases. The literature was systematically reviewed for original studies comparing TEA outcomes among hospitals or surgeons with different annual or career volumes. For each study, data were collected on study design, indications for TEA, number of included patients, implant types, cut-off values for volume, number and types of complications, revision rate and functional outcome measures. The methodological quality of the included studies was assessed using the Newcastle–Ottawa Scale.

  • Results: Two studies, which included a combined 2301 TEAs, found that higher surgeon volumes were associated with lower revision rates. The examined complication rates did not differ between high- and low-volume surgeons. In one study, low-hospital volume is associated with an increased risk of revision compared to high-volume hospitals, but for other complication types, no difference was found.

  • Conclusions: Based on the results, the evidence suggests that high-volume centers have a lower revision rate in the long term. No minimum amount of procedures per year can be advised, as the included studies have different cut-off values between groups. As higher surgeon- and center-volume, (therefore presumably experience) appear to yield better outcomes, centralization of total elbow arthroplasty should be encouraged.

Xiang-Dong Wu, Yixin Zhou, Hongyi Shao, Dejin Yang, Sheng-Jie Guo, and Wei Huang


  • During the past decades, robotic-assisted technology has experienced an incredible advancement in the field of total joint arthroplasty (TJA), which demonstrated promise in improving the accuracy and precision of implantation and alignment in both primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, revision TJA remains a technically challenging procedure with issues of large-scale bone defects and damage to nearby anatomical structures. Thus, surgeons are trying to harness the abilities of robotic-assisted technology for revision TJA surgery.


  • PubMed, Embase, Cochrane Library, and Google Scholar were comprehensively searched to identify relevant publications that reported the application of robotic-assisted technology in revision TJA.


  • Overall, ten studies reported the use of the robotic system in revision TJA, including active (ROBODOC) and semi-active (MAKO and NAVIO) systems. One clinical case reported conversion from hip fusion to THA, and three studies reported revision from primary THA to revision THA. Moreover, four studies reported that robotic-assisted technology is helpful in revising unicompartmental knee arthroplasty (UKA) to TKA, and two case reports converted primary TKA to revision TKA. In this study, we present the latest evolvements, applications, and technical obstacles of robotic-assisted technology in the revision of TJA and the current state-of-the-art.


  • Current available evidence suggests that robotic-assisted technology may help surgeons to reproducibly perform preoperative plans and accurately achieve operative targets during revision TJA. However, concerns remain regarding preoperative metal artifacts, registration techniques, closed software platforms, further bone loss after implant removal, and whether robotic-assisted surgery will improve implant positioning and long-term survivorship.

Anna Wawrzyniak and Przemysław Lubiatowski


  • The purpose of this study was to collect and evaluate clinical and radiological evidence on shoulder neuroarthropathy (NA) in syringomyelia (SM) that may support the management and treatment of patients with this condition.

Materials and methods

  • This systematic review is based on the analysis of reports available in PubMed, Embase, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials using the following keywords: syringomyelia, neuroarthropathy, Charcot joint and shoulder degeneration. Thirty-nine publications were found presenting case reports or case series meeting our criteria. Pooled data included a group of 65 patients and 71 shoulders with NA secondary to SM.


  • The most commonly reported symptoms were range of motion (ROM) limitation, weakness, swelling, pain and dissociated sensory loss. NA is usually monolateral and concerns only the shoulder. The average active shoulder ROM was flexion −59.2° (s.d. 37.9), internal rotation −29.8° (s.d. 22.6) and external rotation −21.1° (s.d. 23.6). Most of the patients (75%) presented with complete or nearly complete proximal humerus degeneration, while the degree of glenoid preservation varied. Fifty-two neuroarthropathic shoulders were treated conservatively with physiotherapy, anti-inflammatory medication and splinting. Eighteen patients were treated by surgical intervention.


  • Shoulder NA due to SM is a devastating and progressive condition, and its course is often unpredictable. Patients with unexplained shoulder degeneration should be evaluated for SM, especially if there are additional neurological symptoms. Conservative treatment usually reduces shoulder pain without improving ROM. For select patients, shoulder arthroplasty may be a better option for restoring function.

Maria E Dey Hazra, Rony-Orijit Dey Hazra, Jared A Hanson, Phob Ganokroj, Matthew L Vopat, Joan C Rutledge, Kohei Yamaura, Sunikom Suppauksorn, and Peter J Millett

  • While functional reconstruction of massive irreparable rotator cuff tears remains a challenge, current techniques aimed at recentering and preventing superior migration of the humeral head allow for clinical and biomechanical improvements in shoulder pain and function.

  • Recentering of the glenohumeral joint reduces the moment arm and helps the deltoid to recruit more fibers, which compensates for insufficient rotator cuff function and reduces joint pressure.

  • In the past, the concept of a superior capsular reconstruction with a patch secured by suture anchors has been used.

  • However, several innovative arthroscopic treatment options have also been developed.

  • The purpose of this article is to present an overview of new strategies and surgical techniques and if existing present initial clinical results.

  • Techniques that will be covered include rerouting the long head of the biceps tendon, utilization of the biceps tendon as an autograft to reconstruct the superior capsule, utilization of a semitendinosus tendon allograft to reconstruct the superior capsule, superior capsular reconstruction with dermal allografts, and subacromial spacers.