Tag Archive | hemiarthroplasty

A Real-World Economic Evaluation: TSA vs Hemiarthroplasty

In a new study reported in JBJS, Lapner et al. conducted a cost-utility analysis of total shoulder arthroplasty (TSA) versus hemiarthroplasty from the perspective of Canada’s publicly funded health-care system. They used a Markov model to simulate the costs and quality-adjusted life-years (QALYs) for patients undergoing either TSA or hemiarthroplasty over a lifetime horizon to account for costs and medically important events over the patient lifetime. Subgroup analyses by age groups (≤50 or >50 years) were also performed.

Discussing their findings, the authors note:

Our analysis demonstrated that TSA was more cost-effective compared with hemiarthroplasty. This study involved a large cohort of patients (5,777) who underwent TSA or hemiarthroplasty. The data demonstrate that, despite the additional initial cost of TSA implants, health-care utilization postoperatively was greater for hemiarthroplasty compared with TSA and utility scores for hemiarthroplasty were inferior. Our findings can help inform both clinical decision-making as well as health-care policy with respect to these treatments.”

Click here for the full JBJS report.

What’s New in Orthopaedic Trauma 2021 

Every month, JBJS publishes a review of the most pertinent and impactful studies reported in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.

This month, co-author Mai P. Nguyen, MD summarizes the 5 most compelling findings from the >30 studies highlighted in the recently published “What’s New in Orthopaedic Trauma.”

Proximal Humeral Fracture 

–The DelPhi (Delta prosthesis-PHILOS plate) study, a multicenter, single-blinded, randomized controlled trial (RCT), evaluated the outcomes of reverse shoulder arthroplasty vs open reduction and internal fixation for displaced proximal humeral fractures in elderly patients. The results favored reverse shoulder arthroplasty (mean 2-year Constant-Murley score of 68.0 vs. 54.6 points for the 2 groups, respectively).

Hip Fracture 

–An RCT comparing hemiarthroplasty with or without cement in elderly patients with a displaced intracapsular fracture of the hip found better results for cemented hemiarthroplasty1. The number of mortalities was slightly higher in the uncemented group, although not significantly so (64 patients compared with 51; p 0.18). Although pain scores and reoperations were similar between the groups, better recovery of mobility was noted for the cemented group.

Proximal Femoral Fracture 

–Another recent RCT investigated the efficacy of a preoperative fascia iliaca compartment block (FICB) for patients with proximal femoral fractures (neck, intertrochanteric, or subtrochanteric regions)2. Lower morphine consumption (0.4 vs 19.4 mg; p = 0.05) and greater patient-reported satisfaction (31%; p = 0.01) were noted for the FICB cohort.

Ankle Fracture

–Among patients treated for unstable, rotational-type ankle fractures, a prospective RCT compared weight-bearing at 2 vs 6 weeks postoperatively3. Early weight-bearing at 2 weeks was associated with higher EuroQol-5 Dimension (EQ-5D) visual analog scale (VAS) scores at the 6-week follow-up. No difference, however, was seen at later follow-up time points.

Recovery After Trauma 

–The impact of trauma recovery services (TRS), which provide education and psychosocial support to patients with trauma and their families, was assessed in a recent study4. A total of 294 patients with operatively treated extremity fractures were prospectively surveyed. Injury, social, and demographic characteristics were studied for a possible association with patient-satisfaction scores. Use of TRS was the greatest predictor of better overall care ratings.

References

  1. Parker MJ, Cawley S. Cemented or uncemented hemiarthroplasty for displaced intracapsular fractures of the hip: a randomized trial of 400 patients. Bone Joint J. 2020 Jan;102-B(1):11-6.
  2. Thompson J, Long M, Rogers E, Pesso R, Galos D, Dengenis RC, Ruotolo C. Fascia iliaca block decreases hip fracture postoperative opioid consumption: a prospective randomized controlled trial. J Orthop Trauma. 2020 Jan;34(1):49-54.
  3. Schubert J, Lambers KTA, Kimber C, Denk K, Cho M, Doornberg JN, Jaarsma RL. Effect on overall health status with weightbearing at 2 weeks vs 6 weeks after open reduction and internal fixation of ankle fractures. Foot Ankle Int. 2020 Jun;41(6):658-65. Epub 2020 Mar 6.
  4. Simske NM, Benedick A, Rascoe AS, Hendrickson SB, Vallier HA. Patient satisfaction is improved with exposure to Trauma Recovery Services. J Am Acad Orthop Surg. 2020 Jul 15;28(14):597-605.

JBJS Webinar June 28–Femoral Neck Fractures: The THA vs Hemi Toss-Up

Consulting with their patients, orthopaedic surgeons make many decisions each day by weighing the best evidence available. One frequent—and controversial—decision is how best to treat displaced femoral neck fractures, a common injury among elderly patients.

Often this choice comes down to hemiarthroplasty (HA) or total hip arthroplasty (THA). The preponderance of evidence suggests that outcomes from both procedures are nearly equivalent. On Monday, June 28, 2021 at 8 pm EDT, JBJS will host a complimentary 1-hour webinar delving into the most recent findings about this dilemma. 

Mohit Bhandari, MD, PhD will present findings from a 2020 Level-I meta-analysis of 16 randomized controlled trials. Functional outcomes and 5-year rates of revision and dislocation were similar between groups. THA eked out a small advantage in health-related quality of life, and HA yielded minor reductions in operative time.

Bheeshma Ravi, MD, PhD will discuss data comparing the 2 procedures in terms of complications and costs. Based on findings from this propensity score-matched analysis, the nod goes to THA, with lower 1-year rates of revision surgery and lower health-care costs. 

Moderated by Bassam A. Masri, MD, FRCSC, the webinar will feature expert commentaries on these “neck-and-neck” findings. Pierre Guy, MD will comment on Dr. Bhandari’s paper, and Kelly Lefaivre, MD will weigh in on Dr. Ravi’s paper. 

The webinar will conclude with a 15-minute live Q&A session during which attendees can ask questions of all the panelists. 

Seats are limited–so Register Today!  

CME credit will be available for surgeons and PAs attending this event live for a minimum of 50 minutes. Directions to claim your CME credit will be sent out within 48 hours of the broadcast. 

Life Expectancy Informs Choice of Hemi Implant after Femoral Neck Fracture

Predicting life expectancy is not an exact science. But estimating the remaining years of life in elderly patients with a femoral neck fracture may help orthopaedists determine whether to use unipolar or bipolar hemiarthroplasty components when surgically managing that population. So suggest Farey et al. in the February 3, 2021 issue of The Journal of Bone & Joint Surgery.

The relevant “magic number” for life expectancy after femoral neck fracture is 2.5 years. The authors arrived at that number by performing statistical analyses on nearly 63,000 cases of femoral neck fractures treated with either modular unipolar or bipolar hemiarthroplasty. Patients were in their early 80s on average at the time of surgery. The researchers focused on revision rates because reoperations in this vulnerable group of patients typically yield poor results.

There was no between-group difference in overall revision rate within 0 and 2.5 years after the procedure. However, unipolar hemiarthroplasty was associated with a higher overall revision rate than bipolar hemiarthroplasty beyond 2.5 years after surgery (hazard ratio [HR], 1.86).

Farey et al. also drilled down into reasons for revision and found that unipolar prostheses had a greater risk of revision for acetabular erosion, particularly in later postoperative time periods. Conversely, bipolar hemiarthroplasty was associated with a higher risk of revision for periprosthetic fracture, which the authors surmise might have arisen from the greater range of motion (and therefore activity levels) permitted by bipolar implants.

Although the authors did not perform a formal cost-benefit analysis related to this dilemma, they observed a nearly $1,000 USD price difference between the most commonly used bipolar and unipolar prostheses. Farey et al. therefore propose that the more expensive bipolar prosthesis may be justified for patients with a life expectancy beyond 2.5 years, but that the unipolar design is justified for patients with a postoperative life expectancy of ≤2.5 years.

Click here to listen to a 15-minute OrthoJOE podcast about this topic, featuring JBJS Editor-in-Chief Dr. Marc Swiontkowski and OrthoEvidence Editor-in-Chief Dr. Mo Bhandari.

Click here to see a 3-minute Video Summary of this study.

Click here to read a JBJS Clinical Summary comparing total hip arthroplasty with hemiarthroplasty for displaced femoral neck fractures.

What’s New in Orthopaedic Trauma 2020

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, co-author Niloofar Dehghan, MD, selected the 5 most clinically compelling findings from the >20 studies summarized in the July 1, 2020 “What’s New in Orthopaedic Trauma.

Hip Fracture
—An international randomized controlled trial (RCT) of hip fracture patients ≥45 years of age1 compared outcomes among 1,487 who underwent an “accelerated” surgical procedure (within 6 hours of diagnosis) and 1,483 who received “standard care” (surgery within 24 hours of diagnosis). Mortality and major complication percentages were similar in both groups, but it is important to note that even the standard-care group had a relatively rapid median time-to-surgery of 24 hours.

—An RCT of nearly 1,500 patients who were ≥50 years of age and followed for 2 years2 compared total hip arthroplasty (THA) with hemiarthroplasty for the treatment of displaced femoral neck fractures. There was no between-group difference in the need for secondary surgical procedures, but hip instability or dislocation occurred in 4.7% of the THA group versus 2.4% of the hemiarthroplasty group. Functional outcomes measured with the WOMAC index were slightly better (statistically, but not clinically) in the THA group. Serious adverse events were high in both groups (41.8% in the THA group and 36.7% in the hemiarthroplasty group). Although the authors conclude that the advantages of THA may not be as compelling as has been purported, THA’s benefits may become more pronounced with follow-up >2 years.

—A preplanned secondary analysis of data from the FAITH RCT examined the effect of posterior tilt on the need for subsequent arthroplasty among older patients with a Garden I or II femoral neck fracture who were treated with either a sliding hip screw or cannulated screws. Patients with a posterior tilt of ≥20° had a significantly higher risk of subsequent arthroplasty (22.4%) compared with those with a posterior tilt of <20° (11.9%). In light of these findings, instead of internal fixation, primary arthroplasty may be an appropriate treatment for older patients who have Garden I and II femoral neck fractures with posterior tilt of >20°.

Ankle Syndesmotic Injury
—An RCT that compared ankle syndesmosis fixation using a suture button with fixation using two 3.5-mm screws3 found a higher rate of malreduction at 3 months postoperatively with screw fixation (39%) than with suture button repair (15%). With the rate of reoperation also higher in the screw group due to implant removal, these findings add to the preponderance of recent evidence that the suture button technique is preferred.

Wound Management
—A 460-patient RCT examining the cost-effectiveness of negative-pressure wound therapy4 for initial wound management in severe open fractures of the lower extremity found the technique to  be associated with higher costs and only marginal improvement in quality-adjusted life-years for patients.

References

  1. HIP ATTACK Investigators. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet.2020 Feb 29;395(10225):698-708. Epub 2020 Feb 9.
  2. Bhandari M, Einhorn TA, Guyatt G, Schemitsch EH, Zura RD, Sprague S, Frihagen F, Guerra-Farfán E, Kleinlugtenbelt YV, Poolman RW, Rangan A, Bzovsky S, Heels-Ansdell D, Thabane L, Walter SD, Devereaux PJ; HEALTH Investigators. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med.2019 Dec 5;381(23):2199-208. Epub 2019 Sep 26.
  3. Sanders D, Schneider P, Taylor M, Tieszer C, Lawendy AR; Canadian Orthopaedic Trauma Society. Improved reduction of the tibiofibular syndesmosis with TightRope compared with screw fixation: results of a randomized controlled study. J Orthop Trauma.2019 Nov;33(11):531-7.
  4. Petrou S, Parker B, Masters J, Achten J, Bruce J, Lamb SE, Parsons N, Costa ML; WOLLF Trial Collaborators. Cost-effectiveness of negative-pressure wound therapy in adults with severe open fractures of the lower limb: evidence from the WOLLF randomized controlled trial. Bone Joint J.2019 Nov;101-B(11):1392-401.

Hemi vs THA Findings Helpful, But Not Practice-Changing

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The New England Journal of Medicinethe following commentary comes from Paul E. Matuszewski, MD.

A recent issue of The New England Journal of Medicine published the results from a large, multicenter randomized trial comparing the outcomes of hemiarthroplasty versus total hip arthroplasty (THA) to treat displaced femoral neck fractures in ambulatory adults.

The HEALTH investigators enrolled 1,495 patients in the study, and 85.1% of those patients had complete data for analysis after 2 years. The researchers found no significant differences between the groups with regard to the primary outcome—secondary hip procedures (7.9% in the THA group vs 8.3% in the hemi group). The risk of secondary hip procedures during the first year was higher in the THA group, but the hemiarthroplasty group had a higher risk of secondary procedures in the second year. Open/closed reductions of hip dislocations were the most common secondary procedures among the THA group, and revision to THA was the most common secondary procedure in the hemiarthroplasty group. The THA group had slightly better WOMAC scores, but the difference was not within a clinically significant range. There were no between-group differences noted in other patient-reported outcomes.

The HEALTH investigators followed these patients for only two years, which is notably the standard for many orthopaedic studies, but this short follow-up limits the practical application of these findings. The authors note that after the first year, primary THA was favorable with regard to secondary hip procedures. It is reasonable to think that this difference may become more compelling beyond 2 years, as more patients who received hemiarthroplasty are likely to be converted to THA.

The suggestion that there may not be an early benefit of THA over hemiarthroplasty in the ambulatory adult with a displaced femoral neck fracture contrasts with current recommendations from the American Academy of Orthopaedic Surgeons. However, the 2-year follow-up of this trial represents only a “snapshot” of the continuum of outcomes from these two hip-fracture treatments. The findings may add to our understanding of what our patients can expect during the first 2 years following these procedures, but I would caution surgeons against making any drastic changes to their current practice in response to this data.

Paul E. Matuszewski, MD is the Director of Orthopaedic Trauma Research and Assistant Professor of Orthopaedic Traumatology at the University of Kentucky.

Nondisplaced Femoral Neck Fractures in the Elderly: Minimizing Complications

Trying to educate elderly patients and their family members about how to best treat a femoral neck fracture can be difficult. These patients typically have multiple—and often severe—medical comorbidities that can make even the most “simple” surgery complex and life-threatening. Making such discussions even harder is the lack of Level-I evidence related to treating these common injuries. For severely displaced fractures, the evidence supports performing either a hemi- or total hip arthroplasty on most patients. But the data is much less clear for minimally or nondisplaced fractures.

For these reasons, I was excited to read the study by Dolatowski et al. in the January 16, 2019 issue of JBJS. The authors performed a prospective, randomized controlled trial comparing internal screw fixation to hemiarthroplasty for valgus impacted or nondisplaced femoral neck fractures in >200 patients with a mean age of 83 years. They found that patients who underwent hemiarthroplasty had a significantly faster “up-and-go” test and were significantly less likely to undergo a major reoperation than those who underwent internal fixation. However, patients in the internal-fixation group were less likely to develop pulmonary complications. There were no between-group differences in overall hip function (as evaluated with the Harris hip score) or in the 24-month mortality rate.

This study lends support to what many surgeons tell elderly patients with a nondisplaced femoral neck fracture: a hemi- (or total) arthroplasty will probably provide the lowest risk of needing a repeat operation for the injury, while placing percutaneous screws may decrease the risk of cardiopulmonary complications related to the operation. While these findings may not be surprising, this study provides important Level I data that can help us educate patients and their families so that the best treatment for each individual patient can be determined.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

JBJS Editor’s Choice: How Best to Treat Femoral Neck Fractures in Younger Adults

ORIF or THA for Femoral Neck Fx.gifIn the January 4, 2017 issue of The Journal, Swart et al. provide a well-done Markov decision analysis on the cost effectiveness of three treatment options for femoral neck fractures in patients between the age of 40 and 65: open reduction and internal fixation (ORIF), total hip arthroplasty (THA), and hemiarthroplasty. Plugging the best data available from the current orthopaedic literature into their model, the authors estimated the threshold age above which THA would be the superior strategy in this relatively young population.

For patients in this age group, traditional thinking has been to perform ORIF in order to “save” the patient’s native hip and avoid the likelihood of later revision arthroplasty. However, in this analysis THA emerges as a cost-effective option in otherwise healthy patients >54 years old, in patients >47 years old with mild comorbidity, and in patients >44 years old with multiple comorbidities.

On average, both THA and ORIF have similar outcomes across the age range analyzed. But ORIF with successful fracture healing yields slightly better outcomes and considerably lower costs than THA, whereas patients whose fracture does not heal with ORIF have notably worse outcomes than THA patients. This finding supports my personal bias that anatomical reduction and biomechanically sound fixation must be achieved in this younger population with displaced femoral neck fractures. The analysis confirmed that, because of poor functional outcomes with hemiarthroplasty in this population, hemiarthroplasty should not be considered. Poor hemiarthroplasty outcomes are likely related to the mismatch between the metal femoral head and the native acetabular cartilage, leading to fairly rapid loss of the articular cartilage and subsequent need for revision.

This analysis by Swart et al. provides very valuable data to discuss with younger patients and families when engaging in shared decision making about treating an acute femoral neck fracture. In my experience, most patients in this age group prefer to “keep” their own hip whenever possible, which puts the onus on the surgeon to gain anatomic reduction and biomechanically sound fixation with ORIF.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

JBJS Webinar: Managing Complex Proximal Humeral Fractures

PHF.gifProximal humeral fractures are the third most common occurring fracture in patients over the age of sixty-five years. These fractures are often difficult to accurately classify, and they can also be challenging to treat surgically.

On Tuesday, April 19, 2016 at 8:00 pm EDT, a complimentary webinar, hosted by The Journal of Bone & Joint Surgery, will present findings from two recent JBJS studies that explore the classification and treatment of complex proximal humeral fractures.

Milton Little, MD will examine whether 3D CT imaging helps orthopaedic surgeons classify proximal humeral fractures, and Derek J. Cuff, MD will analyze findings from a study that compared reverse total shoulder arthroplasty with hemiarthroplasty for treating these fractures in elderly patients.

Moderated by JBJS Deputy Editor Andrew Green, MD, the webinar will also feature commentaries on the study findings from shoulder experts Michael J. Gardner, MD and J. Michael Wiater, MD. The last 15 minutes of the webinar will be devoted to a live Q&A session.

Click here to register.

What’s New in Shoulder and Elbow Surgery: Level I and II Studies

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the October 21, 2015 Specialty Update on shoulder and elbow surgery:

Shoulder

–A prospective evaluation of 224 subjects with asymptomatic rotator cuff tears followed annually for an average of five years found that the risk of tear enlargement and muscle degeneration was greater in full-thickness tears, and that pain and supraspinatus muscle degeneration were associated with tear enlargement.

–The authors of a randomized trial comparing physical therapy and primary surgical repair for initial management of degenerative rotator cuff tears concluded that the effects of surgery were not profound enough to justify surgical management for patients who present initially with painful degenerative cuff tears.

–A randomized trial comparing clinical outcomes in 58 patients with a rotator cuff tear and symptomatic acromioclavicular joint arthritis found no differences in function or pain scores between those who underwent cuff repair + distal clavicle resection and those who underwent cuff repair alone.1

–After two years of follow-up, no differences in functional outcomes or rate or quality of postoperative tendon healing were found in a randomized trial comparing patients who received platelet-rich plasma following surgical cuff repair and those who did not.2

–In a three-way randomized trial comparing physical therapy, acromioplasty + physical therapy, and cuff repair + acromioplasty + physical therapy for treating symptomatic, nontraumatic supraspinatus tendon tears in patients older than 55, there were no between-group differences in the mean Constant score one year after treatment.3

–A randomized trial comparing treatments for calcific tendinitis found that ultrasound-guided needling plus a subacromial corticosteroid injection resulted in better functional scores and larger decreases in calcium-deposit size than extracorporeal shock wave therapy.4

–A randomized trial of 196 patients with recurrent traumatic anterior shoulder instability found no significant differences in WOSI and ASES scores or range of motion between groups that underwent open or arthroscopic stabilization procedures.

–A randomized study comparing the effectiveness of immobilization in abduction (15°) and external rotation (10°) versus adduction and internal rotation after primary anterior shoulder dislocation found that after two years, only 3.9% of patients in the abduction/external-rotation group had repeat instability, compared to 33.3% in the adduction/internal-rotation group.5 A separate randomized trial found no significant difference in instability recurrence after one year between a group immobilized in internal rotation (sling) and a group immobilized in adduction and external rotation (brace).6

–A randomized trial of 250 patients (mean age of 65 years) with displaced surgical neck fractures of the proximal humerus compared surgical treatment (internal fixation or hemiarthroplasty) with conservative treatment. Finding no statistically or clinically significant difference in outcomes, the authors concluded that these results do not support the recent trend toward surgical management for proximal humeral fractures.7

–A randomized trial comparing reverse shoulder arthroplasty with hemiarthroplasty for acute proximal humeral fractures found that after two years of follow-up, reverse arthroplasty yielded better functional scores, better active elevation, and fewer complications than hemiarthroplasty.8

–A randomized trial comparing the use of concentric and eccentric glenospheres in reverse shoulder arthroplasty revealed no differences in scapular notching rates or clinical outcomes at a minimum follow-up of two years.

–A systematic review comparing radiographic and clinical survivorship of all-polyethylene versus metal-backed glenoid components used in total shoulder arthroplasty found that all-poly glenoids had a higher rate of radiolucencies and radiographic loosening but a much lower rate of revision after a mean follow-up of 5.8 years.

–A retrospective review found that arthroscopic biopsy was much more accurate than fluoroscopically guided fluid aspiration in diagnosing periprosthetic shoulder infections caused by Propionibacterium acnes.

–In a randomized trial of 76 workers’-comp patients with a displaced midshaft clavicular fracture, those receiving surgical management had faster time to union and return to work and better Constant scores than those managed conservatively.9

–Two studies compared plate fixation with intramedullary fixation for stabilizing clavicular fractures. One that randomized 59 patients found no differences in functional outcomes or time to healing. The other, which randomized 120 patients, found no between-group differences in DASH or Constant-Murley scores, but shoulder function improved more quickly in the plate-fixation group.

–A study that compared standard arthroscopic capsular release with capsular release extending to the posterior capsule for treating frozen shoulder found no difference in postoperative clinical or range-of-motion outcomes between the two groups.10

Elbow

–A randomized trial comparing regional analgesia to local anesthetic injections in patients undergoing elbow arthroscopy found no differences in pain, oral analgesic use, or patient satisfaction within 48 hours after surgery.11

–A randomized trial comparing eccentric and concentric resistance exercises for the treatment of chronic lateral epicondylitis found that the eccentric-exercise group had faster pain regression, lower pain scores at 12 months, and greater strength increases.12

References

  1. Park YB, Koh KH, Shon MS, Park YE, Yoo JC. Arthroscopic distal clavicle resection in symptomatic acromioclavicular joint arthritis combined with rotator cuff tear: a prospective randomized trial. Am J Sports Med. 2015 Apr;43(4):985-90.Epub 2015 Jan 12.
  2. Malavolta EA, Gracitelli ME, Ferreira Neto AA, Assunção JH, Bordalo-RodriguesM, de Camargo OP. Platelet-rich plasma in rotator cuff repair: a prospective randomized study. Am J Sports Med. 2014 Oct;42(10):2446-54. Epub 2014 Aug 1.
  3. Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, Aärimaa V.Treatment of non-traumatic rotator cuff tears: a randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81.
  4. Kim YS, Lee HJ, Kim YV, Kong CG. Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy. J Shoulder Elbow Surg. 2014 Nov;23(11):1640-6. Epub 2014 Sep 12.
  5. Heidari K, Asadollahi S, Vafaee R, Barfehei A, Kamalifar H, Chaboksavar ZA,Sabbaghi M. Immobilization in external rotation combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation. J Shoulder Elbow Surg. 2014 Jun;23(6):759-66. Epub 2014 Apr 13.
  6. Whelan DB, Litchfield R, Wambolt E, Dainty KN; Joint Orthopaedic Initiative for National Trials of the Shoulder (JOINTS).External rotation immobilization for primary shoulder dislocation: a randomized controlled trial. Clin Orthop Relat Res. 2014 Aug;472(8):2380-6.
  7. 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 Mar 10;313(10):1037-47.
  8. Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg. 2014Oct;23(10):1419-26. Epub 2014 Jul 30
  9. 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 Apr;24(4):587-92. Epub 2015 Jan 22.
  10. Kim YS, Lee HJ, Park IJ. Clinical outcomes do not support arthroscopic posterior capsular release in addition to anterior release for shoulder stiffness: a randomized controlled study. Am J Sports Med. 2014 May;42(5):1143-9. Epub 2014 Feb 28.
  11. Wada T, Yamauchi M, Oki G, Sonoda T, Yamakage M, Yamashita T. Efficacy of axillary nerve block in elbow arthroscopic surgery: a randomized trial. J Shoulder Elbow Surg. 2014 Mar;23(3):291-6. Epub 2014 Jan 15.
  12. Peterson M, Butler S, Eriksson M, Svärdsudd K.A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy). Clin Rehabil. 2014 Sep;28(9):862-72. Epub 2014 Mar 14.