Landmark trials
The permanent backlist: trials that changed (or refused to change) orthopaedic practice, in chronological order.
2001 · Spine · Spine: low back pain
Fritzell
Lumbar fusion vs non-surgical care for chronic low back pain?
Fusion modestly reduced pain and disability at two years, though the non-operative comparator was weak.
2002 · NEJM · Trauma: limb salvage
LEAP
Limb salvage vs amputation after severe lower extremity trauma?
Two-year function was equivalent either way, and injury severity scores could not predict which limbs to salvage.
2002 · NEJM · Sports: knee
Moseley
Arthroscopic debridement or lavage vs placebo surgery for knee osteoarthritis?
Arthroscopy was no better than sham at any point over two years, ending its routine use for osteoarthritis.
2006 · JAMA/NEJM · Spine: lumbar
SPORT
Surgery vs non-operative care for disc herniation, spinal stenosis, and degenerative spondylolisthesis?
Heavy crossover blurred the intention-to-treat result; as-treated analyses favoured surgery, most clearly for stenosis and spondylolisthesis.
2007 · JBJS · Trauma: clavicle · 🇨🇦 Canadian-led
COTS
Plate fixation vs sling for completely displaced midshaft clavicle fractures?
Plating reduced nonunion and symptomatic malunion, though later trials tempered how much function that actually buys.
2008 · JBJS · Trauma: tibia · 🇨🇦 Canadian-led
SPRINT
Reamed vs unreamed intramedullary nailing for tibial shaft fractures?
Reamed nailing reduced reoperations in closed fractures; no advantage in open fractures.
2009 · NEJM · Spine: osteoporotic fracture
Vertebroplasty sham trials
Vertebroplasty vs a sham procedure for painful osteoporotic vertebral compression fractures?
Two simultaneous blinded trials found no benefit over sham out to six months; patient selection remains contested.
2010 · Lancet · Trauma: resuscitation
CRASH-2
Tranexamic acid vs placebo in bleeding trauma patients?
TXA cut all-cause mortality without excess thrombosis, with the benefit concentrated within three hours of injury.
2010 · NEJM · Sports: knee
KANON
Early ACL reconstruction plus rehabilitation vs rehabilitation with optional delayed reconstruction?
Outcomes matched at 2 and 5 years; over half the reconstructions could have been avoided.
2010 · JBJS · Foot & ankle · 🇨🇦 Canadian-led
Willits
Operative vs non-operative treatment of acute Achilles rupture with accelerated functional rehabilitation?
With early functional rehab, non-operative care matched surgery and rerupture rates were far closer than historically taught.
2013 · NEJM · Sports: knee
FIDELITY
Arthroscopic partial meniscectomy vs sham surgery for degenerative meniscal tears?
Meniscectomy was no better than sham surgery, a landmark for surgical placebo effects.
2013 · NEJM · Sports: knee
METEOR
Surgery vs physiotherapy for meniscal tear with knee osteoarthritis?
No significant functional difference at 6–12 months, though many PT patients crossed over.
2014 · BMJ · Hand & wrist
DRAFFT
K-wires vs volar locking plates for dorsally displaced distal radius fractures?
No difference in patient-reported wrist function at 12 months; wires were cheaper.
2015 · JAMA · Shoulder & elbow
PROFHER
Surgical vs nonsurgical treatment for displaced proximal humerus fractures?
No difference in patient-reported outcomes over two years.
2015 · NEJM · Trauma: open fractures · 🇨🇦 Canadian-led
FLOW
Irrigation pressure and soap vs saline for open fracture wounds?
Very low pressure was acceptable; soap led to more reoperations than saline.
2017 · Lancet · Trauma: hip · 🇨🇦 Canadian-led
FAITH
Sliding hip screw vs cancellous screws for femoral neck fractures?
No overall difference in reoperation at 24 months between fixation strategies.
2018 · Lancet · Shoulder & elbow
CSAW
Arthroscopic subacromial decompression vs placebo arthroscopy for shoulder impingement?
Decompression offered no meaningful benefit over placebo surgery.
2018 · JAMA · Trauma: open fractures
WOLLF
Negative pressure wound therapy vs standard dressings for severe open lower limb fractures?
No difference in disability at 12 months.
2019 · NEJM · Arthroplasty: hip · 🇨🇦 Canadian-led
HEALTH
Total hip arthroplasty vs hemiarthroplasty for displaced femoral neck fractures?
No significant difference in secondary procedures at 24 months; modest functional gains with THA.
2019 · Lancet · Arthroplasty: knee
TOPKAT
Total vs partial knee replacement for isolated medial compartment osteoarthritis?
Both were effective at 5 years; partial replacement was cost-effective with similar outcomes.
2020 · Lancet · Trauma: hip · 🇨🇦 Canadian-led
HIP ATTACK
Accelerated surgery (within ~6 h) vs standard care for hip fracture?
Accelerated surgery did not reduce mortality or major complications versus standard timing.
2020 · Lancet · Shoulder & elbow
UK FROST
Capsular release vs manipulation under anaesthesia vs structured physiotherapy for frozen shoulder?
No option was clearly superior; manipulation was the most cost-effective.
2020 · Lancet · Foot & ankle
UKSTAR
Plaster cast vs functional brace for non-operatively treated Achilles rupture?
Early weight-bearing in a functional brace matched casting at nine months and was safe.
2020 · Plast Reconstr Surg · Hand & wrist
WRIST
Volar plate vs external fixation vs pinning vs casting for distal radius fractures in adults 60 and over?
The plate recovered faster early but all arms converged by 12 months; cast malunion did not translate into worse function.
2021 · JAMA Surgery · Hand & wrist
CROSSFIRE
Volar locking plate vs closed reduction and casting for distal radius fractures in adults 60 and over?
No clinically important difference in wrist function at 12 months, though patients rated surgery as more successful.
2022 · BMJ · Hand & wrist
DRAFFT2
K-wire fixation vs moulded cast after manipulation of dorsally displaced distal radius fractures?
Wrist function was the same at 12 months, but roughly one in eight cast patients needed later surgery for redisplacement.
2022 · JAMA · Arthroplasty: VTE
CRISTAL
Aspirin vs enoxaparin for VTE prophylaxis after hip or knee arthroplasty?
Aspirin failed non-inferiority, with significantly more symptomatic VTE at 90 days after primary joint replacement.
2026 · conference report · Arthroplasty: VTE
PEPPER
Aspirin vs warfarin vs rivaroxaban for thromboprophylaxis after hip or knee replacement?
Interim reports suggest more VTE with aspirin and more bleeding with the anticoagulants; the definitive publication is still pending.
One-line takeaways are simplifications; read the trials themselves before quoting them in an exam or the OR.