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Juan Carlos Monllau, Simone Perelli, and Giuseppe Gianluca Costa

  • Anterior cruciate ligament (ACL) reconstruction failure can be defined as abnormal knee function due to graft insufficiency with abnormal laxity or failure to recreate a functional knee according to the expected outcome.

  • Traumatic ruptures have been reported as the most common reason for failure. They are followed by technical errors, missed concomitant knee injuries, and biological failures.

  • An in-depth preoperative examination that includes a medical history, clinical examinations, advanced imaging, and other appropriate methods is of utmost importance.

  • There is still no consensus as to the ideal graft, but autografts are the favorite choice even in ACL revision.

  • Concomitant meniscal treatment, ligamentous reconstruction, and osteotomies can be performed in the same surgical session to remove anatomical or biomechanical risk factors for the failure.

  • Patient expectations should be managed since outcomes after ACL revision are not as good as those following primary ACL reconstruction.

Agnieszka Halm-Pozniak, Christoph H Lohmann, Luigi Zagra, Benedikt Braun, Max Gordon, and Bernd Grimm

  • Digitization in orthopaedics and traumatology is an enormously fast-evolving field with numerous players and stakeholders. It will be of utmost importance that the different groups of technologists, users, patients, and actors in the healthcare systems learn to communicate in a language with a common basis.

  • Understanding the requirements of technologies, the potentials of digital application, their interplay, and the combined aim to improve health of patients, would lead to an extraordinary chance to improve health care.

  • Patients' expectations and surgeons’ capacities to use digital technologies must be transparent and accepted by both sides.

  • The management of big data needs tremendous care as well as concepts for the ethics in handling data and technologies have to be established while also considering the impact of withholding or delaying benefits thereof.

  • This review focuses on the available technologies such as Apps, wearables, robotics, artificial intelligence, virtual and augmented reality, smart implants, and telemedicine.

  • It will be necessary to closely follow the future developments and carefully pay attention to ethical aspects and transparency.

Paul L Rodham, Vasileios P Giannoudis, Nikolaos K Kanakaris, and Peter V Giannoudis

  • The ability to enhance fracture healing is paramount in modern orthopaedic trauma, particularly in the management of challenging cases including peri-prosthetic fractures, non-union and acute bone loss.

  • Materials utilised in enhancing fracture healing should ideally be osteogenic, osteoinductive, osteoconductive, and facilitate vascular in-growth.

  • Autologous bone graft remains the gold standard, providing all of these qualities. Limitations to this technique include low graft volume and donor site morbidity, with alternative techniques including the use of allograft or xenograft.

  • Artificial scaffolds can provide an osteoconductive construct, however fail to provide an osteoinductive stimulus, and frequently have poor mechanical properties.

  • Recombinant bone morphogenetic proteins can provide an osteoinductive stimulus; however, their licencing is limited and larger studies are required to clarify their role.

  • For recalcitricant non-unions or high-risk cases, the use of composite graft combining the above techniques provides the highest chances of successfully achieving bony union.

Martin McNally, Irene Sigmund, Andrew Hotchen, and Ricardo Sousa

  • Prosthetic joint infections (PJI) can be difficult to diagnose.

  • Studies have shown that we are missing many infections, possibly due to poor diagnostic workup and the presence of culture-negative infection.

  • PJI diagnosis requires a methodical approach and a standardised set of criteria.

  • Multiple PJI definitions have been published with improved accuracy in recent years.

  • The new European Bone and Joint Infection Society definition offers some advantages in clinical practice. It identifies more clinically important infections and accurately defines those with the highest risk of treatment failure. It reduces the number of patients with uncertain diagnoses.

  • Classification of PJIs may offer a better understanding of treatment outcomes and risk factors for failure.

T Gosens and B L den Oudsten

  • Mental health is important as a predictor of outcomes after orthopedic treatment.

  • Psychological parameters (e.g. expectations, coping strategies, personality) are as important as biological and mechanical factors in the severity of musculoskeletal complaints and treatment results.

  • Orthopedic surgeons should not only treat physical conditions but also address psychosocial factors. If necessary, they should refer to clinical psychologists.

  • Multidisciplinary approach, patient-oriented treatment, (psycho)education, emotional support, and teaching coping strategies are elements of psychosocial attention within orthopedics and traumatology.

Marjan Wouthuyzen-Bakker

  • Culture-negative periprosthetic joint infections (PJI) are commonly described in the literature.

  • By implementing a routine diagnostic workup and by optimizing tissue sampling and processing, the culture-negative rate can easily be reduced.

  • When faced with a culture-negative PJI, several serological and molecular techniques are available that may aid in finding the causative microorganism. Clinical clues may guide the treating physician towards more atypical and rare microorganisms.

  • A multidisciplinary team consisting of orthopaedic surgeons, microbiologists and infectious disease specialist are warranted in tailoring diagnostic testing and deciding on the surgical and antibiotic treatment approach.

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.

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.

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.

Leonard Christianto Singjie, Reynaldo Halomoan, Ifran Saleh, Endrotomo Sumargono, and Erica Kholinne


  • Patients undergoing major orthopedic surgeries, such as total hip replacement (THR), total knee replacement (TKR), and trauma surgery, are at an elevated risk of venous thromboembolism (VTE), causing significant morbidity and mortality. Previous studies have investigated aspirin as a thromboprophylactic agent for arthroplasty, besides trauma surgery. Therefore, we sought to analyze the efficacy of aspirin compared to that of other anticoagulants for VTE prophylaxis in patients undergoing major orthopedic surgeries.


  • This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study protocol was registered with the PROSPERO register. Randomized controlled trials that investigated the use of aspirin for thromboprophylaxis in major orthopedic lower limb surgeries were included and analyzed. Quality analysis of the literature and level of evidence were assessed. The primary clinical outcome was VTE. Secondary clinical outcomes included mortality, bleeding events, and wound complications.


  • Eight high-quality studies with level 2 evidence (published within 2006–2021) were included, comprising 6220 patients. The incidence of VTE with aspirin was not found to be more significant than other anticoagulants (risk ratio (RR) = 1.18, 95% CI: 0.89–1.58, P = 0.25). Regarding secondary outcomes, there were no significant differences between aspirin and other anticoagulants (mortality (RR = 1.40, 95% CI: 0.27–7.23, P = 0.69), bleeding events (RR = 0.89, 95% CI: 0.57–1.39, P = 0.61), or wound complications (RR = 0.64, 95% CI: 0.30–1.35, P = 0.24)).


  • The current meta-analysis did not show any difference between aspirin and other anticoagulants as thromboprophylactic agents in preventing VTE in patients who underwent major orthopedic surgeries.