What’s New in Orthopaedic Trauma

Shoulder The treatment of displaced proximal humeral fractures remains controversial. An updated systematic review and meta-analysis compared conservative treatment and surgical treatment (plating, nailing, or arthroplasty) of displaced fractures in adults ≥50 years of age1. Twenty-two trials (1,814 patients) were included, and no meaningful differences in clinical outcome or range of motion were identified. Complications were 3.3 times higher in the surgical treatment group. However, the study did not differentiate among 2-part, 3-part, or 4-part fractures. It also included both randomized controlled trials (RCTs) and comparative observational studies, which may have been impacted by a high risk of bias. Surgical treatment may be warranted in select populations. The lack of restoration of the medial column has been suggested to contribute to fixation failure. An RCT compared clinical and radiographic outcomes following locking plate fixation with (39 patients) or without (41 patients) a fibular allograft for proximal humeral fractures with medial column comminution2. There was no clinically important improvement in the Disabilities of the Arm, Shoulder and Hand (DASH) score or improvement in postoperative radiographs with addition of fibular allograft augmentation at 1 year. In certain fractures in the elderly population, reverse shoulder arthroplasty is chosen for definitive treatment. However, the ideal timing for a surgical procedure is unclear. A systematic review and meta-analysis compared outcomes following acute and delayed reverse shoulder arthroplasty (≥4 weeks after the injury) in patients ≥65 years of age3. Sixteen studies were included, and the overall complication rate was higher in the delayed group (18.5%) compared with the acute group (11.7%). Patients who underwent acute reverse shoulder arthroplasty also had better range-of-motion measurements as well as better American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores. The results suggest that the surgical timing of arthroplasty for fracture treatment is important. High-grade injuries to the acromioclavicular joint may warrant fixation. Controversy remains with regard to the best type of fixation. A systematic review compared outcomes following suture button fixation (363 patients) and hook plate fixation (432 patients) for acute injuries (≤21 days)4. Fourteen comparative studies were included, with suture button fixation being performed arthroscopically (6 studies) or with an open technique (8 studies). A clinically important difference was not noted in visual analog scale (VAS) pain, coracoclavicular distance, or complications. However, the arthroscopic suture button technique appeared to yield higher Constant-Murley scores than hook plate fixation. This study was limited by not accounting for the grade of displacement. A meta-analysis of RCTs examined a more homogenous group of displaced acromioclavicular dislocations (Rockwood types III to V) to help to define optimal surgical treatment5. Twenty-six trials with 1,581 patients were included, with 10 different treatment options. Coracoclavicular fixation with a cortical button and either graft augmentation or acromioclavicular fixation improved pain and functional outcomes (Constant-Murley and DASH scores) while reducing recurrence rates. Older techniques such as a hook plate, Kirschner wire fixation, and screw fixation appeared to yield lower VAS pain, Constant-Murley, and DASH scores compared with more contemporary techniques. Humeral Shaft and Elbow Humeral shaft fractures have historically been predominantly treated nonoperatively, but recent studies have suggested that nonunion rates are much higher than previously reported. A meta-analysis of 21 RCTs compared functional bracing with various operative fixation techniques6. Bracing had a significantly higher rate of nonunion (17.4%) than open reduction and internal fixation (ORIF) (5.2%), minimally invasive plate osteosynthesis (0.6%), and antegrade nailing (6.1%). However, not surprisingly, there was a higher rate of an iatrogenic radial nerve palsy with ORIF (6.3%) compared with bracing (0.5%). This study noted that functional bracing has a high rate of nonunion and a rate of 20.5% of conversion to surgical intervention, which is an important topic on which to counsel patients. Heterotopic ossification is a known complication following elbow trauma. An RCT evaluated the impact of postoperative indomethacin on heterotopic ossification formation following surgical treatment of an elbow fracture and/or dislocation by evaluating radiographs at 1 year7. There was an overall high rate of heterotopic ossification (52%), but this was not different between those who received indomethacin and those who received placebo. Functional outcomes and complications were similar as well. These results suggest no apparent benefit to indomethacin for heterotopic ossification prophylaxis after elbow trauma. Distal Radius and Wrist Previous meta-analyses comparing operative and nonoperative treatments of distal radial fractures have focused on long-term outcomes (>1 year). A network meta-analysis of 23 RCTs compared treatment of patients ≥50 years of age, focusing on short-term (3 months) and intermediate-term (>3 months to 1 year) patient-reported outcomes8. At both time points, ORIF with volar locked plating yielded significant improvements in DASH and Patient-Rated Wrist Evaluation (PRWE) scores compared with casting. There was no difference in complications between groups at 1 year. The authors suggested that ORIF may be reasonable to offer older adults who desire a more rapid recovery. Volar locked plate fixation is the most frequently used surgical technique for the treatment of distal radial fractures in adults. Adjuvant arthroscopy has been suggested to help to improve articular reduction while also evaluating and treating other concomitant soft-tissue injuries. An RCT evaluated the impact of arthroscopy with volar locked plate fixation on functional outcomes at 1 year in patients >18 years of age9. Although additional lesions were identified with arthroscopy, there was ultimately no difference in the median PRWE score between the groups. However, this study was underpowered. Although the surgical standard of care for distal radial fractures is volar plating, there are circumstances in which application of an external fixator may be advantageous, such as gross contamination or soft-tissue loss. An RCT evaluated the impact of the direction of force exertion with an external fixator on radiographic and clinical outcomes of distal radial fractures10. Specifically, they compared distractive forces parallel to the radial shaft and perpendicular to the articular surface. Distractive force exerted perpendicularly improved palmar tilt and restoration of radial height and inclination on 6-week radiographs. However, no clinical difference was noted at 12 weeks. Ulnar styloid fractures associated with distal radial fractures are typically treated nonoperatively. Debate remains with regard to the management of very distal ulnar fractures involving the ulnar head or metaphysis. A systematic review of 17 studies compared complications and reoperations following nonoperative treatment (209 fractures), ORIF (237 fractures), and distal ulnar resection (66 fractures)11. ORIF had the highest complication rate (14.3%) and reoperation rate (9.3%). However, definitive conclusions are limited given that the ORIF population was younger, and there was a trend for the fractures to be more complex. Proximal Femur The importance of an anatomic reduction for a femoral neck fracture is clear, but the optimal implant for fixation remains unclear. A systematic review and meta-analysis compared the femoral neck system with cannulated screws12. Eight studies with 448 patients were included. Although there was no difference in intraoperative time, significantly fewer fluoroscopic shots were used in the femoral neck system group (weighted mean difference, −10.16 [95% confidence interval (CI), −11.44 to −8.88]). The femoral neck system also resulted in shorter healing times (weighted mean difference, −1.54 months [95% CI, −2.38 to −0.70 months) as well as less femoral neck shortening (weighted mean difference, −2.01 mm [95% CI, −3.11 to −0.91 mm]). There was no difference in nonunion rates, but there was less evidence of femoral-head necrosis and implant failure or cutout with the femoral-neck system. VAS and Harris hip scores were also improved in the femoral-neck system group. However, all of the studies included were retrospective, and the follow-up time was quite short in most of them. Arthroplasty remains the standard of care for displaced femoral neck fractures in older adults. Controversy exists with regard to an increased use of antibiotic-loaded cement during arthroplasty, with concerns regarding renal toxicity and increasing antibiotic resistance13. An RCT of nearly 5,000 patients who underwent hemiarthroplasty compared the rates of deep surgical site infection between patients who received high-dose, dual-antibiotic-loaded cement (gentamycin and clindamycin) and patients who received single-antibiotic-loaded cement (gentamycin). No appreciable benefit for the high-dose antibiotic cement was noted. The optimal treatment of nondisplaced femoral neck fractures in the elderly population remains debatable. A meta-analysis of 3 RCTs compared internal fixation and hemiarthroplasty14. Hemiarthroplasty was associated with earlier recovery and better quality of life as noted by better Harris hip scores at 6 months and EuroQol-5 Dimensions (EQ-5D) at 1 year. The EQ-5D was equivocal at 2 years. Internal fixation had a higher implant-related complication rate (relative risk, 3.18) and reoperation rate (relative risk, 3.30), but less blood loss and operative time. Hip fracture surgical procedures in elderly patients can often be delayed for a multitude of reasons, including medical optimization or operating room availability, and preoperative pain control is of utmost importance. A recent RCT assessed the impact of skeletal traction on pain in patients with a stable intertrochanteric femoral fracture15. Skin traction did not impact the VAS pain score or morphine usage at 2 hours prior to the surgical procedure or 24 hours after the surgical procedure. The authors did not appreciate any benefit to skin traction for an isolated stable intertrochanteric femoral fracture. Distal Femur and Proximal Tibia Periprosthetic distal femoral fractures remain challenging in the elderly population and there are proponents of both distal femoral replacement and ORIF. A systematic review and meta-analysis evaluated 32 studies comparing complications between 977 patients who underwent ORIF and 281 patients who underwent distal femoral replacement16. The authors did not identify any difference in surgical complications or reoperations, but did note a higher medical complication rate in the distal femoral replacement group (23.1%) compared with the ORIF group (8.5%). The authors suggested that this may be secondary to prolonged operative time or selection bias. However, the overall quality of studies was low and, although dual-implant fixation was included with the ORIF group, the number of patients were limited, given the older study time frame. Conventional plating of proximal tibial fractures was prone to varus deformity, and early techniques of intramedullary nailing were prone to valgus and procurvatum deformities. Locked plating and modern nailing with new techniques and instrumentation have helped to improve results. A multicenter RCT compared locked plating (47 patients) with intramedullary nailing (52 patients) for extra-articular proximal tibial fractures17. At 12 months, there was no difference in patient-reported outcomes, complications, or malalignment. Regardless of the surgical technique, patients continued to have high residual disability at 1 year. Pediatrics Optimal treatment strategies for tibial spine fractures in children and adolescents remain unclear. A systematic review of 47 studies was performed evaluating 1,922 patients (<18 years old) with tibial spine fractures18. Patients underwent nonoperative treatment (297), ORIF (291), or arthroscopic reduction and internal fixation (1,236). Arthrofibrosis was noted in 11.2% of patients, but there was no notable difference between open or arthroscopic fixation or between fixation types (screw compared with suture). Overall good outcomes were achieved despite the different techniques. This review was limited by most studies having a Level of Evidence of IV. Radiographs are routinely made when fractures of the distal forearm are suspected in the pediatric population. However, radiography is not always readily available in low-income and middle-income countries or in rural and remote centers. A noninferiority RCT compared diagnostic radiography and ultrasonography for patients 5 to 15 years old with a clinically nondeformed distal forearm injury19. The Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Upper Extremity Short Form scores at 4 weeks in the ultrasonography group were similar and noninferior to those in the radiography group, suggesting its potential diagnostic use for children with nondeformed distal forearm injuries. Blood Loss and Transfusion A Cochrane Review examined different pharmacologic interventions for reducing blood loss during surgical treatment of hip, pelvic, and long-bone fractures20. Nine trials involved intravenous tranexamic acid (7) or topical tranexamic acid (2) compared with placebo. Intravenous tranexamic acid may slightly reduce the risk of requiring a blood transfusion at up to 30 days (risk ratio, 0.48). However, it is unclear if topical tranexamic acid has any impact on the need for transfusion. It is also unclear if tranexamic acid via any route has any impact on thrombotic events. However, there are many ongoing trials to help to elucidate this. A separate network meta-analysis compared the impact of different doses of intravenous tranexamic acid on hip fractures21. Specifically, they looked at high-dose use (≥20 mg/kg or >1 g) and low-dose use compared with no tranexamic acid in 19 RCTs. The use of both high-dose and low-dose tranexamic acid decreased the number of transfusions required, with no significant increase in thrombotic events. However, they were unable to draw a conclusion regarding the optimal dosage for administration. This topic was further examined with an additional Cochrane Review evaluating tranexamic acid and iron use with hip fractures22. They concluded with moderate confidence that tranexamic acid reduces the need for blood transfusion in adults who undergo a surgical procedure for a hip fracture. Intravenous iron appeared to make little or no difference in the need for transfusion, but this was based on only 2 studies and, therefore, the confidence in these findings was low. Perioperative Pain Management There has been a large focus on multimodal pain therapy to decrease opioid use in orthopaedic trauma. An RCT evaluated the impact of an intraoperative hematoma block after intramedullary nail fixation of femoral shaft fractures23. Forty-one patients received 20 mL of 0.5% ropivacaine and 41 patients received 20 mL of normal saline solution at the fracture site. The ropivacaine group had significantly lower VAS pain scores and lower opioid consumption during the first 24 hours. As most patients were discharged on postoperative day 1, it is unclear what benefit exists after 24 hours. ORIF of clavicular fractures is often performed under regional anesthesia with an interscalene block and an intermediate cervical plexus block. An RCT compared this with a C3, 4, and 5 nerve root block for midshaft and medial clavicular fractures24. More patients in the nerve root block group had a successful block, defined as not requiring general anesthesia (97% compared with 68%). The mean onset time was significantly shorter (2.5 compared with 12 minutes), and the block lasted longer. Furthermore, decreased analgesia was required postoperatively in the nerve root block. However, safety was unable to be assessed because of the small sample size (62 patients), given that serious complications are uncommon. There are continued efforts to reduce perioperative complications secondary to narcotics in hip fracture surgery, especially in the elderly population. An RCT evaluated the effect of a multimodal local cocktail injection of bupivacaine, morphine sulfate, and ketorolac at the time of the surgical procedures (excluding arthroplasty)25. In the first 24 hours, VAS pain scores were improved, and there was decreased narcotic use, in the multimodal group. Patients had improved ambulation distance on postoperative days 2 and 3. They also noted less pain, less trouble falling and staying asleep, less anxiety, and less drowsiness compared with the control group based on the American Pain Society Patient Outcome Questionnaire (APS-POQ). Follow-up at 6 weeks demonstrated continued improved quality of life as well. These data suggest that intraoperative multimodal analgesia is effective in the population with a hip fracture. Another RCT in elderly patients with a hip fracture evaluated the impact of an ultrasound-guided pericapsular nerve group (PENG) block compared with a sham block26. The primary end point was the pain score (0 to 10) at 30 minutes after the block. The authors noted improvement in scores with the PENG block (3) compared with the control group (5) at this time. They also noted decreased opioid use in the first 24 hours. However, their results were limited by the absence of standardization of the timing of the surgical procedure after the block was performed. Only 10 of 57 patients underwent a surgical procedure within 24 hours of the block. Miscellaneous Topics Venous thromboembolism can potentially be a fatal complication following orthopaedic trauma. The Major Extremity Trauma Research Consortium conducted an RCT at 21 trauma centers to compare the efficacy and safety of aspirin (81 mg twice daily) and low-molecular-weight heparin (30 mg twice daily) in patients ≥18 years old who had an operatively treated fracture or a nonoperatively treated pelvic or acetabular fracture27. Over 12,000 patients were enrolled, and there was no difference in mortality at 90 days between the groups. The incidence of pulmonary embolism in both groups was 1.49%. The authors concluded that aspirin was noninferior to low-molecular-weight heparin for blood clot prophylaxis. Thorough debridement of osteomyelitis and infected nonunions often result in bone defects that are challenging to manage. An RCT was performed to compare the conventional bone transport technique (1 stage) with a bone transport technique through an induced membrane (2 stage)28. The latter technique included debridement and placement of an antibiotic spacer in the first stage, and spacer removal and a metaphyseal osteotomy in the second stage. Fifteen patients were in each group, and the minimum follow-up was 1 year after external fixator removal. Functional outcomes, using the Association for the Study and Application of the Methods of Ilizarov, were not different between groups. The induced membrane technique had a lower mean docking time (4.8 compared with 3.6 months), a lower docking site nonunion rate (0% compared with 40%), and a lower rate of infection recurrence (0% compared with 33.3%). However, the patients in the induced membrane group were younger, had undergone more previous operations, and had fewer Pseudomonas pathogens isolated. Ultrasound and shock wave therapy have been suggested as adjuvants to assist in acute fracture healing. A Cochrane Review evaluated 21 studies, with all except 1 testing low-intensity ultrasound (LIPUS)29. The other study examined extracorporeal shockwave therapy. There was substantial heterogeneity, complicating interpretation of results. However, with the available data, there was no clear impact on quality of life or time to union with LIPUS or shockwave therapy for acute fractures. Trauma Systems The biggest opportunity to improve trauma care will stem from addressing the disparities in trauma systems. There are extraordinary differences in the structure and regulation of trauma systems in the United States. Regulations governing trauma care are established by states and, in the absence of a national health system, there are major differences between states, resulting in highly variable quality. The hallmarks of a model trauma system are a legislative framework and laws that specify a trauma authority with clear responsibility, including sanctions, for regulating most if not all of the agents within the trauma system, including first responders, transport services, emergency care, and hospitals designated as trauma centers. The legislative framework ideally includes mechanisms to support trauma services through specific financing mechanisms based on taxation, user fees, and/or reimbursement adjustments. Washington and Maryland are 2 states with highly regulated model systems. States with limited regulation and a wide range of hospitals, including public, nonprofit, and for-profit health-care facilities, have notable differences in performance and outcomes30. The standardization of trauma care in the United Kingdom with the establishment of a "trauma czar," an executive role within the National Health Service (NHS), led to a reduction in the number of designated centers and lower mortality, estimated to have saved 600 lives per year following implementation. Orthopaedic Trauma Association (OTA) Annual Meeting and Educational Resources The 2024 OTA Annual Meeting is planned for October 23 to 26, 2024, in Montreal, Quebec, Canada. In addition to research presentations, symposia, case presentations, and technical sessions, multiple premeeting events are planned. This will include the International Trauma Care Forum, coding and billing, the Young Practitioners Forum, pelvic and acetabular fractures, and a soft-tissue coverage course. The guest nation for 2024 will be Colombia. The OTA provides multiple additional educational offerings, including Fracture Night in America, additional webinars, and podcasts; up-to-date schedules are available online at www.ota.org. OTA Online (www.otaonline.org) has continued to grow in content with new surgical technique videos, core curriculum lectures, an evidence-based medicine resource list, and an online textbook being published soon. Evidence-Based Orthopaedics The editorial staff of JBJS 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, 4 other articles relevant to orthopaedic trauma surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Händel MN, Cardoso I, von Bülow C, Rohde JF, Ussing A, Nielsen SM, Christensen R, Body JJ, Brandi ML, Diez-Perez A, Hadji P, Javaid MK, Lems WF, Nogues X, Roux C, Minisola S, Kurth A, Thomas T, Prieto-Alhambra D, Ferrari SL, Langdahl B, Abrahamsen B. Fracture risk reduction and safety by osteoporosis treatment compared with placebo or active comparator in postmenopausal women: systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. BMJ. 2023 May 2;381:e068033. Postmenopausal women are at high risk for osteoporosis. A network meta-analysis was conducted to compare the effectiveness of different treatment types on the risk of fractures in postmenopausal women while also considering baseline risk factors. The results were based on 69 trials with >80,000 patients. Bisphosphonates, parathyroid hormone receptor agonists, and romosozumab each reduced the overall fracture risk compared with placebo. Anabolic agents were more effective in reducing the risk of fractures compared with bisphosphonates in postmenopausal women, thus suggesting that there was no evidence that anabolic agents should only be restricted to those at high risk for fractures. This study offers evidence supporting current medications to treat postmenopausal osteoporosis by reducing the risk of fractures. Miksch RC, Herterich V, Barg A, Böcker W, Polzer H, Baumbach SF. Open reduction and internal fixation of the posterior malleolus fragment in ankle fractures improves the patient-rated outcome: a systematic review. Foot Ankle Int. 2023 Aug;44(8):727-37. Debate has continued with regard to the best treatment of posterior malleolar fractures in the ankle. Many have advocated for fixation not only to restore osseous anatomy and the articular surface, but also for ligamentous stability of the syndesmosis. A systematic review compared patient-rated outcomes between ORIF of the posterior malleolus and closed reduction and internal fixation (CRIF) or no fixation in bimalleolar or trimalleolar ankle fractures. Only 6 of the 12 studies identified were included for quantitative analysis, and this analysis was limited by heterogeneity, including in fragment size, the fractures included, and the surgical approach. The American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score was noted in 4 studies to be better in the ORIF group (90.9 points) compared with the CRIF group (83.4 points). In 3 studies, the AOFAS score was higher in the ORIF group (92.0) compared with nonoperative management of the posterior malleolar fragment (82.5 points). The findings of this study support ORIF as the best treatment for posterior malleolar fractures to achieve optimal clinical outcomes. Phang JK, Lim ZY, Yee WQ, Tan CYF, Kwan YH, Low LL. Post-surgery interventions for hip fracture: a systematic review of randomized controlled trials. BMC Musculoskelet Disord. 2023 May 25;24(1):417. A systematic review summarized postoperative interventions after hip fracture surgery and their impact on outcomes and mortality. Sixty-three percent of the 109 RCTs identified were focused on rehabilitation or medication and nutrition supplementation. Rehabilitation interventions involved inpatients and outpatients. All supplementation interventions except anabolic steroids were beneficial. Not surprisingly, no studies focusing on post-discharge osteoporosis management demonstrated worse outcomes. The authors did note that compliance issues in this population could contribute to the lack of positive outcomes. Future studies should be performed to evaluate and assess the cost-effectiveness of these interventions. This study adds to the body of evidence supporting the benefit of postoperative interventions after hip fractures. Zheng R, Fan Y, Guan B, Fu R, Yao L, Wang W, Li G, Zhou Y, Chen L, Feng S, Zhou H. A critical appraisal of clinical practice guidelines on surgical treatments for spinal cord injury. Spine J. 2023 Dec;23(12):1739-49. A critical appraisal of guidelines for the surgical treatment of spinal cord injury was conducted, as recommendations have varied. Ten guidelines were identified, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was utilized for appraisal. All guidelines were flawed in the domain of applicability. The grades of recommendation (referred to in this study as the Levels of Evidence) for 14 recommendations (8 evidence-based and 6 consensus-based) were graded as B (8), C (3), and D (3). With these noted limitations, they concluded that most guidelines (80%) recommended early surgical treatment after spinal cord injury. Timing varied, but was usually between 8 and 48 hours. Despite flaws in the guidelines, the findings of this study support early surgical treatment for patients with spinal cord injury to improve neurological recovery and decrease complications.