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Although increasingly used, the benefit of surgical treatment of displaced 2-part proximal humerus fractures has not been proven. This trial evaluates the clinical effectiveness of surgery with locking plate compared with non-operative treatment for these fractures. The NITEP group conducted a superiority, assessor-blinded, multicenter randomized trial in 6 hospitals in Finland, Estonia, Sweden, and Denmark. Eighty-eight patients aged 60 years or older with displaced (more than 1 cm or 45 degrees) 2-part surgical or anatomical neck proximal humerus fracture were randomly assigned in a 1:1 ratio to undergo either operative treatment with a locking plate or non-operative treatment. The mean age of patients was 72 years in the non-operative group and 73 years in the operative group, with a female sex distribution of 95% and 87%, respectively. Patients were recruited between February 2011 and April 2016. The primary outcome measure was Disabilities of Arm, Shoulder, and Hand (DASH) score at 2-year follow-up. Secondary outcomes included Constant-Murley score, the visual analogue scale for pain, the quality of life questionnaire 15D, EuroQol Group's 5-dimension self-reported questionnaire EQ-5D, the Oxford Shoulder Score, and complications. The mean DASH score (0 best, 100 worst) at 2 years was 18.5 points for the operative treatment group and 17.4 points for the non-operative group (mean difference 1.1 [95% CI -7.8 to 9.4], p = 0.81). At 2 years, there were no statistically or clinically significant between-group differences in any of the outcome measures. All 3 complications resulting in secondary surgery occurred in the operative group. The lack of blinding in patient-reported outcome assessment is a limitation of the study. Our assessor physiotherapists were, however, blinded. This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. These results suggest that the current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial. ClinicalTrials.gov NCT01246167.

Background Displaced femoral neck fractures usually are treated with hemiarthroplasty. However, the degree to which the design of the implant used (cemented or uncemented) affects the outcome is not known and may be therapeutically important. Questions/purposes In this randomized controlled trial, we sought to compare cemented with cementless fixation in bipolar hemiarthroplasties at 5 years in terms of (1) Harris hip scores; (2) femoral fractures; (3) overall health outcomes using the Barthel Index and EQ-5D scores; and (4) complications, reoperations, and mortality since our earlier report on this cohort at 1-year followup. Methods We present followup at a median of 5 years after surgery (range, 56–65 months) from a randomized trial comparing a cemented hemiarthroplasty (112 hips) with an uncemented, hydroxyapatite-coated hemiarthroplasty (108 hips), both with a bipolar head. Results were previously reported at 1-year followup. Harris hip scores, Barthel Index, and EQ-5D scores were assessed by one research nurse and one orthopaedic surgeon. Complications and reoperations were determined by chart review and radiographs examined by three orthopaedic surgeons. Sixty patients (56%) had died in the cemented group and 63 (60%) in the uncemented group. Respectively, three and two patients (2.7% and 1.9%) were completely lost to followup. Results Harris hip scores at 5 years were higher in the uncemented group than in the cemented group (86.2 versus 76.3; mean difference 9.9; 95% confidence interval [CI], 1.9–17.9). The prevalence of postoperative periprosthetic femoral fractures was 7.4% in the uncemented group and 0.9% in the cemented group (hazard ratio [HR], 9.3; 95% CI, 1.16–74.5). Barthel Index and EQ-5D scores were not different between the groups. Between 1 and 5 years, we found no additional infections or dislocations. The mortality rate was not different between the groups (HR, 1.2; 95% CI, 0.82–1.7). Conclusions Both arthroplasties may be used with good medium-term results after displaced femoral neck fractures. The uncemented hemiarthroplasty may result in higher hip scores but appears to carry an unacceptably high risk of later femoral fractures. Level of Evidence Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0·41) and sepsis (seven [1%] vs six [1%]; p=0·79). In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws. National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians' Services Incorporated.

Objective To investigate whether surgery by open reduction and internal fixation provides benefit compared with non-operative treatment for displaced, intra-articular calcaneal fractures.Design Pragmatic, multicentre, two arm, parallel group, assessor blinded randomised controlled trial (UK Heel Fracture Trial).Setting 22 tertiary referral hospitals, United Kingdom.Participants 151 patients with acute displaced intra-articular calcaneal fractures randomly allocated to operative (n=73) or non-operative (n=78) treatment.Main outcome measures The primary outcome measure was patient reported Kerr-Atkins score for pain and function (scale 0-100, 100 being the best possible score) at two years after injury. Secondary outcomes were complications; hindfoot pain and function (American Orthopaedic Foot and Ankle Society score); general health (SF-36); quality of life (EQ-5D); clinical examination; walking speed; and gait symmetry. Analysis was by intention to treat.Results 95% follow-up was achieved for the primary outcome (69 in operative group and 74 in non-operative group), and a complete set of secondary outcomes were available for 75% of participants. There was no significant difference in the primary outcome (mean Kerr-Atkins score 69.8 in operative group v 65.7 in non-operative group; adjusted 95% confidence interval of difference −7.1 to 7.0) or in any of the secondary outcomes between treatment groups. Complications and reoperations were more common in those who received operative care (estimated odds ratio 7.5, 95% confidence interval 2.0 to 41.8).Conclusions Operative treatment compared with non-operative care showed no symptomatic or functional advantage after two years in patients with typical displaced intra-articular fractures of the calcaneus, and the risk of complications was higher after surgery. Based on these findings, operative treatment by open reduction and internal fixation is not recommended for these fractures.Trial registration Current Controlled Trials ISRCTN37188541.

This study compared the results of external fixation combined with limited open reduction and internal fixation (EF + LORIF), minimally invasive percutaneous plate osteosynthesis (MIPPO), and intramedullary nailing (IMN) for distal tibia fractures. A total of 84 patients with distal tibia shaft fractures were randomized to operative stabilization using EF + LORIF (28 cases), MIPPO (28 cases), or IMN (28 cases). The 3 groups were comparable with respect to patient demographics. Data were collected on operative time and radiation time, union time, complications, time of recovery to work, secondary operations, and measured joint function using the American Orthopaedic Foot and Ankle Society (AOFAS) score. There was no significant difference in time to union, incidence of union status, time of recovery to work, and AOFAS scores among the 3 groups ( P >.05). Mean operative time and radiation time in the MIPPO group were longer than those in the IMN or EF + LORIF groups ( P <.05). Wound complications after MIPPO were more common compared with IMN or EF + LORIF ( P <.05). Anterior knee pain occurred frequently after IMN (32.1%), and irritation symptoms were encountered more frequently after MIPPO (46.4%). Although EF + LORIF was associated with fewer secondary procedures vs MIPPO or IMN, it was related with more pin-tract infections (14.3%). Findings indicated that EF + LORIF, MIPPO, and IMN all achieved similar good functional results. However, EF + LORIF had some advantages over MIPPO and IMN in reducing operative and radiation times, postoperative complications, and reoperation rate. [ Orthopedics. 2016; 39(4):e627–e633.]

Background This study was performed to compare the operative clinical outcomes of helical plating, intramedullary nailing (IMN), and long straight lateral plating in the treatment of humeral shaft fractures extending into the proximal humerus, as well as to identify the optimal fixation strategy for managing such injuries. Methods In total, 81 patients with humeral shaft fractures extending into the proximal humerus were divided into three groups based on treatment strategy: helical plating (Group A, n  = 16), IMN (Group B, n  = 12), and long straight lateral plating (Group C, n  = 53). Preoperative demographic data and imaging were collected from the medical records. Operative time, blood transfusion, bone reduction quality, bone healing rate, and incidence of complications were recorded. Clinical evaluation included the Constant–Murley score for shoulder function, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire for upper limb function, the visual analogue scale (VAS) for pain, and assessments of shoulder stiffness or instability and patient satisfaction. Results Compared with Groups A and C, patients in Group B had a longer operative time and lower blood transfusion requirements. More than 80% of patients in each group achieved bone reduction quality rated as “better than good.” There were no significant differences among the three groups in operative time, blood transfusion, or shaft angulation. Bone healing rates were 100%, 91.7%, and 94.3% in Groups A, B, and C, respectively. Mean shoulder flexion was 155.0°, 130.0°, and 150.0°, respectively. Functional outcomes, including the Constant–Murley score, DASH score, VAS score, and patient satisfaction, were significantly better in Group A than in Groups B and C. No complications occurred in Group A. One patient in Group B developed nonunion. In Group C, complications were observed in five patients (9.4%). Conclusion In the treatment of humeral shaft fractures extending into the proximal humerus, helical plating was associated with a higher bone union rate, better functional outcomes, and a lower postoperative complication rate compared with IMN or long straight lateral locking plates. Outcomes after nailing and long straight lateral plating were similar.

Background Hip fracture is a severe and common injury that occurs predominantly in the elderly. Blood loss in the perioperative period is associated with a greater risk of dying in anaemic patients. The aim of the study was to explore the best way to treat stable intertrochanteric fractures, taking hidden blood loss into account. Methods This prospective, randomised blinded study included patients aged over 65 years with stable intertrochanteric fractures (Evans grades I and II). The patients were allocated to one of two groups treated via extramedullary or intramedullary fixation. Patient data were retrieved from electronic charts. Functional recovery was evaluated using the Functional Recovery Score of Zuckerman. Postoperative complications were also recorded. The formula of Nadler and Gross was used to calculate blood loss. Results There were 92 patients in the extramedullary and 106 in the intramedullary group. Age, sex, the cause of injury, the type of fracture, the observed blood loss, functional recovery, time to union, complications, and American Society of Anesthesiologists classification did not differ significantly between the two groups (all p -values > 0.05). The frequencies of lung infection, electrolyte imbalance, and hypoproteinemia differed between groups (all p -values < 0.05). Total and hidden blood loss were higher in the intramedullary group ( p  = 0.001). Conclusion Extramedullary (compared with intramedullary) fixation of stable intertrochanteric fractures significantly reduces perioperative blood loss but affords similar functional outcomes and times to union. In view of the morbidity and complications associated with acute anaemia and transfusions, extramedullary fixation may be the optimal choice for treatment of stable fractures, being associated with reduced blood loss. Trial registration The study was retrospectively registered at the Chinese Clinical Trial Registry, number: ChiCTR-INQ-16009754 , trial registration date: 6th Nov. 2016.

Complications affect treatment outcomes and quality of life in addition to increasing treatment costs. To evaluate complication rates after the treatment of a distal radius fracture, to determine whether the rate or complication type is associated with treatment method, and to determine predictors of complications. The multicenter Wrist and Radius Injury Surgical Trial (WRIST), a randomized clinical trial, enrolled participants from April 10, 2012, to December 31, 2016. The study included 304 adults 60 years or older with isolated unstable distal radius fractures; 187 were randomized and 117 opted for casting. The study was conducted at 24 health systems in the United States, Canada, and Singapore. Data for this secondary analysis were collected from April 24, 2012, to February 28, 2018. Participants opting for surgery were randomized to receive the volar locking plate system (n = 65), percutaneous pinning (n = 58), or bridging external fixation with or without supplemental pinning (n = 64). Patients who chose not to have surgery (n = 117) were not randomized and were enrolled for casting. Complication rate. The WRIST enrolled a total of 304 participants, of whom 8 casting group participants were later found to be ineligible and were excluded from the analysis, leaving 296 participants. Randomized participants' mean (SD) age was 68 (7.2) years, 163 (87%) were female, and 165 (88%) were white. Casting participants' mean (SD) age was 75.6 (9.6) years, 93 (84%) were female, and 85 (85%) were white. The most common type of complications varied by treatment. Twelve of 65 participants (18.5%) in the internal fixation group reported a median nerve compression, while 16 of 26 participants (25.8%) who received external fixation and 13 of 56 participants (23.2%) who received pinning sustained pin site infections. Compared with the internal fixation group, complication rate for any severity complication was higher in participants who initially received casting (adjusted rate ratio, 1.88; 95% CI, 1.22-2.88), whereas the rate for moderate complications was higher in the external fixation group (adjusted rate ratio, 2.52; 95% CI, 1.25-5.09). The distal radius fracture treatment decision-making process for older patients should incorporate a complication profile for each treatment type. For example, external fixation and pinning could be used for patients after apprising them of pin site infection risk. Internal fixation can be done in patients with high functional demands who are willing to receive surgery. Internal fixation use should be substantiated owing to the time and cost involved. ClinicalTrials.gov Identifier: NCT01589692.

Purpose The primary goal of this randomised controlled trial was to investigate whether there are differences in the outcome between the Gamma3 nail and a sliding hip screw (SHS) regarding quality of life 1 year after surgery. Methods In a controlled randomised trial, we compared the Gamma3 nail (Stryker) and a SHS (Omega, Stryker) in the treatment of 193 patients with pertrochanteric fractures. The follow-up period was 12 months. The outcomes included the surgical duration, health-related quality of life measured with the EQ-5D Index and a Visual Analogue Scale (VAS), the living situation and use of walking aid before trauma and 52 weeks after surgery; the Parker Mobility Score; the Harris Hip Score; and the revision, complication and mortality rates. Results The Gamma3 group had a significantly shorter surgical duration than the SHS group ( p  < 0.0001). Implant-related complications were significantly lower in the Gamma3 group ( p  > 0.05). The revision rate was significantly lower in the Gamma3 group based on intention-to-treat (p = 0.0336) as well as as-treated (p = 0.0302) analyses. Otherwise, we did not find significant difference between the two groups regarding the EQ-5D Index and VAS scores, the Parker Mobility Score, the Harris Hip Score, the mortality rate, the use of walking aids and the living situation. Conclusion There were no detectable differences between the groups in terms of quality of life and clinical scores 12 months after surgery. The surgical duration and revision rate were superior for the Gamma3 group.