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What’s New in Orthopaedic Trauma

Dehghan, Niloofar MD, FRCSC1,2,3; McKee, Michael D. MD, FRCSC1,2

doi: 10.2106/JBJS.19.00327
Editorial
Free
Disclosures

1Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona

2Banner University Medical Center-Phoenix, Phoenix, Arizona

3The CORE Institute, Phoenix, Arizona

E-mail address for N. Dehghan: niloofar.dehghan@thecoreinstitute.com

Investigation performed at the Banner University Medical Center-Phoenix and The CORE Institute, Phoenix, Arizona

Disclosure: The authors received a stipend from JBJS for the writing of this manuscript. 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 and “yes” to indicate that the author had other relationships or activities that could be perceived to influence, or have the potential to influence, what was written in this work (http://links.lww.com/JBJS/F353).

The field of orthopaedic trauma is constantly evolving, and it can be difficult to keep up to date on all of the important developments and advancements. This article provides a summary of high-quality studies that were published or read in 2018. It was our aim to aid practicing orthopaedic surgeons by highlighting studies that have the potential to influence practice decisions and have an impact on orthopaedic trauma care.

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Acromioclavicular (AC) Joint Injuries

A recent systematic review evaluated studies comparing operative and nonoperative treatment of high-grade AC joint injuries (types III to V); 19 studies (5 randomized controlled trials [RCTs] and 14 retrospective cohort studies), with a total of 954 patients, were included1. The surgical fixation techniques varied and included Kirschner-wire fixation, Bosworth screw insertion, Steinmann pin fixation, Weaver-Dunn repair, hook-plate application, direct coracoclavicular ligament repair, and arthroscopic-assisted TightRope (Arthrex) fixation. The authors reported that, with regard to functional outcome scores (Disabilities of the Arm, Shoulder and Hand [DASH], Constant-Murley, and visual analog scale [VAS] for pain), there were no clinically important or statistical differences between operative and nonoperative management. The nonoperative group had a faster return to work, by 4.17 weeks (p < 0.0001), compared with the operative group. The operative group had better radiographic and cosmetic appearance of the AC joint (p < 0.0001); however, it also had a higher rate of implant complications (p < 0.001) and infection and soft-tissue complications (p = 0.007). The findings of this study suggest that there is little functional benefit of routine surgical fixation of acute type-III to V injuries of the AC joint. However, the study included a heterogeneous group of injuries and operative procedures and involved a large number of retrospective cohort studies. While the surgical treatment of type-III injuries may not yield functional improvements, this study does not answer the question of whether surgery would be beneficial in the treatment of type-IV and V injuries, due to the relative rarity of these injuries in the included studies1.

In a small RCT including 60 patients with an acute type-III or IV dislocation of the AC joint, the patients (aged 16 to 35 years) were randomized to nonoperative treatment with a sling (n = 31) or surgery involving coracoclavicular suspensory device fixation with 2 TightRope devices (n = 29)2. The primary outcome measure was the DASH score. At 6 weeks post-injury, the operative group had greater disability and higher DASH scores compared with the nonoperative group (p < 0.01). However, at 1 year post-injury, there were no functional differences between the 2 groups as assessed by the DASH score or the Oxford Shoulder Score. The operative group had less radiographic displacement than did the nonoperative group (2 compared with 11 mm; p < 0.0001). The total cost of treatment was significantly higher in the surgical group (£3,360 compared with £796 [British pounds]; p < 0.0001). Five patients in the nonoperative group underwent surgical fixation because of failure of nonoperative management. This is yet another study demonstrating no functional improvement with routine surgical fixation of high-grade AC joint injuries. Further research in this area is warranted to identify prognostic factors and patients who would benefit from surgery, especially given the notable rate of treatment failure (5 of 29 patients) in the nonoperative group2.

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Proximal Humeral Fractures

The outcomes of operative versus nonoperative treatment of proximal humeral fractures in patients >65 years of age were evaluated in a recent meta-analysis3. The analysis included 7 RCTs and 15 observational studies, with a total of 1,743 patients (910 treated operatively and 833 treated nonoperatively). The majority of patients who underwent surgery were treated with open reduction and internal fixation (ORIF) with use of a locking plate (80%), while other surgical management included hemiarthroplasty, reverse shoulder arthroplasty, and the use of proximal humeral nails and Kirschner wires. There was no difference in Constant-Murley scores at 1 year between patients treated operatively and those treated nonoperatively, and the results were similar when RCTs and observational studies were analyzed separately. Reoperation rates were higher in the surgical group (relative risk [RR], 2.72; 95% confidence interval [CI], 1.71 to 4.34; p < 0.001); however, a subgroup analysis revealed that, while this was true for the observational studies, there was no difference with respect to reoperation rates in the RCTs. Although there were several limitations of this study, including the heterogeneous nature of the surgical patients, it demonstrated that, in elderly patients with proximal humeral fractures, surgical management in varying forms does not offer any functional benefit compared with nonoperative treatment3.

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Elbow Injuries

In 2 studies, magnetic resonance imaging (MRI) was used to assess the pattern of soft-tissue injury after elbow dislocation4,5. One study involved 17 cases of simple elbow dislocation. Initial radiographs for 16 of the patients demonstrated posterolateral elbow dislocation in 12, while in 3, the dislocation was directly posterior, and in 1, it was posteromedial. Overall, MRI revealed that the most common injury was a complete tear of the anterior capsule (71% of the 17 cases), followed by complete medial collateral ligament (MCL) tear (59%) and complete lateral collateral ligament (LCL) tear (53%). Among the patients with posterolateral elbow dislocation, a complete MCL tear was more prevalent (90%) than was a complete LCL tear (50%). The findings of this study call into question the pattern of soft-tissue injury following a simple elbow dislocation, challenging the previous theory of elbow instability whereby the injury was thought to start laterally, with the MCL being the last structure to be injured. In this study, patients with posterolateral elbow dislocation were more likely to have a complete MCL tear than an LCL tear4.

The second study focused on posteromedial elbow dislocations, with the authors reporting a 100% rate of complete LCL tear among all 15 patients assessed with MRI, while a complete tear of the MCL was noted in 47%5. The findings of this study suggest that, in posteromedial elbow dislocation, the pattern of injury begins on the lateral side. Eighty-five percent of the patients required surgical treatment because of acute instability, which may indicate an injury pattern more severe than the more common posterolateral elbow dislocation5. Further research in this area is warranted to better understand the pattern of soft-tissue injury and to match this to appropriate treatment options.

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Distal Radial Fractures

In a small RCT that included 40 patients with distal radial fractures, the costs of surgical treatment were compared between ORIF with a volar locking plate (n = 23) and closed reduction and percutaneous pinning (CRPP, n = 17)6. Costs were reported as the cost ratio (CR) relative to the CRPP group. The study revealed a higher perioperative cost for the ORIF group (CR = 2.7/1.0; p < 0.001), primarily due to increased surgical time and implant costs. However, the cost difference between the 2 groups decreased over time: while ORIF treatment was still associated with a higher cost at 1 year (1.6/1.0; p < 0.001), the difference between the 2 groups was lower than in the perioperative period. The authors suggested that, although the initial cost of ORIF was higher than that of CRPP, CRPP was associated with higher costs after the perioperative period because of an increased number of patient visits, and rehabilitation costs. While functional outcomes (DASH scores, range of motion, and strength) were better in the ORIF group in the first 9 weeks postoperatively, the 2 groups did not differ at 1 year. The cost and outcome differences between the 2 groups should be considered when choosing a treatment strategy for displaced distal radial fractures6.

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Pelvic Fractures

In a database study from Taiwan, the authors looked at the potential effect of arterial embolization on erectile dysfunction in male patients, aged 15 to 45 years, after traumatic pelvic fracture7. The authors used data from the National Health Insurance program, a single-payer universal insurance plan, which includes data of nearly 99% of the Taiwanese population. The database identified 85 patients with pelvic fractures treated with arterial embolization and 82,717 patients who did not receive embolization. The authors reported that the prevalence of erectile dysfunction was significantly higher in the group treated with embolization (8.2% compared with 0.3%; p < 0.001). When adjusting for other confounders, factors associated with an increased risk of erectile dysfunction were arterial embolization (odds ratio [OR], 32.6; 95% CI, 14.1 to 75.3; p < 0.001), surgical intervention (OR, 4.25; 95% CI, 2.0 to 9.0; p < 0.001), urethral injury (OR, 52.3; 95% CI, 36.1 to 75.6; p < 0.001), and younger age (15 to 35 years versus 36 to 45 years: OR, 2.5; 95% CI, 1.7 to 3.6; p < 0.001). The findings of this study suggest that arterial embolization is an independent factor associated with an increased risk of erectile dysfunction, which makes sense intuitively. However, the authors also reported that injuries of higher severity (such as associated urethral injury, or the need for surgical fracture repair) were also associated with a higher risk of erectile problems. This suggests a potential selection bias, as those with injuries of higher severity would potentially undergo arterial embolization. More research in this area is warranted to determine the effect of arterial embolization on erectile dysfunction after pelvic fracture7.

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Hip Trauma

The outcomes of 3 surgical approaches used in hemiarthroplasty for the treatment of femoral neck fractures were compared in a recent meta-analysis8. Included in the analysis were 21 studies (3 RCTs and 7 prospective and 11 retrospective cohort studies), with a total of 61,487 patients who were treated with hemiarthroplasty via the anterior, lateral, or posterior approach. The results revealed a significantly higher rate of hip dislocation among the patients treated with use of the posterior approach compared with the lateral approach (OR, 2.90; p = 0.0003) and the posterior approach (OR, 2.61; p = 0.01) compared with the anterior approach. In addition, the rate of reoperation was higher for patients treated with use of the posterior approach compared with the lateral approach (OR, 1.25; 95% CI, 1.12 to 1.41; p < 0.0001). There were no differences with respect to surgical time, perioperative fractures, wound infection, or hospital length of stay. The authors indicated that, compared with the lateral and the anterior approach, the posterior approach in hemiarthroplasty for the treatment of femoral neck fracture was associated with an increased risk of hip dislocation and reoperation, and its routine use may not be warranted. High-quality, comparative studies are needed to further assess the best surgical approach among these patients8.

An RCT was conducted to compare the use of short and long cephalomedullary nail fixation in the treatment of pertrochanteric fractures9. The study included 220 patients; 110 were randomized to short (SN) and 110 were randomized to long (LN) cephalomedullary nail fixation. The primary outcome was function, assessed with use of Short Form (SF)-36 and the Harris hip score (HHS) at 3 months. No significant differences were found between the 2 groups regarding the SF-36 and HHS scores. Patients treated with SN had a shorter operative time (51 compared with 80 minutes; p < 0.0001), less blood loss (70 compared with 207 mL; p < 0.001), and shorter hospital stay (5 compared with 7 days; p = 0.01). There was no difference in the rate of lag-screw cutout or peri-implant fractures. Given the shorter operative time and hospital stay, and less blood loss, the treatment of pertrochanteric hip fractures with SN seems to be advantageous compared with treatment with LN. The incidence of peri-implant fractures between the 2 devices was similar. However, a peri-implant fracture around a short nail is less complicated to treat (revision to long nail) compared with a fracture around a long nail, which may require ORIF with a distal femoral plate9.

In a multicenter retrospective study, the authors assessed outcomes following femoral neck fracture fixation in patients aged 18 to 59 years10. The aim of this study was to identify the results of fixation and any differences between treatment with use of a dynamic hip screw or cannulated screws. Included were 596 patients with a minimum follow-up of 6 months, from 16 trauma centers across North America. One hundred and ninety-one patients were treated with use of dynamic hip screws, and 405 were treated with use of cannulated screws. Union without complications occurred in 62%, while 38% of the patients experienced ≥1 complication. Complications included nonunion (17%), fixation failure (16%), malunion (10%), and osteonecrosis (14%), with no differences between patients treated with use of a dynamic hip screw or cannulated screws. To our knowledge, this is the largest study reporting outcomes of young patients with femoral neck fractures treated with modern techniques in North American centers, with the finding of an unexpectedly high rate of complications overall. Further comparative studies are needed to determine outcome differences between treatment modalities with use of dynamic hip screws and cannulated screws10.

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Ankle Injuries

The authors of an RCT in Norway assessed outcomes of syndesmosis injuries treated with use of a single syndesmotic screw compared with suture-button fixation11. The study involved 97 patients, 49 randomized to syndesmotic screw and 48 randomized to suture-button fixation. Patients were followed for 2 years post-injury, and computed tomography (CT) scans were obtained at 2 weeks, 1 year, and 2 years postoperatively. The primary outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) scale. The authors reported improved AOFAS scores in the suture-button group compared with the syndesmotic screw group at 6 months, 1 year, and 2 years postoperatively (median score at 2 years: suture button = 96, and syndesmotic screw = 86; p = 0.001). The suture-button group also had improved Olerud-Molander Ankle scores up to 2 years postoperatively (median score: suture button = 100, and syndesmotic screw = 90; p < 0.001). The syndesmotic reduction (tibiofibular distance compared between injured and uninjured ankles as noted on CT scanning) was similar between the 2 groups at 2 weeks postoperatively. However, at 2 years postoperatively, the tibiofibular distance was significantly higher in the syndesmotic screw group, with a 2.5-times higher rate of malreduction. This increase in tibiofibular distance was likely due to routine early screw removal (10 to 12 weeks postoperatively) in the syndesmotic screw group and secondary loss of syndesmotic reduction. At 2 years postoperatively, ankle osteoarthritis was noted in 29% of the patients in the syndesmotic screw group and in 20% of the patients in the suture-button group (p = 0.4). The findings of this study suggest that, compared with screw fixation, suture-button fixation of syndesmosis injuries may help improve functional outcome scores. The rate of malreduction of the syndesmosis was similar between the 2 groups initially, and an increase in malreduction was only noted after screw removal. It is difficult to assess whether the lower functional outcomes were due to the loss of syndesmotic reduction in the screw group, and the results of this study may argue against early routine syndesmotic screw removal11.

Two meta-analyses published in 2018 assessed outcomes of syndesmosis injuries treated with screw or suture-button fixation. While both meta-analyses included the same 5 RCTs, they used contrasting methods of data analysis, with differing results12,13. High-quality studies in this area are warranted to assess long-term clinical and radiographic differences between screw and suture-button fixation of syndesmosis injuries.

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Pediatric Fractures

In an RCT involving pediatric patients with nondisplaced elbow fractures, immobilization with a removable long arm cast made of soft fiberglass (n = 50) was compared with use of a long arm hard fiberglass cast (n = 50)14. Inclusion criteria included the diagnosis of a nondisplaced type-I supracondylar fracture or a positive posterior fat pad sign without an obvious fracture, and an age of 2 to 10 years. All patients were immobilized for 4 weeks. At 4 weeks post-injury, the hard casts were removed by a cast technician, while the soft casts were removed by patients’ parents while in the clinic. No fracture displacement was found in either group. Both groups regained an arc of motion identical to that of the contralateral side at 8 weeks and had similar pain scores. The authors concluded that treatment of these nondisplaced elbow fractures with a removable long arm cast is safe; and removal at home by a parent has the potential to decrease the number of patient visits and health-care costs14.

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Geriatric Fractures

The authors of a retrospective study evaluated the outcomes of elderly patients with sacral fragility fractures who were treated with percutaneous screw fixation compared with nonoperative treatment15. Exclusion criteria included an age of <60 years, the presence of an unstable sacral fracture meeting criteria for surgical fixation, the inability to walk prior to injury, and residence in a facility prior to injury. All patients received a trial of nonoperative treatment and physical therapy; patients with severe pain or who were unable to mobilize were then offered surgical fixation. A total of 41 patients were included: 25 were treated nonoperatively, and 16 underwent percutaneous transiliac-transsacral screw fixation. The authors reported that pain measured by a VAS was significantly higher in the operative group at admission (mean, 7.4 compared with 5.7; p = 0.02); however, at discharge the pain level in the operative group had improved significantly more than the nonoperative group (mean decrease in VAS score of 3.9 compared with 0.6; p < 0.001). Patients treated surgically were more likely to be ambulatory at discharge (100% compared 73%; p = 0.03), to walk a longer distance (95 compared with 35 feet; p > 0.01), and to be discharged home (75% compared with 20%; p < 0.001). Length of hospital stay did not differ between the groups. The findings of this study suggest that surgical treatment of sacral fragility fractures among the elderly may improve mobilization and pain. However, as with all retrospective studies, there were issues with selection bias. Further research in this area is warranted to determine the benefits of surgical fixation (if any), and to identify which patient and fracture characteristics would indicate benefit from surgery15.

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Infection

In the Netherlands, a multicenter, double-blinded RCT was conducted to assess the effect of prophylactic antibiotic administration on surgical site infections (SSIs) following the elective removal of hardware used in the treatment of fractures below the knee16. Patients were randomized to preoperative intravenous administration of 1,000 mg of cephazolin (n = 228) or saline solution (n = 242). The study revealed an SSI rate of 13.2% in the cefazolin group and 14.9% in the saline-solution group, a difference that was not statistically significant (p = 0.60). While 7 of the 8 deep infections were in the saline-solution group, this did not reach significance. The authors reported that the rate of SSI in such patients was anticipated to be around 3.3% and they were surprised at the high rate of SSI in both groups. They indicated that such high rates may be due to improper diagnosis of wound dehiscence or wound necrosis as SSI. Moreover, they reported that the incidence of SSI in Dutch retrospective studies at the time of the study design was 9% to 19%. While the study showed no improvement with prophylactic antibiotic use, the results should be interpreted with caution, as (1) there may have been an error in the diagnosis of the primary outcome (SSI), and (2) such a high rate of SSI is concerning, may be due to local factors, and may not be applicable to patients treated in different settings or from other regions16.

Another recent study assessed the role of histological analysis in fracture nonunion to determine the presence of infection17. Histological samples from 156 cases of nonunion were obtained: for 64, infection was confirmed; 66 were aseptic; and 26 were cases of possible infection (diagnosed via clinical and microbiological criteria). The samples were then assessed for mean neutrophil counts per high-power field (HPF), and the results were compared with the established diagnosis. The authors reported that, at a cutoff of ≥5 neutrophils per HPF, there was 80% sensitivity and 100% specificity for the presence of infection, while the lack of any neutrophils seen had a sensitivity of 85% and a specificity of 98% for aseptic nonunion. The results of this study suggest that, if ≥5 neutrophils per HPF are present, there is a 100% positive predictive value for infection, while the complete absence of neutrophils is almost always indicative of an aseptic nonunion (positive predictive value of 98%)17. It remains unclear how to interpret intermediate counts (1 to 4 neutrophils per HPF).

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Pain

A small RCT in Iran assessed the effect of massage on pain and anxiety scores among patients undergoing surgery for tibial fracture18. Sixty-six patients with surgically treated tibial fractures were randomized to receive a foot massage in addition to routine care (n = 33) or routine care only (n = 33). The foot massage was a 10-minute intervention performed on the day after surgery and involved bilateral massage of feet, legs, heels, and toes. Pain was assessed by a numeric rating scale (from 0 to 10), and anxiety was assessed by the Spielberger State-Trait Anxiety Inventory. The authors reported that, while both groups had a similar level of pain prior to the intervention (5.7), patients in the massage group had improved pain scores at 2 hours after the intervention (4.7 versus 5.7; p < 0.001). The authors also reported improved anxiety scores in the massage group immediately post-intervention compared with pre-intervention (12-point decrease in massage group versus 1-point increase in control group; p < 0.001). The findings of this study suggest that massage therapy may be used as an adjunct measure for reducing pain and anxiety in orthopaedic trauma patients. This may be of importance, given the high prevalence of anxiety, depression, and pain in this patient population, and the negative influences of anxiety and depression on pain. More studies in this area are warranted18.

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Deep-Vein Thrombosis (DVT) Prophylaxis

In an RCT including orthopaedic trauma patients, the authors evaluated DVT prophylaxis with aspirin compared with low-molecular-weight heparin (LMWH), assessing bleeding events in the 2 treatment groups19. Patients were treated with 81 mg of aspirin twice daily (n = 165) or 30 mg of LMWH twice daily (n = 164). The results revealed a 32% bleeding-event rate in each of the groups. The rate of DVT was similar between the 2 groups (aspirin, 6%; LMWH, 3%; p = 0.28), as was the rate of pulmonary embolism (PE) (aspirin, 1%; LMWH, 4%; p = 0.14). Among patients with a concomitant abdominal injury, those in the aspirin group were more likely to have a bleeding complication (aspirin, 65%; LMWH, 21%; p = 0.02). Although this study was small for a drug trial, its results indicate similar bleeding risk for both modalities. However, the study does not answer which medication is associated with lower risk of DVT or PE in this patient population19.

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Upcoming Meetings of the Orthopaedic Trauma Association (OTA)

The OTA Annual Meeting has a diverse program, including the Basic Science Fracture Forum and the International Forum, and is of interest to a variety of practitioners, including orthopaedic traumatologists, general orthopaedic surgeons, residents, fellows, nurse practitioners, physician assistants, researchers, and basic scientists. The 2019 OTA Annual Meeting will take place September 25-28, 2019, in Denver, Colorado. The 2020 OTA Annual Meeting will take place September 30-October 3, 2020, in Nashville, Tennessee. Additional information is available at www.ota.org.

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Evidence-Based Orthopaedics

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

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Evidence-Based Orthopaedics

Boylan MR, Riesgo AM, Paulino CB, Tejwani NC. Day of admission is associated with variation in geriatric hip fracture care. J Am Acad Orthop Surg. 2019 Jan 1;27(1):e33-40.

The data of 62,303 patients from the State of New York were used to assess outcomes of hip-fracture care among elderly patients. The authors reported a “weekend effect,” with a significant increase in preoperative delay for patients admitted on Saturdays and Sundays compared with Mondays.

Cannada L, Tornetta P, Obremskey W, Reider L, Luly J, MacKenzie E. The METRC. A randomized controlled trial comparing rhBMP-2 versus autograft for the treatment of tibia fractures with critical size defects. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2018 Oct 17-20; Orlando, FL. Paper no. 65.

In this RCT, recombinant human bone morphogenetic protein-2 (rhBMP-2) was compared with autograft for the treatment of tibial fractures with a critical-sized defect. The study included 30 patients aged 18 to 65 years with open tibial shaft fractures and a bone defect of at least 1 cm who were treated with use of an intramedullary nail. Sixteen patients received rhBMP-2 with morcellized allograft, and 14 patients underwent iliac crest bone graft (ICBG) application. The primary outcome was the rate of union at 1 year postoperatively. The results revealed a rate of radiographic union of 58% in the rhBMP-2 group and 82% in the ICBG group, a nonsignificant difference. The mean treatment cost for the rhBMP-2 group was $13,033 (USD) compared with $7,535 for the ICBG group.

Chivot M, Lami D, Bizzozero P, Galland A, Argenson JN. Three- and four-part displaced proximal humeral fractures in patients older than 70 years: reverse shoulder arthroplasty or nonsurgical treatment? J Shoulder Elbow Surg. 2019 Feb;28(2):252-9. Epub 2018 Oct 19.

The authors of this retrospective study of 60 patients reported marginally improved functional outcomes after reverse total shoulder arthroplasty (RTSA) compared with nonoperative treatment at 2 years post-injury (Constant-Murley score of 57 versus 51; p = 0.03); however, the improvement did not meet the minimal clinically important difference. There was no difference between the 2 groups with regard to QuickDASH scores. Among the patients treated with RTSA, 7% had a complication, and 3% needed revision surgery.

Neuburger J, Currie C, Wakeman R, Georghiou T, Boulton C, Johansen A, Tsang C, Wilson H, Cromwell DA, van der Meulen J. Safe working in a 7-day service. Experience of hip fracture care as documented by the UK National Hip Fracture Database. Age Ageing. 2018 Sep 1;47(5):741-5.

Data from the National Hip Fracture Database in England were analyzed to determine if there was a difference in the rate of mortality for patients with hip fractures admitted on weekends. The authors reported that the 30-day mortality was lower in units with higher levels of geriatrician involvement. A lower proportion of patients received geriatrician assessment on weekends; however, there was no difference in 30-day mortality noted as a result of a weekend admission.

Qvist AH, Vaesel MT, Jensen CM, Jensen SL. Plate fixation compared with nonoperative treatment of displaced midshaft clavicular fractures: a randomized clinical trial. Bone Joint J. 2018;100-B(10):1385-91.

In this RCT including 146 patients with midshaft clavicular fractures, surgical fixation with a pre-contoured plate was compared with nonoperative treatment with use of a sling. The authors reported improved DASH and Constant-Murley scores in the operative group at 3 months, but no difference at any other time beyond that. The rate of nonunion was significantly higher in the nonoperative group (11 of 60 patients [18%] versus 2 of 64 patients [3%] in the operative group; p = 0.009). Fourteen percent of patients in the nonoperative group underwent surgical fixation for nonunion, while 25% of the patients in the surgical group underwent revision surgery for hardware removal.

White TO. In defence of the posterior malleolus. Bone Joint J. 2018 May 1;100-B(5):566-9.

This is an excellent review of the literature including studies advocating for the surgical fixation of posterior malleolar fractures. This manuscript states that, despite the recent enthusiasm for CT-scan diagnosis and surgical fixation of posterior malleolar fractures, there is no evidence that surgery leads to improved patient outcomes in the majority of cases.

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References

1. Chang N, Furey A, Kurdin A. Operative versus nonoperative management of acute high-grade acromioclavicular dislocations: a systematic review and meta-analysis. J Orthop Trauma. 2018 Jan;32(1):1-9.
2. Murray IR, Robinson PG, Goudie EB, Duckworth AD, Clark K, Robinson CM. Open reduction and tunneled suspensory device fixation compared with nonoperative treatment for type-III and type-IV acromioclavicular joint dislocations: the ACORN prospective, randomized controlled trial. J Bone Joint Surg Am. 2018 Nov 21;100(22):1912-8.
3. Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH, Groenwold RHH, Houwert RM. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg. 2018 Aug;27(8):1526-34. Epub 2018 May 4.
4. Luokkala T, Temperley D, Basu S, Karjalainen TV, Watts AC. Analysis of magnetic resonance imaging-confirmed soft tissue injury pattern in simple elbow dislocations. J Shoulder Elbow Surg. 2019 Feb;28(2):341-8. Epub 2018 Nov 8.
5. Cho CH, Kim BS, Rhyou IH, Park SG, Choi S, Yoon JP, Choi CH, Dan J. Posteromedial elbow dislocations without relevant osseous lesions: clinical characteristics, soft-tissue injury patterns, treatments, and outcomes. J Bone Joint Surg Am. 2018 Dec 5;100(23):2066-72.
6. Nandyala SV, Giladi AM, Parker AM, Rozental TD. Comparison of direct perioperative costs in treatment of unstable distal radial fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning. J Bone Joint Surg Am. 2018 May 2;100(9):786-92.
7. Hsu SD, Chen CJ, Wang ID, Lin KT, Wang CC, Chien WC, Chung CH, Chang WK. The risk of erectile dysfunction following pelvic angiographic embolization in pelvic fracture patients: a nationwide population-based cohort study in Taiwan. World J Surg. 2019 Feb;43(2):476-85.
8. van der Sijp MPL, van Delft D, Krijnen P, Niggebrugge AHP, Schipper IB. Surgical approaches and hemiarthroplasty outcomes for femoral neck fractures: a meta-analysis. J Arthroplasty. 2018 May;33(5):1617-1627.e9. Epub 2017 Dec 29.
9. Shannon S, Yuan B, Cross W, Barlow J, Torchia M, Sems A. Short versus long cephalomedullary nailing of pertrochanteric hip fractures: a randomized prospective study. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2018 Oct 17-20; Orlando, FL. Paper no. 68.
10. Collinge C, Rodriguez-Buitrago A, Mir H, Sems A, Scolaro J, Crist B, Bergin P, Ahn J, Hsu J, Schmidt A, Tejwani N, Virkus W, Weber T, Mullis B, Gardner M, Liporace F, Avilucea F, Horwitz D, Hymes R, Coles C. Results of operative fixation for femoral neck fractures in patients aged 18 to 59 years: a study of 16 centers and 596 cases. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2018 Oct 17-20; Orlando, FL. Paper no. 69.
11. Andersen MR, Frihagen F, Hellund JC, Madsen JE, Figved W. Randomized trial comparing suture button with single syndesmotic screw for syndesmosis injury. J Bone Joint Surg Am. 2018 Jan 3;100(1):2-12.
12. Shimozono Y, Hurley ET, Myerson CL, Murawski CD, Kennedy JG. Suture button versus syndesmotic screw for syndesmosis injuries: a meta-analysis of randomized controlled trials. Am J Sports Med. 2018 Nov 26 [Epub ahead of print].
13. Onggo JR, Nambiar M, Phan K, Hickey B, Ambikaipalan A, Hau R, Bedi H. Suture button versus syndesmosis screw constructs for acute ankle diastasis injuries: a meta-analysis and systematic review of randomised controlled trials. Foot Ankle Surg. 2018 Nov 22 [Epub ahead of print].
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