Whats New in Orthopaedic Trauma

Teague, David C. MD; Ertl, William J. MD; Hickerson, Lindsay MD; Roberts, Zachary MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.16.00378
Specialty Update
Author Information

1Department of Orthopedic Surgery, University of Oklahoma Health Sciences Center, College of Medicine, Oklahoma City, Oklahoma

E-mail address for D.C. Teague: david-teague@oushc.edu

Article Outline

The following update provides a summary of selected studies related to orthopaedic trauma that were published mainly in 2015. Methods (→), results (✧), and take-home points () are presented in an abridged fashion.

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→ In a retrospective, single-center study that included 235 consecutive patients over a 9-year period who were treated with primary plate fixation (superior placement only) for a substantially displaced midshaft clavicular fracture with shortening and/or deformity, the authors evaluated 20 potential risk factors for reoperation related to implant removal or nonunion, infection, or fixation failure1.

✧ Among the 65% of patients who had 2-year follow-up, 38% (58) underwent reoperation.

Intraoperative plate contouring and a patient height of <175 cm enhanced the risk of hardware removal (n = 42). Reoperation for nonunion, infection, or fixation failure (n = 16) was associated with illicit drug use, diabetes, and previous shoulder surgery. Multiple reoperations (n = 8) were related to an age of >55 years and alcohol use (>15 drinks per week); the presence of both factors led to a 78% reoperation risk.

→ In a prospective study, 76 consecutive Workers’ Compensation patients with displaced middle-third clavicular fractures were randomized to conservative treatment (n = 42) or surgical anatomic plate fixation (n = 34)2.

✧ Computed tomography (CT) scans at 6 and 12 weeks revealed advanced healing in the surgical treatment group: 24.1% at 6 weeks and 81% at 12 weeks versus 5.3% and 16.7%, respectively, in the conservative treatment group. The time from discharge to the return to full occupational duties was 3.7 ± 1.1 months in the conservative treatment group and 2.9 ± 0.8 months in the surgical treatment group. Four patients in the conservative treatment group experienced nonunion requiring surgery compared with no patient in the surgical treatment group. The reoperation rate for the surgical treatment group was 12%, for plate prominence.

In the Workers’ Compensation population, surgical fixation resulted in a shorter time to union, fewer cases of nonunion, and a slightly earlier return to work by 3 weeks.

→ A prospective randomized trial at 11 hospitals investigated the treatment of acute type-III, IV, and V acromioclavicular (AC) joint separations, comparing nonoperative treatment (n = 43) and hook plate fixation (n = 40)3. Removal of the hook plate was delayed until 6 months after insertion, when possible.

✧ Clinical and radiographic assessments were documented for 2 years. The primary outcome, the Disabilities of the Arm, Shoulder and Hand (DASH) score, was significantly better in the nonoperative group at 6 weeks and 3 months, with no differences between the groups thereafter. The secondary outcome, the Constant-Murley score, was significantly better in the nonoperative group for the first 6 months and equivalent between the groups thereafter. An assessment of coracoclavicular distance revealed more reduced joints in the operative group at all time points. Significantly fewer operative patients returned to work by 3 months, but rates equalized in subsequent periods. The operative group had 7 major and 7 minor complications, while the nonoperative group had only 2 major complications and 1 minor complication.

The natural history of acute AC joint dislocations is better than the status after surgical fixation with a hook plate up to 6 months. After 6 months, no functional difference between the groups and no operative clinical benefit were demonstrated.

→ The multicenter Proximal Fracture of the Humerus Evaluation by Randomization (PROFHER) trial evaluated the cost-effectiveness and clinical outcomes of surgical (open reduction and internal fixation [ORIF] or hemiarthroplasty) compared with nonsurgical (sling) treatment for acute displaced proximal humeral fractures in adults4. Rehabilitation was standardized, and the primary outcome was the Oxford Shoulder Score (OSS) at 6, 12, and 24 months.

✧ No significant difference was noted in the OSS or secondary outcomes (the Short Form [SF]-12, complications, subsequent therapy, mortality, and EuroQol [EQ]-5D-3L) between the surgical and nonsurgical groups. Surgery was significantly more expensive. A subgroup analysis of patients >65 years of age treated with either surgery or nonoperative treatment did not show a difference in any outcome measure.

The trial demonstrated that surgical treatment of proximal humeral fractures is neither cost-effective nor results in improved patient outcomes at time points up to 2 years. However, some patients without a clear surgical indication were included, while 87 patients with a clear surgical indication were excluded along with 195 additional patients excluded for other reasons. Nonetheless, among the compared cohorts, no surgical benefit was observed.

→ Forty postmenopausal women with Neer type-I proximal humeral fractures were treated with analgesics and physiotherapy and randomized to receive or not to receive 20 μg teriparatide daily, beginning within 10 days of injury, for a duration of 4 weeks5. Patients previously on bisphosphonates were excluded. Pain with rest and activity, function (as measured by the DASH score), and radiographs were assessed at the time of randomization, at 7 weeks, and at 3 months.

✧ Radiographic assessment of healing at 7 weeks, performed by 2 radiologists blinded to treatment, demonstrated a correlation that suggested better callus in the teriparatide group in 21 of the 39 patients with follow-up. Pain and DASH scores at all time points were not significantly different.

Early outcomes of nonoperatively managed proximal humeral fractures suggested a healing benefit from teriparatide treatment radiographically but no early clinical benefit.

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Humeral Shaft and Elbow

→ A randomized prospective study of 5 level-I trauma centers compared open plating (n = 32) and minimally invasive plate osteosynthesis (MIPO) (n = 36) for the treatment of acute noncomminuted humeral shaft fractures with a 5.0 narrow locking compression plate, a metaphyseal locking compression plate, or a proximal humeral internal locking plate6.

✧ No significant differences in the time to union, alignment, operative time, complication rates, or functional outcomes were identified.

MIPO is biomechanically optimal for comminuted humeral fractures, and it was demonstrated to be a safe and equally effective treatment option for simple humeral shaft fractures.

→ In a systematic review and meta-analysis, the authors analyzed 27 observational cohort studies and randomized controlled trials from before 2013, in which the objective functional and radiographic outcomes of intra-articular distal humeral fractures in patients >60 years of age who were treated with total elbow arthroplasty (TEA) or ORIF with locking plates in the acute or subacute time frame had been evaluated7.

✧ The time to surgery did not affect the complication rate. No differences between treatment groups in the rates of neurapraxia, superficial wound infection, and deep infection; the arc of motion; the Mayo Elbow Performance Score; or the need to return to the operating room because of major complications or elbow stiffness were noted. The TEA group had a higher total complication rate secondary to more minor complications. The ORIF group had more major complications requiring a return trip to the operating room. The weighted mean follow-up was >3.5 years.

For a subset of patients with unreconstructible intra-articular distal humeral fractures (due to osteoporosis, comminution, or bone loss), TEA is a suitable option.

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→ A multicenter trial randomized (stratified 1:1 by center, age, and intra-articular fracture extension) 461 patients to Kirschner-wire fixation or volar locking-plate fixation for an acute dorsally displaced distal radial fracture8. All distal radial fractures included could be reduced by indirect means and did not extend >3 cm from the joint. A plaster cast augmented Kirschner-wire fixation; cast use was less frequent in the ORIF group.

✧ No difference between the groups in the primary outcome, the Patient-Rated Wrist Evaluation (PRWE) questionnaire, was identified at any time point up to 12 months. No differences in the secondary outcomes of complication rate and quality-adjusted life-years (QALYs) were encountered. Radiographic parameters favored locking-plate fixation. The cost difference for implants and operating-room consumables was £764 U.K. (£818 for volar locking-plate fixation compared with £54 for Kirschner-wire fixation). The higher cost of volar-locking plate fixation was not offset through decreases in the use of health-care resources during the 12 months of follow-up after discharge.

No difference between first-year outcomes could be demonstrated. The use of Kirschner-wire fixation was demonstrated to be more cost-effective.

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→ A retrospective, multicenter study assessed mortality following all modalities of treatment among 454 elderly patients (≥60 years of age) with acetabular fracture9.

✧ The average age was 74 years. Overall mortality was 16% at 1 year for all methods of treatment. Unadjusted survivorship suggested higher 1-year mortality for nonoperative patients. After accounting for risk factors that portend higher mortality risk, there appeared to be no significant difference in the hazard of death for nonoperative treatment or surgical treatment. Associated fracture patterns compared with elementary fracture patterns increased the hazard of death by a ratio of 1.51.

Adjusting for comorbidities, there was no difference in 1-year mortality for elderly patients treated nonoperatively or with surgical stabilization.

→ A retrospective review investigated how often the findings of a postoperative CT scan resulted in reoperation after acetabular fracture surgery10.

✧ Among 563 patients with an axial postoperative CT scan of the pelvis, 14 (2.5%) underwent reoperation. Reasons included intra-articular screw penetration (1.1%), residual intra-articular fracture debris (0.7%), and unacceptable malreduction (0.5%). One patient (0.2%) had both retained intra-articular fracture debris and an unacceptable malreduction.

In a high-volume center, postoperative CT identified surgically correctable findings in 2.5% of the patients who underwent acetabular fracture surgery.

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→ A retrospective, case-control study reviewed the occurrence of morbidity and mortality after intramedullary nailing of closed femoral shaft fractures11. Patients were categorized according to body mass index (BMI): normal weight (<25 kg/m2), overweight (25 to 30 kg/m2), obese (>30 to 40 kg/m2), and morbidly obese (>40 kg/m2).

✧ A total of 526 femoral shaft fractures in 507 patients were reviewed. Comparing patients who were of normal weight, overweight, and obese, no significant differences were found in the rates of acute respiratory distress syndrome (ARDS), sepsis, pneumonia, and death. Morbid obesity significantly increased the odds of ARDS and sepsis. Overall, a systemic complication occurred in 23% of the morbidly obese patients compared with 9% of the patients of normal weight. Morbid obesity significantly increased the odds of mortality, especially in those with an Injury Severity Score (ISS) of >17 (odds ratio = 46.77; p = 0.01).

The subset of patients with morbid obesity was at increased risk of systemic complications and mortality following the management of a femoral shaft fracture, particularly patients with polytrauma.

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→ Functional outcomes of partial patellectomy or ORIF after patellar fracture were evaluated among 52 patients using the Knee Outcome Survey-Activities of Daily Living Scale and the SF-36 Health Survey12.

✧ While underpowered, this study did not demonstrate a difference in outcome between the 2 treatments. The use of wire in the fixation construct was associated with more frequent hardware removal.

Similar functional outcomes were achieved with ORIF and partial patellectomy.

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→ Data regarding complications among 138 patients with 140 high-energy bicondylar tibial plateau fractures treated with dual plating were retrospectively reviewed13.

✧ For 33 (23.6%) of the fractures, the patient developed deep infection; for 14 (10%), nonunion; and for 8 (5.7%), nonunion with infection. Staphylococcus aureus accounted for 50% of the infections, with 33% caused by methicillin-resistant S. aureus (MRSA). Whether fasciotomy wounds were closed prior to ORIF was the only variable found to influence the deep-infection rate (12% if closed before ORIF versus 50% if closed during or after). For 10 of the fractures, the patient developed a flexion contracture of >10°.

Complications following these high-energy injuries may be more common than previously reported, emphasizing the importance of the soft-tissue component of the injury.

→ A total of 661 tibial plateau fractures were reviewed retrospectively to identify the incidence of meniscal tear requiring surgical repair14.

✧ Among 602 patients included in the final analysis, 179 (30%) were noted to have meniscal tears requiring repair or partial meniscectomy. Split-depression patterns were more commonly associated with meniscal tears (45%), and those tears more commonly were peripheral meniscocapsular avulsions (83%).

Visual inspection of the meniscus should be considered in lateral split-depression tibial plateau fractures.

→ In a retrospective study, 137 type-III open tibial fractures were evaluated to determine whether the deep-infection rate is affected by the timing of antibiotic administration and wound coverage15.

✧ Deep infection was reduced among the patients who received prophylactic antibiotics within 66 minutes of injury (4 of 57, 7%) versus those for whom the administration of prophylactic antibiotics was delayed (20 of 80, 25%). There were fewer deep infections when wound coverage was accomplished within 5 days (4 of 74, 5.4%) versus when wound coverage was delayed (20 of 63, 31.7%). The timing of surgical debridement did not independently predict deep surgical infection.

Both antibiotic prophylaxis and definitive wound coverage should occur as soon as possible for severe open fractures. Prehospital antibiotic administration should be considered when transport is expected to take >1 hour.

→ The success rates of exchange nailing (n = 97) and dynamization (n = 97) were evaluated for 194 nonunited tibial fractures using prospectively gathered data from the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) database16.

✧ Successful union was observed for 83% of the dynamizations and 90% of the exchanges at a median time of 334 and 407 days, respectively, after the index procedure. A persistent fracture gap of >5 mm predicted failure of both interventions, reducing the overall success rate to 78% when present, compared with 92% success when no gap was present.

Similar results were observed for both dynamization and exchange nailing. A persistent fracture gap predicts treatment failure.

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Ankle and Foot

→ A prospective randomized trial compared the clinical outcomes of 70 patients with ankle fractures and syndesmotic injuries treated with surgical repair using either static syndesmotic fixation (a single quadricortical screw) or dynamic syndesmotic fixation (TightRope; Arthrex)17.

✧ Outcomes (American Orthopaedic Foot & Ankle Society [AOFAS] and Olerud-Molander [OM] scores) were significantly better in the dynamic fixation group at 3 months (AOFAS) and 12 months (OM). Reoperation due to symptomatic hardware was significantly higher in the static fixation group (31%) compared with the dynamic fixation group (6%).

Surgical treatment of unstable syndesmotic injuries using a dynamic fixation construct (TightRope) yielded better functional outcome scores and a lower reoperation rate than treatment using a traditional static screw-fixation method. It is unclear whether differences in outcomes between the 2 groups are clinically relevant or whether use of a tricortical screw-fixation construct would have impacted the results.

→ Two hundred and fourteen patients were randomized to receive either supervised physical therapy or a self-directed home exercise program after immobilization for the treatment of an ankle fracture18. Activity limitation and quality of life were assessed using the Lower Extremity Functional Scale and the Assessment of Quality of Life score.

✧ No difference was demonstrated between the groups at 1 month, 3 months, and 6 months post-immobilization. The mean duration of immobilization was 45 days for both groups.

Supervised physical therapy did not provide additional benefits over a self-directed home exercise program after 6 weeks of immobilization for ankle fracture.

→ Two randomized controlled trials and 1 retrospective cohort study (110 combined patients) assessed outcomes of Lisfranc trauma after ORIF or primary fusion19.

✧ Hardware removal was more common in the ORIF group, but hardware removal was standard protocol after ORIF in 1 study and not reported in another. There were no clear differences between the groups in patient-reported outcomes or revision surgery.

Similar results were observed after Lisfranc trauma treated with ORIF or primary fusion. Hardware removal was more prevalent in the ORIF group but may have been influenced by protocol differences.

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Management of Thromboembolic Events

→ In a multicenter, double-blinded trial investigating clinically important venous thromboembolism (CIVTE), the outcomes of 258 of 265 patients with an isolated below-the-knee injury of the lower extremity requiring surgery were analyzed20. The patients were randomized to dalteparin (5,000 units) or matching placebo daily for 2 weeks. Doppler ultrasound was utilized for diagnosis.

✧ The incidence of CIVTE was 1.5% in the dalteparin group and 2.3% in the placebo group. No fatal pulmonary emboli or major bleeding occurred. The study was discontinued early when analysis determined that the very low event rate would require the inclusion of many hundreds more patients for the study to be adequately powered.

The authors concluded that VTE prophylaxis is not indicated after surgery for patients with isolated fractures distal to the knee. The authors could not predict whether certain subgroups of patients may require thromboprophylaxis.

→ The Danish National Patient Registry identified 57,619 patients who had undergone surgery for a fracture distal to the knee and been assessed for clinically symptomatic deep venous thrombosis/pulmonary embolism (DVT/PE) after surgery21.

✧ The symptomatic DVT/PE incidence was 1% (594 of 57,619), with the highest risk during the first 13 weeks postoperatively. There were 39 fatal PEs (0.07%). Risk factors for postoperative DVT/PE were previous DVT (6-fold increase), previous PE (5-fold increase), oral contraceptive use (4-fold increase), and obesity (linear risk increase with increasing BMI).

Clinically symptomatic DVT and PE are rare. Chemical prophylaxis could be considered for patients with identifiable risk factors such as previous DVT/PE, oral contraceptive use, or obesity.

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Limb Salvage and Wound Care

→ A randomized controlled trial compared the efficacy of open-fracture wound irrigation using castile soap or normal saline solution at high (>20 psi), low (5 to 10 psi), or very low (1 to 2 psi) pressure22. The study included 2,447 patients, with 12-month follow-up data for 90% of those enrolled.

✧ More reoperations occurred in the soap group (14.8%) than in the saline solution group (11.6%). Reoperation rates were similar among the 3 irrigation-pressure groups.

Normal saline solution is superior to castile soap for the routine irrigation of open fractures. Irrigation pressure does not influence the reoperation rate.

→ In a retrospective chart review, the authors assessed the clinical effectiveness and cost of negative pressure dressings (NPDs) compared with compressive dressings (CDs) as bolsters for split-thickness skin grafts in the treatment of low-risk, traumatic extremity wounds23.

✧ One hundred and twenty patients received NPDs, and 40 received CDs. The analysis showed a higher likelihood of healing with the CD bolsters than with the NPD bolsters. There appeared to be no difference in the failure rates between the 2 groups. Cost was higher when utilizing an NPD as a bolster.

The utilization of standard CDs with low-risk, traumatic extremity wounds appears to be as effective as, or better than, utilizing NPDs as bolsters for split-thickness skin grafts.

→ The authors of a retrospective cohort study involving 104 patients requiring fasciotomies evaluated whether subsequent debridements achieved delayed primary closure (DPC) and influenced length of stay24.

✧ In 19 patients, closure was achieved with DPC in the first post-fasciotomy surgery and in 42 patients, through the use of split-thickness skin graft. The remaining 43 patients underwent subsequent surgeries for attempted DPC. Patients requiring >2 debridements could not be treated with DPC. Hospital stays were shorter among the patients who underwent DPC or use of split-thickness skin graft on the first post-fasciotomy surgery.

The authors noted the limited utility of multiple trips to the operating room in an effort to achieve DPC if the fasciotomy wounds cannot be closed primarily on the first return trip.

→ A retrospective case series detailed the outcomes of 69 skeletally mature patients who were treated for bone loss with the induced-membrane technique. Osseous defects received antibiotic-impregnated cement spacers. The mean bone loss was 5.0 cm. An autograft was implanted at an average of 8 weeks after spacer placement. An allograft was added to 44% of the autografts as an extender, and osteoinductive agents were used in 23% of the defects25.

✧ In a heterogeneous population, union was achieved in 83%. Six of the patients developed deep infection after spacer placement; union was achieved in 4 of those patients after antibiotic therapy. Risks associated with nonunion (n = 12) were postgrafting infection, postoperative wound dehiscence, and infection prior to grafting.

The treatment of large bone defects can be accomplished using the induced-membrane technique, but a substantial complication risk exists.

→ The authors of a retrospective review evaluated 214 postoperative infections for which bacterial cultures and antibiotic sensitivities were available26.

✧ Polymicrobial infections were common. S. aureus was identified in 119 (56%) of the 214 infections, with 58% being MRSA. At least 1 gram-negative rod (GNR) was present in 69 (32%) of the infections, and GNR infections were more common in type-III open fractures and fractures involving the pelvis, acetabulum, and proximal aspect of the femur. Infections caused by S. aureus tended to present later than those caused by GNR and other bacteria.

In this series, S. aureus was the most common organism identified, with MRSA being more common than methicillin-sensitive S. aureus (MSSA). GNR infections were more common in type-III open fractures and fractures around the hip and pelvis.

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Trauma Care

→ A prospective, multicenter study analyzed the financial risks under bundled-payment plans for managing orthopaedic trauma patients. Adverse event rates for orthopaedic trauma patients were compared with those for general orthopaedic patients. A risk calculator was developed for treating orthopaedic trauma patients27.

✧ Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, 146,773 orthopaedic patients (22,361 trauma patients and 124,412 nontrauma patients) over 7 years were identified. Among the orthopaedic trauma patients, 11.4% sustained a complication, while 4.1% of the orthopaedic nontrauma patients had a complication. Trauma increased the odds of developing a complication by 1.69-fold. Among trauma patients, those treated for hip and pelvic injuries were 4 times more likely to develop perioperative complications compared with those treated for upper-extremity injuries. Those with lower-extremity injuries were 3 times more likely to develop a complication compared with those with upper-extremity injuries.

Orthopaedic trauma patients are at greater risk for developing complications, and anatomic regions appear to have risk variation. Under bundled payment plans, orthopaedic trauma care should not be compared or benchmarked with that of orthopaedic nontraumatic care.

→ A total of 796 patients with a fracture or dislocation from the pelvis to the foot treated over 3 years were screened with a variation of the Malnutrition Universal Screening Tool (MUST). A retrospective chart review determined the occurrence of infection, VTE, respiratory failure, ulceration, or readmission28.

✧ Of the patients with normal nutritional status on MUST screening, 2.8% developed a specified complication. Of those with abnormal nutritional status on MUST screening, 8% incurred a specified complication. Multivariate regression analysis determined that the MUST score was the only independent variable associated with overall complications.

The MUST screening tool is predictive in identifying malnutrition and the development of complications in malnourished patients receiving orthopaedic trauma care.

→ In a prospective, observational study of 376 trauma patients (ISS of >16) requiring orthopaedic surgery, the authors assessed obese (a BMI of >30 kg/m2) and nonobese patients for initial length of hospital stay and complications associated with their care29.

✧ One hundred and fifty-eight (42%) of the patients were obese and had an overall complication rate of 38%. These patients had longer intensive care unit (ICU) stays, a longer duration of mechanical ventilation, longer hospital stays, increased delay to definitive fixation, increased operative times, higher infection and sepsis rates, higher acute renal failure rates, and a higher incidence of DVT. Stratifying obesity showed a trend of higher complication rates as obesity increased.

Obesity elevates the complication risks associated with orthopaedic trauma and negatively impacts length of stay.

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Upcoming Meetings and Events

The 2016 Annual Meeting of the Orthopaedic Trauma Association (OTA) will take place October 5-8, in National Harbor, Maryland. The meeting will include programming for trauma specialists, generalists, young practitioners, international surgeons, basic scientists, nurse practitioners, physician assistants, residents, and fellows.

The OTA web site, http://www.ota.org, contains multiple helpful resources for members and visitors, including links to videos, educational offerings, newsletters, health policy statements, committee activities, and membership and volunteer opportunities.

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Evidence-Based Orthopaedics

The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in the Update, 6 other articles with a higher Level of Evidence grade were identified that were relevant to orthopaedic trauma. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area.

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Evidence-Based Articles Related to Orthopaedic Trauma

Teunis T, Mulder F, Nota SP, Milne LW, Dyer GS, Ring D. No difference in adverse events between surgically treated reduced and unreduced distal radius fractures. J Orthop Trauma. 2015 Nov;29(11):521-5.

A retrospective study of 1,511 patients from 3 urban hospitals compared the 6.8% of patients with a distal radial fracture that was not reduced prior to surgery with the remainder who underwent closed reduction and application of a splint prior to surgery. A 15% overall adverse event rate, which included any subsequent surgery, stiffness, and transient nerve dysfunction, was identified for all patients, with no difference noted between the groups. The authors concluded that it is possible to forego preoperative closed reduction and molded splinting of a distal radial fracture without an increase in adverse events including subsequent surgery in a patient with a clear, nonurgent indication for surgery if surgery is planned within an average of 5 days.

Chaudhry H, Kleinlugtenbelt YV, Mundi R, Ristevski B, Goslings JC, Bhandari M. Are volar locking plates superior to percutaneous K-wires for distal radius fractures? A meta-analysis. Clin Orthop Relat Res. 2015 Sep;473(9):3017-27. Epub 2015 May 16.

A meta-analysis of 7 studies and a total of 875 patients assessed whether the use of volar locking plates results in better function, wrist motion, and radiographic appearance and fewer complications compared with the use of percutaneous Kirschner-wire fixation for dorsally displaced intra-articular and extra-articular distal radial fractures. Significantly better DASH scores at 3 and 12 months were found in the plating group, but the difference was below the clinically important 10-point threshold. There were no differences in radiographic outcomes. A higher rate of superficial wound infection in the Kirschner-wire group (8.2% compared with 3.2%) was demonstrated. All other common complications were not significantly different between the groups. The authors concluded that the general practice shift toward the use of volar locking plates has not been accompanied by a demonstrable corresponding clinical benefit.

Kuo LT, Chi CC, Chuang CH. Surgical interventions for treating distal tibial metaphyseal fractures in adults. Cochrane Database Syst Rev. 2015;3:CD010261. Epub 2015 Mar 30.

Three randomized controlled trials compared outcomes of closed or type-I open distal metaphyseal tibial fractures treated with the use of either intramedullary nailing or plating. There were no trials comparing surgical with nonsurgical treatment. The plating group was a heterogeneous mix of patients undergoing MIPO with use of a locking plate or ORIF with use of a conventional nonlocking plate. This review did not confirm any clinically important differences between the 2 groups in function, pain, complication risk, or reoperation rate.

Griffin XL, Parsons N, Zbaeda MM, McArthur J. Interventions for treating fractures of the distal femur in adults. Cochrane Database Syst Rev. 2015;8:CD010606. Epub 2015 Aug 13.

This analysis, which included 345 distal femoral fractures from 7 studies, compared the use of reamed intramedullary nailing, nonlocking-plate fixation, locking-plate fixation, dynamic condylar-screw fixation, and nonsurgical management (skeletal traction). The largest study comparing contemporary implants showed an insignificant trend toward improved patient-reported musculoskeletal function and quality of life when treatment involved reamed intramedullary nailing compared with locking-plate fixation. As a whole, the remaining studies were difficult to compare because of incomplete functional outcome reporting and implant heterogeneity. The available evidence is insufficient to direct clinical practice with regard to implant choice for distal femoral fractures.

Sohn HS, Yoon YC, Cho JW, Cho WT, Oh CW, Oh JK. Incidence and fracture morphology of posterolateral fragments in lateral and bicondylar tibial plateau fractures. J Orthop Trauma. 2015 Feb;29(2):91-7.

CT scans of 190 tibial plateau fractures were assessed with the intent to characterize fracture morphology involving the posterolateral part of the tibial plateau. Posterolateral fracture involvement was noted in 84 (44.2%) of 190 cases. The posterolateral fragment contains a coronal-plane shear component and is often of insufficient size to be captured by traditional lateral locked implants. The investigators noted that coronal-plane fractures of the posterolateral aspect of the tibial plateau are relatively common and are not easily addressed using traditional implants.

McNamara AR, Boudreau JA, Moed BR. Nonoperative treatment of posterior wall acetabular fractures after dynamic stress examination under anesthesia: revisited. J Orthop Trauma. 2015 Aug;29(8):359-64.

Twenty-four of 31 patients with nonoperatively treated posterior-wall acetabular fractures who underwent examination under general anesthesia (EUA) were retrospectively evaluated for radiographic and functional outcomes following treatment. All but 1 patient had excellent radiographic results, with no evidence of ongoing instability or incongruity. Functional results, as measured using the modified Merle d’Aubigné scoring system, ranged from fair (14 points) to excellent (18 points). Posterior-wall fragment size ranged from 6% to 41% and did not correlate with functional results. The authors asserted that dynamic stress examination under anesthesia is a reliable predictor of hip stability after posterior-wall acetabular fracture and can be used to differentiate between fractures that require surgical repair and those that are amenable to nonoperative treatment.

Investigation performed at the Department of Orthopedic Surgery, University of Oklahoma Health Sciences Center, College of Medicine, Oklahoma City, Oklahoma

Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

Disclosure: One or more of the authors received a stipend from JBJS for writing this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work.

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1. Schemitsch LA, Schemitsch EH, Kuzyk P, McKee MD. Prognostic factors for reoperation after plate fixation of the midshaft clavicle. J Orthop Trauma. 2015 ;29(12):533–7.
2. Melean PA, Zuniga A, Marsalli M, Fritis NA, Cook ER, Zilleruelo M, Alvarez C. Surgical treatment of displaced middle-third clavicular fractures: a prospective, randomized trial in a working compensation population. J Shoulder Elbow Surg. 2015 ;24(4):587–92. Epub 2015 Jan 22.
3. Canadian Orthopaedic Trauma Society. Multicenter randomized clinical trial of nonoperative versus operative treatment of acute acromio-clavicular joint dislocation. J Orthop Trauma. 2015 ;29(11):479–87.
4. Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C, Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 ;313(10):1037–47.
5. Johansson T. PTH 1-34 (teriparatide) may not improve healing in proximal humerus fractures. Acta Orthop. 2016 ;87(1):79–82. Epub 2015 Jul 15.
6. Kim JW, Oh CW, Byun YS, Kim JJ, Park KC. A prospective randomized study of operative treatment for noncomminuted humeral shaft fractures: conventional open plating versus minimal invasive plate osteosynthesis. J Orthop Trauma. 2015 ;29(4):189–94.
7. Githens M, Yao J, Sox AH, Bishop J. Open reduction and internal fixation versus total elbow arthroplasty for the treatment of geriatric distal humerus fractures: a systematic review and meta-analysis. J Orthop Trauma. 2014 ;28(8):481–8.
8. Costa ML, Achten J, Plant C, Parsons NR, Rangan A, Tubeuf S, Yu G, Lamb SEUK. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess. 2015 ;19(17):1–124: v-vi.
9. Gary JL, Paryavi E, Gibbons SD, Weaver MJ, Morgan JH, Ryan SP, Starr AJ, O'Toole RV. Effect of surgical treatment on mortality after acetabular fracture in the elderly: a multicenter study of 454 patients. J Orthop Trauma. 2015 ;29(4):202–8.
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