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Ricardo Sousa, André Carvalho, Ana Cláudia Santos, and Miguel Araújo Abreu

  • Infection is a dire complication afflicting every field of orthopaedics and traumatology. If specific clinical, laboratory and imaging parameters are present, infection is often assumed even in the absence of microbiological confirmation. However, apart from confirming infection, knowing the exact infecting pathogen(s) and their antimicrobial susceptibility patterns is paramount to help guide treatment. Every effort should therefore be undertaken with that goal in mind.

  • Not all microbiological findings carry the same relevance, and knowing exactly how and where a sample was collected is key. Several different sampling techniques are available, and one must be aware of both advantages and limitations. Microbiological sampling alternatives in some of the most common clinical scenarios such as native and prosthetic joint infections, osteomyelitis and fracture-related infections, spinal and diabetic foot infections will be discussed.

  • Orthopaedic surgeons should also be aware of basic laboratory sample processing techniques as they have a direct impact on the way specimens should be dealt with and transported to the laboratory. Only by knowing these basic principles will surgeons be able to participate in the multidisciplinary discussion and decision making around how to interpret microbiological findings in each specific patient.

Cite this article: EFORT Open Rev 2021;6:390-398. DOI: 10.1302/2058-5241.6.210011

Razvan Ene, Mihai Nica, Dragos Ene, Adrian Cursaru, and Catalin Cirstoiu

  • Infection in orthopaedic and trauma surgery remains a destructive complication with particularly challenging diagnosis and treatment due to bacterial antibiotic resistance and biofilm formation.

  • Along with surgical debridement and systemic antibiotics, an important type of adjuvant therapy is local antibiotic delivery, with the purpose of eliminating bacterial colonization and biofilm development.

  • Calcium sulphate, as a synthetic absorbable biomaterial used for local antibiotic delivery, has experienced an increasing popularity during the last decade, with multiple promoted advantages such as predictable antibiotic elution kinetics, complete and quick biodegradation, good biocompatibility, and limited associated complications.

  • A series of commercially available antibiotic-delivery systems based on calcium sulphate are under investigation and in clinical use, with different presentations, compositions, and application techniques.

  • The current article presents the main available calcium-sulphate-based products and the existing data about the clinical and preclinical research results, stemming from their implementation as local antibiotic carriers for surgical site and implant-associated infections treatment and prevention.

Cite this article: EFORT Open Rev 2021;6:297-304. DOI: 10.1302/2058-5241.6.200083

Achi Kamaraj, Nikhil Agarwal, K. T. Matthew Seah, and Wasim Khan

  • Cost-utility analysis (CUA) studies are becoming increasingly important due to the need to reduce healthcare spending, especially in the field of trauma and orthopaedics.

  • There is an increasing need for trauma and orthopaedic surgeons to understand these economic evaluations to ensure informed cost-effective decisions can be made to benefit the patient and funding body.

  • This review discusses the fundamental principles required to understand CUA studies in the literature, including a discussion of the different methods employed to assess the health outcomes associated with different management options and the various approaches used to calculate the costs involved.

  • Different types of model design may be used to conduct a CUA which can be broadly categorized into real-life clinical studies and computer-simulated modelling. We discuss the main types of study designs used within each category. We also cover the different types of sensitivity analysis used to quantify uncertainty in these studies and the commonly employed instruments used to assess the quality of CUAs. Finally, we discuss some of the important limitations of CUAs that need to be considered.

  • This review outlines the main concepts required to understand the CUA literature and provides a basic framework for their future conduct.

Cite this article: EFORT Open Rev 2021;6:305-315. DOI: 10.1302/2058-5241.6.200115

Pier F. Indelli, Stefano Ghirardelli, Bruno Violante, and Derek F. Amanatullah

  • Periprosthetic joint infections (PJI) represent one of the most catastrophic complications following total joint arthroplasty (TJA). The lack of standardized diagnostic tests and protocols for PJI is a challenge for arthroplasty surgeons.

  • Next generation sequencing (NGS) is an innovative diagnostic tool that can sequence microbial deoxyribonucleic acids (DNA) from a synovial fluid sample: all DNA present in a specimen is sequenced in parallel, generating millions of reads. It has been shown to be extremely useful in a culture-negative PJI setting.

  • Metagenomic NGS (mNGS) allows for universal pathogen detection, regardless of microbe type, in a 24–48-hour timeframe: in its nanopore-base variation, mNGS also allows for antimicrobial resistance characterization.

  • Cell-free DNA (cfDNA) NGS, characterized by lack of the cell lysis step, has a fast run-time (hours) and, together with a high sensitivity and specificity in microorganism isolation, may provide information on the presence of antimicrobial resistance genes.

  • Metagenomics and cfDNA testing have reduced the time needed to detect infecting bacteria and represent very promising technologies for fast PJI diagnosis.

  • NGS technologies are revolutionary methods that could disrupt the diagnostic paradigm of PJI, but a comprehensive collection of clinical evidence is still needed before they become widely used diagnostic tools.

Cite this article: EFORT Open Rev 2021;6:236-244. DOI: 10.1302/2058-5241.6.200099

Laura Stiegel, Alison K. Klika, Carlos A. Higuera, Wael K.Barsoum, and Nicolas S. Piuzzi

  • Medical progress, including in the orthopaedic surgery field, depends on the interaction and collaboration between: physicians, with their expertise on the clinical setting; scientists, with their expertise on the research setting; and professionals who are skilled in both settings (clinical scientists). This leads to the need to develop research approaches which involves people who are committed and support the process, strategic planning, and a cohesive team that can execute the tasks. All these interactions must be supported financially in order to maintain the long-term viability of such team.

  • Time management is crucial for the clinical research team. To ensure success, the research team must be flexible in order to adapt to dynamic clinical and surgical schedules. It is especially important that surgeons have regular, dedicated quality research time to maintain a consistent interaction with the team.

  • Building a successful and productive orthopaedic clinical research programme involves many challenges in creating proper leadership, obtaining funding, setting proper resources, establishing necessary training, and providing guidance and insight around the importance of each role that every member plays on the team.

Cite this article: EFORT Open Rev 2021;6:245-251. DOI: 10.1302/2058-5241.6.200058

Thomas Collins, Dinesh Alexander, and Bilal Barkatali

  • The aim of this article was to synopsize platelet-rich plasma (PRP) use in musculoskeletal pathologies through evidence-based assessment of the preparation, classification, mechanism of action and applications of PRP, thereby answering which PRP type is best for each clinical indication.

  • The literature search was performed using Medline, EMBASE and Cochrane Reviews databases for papers containing the key terms “platelet-rich plasma” AND “orthopaedics” AND (“classification” OR “mechanism of action” OR “preparation” OR “clinical application”). Generated papers were evaluated for pertinence in following areas: preparation, classification, mechanism of action, clinical application within orthopaedics. Non-English papers were excluded. Included studies were evaluated for quality.

  • Sixty studies were included in our review. There are many commercial PRP preparation kits with differing component concentrations. There is no consensus on optimal component concentrations. Multiple PRP classifications exist but none have been validated. Platelet-rich plasma acts via growth factors (GFs) released from α-granules within platelets. Growth factors have been shown to be beneficial in healing. Grossly elevated concentrations of GFs may have inhibitory effects on healing. Multiple systematic reviews show efficacy of PRP in tendinopathies, early osteoarthritis, acute muscle injuries and in combination with rotator cuff repair and anterior cruciate ligament reconstruction.

  • The literature suggests leukocyte-rich PRP (L-PRP) is more beneficial in tendinopathies and pure PRP (P-PRP) is more beneficial in cartilage pathology. However, different PRP preparations have not been directly compared in any pathology. Classification of PRP type is frequently not stated in research. Standardization of PRP research parameters is needed to streamline findings and generate clear indications for PRP types to yield maximum clinical benefit.

Cite this article: EFORT Open Rev 2021;6:225-235. DOI: 10.1302/2058-5241.6.200017

Anne Lübbeke, James A. Smith, Daniel Prieto-Alhambra, and Andrew J. Carr

  • Medical devices are a very important but largely under-recognized and fragmented component of healthcare.

  • The limited regulation of the past and the lack of systematic rigorous evaluation of devices leading to numerous high-profile failures will now be replaced by stricter legal requirements and more transparent evaluation processes.

  • This constitutes an unprecedented opportunity, but it also uncovers urgent needs in landscaping, methodology development, and independent comprehensive assessment of device risks and benefits for individual patients and society, especially in the context of increasingly complex devices.

  • We argue that an academic discipline of ‘medical device science’ is well placed to lead and coordinate the efforts necessary to achieve much needed improvement in the medical device sector.

  • Orthopaedics and traumatology could contribute and benefit considerably as one of the medical specialties with the highest use of medical devices.

Cite this article: EFORT Open Rev 2021;6:160-163. DOI: 10.1302/2058-5241.6.200094

Haroon Majeed

  • This study analyses the outcomes of litigation claims in trauma and orthopaedic surgery between 2008/2009 and 2018/2019.

  • Utilizing a formal request to the NHS Resolution under the Freedom of Information Act, the data related to claims against orthopaedic surgery were obtained. A total of 8548 claims were analysed and re-grouped to perform a meaningful analysis for the type of claims and the type of injuries.

  • The total pay-out cost for the settled claims was over £1.2 billion. The most common types of claims were related to mismanagement (39.0%), diagnostic issues (17.6%), perioperative issues (15.9%) and alleged incompetence (10.2%). The most common primary causes for claims were patients’ dissatisfaction (52.2%), damage to the limbs (19.0%) and neurological injuries (9.2%).

  • The highest amounts of damages paid out were related to patients’ dissatisfaction (37.7%), burns and bruising (31.0%), neurological injuries (24.5%) and damage to the limbs (22.3%). The number of claims and the pay-out cost were found to be steadily increasing; however, there was a slightly declining trend observed during the last two years.

  • The cost of litigation continues to have a significant financial impact on the NHS. The recent declining trend is encouraging; however, surgeons need to take consistent diligent steps to avoid preventable causes that lead to litigation claims.

  • The proposed change in the coding system of claims in the NHS Resolution will not only help to formulate a clear classification system but will also improve the learning from previous experience.

Cite this article: EFORT Open Rev 2021;6:152-159. DOI: 10.1302/2058-5241.6.200100

Jaime Esteban and Enrique Gómez-Barrena

  • Despite different criteria to diagnose a prosthetic joint infection (PJI), aetiological diagnosis of the causing microorganism remains essential to guide treatment.

  • Molecular-biology-based PJI diagnosis is progressing (faster, higher specificity) in different techniques, from the experimental laboratory into clinical use.

  • Multiplex polymerase chain reaction techniques (custom-made or commercial) provide satisfactory results in clinical series of cases, with specificity close to 100% and sensitivity over 70–80%.

  • Next-generation metagenomics may increase sensitivity while maintaining high specificity.

  • Molecular biology techniques may represent, in the next five years, a significant transformation of the currently available microbiological diagnosis in PJI.

Cite this article: EFORT Open Rev 2021;6:93-100. DOI: 10.1302/2058-5241.6.200118

Jacobien H.F. Oosterhoff, Job N. Doornberg, and Machine Learning Consortium

  • Artificial Intelligence (AI) in general, and Machine Learning (ML)-based applications in particular, have the potential to change the scope of healthcare, including orthopaedic surgery.

  • The greatest benefit of ML is in its ability to learn from real-world clinical use and experience, and thereby its capability to improve its own performance.

  • Many successful applications are known in orthopaedics, but have yet to be adopted and evaluated for accuracy and efficacy in patients’ care and doctors’ workflows.

  • The recent hype around AI triggered hope for development of better risk stratification tools to personalize orthopaedics in all subsequent steps of care, from diagnosis to treatment.

  • Computer vision applications for fracture recognition show promising results to support decision-making, overcome bias, process high-volume workloads without fatigue, and hold the promise of even outperforming doctors in certain tasks.

  • In the near future, AI-derived applications are very likely to assist orthopaedic surgeons rather than replace us. ‘If the computer takes over the simple stuff, doctors will have more time again to practice the art of medicine’.76

Cite this article: EFORT Open Rev 2020;5:593-603. DOI: 10.1302/2058-5241.5.190092