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Cora Rebecca Schindler, Ramona Sturm, Jason Alexander Hörauf, Ingo Marzi, and Philipp Störmann

  • ‘Damage control’ is the therapeutic strategy in the treatment of polytraumatized patients and aims at securing vital functions and controlling bleeding with a favorable effect on the post-traumatic immune response.

  • The post-traumatic immune dysfunction is based on a disturbed balance between immunostimulatory and anti-inflammatory mechanisms. The extent of the immunological ‘second hit’ can be limited by delaying deferable surgical therapies until organ stabilization has been achieved by the treating surgeon.

  • Pelvic sling is easy to apply and noninvasive with effective pelvic reduction. Pelvic angiography vs pelvic packing are not antagonistic, but rather should be considered as complementary methods.

  • Operating as early as possible on unstable spinal injuries with confirmed or suspected neurological deficits by decompression and stabilization with a dorsal internal fixator.

  • Dislocations, unstable or open fracture, vascular involvement, and compartment syndrome are considered emergency indications. In extremity fracture treatment, primary definitive osteosynthesis is often dispensed with and instead, temporary stabilization with an external fixator is performed.

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

  • Management of severely injured patients remains a challenge, characterised by a number of advances in clinical practice over the last decades. This evolution refers to all different phases of patient treatment from prehospital to the long-term rehabilitation of the survivors.

  • The spectrum of injuries and their severity is quite extensive, which dictates a clear understanding of the existing nomenclature.

  • What is defined nowadays as polytrauma or major trauma, together with other essential terms used in the orthopaedic trauma literature, is described in this instructional review.

  • Furthermore, an analysis of contemporary management strategies (early total care (ETG), damage control orthopaedics (DCO), early appropriate care (EAC), safe definitive surgery (SDS), prompt individualised safe management (PRISM) and musculoskeletal temporary surgery (MuST)) advocated over the last two decades is presented.

  • A focused description of new methods and techniques that have been introduced in clinical practice recently in all different phases of trauma management will also be presented.

  • As the understanding of trauma pathophysiology and subsequently the clinical practice continuously evolves, as the means of scientific interaction and exchange of knowledge improves dramatically, observing different standards between different healthcare systems and geographic regions remains problematic.

  • Positive impact on the survivorship rates and decrease in disability can only be achieved with teamwork training on technical and non-technical skills, as well as with efficient use of the available resources.

George Grammatopoulos, Moritz Innmann, Philippe Phan, Russell Bodner, and Geert Meermans

  • There is no universal safe zone for cup orientation. Patients with spinal arthrodesis or a degenerative lumbar spine are at increased risk of dislocation.

  • The relative contributions of the hip (femur and acetabulum) and of the spine (lumbar spine) in body motion must be considered together. The pelvis links the two and influences both acetabular orientation (i.e. hip flexion/extension) and sagittal balance/lumbar lordosis (i.e. spine flexion/extension).

  • Examination of the spino-pelvic motion can be done through clinical examination and standard radiographs or stereographic imaging. A single, lateral, standing spinopelvic radiograph would be able to providemost relevant information required for screening and pre-operative planning.

  • A significant variability in static and dynamic spinopelvic characteristics exists amongst healthy volunteers without known spinal or hip pathology.

  • The stiff, arthritic, hip leads to greater changes in pelvic tilt (changes are almost doubled), with associated obligatory change in lumbar lordosis to maintain upright posture (lumbar lordosis is reduced to counterbalance for the reduction in sacral slope). Following total hip arthroplasty and restoration of hip flexion, spinopelvic characteristics tend to change/normalize (to age-matched healthy volunteers).

  • The static spinopelvic parameters that are directly associated with increased risk of dislocation are lumbo-pelvic mismatch (pelvic incidence – lumbar lordosis angle >10°), high pelvic tilt (>19°), and low sacral slope when standing. A high combined sagittal index (CSI) when standing (>245°) is associated with increased risk of anterior instability, whilst low CSI when standing (<205°) is associated with increased risk of posterior instability.

  • Aiming to achieve an optimum CSI when standing within 205–245° (with narrower target for those with spinal disease) whilst ensuring the coronal targets of cup orientation targets are achieved (inclination/version of 40/20 ±10°) is our preferred method.

Rui Claro and Hélder Fonte

  • The treatment of rotator cuff tears (RCTs) has evolved. Nonsurgical treatment is adequate for many patients; however, for those for whom surgical treatment is indicated, rotator cuff repair provides reliable pain relief and good functional results. However, massive and irreparable RCTs are a significant challenge for both patients and surgeons.

  • Superior capsular reconstruction (SCR) has become increasingly popular in recent years. It works by passively restoring the superior restriction of the humeral head, thus restoring the pair of forces and improving the kinematics of the glenohumeral joint. Early clinical results using fascia lata (FL) autograft were promising in terms of pain relief and function.

  • The procedure has evolved, and some authors have suggested that FL autografts could be replaced by other methods. However, surgical techniques for SCR are highly variable, and patient indications remain undefined. There are concerns that the available scientific evidence does not support the popularity of the procedure.

  • This review aimed to critically evaluate the biomechanics, indications, procedural considerations, and clinical outcomes associated with the SCR procedure.

Charles Court, Leonard Chatelain, Barthelemy Valteau, and Charlie Bouthors

  • In young patients, lumbosacral fractures result primarily from high-energy traumas. Life-threatening lesions (e.g. visceral organs) are frequently associated with these fractures. Management consists of medical intensive care for adequate resuscitation and specialized surgical input.

  • Lumbosacral junction represents a frontier between the spine and pelvic ring. Any injury in this area implies a thorough examination of both spine and pelvis through clinical examinations and CT scans. Patients must be assessed specifically for neurological and bladder/bowel symptoms. Several surgical classifications may be required to describe the entire fracture pattern.

  • In unstable fracture with large displacements, definitive surgical fixation is often recommended. Various pelvic and spine surgery techniques can be used depending on the fracture pattern, surgeon’s experience, and available equipment. The use of intraoperative navigation may enhance placement of instrumentation, especially in cases of complex fractures, percutaneous fixations, and/or atypical patients’ anatomy.

  • The fracture itself can cause debilitating complications with long-term consequences such as pain, neurological deficits, and bladder/bowel impairments. Wound infection remains the most common postoperative complication and prominent posterior instrumentation is frequently a source of pain. Irrespective of the treatment, leg discrepancy can be problematic in the case of malunion.

  • Management of lumbosacral fractures requires a thorough understanding of both lumbar spine and pelvic injuries. Surgical treatment may involve a combination of spine and pelvic surgery techniques. Therefore, this implies for the surgeon to be trained specifically for these fractures, or else a close cooperation between the pelvic surgeon and the spine surgeon in managing the patients.

David Barrett and Angela Brivio

  • The anterior part (third space) of the knee appears important in the soft tissue functional outcome following knee replacement surgery.

  • Native patellofemoral kinematics are complex and variable, and further understanding has led to prosthetic redesign.

  • Attention to soft tissue tension anteriorly (balancing the third space) during knee replacement may maximise post-operative function and avoid issues with understuffing and overstuffing.

  • Patellofemoral compression forces may now be measured dynamically during knee replacement, allowing an objective approach to balancing the third space.

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.

Sohrab Keyhani, Mohammad Movahedinia, Arash Sherafat Vaziri, Mehran Soleymanha, Fardis Vosoughi, Mohammad Tahami, and Robert F LaPrade

  • Various uses of posterior knee arthroscopy have been shown, including all-inside repair of posterior meniscal lesions, posterior cruciate ligament (PCL) reconstruction or PCL avulsion fixation, extensile posterior knee synovectomy for pigmented villonodular synovitis or synovial chondromatosis, posterior capsular release in the setting of knee flexion contractures, and loose bodies removal.

  • Posterior arthroscopy provides direct access to the posterior meniscal borders for adequate abrasion and fibrous tissue removal. This direct view of the knee posterior structures enables the surgeon to create a stronger biomechanical repair using vertical mattress sutures.

  • During PCL reconstruction, posterior arthroscopy gives the surgeon proper double access to the tibial insertion site, which can result in less acute curve angles and the creation of a more anatomic tibial tunnel. Moreover, it gives the best opportunity to preserve the PCL remnant. Arthroscopic PCL avulsion fixation is more time-consuming with a larger cost burden compared to open approaches, but in the case of other concomitant intra-articular injuries, it may lead to a better chance of a return to pre-injury activities.

  • The high learning curve and overcaution of neuromuscular injury have discouraged surgeons from practicing posterior knee arthroscopy using posterior portals. Evidence for using posterior portals by experienced surgeons suggests fewer complications.

  • The evidence suggests toward learning posterior knee arthroscopy, and this technique must be part of the education about arthroscopy. In today's professional sports world, where the quick and complete return of athletes to their professional activities is irreplaceable, the use of posterior knee arthroscopy is necessary.

Mark D Kohn, Charles J Wolock, Isaac J Poulson, and Navin D Fernando


  • This investigation provides a rigorous systematic review of the postoperative outcomes of patients with and without chronic hepatitis C who underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA).


  • We queried PubMed, Embase, Cochrane Database of Systematic Reviews, Scopus, Web of Science and the ‘gray’ literature, including supplemental materials, conference abstracts and proceedings as well as commentary published in various peer-reviewed journals from 1992 to present to evaluate studies that compared the postoperative outcomes of patients with and without chronic hepatitis C who underwent primary THA or TKA. This investigation was registered in the PROSPERO international prospective register of systematic reviews and follows the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In our literature search, we identified 14 articles that met our inclusion criteria and were included in our fixed-effects meta-analysis. The postoperative outcomes analyzed included periprosthetic joint infection (PJI), aseptic revision, non-homebound discharge and inpatient mortality.


  • Our statistical analysis demonstrated a statistically significant increase in postoperative complications of patients with chronic hepatitis C who underwent primary THA or TKA including PJI (odds ratio (OR): 1.98, 95% CI: 1.86 – 2.10), aseptic revision (OR: 1.58, 95% CI: 1.50 – 1.67), non-homebound discharge (OR: 1.31, 95% CI: 1.28– 1.34) and inpatient mortality (OR: 9.37, 95% CI: 8.17 – 10.75).


  • This meta-analysis demonstrated a statistically significant increase in adverse postoperative complications in patients with chronic hepatitis C who underwent primary THA or TKA compared to patients without chronic hepatitis C.

Marco Gupton and Jessica Burns

  • Osteoarticular infections (OAI) are a significant cause of morbidity and mortality. Cultures and serology are some of the gold standards for identifying infection but are often unable to provide a timely diagnosis or a diagnosis at all.

  • Genetic testing offers capabilities that other modalities lack. Polymerase chain reaction has multiple versions with various costs and turnaround times. This technology has become implemented in multiple pediatric center OAI diagnostic protocols. There is sufficient literature documenting effectiveness in certain clinical situations, especially with fastidious organism diagnosis, but significant limitation still exists.

  • Metagenomic next-generation sequencing is an unbiased or hypothesis-free modality with the capability to detect the genetic material of bacteria, viruses, parasites, fungi, and humans from a single sample.

  • Potential benefits include pathogen identification unaffected by antimicrobial administration, detection of fastidious organisms more quickly, delineation of pathogens in polymicrobial infections, antimicrobial susceptibility, and avoidance of invasive procedures.

  • It is a resource-intensive modality with little standardization of the complex processes. Appropriate use and definitive clinical impact have yet to be determined.