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. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Niloofar Dehghan, MD, co-author of the July 5, 2018 Specialty Update on Orthopaedic Trauma, selected the five most clinically compelling findings from among the 32 studies summarized in the Specialty Update.
–Findings from a multicenter randomized trial comparing open reduction/internal fixation with nonoperative treatment for acute, displaced, distal-third clavicle fractures1 included the following:
- No between-group differences in DASH and Constant scores at 1 year post-injury
- Higher rates of nonunion and malunion in the nonoperative group
- Similar rates of secondary surgical procedures in the two groups
Despite no significant differences in functional outcomes between the two groups, primary fixation of these fractures reduced the risk of nonunion and malunion and decreased the magnitude of secondary procedures.
–A retrospective cohort study of 84 patients with nonoperatively treated humerus shaft fractures2 showed fracture union in 87% of the cohort at a mean of 18 weeks. However, researchers found that if physical examination at 6 weeks after injury revealed motion at the fracture site, progression to fracture union was unlikely. They concluded that results from clinical examination of fracture motion at 6 weeks could help patients and physicians with shared decision-making regarding the appropriateness of transitioning to surgical fixation
Syndesmotic Ankle Injuries
–A randomized controlled trial compared outcomes between a suture button and 1 quadricortical syndesmotic screw in patients undergoing syndesmosis fixation. After 2 years, patients in the suture button group had higher AOFAS ankle scores, higher Olerud-Molander ankle scores, and a lower rate of tibiofibular widening of ≥2 mm than the syndesmotic screw group. Findings also favored the suture button group in terms of symptomatic recurrent syndesmotic diastasis.
–A similar randomized trial compared suture button fixation with screw fixation using two 3.5-mm cortical screws.3 There were no between-group differences in functional outcomes, but the rates of malreduction and unplanned reoperations were higher in the screw group. The suture button group had greater syndesmosis diastasis and less fibular medialization.
Blood Loss Management
–In a randomized trial comparing transfusion rates among 138 patients who underwent arthroplasty for low-energy femoral neck fractures,4 researchers found no significant differences among those treated with tranexamic acid versus those treated with placebo. However, tranexamic acid reduced the amount transfused by 305 mL. There were no between-group differences in adverse events at 30 and 90 days.
- Canadian Orthopaedic Trauma Society, Hall J, Dehghan N, Schemitsch EH, Nauth A, Korley R, McCormack R, Guy P, Papp S, McKee MD. Operative vs nonoperative treatment of acute displaced distal clavicle fractures: a multicenter randomized controlled trial. Read at the Orthopaedic Trauma Association 33rd Annual Meeting; 2017 Oct 11-14; Vancouver, Canada. Paper no. 4.
- Driesman AS, Fisher N, Karia R, Konda S, Egol KA. Fracture site mobility at 6 weeks after humeral shaft fracture predicts nonunion without surgery. J Orthop Trauma.2017 Dec;31(12):657-62.
- Canadian Orthopaedic Trauma Society, Sanders D, Schneider P, Tieszer C, Lawendy AR, Taylor M. Improved reduction of the tibiofibular syndesmosis with TightRope compared to screw fixation: results of a randomized controlled study. Read at the Orthopaedic Trauma Association 33rd Annual Meeting; 2017 Oct 11-14; Vancouver, Canada.
- Watts CD, Houdek MT, Sems SA, Cross WW, Pagnano MW. Tranexamic acid safely reduced blood loss in hemi- and total hip arthroplasty for acute femoral neck fracture: a randomized clinical trial. J Orthop Trauma.2017 Jul;31(7):345-51.
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:
–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
–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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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.
- 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.
- 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.
- 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.
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 July 15, 2015 Specialty Update on orthopaedic trauma:
–Among 46 patients with acute clavicular fractures, upright radiographs were better than supine radiographs at demonstrating clavicular displacement.
Proximal Humeral Fractures
–A prospective randomized study of 120 patients undergoing open reduction and internal fixation (ORIF) of proximal humeral fractures showed that the deltoid-split and deltopectoral approaches resulted in similar patient outcomes.
Femoral Shaft Fractures
–Multiple studies investigating femoral rotation after treatment with intramedullary rods found that, other than increasing comminution, no patient, injury, or surgical variables increased the risk for malrotation.
–Use of electromagnetic targeting for placing femoral-rod locking bolts decreased radiation exposure and may decrease surgical time when using retrograde rods.
Distal Femoral Fractures
–Proximal fixation with far cortical locking screws to dynamize bridge-plate fixation was safe and produced better healing than did standard locking implants investigated in previous studies.
Tibial Plateau Fractures
–Ten years after surgery for displaced tibial plateau fractures, 7.3% of 8426 patients needed a total knee arthroplasty, a 5.3-fold increase relative to the general population’s need for knee arthroplasty.
–Among 40 patients with surgically treated intra-articular tibial plateau fractures, the use of continuous passive motion immediately after surgery did not provide lasting range-of-motion or other clinical benefits.
Distal Tibial Fractures
–A prospective randomized trial of 142 patients found that the use of angular stable locking screws with intramedullary nailing did not improve short-term outcomes relative to the use of conventional locking screws.
–A post hoc analysis of 8- to 12-year results from a randomized trial of 56 patients demonstrated better long-term outcomes among those who were treated operatively versus nonoperatively.
–Among 31 patients randomized to undergo either ORIF or ORIF with primary subtalar fusion, researchers found no functional differences, although ORIF with primary fusion may provide quicker healing and prevents the need for late secondary fusion.
Mental Health Issues
–Among a prospective cohort of 152 patients treated operatively for one or more fractures, psychological challenges were highly prevalent, with catastrophic thinking associated with worse mid-term outcomes.
–In a prospective cohort study of 110 patients admitted with orthopaedic injuries, researchers found persistent depression to be associated with higher depression-screening scores and prior psychiatric history.
–In a prospective cohort study of 737 open fractures, injury severity—not time to surgery—was associated with deep infection.
Technological advances in orthopaedic surgery occur steadily and incrementally. However, every so often, something comes along that really changes orthopaedic practice. Such is the case with the introduction of reverse shoulder arthroplasty, which is a unique, novel procedure that can be used to treat a variety of conditions affecting the shoulder. In this month’s issue of JBJS Reviews, George et al. review the use of reverse shoulder arthroplasty for the treatment of proximal humeral fractures.
Proximal humeral fractures, particularly those that occur in osteoporotic bone, can be complex and difficult to manage. While the majority of these fractures can be successfully treated with initial mobilization in a sling followed by return to activities, three and four-part fractures often are associated with poor functional outcomes, including nonunion, malunion, posttraumatic glenohumeral arthritis, and stiffness. Thus, operative interventions such as closed reduction and percutaneous pinning, open reduction and internal fixation with locked or unlocked plates, and locked intramedullary nailing are available options. However, because of the difficulty associated with reduction of three and four-part fractures, open reduction and internal fixation is associated with a high rate of complications.
Nearly sixty years ago, Neer described the use of hemiarthroplasty for the treatment of three and four-part fractures of the proximal part of the humerus. Implants and techniques steadily improved over the ensuing six decades, but the introduction of reverse shoulder arthroplasty may represent a major step forward. In the article by George et al., the use of reverse shoulder arthroplasty for the treatment of complex fractures of the proximal part of the humerus appears to have led to good results after short and intermediate-term follow up. Malunion or nonunion of the tuberosities did not affect the functional result after reverse total shoulder arthroplasty as much as it did after hemi-arthroplasty, but it did lead to decreased postoperative external rotation.
The long-term outcomes of reverse shoulder arthroplasty for the treatment of these fractures still have not been well established, so we probably should not rush to change our practice on the basis of this article alone. Indeed, since the results have been shown to deteriorate as early as six years postoperatively, reverse shoulder arthroplasty should be reserved for older patients and should be avoided in younger patients. Reverse shoulder arthroplasty can be used for the treatment of rotator cuff arthroplasty and recently has gained popularity for the treatment of severe proximal humeral fractures. This article provides a thorough yet concise overview of the application of this novel technique and implant to the treatment of these difficult and complex injuries.
Thomas A. Einhorn, MD, Editor