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• Fracture-related infection (FRI) is common and often diagnosed late.

• Accurate diagnosis is the beginning of effective treatment.

• Diagnosis can be difficult, particularly when there are no outward signs of infection.

• The new FRI definition, together with clear protocols for nuclear imaging, microbiological culture and histological analysis, should allow much better study design and a clearer understanding of infected fractures.

• In recent years, there has been a new focus on defining FRI and avoiding non-specific, poorly targeted treatment. Previous studies on FRI have often failed to define infection precisely and so are of limited value. This review highlights the essential principles of making the diagnosis and how clinical signs, serum tests, imaging, microbiology, molecular biology and histology all contribute to the diagnostic pathway.

Cite this article: EFORT Open Rev 2020;5:614-619. DOI: 10.1302/2058-5241.5.190072

• Europe represents true diversity, with cultural, linguistic and geopolitical variation spanning a large geographical area. Politics for many of its 750 million inhabitants revolves around the European Union (EU) and its 27 member states. The overarching goal of the EU is to promote peace and the values of the union (inclusion, tolerance, justice, solidarity and non-discrimination).^1,2

• EFORT was created to connect orthopaedic associations across Europe, fostering relationships between member countries that celebrated diversity and facilitated the exchange of knowledge. Whilst the global landscape changes and politics attempts to interfere in how we live our lives, it is important to remember that a strong organization is a diverse one that evolves over time.

• Various initiatives exist across the global landscape to support diversity in terms of culture; gender; black, Asian and minority ethnic (BAME) groups; disability groups; lesbian, gay, bisexual, transgender and queer (or questioning) and others (LGBTQ+); and the ‘ageing’ surgeon. This article explores the creation of some of these initiatives and how they have been supported by different orthopaedic organizations.

Cite this article: EFORT Open Rev 2020;5:743-752. DOI: 10.1302/2058-5241.5.200022

• Rates of peri-prosthetic joint infection (PJI) in primary total hip and total knee arthroplasty range between 0.3% and 1.9%, and up to 10% in revision cases. Significant morbidity is associated with this devastating complication, the economic burden on our healthcare system is considerable, and the personal cost to the affected patient is immeasurable.

• The risk of surgical site infection (SSI) and PJI is related to surgical factors and patient factors such as age, body mass index (BMI), co-morbidities, and lifestyle. Reducing the risk of SSI in primary hip and knee arthroplasty requires a multi-faceted strategy including pre-operative patient bacterial decolonization, screening and avoidance of anaemia, peri-operative patient warming, skin antisepsis, povidone-iodine wound lavage, and anti-bacterial coated sutures.

• This article also considers newer concepts such as the influence of bearing surfaces on infection risk, as well as current controversies such as the potential effects of blood transfusion, laminar flow, and protective hoods and suits, on infection risk.

Cite this article: EFORT Open Rev 2020;5:604-613. DOI: 10.1302/2058-5241.5.200004

• Virtual fracture clinics (VFC) are advocated by new orthopaedic (British Orthopaedic Association) and National Health Service (NHS) guidelines in the United Kingdom. We discuss benefits and limitations, reviewing the literature, as well as recommendations on introducing a VFC service during the coronavirus pandemic and into the future.

• A narrative review identifying current literature on virtual fracture clinic outcomes when compared to traditional model fracture clinics in the UK. We identify nine relevant publications related to VFC.

• The Glasgow model, initiated in 2011, has become the benchmark. Clinical efficiency can be improved, reducing the number of emergency department (ED) referrals seen in VFC by 15–28% and face-to-face consultations by 65%. After review in the VFC, 33–60% of patients may be discharged. Some studies have shown no negative impact on the ED; the time to discharge was not increased. Patient satisfaction ranges from 91–97% using a VFC service, and there may be cost-saving benefits annually of £67,385 to £212,705. Non-attendance may be reduced by 75% and there are educational opportunities for trainees. However, evidence is limited; 28% of patients prefer face-to-face consultations and not all have access to internet or email (72%).

• We propose a pathway integrating the VFC model, whilst having senior orthopaedic decision makers available in the ED, during normal working hours, to cope with the pandemic. Beyond the pandemic, evidence suggests the Glasgow model is viable for day-to-day practice.

Cite this article: EFORT Open Rev 2020;5:442-448. DOI: 10.1302/2058-5241.5.200041

• There are many digital solutions which assist the orthopaedic trauma surgeon. This already broad field is rapidly expanding, making a complete overview of the existing solutions difficult.

• The AO Foundation has established a task force to address the need for an overview of digital solutions in the field of orthopaedic trauma surgery.

• Areas of new technology which will help the surgeon gain a greater understanding of these possible solutions are reviewed.

• We propose a categorization of the current needs in orthopaedic trauma surgery matched with available or potential digital solutions, and provide a narrative overview of this broad topic, including the needs, solutions and basic rules to ensure adequate use in orthopaedic trauma surgery. We seek to make this field more accessible, allowing for technological solutions to be clearly matched to trauma surgeons’ needs.

Cite this article: EFORT Open Rev 2020;5:408-420. DOI: 10.1302/2058-5241.5.200021

• Three-dimensional printing (3DP) has become more frequently used in surgical specialties in recent years. These uses include pre-operative planning, patient-specific instrumentation (PSI), and patient-specific implant production.

• The purpose of this review was to understand the current uses of 3DP in orthopaedic surgery, the geographical and temporal trends of its use, and its impact on peri-operative outcomes

• One-hundred and eight studies (N = 2328) were included, published between 2012 and 2018, with over half based in China.

• The most commonly used material was titanium.

• Three-dimensional printing was most commonly reported in trauma (N = 41) and oncology (N = 22). Pre-operative planning was the most common use of 3DP (N = 63), followed by final implants (N = 32) and PSI (N = 22).

• Take-home message: Overall, 3DP is becoming more common in orthopaedic surgery, with wide range of uses, particularly in complex cases. 3DP may also confer some important peri-operative benefits.

Cite this article: EFORT Open Rev 2020;5:430-441. DOI: 10.1302/2058-5241.5.190024

• Because of the risk of bacterial biofilm infections, prophylactic use of antibiotics in orthopaedic procedures involving the implantation of large prosthesis systems is considered mandatory.

• A strategy based on the rationale that local antibiotics released from bone cement or other carriers establish a second antibacterial frontline in and around the prosthesis is considered complementary to the administration of systemic antibiotics.

• Although less common as a consequence of the initially very high drug concentrations of local antibiotics in the tissues, a selection process of previous high resistance bacteria may occur, leading to antibiotic resistance.

• The use of antibiotic combinations in bone cement is generally accepted to improve antibiotic efficacy and minimizes the treatment failure risk due to antibiotic resistance. This is important in septic revisions and/or in patients at particularly high risk of infection.

• On an individual basis, the benefit of a lower infection probability with combined systemic and local antibiotic application should outweigh the risk of the selection of more resistant bacteria. Each prevented infection means that a complex and extended antibiotic therapy with risk of resistance development over time has been avoided.

• On an epidemiological level there is no clinical evidence that the routine use of bone cement impregnated with appropriate bactericidal antibiotics promotes the widespread development of antibiotic resistance and thereby puts the successful treatment of a prosthetic joint infection at higher risk.

Cite this article: EFORT Open Rev 2019;4:576-584. DOI: 10.1302/2058-5241.4.180104

• Culture-negative periprosthetic joint infections (CN-PJI) pose a significant challenge in terms of diagnosis and management. The reported incidence of CN-PJI is reported to be between 7% and 15%.

• Fungi and mycobacterium are thought to be responsible for over 85% of such cases with more fastidious bacteria accounting for the rest.

• With the advent of polymerase chain reaction, mass spectrometry and next generation sequencing, identifying the causative organism(s) may become easier but such techniques are not readily available and are very costly.

• There are a number of more straightforward and relatively low-cost methods to help surgeons maximize the chances of diagnosing a PJI and identify the organisms responsible.

• This review article summarizes the main diagnostic tests currently available as well as providing a simple diagnostic clinical algorithm for CN-PJI.

Cite this article: EFORT Open Rev 2019;4:585-594. DOI: 10.1302/2058-5241.4.180067

• The majority of included studies (8 out of 11, n = 54) supported the concept of considering amputation for selected, unresponsive cases of complex regional pain syndrome (CRPS) as a justifiable alternative to an unsuccessful multimodality nonoperative option.

• Of patients who underwent amputation, 66% experienced improvement in quality of life (QOL) and 37% were able to use a prosthesis, 16% had an obvious decline in QOL and for 12% of patients, no clear details were given, although it was suggested by authors that these patients also encountered deterioration after amputation.

• Complications of phantom limb pain, recurrence of CRPS and stump pain were predominant risks and were noticed in 65%, 45% and 30% of cases after amputation, respectively and two-thirds of patients were satisfied.

• Amputation can be considered by clinicians and patients as an option to improve QOL and to relieve agonizing, excruciating pain of severe, resistant CRPS at a specialized centre after multidisclipinary involvement but it must be acknowledged that evidence is limited, and the there are risks of aggravating or recurrence of CRPS, phantom pain and unpredictable consequences of rehabilitation.

• Amputation, if considered for resistant CRPS, should be carried out at specialist centres and after MDT involvement before and after surgery. It should only be considered if requested by patients with poor quality of life who have failed to improve after multiple treatment modalities.

• Further high quality and comprehensive research is needed to understand the severe form of CRPS which behaves differently form less severe stages.

Cite this article: EFORT Open Rev 2019;4:533-540. DOI: 10.1302/2058-5241.4.190008

• Periprosthetic joint infection (PJI) is a serious complication occurring in 1% to 2% of primary arthroplasties, which is associated with high morbidity and need for complex interdisciplinary treatment strategies.

• The challenge in the management of PJI is the persistence of micro-organisms on the implant surface in the form of biofilm. Understanding this ability, the phases of biofilm formation, antimicrobial susceptibility and the limitations of host local immune response allows an individual choice of the most suitable treatment.

• By using diagnostic methods for biofilm detection such as sonication, the sensitivity for diagnosing PJI is increasing, especially in chronic infections caused by low-virulence pathogens.

• The use of biofilm-active antibiotics enables eradication of micro-organisms in the presence of a foreign body. The total duration of antibiotic treatment following revision surgery should not exceed 12 weeks.

Cite this article: EFORT Open Rev 2019;4:482-494. DOI: 10.1302/2058-5241.4.180092