What’s New in Orthopaedic Trauma

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Clavicle Most acromioclavicular joint injuries do not require fixation; however, more displaced dislocations may benefit from operative intervention. One meta-analysis compared the results of hook plate fixation only with those of hook plate fixation plus coracoclavicular augmentation. Pooling 474 patients with Rockwood type-III or V injuries from 1 randomized controlled trial (RCT) and 4 case-control trials, acromion osteolysis odds (odds ratio [OR], 0.27 [95% confidence interval (CI), 0.10 to 0.74]; p = 0.01) and coracoclavicular distance (weighted standardized mean difference, –0.29 [95% CI, –0.57 to –0.01]; p = 0.04) decreased with coracoclavicular augmentation. However, these changes did not translate to improvements in pain or functional outcomes, as Constant-Murley, American Shoulder and Elbow Surgeons (ASES), University of California Los Angeles (UCLA) shoulder rating, and visual analog scale (VAS) pain scores did not differ. A small RCT (n = 30) also evaluated coracoclavicular augmentation in the setting of distal clavicular fixation; the authors compared the results of traditional hook plate fixation with those of anatomically contoured locking plate fixation plus coracoclavicular augmentation. At the 12-month follow-up, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Constant-Murley scores did not differ. The authors did not comment on implant removal2. Proximal Humerus The optimal treatment for proximal humeral fractures continues to generate debate. A 2022 updated Cochrane Review evaluated randomized trials comparing treatments for acute proximal humeral fractures in adults. The results applied most saliently to patients who were >60 years of age and had low-energy mechanisms. Ten trials (717 total patients, including 473 patients with 3- or 4-part fractures) cumulatively showed no clinically meaningful functional difference between operatively and nonoperatively treated groups at 6, 12, or 24 months and no differences in quality of life at 12 months. Low-certainty evidence indicated an extra 38 subsequent operations per 1,000 operatively treated patients (95% CI, 8 to 94 extra subsequent operations per 1,000 operatively treated patients) compared with nonoperatively treated patients. Low-quality evidence suggested equivalent functional outcomes between locked plating and intramedullary nail fixation. The review did not evaluate arthroplasty compared with open reduction and internal fixation (ORIF)3. Although some recent studies have suggested better outcomes following reverse total shoulder arthroplasty (TSA) compared with ORIF for proximal humeral fractures, no high-quality RCTs have compared closed management with reverse TSA. As such, the best evidence to date suggests that a surgical procedure does not improve outcomes in low-energy, geriatric, proximal humeral fractures compared with closed management. Proximal humeral fractures with concomitant irreducible dislocations warrant operative intervention. However, the energy involved in these injuries increases the risk of devascularization of the humeral head. A systematic review of 12 studies evaluated ORIF of proximal humeral fracture-dislocations. Although reoperation rates varied, the mean rate was 35.6%, including a 10.7% rate of conversion to arthroplasty. Thus, surgeons should counsel patients with regard to the high likelihood of secondary intervention following ORIF4. Given the risks of implant failure, nonunion, and osteonecrosis associated with ORIF of displaced proximal humeral fractures, some authors have proposed acute reverse TSA as the preferred treatment recommendation. An economic analysis conducted in parallel to a multicenter RCT of reverse TSA compared with ORIF of displaced proximal humeral fractures showed the mean cost of reverse TSA (€36,755) to be higher than that of ORIF (€31,953), but the plots were centered around the origin in a probabilistic sensitivity analysis with 1,000 replications. This cost-utility analysis suggests no difference between the 2 groups5. Distal Humerus and Elbow Geriatric distal humeral fractures present unique fixation challenges. At times, fracture severity may be coupled with osteopenia, generating an unreconstructible entity. The surgeon may opt for elbow hemiarthroplasty (HA) (distal humerus only) or total elbow arthroplasty (TEA) (distal humerus and proximal forearm). A meta-analysis of 29 studies compared functional outcomes and complications for HA and TEA, and showed that HA yielded better mean scores for the DASH (19.6 compared with 38) and QuickDASH (the abbreviated version of the DASH questionnaire) scores (17.2 compared with 24.9). Both techniques had high complication rates (approximately 22%). However, the authors noted heterogeneity and small sample sizes in the included studies6. Radial head fractures may also benefit from replacement, especially if there are ≥3 fracture fragments. Two radial head arthroplasty designs exist: unipolar and bipolar. A systematic review and meta-analysis of 591 patients evaluated range of motion, functional outcomes, pain, and complications for both implants. No differences existed in any of these domains7. Although future studies may demonstrate treatment differences, current evidence has suggested equivalent outcomes, so implant cost considerations should drive the choice of prosthesis. Distal Radius and Wrist Many geriatric distal radial fractures have acceptable outcomes with closed management. Several randomized studies have demonstrated no difference in functional outcomes between closed reduction and casting (CR) and volar locking plating (VLP) at 12 months. A secondary analysis of an RCT evaluating CR compared with VLP assessed outcomes at 24 months in approximately 90% of the original cohort. No clinically important differences occurred in Patient-Rated Wrist Evaluation (PRWE) scores (13.6 points for VLP fixation compared with 15.8 for CR; p = 0.50) or complication rates. Despite this, only 44.6% of the CR group perceived their treatment as “very successful,” compared with 75% of the VLP group. The reasons remain unclear but may include preexisting perceptions with regard to the benefits of a surgical procedure8. Debate remains with regard to the necessity of elbow immobilization following closed reduction and splinting of distal radial fractures. In a study of 89 patients randomized to a sugar-tong splint or a clam-shell splint, equivalent DASH scores, loss of reduction rates, and surgical conversion were reported. Thus, avoiding elbow immobilization appears to be safe and may minimize elbow stiffness, although this study did not measure the final elbow range of motion9. Scaphoid fractures have high rates of nonunion secondary to retrograde blood supply, with the osteonecrosis risk increasing with more proximal fractures. A systematic review and meta-analysis investigated union rates of scaphoid nonunions managed with vascularized and nonvascularized grafting techniques. This study included 7,671 patients, and no differences in mean union rate (p = 0.6) were noted between nonvascularized grafts (88.7% [95% CI, 85.0 to 92.5]) and vascularized grafts (87.5% [95% CI, 82.8 to 92.2]). The fixation technique and type of graft also did not influence union rates. However, multiple studies excluded patients with proximal pole fractures and those with osteonecrosis; these studies showed significantly higher mean union rates (96.5%) than in the remaining studies (86.8%), suggesting bias and lowering the certainty of the results10. Hip Arthroplasty represents the current standard of care for displaced femoral neck fractures in adults. However, the type of arthroplasty (HA compared with total hip arthroplasty [THA]) and cemented compared with uncemented constructs remain controversial. A Cochrane Review of 58 RCTs including 10,654 patients reported that HA performed with cement had lower intraoperative fracture risk (relative risk [RR], 0.20 [95% CI, 0.08 to 0.46])

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