JBJS Orthopaedic Trauma: Which Gold Standards Have Been Overturned in the Past 7 Years?

From the debate over operative vs. conservative treatment for clavicle fractures, to the cemented vs. uncemented controversy in hip fractures, and the rise of aspirin as a standard for thromboprophylaxis, this article systematically reviews the latest insights from JBJS’s “What’s New in Orthopaedic Trauma” (2018–2025).

In the field of orthopaedic trauma, evidence-based medicine continues to reshape clinical decision-making. Based on JBJS annual reviews, we summarize the most impactful high-level evidence you need to know.

1.Upper Extremity Trauma: The Rise of Conservative Treatment & Refined Surgical Indications

Clavicle Fractures: Surgery Is Not Always Superior

Midshaft Fractures

Multiple RCTs and meta-analyses show that while surgery reduces nonunion rates, long-term functional outcomes (DASH, Constant scores) are comparable to nonoperative treatment.

Adolescents

For most displaced fractures in adolescents, conservative treatment should be the first choice, as surgery offers no functional benefit and carries higher complication risks.

Timing of Surgery

If surgery is chosen, it should ideally be performed within 3 months. Delayed surgery (>3 months) significantly increases complications and revision rates.

Distal Clavicle Fractures

Surgical fixation significantly reduces nonunion rates, making it a stronger indication for operative treatment.

Acromioclavicular Joint Dislocation (Rockwood III–V): Shift Toward Suspensory Fixation

Acute Management

Evidence shows that surgical treatment does not provide superior pain or functional outcomes compared to conservative care, while having higher complication rates.

Fixation Methods

If surgery is necessary, arthroscopic-assisted suture button fixation demonstrates better reduction maintenance and lower reoperation rates than hook plates or screws.

Proximal Humerus Fractures: A Gray Zone in the Elderly

Nonoperative vs Operative

In patients over 65, ORIF does not outperform conservative treatment in functional outcomes.

Reverse Shoulder Arthroplasty (RSA)

For complex 3- or 4-part fractures, especially in elderly patients, RSA shows superior outcomes compared to ORIF, particularly when performed within 4 weeks.

Medial Column Support

Fibular graft augmentation does not significantly improve clinical outcomes, highlighting that radiographic perfection does not equal functional success.

Humeral Shaft Fractures: Functional Bracing Is Not Always Enough

Recent evidence indicates that nonunion rates with functional bracing (17–20%) are significantly higher than surgical treatment.

While surgery carries a risk of iatrogenic radial nerve palsy, it remains a reasonable option for patients needing faster recovery or unable to tolerate bracing.

Nail vs Plate Fixation

• Similar functional outcomes

• ORIF: higher radial nerve injury risk

• Intramedullary nail: higher shoulder irritation and reoperation rate

Distal Radius Fractures: Focus on Patient Needs in the Elderly

For patients over 60:

• Volar locking plates (VLP) provide faster early recovery

• No significant difference at 1 year compared to casting

Pronator Quadratus Repair

Repairing the muscle does not affect outcomes, and is not necessary.

2.Lower Extremity Trauma: Implant Innovation & Early Weight-Bearing

Hip Fractures: Aspirin, Cement, and Timing

Cemented Prosthesis as Gold Standard

For displaced femoral neck fractures in the elderly:

• Cemented hemiarthroplasty reduces periprosthetic fractures and reoperation rates

• No increase in mortality

Total Hip Arthroplasty vs Hemiarthroplasty

• THA: slightly better function

• Higher dislocation risk

• No difference in revision rates (HEALTH trial)

Intramedullary Nail Choice

• Short nails are generally sufficient

• Long nails increase operative time without clear benefit

• Dual-screw systems may increase cut-out risk

Timing of Surgery

• Ultra-early surgery (<6h) shows no mortality benefit

• Surgery within 24–48 hours remains standard

• Anticoagulants should not delay surgery

Distal Femur Fractures: Dual Fixation & Early Weight-Bearing

Fixation Strategy

Combined nail + plate fixation shows fewer complications than lateral plating alone.

Weight-Bearing

Early weight-bearing is safe and beneficial, especially in elderly patients.

Tibial Fractures: Evolution of Surgical Approach

Suprapatellar Approach

Supported by RCTs and meta-analyses:

• Better alignment accuracy

• Less anterior knee pain

• Improved functional recovery

Open Fractures

For severe type III open tibial fractures:

• Intramedullary nailing outperforms external fixation

Ankle Fractures: Syndesmotic Fixation Preference

Suture Button Fixation

Compared to syndesmotic screws:

• Better reduction quality

• Lower reoperation rates

• Improved long-term outcomes

Posterior Malleolus Fractures

Increasing trend toward ORIF to restore joint congruity and stability.

Postoperative Rehabilitation

Early weight-bearing (2 vs 6 weeks):

• No increased complications

• Improved short-term quality of life

3.Perioperative Management: Paradigm Shifts

Thromboprophylaxis: The Rise of Aspirin

A landmark METRC trial (12,000 patients) showed:

• Aspirin is non-inferior to LMWH in preventing fatal PE and DVT

• Lower cost and easier administration
  → Becoming a new standard of care

Infection Control: Local Antibiotics & Oral Therapy

Vancomycin Powder

Local application reduces deep Gram-positive infections in high-risk fractures.

Oral Antibiotics (POvIV Trial)

Oral therapy is as effective as IV antibiotics after debridement in fracture-related infections.

Skin Preparation

• Closed fractures: Iodine may be superior

• Open fractures: no significant difference

Tranexamic Acid (TXA): Universal Adoption

Widely used in trauma surgeries:

• Reduces blood loss

• Lowers transfusion rates

• No increased thrombotic risk

Pain Management

Regional Nerve Blocks

• Fascia iliaca block (FICB)

• PENG block

Both provide effective analgesia and reduce opioid consumption.

Conclusion

Orthopaedic trauma care is rapidly shifting from experience-based medicine to evidence-based practice.

Key Trends

1. Aspirin is becoming the primary choice for thromboprophylaxis

2. Suprapatellar approach is preferred for tibial nailing

3. Cemented hemiarthroplasty is the gold standard for elderly femoral neck fractures

4. Conservative treatment is being re-evaluated for many displaced fractures

5. Early weight-bearing is safer than previously believed

References

Based on:
“Guest Editorial: What’s New in Orthopaedic Trauma” — JBJS (2018–2025)