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The role of body mass index in high- and low-velocity trauma causing knee injury associated with popliteal artery lesions

Among arterial traumas, osteoarticular traumas are particularly dangerous, and those involving the popliteal artery are associated with a high amputation rate. Despite representing a minority of arterial traum...

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Comparison of operatively and nonoperatively treated isolated Weber B ankle fractures: a systematic review and meta-analysis

Despite fractures of Isolated Weber B being prevalent, there is a lack of clarity regarding the relative effectiveness of surgical versus conservative treatment. This systematic review and meta-analysis aimed ...

A thorough analysis of data on the correlation between COL9A1 polymorphisms and the susceptibility to congenital talipes equinovarus: a meta-analysis

Congenital talipes equinovarus (CTEV) is a prevalent pediatric deformity with a multifactorial etiology. The objective of this meta-analysis was to explore the association between genetic variations in COL9A1 ...

Can zoledronic acid reduce the risk of cage subsidence after oblique lumbar interbody fusion combined with bilateral pedicle screw fixation in the elderly population? A retrospective study

The objective of this study was to evaluate the potential of zoledronic acid for reducing the incidence of cage subsidence and enhancing interbody fusion rates following oblique lumbar interbody fusion (OLIF) ...

Long non-coding RNA MIAT serves as a biomarker of fragility fracture and promotes fracture healing

Fragility fracture is common in the elderly. Osteoblast differentiation is essential for bone healing and regeneration. Expression pattern of long non-coding RNA MIAT during fracture healing was examined, and ...

Transforaminal posterior lumbar interbody fusion microscopic safe operating area: a three-dimensional model study based on computed tomography imaging

Endoscopic spine lumbar interbody fusion (Endo-LIF) is well-regarded within the academic community. However, it presents challenges such as intraoperative disorientation, high rates of nerve damage, a steep le...

A new technique for low back pain in lumbar disc herniation: percutaneous endoscopic lumbar discectomy combined with sinuvertebral nerve ablation

Percutaneous endoscopic lumbar discectomy (PELD) has demonstrated efficacy in alleviating leg pain among patients with lumbar disc herniation. Nonetheless, residual back pain persists as a troubling issue for ...

Buck technique supplemented by temporary intersegmental pedicle screw fixation to repair lumbar spondylolysis in youth

Lumbar spondylolysis is a bone defect in the pars interarticularis of the lumbar vertebral, which is a common cause of low back pain in youth. Although non-surgical treatment is a mainstream option, surgery is...

A proof-of-concept study of ultrasound-guided continuous parasacral ischial plane block for postoperative pain control in patients undergoing total knee arthroplasty

Continuous peripheral nerve blocks are widely used for anesthesia and postoperative analgesia in lower limb surgeries. The authors aimed to develop a novel continuous sacral plexus block procedure for analgesi...

Intra-articular administration of extra-virgin olive oil in degenerative osteoarthritis

We aimed to analyze the outcomes of intraarticular extra virgin olive oil (EVOO) injection on mechanically induced rabbit knee osteoarthritis (OA) by studying the morphological, histological, and radiological ...

Effects of lower limb length discrepancy on spinopelvic compensation following total hip arthroplasty in patients with developmental dysplasia of the hip

Limited research has examined the impact of lower limb length discrepancy (LLLD) alteration on spinopelvic compensation in individuals with developmental dysplasia of the hip (DDH). This study aimed to investi...

Tuberoplasty reduces resistance force in dynamic shoulder abduction for irreparable rotator cuff tears: a cadaveric biomechanical study

Arthroscopic tuberoplasty is an optional technique for managing irreparable rotator cuff tears. However, there is a lack of studies investigating the resistance force during shoulder abduction in cases of irre...

Vertebral HU value and the pectoral muscle index based on chest CT can be used to opportunistically screen for osteoporosis

Existing studies have shown that computed tomography (CT) attenuation and skeletal muscle tissue are strongly associated with osteoporosis; however, few studies have examined whether vertebral HU values and th...

Correction: Preoperative handgrip strength can predict early postoperative shoulder function in patients undergoing arthroscopic rotator cuf repair

The original article was published in Journal of Orthopaedic Surgery and Research 2024 19 :270

How effective is proximal fibular osteotomy in redistributing joint pressures? Insights from an HTO comparative in-silico study

Knee osteoarthritis (KOA) represents a widespread degenerative condition among adults that significantly affects quality of life. This study aims to elucidate the biomechanical implications of proximal fibular...

Association between the procedure of tibiotalocalcaneal arthrodesis by hindfoot nailing and quality of life in Charcot’s joint

Charcot arthropathy is a progressive disorder of the ankle and foot joints that can lead to foot deformity and instability. Surgical intervention is often necessary for deformity and ulcer management during th...

Acute anterior cruciate ligament rupture: can repair become an alternative to reconstruction: a meta-analysis of randomized controlled trials and cohort studies

To perform a meta-analysis to compare clinical outcomes of anterior cruciate ligament (ACL) repair and ACL reconstruction for acute ACL rupture.

Involvement of RAMP1/p38MAPK signaling pathway in osteoblast differentiation in response to mechanical stimulation: a preliminary study

The present study aimed to investigate the underlying mechanism of mechanical stimulation in regulating osteogenic differentiation.

miR-27b-3p reduces muscle fibrosis during chronic skeletal muscle injury by targeting TGF-βR1/Smad pathway

Fibrosis is a significant pathological feature of chronic skeletal muscle injury, profoundly affecting muscle regeneration. Fibro-adipogenic progenitors (FAPs) have the ability to differentiate into myofibrobl...

Evaluating the risk of return to the operating room across all elective orthopaedic procedures

Although elective procedures have life-changing potential, all surgeries come with an inherent risk of reoperation. There is a gap in knowledge investigating the risk of reoperation across orthopaedics. We aim...

Clinical, functional and radiological outcome after osteosynthesis of ankle fractures using a specific provocation test

Ankle fractures are frequent, and despite numerous publications on their treatment and outcome, there is a lack of precise data on the functional results in young, healthy and physically active patients. We hy...

Unilateral biportal endoscopic versus microscopic transforaminal lumbar interbody fusion for lumbar degenerative disease: a retrospective study

In the past decade, Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with a microscopic tubular technique has become a surgical procedure that reduces surgical-related morbidity, shortens h...

Exercise following joint distraction inhibits muscle wasting and delays the progression of post-traumatic osteoarthritis in rabbits by activating PGC-1α in skeletal muscle

Muscle wasting frequently occurs following joint trauma. Previous research has demonstrated that joint distraction in combination with treadmill exercise (TRE) can mitigate intra-articular inflammation and car...

Deep learning-based automatic measurement system for patellar height: a multicenter retrospective study

The patellar height index is important; however, the measurement procedures are time-consuming and prone to significant variability among and within observers. We developed a deep learning-based automatic meas...

Effect of umbilical cord blood-mononuclear cells on knee osteoarthritis in rabbits

To investigate the effect and underlying mechanism of umbilical cord blood-mononuclear cells (UCB-MNCs) in treating knee osteoarthritis (KOA) in rabbits.

Comparison of the biomechanical properties of grafts in three anterior cruciate ligament reconstruction techniques based on three-dimensional finite element analysis

To evaluate the biomechanical characteristics of grafts from three different anterior cruciate ligament (ACL) reconstructive surgeries and to determine which method is better at restoring knee joint stability.

mTOR mutation disrupts larval zebrafish tail fin regeneration via regulating proliferation of blastema cells and mitochondrial functions

The larval zebrafish tail fin can completely regenerate in 3 days post amputation. mTOR , the main regulator of cell growth and metabolism, plays an essential role in regeneration. Lots of studies have documented ...

Risk factors of chronic postoperative pain after total knee arthroplasty: a systematic review

There is a lack of relevant studies to grade the evidence on the risk factors of chronic pain after total knee arthroplasty (TKA), and only quantitative methods are used for systematic evaluation. The review a...

Surgical approach on combined chronic patellar tendon and bicruciate knee ligament injury

A combined injury of the patellar tendon and both the anterior and posterior cruciate ligaments is disabling. It directly affects knee kinematics and biomechanics, presenting a considerable surgical challenge....

In vivo study of a novel 3D-printed motion-preservation artificial cervical corpectomy construct: short-term imaging and biocompatibility evaluations in a goat model

Nonfusion technologies, such as motion-preservation devices, have begun a new era of treatment options in spine surgery. Motion-preservation approaches mainly include total disc replacement for anterior cervic...

Clinical efficacy and complications of MIS-TLIF and TLIF in the treatment of upper lumbar disc herniation: a comparative study

The optimal treatment modality for upper lumbar disc herniation remains unclear. Herein, we compared the clinical efficacy and application value of minimally invasive transforaminal lumbar interbody fusion (MI...

The outcome of nonoperative treatment for adult humeral shaft fractures using a U-shaped slab in resource-limited settings: a prospective cohort study

Humeral shaft fractures, constituting 3–5% of musculoskeletal injuries, are commonly managed conservatively using functional braces. However, this approach may not be feasible in resource-limited settings. Thi...

Correlation between higher lateral tibial slope and inferior long term subjective outcomes following single bundle anterior cruciate ligament reconstruction

The impact of anatomical factors, such as the lateral tibial slope (LTS), on outcomes following anterior cruciate ligament (ACL) reconstruction is an area of growing interest. This study was led by the observa...

Association between the systemic immune-inflammation index and sarcopenia: a systematic review and meta-analysis

Sarcopenia is associated with increased morbidity and mortality. The systemic immune-inflammation index (SII) has been correlated to a variety of disorders. The present study conducted a systematic review and ...

Early functional improvements using continuous passive motion therapy after angular-stable plate osteosynthesis of proximal humerus fractures – results of a prospective, randomized trial

The use of continuous passive motion therapy (CPM) has led to promising results in the early phase of rehabilitation after surgical treatment of rotator cuff tears and arthrolysis of the elbow. However, its us...

Comparative analysis of arthroscopic technique for anterior talofibular and calcaneofibular ligament reconstruction versus open modified brostrom-gould procedure in chronic lateral ankle instability management

Chronic Lateral Ankle Instability (CLAI) is a common condition treated using either Anterior Talofibular and Calcaneofibular Ligament (ATFL and CFL) reconstruction or Modified Brostrom Procedure (MBP). However...

The influence of operation time for hip hemiarthroplasty on complication rates and mortality in patients with femoral neck fracture: a retrospective data analysis

The aim of the present study was to investigate the influence of various factors, in particular operation time, on mortality and complication rates in patients with femoral neck fractures who have undergone hi...

Vertebral hemangiomas: a review on diagnosis and management

Vertebral hemangiomas (VHs) are the most common benign tumors of the spinal column and are often encountered incidentally during routine spinal imaging.

Local Application of Tanshinone IIA protects mesenchymal stem cells from apoptosis and promotes fracture healing in ovariectomized mice

Elderly patients suffering from osteoporotic fractures are more susceptible to delayed union or nonunion, and their bodies then are in a state of low-grade chronic inflammation with decreased antioxidant capac...

Phillyrin reduces ROS production to alleviate the progression of intervertebral disc degeneration by inhibiting NF-κB pathway

Intervertebral disc degeneration (IDD) is an increasingly important cause of low back pain (LBP) that results in substantial health and economic burdens. Inflammatory pathway activation and the production of r...

Massage for rehabilitation after total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

This study aimed to evaluate the effectiveness of massage for postoperative rehabilitation after total knee arthroplasty (TKA).

Risk factors and prognosis of postoperative acute myocardial infarction in elderly hip fracture patients combined with coronary heart disease

This article mainly studies the risk factors for postoperative acute myocardial infarction (AMI) in elderly hip fracture patients combined with coronary heart disease (CHD), constructs a prediction model, and ...

Bone marrow lesion and 5-year incident joint surgery in patients with knee osteoarthritis: a retrospective cohort study

It is beneficial for society to discover the risk factors associated with surgery and to carry out some early interventions for patients with these risk factors. Few studies specifically explored the relations...

Biofilm on total joint replacement materials can be reduced through electromagnetic induction heating using a portable device

Periprosthetic joint infection is a serious complication following joint replacement. The development of bacterial biofilms bestows antibiotic resistance and restricts treatment via implant retention surgery. ...

Clinical differences between periprosthetic and native distal femur fractures: a comparative observational study

The incidence of periprosthetic distal femur fractures (PDFF) is increasing as the number of total knee replacements becomes more common. This study compared the demographics, fracture characteristics, treatme...

A study on vertebral refracture and scoliosis after percutaneous kyphoplasty in patients with osteoporotic vertebral compression fractures

To analyze the association between scoliosis and vertebral refracture after percutaneous kyphoplasty (PKP) in patients with osteoporotic vertebral compression fractures (OVCFs).

Clinical applications of metagenomic next-generation sequencing in the identification of pathogens in periprosthetic joint infections: a retrospective study

This study aimed to evaluate the application of metagenomic next-generation sequencing (mNGS) technology to identify pathogens in periprosthetic joint infection (PJI).

Association between incorrect postures and curve magnitude of adolescent idiopathic scoliosis in china

Despite advancements in school scoliosis screening (SSS), there are still no effective indicators to estimate the severity of spinal curvature. We aim to investigate the association between incorrect postures ...

Evaluation optimum ratio of synthetic bone graft material and platelet rich fibrin mixture in a metal 3D printed implant to enhance bone regeneration

This study aims to evaluate the optimal ratio of synthetic bone graft (SBG) material and platelet rich fibrin (PRF) mixed in a metal 3D-printed implant to enhance bone regeneration.

Quadrilateral plate classification program of acetabular fractures based on three-column classification: a three-dimensional fracture mapping study

A new classification system for acetabular fractures has been proposed in recent years, which is called the 3-column classification. However, this system does not provide information regarding quadrilateral pl...

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Journal of Orthopaedic Surgery and Research

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Official Journal of the Italian Society of Orthopaedics and Traumatology

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Page 1 of 17

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...

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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 ...

Bernese periacetabular osteotomy (PAO): from its local inception to its worldwide adoption

The development of the Bernese periacetabular osteotomy (PAO) is based on a structured approach starting with an analysis of the preexisting procedures to improve the coverage of the femoral head and was follo...

Correct positioning of the calcar screw leads to superior results in proximal humerus fractures treated with carbon-fibre-reinforced polyetheretherketone plate osteosynthesis with polyaxial locking screws

Plate osteosynthesis with implants made of carbon-fibre-reinforced polyetheretherketone (CFR-PEEK) has recently been introduced for the treatment of fractures of the proximal humerus (PHFs). The advantages of ...

LARAI portal provides a safe method for lateral meniscus repair: three-dimensional computed tomography and cadaveric assessment

Lateral, All-Round and All-Inside (LARAI) portal is a viewing or working portal for observing and repairing the lesions of the lateral meniscus. However, there are safety concerns about popliteal artery (PA) i...

Functional leg performance 2 years after ACL surgery: a comparison between InternalBrace™-augmented repair versus reconstruction versus healthy controls

While clinical and patient-reported outcomes have been investigated in patients after InternalBrace™-augmented anterior cruciate ligament repair (ACL-IB), less is known regarding restoration of functional perf...

Higher pelvic incidence values are a risk factor for trans-iliac trans-sacral screw malposition in sacroiliac complex fracture treatment

Percutaneous iliosacral (IS) screw fixation and trans-iliac trans-sacral (TITS) screw fixation are clinically effective treatments of posterior pelvic sacroiliac fractures. In order to accurately assess the sa...

Efficacy and safety of modular versus monoblock stems in revision total hip arthroplasty: a systematic review and meta-analysis

Both modular and monoblock tapered fluted titanium (TFT) stems are increasingly being used for revision total hip arthroplasty (rTHA). However, the differences between the two designs in clinical outcomes and ...

National spine surgery registries’ characteristics and aims: globally accepted standards have yet to be met. Results of a scoping review and a complementary survey

Surgery involving implantable devices is widely used to solve several health issues. National registries are essential tools for implantable device surveillance and vigilance. In 2017, the European Union encou...

Anterior debridement combined with autogenous iliac bone graft fusion for the treatment of lower cervical tuberculosis: a multicenter retrospective study

This study aimed to analyze the clinical efficacy of one-stage anterior debridement of lower cervical tuberculosis using iliac crest bone graft fusion and internal fixation.

Italian Orthopaedic and Traumatology Society (SIOT) position statement on the non-surgical management of knee osteoarthritis

Knee osteoarthritis (OA) is a chronic disease associated with a severe impact on quality of life. However, unfortunately, there are no evidence-based guidelines for the non-surgical management of this disease....

Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures

There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment.

Intramedullary nailing versus cemented plate for treating metastatic pathological fracture of the proximal humerus: a comparison study and literature review

Pathological fracture of the humerus causes severe pain, limited use of the hand, and decreased quality of life. This study aimed to compare the outcomes of intramedullary nailing and locking plate in treating...

Not all questions are created equal: the weight of the Oxford Knee Scores questions in a multicentric validation study

The Oxford Knee Score (OKS) has been designed for patients with knee osteoarthritis and has a widespread use. It has 12 questions, with each question having the same weight for the overall score. Some authors ...

Are the outcomes of single-stage open reduction and Dega osteotomy the same when treating DDH in patients younger than 8 years old? A prospective cohort study

The primary objective was to report our early results after a one-stage procedure [open reduction (OR), Dega pelvic osteotomy (DPO), and femoral osteotomy (FO) when needed] for surgical management of a cohort ...

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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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Orthopedic Surgery

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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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Insights in Orthopedic Surgery: 2021

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We are now entering the third decade of the 21st Century, and, especially in the last years, the achievements made by scientists have been exceptional, leading to major advancements in the fast-growing field of surgery. Frontiers in Surgery has organized a series of Research Topics to highlight the ...

Keywords : Orthopedic Surgery, Insights, 2021, Advancements in Orthopedic Surgery

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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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There are no competing interests.

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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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2024 Resident Research Day

June 10, 2024 by [email protected]   |   Leave a Comment

The Department of Orthopaedic Surgery will host the 10th Annual Young & Carol Shen Resident Research Day on Friday, June 21st. Please browse below to see what our residents have planned for this year.

Abstracts for each research project are linked below:

Chief Residents:

• Retirement Trends and Plans for Practicing Orthopedic Surgeons in Virginia
• On Field Management of Athletic Cervical Spine Injuries; Equipment Removal and Spine Boarding
• Arthroscopy After Shoulder Arthroplasty Results in Identification of Complications
• Sulcus-Deepening Trochleoplasty and Medial Patellofemoral Ligament Reconstruction Provide Good Clinical Outcomes in Addressing Patellar Instability at Mid-Term Follow-Up
• Correlation between Child Opportunity Index (COI) and Outcomes After Pediatric Anterior   Cruciate Ligament Reconstruction.
• Animal Assisted Interven ti on during Pediatric Outpa tie nt Orthopedic Procedures: A pilot Study.
• Comparison of the Novel Coin Test and the Modified Japanese Orthopaedic Association (mJOA) Score in Assessing Cervical Spondylotic Myelopathy: Preliminary Results.
• Carpal Tunnel Release in the Dialysis-Dependent Popula ti on: Incidence and Outcomes
• Clinical and radiographic outcomes after hindfoot and ankle arthrodesis using cellular bone allograft augmentation
• Long, single screw fixation of the medial malleolus: A novel and successful technique
• Does timing of total elbow arthroplasty after distal humerus fracture affect 2-year complication rates?
• Magnetic Resonance Imaging versus Diagnostic Arthroscopy to Identify Intra-articular Pathology Associated with Patellar Instability: A High Rate of Discordant Findings Altering Surgical Treatment.
• Sarcopenia and Cage Subsidence after Single Level Anterior Cervical Discectomy and Fusion
• Arthroscopy Within 3 Months Prior to Unicompartmental Knee Arthroplasty is Associated with Increased Rate of Prosthetic Joint Infection
• Clinical Effectiveness of Serum D-Dimer in Evaluating Periprosthetic Joint Infections (PJI)
• Timing of Hindfoot Arthrodesis and Early Reoperation Rates for Total Ankle Arthroplasty
• Total Hip Arthroplasty for Osteonecrosis in Patients Under 50 years old is Associated with an Increased risk of post-surgical Complications
• A Matched Cohort Study of Posterior Tibial Slope in Primary Pediatric ACL Reconstruction Compared to Unaffected Peers

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Open Access

Peer-reviewed

Research Article

Orthopaedic and trauma research in Tanzania: A scoping review

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation School of Medicine, University of Limerick, Limerick, Ireland

Roles Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing

Affiliation Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America

Roles Formal analysis, Project administration, Supervision, Validation, Writing – review & editing

Affiliation Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, United States of America

Roles Conceptualization, Methodology, Project administration, Supervision, Validation, Visualization, Writing – review & editing

Affiliations Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America, Department of Orthopaedic Surgery, Philadelphia, Pennsylvania, United States of America

• Benjamin Blackman, 
• Sarah Barnett, 
• Ajay Premkumar, 
• Neil P. Sheth

• Published: June 5, 2024
• https://doi.org/10.1371/journal.pone.0304218
• Reader Comments

Tanzania is disproportionately burdened by musculoskeletal injuries as it faces unique challenges when dealing with trauma care. This scoping review aims to summarize and assess the current state of orthopaedic and trauma research in Tanzania. By identifying key themes, trends, and gaps in the literature, this review seeks to guide future research initiatives catered specifically to the needs of Tanzania’s healthcare system. Utilizing the PRISMA-ScR protocol, OVID Medline, PubMed, and CINAHL databases were searched from inception to June 17, 2023, using keywords such as “Orthopaedics” “Trauma” and “Tanzania”. One hundred and ninety-two eligible studies were included and the Arksey and O’Malley framework for scoping studies was followed. There was a notable growth of relevant publications from 2015 onward, with peaks in growth in the years 2019, 2021, and 2020. The studies employed diverse research methodologies, with cross-sectional (n = 41, 21%) and prospective studies (n = 39, 20%) being the most prevalent, and randomized-controlled trials being the least prevalent methodology, making up eight studies (4.2%). The most common study themes were trauma (n = 101, 52.6%), lower extremity (n = 31, 16%), and spine-related issues (n = 27, 14%). Only three studies looked at work-related injuries (1.6%). Road traffic injuries (RTIs) were the most common mechanism of trauma in 77.0% of the trauma focused studies. Fifty-three percent of the studies were conducted by a majority of Tanzanian authors. This scoping review highlights various trends in orthopaedic and trauma research in Tanzania, with a particular emphasis on road traffic-related injuries. Various gaps are explored, including a lack of research on work-related injuries and a paucity of experimental research. Our findings underline areas where future research is warranted. The future of orthopaedic and trauma care in Tanzania depends on the efforts and collaboration of both local and international stakeholders.

Citation: Blackman B, Barnett S, Premkumar A, Sheth NP (2024) Orthopaedic and trauma research in Tanzania: A scoping review. PLoS ONE 19(6): e0304218. https://doi.org/10.1371/journal.pone.0304218

Editor: Hans-Peter Simmen, University Hospital Zurich, SWITZERLAND

Received: January 11, 2024; Accepted: May 9, 2024; Published: June 5, 2024

Copyright: © 2024 Blackman et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Injuries make up 9% of global deaths, with 90% occurring in low and middle-income countries (LMIC) [ 1 ]. Alongside other developing countries, Tanzania faces unique challenges when dealing with orthopaedic and trauma care [ 2 ].

With a rapidly growing population and increased economic development, orthopaedic injuries continue to rise markedly, mainly due to road traffic injuries (RTI). In a one-day survey conducted in Tanzania, nearly half of all trauma cases were attributed to RTIs [ 3 ]. While the need for orthopaedic care is on the rise, there is a lack of available orthopaedic services and an insufficient number of adequately trained healthcare professionals in the field [ 4 ]. Limited access to surgical equipment and inadequate infrastructure for the volume of required care [ 5 ] renders orthopaedic and trauma management a significant strain on the country of Tanzania.

Multiple reports have highlighted the need for local healthcare research to improve health outcomes in developing countries [ 6 , 7 ]. Furthermore, local research in developing countries has been shown to be of utmost importance in contributing to infrastructural growth [ 8 – 10 ]. In Tanzania, the significance of generating robust local research becomes particularly pronounced due to persistent obstacles in the provision of adequate trauma care [ 11 , 12 ].

By employing a scoping review approach, this study aims to comprehensively survey and synthesize the existing orthopaedic and trauma literature within the context of Tanzania. This methodology facilitates the examination of a wide spectrum of literature by date of publication, research methodologies employed, and overarching themes addressed. This thorough assessment provides a comprehensive summary of the existing literature, as well as a foundational platform for future research endeavors. Moreover, this review seeks to align its findings with the unique requirements of Tanzania’s healthcare system, enhancing its capacity to contribute meaningfully to the advancement of orthopaedic and trauma care in the region.

A scoping review was chosen due to the breadth of the research topic and the expected variation in study design, and was conducted using the Arksey and O’Malley framework [ 13 ].

Identification of the research question

Our research question was, “What is the current state of orthopaedic and trauma literature in Tanzania, and where should future research be directed?”

The preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) protocol was used to present the study methodology and findings ( S1 Checklist ) [ 14 ].

Identification of the relevant studies

The authors executed a search using the following databases: OVID Medline, PubMed, and CINAHL using controlled vocabulary (e.g. MeSH) and keywords representing the topics “Orthopaedics”, “Trauma” and “Tanzania”.

Databases were searched from inception to June 17, 2023. With the goal of capturing the entirety of the relevant existing literature, no limits were applied. Results (n = 1573) were exported to Rayyan citation management system [ 15 ]. A detailed search strategy is available in S1 File .

Study selection

Two co-authors independently screened titles and abstracts of identified papers. After full-text screening by each reviewer, papers were categorized into retrospective cohort, prospective cohort, cross-sectional studies, case studies and reviews, randomized controlled trials, and other research (for e.g., cost analysis, discussion, mixed-method). Full-text extraction was then carried out using a data extraction sheet developed for the purpose of this study. Each author verified that the papers met the inclusion criteria and focused on the topic of interest. Discrepancies in reviewers’ decisions were resolved through discussion.

Inclusion and exclusion criteria

Studies met the inclusion criteria if they met the following criteria: (1) Study focused on orthopaedic conditions or injuries suffered from trauma, and (2) Study reported findings from a Tanzanian population.

Data charting

The same two co-authors independently reviewed each paper, discussed charted data, and updated a password protected Google Sheets [ 16 ] datasheet accordingly. Information extracted from the selected studies was organized and categorized as follows: authors and publication date, study type, study topic, and study context. Studies pertaining to trauma were further categorized by mechanism of injury from RTIs, falls, and violence, where the percentage of patients from each category was documented. Additionally, the country of origin pertaining to authorship was charted.

Collating and summarizing findings

A thematic data synthesis was performed to identify the state of orthopaedic literature in Tanzania. The synthesis includes useful information on past research focus, existing gaps, and suggested future initiatives.

Due to the heterogeneity of study designs and outcomes, a narrative summary of results is presented.

Search results

A preliminary search of scientific databases yielded a total of 1,573 studies. After removing the duplicates (n = 700), titles and abstracts of 873 studies were screened. This process excluded an additional 658 studies, leaving a sample of 215 studies. Screening of full texts yielded a total sample of 192 studies eligible for this review. A complete PRISMA study flow diagram is shown in Fig 1 .

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0304218.g001

Distribution of studies by year

There were no limits placed on the dates of studies included, as this scoping review aimed to capture all the relevant literature on orthopaedics and trauma in Tanzania. As a result, several decades of research were examined, dating back to 1966. Since then, the body of research grew sporadically, with the early 2000s showing a relatively steady increase. From 2015 onwards, there was a significant increase in published studies in this field. The years 2019, 2021, and 2020 marked the peaks in the literature, during which 23, 21, and 20 studies were published, respectively. In 2022, there were 16 studies, and in 2023, there have been 9 studies to date ( Fig 2 ).

https://doi.org/10.1371/journal.pone.0304218.g002

Research methodology

The scoping review examination of orthopaedic research and trauma care in Tanzania yielded diverse research methodologies that represented the multifaceted field of inquiry. The studies were primarily categorized as follows: retrospective cohort studies (14), cross-sectional studies (41), prospective studies (39), case studies (24), retrospective reviews (34), case series (9) and randomized controlled trials (8). Twenty-six studies fell in the category of other research: cost analysis (5), survey (4), qualitative (4), discussion (3), descriptive (3), mixed-method (3), modelling (1). A breakdown of study methodology is shown in Table 1 . This diversity in study methodologies presents opportunities and challenges when reviewing the data to guide future research in Tanzania.

https://doi.org/10.1371/journal.pone.0304218.t001

Thematic analysis

Various themes were identified which highlighted the existing breadth of research in the field and identified areas where research is lacking. There were 101 trauma-specific studies, which included a focus on RTIs, falls, violence, and other trauma. Fifty-six studies focused on fractures. Overall, 31 studies looked specifically at the lower extremity and seven focused on the upper extremity. Twenty-seven studies addressed spine-related issues, and 27 studies examined a pediatric population. Fifteen studies discussed infections, eight discussed genetic conditions, and four discussed cancer. Finally, seven studies addressed health economics, and seven addressed public health. These results are depicted in Table 2 .

https://doi.org/10.1371/journal.pone.0304218.t002

Trauma specific studies

Of the 101 trauma related studies, 61 (60.3%) further explored injury mechanisms in cohorts involving multiple admission causes (RTI, falls, violence, etc.). Of these studies, the most common cause of trauma were RTIs (77.0%), followed by falls (18.0%) and violence (4.92%). Almost 97% of trauma-focused studies included patients injured in RTI, 74.2% included patients injured from falls, and 50% included patients injured because of violence ( Table 3 ).

https://doi.org/10.1371/journal.pone.0304218.t003

Randomized controlled trials analysis

Of the eight studies classified in the category of RCT, there were four unique trials, one of which is in progress. There were five studies that reported results from RCTs [ 17 , 18 , 22 – 24 ], two RCT protocols [ 19 , 20 ], and one pilot study [ 21 ]. Four of the eight studies focused on infection prevention [ 17 – 20 ]. In 1989, Museru, Kumar, and Ickler compared isotonic saline, distilled water, and boiled water in irrigation of open fractures, and found no difference in outcomes [ 17 ]. In 2015, Marwa et al. examined the use of cefepime versus ceftriaxone prophylaxis in elective orthopaedic procedures and found no significant difference [ 18 ]. Two protocols were published with reference to the Go-Tibia trial, which aims to be completed by 2028 [ 19 , 20 ]. This trial is a masked randomized control trial assessing the rate of infection after gentamicin or saline administration in patients with open tibia fractures. The other four included RCTs related to a prospective trial comparing intramedullary nailing versus external fixation in the treatment of open tibial fractures [ 21 – 24 ]. The pilot study was published in 2018 [ 21 ], which was followed by a cost effectiveness analysis in 2019 [ 22 ], which revealed that intramedullary nailing was more cost effective and had better union rates at three months follow-up. The following publication at a one-year follow-up showed no difference in primary events, however found that intramedullary nailing yielded better coronal alignment [ 23 ]. A three to five year follow up of this cohort revealed that 25% of patients suffered chronic fracture-related infection and non-union, regardless of reintervention [ 24 ].

Work related injuries

There were three studies focusing specifically on work-related injuries. In 2010, Kishashu et al. surveyed 1385 patients with injuries from 2007 to 2008 and found that 638 (46%) were work related [ 25 ]. In 2013, Boniface et al. examined 248 miners suffering WRI from 2009 to 2012 and found that 98.7% of workers did not use protective gear and worked over 12 hours daily. Falling rocks were the leading cause of injury, and in total 41.3% of these patients died [ 26 ]. In 2021, Shewiyo et al. performed a retrospective review of 4578 claims to the Workers Compensatory Fund in Tanzania from 2016 to 2019. They concluded that motor accidents, machine faults, and falls were the most common causes of WRI. They also reported the odds of a work-related fatalities increased greater than 6-fold in injuries occurring during conveyance [ 27 ].

Country of origin

Of the 192 studies included, 91% had Tanzanian authors and 53% had a majority of Tanzanian authors. Of the studies with a majority of out-of-county authors, 55% of these studies had a majority of authors from the United States. Further, the USA was the most represented country after Tanzania, with 40% of all included studies including an American author. Africa was the most represented continent (54%), followed by North America (26%) and Europe (10.4%).

This scoping review outlines the evolution of orthopaedic trauma care in Tanzania, as reflected in the distribution of studies spanning several decades. The growth in orthopaedic and trauma research in Tanzania since 1966 is noteworthy as it represents shifts in scientific, societal, and health policy interests. The early years of research were marked by subtle and inconsistent growth, indicating the lower priority of trauma care in Tanzania. This is likely because infectious diseases such as HIV/AIDS, malaria, and tuberculosis had posed a more imminent threat to public health [ 28 ]. In particular, the last decade marked a significant period of growth for orthopaedic and trauma research. This may be attributed to increased awareness and international collaboration among world experts [ 29 , 30 ].

Road traffic injuries

The predominant focus on RTIs among trauma cases reveals the substantial burden created by these injuries. The increased incidence of RTIs is likely a result of the exponential proliferation of roads, which led to underdeveloped and unsafe driving conditions [ 31 , 32 ]. Roughly 10% of the roads in Tanzania are paved [ 33 ]. The increase in RTIs is multi-factorial and has increased due to more motorized vehicle use (e.g., cheaper foreign motorcycles from China and India) in conjunction with a lack of proper infrastructure (e.g., lack of sidewalks, lights on roads, road quality) and inadequate safety measures (e.g., seatbelt and helmet laws, traffic lights, stop signs) [ 34 – 36 ]. In 2011, the World Health Organization (WHO) and the World Bank launched a Decade of Action for Road Safety with the goal of cutting RTIs and deaths in half [ 37 ]. However, minimal progress has been made in LMICs [ 38 ], underscoring the need for further preventative initiatives.

Addressing road safety remains of utmost importance for the Tanzanian population. Ahmed et al. (2013) report that raising awareness of RTIs is integral in low-income countries [ 39 ]. They recommend increasing public awareness, road safety infrastructure, and traffic rules as the most effective means for reducing traffic accidents [ 39 ]. Thus, further research on the outcomes of these initiatives, and the formulation of health policy specific to the Tanzanian population, will be vital in minimizing the burden of RTIs.

In addition to raising awareness, future research should focus on rehabilitation and post-operative management of trauma patients, as this theme was seldom examined in the literature. By optimizing rehabilitation, patients will be better able to return to their livelihood, support their families, and contribute to the country’s economic growth, benefiting all shareholders [ 40 ].

Economic impact of injury

The financial implications of injuries remain a prevalent concern in Tanzania. On average, 52% of a citizen’s total health expenditure is out-of-pocket [ 41 ]. Over a one-month period, 75% of Tanzanians surveyed in the Kilimanjaro Christian Medical Center orthopaedic ward reported that their healthcare expenditure cost more than their monthly income, and roughly 40% of these patients reported losing their job due to their disability after their injury [ 42 ]. With nearly 26 million people in Tanzania living in extreme poverty (below 1.90 U.S. dollars a day) [ 43 ], the cost of health care augments the economic strain on trauma victims.

In addition to improving infrastructure and raising awareness, addressing work-related injuries (WRI) will help alleviate the overall trauma burden. When appropriate measures are put into place, WRIs are often preventable [ 44 ]. Such measures include safe working environments, appropriate protective equipment, appropriate training, and rehabilitation initiatives [ 45 ]. Poor workplace conditions place an economic and health burden on society [ 45 , 46 ]. The International Labour Organization (ILO) estimates that approximately 4% of the world’s gross domestic product is lost due to WRIs, and low-income countries are particularly affected [ 47 , 48 ]. In 2015, it was estimated that, in the Southern Africa region alone, 18,000 workers died from work-related accidents [ 49 ]. In Tanzania, WRI remains an unaddressed epidemic. This scoping review found a scarcity of research specifically related to WRI, with only three studies focusing on this topic. Although many of the trauma studies included patients who were injured at work, there is little research on interventions and initiatives focused on reducing injuries in the workplace.

Sustainability

Under conservative assumptions, over 90% of the Northern Tanzania population cannot access orthopaedic surgical services [ 50 ]. Tanzania has an estimated 118 orthopaedic surgeons for a population of over 60 million [ 51 ], which equates to one orthopaedic surgeon for every 508,000 citizens. In stark contrast, this ratio in America is one orthopaedic surgeon for every 10.8 thousand citizens [ 52 ].

In recent years, there has been increased enthusiasm for medical missions to developing countries as initiatives such as Doctors without Borders continue to expand [ 53 – 55 ]. As international orthopaedic surgeons volunteer in Africa on medical missions, addressing the long-term sequelae of their work is vital. These mission trips often involve completing many surgeries quickly, introducing new equipment and thus, potentially new complications, which further increase the burden on the local healthcare system [ 30 , 56 ]. For a more sustainable future of care, global collaboration is critical to develop adequate infrastructure for continuous orthopaedic management in Tanzania [ 30 , 57 , 58 ].

Future research

Given that developing countries constitute the majority of the global population [ 59 ], conducting research tailored to these populations is imperative. As delineated by the 10/90 phenomenon, only 10% of worldwide resources are devoted to the population which suffers 90% of the burden [ 60 ]. This scoping review found eight studies pertaining to randomized controlled trials, with four being unique trials. This scarcity highlights the need for further research into the population-specific determinants of health in Tanzania. In their systematic review of orthopaedic global outreach efforts, Nolte et al. concluded that orthopaedic outreach initiatives in LMICs are cost-effective and direct funding is needed to ameliorate global orthopaedic health [ 61 ]. Of the ten studies on surgical mission trips to Africa included in their review [ 61 ], none were in Tanzania, further highlighting the need for research in this specific population.

It is well-accepted that randomized clinical trials are the gold standard for assessing causal relationships in research [ 62 ]. However, this research methodology is often expensive and time-consuming [ 63 ]. In developing countries, various barriers exist to conducting high-quality research [ 64 ], such as lack of suitable research infrastructure, deficiency in policymakers understanding of the importance of research, and absence of research materials [ 65 – 67 ]. Historically, research in Tanzania has not been focused on the context-specific structural determinants of health and inequities, which warrants wider implementation of local investigator-initiated trials [ 64 , 67 ]. Further initiatives should focus on interdisciplinary collaboration in creating appropriate research infrastructure to better suit randomized controlled trials. As more experimental research is done in Tanzania, the management of orthopaedic conditions will be better understood to ultimately improve patient outcomes.

Most of the studies included were conducted by Tanzanian authors. Nevertheless, addressing orthopaedic and trauma care in other LMICs remains a global health priority. In LMICs, RTIs remains a significant health burden, due to similar factors discussed in this review [ 1 ]. Longitudinal partnerships and research that reflect the interests and goals of local populations in other LMICs are needed to further explore this topic, and ultimately improve global health outcomes [ 6 – 10 ].

Strengths and limitations

The major strength of this scoping review is its comprehensive overview of the literature. By including studies dating back to 1966, this review encapsulates the wide range of methodologies, focuses, and themes in orthopaedic and trauma research in Tanzania. This breadth of included studies allowed for a thorough review of trends and gaps in the literature, highlighting areas where future research is warranted. The main limitations are the lack of ability to perform a meta-analysis and lack of study quality (risk of bias) assessment.

The escalating orthopaedic and trauma crisis in Tanzania demands immediate attention and international intervention to mitigate the country’s massive health and economic burden. This scoping review offers a comprehensive analysis of orthopaedic and trauma research conducted in Tanzania from 1966 to 2023. Our findings highlight the prevalence of RTIs as a significant cause of injuries, emphasizing the pressing need for more effective interventions and health policies to reduce this burden. The notable scarcity of research on WRIs and randomized controlled trials indicates a significant gap in the existing literature, highlighting the need for high-quality research in these areas in Tanzania. A commitment to implementing sustainable orthopaedic and trauma care should be a local and global priority. This scoping review aims to catalyze further research endeavors and outreach initiatives in Tanzania’s orthopaedic and trauma sectors.

Supporting information

S1 checklist. prisma-scr checklist..

https://doi.org/10.1371/journal.pone.0304218.s001

S1 File. Search strategy.

https://doi.org/10.1371/journal.pone.0304218.s002

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IU School of Medicine names 2024 Showalter Scholars

Jun 07, 2024

The Indiana University School of Medicine has named four outstanding scientists as recipients of the 2024 Showalter Scholars Award.

These research awards, funded by the Ralph W. and Grace M. Showalter Trust and IU School of Medicine, support research that is “most likely to benefit mankind.” The program awards up to $75,000 in funding per scholar over the course of three years and is particularly useful to emergent scientists in advancing their work.

The 2024 Showalter Scholars are:

• Thomas Everett, PhD , associate professor of medicine 
• Troy Markel, MD , associate professor of surgery 
• Roman Natoli, MD, PhD , associate professor of orthopaedic surgery 
• Yong Zang, PhD , associate professor of biostatistics and health data science

Over the last five years, these IU School of Medicine researchers have authored a combined 124 scholarly publications and have brought in about $9.5 million in funding as the principal investigators on their respective research projects — advancing scientific knowledge in cardiac medicine, neonatal surgery, bone healing and clinical trial design.

Thomas Everett: Wearable tech to monitor nerve activity in cardiac patients

Everett’s lab developed SKNA technology, which can non-invasively measure sympathetic nerve activity over long periods of time using signals recorded from ECG electrodes placed on the skin. The technology received an Indiana TechPoint Mira Award for Innovation of the Year in 2017 and has continued to advance through several NIH grants.

“Dr. Everett has fostered extensive collaborations with faculty within the IU School of Medicine, in the Purdue University Department of Biomedical Engineering and at the Cedars-Sinai Medical Center,” noted David Aronoff, MD, chair of the Department of Medicine, and Richard Kovacs, MD, interim chair of the Division of Cardiovascular Medicine, in a joint nomination for Everett.

“His scientific expertise and productivity within the field of cardiac electrophysiology and the autonomic nervous system have resulted in significant contributions to the IU School of Medicine and the research community,” Aronoff and Kovacs wrote.

Among Everett’s many collaborative research projects is an NIH-funded research program involving multiple research centers worldwide evaluating the effect of the nervous system on peripheral organs.

“He is becoming one of the major leaders in the field of cardiac arrhythmia research,” wrote Peng-Sheng Chen, MD, a collaborator from Cedars-Sinai Medical Center, in a letter supporting Everett’s nomination. Chen and Everett have published over 40 peer-reviewed manuscripts together advancing scientific knowledge in the field.

Troy Markel: Helping infants survive intestinal death

Markel recently discovered a beneficial compound in breast milk that is absent in commercial baby formulas, which may help reverse the devastating effects of NEC in preterm infants. He is currently working with formula companies to create a new formulation including this compound for therapeutic use in the NICU.

“It has been very rewarding to follow Troy’s progress in this arena,” wrote Department of Surgery Chair Karl Bilimoria, MD, in his nomination of Markel.

Markel has been extensively published in scientific journals and sits on the Scientific Advisory Board for the NEC Society, a nonprofit started by two mothers who lost their infants to NEC and for which Markel has planned several annual symposiums.

Markel has mentored 12 medical students and 18 post-doctoral fellows and has trained 13 pediatric surgery fellows during his time at IU. He also serves on multiple local and national committees and collaborates with NEC researchers from institutions throughout the nation.

“I have had the pleasure of following Troy’s work over the last two decades,” said David Hackam, MD, PhD, a research collaborator from Johns Hopkins University School of Medicine, who wrote a letter supporting Markel’s nomination. “Troy is a wonderful example of how a great person can be a great surgeon and a great scientist.”

Roman Natoli: Fracture healing and infection prevention after traumatic injury

“We are very lucky to have Roman Natoli as he is truly a ‘star among the night sky of orthopaedic surgeons,’” wrote Lynda Bonewald, PhD, the musculoskeletal center’s founding director, in a letter supporting Natoli’s nomination.

After being recruited to IU in 2016 as an orthopaedic trauma surgeon, Natoli “quickly emerged as one of the most productive academic junior surgical faculty in the history of our department,” said Orthopaedic Surgery Chair L. Daniel Wurtz, MD, in his nomination letter. “Dr. Natoli has proven to be a highly productive orthopaedic traumatologist with a growing national reputation.”

Natoli’s research focuses on post-traumatic arthritis, fracture-related infection, fracture healing and chronic pain after fracture. He is the principal investigator on numerous studies, including international, multi-institutional clinical trials, and he has published over 80 peer-reviewed papers in top scientific journals. 

Several colleagues from outside of IU testified to Natoli’s impact on the field. Jaimo Ahn, MD, PhD, a research collaborator from the University of Michigan, called Natoli “a rare surgeon-scholar-educator with notable, overwhelming strengths.”

“He has demonstrated he can affect the world of our patients and learners through his research, and with IU’s ongoing support, he will continue to contribute at the highest of levels,” Ahn wrote. “I have no doubt he will make fracture care, orthopaedics and medicine better for the future.”

Yong Zang: Developing statistical methods for better clinical trials

Zang is an associate professor and a member of the Center for Computational Biology and Bioinformatics  at the IU School of Medicine, as well as co-director of the Biostatistics and Data Management Core with the IU Melvin and Bren Simon Comprehensive Cancer Center .

“As an expert in clinical trial design, Yong’s expertise is highly sought after,” said Kun Huang, PhD, chair of the Department of Biostatistics and Health Data Science , in his nomination of Zang. “He has extensively collaborated with clinicians and biostatisticians both within and outside IU.” 

Zang is an accomplished researcher, teacher and mentor who has helped produce 74 scholarly works published in scientific journals including Biometrics, Statistical Methods in Medical Research, and Statistics in Medicine. As an internationally recognized leader in the field of biostatistics, Zang has developed strong collaborations with researchers at MD Anderson Cancer Center, Tulane University, The Ohio State University and other institutions.

Zang’s research focuses on development of theory, algorithms and software for adaptive clinical trial design, “a cornerstone in advancing medical research and patient care,” said Yunlong Liu, PhD, director of the Center for Computational Biology and Bioinformatics.

“I have had the privilege to witness firsthand his remarkable contributions to the field of biostatistics, particularly in the design of innovative clinical trial methodologies,” Liu wrote in a letter supporting Zang’s nomination. “His work is not only innovative but also critical to the continuous improvement of clinical trial efficiency and effectiveness.”

2023 Showalter Scholars advancing research

The following IU School of Medicine faculty were named Showalter Scholars in 2023 and are continuing their grant-funded research with supporting departmental awards in 2024:

• Ashay Bhatwadekar, PhD , associate professor of ophthalmology; new treatments for diabetic retinopathy 
• Takashi Hato, MD , associate professor of medicine; targeted therapies for sepsis-induced organ failure 
• Emily Sims, MD , associate professor of pediatrics; slowing the progression of diabetes 
• Jun Wan, PhD , associate professor of medical and molecular genetics; bioinformatics and computational systems biology

Additionally, Martin Plawecki, MD, PhD , associate professor of psychiatry, was named an IU School of Medicine Scholar in 2023 with equivalent grant funding from the Office of the Executive Associate Dean for Research Affairs. Plawecki is a researcher with the school’s Indiana Alcohol Research Center.

Suggested for you

Meet the anti-abortion group using white coats and research to advance its cause

On a winter day less than two years after the fall of Roe v. Wade, Dr. Ingrid Skop beamed at a crowd of anti-abortion activists gathered at the Texas Capitol.

“The sun is shining on us. I think someone is happy with what we’re doing,” said Skop, a longtime OB-GYN, clad in a white doctor's coat.

Her smile dropped as she launched into a speech attacking the Food and Drug Administration’s regulation of mifepristone for medication abortions. “One out of 20 women ends up needing emergency surgery with these dangerous pills,” she said.

The statistic isn’t far off, but the procedure that Skop warned of is a vacuum aspiration to clear the uterus, considered routine in miscarriage care and low-risk .

Skop’s warnings about abortion extend far beyond this rally. She is the vice president and director of medical affairs of the Charlotte Lozier Institute, established in 2011 as the research arm of Susan B. Anthony Pro-Life America, a nonprofit group that works to elect anti-abortion candidates. 

In a movement where many adherents are guided by religious or ideological beliefs, the institute has tried to win on secular grounds by offering research and studies aimed at countering the well-established scientific consensus that abortion care is safe.

Since Roe v. Wade was overturned in 2022, the institute has gained visibility and notoriety as it has worked to justify abortion bans the majority of Americans don’t support . Two studies led by its vice president, James Studnicki, were cited in a federal ruling challenging the approval of mifepristone. Skop is part of a group that brought the original suit. The Supreme Court is expected to rule on a narrower version of the case this month. 

But the institute has also taken heat. The two studies were later retracted — unfairly, the authors argued — by the journal that published them.

In May, Skop's appointment to the Texas maternal mortality review committee drew the ire of maternal health advocates and abortion rights supporters who see her positions as ideological and in conflict with the committee’s mission to improve maternal health.

The institute is often described as the anti-abortion movement’s answer to the Guttmacher Institute, a research and policy group that supports abortion rights. Skop and her peers have provided conservative officials with their own bench of experts.

“Abortion activists dominate the scientific community,” Skop told NBC News by email. “CLI research is one of the only voices to counter the biased, abortion-affirming research.”

Over the past decade, the institute’s studies, including ones assailing abortion medication and promoting crisis pregnancy centers that counsel women against abortion, have been cited by politicians and judges alike .

Mary Ziegler, a historian and expert on abortion law, said the group’s work may help give legislators “political cover.”

“The scientific arguments that CLI is making," she said, "are just one more arrow in the quiver of legislators who already think abortion is contrary to God’s law."

Named for one of the first female physicians in the U.S., the Charlotte Lozier Institute was launched in a different era for abortion rights. Roe v. Wade was still the law of the land, and Susan B. Anthony Pro-Life America was working to elect candidates who would make it harder to access abortions.

The institute’s job, under the guidance of its founder and first president, Chuck Donovan, a veteran of the anti-abortion movement, was to provide data to help them. In a 2018 promotional video , a series of state lawmakers praised the group as a source of “facts” and “credibility.”

Kristi Hamrick, a spokesperson for Students for Life of America, said the institute plays a “very important role” by providing “an alternative scientific voice that looks at data” that groups like hers can use in their campaigns.

The institute’s influence extends to state legislatures, where its team testified in favor of bills that would prohibit most abortions after 20 weeks, and require that patients be told about a process called “abortion reversal,” a disputed treatment that abortion opponents claim can undo a medication abortion. 

Skop and others on the institute’s roster of staff and representatives are open about their religious beliefs . On a recent episode of a podcast affiliated with the American Family Association, a right-wing Christian activist group, she launched into a fierce critique of other abortion research.

“The abortion industry drives the narrative. They publish poor-quality studies. The mainstream media, of course, promotes abortion and picks it up,” she said. “So the American people have been gaslighted.”

In an interview, Rachel Jones, a principal research scientist with the Guttmacher Institute, said its work holds up under scrutiny. “We’ve been doing research for over 50 years on abortion, and we haven’t had any studies retracted,” Jones said, noting that the group is transparent about its data and its shortcomings. “Our track record speaks for itself.”

As patients with pregnancy complications in restrictive states like Texas go public with experiences of being denied treatment, the Charlotte Lozier Institute, like many anti-abortion groups, has argued that these have resulted from a misreading of the laws, rather than the bans themselves.

“Rather than blame pro-life laws when confused physicians have withheld emergency medical care, a result of abortion advocates’ fear mongering, state medical boards must provide guidance to clarify confusion, but many have not done so,” Skop said in a statement to NBC News.

But doctors have said the bans — which call for stripping medical licenses, and imposing fines or criminal charges on violators — create a chilling effect , and the institute itself cites guidance that discourages abortions as an emergency intervention.

When it’s necessary to perform what Skop calls a “separation of the mother and her unborn child” in the second trimester, she has cited the American Association of Pro-Life Obstetricians and Gynecologists , of which she is a member, in arguing that doctors should perform cesarean sections or induce labor, rather than an abortion procedure commonly called dilation and evacuation (D&E). More OBGYNs have the skills to perform C-sections and induction, Skop has noted , and in some cases they could preserve a chance of saving the fetus’ life.

Dr. Ghazaleh Moayedi, an OB-GYN who practices in Texas, serves as the board chair for Physicians for Reproductive Health, which supports abortion rights. She sees recommendations like these as an attempt to limit doctors’ ability to provide necessary care. In many cases, she added, it’s clear that a fetus won’t survive, and to imply otherwise is misleading.

“They view it as more dignified in some way for the fetus,” she said of the institute’s stance that doctors should avoid D&E’s. “What’s left unsaid in that statement is that it’s at the expense of any dignity, humanity or care for pregnant people themselves.”

Skop pushed back on the assertion that some patients might prefer a D&E to induction in these cases, referring to it by a term commonly used by abortion opponents.

“When experiencing a tragic loss, I have never had a pregnant mother prefer a dismemberment abortion over induction because mothers want to hold and bury their babies, which assists in their grief,” she wrote.

In March, the institute named a new leader, Karen Czarnecki, who previously worked for the American Legislative Exchange Council and Heritage Foundation.

It continues to rely on private funding. In recent years, its donors have included the Alliance Defending Freedom, which brought the mifepristone case; The 85 Fund, a group tied to the conservative judicial activist Leonard Leo; and the Knights of Columbus, a Catholic fraternal order.

In a recent video appearance , Studnicki, highlighted the institute’s recent wins. “If you look at our record in the last three or four years, we’ve been very, very successful,” he said.

But it also suffered a major blow this February when the medical publisher Sage retracted three studies on which Studnicki was a lead author. In a blog post, Sage said it flagged problems including conflicts of interest, “misleading presentations of data,” and “fundamental problems with the study design and methodology.”

One of the studies, published in 2021, made an alarming claim: that hospital visits had skyrocketed between 2002 and 2015 among Medicaid patients who had medication abortions. 

Ushma Upadhyay, who researches medication abortion at the University of California, San Francisco, published a paper that reviewed the study. She said the institute conflated visits to the ER within 30 days of an abortion with “adverse events.” But patients may go to the ER just to get reassurance that the procedure has gone smoothly, Upadhyay said.

Her research has shown that more than half of these visits don’t result in treatment. Lozier's study, she said, didn’t address whether patients were admitted or received treatments, which would present a fuller picture of what, if any, complications occurred.

In response to that critique, Skop said ER visits, even without treatment, showed that patients “don’t know what to expect because they are not receiving adequate informed consent.”

She called the retractions “meritless,” contending that the group’s anti-abortion stance has led to “unprovoked and partisan attacks.”

The Supreme Court will soon rule on mifepristone. It opted not to hear arguments challenging the FDA’s initial approval of the drug, but will consider whether to restrict its availability. The changes proposed would require patients to visit a doctor in person to get the medication, as was the case before the Covid pandemic, and mandate that the pills only be used up to seven weeks in a pregnancy, rather than 10.

The retractions so far don’t seem to have damaged the institute’s standing in the anti-abortion movement. 

“These findings have been used in legal action in many of the states,” Studnicki recently said in a video response to the retractions. “We have become visible. People are quoting us. And for that reason, we are dangerous.”

Bracey Harris is a national reporter for NBC News, based in Jackson, Mississippi. 

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• Gun Violence Widely Viewed as a Major – and Growing – National Problem

U.S. public evenly split on whether gun ownership does more to increase or decrease safety

Table of contents.

• Majority of Americans say gun laws should be stricter
• Views of gun policies among gun owners, non-owners
• Acknowledgments
• Methodology

Pew Research Center conducted this study to better understand Americans’ views of gun policy. For this analysis, we surveyed 5,115 adults from June 5-11, 2023. Everyone who took part in this survey is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

Here are the questions used for the report and its methodology .

With total gun-related deaths reaching new highs in recent years, growing shares of Americans view both gun violence and violent crime as very big national problems.

Looking ahead, twice as many Americans expect the level of gun violence to increase rather than stay about the same over the next five years (62% vs. 31%). Just 7% say it will decrease.

The question of whether gun ownership does more to increase or decrease safety evenly divides Americans: 49% say it increases safety by allowing law-abiding citizens to protect themselves; an identical share says it reduces safety by giving too many people access to firearms and increasing misuse.

The new survey, conducted June 5-11, 2023, among 5,115 members of Pew Research Center’s nationally representative American Trends Panel, also finds:

• A majority of Americans (58%) say gun laws in the country should be stricter; 26% say they are about right, while just 15% say they should be less strict. Support for stricter gun laws has ticked up since 2021 and is at about the same level as in 2019.
• Large majorities favor preventing mentally ill people from buying guns (88%) and increasing the minimum age for buying guns to 21 years old (79%).
• Other gun policy proposals, including banning high-capacity magazines (66%) and banning assault-style weapons (64%), continue to draw majority support.

Large divides by party, community type in views of impact of gun ownership on safety

Gun policy continues to be one of the most polarizing issues in American politics. Republicans and Democrats are sharply divided over the impact of gun ownership on public safety: 79% of Republicans and independents who lean toward the Republican Party say that gun ownership increases safety, while a nearly identical share of Democrats and Democratic leaners (78%) say it decreases safety.

Views of gun ownership are also closely tied to where one lives, with those who say they live in rural areas about twice as likely as those who live in urban areas to say that gun ownership increases safety (65% vs. 34%). And those who personally own guns are nearly twice as likely as non-owners to say this (71% vs. 37%).

Overall, 32% of Americans report owning a gun.

Gun violence and violent crime increasingly viewed as major problems

While there are wide partisan gaps in views of the impact of gun ownership and in views of many gun policies, Republicans and Democrats also differ over whether gun violence is a major problem for the country. About twice as many Democrats as Republicans say it is “a very big” national problem (81% vs. 38%).

Over the past year, however, there have been 11 percentage point increases in the shares of both parties saying it is a very big problem.

Views of whether violent crime is a major problem have tended to be less partisan. And growing shares in both parties also view crime as a very big problem.

Since last year, the share of Republicans who say violent crime is a major problem has slightly increased from 60% to 64%. There has been a comparable shift among Democrats, from 47% to 52%.

Both violent crime and gun violence rank high on the public’s list of top national problems. Refer to our recent report for more.

CORRECTION (June 28, 2023): In the chart “Growing shares of Americans say gun violence, violent crime are ‘very big’ national problems,” a previous version of the chart omitted a July 2021 data point of the shares saying violent crime was a very big problem for the country. The chart has now been updated to include the following: 61% of Americans (including 67% of Republicans and 55% of Democrats) said violent crime was a very big problem for the country in July 2021.

The following sentence was also updated to reflect the above additions: “Since last year, the share of Republicans who say violent crime is a major problem has slightly increased from 60% to 64%. There has been a comparable shift among Democrats, from 47% to 52%.”

Views of gun policies

There continues to be wide public support for various specific gun policy proposals. For example, 88% of Americans favor preventing people with mental illnesses from purchasing guns, including 72% who strongly favor this.

This is the only policy proposal among eight asked about in the survey which draws overwhelming bipartisan support (89% of Democrats, 88% of Republicans).

While opinions about most gun policies have not changed much in recent years, an increasing share of the public favors allowing teachers and school officials to arm themselves.

Half of adults now favor allowing teachers and other school officials to carry guns in K-12 schools, up from 43% two years ago.

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ABOUT PEW RESEARCH CENTER  Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of  The Pew Charitable Trusts .

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