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The use of biomaterials in orthopaedics for joint replacement, fracture healing and bone regeneration is a rapidly expanding field. Infection of these biomaterials is a major healthcare burden, leading to significant morbidity and mortality. Furthermore, the cost to healthcare systems is increasing dramatically. With advances in implant design and production, research has predominately focussed on osseointegration; however, modification of implant material, surface topography and chemistry can also provide antibacterial activity. With the increasing burden of infection, it is vitally important that we consider the bacterial interaction with the biomaterial and the host when designing and manufacturing future implants. During this review, we will elucidate the interaction between patient, biomaterial surface and bacteria. We aim to review current and developing surface modifications with a view towards antibacterial orthopaedic implants for clinical applications.

There is a pressing clinical need to develop cell-based bone therapies due to a lack of viable, autologous bone grafts and a growing demand for bone grafts in musculoskeletal surgery. Such therapies can be tissue engineered and cellular, such as osteoblasts, combined with a material scaffold. Because mesenchymal stem cells (MSCs) are both available and fast growing compared to mature osteoblasts, therapies that utilize these progenitor cells are particularly promising. We have developed a nanovibrational bioreactor that can convert MSCs into bone-forming osteoblasts in two- and three-dimensional, but the mechanisms involved in this osteoinduction process remain unclear. Here, to elucidate this mechanism, we use increasing vibrational amplitude, from 30 nm (N30) to 90 nm (N90) amplitudes at 1000 Hz and assess MSC metabolite, gene, and protein changes. These approaches reveal that dose-dependent changes occur in MSCs’ responses to increased vibrational amplitude, particularly in adhesion and mechanosensitive ion channel expression and that energetic metabolic pathways are activated, leading to low-level reactive oxygen species (ROS) production and to low-level inflammation as well as to ROS- and inflammation-balancing pathways. These events are analogous to those that occur in the natural bone-healing processes. We have also developed a tissue engineered MSC-laden scaffold designed using cells’ mechanical memory, driven by the stronger N90 stimulation. These mechanistic insights and cell-scaffold design are underpinned by a process that is free of inductive chemicals.

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The PL approach provides better access for buttressing the posterolateral tibial plateau fracture than the R-PM approach. With the R-PM approach, the blind area on the lateral plateau which can be accessed only by the PL approach starts approximately at 43.72% and ends at 81.41% of the lateral tibial plateau width. When a fracture is located in this zone, the posterolateral approach is recommended.

When the Hoffa fragment is less than 18.3% of the AP diameter of medial condyle or 10.1% of lateral condyle, the fracture is invisible with the PPA. When the Hoffa fragment is more than 28.7% of the medial condyle or 19.9% of the lateral condyle, the PPA should be selected. If the Hoffa fragment is less than 28.7% of the medial condyle or 19.9% of the lateral condyle, the DMA or PLA with posterior-to-anterior screws is recommended. Combined approaches should be considered in some complex cases with articular comminution.

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