• A tarsal coalition is an abnormal connection between two or more tarsal bones caused by failure of mesenchymal segmentation.

• The two most common tarsal coalitions are calcaneonavicular coalition (CNC) and talocalcaneal coalition (TCC). Both CNC and TCC can be associated with significant foot and ankle pain and impaired quality of life; there may also be concomitant foot and ankle deformity.

• Initial, non-operative management for symptomatic tarsal coalition commonly fails, leaving surgical intervention as the only recourse.

• The focus of this article is to critically describe the variety of methods used to surgically manage CNC and TCC. In review of the pertinent literature we highlight the ongoing treatment controversies in this field and discuss new innovations.

• The evidence-based algorithmic approach used by the authors in the management of tarsal coalitions is illustrated alongside some clinical pearls that should help surgeons treating this common, and at times complex, condition.

Cite this article: EFORT Open Rev 2020;5:80-89. DOI: 10.1302/2058-5241.5.180106

• Billions of screws are inserted by surgeons each year, making them the most commonly inserted implant. When using non-locking screws, insertion technique is decided by the surgeon, including how much to tighten each screw. The aims of this study were to assess, through a systematic review, the screw tightness and rate of material stripping produced by surgeons and the effect of different variables related to screw insertion.

• Twelve studies were included, with 260 surgeons inserting a total of 2793 screws; an average of 11 screws each, although only 1510 screws have been inserted by 145 surgeons where tightness was measured – average tightness was 78±10% for cortical (n = 1079) and 80±6% for cancellous screw insertions (n = 431).

• An average of 26% of all inserted screws irreparably damaged and stripped screw holes, reducing the construct pullout strength. Furthermore, awareness of bone stripping is very poor, meaning that screws must be considerably overtightened before a surgeon will typically detect it.

• Variation between individual surgeons’ ability to optimally insert screws was seen, with some surgeons stripping more than 90% of samples and others hardly any. Contradictory findings were seen for the relationship between the tightness achieved and bone density.

• The optimum tightness for screws remains unknown, thus subjectively chosen screw tightness, which varies greatly, remains without an established target to generate the best possible construct for any given situation. Work is needed to establish these targets, and to develop methods to accurately and repeatably achieve them.

Cite this article: EFORT Open Rev 2020;5:26-36. DOI: 10.1302/2058-5241.5.180066

• Studies of the effectiveness of orthopaedic interventions do not generally measure physical activity (PA). Applying accelerometer-based activity monitoring in orthopaedic studies will add relevant information to the generally examined physical function and pain assessment.

• Accelerometer-based activity monitoring is practically feasible in orthopaedic patient populations, since current day activity sensors have battery time and memory to measure continuously for several weeks without requiring technical expertise.

• The ongoing development in sensor technology has made it possible to combine functional tests with activity monitoring.

• For clinicians, the application of accelerometer-based activity monitoring can provide a measure of PA and can be used for clinical comparisons before and after interventions.

• In orthopaedic rehabilitation, accelerometer-based activity monitoring may be used to help patients reach their targets for PA and to coach patients towards a more active lifestyle through direct feedback.

Cite this article: EFORT Open Rev 2019;4:678-685. DOI: 10.1302/2058-5241.4.180041

• Developmental dysplasia of the hip (DDH) is one of the most prevalent congenital malformations. It has a wide spectrum of anatomical abnormalities of the hip joint and is characterized by mild or incomplete formation of the acetabulum leading to laxity of the joint capsule, secondary deformity of the proximal femur and irreducible hip dislocation. It is the leading cause of early hip osteoarthritis in young individuals.

• Both genetic and environmental factors have been proposed to play an important role in the pathogenesis of DDH. A high prevalence is present in Asian, Caucasian, Mediterranean and American populations, with females being more frequently affected. We evaluated a variety of genetic studies indexed in the PubMed database.

• Several susceptive genes, including WISP3, PAPPA2, HOXB9, HOXD9, GDF5, TGF Beta 1, CX3CR1, UQCC, COL1A1, TbX4 and ASPN have been identified as being associated with the development of DDH. Moreover, genetic association has also been reported between hip dysplasia and other comorbidities. Even though genetic components are a crucial part in the aetiology of DDH, several DDH susceptibility genes need further investigation.

• The purpose of this review is to present current literature evidence regarding genes responsible for DDH development.

Cite this article: EFORT Open Rev 2019;4:595-601. DOI: 10.1302/2058-5241.4.190006

• The term ‘developmental dysplasia of the hip’ (DDH) includes a wide spectrum of hip alterations: neonatal instability; acetabular dysplasia; hip subluxation; and true dislocation of the hip.

• DDH alters hip biomechanics, overloading the articular cartilage and leading to early osteoarthritis. DDH is the main cause of total hip replacement in young people (about 21% to 29%).

• Development of the acetabular cavity is determined by the presence of a concentrically reduced femoral head. Hip subluxation or dislocation in a child will cause an inadequate development of the acetabulum during the remaining growth.

• Clinical screening (instability manoeuvres) should be done universally as a part of the physical examination of the newborn. After two or three months of life, limited hip abduction is the most important clinical sign.

• Selective ultrasound screening should be performed in any child with abnormal physical examination or in those with high-risk factors (breech presentation and positive family history). Universal ultrasound screening has not demonstrated its utility in diminishing the incidence of late dysplasia.

• Almost 90% of patients with mild hip instability at birth are resolved spontaneously within the first eight weeks and 96% of pathologic changes observed in echography are resolved spontaneously within the first six weeks of life. However, an Ortolani-positive hip requires immediate treatment.

• When the hip is dislocated or subluxated, a concentric and stable reduction without forceful abduction needs to be obtained by closed or open means. Pavlik harness is usually the first line of treatment under the age of six months.

• Hip arthrogram is useful for guiding the decision of performing a closed or open reduction when needed.

• Acetabular dysplasia improves in the majority due to the stimulus provoked by hip reduction. The best parameter to predict persistent acetabular dysplasia at maturity is the evolution of the acetabular index.

• Pelvic or femoral osteotomies should be performed when residual acetabular dysplasia is present or in older children when a spontaneous correction after hip reduction is not expected.

• Avascular necrosis is the most serious complication and is related to: an excessive abduction of the hip; a force closed reduction when obstacles for reduction are present; a maintained dislocated hip within the harness or spica cast; and a surgical open reduction.

Cite this article: EFORT Open Rev 2019;4:548-556. DOI: 10.1302/2058-5241.4.180019

• Haemophilia is a group of coagulation disorders inherited in an X-linked recessive pattern.

• Nearly three-quarters of all haemorrhages in haemophilia occur in the musculoskeletal system, usually in the large muscles and joints of the lower extremity.

• While prevention of bleeding with active prophylaxis is the recommended optimal therapy for severe haemophilia, there are many patients suffering from musculoskeletal system complications subsequent to uncontrolled bleeding.

• Recombinant clotting factor concentrates led to home treatment of acute bleeding episodes as well as allowing for minor and major surgical interventions.

• Avoiding of further complications by radiosynoviorthesis is the first-line recommendation, and arthroplasty is regarded as the effective salvage procedure for patients presenting with severe disability.

• Physiotherapy and rehabilitation in haemophilia patients are important to return the normal status of joint motion, to regain the muscle strength, to obtain the optimal functional levels and to improve patients’ quality of life.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180068

• The objective of the paper is to analyse the role of the labrum with particular attention to its morphological changes in unstable dysplastic hips during treatment.

• Between January 2013 and December 2015, data were collected on 86 unstable, dysplastic hips, which were divided into type D (n = 13), type III (n = 49) and type IV (n = 24). The labrum was evaluated with ultrasound examination (US) for echogenicity and dimensions with inter-/intra-observer tests comparing the US images at diagnosis and at the end of treatment. Statistical analysis was performed.

• At the end of treatment of unstable, dysplastic hips, the labrum was more echogenic with a frequency of 97% and was larger with a frequency of 96%.

• The labrum has an active stabilizing role in unstable dysplastic hips and it undergoes a statistically significant increase of echogenicity and dimensions after treatment.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180053

• Juvenile osteochondritis dissecans (JOCD) is a joint disorder of the subchondral bone and articular cartilage that affects skeletally immature patients.

• The aetiology of JOCD is unknown and the natural history is poorly characterized in part due to inconsistent and largely retrospective literature.

• Most OCD in children and adolescents presents as a stable lesion amenable to non-operative treatment or minimally invasive drilling. However, unstable forms can require a more aggressive approach.

• This article reviews the most recent literature available and focuses on the pathophysiology, diagnosis and treatment of JOCD of the knee.

Cite this article: EFORT Open Rev 2019;4:201-212. DOI: 10.1302/2058-5241.4.180079

• Osteoporosis is a serious health concern, particularly in aged societies. The burden of osteoporosis with its associated morbidity and mortality due to fracture has become a critical socioeconomic problem.

• Skeletal integrity is maintained through a balance of bone resorption and bone formation. The bone turnover process, called bone remodelling.

• Recently, a number of anti-osteoporosis drugs with excellent anti-osteoporosis and fracture effects have been developed. They are mainly classified into two groups according to their effects on bone remodelling: anti-resorptive agents and anabolic agents.

Cite this article: EFORT Open Rev 2019;4:158-164. DOI: 10.1302/2058-5241.4.180018

• Supracondylar fractures of the humerus are the most frequent fractures of the paediatric elbow, with a peak incidence at the ages of five to eight years.

• Extension-type fractures represent 97% to 99% of cases. Posteromedial displacement of the distal fragment is the most frequent; however, the radial and median nerves are equally affected. Flexion-type fractures are more commonly associated with ulnar nerve injuries.

• Concomitant upper-limb fractures should always be excluded. To manage the vascular status, distal pulse and hand perfusion should be monitored. Compartment syndrome should always be borne in mind, especially when skin puckering, severe ecchymosis/swelling, vascular alterations or concomitant forearm fractures are present.

• Gartland’s classification shows high intra- and inter-observer reliability. Type I is treated with casting. Surgical treatment is the standard for almost all displaced fractures. Type IV fractures can only be diagnosed intra-operatively.

• Closed reduction and percutaneous pinning is the gold standard surgical treatment. Open reduction via the anterior approach is indicated for open fractures, absence of the distal vascular flow for > 10 to 15 minutes after closed reduction, and failed closed reduction.

• Lateral entry pins provide stable fixation, avoiding the risk of iatrogenic ulnar nerve injury.

• About 10% to 20% of displaced supracondylar fractures present with alterations in vascular status. In most cases, fracture reduction restores perfusion.

• Neural injuries occur in 6.5% to 19% of cases involving displaced fractures. Most of them are neurapraxias and it is not routinely indicated to explore the nerve surgically.

Cite this article: EFORT Open Rev 2018;3:526-540. DOI: 10.1302/2058-5241.3.170049