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Maria-Pau Ginebra, Montserrat Espanol, Yassine Maazouz, Victor Bergez, and David Pastorino

  • Calcium phosphates have long been used as synthetic bone grafts. Recent studies have shown that the modulation of composition and textural properties, such as nano-, micro- and macro-porosity, is a powerful strategy to control and synchronize material resorption and bone formation.

  • Biomimetic calcium phosphates, which closely mimic the composition and structure of bone mineral, can be produced using low-temperature processing routes, and offer the possibility to modulate the material properties to a larger extent than conventional high temperature sintering processes.

  • Advanced technologies open up new possibilities in the design of bioceramics for bone regeneration; 3D-printing technologies, in combination with the development of hybrid materials with enhanced mechanical properties, supported by finite element modelling tools, are expected to enable the design and fabrication of mechanically competent patient-specific bone grafts.

  • The association of ions, drugs and cells allows leveraging of the osteogenic potential of bioceramic scaffolds in compromised clinical situations, where the intrinsic bone regeneration potential is impaired.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170056

Peter H. Richter, Florian Gebhard, Alexander Eickhoff, and Konrad Schütze

  • The invention of flat-panel detectors led to a revolution in medical imaging. The major benefits of this technology are a higher image quality and dose reduction. Flat-panel detectors have proved to be superior to standard C-arms (= C-arm with radiograph source and image intensifier).

  • Cone-beam computed tomography (cone-beam CT) is a 3D data set, which can be acquired with a flat-panel detector. The cone-shaped beam is used for 3D data generation. For cone-beam CT acquisition, the flat-panel detector rotates around the patient lying on the operating table. Intra-operative cone-beam CT can be a very helpful tool in orthopaedic surgery. Immediate control of fracture reduction and implant positioning in high image quality can reduce the need for secondary revision surgery due to implant malposition.

  • In recent years there has been a revival of standard fan beam CT technology in operating rooms. Fixed and mobile systems are available. Fixed systems are typically placed on a sliding gantry. Different mobile intra-operative CT scanners were recently introduced. Due to their mobility, they are not bound to a specific operating room. The use of standard intra-operative CT scanners results in high 3D image quality but, in comparison with a cone-beam CT scanner, fluoroscopy is not possible.

  • The introduction of flat-panel detectors has led to improvements in intra-operative image quality combined with dose reduction. The possibility of high-quality 3D imaging in combination with navigation can assure optimal implant placement. Due to immediate control of the osteosynthesis, revision surgery at a later time can be prevented.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170055

Anne Lübbeke

  • Since improving the patient’s condition is the ultimate goal of clinical care and research, this review of research methodology focuses on outcomes in the musculoskeletal field.

  • This paper provides an overview of conceptual models, different types of outcomes and commonly assessed outcomes in orthopaedics as well as epidemiological and statistical aspects of outcomes determination, measurement and interpretation.

  • Clinicians should determine the outcome(s) most important to patients and/or public health in collaboration with the patients, epidemiologists/statisticians and other stakeholders.

  • Key points in outcome choice are to evaluate both the benefit and harm of a health intervention, and to consider short- and longer-term outcomes including patient-reported outcomes.

  • Outcome estimation should aim at identifying a clinically important difference (not the same as a statistically significant difference), at presenting measures of effects with confidence intervals and at taking the necessary steps to minimize bias.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170064

Cristina Alves

  • Scientific education and a clinical background allow orthopaedic surgeons to perform leading research. Several resources, skills and techniques may be developed to maximize their research potential.

  • Surgeon-researchers should develop Specific, Measurable, Achievable, Realistic, and Time-defined (SMART) goals. It is critical to define a timeline – which can be 1 year, 3 years, 5 years – to re-evaluate goals and to plan and identify potential obstacles.

  • Physician-scientists are a product of training, funding, resources, practice setting, context, environment, and infrastructure. Although orthopaedic surgery has difficulty in recruiting surgeon-scientists, these are essential for the promotion of advances in technologies and treatment, as they have unique abilities to raise questions from the bedside and the operating room.

  • The most critical personal traits necessary to succeed as a surgeon-scientist are persistence, resilience, and passion for research. These traits may be innate or acquired through mentorship and from role models.

  • Mentors can improve mentees’ research efficiency and help them to persevere.

  • Clinical researchers and surgeon-scientists should focus their research interests and efforts in their areas of clinical expertise.

  • For surgeon-researchers to succeed they must have passion for research, persistence in working toward a goal, collaboration/teamwork skills, resilience, research training/experience, a track record of publications, clear goals and expectations, and a defined research plan as well as being clinically excellent. A formal research degree is desirable.

  • Having non-clinician scientists in the team brings added expertise and value.

  • Funding and protected research time are important. To provide outstanding clinical care and improve the quality of the care delivered, surgeons must be leaders in innovation and research.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170065

Dimitrios A. Flevas, Panayiotis D. Megaloikonomos, Leonidas Dimopoulos, Evanthia Mitsiokapa, Panayiotis Koulouvaris, and Andreas F. Mavrogenis

  • Venous thromboembolism (VTE) is a serious complication during and after hospitalization, yet is a preventable cause of in-hospital death.

  • Without VTE prophylaxis, the overall VTE incidence in medical and general surgery hospitalized patients is in the range of 10% to 40%, while it ranges up to 40% to 60% in major orthopaedic surgery. With routine VTE prophylaxis, fatal pulmonary embolism is uncommon in orthopaedic patients and the rates of symptomatic VTE within three months are in the range of 1.3% to 10%.

  • VTE prophylaxis methods are divided into mechanical and pharmacological. The former include mobilization, graduated compression stockings, intermittent pneumatic compression device and venous foot pumps; the latter include aspirin, unfractionated heparin, low molecular weight heparin (LMWH), adjusted dose vitamin K antagonists, synthetic pentasaccharid factor Xa inhibitor (fondaparinux) and newer oral anticoagulants. LMWH seems to be more efficient overall compared with the other available agents. We remain sceptical about the use of aspirin as a sole method of prophylaxis in total hip and knee replacement and hip fracture surgery, while controversy still exists regarding the use of VTE prophylaxis in knee arthroscopy, lower leg injuries and upper extremity surgery.

Cite this article: EFORT Open Rev 2018;3:130-142. DOI: 10.1302/2058-5241.3.170018

Marc Beirer, Chlodwig Kirchhoff, and Peter Biberthaler

  • Continuous evaluation of current treatment methods is crucial in orthopaedic trauma surgery.

  • Existing fracture registries substantially contribute to improving fracture care and quality of life in trauma patients.

  • Currently there is no universal German fracture register recording the patient-centred outcome of non-surgical as well as surgical fracture treatment in all anatomical regions.

  • Conclusions regarding nationwide fracture treatment and quality of care are only significant to a limited extent.

Cite this article: EFORT Open Rev 2017;2:474–477. DOI: 10.1302/2058-5241.2.160086.

Fan Wu, Michael Nerlich, and Denitsa Docheva

  • Tendons connect muscles to bones, ensuring joint movement. With advanced age, tendons become more prone to degeneration followed by injuries. Tendon repair often requires lengthy periods of rehabilitation, especially in elderly patients. Existing medical and surgical treatments often fail to regain full tendon function.

  • The development of novel treatment methods has been hampered due to limited understanding of basic tendon biology. Recently, it was discovered that tendons, similar to other mesenchymal tissues, contain tendon stem/progenitor cells (TSPCs) which possess the common stem cell properties.

  • The current strategies for enhancing tendon repair consist mainly of applying stem cells, growth factors, natural and artificial biomaterials alone or in combination. In this review, we summarise the basic biology of tendon tissues and provide an update on the latest repair proposals for tendon tears.

Cite this article: EFORT Open Rev 2017;2:332-342. DOI: 10.1302/2058-5241.2.160075

Jennette Higgs, Emma Derbyshire, and Kathryn Styles

  • Osteoporosis is a prevalent and debilitating condition with no signs of subsiding. Rising numbers of people consuming nutrient-poor diets coupled with ageing populations and sedentary lifestyles appear to be the main drivers behind this.

  • While the nutrients calcium and vitamin D have received most attention, there is growing evidence that wholefoods and other micronutrients have roles to play in primary and potentially secondary osteoporosis prevention.

  • Until recently, calcium and vitamin D were regarded as the main nutrients essential to bone health but now there are emerging roles for iron, copper and selenium, among others.

  • Fruit and vegetables are still not being eaten in adequate amounts and yet contain micronutrients and phytochemicals useful for bone remodelling (bone formation and resorption) and are essential for reducing inflammation and oxidative stress.

  • There is emerging evidence that dried fruits, such as prunes, provide significant amounts of vitamin K, manganese, boron, copper and potassium which could help to support bone health.

  • Just 50 g of prunes daily have been found to reduce bone resorption after six months when eaten by osteopaenic, postmenopausal women.

  • Dairy foods have an important role in bone health. Carbonated drinks should not replace milk in the diet.

  • A balanced diet containing food groups and nutrients needed for bone health across the whole lifecycle may help to prevent osteoporosis.

  • Greater efforts are needed to employ preventative strategies which involve dietary and physical activity modifications, if the current situation is to improve.

Cite this article: EFORT Open Rev 2017;2:300-308. DOI: 10.1302/2058-5241.2.160079

Christoph H. Lohmann, Sanjiv Rampal, Martin Lohrengel, and Gurpal Singh

  • As imaging techniques are ever-evolving, this article aims to provide a brief overview of the various modalities including their limitations. The ability of imaging for evaluation of implant osseo-integration will be addressed and also the role of imaging in assessing septic and aseptic loosening, with a particular focus on adverse tissue reactions, will be discussed. Specific features when imaging the big joints such as shoulder, hip, knee and ankle joint will also be outlined.

  • Overall, a lack of standardisation and validity was noted and despite the gross variety of imaging modalities, there is no technique covering all aspects required for evaluation of implant fixation and septic and aseptic loosening. Each imaging modality has a role, depending on the information required and anticipated. The choice of imaging technique should not be primarily based on medical considerations but also on availability, accessibility, expertise and costs. Plain radiographs alone have been recommended in cases of suspected peri-prosthetic joint infections, given the lack of evidence for additional imaging techniques in this context. For aseptic loosening, ultrasound and plain radiographs may serve as initial screening tools. Metal artefact reducing sequences (MARS) MRI are advancing cross-sectional imaging and are likely to promote their role in patient evaluation.

  • We conclude that imaging is one essential part in the work-up of patients with total joint replacements, within a specific clinical context. Close teamwork between experienced radiologists and orthopaedic surgeons is required for optimal patient care.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160058. Originally published online at

Hasan Huseyin Ceylan, Nurdan Güngören, and Fatih Küçükdurmaz

  • Online resources provide access to large amounts of information which is expanding every day. Using search engines for reaching the relevant, updated and complete literature that is indexed in various bibliographical databases has already become part of the medical professionals’ everyday life.

  • However, most researchers often fail to conduct a efficient literature search on the internet. The right techniques in literature search save time and improve the quality of the retrieved data.

  • Efficient literature search is not a talent but a learnable skill, which should be a formal part of medical education.

  • This review briefly outlines the commonly used bibliographic databases, namely Pubmed, Cochrane Library, Web of Science, Scopus, EMBASE, CINAHL and Google Scholar. Also the definition of grey literature and its features are summarised.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160066. Originally published online at