Orthopaedic surgeons are at high risk for experiencing work-related musculoskeletal (MSK) injuries and chronic pain due to repetitive large magnitude forces, altered posture from lead vests, and prolonged irregular body positions. We sought to synthesize available evidence regarding (1) the biomechanics of orthopaedic surgery and (2) MSK injuries sustained by orthopaedic surgeons with subsequent treatment and consequences. To conduct this systematic review, we queried 4 databases (PubMed, Embase, MEDLINE, and Web of Science) for original research studies presenting on the biomechanics of orthopaedic surgery or MSK injuries sustained by orthopaedic surgeons. Studies were excluded if they were not original research (i.e., reviews) or reported on non-MSK injuries and injuries in patients or nonorthopaedic specialists. The literature search yielded 3,202 publications, 34 of which were included in the final analysis. Eight studies reported on the biomechanics of orthopaedic surgery. Surgeons spent an average 41.6% of operating time slouched. Head and whole spine angles were closest to natural standing position when using a microscope for visualization and with higher surgical field heights. Use of lead aprons resulted in a shifted weight distribution on the forefoot, gain in thoracic kyphosis, and increase in lateral deviation from postural loading. Twenty-six studies reported on MSK symptoms and injuries experienced by orthopaedic surgeons, with an overall prevalence from 44% to 97%. The most common body regions involved were lower back (15.2%-89.5%), hip/thigh (5.0%-86.6%), neck (2.4%-74%), hand/wrist (10.5%-54%), shoulder (7.1%-48.5%), elbow (3.1%-28.3%), knee/lower leg (7.9%-27.4%), and foot/ankle (7%-25.7%). Of surgeons with any reported MSK symptom or injury, 27% to 65.7% required nonoperative treatment, 3.2% to 34.3% surgery, and 4.5% to 31% time off work. Up to 59.3% of surgeons reported that their injuries would negatively influence their ability to perform surgical procedures in the future. The orthopaedic surgeon population experiences a high prevalence of MSK symptoms and injuries, likely secondary to the biomechanical burdens of tasks required of them during strenuous operations. Level III. See Instructions for Authors for a complete description of levels of evidence.

Certain anatomic factors, such as patella alta, increased tibial tubercle-trochlear groove distance, rotational deformity, and trochlear dysplasia, are associated with an increased risk of recurrent patellar instability. The presence of a preoperative J-sign is predictive of recurrent instability after operative management. Isolated medial patellofemoral ligament reconstruction may be considered on an individualized basis, considering whether the patient has anatomic abnormalities such as valgus malalignment, trochlear dysplasia, or patella alta in addition to the patient activity level. More complex operative management (bony or cartilaginous procedures) should be considered in patients with recurrent instability, malalignment, and certain anatomic factors.

Femoral stem cementation has undergone considerable investigation since bone cement was first used in arthroplasty, leading to the evolution of modern femoral stem cementation techniques. Although there is a worldwide trend toward the use of cementless components, cemented femoral stems have shown superiority in some studies and have clear indications in specific populations. There is a large evidence base regarding cement properties, preparation, and application techniques that underlie current beliefs and practice, but considerable controversy still exists. Although the cementing process adds technical complexity to total hip arthroplasty, growing evidence supports its use in certain cohorts. As such, it is critical that orthopaedic surgeons and investigators have a thorough understanding of the fundamentals and evidence underlying modern cementation techniques.

Periprosthetic joint infection (PJI) following hip hemiarthroplasty (HA) is a devastating complication, incurring immense health-care costs associated with its treatment and placing considerable burden on patients and their families. These patients often require multiple surgical procedures, extended hospitalization, and prolonged antimicrobial therapy. Notable risk factors include older age, higher American Society of Anesthesiologists (ASA) score, inadequate antibiotic prophylaxis, non-antibiotic-loaded cementation of the femoral implant, longer duration of the surgical procedure, and postoperative drainage and hematoma. Although the most frequent infecting organisms are gram-positive cocci such as Staphylococcus aureus, there is a higher proportion of patients with gram-negative and polymicrobial infections after hip HA compared with patients who underwent total hip arthroplasty. Several surgical strategies exist. Regardless of the preferred surgical treatment, successful management of these infections requires a comprehensive surgical debridement focused on eradicating the biofilm followed by appropriate antibiotic therapy. A multidisciplinary approach led by surgeons familiar with PJI treatment and infectious disease specialists is recommended for all cases of PJI after hip HA to increase the likelihood of treatment success.

Approximately 25% of all patients who sustain perilunate dislocations present in a delayed fashion. While management of acute injuries is relatively well-described, treatment of chronic injuries can be complex and there is a paucity of scientific evidence to guide management. Treatment options include open reduction internal fixation, proximal row carpectomy, scaphoid or lunate excision with or without arthrodesis, and total wrist arthrodesis, although indications vary based on chronicity of injury and patient factors. The purpose of this article was to determine the quality of evidence supporting surgical options for the treatment of these injuries.

Periprosthetic acetabular fractures are uncommon and infrequently the focus of studies. Acetabular fractures are occasionally recognized postoperatively when patients report unremitting groin pain weeks after surgery. The widespread use of cementless acetabular cups might lead to a higher number of fractures than are clinically detectable. Appropriate recognition, including mindfulness of preoperative patient and surgical risk factors, is critical to the successful management of acetabular complications.

The majority of proximal humeral fractures (PHFs) in patients who are ≥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population. Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are ≥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence. RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve. RTSA for an acute PHF is indicated in patients who are ≥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures. RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.

Everyone appreciates a good review article. When comprehensive, well researched, well organized, and well written, a review article can be an essential part of every reader’s portfolio of knowledge. However, while the narrative or systematic format of most review articles may meet these qualifications, there are often missed opportunities for readers to derive the maximum benefit from these methods of communication. This is why JBJS Reviews provides 2 types of articles that take information in the literature to the next level of value: the Critical Analysis Review and the Team Approach article. Critical Analysis Review articles communicate clinical care recommendations that are derived from a complete evaluation of appropriate literature and are made explicit in a standard format known as a Recommendations for Care Table1. The added value of this information, which can pertain to treatment, diagnosis, or prognosis, is supported by the JBJS Levels of Evidence. As a result, the reader learns not only what information is current but also how reliable the information is and thus how dependable it may be for guiding clinical care. Team Approach articles focus on the multidisciplinary nature of musculoskeletal care by creating a clinical scenario and reviewing the potential input and involvement of key medical professionals in a co-management format2. A treatment recommendation from each specialist is presented in a logical sequence that reflects both the continuity of care and the collaborative approach. Although the Editor and the Board of Associate Editors are charged with making recommendations for invited articles, manuscripts submitted to JBJS Reviews need not always be invited. In fact, the majority of articles published to date have not been invited, which we view as a desirable trend. However, while the most outstanding narrative and Systematic Review articles will continue to be accepted, Critical Analysis Review and Team Approach articles will be preferred.

Telemedicine has become an emerging necessity in the practice of orthopaedic surgery following the paradigm shift that was brought on by the COVID-19 pandemic. Physical examination is an integral component of orthopaedic care and plays a crucial role in diagnosis. Based on our experience and expert opinion in the literature, we recommend the following infrastructure for a virtual orthopaedic physical examination: a computing device with a functioning camera and high-definition input/output audio, a 720p (high-definition) display, a processing speed of 3.4 GHz, an internet connection speed range from 1 to 25 Mbps, adequate lighting, a steady camera that is positioned 3 to 6 ft (0.9 to 1.8 m) from the patient, a quiet environment for the examination, and clothing that exposes the area to be examined. When performing a virtual examination of the lower extremity, inspection, range of motion, and gait analysis can be easily translated by verbally instructing the patient to position his or her body or perform the relevant motion. Self-palpation accompanied by visual observation can be used to assess points of tenderness. Strength testing can be performed against gravity or by using household objects with known weights. Many special tests (e.g., the Thessaly test with knee flexion at 20° for meniscal tears) can also be translated to a virtual setting by verbally guiding patients through relevant positioning and motions. Postoperative wound assessment can be performed in the virtual setting by instructing the patient to place a ruler next to the wound for measuring the dimensions and using white gauze for color control. The wound can be visually assessed when the patient's camera or smartphone is positioned 6 to 18 in (15 to 46 cm) away and is held at a 45° angle to the incision.