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Heinz Winkler

  • Chronic infections are one of the major challenges in orthopaedic surgery, both for surgeons and patients. They are characterised by obstinate persistency of the causing microorganisms and resulting long-term disablement of the patients, associated with remarkable costs for the health care system.

  • Difficulties derive from the biofilm-mode of living of pathogens with resistances against immunological defence and antimicrobial substances, and osseous defects resulting from the disease itself and surgical interventions.

  • Established techniques usually require multiple costly operations with extended periods of disablement and impairment of the patients, sometimes making the therapy worse than the disease.

  • Better understanding of the backgrounds of the conditions has led to new surgical techniques and differentiated application of antibiotics, aiming in improved quality of life for our patients.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160063. Originally published online at

G. Ulrich Exner, Michael O. Kurrer, Nadja Mamisch-Saupe, and Stephen R. Cannon

  • The treatment of musculoskeletal neoplasms and infection is usually based on an initial diagnostic biopsy.

  • Prior to biopsy, a hypothesis should be formed about the most likely diagnosis and a differential diagnosis. These deliberations should consider whether the lesion is a primary benign or malignant tumour, a metastasis, a haematological problem or an infection.

  • A tactical plan should be developed which evaluates the necessity, the risk, the approach and finally defines the technique of biopsy most likely to achieve a representative result in the clinical case.

  • In developing this technical approach, the pitfalls should be anticipated, i.e. inadequate sampling, difficulty of pathological interpretation and contamination.

  • The tactical approach should be developed in conjunction with a multi-disciplinary team together with appropriate pre-biopsy imaging.

Cite this article: EFORT Open Rev 2017;2:51–57. DOI: 10.1302/2058-5241.2.160065

Low-dose dexamethasone during arthroplasty

What do we know about the risks?

Jessica T. Wegener, Tim Kraal, Markus F. Stevens, Markus W. Hollmann, Gino M.M.J. Kerkhoffs, and Daniël Haverkamp

  • Dexamethasone is commonly applied during arthroplasty to control post-operative nausea and vomiting (PONV). However, conflicting views of orthopaedic surgeons and anaesthesiologists regarding the use of dexamethasone raise questions about risks of impaired wound healing and surgical site infections (SSI).

  • The aim of this systematic review is to determine the level of evidence for the safety of a peri-operative single low dose of dexamethasone in hip and knee arthroplasty.

  • We systematically reviewed literature in PubMed, EMBASE and Cochrane databases and cited references in articles found in the initial search from 1980 to 2013 based on predefined inclusion criteria. The review was completed with a ‘pro’ and ‘con’ discussion.

  • After identifying 11 studies out of 104, only eight studies met the inclusion criteria. In total, 1335 patients were studied without any incidence of SSI. Causes of SSI are multifactorial. Therefore, 27 205 patients would be required (power = 90%, alpha = 0.05) to provide substantiated conclusions on safety of a single low dose of dexamethasone.

  • Positively, many studies demonstrated showed convincing effects of low-dose dexamethasone on prevention of PONV and dose-dependent effects on post-operative pain and quality of recovery. Dexamethasone induces hyperglycaemia, but none of the studies demonstrated a concomitant SSI.

  • Conversely, animal studies showed that high dose dexamethasone inhibits wound healing.

  • A team approach of anaesthesiologists and orthopaedic surgeons is mandatory in order to balance the risk–benefit ratio of peri-operatively applied steroids for individual arthroplasty patients.

  • We did not find evidence that a single low dose of dexamethasone contributes to SSI or wound healing impairment from the current studies.

Cite this article: Wegener JT, Kraal T, Stevens MF, Hollman MW, Kerkhoffs GMMJ, Haverkamp D. Low-dose dexamethasone during arthroplasty: what do we know about the risks? EFORT Open Rev 2016;1:303-309. DOI: 10.1302/2058-5241.1.000039.

AliSina Shahi and Javad Parvizi

  • The role of serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as the first line for evaluating a patient with periprosthetic joint infection (PJI) has been debunked.

  • We are living in the era of biomarkers for the diagnosis of PJI, and to that effect, several biomarkers have been introduced such as synovial fluid alpha defensin and leukocyte esterase.

  • The synovial fluid leukocyte esterase test has a low cost, is accessible, and has provided promising results for diagnosing PJI.

  • There is an urgent need for an accurate and reliable serum biomarker for diagnosing patients with PJI.

Cite this article: Shahi A, Parvizi J. The role of biomarkers in the diagnosis of periprosthetic joint infection. EFORT Open Rev 2016;1:275-278. DOI: 10.1302/2058-5241.1.160019.

Ferdinando Auricchio and Stefania Marconi

  • Advances in image processing have led to the clinical use of 3D printing technology, giving the surgeon a realistic physical model of the anatomy upon which he or she will operate.

  • Relying on CT images, the surgeon creates a virtual 3D model of the target anatomy from a series of bi-dimensional images, translating the information contained in CT images into a more usable format.

  • 3D printed models can play a central role in surgical planning and in the training of novice surgeons, as well as reducing the rate of re-operation.

Cite this article: Auricchio F, Marconi S. 3D printing: clinical applications in orthopaedics and traumatology. EFORT Open Rev 2016;1:121–127. DOI: 10.1302/2058-5241.1.000012.

Michalis Panteli and Peter V. Giannoudis

  • Chronic osteomyelitis represents a progressive inflammatory process caused by pathogens, resulting in bone destruction and sequestrum formation.

  • It may present with periods of quiescence of variable duration, whereas its occurrence, type, severity and prognosis is multifactorial.

  • The ‘gold standard’ for the diagnosis of chronic osteomyelitis is the presence of positive bone cultures and histopathologic examination of the bone.

  • Its management remains challenging to the treating physician, with a multidisciplinary approach involving radiologists, microbiologists with expertise in infectious diseases, orthopaedic surgeons and plastic surgeons.

  • Treatment should be tailored to each patient according the severity and duration of symptoms, as well as to the clinical and radiological response to treatment.

  • A combined antimicrobial and surgical treatment should be considered in all cases, including appropriate dead space management and subsequent reconstruction. Relapse can occur, even following an apparently successful treatment, which has a major impact on the quality of life of patients and is a substantial financial burden to any healthcare system.

Cite this article EFORT Open Rev 2016;1:128–135. DOI: 10.1302/2058-5241.1.000017.

Bernd Grimm and Stijn Bolink

  • Wearable sensors, in particular inertial measurement units (IMUs) allow the objective, valid, discriminative and responsive assessment of physical function during functional tests such as gait, stair climbing or sit-to-stand.

  • Applied to various body segments, precise capture of time-to-task achievement, spatiotemporal gait and kinematic parameters of demanding tests or specific to an affected limb are the most used measures.

  • In activity monitoring (AM), accelerometry has mainly been used to derive energy expenditure or general health related parameters such as total step counts.

  • In orthopaedics and the elderly, counting specific events such as stairs or high intensity activities were clinimetrically most powerful; as were qualitative parameters at the ‘micro-level’ of activity such as step frequency or sit-stand duration.

  • Low cost and ease of use allow routine clinical application but with many options for sensors, algorithms, test and parameter definitions, choice and comparability remain difficult, calling for consensus or standardisation.

Cite this article: Grimm B, Bolink S. Evaluating physical function and activity in the elderly patient using wearable motion sensors. EFORT Open Rev 2016;1:112–120. DOI: 10.1302/2058-5241.1.160022.

Ann Alriksson-Schmidt, Jonas Ranstam, Otto Robertsson, and Lars Lidgren

T. Fintan Moriarty, Richard Kuehl, Tom Coenye, Willem-Jan Metsemakers, Mario Morgenstern, Edward M. Schwarz, Martijn Riool, Sebastian A.J. Zaat, Nina Khana, Stephen L. Kates, and R. Geoff Richards

  • Orthopaedic and trauma device-related infection (ODRI) remains one of the major complications in modern trauma and orthopaedic surgery.

  • Despite best practice in medical and surgical management, neither prophylaxis nor treatment of ODRI is effective in all cases, leading to infections that negatively impact clinical outcome and significantly increase healthcare expenditure.

  • The following review summarises the microbiological profile of modern ODRI, the impact antibiotic resistance has on treatment outcomes, and some of the principles and weaknesses of the current systemic and local antibiotic delivery strategies.

  • The emerging novel strategies aimed at preventing or treating ODRI will be reviewed. Particular attention will be paid to the potential for clinical impact in the coming decades, when such interventions are likely to be critically important.

  • The review focuses on this problem from an interdisciplinary perspective, including basic science innovations and best practice in infectious disease.

Cite this article: Moriarty TF, Kuehl R, Coenye T, et al. Orthopaedic device related infection: current and future interventions for improved prevention and treatment. EFORT Open Rev 2016;1:89-99. DOI: 10.1302/2058-5241.1.000037.