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• The management of femoral neck fractures remains controversial. Treatment options include a wide variety of internal fixation methods, unipolar or bipolar hemiarthroplasty or total hip replacement.

• We carried out a systematic review of the available literature to detect differences between cemented and cementless fixation of bipolar prostheses in treating femoral neck fractures in patients aged 60 years or older.

• Thirteen studies involving a total of 1561 bipolar hemiarthroplasties (770 cemented and 791 uncemented) were identified. Uncemented hemiarthroplasty was associated with significantly lower blood loss (p < 0.0001), shorter operative time (p < 0.0001), less infection (p = 0.03) and lower risk of heterotopic ossification (p = 0.007). On the other hand, patients with cemented hemiarthroplasty suffered significantly less postoperative thigh pain than those with cementless implantation (p < 0.00001).

• The existing evidence indicates that uncemented bipolar hemiarthroplasty offers shorter operative time, less blood loss, lower local complications and a similar rate of systemic complications and reoperations as compared to cemented implantation.

Cite this article: EFORT Open Rev 2021;6:380-386. DOI: 10.1302/2058-5241.6.200057

• This article serves to review the existing clinical guidelines, and highlight the most recent medical and surgical recommendations, for the management of displaced femoral neck fractures (FNFs). It stresses the need for multi-disciplinary intervention to potentially improve mortality rates, limit adverse events and prevent further economic liability.

• Globally, the incidence of FNFs continues to rise as the general population ages and becomes more active. The annual number of FNFs is expected to exceed six million by 2050. The increased burden of FNFs exacerbates the demand on all services associated with treating these injuries.

• The management of FNFs may serve as an indicator of the quality of care of the geriatric population. However, despite escalating health costs, a significant 30-day and one-year mortality rate, increased rate of peri-operative adverse events and sub-optimal functional clinical outcomes, continued controversy exists over optimal patient care.

• Much debate exists over the type of surgery, implant selection and peri-operative clinical care and rehabilitation. FNF care models, systematized clinical pathways, formal geriatrics consultation and specialized wards within an established interdisciplinary care framework may improve outcomes, mitigate adverse events and limit unnecessary costs.

Cite this article: EFORT Open Rev 2021;6:139-144. DOI: 10.1302/2058-5241.6.200036

• Subtrochanteric (ST) femur fractures are proximal femur fractures, which are often difficult to manage effectively because of their deforming anatomical forces.

• Operative management of ST fractures is the mainstay of treatment, with the two primary surgical implant options being intramedullary (IM) nails and extramedullary plates.

• Of these, IM nails have a biologic and biomechanical superiority, and have become the gold standard for ST femur fractures.

• The orthopaedic surgeon should become familiar and facile with several reduction techniques to create anatomical alignment in all unique ST fracture patterns.

• This article presents a comprehensive and current review of the epidemiology, anatomy, biomechanics, clinical presentation, diagnosis, and management of subtrochanteric femur fractures.

Cite this article: EFORT Open Rev 2021;6:145-151. DOI: 10.1302/2058-5241.6.200048

• The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess additional factors.

• Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries.

• Preoperative confirmation of the THA (total hip arthroplasty) stability is sometimes challenging. The most reliable method remains intraoperative assessment during surgical exploration of the hip joint.

• Certain B1 fractures will benefit from revision surgery, whilst some B2 fractures can be effectively managed with osteosynthesis, especially in frail patients.

• Less invasive osteosynthesis, balanced plate–bone constructs, composite implant solutions, together with an appropriate reduction of the limb axis, rotation and length are critical for a successful fixation and uneventful fracture healing.

Cite this article: EFORT Open Rev 2021;6:75-92. DOI: 10.1302/2058-5241.6.200050

• In aseptic tibial diaphyseal nonunions after failed conservative treatment, the recommended treatment is a reamed intramedullary (IM) nail.

• Typically, when an aseptic tibial nonunion previously treated with an IM nail is found, it is advisable to change the previous IM nail for a larger diameter reamed and locked IM nail (the rate of success of renailing is around 90%).

• A second change after an IM nail failure is also a good option, especially if bone healing has progressed after the first change.

• Fibular osteotomy is not routinely advised; it is only recommended when it interferes with the nonunion site.

• In delayed unions before 24 weeks, IM nail dynamization can be performed as a less invasive option before deciding on a nail change.

• If there is a bone defect, a bone graft must be recommended, with the gold standard being the autologous iliac crest bone graft (AICBG).

• A reamer-irrigator-aspirator (RIA) system might also obtain a bone autograft that is comparable to AICBG.

• Although the size of the bone defect suitable to perform bone transport techniques is a controversial issue, we believe that such techniques can be considered in bone defects > 3 cm.

• Non-invasive therapies and biologic therapies could be applied in isolation for patients with high surgical risk, or could be used as adjuvants to the aforementioned surgical treatments.

Cite this article: EFORT Open Rev 2020;5:835-844. DOI: 10.1302/2058-5241.5.190077

• Bone-anchored implants give patients with unmanageable stump problems hope for drastic improvements in function and quality of life and are therefore increasingly considered a viable solution for lower-limb amputees and their orthopaedic surgeons, despite high infection rates.

• Regarding diversity and increasing numbers of implants worldwide, efforts are to be supported to arrange an international bone-anchored implant register to transparently overview pros and cons.

• Due to few, but high-quality, articles about the beneficial effects of targeted muscle innervation (TMR) and regenerative peripheral nerve interface (RPNI), these surgical techniques ought to be directly transferred into clinical protocols, observations and routines.

• Bionics of the lower extremity is an emerging cutting-edge technology. The main goal lies in the reduction of recognition and classification errors in changes of ambulant modes. Agonist–antagonist myoneuronal interfaces may be a most promising start in controlling of actively powered ankle joints.

• As advanced amputation surgical techniques are becoming part of clinical routine, the development of financing strategies besides medical strategies ought to be boosted, leading to cutting-edge technology at an affordable price.

• Microprocessor-controlled components are broadly available, and amputees do see benefits. Devices from different manufacturers differ in gait kinematics with huge inter-individual varieties between amputees that cannot be explained by age. Active microprocessor-controlled knees/ankles (A-MPK/As) might succeed in uneven ground-walking. Patients ought to be supported to receive appropriate prosthetic components to reach their everyday goals in a desirable way.

• Increased funding of research in the field of prosthetic technology could enhance more high-quality research in order to generate a high level of evidence and to identify individuals who can profit most from microprocessor-controlled prosthetic components.

Cite this article: EFORT Open Rev 2020;5:724-741. DOI: 10.1302/2058-5241.5.190070

• Surgical treatment of acetabular fractures remains challenging even for experienced surgeons.

• Whilst the ilioinguinal and the Kocher-Langenbeck approach remain the standard procedures to expose the anterior or posterior aspects of the acetabulum, some modified anterior approaches for the stabilization of the acetabulum have been introduced.

• This article will provide an overview of approaches to the anterior aspect of the acetabulum and explain the efforts that have been made to improve the surgeon’s options for certain fracture modifications, such as fractures with separation of the quadrilateral surface.

Cite this article: EFORT Open Rev 2020;5:707-712. DOI: 10.1302/2058-5241.5.190061

• Results of open reduction and internal fixation for complex articular fractures around the knee are poor, particularly in elderly osteoporotic patients.

• Open reduction and internal fixation may lead to an extended hospital stay and non-weight-bearing period.

• This may lead to occurrence of complications related to decubitus such as thrombo-embolic events, pneumonia and disorientation.

• Primary arthroplasty can be a valuable option in a case-based and patient-specific approach. It may reduce the number of procedures and allow early full weight-bearing, avoiding the above-mentioned complications.

• There are four main indications:

  • 1) Elderly (osteoporotic) patients with pre-existing (symptomatic) end-stage osteoarthritis.

  • 2) Elderly (osteoporotic) patients with severe articular and metaphyseal destruction.

  • 3) Pathological fractures of the distal femur and/or tibia.

  • 4) Young patients with complete destruction of the distal femur and/or tibia.

• The principles of knee (revision) arthroplasty should be applied; choice of implant and level of constraint should be considered depending on the type of fracture and involvement of stabilizing ligaments. The aim of treatment is to obtain a stable and functional joint.

• Long-term data remain scarce in the literature due to limited indications.

Cite this article: EFORT Open Rev 2020;5:713-723. DOI: 10.1302/2058-5241.5.190059

• Thirty per cent of patients presenting with proximal femoral fractures are receiving anticoagulant treatment for various other medical reasons. This pharmacological effect may necessitate reversal prior to surgical intervention to avoid interference with anaesthesia or excessive peri/post-operative bleeding. Consequently, delay to surgery usually occurs.

• Platelet inhibitors (aspirin, clopidogrel) either alone or combined do not need to be discontinued to allow acute hip surgery. Platelet transfusions can be useful but are rarely needed.

• Vitamin K antagonists (VKA, e.g. warfarin) should be reversed in a timely fashion and according to established readily accessible departmental protocols. Intravenous vitamin K on admission facilitates reliable reversal, and platelet complex concentrate (PCC) should be reserved for extreme scenarios.

• Direct oral anticoagulants (DOAC) must be discontinued prior to hip fracture surgery but the length of time depends on renal function ranging traditionally from two to four days.

• Recent evidence suggests that early surgery (within 48 hours) can be safe. No bridging therapy is generally recommended.

• There is an urgent need for development of new commonly available antidotes for every DOAC as well as high-level evidence exploring DOAC effects in the acute hip fracture surgical setting.

Cite this article: EFORT Open Rev 2020;5:699-706. DOI: 10.1302/2058-5241.5.190071

• Injuries sustained in motorcycle collisions can be organized into distinct patterns to improve recognition and treatment.

• Lowside, highside, topside, and collision are the four main categories of motorcycle crash types.

• Within those four crash types, mechanisms of injury include head-leading collisions, direct vertical impact, motorcycle radius, motorcycle thumb, fuel tank injures, limb entrapment, tyre-spoke injury, and crash modifying manoeuvre.

Cite this article: EFORT Open Rev 2020;5:544-548. DOI: 10.1302/2058-5241.5.190090