Clavicle The treatment of adolescent clavicular fractures is evolving. One study reviewed 671 adolescents with midshaft displaced fractures1 assessed with the abbreviated version of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) and the EuroQol-5 Dimensions (EQ-5D). Only 7% of fractures were treated operatively, and all united primarily. One patient had a nonunion after nonoperative management. The rate of refracture over 10 years was 3.2% and was not associated with fracture type or displacement. The median QuickDASH score was 0, and 94% of patients returned to sports, showing that most nonoperatively treated adolescents have primary union and no functional deficits. Many trials have evaluated outcomes after midshaft clavicular fractures. One partially blinded trial from Denmark2 assessed the functionality of healthy adults treated operatively (n = 51) or nonoperatively (n = 54) using the Constant score and the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) score. Although there were early advantages (6 weeks) to operative management, at 12 months, no difference was observed. Symptomatic nonunion occurred in 18% of patients at 6 months, and 80% of those patients required a surgical procedure. The rates of secondary surgical procedures did not differ among groups (26% for both). Proximal Part of the Humerus and Humeral Shaft Nonoperative management remains the mainstay of proximal humeral fracture treatment. One randomized study investigated 2 protocols for immobilization (1 week compared with 3 weeks).3 The visual analog scale (VAS) pain scores, Constant scores, and Simple Shoulder Test (SST) were determined. The final cohort included 111 patients with a mean age of 70 years. Nearly 70% of fractures were displaced. No differences in displacement, complications, VAS score, Constant scores, or SST were seen for 1-part or 2-part fractures. Two nonunions and 5 displacements were noted (no difference between groups), suggesting safety with early motion. Although the mainstay of proximal humeral fracture treatment in the elderly population is nonoperative treatment, surgical treatment may be indicated in select populations. One Swedish randomized trial4 compared functional outcomes following hemiarthroplasty (43 patients after attrition) with reverse total shoulder arthroplasty (TSA) (41 patients after attrition) in independent patients without cognitive impairment who were ≥70 years of age and had 3 or 4-part fractures. There was an 11-point difference in the Constant score favoring reverse TSA (meeting the minimal clinically important difference [MCID]) and better motion (flexion and abduction) and increased satisfaction after reverse TSA. A selected group of patients ≥80 years of age experienced fewer advantages with reverse TSA, suggesting that either treatment may be acceptable. One strength of this study is its minimum follow-up of 2 years. Humeral shaft fractures are primarily treated nonoperatively, with a clinically important nonunion rate. A secondary analysis of the FISH (Finnish Shaft of the Humerus) randomized trial5 assessed whether patients who had initial nonoperative management and nonunion had worse outcomes after surgical treatment than those who successfully healed (either with a surgical procedure or nonoperatively). Eighty-two patients (mean age, 49 years) with unilateral closed midshaft fractures were randomized into 2 groups; 90% of patients had 2-year follow-up. The 32% of patients who required a secondary surgical procedure had inferior DASH scores averaging 17.5, compared with 6.8 in patients who underwent an acute surgical procedure and 6.0 in patients who healed primarily with bracing. This study, despite its small size, underscored the risks of nonoperative management. Distal Part of the Humerus and Elbow The treatment of Mason type-2 radial head fractures is controversial. A multicenter randomized trial (RAMBO [Radial Head – Amsterdam – Amphia – Boston – Others])6 of isolated fractures was conducted in 45 patients with a median age of 50 years; 22 patients underwent open reduction and internal fixation (ORIF) with screw fixation, and 23 patients had nonoperative treatment. Exercise instructions were provided. No differences were seen in motion, complications, or DASH scores. This is comparable with other studies in which authors reported good outcomes following nonoperative management. Notably, this trial was terminated before the expected 78 patients based on an interim analysis and the desire of many patients for nonoperative management; therefore, the study was underpowered. Posttraumatic contracture is a risk following elbow injuries. A recent randomized blinded study (PERK 1 [Prevention of Posttraumatic Contractures with Ketotifen 1])7 investigated ketotifen (an anti-mast cell drug used in asthma treatment) for contracture. Fracture types included distal humeral and Monteggia fractures and pure elbow dislocations. The control group (n = 77) received placebo, and the experimental group (n = 74) received 5-mg ketotifen twice daily for 6 weeks. Injuries included 114 fractures, 18 fracture-dislocations, and 16 pure dislocations. Nonoperative management was used in 57% of patients. Patients treated without a surgical procedure achieved 11° more range of motion at 12 weeks, but there was no difference between the ketotifen group and the placebo group. A major determinant was the initial management of the injury, with more than one-half treated nonoperatively, suggesting the possible value of a trial for operatively treated injuries. Distal Part of the Radius Although volar locking plates are considered the standard of care for most surgically treated distal radial fractures, other modalities such as external fixation are also used with the intent of mitigating complications. A randomized trial8 evaluated outcomes and complications of extra-articular distal radial fractures in patients who were 18 to 70 years of age, treated with either external fixation (n = 73) or volar locking plates (n = 69). All fractures initially had ≥10° of dorsal angulation, ulnar variance of ≥2 mm, and/or dorsal comminution. The external fixation group had a worse primary outcome score (Patient-Rated Wrist/Hand Evaluation [PRWHE]) at 6 weeks, but there was no significant difference in this score between groups at 3 months and 1 year. Eighty-one percent of patients with volar locking plates and 79% of patients with external fixation had full recovery. The volar locking plate group also had less pain during activity and better wrist motion at 1 year. Additionally, more chronic regional pain syndrome was identified in the external fixation group (11% compared with 4%). The treatment of distal radial fractures in the elderly population has been debated. In a randomized controlled trial, Hassellund et al.9 compared surgical treatment and nonoperative treatment (6 weeks of casting) in 100 independently living patients with displaced type-A and C fractures. Patients were primarily female, with a mean age of 74 years. No significant difference in QuickDASH scores was seen at 1 year. Range of motion and complications were similar. Patient satisfaction was slightly higher with operative management. Although functional scores reached a plateau within 1 year after the injury, function improved more rapidly after surgical treatment. Most distal radial fractures in elderly patients are treated without a surgical procedure; however, a recent multinational randomized trial (WRIST [Wrist and Radius Injury Surgical Trial])10 attempted to discern the potential benefits of surgical treatments in patients ≥60 years of age: volar locking plate fixation (n = 65), external fixation (n = 64), or closed reduction and percutaneous pinning (n = 58) compared with 117 patients with casting. The outcomes of interest were the Michigan Hand Questionnaire (MHQ) score (with an MCID of 8), hand strength, and wrist motion. The mean age was 71 years, and 88% of patients were female. After a 2-year follow-up, no differences in MHQ scores were seen. Malunion was highest after casting but was not associated with less employment, worse quality of life, or worse outcome scores. Hand and wrist mobility and strength returned to almost normal. However, the casting group size was limited because of poor follow-up. A randomized trial from the Netherlands11 evaluated a cast (n = 46) compared with a volar locking plate (n = 44) in patients who were 18 to 75 years of age. The primary outcome was the Patient-Rated Wrist Evaluation (PRWE) score after 12 months. Secondary outcomes included the DASH score, the Short Form-36 (SF-36) score, the VAS pain score, radiographic parameters, range of motion, and complications. PRWE scores were better for the volar locking plate group during all times except at 1 year. The cast group had a 28% rate of subsequent surgical procedures; their satisfaction rate was 85%, but only one-half would recommend casting to others, primarily because of the risk of a surgical procedure. Pelvis and Acetabulum Heterotopic ossification is a known complication of acetabular surgery, particularly with posterior approaches. Several methods may mitigate risk, including radiation, indomethacin, and gluteus minimus debridement. In a recent study, 473 patients were treated with radiation (7 to 8 Gy to the abductors), indomethacin, and no prophylaxis.12 Posterior approaches (94%), combined approaches (5.3%), and extensile approaches (0.6%) were used. The mean time to the surgical procedure was 2.7 days. No difference was seen in infection rates; however, radiation yielded more wound complications at 20% compared with 7% for indomethacin and 5% for no prophylaxis. Most wound complications consisted of drainage for up to 3 days, and this drainage was treated with negative-pressure therapy; 33% of these patients’ wounds were treated with subsequent surgical debridement. The use of examination under anesthesia (EUA) to assess pelvic ring injuries is controversial. One study surveyed 15 surgeons in practice for ≥5 years and experienced in pelvic fractures.13 Controversial cases of LC-1 (lateral compression) patterns were presented, with regard to whether EUA would demonstrate a mechanically unstable pelvis and if the surgeon would proceed to fixation. Additionally, the surgeons were asked whether they performed a full, 15-step EUA and how they defined a positive EUA. All participants performed EUA in their practice, with 47% using the 15-step method, and 53% of all respondents had a specific definition of a positive EUA. The results showed agreement that a pelvic fracture was stable or unstable in 80% of cases and that fixation was recommended in 60% of cases. Agreement with regard to pelvic ring stability matched agreement with regard to the recommendation for fixation 75% of the time. With regard to limitations, surgeons were biased in that all used EUA, limiting the generalizability of the study. No consensus exists with regard to indications for EUA, how to perform EUA, and the definition of a positive EUA. Hip Cut-through is a phenomenon of trochanteric nail fixation failure that differs from varus collapse and is associated with helical blade use. One study evaluated cut-out and cut-through rates for blade-type cephalomedullary nails compared with screw-type cephalomedullary nails in 12 studies14 (3 randomized, 1 prospective cohort, and 8 retrospective) with 2,331 total cases (1,084 with a blade and 1,247 with a screw). The InterTAN was excluded. Fixation failure was more common with blades than lag screws, especially cut-through, with an odds ratio (OR) of 5.33, and cut-out rates were no different. The time to union and nonunion rates did not differ. This study was limited by the inclusion of retrospective studies and limited data (authors reported cut-out rates in 11 studies and cut-through rates in only 7 studies) and the failure to evaluate reduction quality or tip-apex distance. Authors of prior studies have suggested reducing the inventory stock of femoral nails, because most mature femora permit a diameter of 10 mm. Similarly, for intertrochanteric fractures treated with cephalomedullary, distally locked nails, Rinehart et al.15 assessed 168 patients, 74 of whom were treated with 10-mm nails and 94 of whom were treated with >10-mm nails. The authors reported no difference in reoperations, with an overall rate of 8.3%. This study suggests that inventory may be decreased by using 10-mm-diameter nails. However, subtrochanteric fractures were excluded. Hip fracture surgery is often delayed because the patient is using oral anticoagulants, and the safe timing of the surgical procedure is unclear. A recent systematic review of oral anticoagulants and effects on surgical timing and mortality16 compared patients who were taking direct oral anticoagulants (such as apixaban) and vitamin K antagonists (such as warfarin) with patients who were not taking anticoagulants. The final analysis of 34 studies and nearly 40,000 patients (10,000 taking anticoagulants) found more delay (mean, 14 hours), longer length of hospital stay (1.6 days longer), and higher risk of in-hospital complications (OR, 1.4) and 30-day mortality (OR, 1.6) in patients who took anticoagulants, without a difference between patients who took direct oral anticoagulants and patients who took vitamin K antagonists. Most cardiology consultations and transthoracic echocardiograms (TTEs) do not result in actionable change in preoperative course (other than delay). Despite new American Heart Association (AHA) and American College of Cardiology (ACC) guidelines, adherence varies. A recent study evaluated 412 patients with hip fracture.17 Although only 18% of patients met criteria, 44% received a preoperative cardiology consultation. Of those, 34% met the criteria for TTE, but 90% had a TTE. The time to the surgical procedure was longer following a cardiology consultation (25 compared with 19 hours). More awareness and collaboration between surgical and medical teams will help to prevent delays by adhering to guidelines. Periarticular injection has been proposed as a component of multimodal pain management in hip fracture care. A randomized trial determined the effectiveness of a periarticular injection during hemiarthroplasty.18 Opioid consumption, ambulation, and length of stay were compared between groups (infiltration of medication into the labrum, ligamentum teres, and soft tissues compared with placebo). All patients (n = 60) received identical postoperative pain control. VAS pain scores were collected at 8, 16, 24, 36, 48, 60, and 72 hours, and both scores and medication consumption were lower in the intervention group. The study provides more support for multimodal pain management, part of which should occur intraoperatively. COVID-19 has affected the care and outcomes of patients with orthopaedic trauma. One review evaluated patients with hip fracture who were >60 years of age with and without concurrent positive COVID-19 tests, with primary outcomes of inpatient and 30-day mortality.19 Most studies gave little or no detail with regard to indications for COVID testing or symptoms among those patients tested. Sixteen studies found a relative risk of 4.42 for early mortality with a positive COVID test (34% compared with 9%), regardless of age, sex, dementia, or intracapsular fracture. Secondary outcomes including length of hospital stay, intensive care unit (ICU) admission, time to the surgical procedure, reoperation, and discharge destination showed longer stays for patients who tested positive for COVID. Although the actual causes of death were not reported in most studies, this analysis confirmed the high rate of concurrent COVID-positive tests among patients with hip fracture. Distal Part of the Femur Distal femoral fractures treated with ORIF are fraught with complications, particularly malalignment and nonunion. One recent basic science study compared the effects of single and dual (lateral and medial) distal femoral plating on vascularity.20 Eight cadaver limb pairs were used, and pre-contrast and post-contrast magnetic resonance imaging (MRI) and computed tomographic (CT) scans were performed to evaluate the superficial femoral and profunda femoris arterial supplies being dissected. The authors noted that dissection during plating destroys the periosteal vessels, but the geniculate branches to the medial and lateral distal femoral condyles remain intact. The mean reduction in vascularity with dual plating only showed a 4% difference compared with single plating (about 20% reduction overall). This study suggests that medial dissection may be safe, although clinical correlation with regard to wound complications and infections is unknown. Periprosthetic distal femoral fractures in the elderly are challenging, with surgeons balancing fracture stability with early weight-bearing in osteoporotic bone. Distal femoral replacement may permit immediate weight-bearing. A systematic review and meta-analysis evaluated distal femoral replacement and ORIF (including intramedullary nailing) in patients ≥55 years of age.21 The results of 58 studies (14 on distal femoral replacement and 44 on ORIF) found no differences in reoperation, revision, or Knee Society scores, with better motion (10° more) after ORIF. However, nail-plate combinations were not examined, and the overall data quality was poor. Tibial Plateau Surgeons debate the ideal bone-grafting material for tibial plateau fractures. A 2020 randomized trial22 (n = 108) compared calcium sulfate (Cerament: 60% calcium sulfate and 40% hydroxyapatite) and autograft from the anterior pelvis for isolated lateral tibial plateau fractures. Outcomes included the VAS pain score and the SF-12 Physical Component Summary (PCS) score at 26 weeks. No difference in healing or subsidence was noted. However, the study was underpowered. Ankle and Foot Tibiotalocalcaneal or hindfoot nailing has emerged as an alternative for the stabilization of ankle fractures, particularly in geriatric patients who have diabetes. A systematic review evaluated the complications of this procedure.23 Ten retrospective case series and 1 randomized trial, totaling 276 patients with acute malleolar ankle fractures or tibial plafond fractures, were included. Except for 1 study, patients were elderly, with a mean age of 75.5 years, and 42% of patients had diabetes. Formal subtalar joint preparation was performed in 2 studies. Secondary surgical procedures were performed in 10% of patients, with major complications in 8% of patients and infection in 6% of patients; a mean proportion of 85% of patients returned to their prior activity level. However, all of the retrospective studies were found to have a moderate to high risk of bias. Indications for this procedure have yet to be clarified. Prospective, comparative data are lacking. Although the extensile approach has long been the gold standard for intra-articular calcaneal fractures, the sinus tarsi approach has come into favor. A randomized trial24 compared these approaches in Sanders type-2A and 2B fractures. All posterior facet fractures were fixed with screws and then plate fixation (extensile, n = 32) or cannulated screw fixation (sinus tarsi, n = 32). Complications occurred in 4 patients (12.5%) in the extensile group and no patients in the sinus tarsi group; the difference was not significant. The VAS pain and American Orthopaedic Foot & Ankle Society (AOFAS) scores were better at 6 months following the sinus tarsi approach, but there was no difference after 1 year. Neither posterior facet reduction quality nor Bohler angle were different. Although this study was small and had short follow-up, both approaches may have similar complications and early outcomes; therefore, the choice of approach rests with the surgeon. However, the sinus tarsi approach allows limited visualization of the posterior facet and is reserved for simple fractures. Ultrasound-guided peripheral nerve blocks for pain control have increased in popularity for patients with orthopaedic trauma. A randomized blinded study tested the analgesic effect of a popliteal block (both divisions of the sciatic nerve near the popliteal fossa) on pain following ORIF of a calcaneal fracture.25 Patients who had Type-II and III Sanders fractures were included; patients who had substance abuse or chronic pain were excluded. Both groups were given an opioid analgesia pump, and outcomes included patient satisfaction. The study was adequately powered with 120 patients and found higher pump use and lower satisfaction in patients who did not receive the block, as well as lower VAS pain scores up to 16 hours, but no difference in VAS scores at 24 or 48 hours following the surgical procedure. Open Fracture The GOLIATH (Global Open Fracture Collaborative to Investigate Available Evidence in the Literature) meta-analysis26 included observational and randomized trials through April 2020 with long bone, foot, and carpal open fractures. Factors such as time to debridement, injury pattern, antibiotic administration, and negative-pressure wound therapy were evaluated. The final cohort included 84 studies and 18,239 patients. The unstratified analysis of all fractures yielded a greater risk of infection with delay: delay of >12 hours for any tibial shaft fracture, especially Gustilo type IIIB, was associated with more infection. When stratified by treatment within 6, 12, and 24 hours, type-IIIB fractures experienced progressively more infection risk, with ORs of 1.46 at 12 hours and 2 at 24 hours. A systematic review and network meta-analysis27 analyzed definitive fixation strategies of extra-articular open tibial fractures in adult patients, with a primary outcome of unplanned reoperation. Eighteen studies (10 randomized) with 1,764 patients and 6 fixation methods were included. The data showed lower risk of reoperation with nailing (both reamed and unreamed) compared with external fixation, particularly in Gustilo type-III open fractures. There was no difference in deep infection and nonunion, a lower risk of malunion with unreamed nailing, and a higher risk of construct failure with unreamed nailing. The limitations included low confidence on the risks of reamed nailing and lack of reporting of certain variables (antibiotics, time to debridement, and infection) by some studies. Infection The decision of implant retention compared with removal for fracture-related infection is controversial. A recent systematic review28 yielded 6 studies (n = 276) that examined debridement, antibiotics, and implant retention in long bone and pelvic fracture infections. Originally, 4,241 abstracts and 82 full-text articles were analyzed; the final 6 studies included 1 randomized, prospective study and 5 retrospective studies. The review found a success rate (defined as an absence of infection recurrence) of a range of 86% to 100% if the duration of the infection was <3 weeks, of a range of 82% to 89% if the duration of the infection was 3 to 10 weeks, and of 67% if the duration of the infection was >10 weeks (data on late infections are limited). The authors concluded that early infection may be successfully treated with implant retention, because biofilm has not matured; however, the heterogeneity of data and studies, patient comorbidities, and treatment variations limited the translation of these findings into practice. Miscellaneous Topics Orthopaedic surgeons have a role in counseling patients to quit smoking, but success has varied. Matuszewski et al.29 published a randomized controlled trial of various counseling programs and their effect on smoking cessation, as measured by exhaled carbon monoxide at 3 and 6 months. Smokers with operatively treated fractures were assigned to no counseling in a control group (n = 40), brief inpatient counseling (n = 111), or extended counseling (n = 115). Patients in the extended counseling group were 3 times more likely to accept referral to a smoking cessation hotline. However, the actual smoking cessation rates were not significantly influenced by counseling. At 6 months, the smoking cessation rate was 15% for the control group, 10% for the brief inpatient counseling group, and 5% for the extended counseling group. A randomized trial compared 2 multimodal pain regimens.30 The first regimen (n = 787) consisted of intravenous medication followed by oral medication including nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentin, and tramadol. The second regimen, which was an opioid-minimizing regimen (n = 774), consisted of oral medication (excluding tramadol) and lidocaine patches only. The primary outcome was morphine milligram equivalents (MMEs) consumed per day, with fewer daily MMEs in the second regimen (34 compared with 48; p < 0.001). It also reduced opioid prescription on discharge, by 27% in patients admitted to the ICU and by 9% in patients admitted to a general floor. However, the mean reported pain scores were not different. Cost-saving practices are the focus of recent literature in orthopaedic trauma. One study evaluated the evidence behind 15 potentially low-value practices, identified by 36 experts.31 Evidence was evaluated using a checklist for quality, and outcomes included complications and change in management. Several trauma practices for which evidence was lacking were identified, such as routine initial imaging of ankle injuries, an orthosis for an A0-A3 thoracolumbar burst fracture in patients <60 years of age, casting or splinting for a fifth metacarpal neck fracture and for an MRI-negative scaphoid fracture, and routine follow-up imaging for distal radial and ankle fractures. However, the quality of the evidence to justify abandoning practices was poor, and many studies had biased conclusions. Orthopaedic Trauma Association (OTA) Annual Meeting and Educational Resources The 2022 OTA Annual Meeting is scheduled for October 12 to 15, 2022, in Tampa, Florida. A comprehensive program of research presentations, symposia, case presentations, and technical sessions is planned. Pre-meeting education will include the International Trauma Care Forum, Basic Science Focus Forum, Coding and Billing Course, Pelvis and Acetabulum Course, Soft-Tissue Skills Course, and an OTA member fireside case discussion, among other offerings. The Annual Meeting attracts an international audience of surgeons, researchers, and other trauma providers. Other educational offerings include Fracture Night in America sessions on the internet and frequent webinars and podcasts, with schedules available at www.ota.org. OTA Online also affords broad educational content, mostly open access, and includes videos of surgical anatomy and techniques, Rockwood and Green chapters, and on-call topic summaries for efficient review, geared toward orthopaedic surgery residents in training. Research presentations, industry resources, and other OTA educational materials are also available; see www.otaonline.org. 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 relevant to orthopaedic trauma surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Dehghan N, Nauth A, Hall J, Vicente M, McKee MD, Schemitsch EH; Canadian Orthopaedic Trauma Society. In situ placement versus anterior transposition of the ulnar nerve for distal humerus fractures treated with plate fixation: a multicenter randomized controlled trial. J Orthop Trauma. 2021 Sep 1;35(9):465-71. A randomized trial from the Canadian Orthopaedic Trauma Society evaluated the results of leaving the nerve in situ compared with subcutaneous transposition following ORIF of bicolumnar acute distal humeral fractures in 8 centers. The primary outcome was the Gabel and Amadio score for ulnar neuropathy (0 to 9, in which 9 is best). Nerve conduction studies were performed at 6 weeks, and outcomes were evaluated up to 1 year. The study achieved >90% power, with the final cohort comprising 31 patients in the in situ group and 27 patients in the transposition group. No differences in outcomes measured by Mayo scores, DASH scores, and 2-point discrimination were noted at any time points. Ulnar nerve dysfunction was initially high in both groups, with improvement increasing at 1 year from a score of 6 to 7.8. Sixty-two percent of patients had abnormal results on nerve conduction testing, with no difference between groups in severity of the findings, suggesting no benefit to routine ulnar nerve transposition. This issue has been often debated; thus, their findings will support ORIF to treat the distal part of the humerus without the need for routine transposition. Ultimately, this should reduce operating room time and the risk of iatrogenic injury to the nerve. Monticone M, Portoghese I, Cazzaniga D, Liquori V, Marongiu G, Capone A, Campagna M, Zatti G. Task-oriented exercises improve disability of working patients with surgically-treated proximal humeral fractures. A randomized controlled trial with 1-year follow-up. BMC Musculoskelet Disord. 2021 Mar 20;22(1):293. Physical therapy facilitates recovery following proximal humeral fractures. A randomized blinded trial sought to determine whether task-specific postoperative exercise (tailored to the work needs of the individual patients) would improve outcome compared with standard physical therapy exercises in employed patients who underwent ORIF to treat proximal humeral fractures. Thirty-five patients with a mean age of 49 years were randomized to each group. Both groups received their allocated therapy 3 times a week for 12 weeks. Blue-collar work (more manual labor) was separated from white-collar work, with an equal distribution of each. At 1 year after the surgical procedure, outcomes in the work-specific physical therapy group including the DASH scores (reaching the MCID), pain scores, and quality of life were better. Blue-collar work compared with white-collar work did not affect results. Notably, patients who received Workers’ Compensation were excluded from the study, and return-to-work time was not evaluated, limiting their conclusions. Precision medicine has been advocated recently as a way to personalize treatment to individuals, so as to enhance their personal level of function. Shoulder function following this common injury treated with ORIF appears best served with work-specific therapy. Nikolaou VS, Masouros P, Floros T, Chronopoulos E, Skertsou M, Babis GC. Single dose of tranexamic acid effectively reduces blood loss and transfusion rates in elderly patients undergoing surgery for hip fracture: a randomized controlled trial. Bone Joint J. 2021 Mar;103-B(3):442-8. A recent trial randomized patients with hip fracture into either the placebo group or a group that received a single dose of tranexamic acid (15 mg/kg). The primary outcome was total perioperative blood loss up to postoperative day 4, using a hemoglobin balance formula for the calculation. The secondary outcome included the number of transfusions. All fractures were treated either with hemiarthroplasty (femoral neck) or a cephalomedullary nail (intertrochanteric). The study enrolled 165 patients (77 who received tranexamic acid and 88 who received placebo), with a mean age of 83 years. The groups’ baseline characteristics and time to the surgical procedure were not different. For the primary outcome, the total blood loss was lower in the tranexamic acid group by about 300 mL. A subgroup analysis showed that tranexamic acid was more likely to have an effect in intertrochanteric fractures than in femoral neck fractures. For the secondary outcome, tranexamic acid lessened transfusion risk by 22%. This study has strengths, including being a single-center study and having 80% power in the randomized sample. Overall, the administration of tranexamic acid appears to be safe, particularly in patients who have a high risk of complications due to excessive hemorrhage. This study adds to the body of evidence supporting tranexamic acid to mitigate bleeding. Less blood loss and fewer transfusions are of substantial benefit to the population with hip fracture, especially considering the baseline morbidity of this group. O’Toole RV, Joshi M, Carlini AR, Murray CK, Allen LE, Huang Y, Scharfstein DO, O’Hara NN, Gary JL, Bosse MJ, Castillo RC, Bishop JA, Weaver MJ, Firoozabadi R, Hsu JR, Karunakar MA, Seymour RB, Sims SH, Churchill C, Brennan ML, Gonzales G, Reilly RM, Zura RD, Howes CR, Mir HR, Wagstrom EA, Westberg J, Gaski GE, Kempton LB, Natoli RM, Sorkin AT, Virkus WW, Hill LC, Hymes RA, Holzman M, Malekzadeh AS, Schulman JE, Ramsey L, Cuff JAN, Haaser S, Osgood GM, Shafiq B, Laljani V, Lee OC, Krause PC, Rowe CJ, Hilliard CL, Morandi MM, Mullins A, Achor TS, Choo AM, Munz JW, Boutte SJ, Vallier HA, Breslin MA, Frisch HM, Kaufman AM, Large TM, LeCroy CM, Riggsbee C, Smith CS, Crickard CV, Phieffer LS, Sheridan E, Jones CB, Sietsema DL, Reid JS, Ringenbach K, Hayda R, Evans AR, Crisco MJ, Rivera JC, Osborn PM, Kimmel J, Stawicki SP, Nwachuku CO, Wojda TR, Rehman S, Donnelly JM, Caroom C, Jenkins MD, Boulton CL, Costales TG, LeBrun CT, Manson TT, Mascarenhas DC, Nascone JW, Pollak AN, Sciadini MF, Slobogean GP, Berger PZ, Connelly DW, Degani Y, Howe AL, Marinos DP, Montalvo RN, Reahl GB, Schoonover CD, Schroder LK, Vang S, Bergin PF, Graves ML, Russell GV, Spitler CA, Hydrick JM, Teague D, Ertl W, Hickerson LE, Moloney GB, Weinlein JC, Zelle BA, Agarwal A, Karia RA, Sathy AK, Au B, Maroto M, Sanders D, Higgins TF, Haller JM, Rothberg DL, Weiss DB, Yarboro SR, McVey ED, Lester-Ballard V, Goodspeed D, Lang GJ, Whiting PS, Siy AB, Obremskey WT, Jahangir AA, Attum B, Burgos EJ, Molina CS, Rodriguez-Buitrago A, Gajari V, Trochez KM, Halvorson JJ, Miller AN, Goodman JB, Holden MB, McAndrew CM, Gardner MJ, Ricci WM, Spraggs-Hughes A, Collins SC, Taylor TJ, Zadnik M; Major Extremity Trauma Research Consortium (METRC). Effect of intrawound vancomycin powder in operatively treated high-risk tibia fractures: a randomized clinical trial. JAMA Surg. 2021 May 1;156(5):e207259. Vancomycin powder has been successfully used in infection prevention in the spine literature. A large multicenter trial (VANCO [Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection]) evaluated the effectiveness of intrawound vancomycin powder compared with placebo in high-risk tibial fractures (tibia plateau and tibia plafond), with the primary outcome of deep surgical site infection. High risk was defined as being initially treated with external fixation followed by definitive fixation >3 days after the injury; having Gustilo type-I, II, or IIIA open fractures; or being associated with compartment syndrome treated with fasciotomy. Secondary outcomes included any superficial surgical site infection, nonunion, and wound dehiscence that required operative intervention. All tibial fractures were treated with plates and screws. The final cohort included 481 patients (vancomycin group) and 499 patients (control group) in 36 centers. Deep surgical site infection was seen in 6.4% (29 patients) in the vancomycin group compared with 9.8% (46 patients) in the control group, with no significant differences in other outcomes. A post hoc analysis showed reduction in gram-positive infection and no difference in gram-negative infections. Subgroup analyses of fracture location (plafond compared with plateau) and fracture severity (open compared with closed) also showed no differences. This study provides robust evidence of reduction of deep infection with gram-positive bacteria in high-risk tibial fractures treated with intrawound vancomycin powder. This low-cost intervention appears to reduce the gram-positive infection risk by almost half, with no local or systemic complications from using the powder. Future work to study topical powder effective against a gram-negative species would be beneficial.