What’s New in Orthopaedic Trauma

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]) and postoperative fracture risk (RR, 0.29 [95% CI, 0.14 to 0.57]), although an increased risk of pulmonary embolus (RR, 3.56 [95% CI, 1.26 to 10.11]), compared with cementless HA11. Moderate-certainty evidence suggested better health-related quality of life and reduced 12-month mortality risk (RR, 0.86 [95% CI, 0.78 to 0.96]) with HA performed with cement compared with cementless HA. In addition, the authors did not find clinically relevant differences between THA and HA, although they conceded that THA may represent an appropriate treatment in some subsets of patients12.

Cost-effectiveness models also suggest a benefit to performing HA with cement compared with cementless HA. A within-trial economic evaluation of an RCT performed in the U.K. National Health System estimated the cost-effectiveness of HA performed with cement. This study suggested a 95% to 97% probability of cemented implants being cost-effective13. Thus, HA performed with cement for displaced femoral neck fractures should strongly be considered.

The differences between unipolar and bipolar HA remain controversial. However, a meta-analysis of 14 RCTs demonstrated a reduced risk of acetabular erosion (RR, 0.38 [95% CI, 0.17 to 0.83]) and better hip function scores after 2 years (mean difference, 0.68 [95% CI, 0.18 to 1.18]) with bipolar compared with unipolar HA. However, the latter result came from trials with substantial heterogeneity, which limited the certainty of the result14.

Tibia

Tibial intramedullary nail insertion can proceed via a suprapatellar or infrapatellar approach. Recent studies have suggested that the suprapatellar approach improves ease and quality of reduction, especially in proximal-third fractures. However, whether these radiographic findings result in differences in patient-reported outcome measures remains unclear. A meta-analysis of 1,196 patients undergoing intramedullary nailing for a tibial shaft fracture showed significantly better patient-reported outcome measures after intramedullary nail fixation when the suprapatellar approach was used compared with the infrapatellar approach, as well as greater reduction accuracy and less fluoroscopy time with the suprapatellar approach. Although the results supported the routine use of the suprapatellar approach, the systematic review and meta-analysis included mostly Level-III studies, lowering the certainty15.

Some authors have advocated for the use of a transverse, rather than longitudinal, incision when utilizing the suprapatellar approach, suggesting that the transverse incision can reduce the risk of infrapatellar nerve injury, potentially reducing rates of anterior knee pain. An RCT of 136 patients demonstrated that the transverse incision resulted in less infrapatellar nerve injury, but anterior knee pain and functional outcomes did not differ16.

Currently, intramedullary nail fixation represents the standard of care for most tibial shaft fractures. However, wire-ring external fixation may reduce complication rates in a subset of these fractures. To investigate this, a multicenter study randomized 260 patients with high-energy, severe, open tibial shaft fractures to either internal or external fixation. External fixation was associated with higher probabilities of major complications (risk difference, 18.4% [95% CI, 5.8% to 30.4%]; p = 0.005) and loss of fixation (risk difference, 14.4% [95% CI, 7.0% to 21.6%]; p = 0.002). Risks of deep infection, amputation, nonunion, malunion, and soft-tissue complications did not differ. These results argue against the routine use of wire-ring external fixators for severe open tibial shaft fractures17.

Bone loss, delayed union, and nonunion often complicate open tibial shaft fractures. A phase-2 RCT of 200 patients investigated KUR-113, a peptide fragment of parathyroid hormone (PTH) (PTH1-34), to improve bone healing. At 6 months, patients in the KUR-113 group had a higher union rate at 80.4% compared with patients in the control group at 64.6%, although the union rates at 12 months were no different. Thus, the future of this adjunct for open tibial shaft fractures remains undetermined, and cost should be considered18.

Foot and Ankle

Optimal fixation techniques and time to weight-bearing remain 2 areas of controversy regarding rotational ankle fractures. A systematic review and meta-analysis of 1,122 clinical patients and 76 cadaveric specimens for biomechanical testing compared posterior antiglide plating with lateral neutralization plating for Weber B distal fibular fractures. The rates of peroneal tendon irritation, infection, and wound complications, operative time, and torque to failure did not differ. However, patients experienced greater odds of implant discomfort (OR, 2.96 [95% CI, 1.83 to 4.80]; p < 0.0001) and implant removal (OR, 2.48 [95% CI, 1.58 to 3.91]; p < 0.0001) after lateral plating compared with posterior plating19.

A recent review of 327 patients with syndesmotic fixation for torsional ankle fractures determined the cost-effectiveness of using suture button fixation compared with standard screws. The estimated additional costs of the suture button ($1,083) compared with removal of screws ($14,220) suggested cost savings of 32%, based on their observed screw removal rates. Offsetting of the greater cost of suture button fixation by fewer secondary procedures may make the suture button economically worthwhile, depending on the frequency of screw removals20.

A systematic literature review and meta-analysis investigated early or delayed weight-bearing following ankle fracture fixation and showing no differences in complications. Patients had better functional outcomes at 6 weeks following early weight-bearing. However, these differences disappeared after 6 and 12 months. Unfortunately, the methodology differed between the included studies; some studies included only lateral malleolar fractures, and others included bimalleolar and trimalleolar fractures. Additionally, the definition of early weight-bearing varied, with some studies allowing immediate weight-bearing in an immobilization device and others delaying weight-bearing until 2 weeks. Thus, at best, these results suggested that early weight-bearing is safe, although it does not have strong clinical superiority21.

Biological adjuncts to fracture-healing, while potentially expensive, may generate value if better outcomes result. Jones fractures of the fifth metatarsal in athletes are often treated with fixation. A systematic review and meta-analysis investigated outcomes associated with fixation alone compared with fixation plus biological augmentation. Although better union rates were noted with biological augmentation (98.5% compared with 93.8%), the rate of return to play (99.04% compared with 98.98%) and time to return to play (9.7 compared with 10.3 weeks) did not differ. Therefore, the utilization of biological augmentation lacks supporting evidence22.

Infection Prophylaxis and Wound Management

A quality metric exists with regard to the administration of intravenous antibiotics within 1 hour of presentation to a trauma center for open fractures. However, a new study has called this practice into question. A query of the Trauma Quality Improvement Program data identified 3,367 adults with open femoral or tibial fractures. Early antibiotics were given to 70% of patients. After adjustment for known infection risks, no association was found between the timing of antibiotics and infection23.

Negative-pressure wound therapy (NPWT) following primary wound closure has also increased in recent years, with the goals of preventing infection and reducing wound dehiscence. A Cochrane Review of RCTs reported with moderate certainty that NPWT reduces surgical site infections compared with standard dressings (risk ratio [RR], 0.73 [95% CI, 0.63 to 0.85]). However, with moderate certainty, NPWT likely does not reduce the risk of wound dehiscence (RR, 0.97 [95% CI, 0.82 to 1.16]). Economic analyses have argued against the cost-effectiveness of routine NPWT for lower-extremity fractures. Overall, these results suggest a potential benefit of NPWT in certain patient groups, although universal use may not provide acceptable health-care value24.

Pediatrics

Torus fractures of the wrist represent the most common fracture in children. An RCT in the United Kingdom evaluated 2 stabilization methods, a soft bandage compared with rigid immobilization, in 965 children who were 4 to 15 years of age. Researchers assessed pain at 3 days and pain and function at 6 weeks. Pain and function did not differ between the groups at any time, suggesting that a soft bandage is safe for these fractures and may have economic and patient-convenience benefits25.

Perioperative Pain Management

Efforts to reduce perioperative complications in hip fracture surgery include interventions to mitigate the anesthesia-related risk. An RCT assessed spinal anesthesia compared with general anesthesia in 1,600 patients with a hip fracture. The primary analysis demonstrated similar survival and ambulation rates with no difference in delirium. Interestingly, patients in the spinal anesthesia group had greater pain at 24 hours and higher opioid use rates at 60 days (25% compared with 18.8%; relative risk, 1.33 [95% CI, 1.06 to 1.65]). However, absolute differences in reported pain were small and may not have reached minimal clinically important difference (MCID) values. These results suggest noninferiority of general anesthesia compared with spinal anesthesia for pain following geriatric hip fractures26.

Another RCT including 154 geriatric hip fractures analyzed intraoperative hypotension with spinal anesthesia compared with general anesthesia. This study showed a higher likelihood of an intraoperative mean arterial pressure of <65 mm Hg for >12 consecutive minutes with general anesthesia (OR, 5.6 [95% CI, 2.7 to 11.7]; p < 0.001). However, when comparing spinal anesthesia with general anesthesia, acute kidney injury (5.1% compared with 11.3%; p = 0.22), myocardial injury (18.0% compared with 14.0%; p = 0.63), and 30-day mortality (2.4% compared with 4.7%; p = 0.65) did not differ. Although the data suggest better intraoperative hemodynamic control with spinal anesthesia, these results did not translate to improved clinical outcomes27.

Miscellaneous Topics

Tranexamic acid (TXA) administration to reduce perioperative blood loss has become common practice. Still, debate continues over contraindications for its use as well as its possible complication profile. An RCT of 9,535 patients evaluated the efficacy and safety of TXA in non-cardiac surgery. The primary efficacy outcome was life-threatening bleeding, major bleeding, or bleeding into a critical organ (composite bleeding outcome) at 30 days. The primary safety outcome was myocardial injury after noncardiac surgery, non-hemorrhagic stroke, peripheral arterial thrombosis, or symptomatic proximal venous thromboembolism (composite cardiovascular outcome) at 30 days. The primary efficacy outcome metric demonstrated the superiority of TXA over placebo (hazard ratio [HR], 0.76 [95% CI, 0.67 to 0.87]; absolute difference, −2.6 percentage points [95% CI, −3.8 to −1.4]; p < 0.001). The primary safety outcome occurred in 14.2% of patients taking TXA compared with 13.9% of patients taking placebo (HR, 1.02 [95% CI, 0.92 to 1.14]). However, it had been established a priori that the upper boundary of the 97.5% CI for the HR would need to be <1.125 to establish noninferiority. Thus, despite the small between-group difference in the composite cardiovascular outcome, this study could not establish noninferiority of TXA compared with placebo28.

Efforts to address mental and social health among patients with trauma are receiving more attention, especially since the American College of Surgeons has included new requirements to screen and manage these concerns. In a recent review of 250 adult patients with trauma screened for posttraumatic stress disorder, 17% responded yes when asked if they had had a fear of death at the time of the injury; this sentiment was associated with a greater than thirteenfold increased risk of a diagnosis of posttraumatic stress disorder. The adoption of this simple question may identify more patients who could benefit from psychiatric support29.

Orthopaedic Trauma Association (OTA) Annual Meeting and Educational Resources

The 2023 OTA Annual Meeting is planned for October 18 to 21, 2023, in Seattle, Washington. In addition to new research presentations, technical presentations and a range of pre-meeting events are anticipated. The pre-meeting schedule will include basic science, international trauma care, coding and billing, pelvic and acetabular fractures, soft-tissue skills, and a senior leadership forum.

The OTA provides a plethora of other educational offerings. In-person courses, webinars, podcasts, and Fracture Night in America remain well-attended or watched. OTA Online (www.otaonline.org) has also grown in content with many new surgical technique videos and an anticipated living textbook to be launched in 2023.

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 were identified that are relevant to orthopaedic trauma. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area.

Evidence-Based Orthopaedics

Heyworth BE, Pennock AT, Li Y, Liotta ES, Dragonetti B, Williams D, Ellis HB, Nepple JJ, Spence D, Willimon SC, Perkins CA, Pandya NK, Kocher MS, Edmonds EW, Wilson PL, Busch MT, Sabatini CS, Farley F, Bae DS. Two-year functional outcomes of operative vs nonoperative treatment of completely displaced midshaft clavicle fractures in adolescents: results from the prospective multicenter FACTS study group. Am J Sports Med. 2022 Sep;50(11):3045-55.

Clavicular fractures in adults can often successfully undergo closed management. A prospective, multicenter, observational trial including patients 10 to 18 years of age sought to determine functional outcomes associated with operative compared with nonoperative management of completely displaced midshaft clavicular fractures in adolescents. The study included 416 patients; individual orthopaedic surgeons independently provided treatment recommendations. At the 2-year follow-up, 68% of patients provided patient-reported outcomes; operatively treated patients (n = 88) were older and had more comminution and greater shortening (25.5 compared with 20.7 mm; p < 0.001) than nonoperatively treated patients. At 2 years, the ASES, DASH, EuroQol (EQ) VAS, and EuroQol-5 Dimensions (EQ-5D) scores did not differ between groups, even when adjusting for confounders; however, the operatively treated group had significantly higher reoperation rates (10.4% compared with 1.4%; p = 0.004) and complication rates (20.8% compared with 5.2%; p = 0.001) compared with the nonoperatively treated group. There were no differences in nonunion, delayed union, symptomatic nonunion, or refracture rates. This study offers compelling evidence against fixation of completely displaced midshaft clavicular fractures in adolescents. Individual patient considerations should be discussed, while also keeping in mind a lack of research evidence demonstrating benefits of fixation for midshaft clavicular fractures in adolescents, even when those adolescents are involved in organized sports.

Kuripla C, Tornetta P 3rd, Foote CJ, Koh J, Sems A, Shamaa T, Vallier H, Sorg D, Mir HR, Streufert B, Spitler C, Mullis B, McGowan B, Weinlein J, Cannada L, Charlu J, Wagstrom E, Westberg J, Morshed S, Cortez A, Krause P, Marcantonio A, Soles G, Lipof J. Timing of flap coverage with respect to definitive fixation in open tibia fractures. J Orthop Trauma. 2021 Aug 1;35(8):430-6.

This retrospective observational study of 296 patients with type-III open tibial shaft fractures requiring flap coverage investigated variables associated with postoperative infection. The authors reported an overall infection rate of 32.4%. Univariate analysis identified multiple factors associated with postoperative infection, including times from injury, debridement, and definitive fixation to flap coverage. Flap failure was associated with the highest odds of postoperative infection. Multivariable modeling identified time from definitive fixation to flap coverage and flap failure as significant predictors of infection. The mean difference in delay from fixation to flap coverage was 2.4 days shorter for those without infection. Of note, the low-quality study design and statistical evaluation weakened the certainty of the results. However, these data suggest that coordinated efforts between orthopaedic trauma and plastic surgery providers for timely flap coverage following type-IIIB open tibial shaft fractures may improve outcomes. Centers that lack staff or operating room resources to provide timely flap coverage should communicate to patients the possibility of an increased risk of infection with a longer delay.

Major Extremity Trauma Research Consortium (METRC). Effect of supplemental perioperative oxygen on SSI among adults with lower-extremity fractures at increased risk for infection: a randomized clinical trial. J Bone Joint Surg Am. 2022 Jul 20;104(14):1236-43.

A multicenter prospective, randomized trial recently evaluated a high fraction of inspired oxygen (FiO2) (80%) compared with low FiO2 (30%) during and after ORIF of a tibial plateau, tibial plafond, or calcaneal fracture. Supplemental perioperative oxygen was proposed to reduce the risk of surgical site infections. The 1,231 enrolled patients received either high or low oxygen intraoperatively and for 2 hours postoperatively. A surgical site infection occurred in 7.0% of the treatment group, compared with 10.7% of the control group. Although a secondary analysis suggested that the difference in infection rates was driven by superficial infections (requiring oral antibiotics only, with no debridement), this simple, low-cost intervention appears to be beneficial in reducing surgical site infections. The provision of supplemental intraoperative oxygen may become the standard of care, as the advantage of a lower infection risk will likely outweigh any costs, risks, or barriers associated with its implementation.

O’Toole RV, Stein DM, O’Hara NN, Frey KP, Taylor TJ, Scharfstein DO, Carlini AR, Sudini K, Degani Y, Slobogean GP, Haut ER, Obremskey W, Firoozabadi R, Bosse MJ, Goldhaber SZ, Marvel D, Castillo RC; Major Extremity Trauma Research Consortium (METRC). Aspirin or low-molecular-weight heparin for thromboprophylaxis after a fracture. N Engl J Med. 2023 Jan 19;388(3):203-13.

Although clinical guidelines have recommended low-molecular-weight heparin (LMWH) for deep vein thrombosis prophylaxis following lower-extremity fracture, studies in other areas of orthopaedics, particularly arthroplasty, have suggested the noninferiority of aspirin. In this multicenter RCT of 12,211 patients with lower-extremity and pelvic fractures, the authors evaluated subcutaneous 30-mg LMWH (enoxaparin) twice per day compared with oral 81-mg aspirin twice per day. The study established noninferiority of aspirin for the primary outcome of death at 90 days, demonstrated low incidences of deep vein thrombosis with aspirin use (2.51% for aspirin compared with 1.71% for LMWH; difference, 0.80 percentage points [95% CI, 0.28 to 1.31]), and equivalent pulmonary embolism incidence between groups (1.49% in each group). Given its cost and ease of administration, surgeons should consider aspirin for deep vein thrombosis prophylaxis following operative treatment of lower-extremity fractures and operative and nonoperative treatment of pelvic fractures. The establishment of aspirin as a routine deep vein thrombosis prophylaxis following pelvic and lower-extremity trauma should improve patient adherence to recommendations and will reduce the cost of care.

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J Shoulder Elbow Surg. 2022 Oct;31(10):e480-9. 5. Bjørdal J, Fraser AN, Wagle TM, Kleven L, Lien OA, Eilertsen L, Mader K, Apold H, Larsen LB, Madsen JE, Fjalestad T. A cost-effectiveness analysis of reverse total shoulder arthroplasty compared with locking plates in the management of displaced proximal humerus fractures in the elderly: the DelPhi trial. J Shoulder Elbow Surg. 2022 Oct;31(10):2187-95. 6. Burden EG, Batten T, Smith C, Evans JP. Hemiarthroplasty or total elbow arthroplasty for unreconstructable distal humeral fractures in patients aged over 65 years: a systematic review and meta-analysis of patient outcomes and complications. Bone Joint J. 2022 May;104-B(5):559-66. 7. Said E, Ameen M, Sayed AA, Mosallam KH, Ahmed AM, Tammam H. Efficacy and safety of monopolar versus bipolar radial head arthroplasty: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2022 Mar;31(3):646-55. 8. 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Should we use bipolar hemiarthroplasty in patients ≥70 years old with a femoral neck fracture? A review of literature and meta-analysis of randomized controlled trials. J Arthroplasty. 2022 Mar;37(3):601-608.e1. 15. Sepehri A, You D, Lobo AA, Schneider P, Lefaivre KA, Guy P. Comparison of patient-reported outcomes after suprapatellar versus infrapatellar nailing techniques for tibial shaft fractures: a systematic review and meta-analysis. J Orthop Trauma. 2022 Jun 1;36(6):e208-14. 16. Leliveld MS, Van Lieshout EMM, Polinder S, Verhofstad MHJ; TRAVEL Study Investigators. Effect of Transverse Versus Longitudinal Incisions on Anterior Knee Pain After Tibial Nailing (TRAVEL): a multicenter randomized trial with 1-year follow-up. J Bone Joint Surg Am. 2022 Oct 25;104(24):2160-9. 17. Major Extremity Trauma Research Consortium (METRC). Modern external ring fixation versus internal fixation for treatment of severe open tibial fractures: a randomized clinical trial (FIXIT Study). J Bone Joint Surg Am. 2022 Jun 15;104(12):1061-7. 18. Orbeanu V, Haragus H, Crisan D, Cirstoiu C, Ristic B, Jamieson V. Novel parathyroid hormone-based bone graft, KUR-113, in treatment of acute open tibial shaft fracture: a phase-2 randomized controlled trial. J Bone Joint Surg Am. 2022 Mar 2;104(5):441-50. 19. Deng Y, Staniforth TL, Zafar MS, Lau YJ. Posterior antiglide plating vs lateral neutralization plating for Weber B distal fibular fractures: a systematic review and meta-analysis of clinical and biomechanical studies. Foot Ankle Int. 2022 Jun;43(6):850-9. 20. Flanagan CD, Solomon E, Michalski J, Stang TS, Stenquist DS, Donohue D, Shah A, Maxson B, Watson D, Ochenjele G, Mir HR. Does a reduced secondary operation rate offset higher implant charges when utilizing suture button fixation for syndesmotic injuries? J Orthop Trauma. 2023 Feb 1;37(2):77-82. 21. Khojaly R, Rowan FE, Hassan M, Hanna S, Mac Niocail R. 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