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Official Journal of the Italian Society of Orthopaedics and Traumatology

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Medium-term clinical results in the treatment of supracondylar humeral fractures in children: does the surgical approach impact outcomes?

Recent literature has found a consensus in favor of conservative treatment for type II supracondylar humeral fractures (SCHF). This retrospective observational study compares the short- to medium-term function...

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Abandoning the use of tension in tibial fracture nailing is associated with lower rate for acute compartment syndrome?

Distal femoral fractures: periprosthetic fractures have four times more complications than non-periprosthetic fractures and cerclage should be avoided: retrospective analysis of 206 patients.

Distal femoral fractures account for less than 1% of all fractures. The therapy of choice is usually surgical stabilization. Despite advances in implant development over the past few years, complication rate r...

Revision shoulder arthroplasty and proximal humeral bone loss: a comprehensive review and proposal of a new algorithm of management

With the rising prevalence of shoulder arthroplasty, the incidence of revision shoulder arthroplasty is also increasing. The complexity of these revision procedures poses significant challenges, with bone loss...

Gender-specific factors influencing the glenoid version and reference values for it

Glenoid version is an important factor in the evaluation of shoulder stability and shoulder pathologies. However, there are neither established reference values nor known factors that influence the glenoid ver...

Polyethylene liner dissociation in total hip arthroplasty: a retrospective case–control study on a single implant design

Modular acetabular components for total hip arthroplasty (THA) provide intraoperative flexibility; however, polyethylene liner dissociation may occur. This study aimed to examine the incidence and causes of li...

Cement loaded with high-dose gentamicin and clindamycin does not reduce the risk of subsequent infection after aseptic total hip or knee revision arthroplasty: a preliminary study

The aim of this study was to quantify the prophylactic effect of high-dose gentamicin and clindamycin antibiotic-loaded bone cement (ALBC) during revision total hip (rTHA) or knee (rTKA) arthroplasty for asept...

Obesity-associated outcomes after ACL reconstruction: a propensity-score-matched analysis of the US Nationwide Inpatient Sample 2005–2018

Anterior cruciate ligament (ACL) injuries are common among physically active individuals, and obesity may increase the risk of such injuries due to factors like biomechanical stress on the knee. We aimed to de...

Comparative outcomes of uncemented and cemented stem revision in managing periprosthetic femoral fractures: a retrospective cohort study

Periprosthetic femoral fractures (PFFs) following hip arthroplasty, especially Vancouver B2 and B3 fractures, present a challenge due to the association with a loose femoral stem, necessitating either open red...

Comparing autologous blood, corticosteroid, and a combined injection of both for treating lateral epicondylitis: a randomized clinical trial

Because lateral epicondylitis is a common musculoskeletal disorder that affects the forearm's extensor tendons, an effective therapeutic approach should reverse the degeneration and promote regeneration. This ...

Radiographic evaluation of robot-assisted versus manual total hip arthroplasty: a multicenter randomized controlled trial

The effectiveness of robot-assisted surgery remains contentious due to the lack of high-quality randomized controlled trials (RCTs) to elevate the level of evidence. We aimed to evaluate the postoperative radi...

Effect of different lumbar–iliac fixation and sacral slope for Tile C1.3 pelvic fractures: a biomechanical study

Lumbar–iliac fixation (LIF) is a common treatment for Tile C1.3 pelvic fractures, but different techniques, including L4–L5/L5 unilateral LIF (L4–L5/L5 ULIF), bilateral LIF (BLIF), and L4–L5/L5 triangular oste...

Efficacy of intramedullary bridge fixation for midshaft clavicle fractures: a retrospective analysis of a novel technique

The aim of this study was to explore the efficacy of a novel intramedullary fixation technique using the ortho-bridge system (OBS) for midshaft clavicle fractures.

Severity of rotator cuff disorders and additional load affect fluoroscopy-based shoulder kinematics during arm abduction

Rotator cuff disorders, whether symptomatic or asymptomatic, may result in abnormal shoulder kinematics (scapular rotation and glenohumeral translation). This study aimed to investigate the effect of rotator c...

Hip arthroscopy with initial access to the peripheral compartment for femoroacetabular impingement: midterm results from a large-scale patient cohort

Hip arthroscopy with initial access to the peripheral compartment could reduce the risk of iatrogenic injury to the labrum and cartilage; furthermore, it avoids the need for large capsulotomies with separate p...

Cellular therapies for bone repair: current insights

Mesenchymal stem cells are core to bone homeostasis and repair. They both provide the progenitor cells from which bone cells are formed and regulate the local cytokine environment to create a pro-osteogenic en...

Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study

Tibial plateau fractures involving posteromedial (PM) and posterolateral (PL) columns are complex injuries that require an appropriate approach. The management of the PL column in these cases can be controvers...

Upcoming evidence in clinical practice of two-stage revision arthroplasty for prosthetic joint infection

Total joint arthroplasty is the recommended treatment for patients with end-stage osteoarthritis, as it reduces disability and pain and restores joint function. However, prosthetic joint infection is a serious...

Accuracy of cup placement compared with preoperative surgeon targets in primary total hip arthroplasty using standard instrumentation and techniques: a global, multicenter study

Acetabular cup positioning in total hip arthroplasty (THA) is closely related to outcomes. The literature has suggested cup parameters defined by the Lewinnek safe zone; however, the validity of such measures...

Metal-backed or all-poly tibial components: which are better for medial unicompartmental knee arthroplasty? A propensity-score-matching retrospective study at the 5-year follow-up

This retrospective medium-term follow-up study compares the outcomes of medial fixed-bearing unicompartmental knee arthroplasty (mUKA) using a cemented metal-backed (MB) or an all-polyethylene (AP) tibial comp...

Unravelling variations: an examination of entry point selection in proximal femoral cephalomedullary nailing

The exact positioning of the cephalomedullary (CM) nail entry point for managing femoral fractures remains debatable, with significant implications for fracture reduction and postoperative complications. This ...

Autogenous structural bone graft reconstruction of ≥ 10-mm-deep uncontained medial proximal tibial defects in primary total knee arthroplasty

Management of uncontained medial proximal tibial defects during primary total knee arthroplasty (TKA) can be challenging, especially for defects ≥ 10 mm in depth. This study sought to assess the outcomes of au...

Polytherapy versus monotherapy in the treatment of tibial non-unions: a retrospective study

Treating tibial non-unions efficiently presents a challenge for orthopaedic trauma surgeons. The established gold standard involves implanting autologous bone graft with adequate fixation, but the addition of ...

Lateralising reverse shoulder arthroplasty using bony increased offset (BIO-RSA) or increasing glenoid component diameter: comparison of clinical, radiographic and patient reported outcomes in a matched cohort

This study aims to compare the range of motion (ROM) of reverse shoulder arthroplasty lateralised by bony increased offset (BIO-RSA) using a standard 38-mm (mm) component to regular reverse shoulder arthroplas...

Delaying anterior cruciate ligament reconstruction for more than 3 or 6 months results in lower risk of revision surgery

The objective of this study is to investigate the risk of revision surgery when delaying anterior cruciate ligament reconstruction (ACLR) past 3 months or 6 months after injury.

Functional and oncological outcomes of patients with proximal humerus osteosarcoma managed by limb salvage

Osteosarcoma is the most common primary bone malignancy in skeletally immature patients. The proximal humerus is the third most common site of osteosarcoma. The literature shows a paucity of published data con...

Capacitive biophysical stimulation improves the healing of vertebral fragility fractures: a prospective multicentre randomized controlled trial

Capacitively coupling electric fields (CCEF) is a method of non-invasive biophysical stimulation that enhances fracture repair and spinal fusion. This multicentre randomized controlled trial aimed to further e...

Interlocking intramedullary nail for forearm diaphyseal fractures in adults—A systematic review and meta-analysis of outcomes and complications

The purpose of this systematic review is to examine the outcomes, complications, and potential advantages of using anatomical interlocking intramedullary nails (IMN) in the treatment of radius and ulnar shaft ...

Evaluation of time to reimplantation as a risk factor in two-stage revision with static spacers for periprosthetic knee joint infection

We investigated the time to reimplantation (TTR) during two-stage revision using static spacers with regard to treatment success and function in patients with chronic periprosthetic joint infection (PJI) of th...

TikTok content as a source of health education regarding epicondylitis: a content analysis

This study aimed to assess the validity and informational value of TikTok content about epicondylitis. The hypothesis tested herein was that TikTok video content would not provide adequate and valid information.

Optimizing periprosthetic fracture management and in-hospital outcome: insights from the PIPPAS multicentric study of 1387 cases in Spain

The incidence of all periprosthetic fractures (PPF), which require complex surgical treatment associated with high morbidity and mortality, is predicted to increase. The evolving surgical management has create...

Unexpected early loosening of rectangular straight femoral Zweymüller stems with an alumina-reduced surface after total hip arthroplasty—a prospective, double-blind, randomized controlled trial

Alumina particles from the grit blasting of Ti-alloy stems are suspected to contribute to aseptic loosening. An alumina-reduced stem surface was hypothesized to improve osseointegration and show comparable sho...

Three-dimensional printed models can reduce costs and surgical time for complex proximal humeral fractures: preoperative planning, patient satisfaction, and improved resident skills

Proximal humeral fractures (PHFs) are still controversial with regards to treatment and are difficult to classify. The study’s objective is to show that preoperative planning performed while handling a three-d...

Reverse shoulder arthroplasty with a 155° neck-shaft angle inlay implant design without reattachment of the subscapularis tendon results in satisfactory functional internal rotation and no instability: a cohort study

The aim of this study was to use the Activities of Daily Living which require Internal Rotation (ADLIR) questionnaire to assess the functional internal rotation in patients who had undergone reverse shoulder a...

Direct anterior approach with conventional instruments versus robotic posterolateral approach in elective total hip replacement for primary osteoarthritis: a case–control study

The purpose of this study is to compare peri-operative and short-term outcomes in patients who underwent elective total hip replacement (THA) for primary osteoarthritis (OA) with direct anterior approach (DAA)...

The effect of cellular nuclear function alteration on the pathogenesis of shoulder adhesive capsulitis: an immunohistochemical study on lamin A/C expression

The network of intermediate filament proteins underlying the inner nuclear membrane forms the nuclear lamina. Lamins have been associated with important cellular functions: DNA replication, chromatin organizat...

All-epiphyseal anterior cruciate ligament reconstruction yields superior sports performances than the trans-epiphyseal technique in skeletally immature patients: a systematic review

Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasingly common. Evidence comparing the outcomes of all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immatu...

Risk factors for early septic failure after two-stage exchange total knee arthroplasty for treatment of periprosthetic joint infection

The cause of early septic failure after two-stage exchange revision total knee arthroplasty (TKA) for chronic periprosthetic joint infection (PJI) and the factors affecting it are not well known. The purpose o...

Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach

Intramedullary tibial nailing (IMN) is the gold standard for stabilizing tibial shaft fractures. IMN can be performed through an infra- or suprapatellar approach.

Preoperative antibiotic prophylaxis and the incidence of surgical site infections in elective clean soft tissue surgery of the hand and upper limb: a systematic review and meta-analysis

Surgical site infections (SSI) are the most frequent early complications of hand surgeries. However, the indications still remain uncertain for antibiotic prophylaxis in elective clean soft tissue surgeries of...

High satisfaction rate and range of motion can be expected in frozen shoulder after awake manipulation with brachial plexus block

Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (...

Validation of Roussouly classification in predicting the occurrence of adjacent segment disease after short-level lumbar fusion surgery

Recent studies demonstrated that restoring sagittal alignment to the original Roussouly type can remarkably reduce complication rates after adult spinal deformity surgery. However, there is still no data provi...

Antithrombotic prophylaxis following total hip arthroplasty: a level I Bayesian network meta-analysis

Several clinical investigations have compared different pharmacologic agents for the prophylaxis of venous thromboembolism (VTE). However, no consensus has been reached. The present investigation compared enox...

Transforaminal lumbar interbody fusion with a tantalum cage: lumbar lordosis redistribution and sacral slope restoration with a modified posterior technique

Transforaminal lumbar interbody fusion (TLIF), a commonly used procedure in spine surgery, has the advantage of a lower incidence of nerve lesions compared to the posterior lumbar interbody fusion (PLIF) techn...

Arthrosis diagnosis and treatment recommendations in clinical practice: an exploratory investigation with the generative AI model GPT-4

The spread of artificial intelligence (AI) has led to transformative advancements in diverse sectors, including healthcare. Specifically, generative writing systems have shown potential in various applications...

Greater medial proximal tibial slope is associated with bone marrow lesions in middle-aged women with early knee osteoarthritis

Bone marrow lesion (BML) is an important magnetic resonance finding (MRI) finding that predicts knee osteoarthritis. The purpose of this study was to investigate the influence of proximal tibial morphology on ...

Reverse shoulder arthroplasty in obstetric brachial plexus injury: our experience with shoulder motion analysis

Obstetric brachial plexus injury (OBPI) is a weakening or paralysis of the upper arm caused by brachial plexus injury followed by a muscle paralysis with severe repercussions on the movement of the shoulder jo...

Clinical effects of different center of rotation reconstructions in total hip arthroplasty after femoral neck fractures: a cohort study including a follow-up analysis on patient’s mobility and daily living ability

The aim of this study is a clinical evaluation of the center of rotation (COR) placement towards a patient’s recovery with respect to daily living ability and mobility. In past experiments based on three-dimen...

Standard views do not suffice in assessing distal scaphoid articular cannulated screw penetration

Articular screw penetration is one of the most common hardware-related problems after scaphoid fracture fixation, occurring in up to two-thirds of patients, in particular into the scaphotrapezotrapezoidal (STT...

Complication rates after proximal femoral nailing: does level of training matter?

Surgical treatment of pertrochanteric fractures is one of the most performed surgeries in orthogeriatrics. Proximal femoral nailing, the most performed procedure, is often used as a training surgery for young ...

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Official Journal of SIOT  Italian Society of Orthopaedics and Traumatology

Affiliated with Official Journal of AUOT - Accademia Universitaria di Ortopedia e Traumatologia

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Citation Impact 2023 Journal Impact Factor: 3.0 5-year Journal Impact Factor: 3.5 Source Normalized Impact per Paper (SNIP): 1.668 SCImago Journal Rank (SJR): 1.009

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Usage 2023 Downloads: 583,584 Altmetric mentions: 125

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• ISSN: 1590-9999 (electronic)
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Orthopaedics articles from across Nature Portfolio

Orthopaedics is a medical specialty concerned with the prevention and treatment of disorders of the musculoskeletal system by use of surgical and non-surgical methods.

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Local and non-local effects (on the posterior chain) of four weeks of foot exercises: a randomized controlled trial

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3D-printed porous titanium rods equipped with vancomycin-loaded hydrogels and polycaprolactone membranes for intelligent antibacterial drug release

Effects of radial extracorporeal shock wave with different frequencies on acute skeletal muscle injury in rabbits

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Synthetic lumbar MRI can aid in diagnosis and treatment strategies based on self-pix networks

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A patient with cervical ligamentum flavum haematoma: case report

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Effectiveness of virtual-walking intervention combined with exercise on improving pain and function in incomplete spinal cord injury: a feasibility study

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Long-lived biomaterials

The design of implantable biomaterials with lasting function is rooted in biomolecular and cellular principles.

Joint implants: An elution solution

An optimized drug-eluting polymer for the surface of articulating artificial joints may make them infection-free.

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Neuronal origin of osteogenic effects of magnesium

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The Department of Orthopaedic Surgery’s distinguished history is grounded on Johns Hopkins Medicine’s principle that laboratory research and bedside teaching need to coexist in the instruction and practice of medicine. The creation of a formal Research Division and the Center for Musculoskeletal Research in 2009 provided a nexus for basic and translational research related to the musculoskeletal system.

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For a complete list of available clinical trials, search the database at the  Johns Hopkins Institute for Clinical and Translational Research . You can search by condition, researcher or doctor’s name.

Experimental Procedure for Children With Knee Cartilage Defects

Summary: A study of MACI in patients aged 10 to 17 years with symptomatic chondral or osteochondral defects of the knee (PEAK). 

Objective: To evaluate an experimental treatment for knee cartilage defects called membrane-induced autologous chondrocyte implantation (MACI).

Principle Investigator: R. Jay Lee, M.D.

Eligibility Criteria: Children age 11-17 with knee cartilage defects

Contact: Gabrielle Richard ( [email protected] )

Learn more about this study.

Integra® Titan™ Modular Shoulder System Generation 2.5 for Primary Shoulder Joint Replacement

Summary: A Post-Market, Prospective, Multi-Center, Open-Label, Single Arm Clinical Evaluation of the Integra TitanTM Modular Shoulder System 2.5 for Primary Shoulder Joint Replacement (IRB00169712).

Objective: To evaluate 2-year implant survivorship in subjects who receive the TSS-2.5 when used for primary shoulder arthroplasty.

Principle Investigator: Umasuthan Srikumaran, M.D., M.P.H., M.B.A.

Eligibility Criteria: Candidate for total shoulder arthroplasty.

Contact: Sanjana Vattigunta ( 443-516-1550  or  [email protected] )

Post-operative Pain Control Following Shoulder Surgery

Summary: A study of MACI in patients aged 10 to 17 years with symptomatic chondral or osteochondral defects of the knee (PEAK). 

Objective: Evaluate overall pain medication consumption following surgical treatment for shoulder pathology

Eligibility Criteria: Opioid-naive adults age 18-90 years old planning to undergo surgical treatment for shoulder pathology with Dr. Uma Srikumaran.

Optimize Low Back Pain

Objective: Improve health care for patients with chronic lower back pain (LBP) and increase the likelihood that patients obtain outcomes that matter most to them.

Principle Investigator: Richard Skolasky, Sc.D.

Eligibility Criteria: Adults age 18 - 64 years old, meets NIH Task Force definition of chronic LBP, had a healthcare visit for LBP in the past 90 days and have moderate levels of pain and disability.

Contact: Tricia Kirkhart ( 410-502-4453  or  [email protected] )

Dysport® (abobotulinumtoxinA) as an Adjunctive Treatment to Bracing in the Management of Adolescent Idiopathic Scoliosis (AIS)

Objective: To evaluate the combined effect of botulinum toxin A (administered as Dysport®) and bracing in children with adolescent idiopathic scoliosis.

Principle Investigator: Paul D. Sponseller, M.D.

Eligibility Criteria: Diagnosed with AIS, 10 to 16-year-old children.

Contact: Vivian Tran and Varun Puvanesarajah ( 410-955-3136  or  [email protected] )

Participants in this study will be compensated.

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Study finds delayed acl surgery may be safe for many adults, less so for some children.

Johns Hopkins Children's Center investigators report active children are prone to further knee cartilage tears while awaiting repair surgery after ACL injury

Lack of Belief in Body's Ability to Function Through Pain Linked to Daily Pre-Surgery Prescribed Opioid Use Among Candidates for Elective Spine Surgery

Researchers discovered a link between pain self-efficacy and preoperative opioid use among patients seeking elective spine surgery

Walking a Leashed Dog Associated with Risk of Traumatic Brain Injury Among Adults

Researchers found that women, and adults age 65 and older, were more likely to sustain serious injuries, such as fractures and TBIs, as a result of walking a leashed dog

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Innovation in Spine Surgery

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Predicting Major Complications and Discharge Disposition After Adult Spinal Deformity Surgery

Surgical Setting in Achilles Tendon Repair: How Does It Relate to Costs and Complications?

Predicting Risk of 30-day Postoperative Morbidity Using the Pathologic Fracture Mortality Index

The Use of Weakly Supervised Machine Learning for Necrosis Assessment in Patients with Osteosarcoma: A Pilot Study

Is Delayed Anterior Cruciate Ligament Reconstruction Associated with a Risk of New Meniscal Tears? Reevaluating a Longstanding Paradigm

Orthopedic Surgery

• New directions for orthopedic surgery research

Aug. 06, 2021

Matthew P. Abdel, M.D. , an orthopedic surgeon at Mayo Clinic in Rochester, Minnesota, answers questions about artificial intelligence (AI) and other research goals in Orthopedic Surgery. Dr. Abdel was recently named chair of Mayo Clinic's Orthopedic Surgery Research.

Why is AI a primary focus of Mayo Clinic's orthopedic surgery research?

All of our research priorities are based on the needs of our patients. Our basic science researchers as well as our clinician-investigators are all engaged in research that is directly translatable to clinical practice.

Musculoskeletal innovation goals

Schematic describes Mayo Clinic's goals for musculoskeletal (MSK) innovation.

AI has a strong potential to improve patient care through the development of predictive analytics to guide surgical decision-making. One example is AI analytics to predict whether or not a prosthetic implant is fixed or loose. But the potential applications of AI touch all nine of our Orthopedic Surgery clinical divisions. Our goal is to transform musculoskeletal care through predictive algorithms and AI .

What infrastructure does Mayo Clinic have for building predictive analytics?

In addition to orthopedic surgical subject matter experts, Mayo Clinic has robust data sets for most orthopedic subspecialties. For example, in hip and knee arthroplasty, we have a patient registry that has captured clinical, radiographic, demographic and operative details going back to March 1969. That type of longitudinal data is key to developing the algorithms that drive predictive analytics.

Applying predictive analytics to individual patients requires state-of-the-art imaging. Mayo Clinic also has a long tradition of imaging expertise that will facilitate the development of AI -based applications.

What additional priorities is the research division pursuing?

In addition to AI , our 2030 strategic vision focuses on cartilage regeneration, infection prevention and treatment, fibrosis, arthritis, and orthopedic oncology.

How might research focused on cartilage regeneration benefit patients?

Pharmacological and gene therapies that slow the degeneration of cartilage can help individuals avoid joint replacement surgery. Patients are eager for nonsurgical options. Like AI , cartilage regeneration can impact many of the services we provide, including our upper and lower extremity practices, spine practice, pediatric orthopedics, and sports medicine.

What does Mayo Clinic hope to achieve regarding orthopedic infection research?

One particular issue we hope to clarify is whether bacteriophages play any role in treating periprosthetic joint infections. As described in Clinical Infectious Diseases, Mayo Clinic successfully used phage therapy to treat a 62-year-old man with a history of knee arthroplasty and multiple episodes of prosthetic knee infection — avoiding the need for amputation.

Infections can plague any bone, muscle, ligament, tendon or joint. The prevention and treatment of these orthopedic infections is evolving rapidly, and Mayo Clinic is committed to innovation.

What are Mayo Clinic's goals in fibrosis and arthritis research?

We are working to develop pharmacological modalities that both prevent and treat fibrosis in the musculoskeletal system. Similarly, learning more about the pathogenesis of arthritis, and how we might slow or prevent its development, is key.

All of our research aims ultimately focus around curing musculoskeletal diseases with innovative diagnostics and therapeutics. Moreover, we want to connect patients to optimal care through predictive analytics and advanced registry technologies.

For more information

Cano EJ, et al. Phage therapy for limb-threatening prosthetic knee Klebsiella pneumoniae infection: Case report and in vitro characterization of anti-biofilm activity. Clinical Infectious Diseases. 2021;73:e144.

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Cutting edge topics and advances in orthopaedic research

Edward Schwarz and Jay Lieberman

Implantable sensor technology: measuring bone and joint biomechanics of daily life in vivo

Stresses and strains are major factors influencing growth, remodeling and repair of musculoskeletal tissues. Therefore, knowledge of forces and deformation within bones and joints is critical to gain insight i...

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Biologic adjuvants for fracture healing

Bone tissue has an exceptional quality to regenerate to native tissue in response to injury. However, the fracture repair process requires mechanical stability or a viable biological microenvironment or both t...

Atypical subtrochanteric femoral shaft fractures: role for mechanics and bone quality

Bisphosphonates are highly effective agents for reducing osteoporotic fractures in women and men, decreasing fracture incidence at the hip and spine up to 50%. In a small subset of patients, however, these age...

Platelet-rich plasma therapy - future or trend?

Chronic complex musculoskeletal injuries that are slow to heal pose challenges to physicians and researchers alike. Orthobiologics is a relatively newer science that involves application of naturally found mat...

Recent advances in shoulder research

Shoulder pathology is a growing concern for the aging population, athletes, and laborers. Shoulder osteoarthritis and rotator cuff disease represent the two most common disorders of the shoulder leading to pai...

Early diagnosis to enable early treatment of pre-osteoarthritis

Osteoarthritis is a prevalent and disabling disease affecting an increasingly large swathe of the world population. While clinical osteoarthritis is a late-stage condition for which disease-modifying opportuni...

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Surgical Innovation and Advancement in Orthopedics

Original Research 11 October 2023 Investigating the effect of autograft diameter for quadriceps and patellar tendons use in anterior cruciate ligament reconstruction: a biomechanical analysis using a simulated Lachman test Farid Amirouche ,  3 more  and  Jason Koh 1,215 views 1 citations

Original Research 29 September 2023 Effectiveness of laser welding in cerclage wiring fixation: a biomechanical study Nachapan Pengrung ,  3 more  and  Eakkachai Warinsiriruk 689 views 0 citations

Original Research 14 July 2023 A randomized controlled study of a psycho-behavioral intervention combined with a non-benzodiazepine to improve perioperative sleep quality in patients undergoing knee arthroplasty Wang Jing ,  5 more  and  Li Lingli 1,321 views 0 citations

Original Research 09 May 2023 Comparative study of halo-vest reduction and skull traction reduction in the treatment of cervical fracture dislocation in patients with ankylosing spondylitis Liang Wang ,  4 more  and  Xuhua Lu 1,761 views 1 citations

Case Report 21 April 2023 Surgical treatment and functional outcome of bilateral symmetrical hip dislocation and Pipkin type II femoral head fracture: a 5-year follow-up case report and literature review Sujan Shakya ,  3 more  and  Xin Duan 1,861 views 0 citations

Original Research 11 April 2023 Anterior shift of the ventral dura mater: A novel concept of the posterior surgery for ossification of the posterior longitudinal ligament in thoracic spine Kohei Takahashi ,  4 more  and  Toshimi Aizawa 1,191 views 0 citations

Original Research 03 April 2023 Deep vein thrombosis screening in pediatric orthopedic patients Saowalak Tongta ,  4 more  and  Patarawan Woratanarat 1,511 views 0 citations

Original Research 30 March 2023 Surgical treatment of patellar dislocation: A network meta-analysis of randomized control trials and cohort studies Mingqing Fang ,  8 more  and  Wenfeng Xiao 1,979 views 0 citations

Loading... Original Research 29 March 2023 New technique for the treatment of fresh bony mallet finger: A retrospective case series study Zhenshuang Yue ,  2 more  and  Yanghua Tang 3,617 views 1 citations

Original Research 24 March 2023 Abductor muscle function after anterolateral approach in patients with unilateral end-stage hip osteoarthritis undergoing total hip arthroplasty: A prospective study Siwadol Wongsak ,  3 more  and  Paphon Sa-ngasoongsong 1,627 views 0 citations

Loading... Brief Research Report 21 March 2023 Outcomes following use of VersaWrap nerve protector in treatment of patients with recurrent compressive neuropathies Keegan M. Hones ,  4 more  and  Harvey Chim 1,882 views 5 citations

Original Research 17 March 2023 Drain vs. no-drain for acetabular fractures after treatment via a modified stoppa approach: A retrospective study Lin Jin ,  5 more  and  Zhiyong Hou 731 views 0 citations

Original Research 16 March 2023 Clinical effect of limited posterior decompression and 13-mm titanium mesh implantation on severe thoracolumbar burst fractures: A case series Liu Jingcheng  and  Lu Lei 861 views 0 citations

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Original Research 23 February 2023 A retrospective case series of the treatment of spontaneous quadriceps tendon rupture in patients with uremia and secondary hyperparathyroidism Shuang Wu ,  2 more  and  Weili Fu 1,709 views 1 citations

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The future of basic science in orthopaedics and traumatology: Cassandra or Prometheus?

Henning madry.

1 Institute of Experimental Orthopaedics and Osteoarthritis Research, Saarland University, Homburg, Germany

Susanne Grässel

2 Experimental Orthopedics, Department of Orthopedic Surgery, University of Regensburg, Regensburg, Germany

Ulrich Nöth

3 Department of Orthopaedics and Trauma Surgery, Evangelisches Waldkrankenhaus Berlin Spandau, Berlin, Germany

Borna Relja

4 Experimental Radiology, University Clinic for Radiology and Nuclear Medicine, Otto-Von-Guericke-University Magdeburg, Magdeburg, Germany

Anke Bernstein

5 G.E.R.N. Research Center for Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Breisgau, Germany

Denitsa Docheva

6 Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg, Germany

Max Daniel Kauther

7 Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Essen, Essen, Germany

Jan Christoph Katthagen

8 Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany

Rainer Bader

9 Department of Orthopaedics, Research Lab for Biomechanics and Implant Technology, Rostock University Medical Center, Rostock, Germany

Martijn van Griensven

10 Department of Cell Biology-Inspired Tissue Engineering, MERLN-Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, The Netherlands

Dieter C. Wirtz

11 Department of Orthopaedics and Trauma Surgery, University Hopsital Bonn, Bonn, Germany

Michael J. Raschke

Markus huber-lang.

12 Institute for Clinical and Experimental Trauma-Immunology (ITI), University Hospital Ulm, Helmholzstr. 8/1, Ulm, Germany

Associated Data

Not applicable since review.

Orthopaedic and trauma research is a gateway to better health and mobility, reflecting the ever-increasing and complex burden of musculoskeletal diseases and injuries in Germany, Europe and worldwide. Basic science in orthopaedics and traumatology addresses the complete organism down to the molecule among an entire life of musculoskeletal mobility. Reflecting the complex and intertwined underlying mechanisms, cooperative research in this field has discovered important mechanisms on the molecular, cellular and organ levels, which subsequently led to innovative diagnostic and therapeutic strategies that reduced individual suffering as well as the burden on the society. However, research efforts are considerably threatened by economical pressures on clinicians and scientists, growing obstacles for urgently needed translational animal research, and insufficient funding. Although sophisticated science is feasible and realized in ever more individual research groups, a main goal of the multidisciplinary members of the Basic Science Section of the German Society for Orthopaedics and Trauma Surgery is to generate overarching structures and networks to answer to the growing clinical needs. The future of basic science in orthopaedics and traumatology can only be managed by an even more intensified exchange between basic scientists and clinicians while fuelling enthusiasm of talented junior scientists and clinicians. Prioritized future projects will master a broad range of opportunities from artificial intelligence, gene- and nano-technologies to large-scale, multi-centre clinical studies. Like Prometheus in the ancient Greek myth, transferring the elucidating knowledge from basic science to the real (clinical) world will reduce the individual suffering from orthopaedic diseases and trauma as well as their socio-economic impact.

Introduction

Orthopaedic and trauma research is a gateway to better health and mobility, reflecting the ever-increasing and complex burden of musculoskeletal diseases and injuries. The field of basic science in orthopaedics and traumatology grows not only in Germany, but also across Europe and worldwide. Questions asked from orthopaedic and trauma surgeons to scientists who are involved in the many facets of musculoskeletal research and vice versa represent the exciting basis of fruitful interactions within this specific field.

Orthopaedic and trauma research is the key competence of the Basic Science Section (“ Sektion Grundlagenforschung ”, SGF) of the German Society for Orthopaedics and Trauma Surgery (“ Deutsche Gesellschaft für Orthopädie und Unfallchirurgie ”, DGOU). The SGF represents a multidisciplinary community of orthopaedic and trauma surgeons, biologists, biochemists, engineers, and veterinarians. Its members are devoted to orthopaedic and trauma research and aid in defining nationwide research policies in orthopaedics and trauma surgery through close cooperation of the corresponding committees and groups with the DGOU. Within the SGF, three networks exist, each of which has a specific focus: the network of musculoskeletal regeneration (MR-Net), the network of musculoskeletal biomechanics (MSB-Net), and the network for trauma research (NTF). The SGF plays also a key role in bringing together researchers, surgeons and other clinicians at the German Congress for Orthopaedics and Trauma Surgery (“ Deutscher Kongress für Orthopädie und Unfallchirurgie ”, DKOU). This annual meeting is considered the most important congress in the field of Orthopaedics and Traumatology in Germany and far beyond as it represents the largest of its sector in Europe with more than 10,000 attendees. At the annual congress, the SGF is responsible for organizing the basic research lectures and scientific poster sessions. Furthermore, the SGF is involved in the selection process of the recipient of the prestigious Basic Research Prize and honours outstanding scientific work with the annual Wilhelm Roux Award and several poster prizes, all of which are awarded during the common meeting.

Besides these national and global research efforts, more and more basic science questions arise which need to be addressed. However, far beyond the orthopaedic and trauma context, the lack of basic knowledge had been challenged already in ancient Greece by Prometheus who, endued with the highest degree of intelligence, brought the “fire” and “light” into the darkness of the human mind. An etymological analysis of the word “pro metheus” suggests that it derives from the Greek word Προμηθεύς, meaning “forethought” and “plan ahead”. Thus, Prometheus could function as a role model for the basic scientist in the field of orthopaedics and traumatology: by a wise study planning with a focussed standardized setting, the scientist is capable to enlighten enigmatic mechanisms, all of which may finally result in an adequate and satisfactory treatment of the patient (Fig.  1 ). In accordance, mechanism-driven trials, in which basic science-revealed specific mechanisms are targeted, are proposed to be more likely to show improvement in a heterogeneous trauma cohort [ 1 ]. On the other hand, basic science is also endangered to play the imposed role of Cassandra, the tragic Greek priestess who could accurately foresee the future but sadly was never believed. In free association, many basic research efforts and exciting findings will never make it to the bedside because they are neither perceived nor apprehended by the clinical-, funding- (Fig.  2 ), and political stakeholders and thus remain neglected. In this regard, during all stages of the career of both the scientist and clinician, a common language and understanding of the basic scientist and the clinician is often missing or underdeveloped. In case of the academic surgeon in the dual role as clinician and basic scientist, a framework has been proposed to accomplish the patient-centred trilogy of clinic, research, and teaching with a high degree of reliability and room for scientific and personal development [ 2 ]. In the case of the surgical/medical scientist such a dual role is rare but conceivable [ 3 ] and its further development is forward-looking (“pro-metheus”) and probably game changing. However, care has to be taken that such a medical scientist is not seen as a Cassandra. The balance between applied science and ethical medical treatment is delicate and needs to be guarded.

The Prometheus paradigm. The societies for orthopaedics and traumatology need to identify and define problems of the patient suffering from orthopaedic or (post)traumatic problems, which are so far diagnostically and therapeutically not satisfactorily resolved. Then, based on the “Prometheus” principle, a highly intelligent and innovative idea, evolved in the interdisciplinary discourse, may lead to a perfectly designed basic science study to reveal the underlying mechanisms. This can be realized, e.g. by a translational study with appropriate in vitro or in vivo (animal) modelling. The gained knowledge can then be translated back to the clinic and subsequently be evaluated for the final benefit of the patient

The Cassandra challenge. Disproportion of the high incidence as well as impact of orthopaedic diseases and trauma as opposed to the funding resources in the corresponding fields. In accordance to the “Cassandra” principle, the basic research societies in orthopaedics and traumatology might point to this imbalance without being heard by the surrounding environment and society—although they crusade for an improved quality of life and for improving the clinical outcome of the affected patients

Orthopaedic and trauma research have overlapping interests, but some differences exist as well. Nevertheless, both fields are closely intertwined and therefore considered here. This paper addresses, from the different viewpoints of both orthopaedics and traumatology, the need of basic science, provides examples of cutting-edge research topics, elaborates on evolving methodologies to reach the state-of-the art, supports the need for high-quality animal research, and aims to define hot scientific topics and urgent needs that will have to be answered in the near and far future.

Past research efforts in orthopaedics and traumatology: Cassandra or Prometheus?

The field of orthopaedics and traumatology addresses all musculoskeletal aspects of body support and motion. For example, a major task is the care for high-impact degenerative diseases such as osteoarthritis (OA) that challenge health-care systems globally. OA represents a high-burden non-communicable disease (NCD), its numbers significantly increase in terms of total burden and age-standardized disability-adjusted life-years (DALY), which considerably rose between 1990 and 2015 [ 4 ]. The hallmark of OA is the breakdown of the articular cartilage, although OA also affects all other tissues related to a joint. For many patients, pain and the slow and often immeasurable reduction in joint function are the main indicators of the disease and therefore also of the key to any potential conservative or surgical therapy. Orthopaedic research and treatment of OA has experienced significant advances over the past decades. Already in the 1960s it became clear that while pain may be relieved by intraarticularly injecting steroids, this treatment does not address cartilage loss and can even be harmful to the articular cartilage [ 5 ]. The discovery of growth factors, dating even back to the middle of the past century [ 6 ], was a crucial step as it led to the identification of factors that stimulate the articular chondrocytes to proliferate and to deposit extracellular matrix. This development can be regarded as a shining beacon enlightening orthopaedic and trauma research in the spirit of Prometheus, the mythological figure reflecting the quest for scientific truth and knowledge. The very first animal study on the effect of growth factors for cartilage repair conducted at the Charité hospital in Berlin was published in 1980 [ 7 ]. Nearly four decades later, the principle of applying growth factors for cartilage repair was finally tested in randomized-controlled clinical trials to potentially modify structural and clinical features of OA. The data revealed reductions in the loss of cartilage thickness over time when compared with placebo, however, without significant reduction in OA pain or other clinical parameters [ 8 ]. These extremely intriguing outcomes raise a number of burning questions to be addressed in the future; most importantly on the clinical relevance of such long searched-for structural changes and how to conduct future clinical trials of disease-modifying drugs that demonstrate effects not only on structure, but also on the clinical endpoints that matter to the patients [ 9 ]. This dilemma was already reflected by the classical remark of Henry Mankin, the renowned orthopaedic clinician scientist, who stated that the “cartilage does not yield its secrets easily, inducing cartilage to heal is not simple, … and progression to OA is sometimes so slow that we delude ourselves into thinking we are doing better than we are” [ 10 ]. Novel approaches for OA are being pursued to overcome this challenge, among which detailed investigation of topographical changes [ 11 ], OA pain [ 7 , 8 ] and possibly contributing environmental factors [ 12 ], while also advancing gene-based [ 13 ] and other targeted approaches [ 14 ] as future therapies.

The field of trauma addresses any individuum since physical trauma can hit anybody and affect any region of the body at any time. Thus, trauma represents a major global burden of the past, presence and future [ 15 ]. Based on the highly interconnected organ systems (e.g. lung–liver, bone–kidneys, neuro-immune system) tissue injury to even a single bone or organ may affect via complex pathophysiological mechanisms various other tissues and thus in principle the whole body [ 16 , 17 ]. Therefore, the field of trauma research comprises the whole human organism—from the first change on the sub-molecular level to the clinical bedside reality and far beyond into the society. As consequence, this cosmic broadness can barely be covered by the trauma research efforts of one nation, nor European- or even world-wide. Thus, trauma-related science has been attributed to be arbitrary, unfocused, fragmented and reduced quality research [ 18 ]. In clinical translation, numerous poorly designed studies have been performed, which addressed emergency, surgical and critical care management in various trauma settings with the main result: an urgent need for state-of-the art meaningful clinical studies remains and is further called for, especially to fill the gaps of corresponding guidelines [ 19 – 21 ]. However, clinical studies in trauma are rather complex and difficult to perform not at least due to the vast heterogeneity of trauma conditions, -patterns and -care [ 18 ]. Thereby, large numbers of patients need to be included to achieve statistically sound results. The involved pathomechanisms, which drive the healing and rehabilitation processes after trauma and in orthopaedics but also any complication directly associated with the quality of life, allegorize a “black box”, which is difficult to enlighten in a reasonable scientific, ethical and economic manner. Basic research in principle is capable to enlighten this “black box” of unknown mechanisms and provide the scientific rationale for an improved design of translational, clinically meaningful studies. These studies will return important insights in complex interactions and adjust the scientific models, which can subsequently be optimized.

However, it is also important not only to set the focus on external factors and trends affecting the evolution of trauma research but also to address—more alike blind Casandra’s approach—internal factors. Therefore, we should also question what could the field have done differently in the past and can we learn from other research disciplines? In this regard, uncertain career development paths for basic and clinical scientist in our field, ongoing separation of bench and bedside research, reduced industry–academic interactions, discouragement of innovative thinking, insufficient transdisciplinary networking, short-term research endeavours, as well as reserved public dissemination of meaningful results represent internal obstacles decelerating past and probably also present research efforts.

Current hot topics in orthopaedics and traumatology

Since the areas of basic research within the field of orthopaedics and traumatology are numerous and steadily growing, only exemplary current hot topics can be delineated here.

In bone fracture healing, after initial inflammation, new cartilage and bone matrices are deposited that result in connecting the fracture ends. Currently, the recruitment of skeletal progenitor cells, vascular cells and subtypes of immune cells during the repair process as well as the direct, cell-to-cell and secretory cross-talk between exogenous and endogenous cells is extensively investigated [ 22 ]. Immunomodulation of musculoskeletal repair represents a very attractive area for novel therapeutic strategies: research efforts can lead to the identification of possible ways to spatio-temporal modulate specific immune cells to beneficially steer the repair process [ 23 , 24 ]. Studies on the tight interplay of vascular, inflammatory and metabolic cascades during fracture healing are increasing [ 25 ]. Research in this area is critical to clarify the intimately intertwined cascades of tissue regeneration. Mesenchymal stromal cells (MSCs) represent also important immunomodulators, as they arise naturally at damaged sites but also when applied in a therapeutic approach. Regarding intercellular communication, current research addresses cellular exchange or even therapeutic application via extracellular vesicles [ 26 , 27 ]. A current review on extracellular vesicles in musculoskeletal pathologies and regeneration serves as a timely example of a scientific network that is actively supported by the DGOOC [ 28 ]. Extracellular vesicles can also contain micro-RNAs that have been shown to be involved in many musculoskeletal diseases [ 29 – 31 ].

Regeneration of cartilage after trauma remains a hot topic since articular cartilage has a very poor capacity to repair itself and if healing occurs through fibrocartilage, it is characterized by insufficient structural and biomechanical properties. A better understanding of the cellular and molecular mechanisms of chondrocyte differentiation, phenotype preservation and the simultaneous response of chondrocytes to biochemical and biomechanical stress [ 32 – 34 ], may here provide insights into mechanisms that can guide chondrocytes and MSCs towards stable articular cartilage formation [ 35 – 37 ], which reflects the contemplations in the introduction about the impact of OA on the field of orthopaedics.

The awareness of the investigators on tendon, ligament, fascia and meniscal repair is also expanding towards understanding the intrinsic capacities of these tissues to heal [ 38 ] and the cell sources that participate in their repair [ 38 – 44 ]. Another fascinating exploratory field is on clarifying the impact of matrix composition, topography and biophysical properties onto the cells [ 45 , 46 ]. Several recent studies have reported interesting novel data on the contribution of different cell types [ 47 – 53 ] as well as on the instructiveness of matrix properties on cell behaviour [ 46 , 52 , 54 , 55 ].

Since it affects countless patients worldwide, intervertebral disc (IVD) regeneration is another basic science focus. Experimental studies explored the performance of different cell types when injected in IVDs [ 56 – 58 ]. Although there are significant advances in the basic understanding of IVD regeneration, this area is still in its prime and far from clinical translation when, for example, compared with the articular cartilage research. Since the IVD is a multilayered anatomical structure, namely nucleus pulposus, annulus fibrosus and the cartilage endplate, successful regeneration will require a simultaneous revival of all three tissues or functionally integrated in one implant [ 59 ]. Therefore, further basic research is needed on characterizing the molecular and cellular composition in homeostasis and degeneration of this unique structure [ 58 , 60 ].

The orthopaedic and trauma fields have also recognized that repair proceeds at a different pace in young and healthy versus aged and degenerated/co-morbidity plagued musculoskeletal tissues and organs. Robust work has demonstrated that cellular niches and their endogenous progenitor cells have a profound impact during the age-related degenerative process [ 49 , 61 ]. Hence, therapeutic principles have to be attuned to satisfactorily restore the structure–function of aged and injured tissues in the elderly. However, the search for the “fountain of youth” seems Prometheus-like, whereas Casandra may propose never to find such a source.

The mechano-biological pairing and the biophysics of cell–matrix interactions are essential in understanding the progression of musculoskeletal diseases and can also empower tissue regeneration. However, if these stimuli become abnormal they can prevent restoration and rather aggravate the disease. Current topics of interest within experimental orthopaedic biomechanics include mechanical testing of normal and diseased musculoskeletal tissues [ 62 , 63 ], medical implant design and testing [ 64 ], tissue engineering [ 65 – 67 ] and translation of biomechanical into biochemical signals [ 68 – 71 ]. This research area will further optimize the biomechanical parameters of tissue-engineered implants and better understand cell- and drug-based therapeutic effects on mechanical behaviour at the tissue-level. In regard to tissue engineering, current biomaterial-related hot topics are “smarter” materials that are both degradable and able to control, steer or modulate biological responses and processes [ 72 , 73 ]. The role of extracellular matrix in instructing biochemical cascades in cells has become rather evident [ 74 , 75 ]. Also, materials that can closely mimic natural tissue properties and can navigate stem cell fates or exert immunomodulatory features are considered cutting edge [ 71 ]. The progress in developing such next generation biomaterials, that embrace the three-dimensional complexity of regenerating tissues as well as the interplay and optimal integration into the host tissue, can revolutionize biomaterial strategies in the near future.

With the rapid evolution of high-throughput, digital and information technologies, implementing system-oriented approaches to study musculoskeletal tissues, their diseases and repair processes become more and more realistic. In bone, the different cell subpopulations are well characterized. However, in cartilage, tendon, ligament, meniscus, and IVD, very interesting findings indicate an unexpected heterogeneity of cell subpopulations in these tissues (based on single cell RNA sequence data) [ 43 , 48 ]. This may shift our understanding of the pathogenesis based on transition and prevalence of specific cell types during disease processes. Such research may result in defining cell subclasses that could be targeted to ameliorate disease progression versus cell types that can augment regeneration.

Another focus is set on platelets, especially after severe trauma. Platelets are fundamental to primary hemostasis, but become profoundly dysfunctional after polytrauma by unknown mechanisms, contributing to acute coagulopathy, severe bleeding and mortality. Circulating platelets are transformed into procoagulant balloons within minutes after trauma, and can release large numbers of activated microparticles/extracellular vesicles which coat leukocytes [ 76 ]. Furthermore, this study reports that the injury-induced danger molecule release (histone H4) functions as a driver of the procoagulant ballooning and subsequent innate immune response.

Concerning microvesicles (MVs), a recent study suggests that burn injury generates MVs, which allow skin keratinocytes to disperse bioactive substances. Applying diverse pharmacologic and genetic tools indicates that the optimal release of MVs is dependent upon the platelet-activating factor receptor [ 77 ]. Furthermore, MVs seem essential for transportation of metabolically labile bioactive lipids as cargo from cells in response to environmental stress. An important role of MVs concerning the complement C5a–C5aR1 axis was suggested in severely traumatized patients as well. C5a-induced MVs shedding from neutrophils decreased C5aR1 surface expression, while on the other hand profound inflammatory signals were induced, which may represent a key driver of the neutrophil dysfunction post trauma [ 78 ].

Trauma-induced emergency hematopoiesis characterizes the dramatic increase in the hematopoietic demand on the bone marrow to replace effector leukocytes upon their consumption during the inflammatory response to infection or injury. In experimental polytrauma, emergency hematopoiesis is mechanistically driven by the IL-1/MyD88/G-CSF-dependent pathway, resulting in the expansion of hematopoietic as well as myeloid-skewed and multipotent progenitor cells [ 79 ]. Furthermore, the role of specific inflammatory leukocyte subsets is currently ever broadened. In a trauma-induced sepsis model, endogenous intrinsic anti-inflammatory signals seem crucial to modulate the early monocyte/macrophages-driven inflammation by modifying their subset distributions [ 80 ]. In the clinical setting, the immunosuppressive properties of a neutrophil subtype (CD16 high CD62L low ) are gaining attention as causative and surrogate markers for increased susceptibility to infections post trauma [ 81 ].

Chronic inflammation in the elderly (“inflamm-aging”) has been proposed as major contributor to the decline in the regenerative capacity of the skeleton [ 82 ], mainly caused by skeletal stem/progenitor cell (SSPC) dysfunction [ 83 ]. A systemic and local proinflammatory environment was the major contributor of the decline in SSPC number and function resulting in cellular senescence [ 83 ]. Concerning muscle injury and regeneration, a metabolic cross-talk between macrophages and satellite cells has been defined, in which macrophage-derived glutamine preserves the function of satellite cells and thus provide a promising target [ 84 ].

Concerning remote organ injury after severe trauma, development of trauma-induced acute kidney injury (TRAKI) represents a role model for the impact of the immuno-pathophysiological trauma response [ 17 ]. In an ischaemia–reperfusion model of TRAKI single nucleus RNA sequencing of the kidneys allowed the characterization of various cell states during repair from acute injury: in the proximal tubule, a specific proinflammatory and profibrotic cell state was found that fails to repair [ 85 ]. “Full regeneration after amputation” could reflect a myth from Prometheus. However, in the ever exciting adult axolotl limb regeneration model, a novel regeneration-specific mitochondria-related cell cluster was discovered, and musculoskeletal cell populations supporting regeneration by providing energy were defined by modern tools (e.g. large-scale single-cell RNA sequencing and reconstructions of the dynamic single-cell transcriptome) [ 86 ].

Traumatic brain injury (TBI) is the strongest environmental risk factor for the accelerated development of neurodegenerative processes. Computational modelling provided insights into the cognitive decline and the presence of neurofibrillary tangles of the protein tau in the brains upon repetitive TBI [ 87 ]. The impacting high-strain rate deformation alone could induce tau mislocalization to dendritic spines and synaptic deficits in cultured hippocampal neurons which was inhibitable on the signalling level [ 87 ]. Thus, a mechanistic pathway directly relating mechanical deformation of neurons to tau-mediated synaptic impairments and a potential exploitable therapeutic approach to improve repetitive TBI consequences has now been provided [ 87 ]. A recently described molecular memory system (C–C-chemokine receptor type 5 (CCR5) signalling) was tested for its role in recovery after TBI [ 88 ]. Genetic and small molecule-based perturbation of CCR5 promotes functional recovery from TBI with preservation of dendritic spines and new patterns of cortical projections to contralateral pre-motor cortex [ 88 ]. Recently, the anti-inflammatory cytokine interleukin 13 (IL-13) was reported to accelerate functional recovery in murine TBI [ 89 ]. Furthermore, IL-13 reduced neuronal tissue loss, preserved white matter integrity, ameliorated the elevation of proinflammatory factors and reduced the number of proinflammatory microglia/macrophages after TBI [ 89 ]. Thus, IL-13 may present a potential immunotherapy to promote long-term recovery from TBI.

An interesting TBI model for basic science was developed and extensively characterized in Drosophila. Precise compression of the head using a piezoelectric actuator inflicts mild, moderate, or severe brain trauma in this Drosophila TBI model and provides a powerful tool to study the genetic system due to many conserved genes and pathways [ 90 ]. This tunable TBI model recapitulates mammalian injury phenotypes with severity-dependent ataxia, life span reduction, brain degeneration, cognitive decline and transient glial dysfunction. This model showed also stimulation of antioxidant, proteasome, and chaperone activity and thus underscores the ability of the stress response to mitigate TBI-induced brain degeneration [ 90 ].

Evolving the methodology to reach the state-of-the art in orthopaedics and traumatology

The clinical care of orthopaedic and trauma patients in Germany can be classified as being at a state-of-the art level to which basic and applied medical and surgical research has significantly contributed. As mentioned above, a major disease burden in the orthopaedic field comes from OA, an age-related and/or trauma-induced multi-factorial, slowly progressing and primarily non-inflammatory degenerative disorder of the synovial joints culminating in the irreversible destruction of the articular cartilage [ 91 ]. The underlying molecular mechanisms have been addressed by basic research since many years. Breakdown of the collagen fibrillar network is a hallmark of cartilage extracellular matrix (ECM) degradation in OA [ 92 , 93 ]. In this context, characterization of collagen triple helical domain structure, fragments thereof and folding mechanisms and kinetics was a basic research focus four to five decades ago. Commonly applied methods to do so were trypsin and pepsin digestion, SDS-PAGE, spectrophotometric measurements of triple helix formation, optical rotation and circular dichroism of collagen chains [ 94 , 95 ]. Chromatography based on DEAE cellulose and amino acid composition analysis after HCl driven hydrolysis were common methods to characterize the molecular composition of collagen chains [ 96 , 97 ]. This research focus on the molecular structure of collagens was followed by genetic based approaches, e.g. in the 1990s by the use of genetically modified mouse strains. Major methodologies to characterize the function and role of collagens and associated non-collagenous proteins in cartilage matrix integrity and turnover were skeletal staining, (immuno-)histochemical assays, in situ hybridization, TUNEL, SDS-PAGE and western blotting and ultrastructural analysis [ 98 – 100 ]. These methods were completed by northern blotting and RT-PCR-based gene expression analysis, biochemical methods such as application of recombinantly produced ECM proteins, solid phase binding assays, immunoprecipitation, immunoelectron- and immunofluorescence microscopy and 3D chondrocyte cell culture models. In addition, genetically modified mouse models for refined analysis of cartilage ECM proteins were designed [ 101 – 104 ].

Since the last two decades, high-end imaging methodology as atomic force microscopy (AFM), micro computed tomography (µCT) and nanoCT became more and more important for biomechanical and microstructural analysis of cartilage and (subchondral) bone. Indentation-type (IT) AFM is particularly useful to determine elastic properties of the chondrocyte pericellular matrix and cartilage ECM and the most sensitive method for detecting minute changes in cartilage biomechanics [ 105 – 108 ]. µCT application for topographical analysis of pathological structural changes of the osteochondral unit in translational animal models is state of the art [ 11 ]. To observe microstructural changes, i.e. in micro-channels in the subchondral bone zone and in the calcified cartilage zone, nanoCT analysis as high-end imaging modality is the preferred choice [ 107 , 109 ]. In this line, the spatial organization of chondrocytes and its potential role in cartilage functioning and physiology became of special interest as reorganization and destruction of the basic spatial pattern during OA is important for responding to mechanical forces [ 110 ].

Increasing attention received the field of cartilage regeneration by employing chondrocytes, MCSs or recently chondrocyte progenitor cells (CPC), the latter residing in the articular cartilage. Regarding this focus, characterization of chondrogenic phenotype and chondrogenic differentiation capacity of MSCs and CPCs was of crucial importance. Sophisticated 3D cell culture techniques as cell pellet cultures, culture in alginate beads or fibrin/agarose gels were developed and refined together with the optimization of cell culture medium in order to maintain the chondrogenic phenotype and prevent dedifferentiation. One research group focused especially on chondrogenic differentiation of MSC and refinement of appropriate 3D culture systems [ 111 – 114 ]. Early key contributions on 3D culture of chondrocytes in order to prevent dedifferentiation and to keep the chondrogenic phenotype focused on the culture of chondrocytes in agarose [ 115 , 116 ] and alginate beads [ 117 , 118 ]. Identification of CPC (or MPC) in OA cartilage and their isolation, and establishing culture regimens was already described as early as 2004 [ 119 ] followed some years later by more extended work on the regenerative potential of CPCs [ 120 , 121 ].

The genetic manipulation of MSCs became an attractive approach to produce therapeutic platforms for translational settings that aim at restoring articular cartilage defects. For that, gene transfer methods received increasing attention in order to improve the chondrogenic phenotype or proper differentiation of chondrocytes and progenitor cells. It was first reported in 2003 that AAV-based vectors can efficiently transduce and stably express foreign genes in articular chondrocytes, including chondrocytes of normal and osteoarthritic human articular cartilage, and MSC [ 122 ]. Numerous publications followed with ever-increasing refinement of gene delivery to the target cells/tissue [ 123 – 125 ]. Recent work focussed on delivery of therapeutic genes using specific biomaterial composites as scaffold-assisted gene therapy is considered as a highly promising tool to treat articular cartilage lesions upon direct delivery of chondrogenic candidate gene sequences [ 126 , 127 ].

Concerning nationwide (trauma-)surgery-related research, a detailed survey was conducted in 1992 [ 128 ]. It revealed that the basic topics in the past mainly addressed transplantation immunology, implant biocompatibility, regulation of cell growth, control of of bone and cartilage growth, and sources of pain. Since then, a lot has changed and the importance of molecular biology for traumatology has steadily increased [ 129 – 132 ]. So far, main methods in surgical research addressed in principle three classical fields: in vitro, in vivo, and in real life, reflected by modern molecular biology-based methods [ 133 , 134 ], animal experiments [ 135 – 138 ], and clinical studies, respectively [ 139 ]. The methodical spectrum in the field of molecular biology is immense, and novel, highly sophisticated methods are constantly added. Based on their widespread acceptance these serve today as a basic tool-box, including vectors for DNA cloning, restriction endonucleases and DNA hybridization, southern blotting, PCR, DNA sequencing and of course the analysis of highly polymorphic markers. For RNA analysis, Northern blotting, PCR, RT-PCR, qPCR, RT-qPCR, and, since a few years ago the digital droplet PCR (ddPCR) [ 140 ] are applied. Further methods are the transfection of eukaryotic cells, protein analysis, DNA cloning, gene mapping and identification, to name but a few. More complex cell cultures such as organ culture models and organoid models are utilized. New imaging methods like µCT, FIB-ESEM, TEM, CLEM, and live cell imaging also contributed to a better spatial resolution and understanding of posttraumatic degeneration and regeneration processes. With the help of molecular markers and the use of antibodies, e.g. also in GMP quality, it is now possible to mark cells and to trace their path within the body.

Moreover, with the help of numerical simulation tools, the behaviour of implants under different loading scenarios and microenvironments can also be predicted. The simulation includes the Finite Element Method (FEM) as well as multi-body simulations (MBS). While FEM is mainly used for field problems such as stress and strain calculations, implant micromovements as well as biological (re)modelling processes, MBS is used for dynamic problems such as gait analyses, investigation of muscle and joint forces or joint kinematics. Frequently in collaborative efforts with industrial partners, new implants have been developed and their design adapted to the respective clinical requirements [ 141 ]. Furthermore, surgical techniques have improved considerably in recent years [ 142 ]. Perioperative and rehabilitation quality management and evidence-based medicine have also found their way into surgical research [ 143 – 145 ].

New focal points in basic research have been established, e.g. in polytrauma research [ 146 , 147 ], biomechanics on macroscopic [ 148 , 149 ] and microscopic levels [ 150 , 151 ], osteoimmunology [ 16 , 152 ], and soft tissue- and wound healing [ 153 ]. Moreover, disturbance factors such as age [ 154 – 156 ] as well as co-morbidities [ 129 , 157 ] such as diabetes, osteoporosis and obesity have been added to reflect a more realistic picture. Furthermore, promoting minimal invasiveness, recently, probe-based confocal laser-endomicroscopy combined with artificial intelligence (AI)-supported quantitative spatial data has been introduced in a proof-of-principle study as non-destructive optical biopsy to clinically detect early disease detection [ 158 ].

Together, these exemplary points indicate a paradigm shift in orthopaedic and trauma surgery research from pure clinical towards more basic research efforts to generate an improved understanding of the underlying mechanisms in trauma, inflammation, regeneration, degeneration, and repair processes. Based on a better micro- and molecular understanding, new diagnostic and therapeutic approaches will be developed and to be proven clinically.

Why animal research in orthopaedics and traumatology?

In one traditional myth, Prometheus established the form of animal sacrifice practised in the ancient Greek religion. Such a sacrifice had been performed not only as service for a worshipped divinity, but also to accomplish some forseeing, i.e. to identify hidden truth and to predict the future from the appearance of inner organs. Thus, it is tempting to speculate that Prometheus was in some favour for animal research. In contrast, Cassandra could represent a person beset by doubt about the importance of animal research, but unheard by the surrounding people and society.

In translation to current orthopaedic and trauma research, both positions are advocated: pro- and anti-animal research although strict opponents to meaningful animal research remain a minority. However, it is undisputed that, like the German Research Foundation (DFG), orthopaedic and trauma research in Germany is committed to animal welfare and scientific validity and thus pursues the 3R principles [ 159 ]: replacement, reduction and refinement of animal experiments.

The necessity of animal modelling in trauma research is mainly deduced and justified by the complexity of the in vivo response to trauma and investigations on novel therapeutic interventions. In this regard, even the usage of organ-on-the chip technology and comptautional study designs cannot fully model the posttraumatic in vivo situation. Furthermore, the research of trauma-specific management, such as specific operation techniques or early resuscitation strategies and subsequent critical care are so far problematic (or even impossible) to model with the help of in vitro or in silico systems. Nevertheless, in the past, the validity of trauma modelling of clinical reality was questioned, e.g. in regard to genetic responses [ 160 ]. However, the murine models investigated indeed lacked a high simulation quality of the clinical setting. Therefore, multiple efforts have been undertaken to closer simulate the real world in trauma, burn and sepsis research [ 161 ] including international expert consensus initiatives to improve animal modelling [ 162 ] addressing among others the principle of “refinement”. Moreover, the use of a mouse- or pig intensive care unit seems to provide a higher degree of clinical simulation, validity and reliability [ 138 , 163 ]. Furthermore, the better definition of the inflicted injury on well-defined anatomical regions helps to standardize the injury pattern and thus provides a better if not superior comparison with specific human situations [ 164 ]. Another development towards translational validity is the increasing consideration of various co-morbidities and their adequate modelling such as diabetes, osteoporosis, smoking, alcohol, atherosclerosis or chronic obstructive pulmonary disease in the context of trauma [ 165 – 167 ].

In the musculoskeletal system, delicate interactions between molecular, cellular, tissue and biomechanical levels exist that can only be incompletely modelled using for example computer-based systems (in silico) or in in vitro models. The need of animal research in orthopaedics may be exemplary highlighted by the cautionary tale of meniscal lesions and their close relationship to the articular cartilage and subchondral bone. The medial and lateral menisci -crescent shaped wedges of fibrocartilage located between the femoral condyles and the tibial plateau- perform important tasks to transmit loads and stabilize the knee joint [ 168 ]. Some hundred years ago, the menisci were regarded as functionless remnants of intraarticular leg muscles [ 169 ] and, consequently, they have been treated until the second decade of the last century with total meniscectomy. However, orthopaedic surgeons soon realized that such meniscectomized knees rapidly developed OA [ 170 ]. As this phenomenon can precisely be reproduced in both small and large animal models [ 171 ], it could have been foreseen if such studies would have been conducted before excising menisci in patients. Subsequently, techniques of meniscal refixation, repair, transplantation and replacement were evaluated and more and more refined over time with the ultimate goal of OA prevention [ 172 , 173 ]. This narrative is in principle also related to the thalidomide disaster that caused numerous horrific birth defects in the human and that could have been prevented by more extensive preclinical testing in laboratory animals [ 174 ].

Today, the intricate relationship between meniscus, cartilage, bone, cruciate ligaments and others has developed into an entirely new field of research [ 175 ]. Although in vitro models immensely helped to elucidate molecular mechanisms and pathways involved in meniscal pathophysiology, the effect of a loss of meniscal tissue on the adjoining tissues and complex interactions within a biomechanically functional knee joint cannot be recapitulated. It is the testing of such clinically relevant interactions in (large) animal models that can help to elucidate these, often, intricate relationships. As a large animal knee joint is similar to that of humans in terms of joint anatomy, biomechanical function, cartilage and subchondral bone morphology [ 168 ], arthroscopic inspections and even reconstructive surgical interventions such as meniscal repair can be performed. Moreover, the postoperative course may be followed over relatively long periods, thus providing clinically relevant data that can only insufficiently be obtained by, for example, using a three-dimensional bioreactor culture with external forces applied.

In regard to “reduction” of animal experiments, orthopaedic and trauma research in Germany, Europe and worldwide has undertaken multiple efforts. An important step has been the formation of national networks such as the network for trauma research (NTF) or international research groups such as the Translational Large Animal Research Network (TREAT). These collaborative groups design, apply and perform common small and large animal studies and finally share tissues on a multi-organ level for synchronically answering different hypotheses. This results in an enormous reduction in animal numbers as if each hypothesis would have been investigated separately at each institution. For example, one recent pig study run by the TREAT group provided material for more then 10 collaborating research groups [ 176 ]. Similar efforts are undertaken at the trauma department at Aachen University [ 177 , 178 ] or at the trauma collaborative research centre (CRC1149) at Ulm where multiple groups share organs from one mouse experiment. We consider these best practise examples of maximal reduction of animal numbers, performed at expert centres and shared by multiple clinical and basic researchers.

Concerning “replacement”, various ex vivo and in silico studies investigating interacting systems such as whole blood [ 179 ] or fracture healing [ 180 , 181 ] are ongoing innovative developments even for first simulations of therapeutic principles. Furthermore, the publishing culture has changed not only in the field of orthopaedics and trauma research e.g. by following the ARRIVE guidelines and exact reporting of the experimental conditions [ 182 ]. Leading journals in the field endorse the use of the ARRIVE guidelines [ 183 , 184 ]. The basic scientist in the field of orthopaedics and trauma is also encouraged to compare the results from the corresponding animal models with clinical reality to assess to which extend they match, e.g. immune and organ profiling in murine versus clinical polytrauma or to translate important scientific discoveries from the bench-to the operation theatre and back within the complex environment of the musculoskeletal system [ 185 , 186 ]. Of course, in this research, the 3Rs principle must always be taken into account [ 159 ].

Taken together, basic research in orthopaedics and traumatology remains a valuable, important column of clinically meaningful research and is certainly committed to animal welfare and scientific validity.

Future aims of basic science in orthopaedics and traumatology

In the near future, basic science in orthopaedics and traumatology will also be impacted by the revolution of technological improvement in materials and methods, especially due to computer-assisted techniques and a rapidly growing digitalization. On-site 3D printing technologies will be transferred to traumatology for research, education, and generation of individual (personalized) implants [ 187 ]. Due to the great variability of materials for 3D printing, further indication of this technology will be the treatment of bone and soft tissue defects with individually printed scaffolds [ 188 ]. Improvements in molecular imaging will increase the understanding of musculoskeletal pathologies. In the next ten years, artificial intelligence (AI) will be most likely introduced into clinical use in radiology and diagnostic imaging for the detection and classification of fractures and multiply injured patients [ 189 ]. Therefore, large databases for the use of AI have to be assembled and scientifically evaluated as AI will be a key feature in patient care in orthopaedics and traumatology. Trauma and implant registries will profit from digitalization with direct transfer of data leading to a more reliable quality. While established trauma registries lead to an improvement in outcome and quality assurance in major trauma in the last decade (e.g. CT in emergency room [ 190 ], prehospital intubation [ 191 ], prehospital tranexamic acid [ 192 ], future registries will focus on the ageing society (e.g. AltersTraumaRegister DGU) as the orthopaedic trauma surgeon will see less (young) multiply injured cases but an increasing number of geriatric patients. This will also need to be taken into account in in vitro studies [ 192 ]. The understanding and the treatment of sepsis and trauma associated immune-modulation will focus on the ageing patient as well [ 193 ]. As osteoporosis and malignant osteolysis will lead to an increasing number of pathologic fractures, finite element models for fracture prevention have to be introduced and evaluated as the CT-scan will be an increasingly used diagnostic tool for the geriatric patient in the future [ 194 ]. Hot topics of musculoskeletal regeneration will be tissue engineering of soft tissue i.e. muscle, tendon, cartilage and bone and their respective transitions [ 45 , 195 ] with a focus on stem cells and extracellular vesicles [ 196 ] as well as further research on biodegradable implants and their clinical results. Biomechanical research will deal with the modulation of implant-derived debris, improvement of implant design and the application of gait analysis in the prevention of sports injuries.

In contrast to the revolution of new technologies and devices derived from basic science in orthopaedics and traumatology, the evolution in clinical life appears to be at a somewhat slower pace. Some authors claim that there is a stagnation in clinical translation of already known biomaterials, surface modifications and antimicrobial strategies for the control of biomaterial-implant-associated infections that has to be changed [ 197 ]. A challenge of clinical research in traumatology is the large variety of patients (e.g. fracture type, soft tissue damage, infection, age, bone quality, activity level, co-morbidities) with increasing treatment options offered by basic science (e.g. implant design, material, approach, molecular theragnostics) with a limited caseload, even in large centres. Therefore, international, industry-independent randomized-controlled trials have to prove the clinical relevance of new and existing devices and therapies on the market that derived from basic science.

What structures do we need in the future?

Experts, progeny, money, and time—it could be as easy as this. But what are the real challenges and goals of orthopaedic and trauma research in the future?” Tempora mutantur, nos et mutamur in illis ” which means that time is changing and changes us within: on the one hand the population is ageing, osteoporosis persists, fractures are becoming even more fragile; on the other hand, diagnostic means, treatment modalities and implant development are rapidly evolving. Digitalization as well as augmented and virtual reality will more and more become part of clinically relevant research and care. Nonetheless, the future of basic science in orthopaedics and traumatology primarily depends on the fascination of future young scientists and clinicians to join our exciting field. We will need to find the right way to inspire medical and natural science students early on for basic science in musculoskeletal research. Modern and contemporary working conditions will help to keep this research field competitive. We should not make the mistake to rely on past achievements but seek for concepts allowing for more protected research time.

A current barrier is sparse funding opportunities for orthopaedic and trauma research. Local intramural research programmes realized at several universities in Germany provide some benevolent start-up funding for young investigators. However, to date national and international research funding only offer limited opportunities to recruit larger peer-reviewed third-party funds due to a high demand but reduced supply. This gap will increase even more in the near future with EU funds for reseach in times of pandemic challenges considerably cut [ 198 ]. While the recent race for a vaccine during COVID-19 pandemic showed that EU countries are stronger if united than separated, the fact that (at the time of submitting this work) the United States added USD 10 billion since May 2020 to health crisis funding while the EU agreed in summer 2020 on slightly over USD 3 billion puts a spotlight on the importance and socio-economic impact of financial support for science [ 199 ]. The significance of understanding the pathomechanism of degeneration and injury and the need for high-end biomechanical research including modern robotic and simulation solutions must result in manifold funding options. Especially European funding for degenerative musculoskeletal and trauma research is largely missing. Excellent ideas of highly motivated and brilliant young investigators should be supported to boost future careers with lower funding threshold and without the need to prove extended preliminary work. The goal should be an easier entrance to the basic science world. In principle, such a path is proposed for “primary” applications at the German Research Foundation (DFG) but rarely established at other funding organizations.

These, together with fading industrial support, represent the “typical” means of funding that are known and used for decades. In other societal areas, other types of funding exist and are successful. Scientists in orthopaedics and trauma surgery should therefore seek to optimize their funding through these modern and creative funding possibilities. One can think of crowdfunding [ 200 , 201 ] or setting up specific charity funds dedicated to orthopaedic and trauma research. Of course ethical and privacy issues needs to be taken into consideration [ 202 , 203 ]. To enhance the effects of such funding strategies, the scientists should also enhance their exposure and outreach with a special emphasis on societal impact.

Although there will always be outstanding individuals—together we are stronger. Therefore, funding tools should also focus on support of research networks working on overarching questions and out of the box solutions. There must be a stimulus for cooperative research groups ( 18 ) such as the aforementioned initiatives like NTF, TREAT, MR-Net, MSB-Net, etc., rather than sole competition of few groups working in an isolated manner. Such cooperative efforts should be built up not just nationally but also European-wide or even globally.

Thereby, it should be strived for to develop an infrastructure for optimization of well-designed experimental animal studies by communicating planned projects prior to the start and invite external parties to participate. This may result in enhanced handling with the 3Rs and add to the translational value of studies as it may not only inspire groups already involved in basic science but also groups normally focussing on clinical work as well. Finally, also options should be explored to integrate projects with other (related and less-related) fields of research such as immunology, chronic inflammation, (cardio)-vascular research and identify in which trends (such as organoids and AI), the field lies behind.

The representatives of the umbrella organizations such as the SGF, DGOU, DGU, and DGOOC should further strengthen their work hand in hand to bring experts, progeny, money, and time for basic science in orthopaedics and traumatology and thereby in a long term to the patient care.

Orthopaedic and trauma research in Germany, Europe- and world-wide gets a Cassandra-like, disproportional attention of funding in comparison to its relevance, to its importance for the individuum and socio-economic impact of related diseases and traumata (Fig.  2 ). Basic science in these fields addresses the whole conceivable spatio-temporal dimension of a human life with high-end structure–function tools. For the future, further development of networks and collaborative work, facilitated by overarching groups such as the SGF, help the multidisciplinary communities to define the urgent needs and research foci. Exciting new discoveries from the various fields of basic research will be translated from the laboratory to the clinical “real world”. Orthopaedic and trauma research should overcome any remaining boundaries between basic research and clinical reality, innovation and implementations in treatment, open research questions and available funding. The future of basic science in these fields can only be mastered by carefully listening to each other and intensified care for a common language between basic scientists and clinicians for a deeper understanding of the clinical mechanisms and therapeutic opportunities. Prioritized future projects will need to address a broad range of opportunities from AI, nano-technologies to large-scale, multi-centric clinical studies. Furthermore, Prometheus-like novel dissemination strategies to bring the light of basic science not only to the bedside but also into the awareness of society are mandatory. Only then, quality of life of the individual, suffering from orthopaedic diseases or trauma, and the global society will benefit from basic science efforts. Now is the time to act and to provide excellent and visionary programmes that will ensure the bright future of basic science in orthopaedics and traumatology.

Acknowledgements

We acknowledge Ebru Karasu for helping in finalizing the manuscript.

Authors' contributions

HM, MvG and MHL designed the outline and figures. All authors wrote and revised and approved the article. All authors read and approved the final manuscript.

No specific funding support.

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What’s Important: Public Health in Orthopaedic Surgery

Bonsu, Janice M. MD, MPH * ; Feroe, Aliya G. MPH *

1 Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia

2 Harvard Medical School, Harvard School of Public Health, Boston, Massachusetts

a Email for corresponding author: [email protected]

* Janice M. Bonsu, MD, MPH, and Aliya G. Feroe, MPH, contributed equally to this work.

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( https://links.lww.com/JBJS/G696 ).

As a visiting medical student on an orthopaedic rotation, I was asked to deliver a case presentation on any orthopaedic research topic of my choice. Motivated by a preventable readmission on the service that month, I proposed a presentation about the impact of the social determinants of health (e.g., economic stability and health literacy) on surgical outcomes after hip fracture. However, my attending physician advised that I present on “real” studies—not just make a commentary on associations.

This incident played in my mind as I spoke with one of my medical student mentees who was pursuing orthopaedic surgery. She was preparing to start her Master of Public Health studies to sharpen her research tools and methods before applying into orthopaedic surgery. While I fervently believe in the inextricable relationship between orthopaedics and public health, I caught myself almost cautioning her to pick up several “real” clinical projects for the sake of her residency application. It turned out that this advice had already been drilled into her: if the study was not explicitly surgical or technical, orthopaedic surgeons would not be interested. This led to a motivating dialogue between us about the compelling case for public health in orthopaedic surgery.

Nearly 127 million Americans—1 in 2 adults—live with a chronic musculoskeletal condition 1 , making orthopaedic surgery a tremendous tool with which to practice public health. A patient’s surgical outcomes can never be determined in the operating room alone. The vast majority of a patient’s surgical outcomes are determined by the environment in which they live, work, and play after being discharged from the hospital. These social determinants of health are the modifiable factors that ultimately determine a patient’s ability to manage and recover from musculoskeletal injuries 2–4 . The advent of bundled payments for care has further intimated the true importance of the care that must happen outside of the operating room 5 . Bundled payments have emerged as the middle ground between fee-for-service and capitation compensation models. Now, more than ever, surgeons must influence patient care in the perioperative period that impacts recovery and rehabilitation so that patients do not exceed their target price for their episode of care. This is where public health research and theory can make a substantial impact.

Consider the case of a 55-year-old woman 10 days following an uncomplicated total knee arthroplasty who presented to the emergency department with wound dehiscence and purulent drainage. Despite success within the operating room, she was discharged home to a caregiver who actively struggled with drug addiction and she lived in a neighborhood in which she did not feel safe walking—let alone rehabilitating—and that lacked accessible fresh food options. The poor outcomes, which required an irrigation and debridement, a revision arthroplasty, and a gastrocnemius skin flap, could very well have been prevented. A public health-informed discharge plan for this woman would have integrated “risk mapping”—a risk assessment framework that stratifies every patient for possible postoperative complications by individual social determinants of health and addresses these factors accordingly. This is just one way in which surgeons can actively integrate public health principles into their surgical practices.

Such integration is not entirely new to orthopaedic practice. Orthopaedic surgery has risen to the challenge of addressing one of the nation’s largest public health concerns: the opioid epidemic. While walking the tightrope that addresses acute surgical pain, surgeons have had to reckon with the risks of opioid misuse and abuse. In response, orthopaedic surgeons have turned to public health research, innovation, and practice to optimize multimodal pain management strategies, advance perioperative interventions, and develop opioid risk-assessment tools 6–8 . Orthopaedic surgeons have been and continue to be active leaders in curbing the opioid epidemic through recognition of the social and behavioral factors that impact patients and communities—even though they extend far beyond the scope of their individual practices. There are many other issues facing our patients that warrant action as well.

• Health literacy: How often are medical forms difficult to understand?
• Economic stability: Do you have trouble paying medical expenses or utilities?
• Food security: Are you able to access and afford nutritious food every month?
• Social support: Who is one person who could bring you to a doctor’s appointment if you could not drive yourself?
• Housing stability: Are you homeless or at risk of becoming homeless?

The responses to these questions could prompt further discussion by the health-care team to connect the patient with social worker and other relevant resources that will ultimately improve surgical outcomes.

This is by no means a call for every orthopaedic surgeon to pursue rigorous public health studies. Instead, we believe that the integration of basic public health principles into surgical practice should be encouraged and celebrated as we innovate our field and advance surgical care both inside and outside of the operating room. There is an important role for every surgeon in this bold mission.

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