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Objective: To determine the effectiveness of vancomycin powder in preventing infection after plate and screw fixation of tibial plateau fractures considered at low risk of infection., Design: Retrospective cohort study., Setting: Single, Level I trauma center., Patients/participants: This study included 459 patients with tibial plateau fractures (OTA/AO 41-B/C) who underwent open reduction and internal fixation from 2006 to 2018 and were considered at low risk of infection based on not meeting the "high risk" definition of the VANCO trial., Intervention: Vancomycin powder administration on wound closure at the time of definitive fixation., Main Outcome Measurements: Deep surgical site infection with at least 1 gram-positive bacteria culture., Results: Vancomycin powder administration was associated with reduction in gram-positive infection from 4% to 0% (odds ratio, 0.12; 95% confidence interval, 0.04-0.32; P < 0.01). No significant effect was reported in gram-negative only infections, which were observed in 0.3% in the control group, compared with 0.9% in the intervention group (odds ratio, 2.71; 95% confidence interval, 0.11-69; P = 0.54). Methicillin-resistant Staphylococcus aureus was the most common organism isolated in the control group, growing in 9 of 18 infections (50%)., Conclusions: Among patients with low-risk tibial plateau fractures, vancomycin powder at the time of definitive fixation showed a reduction in the incidence of gram-positive deep surgical site infection. The observed relative effect was relatively larger than that observed in a previous randomized trial on high-risk fractures. These data might support broadening the indication for use of vancomycin powder to include tibial plateau fractures at low risk of infection., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Operative management of acetabular fractures is technically challenging, but there is little data regarding how surgeon experience affects outcomes. Previous efforts have focused only on reduction quality in a single surgeon series. We hypothesized that increasing surgeon experience would be associated with improved acetabular surgical outcomes in general., Design: Retrospective cohort study., Setting: Urban academic level-I trauma center., Patients/participants: Seven hundred ninety-five patients who underwent an open reduction internal fixation for an acetabular fracture., Results: There was a significant association between surgeon experience and certain outcomes, specifically reoperation rate (16.9% overall), readmission rate (13.9% overall), and reduction quality. Deep infection rate (9.7% overall) and secondary displacement rate (3.7% overall) were not found to have a significant association with surgeon experience. For reoperation rate, the time until 50% peak performance was 2.4 years in practice., Conclusion: Surgeon experience had a significant association with reoperation rate, quality of reduction, and readmission rate after open reduction internal fixation of acetabular fractures. Other patient outcomes were not found to be associated with surgeon experience., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury., Design: Retrospective cohort study., Setting: Level I trauma center., Patients/participants: A total of 3314 patients with pelvic ring injuries who presented to a single referral center from 1999 to 2018 were included in the study., Intervention: Pelvic ring management, years 1999-2006 versus years 2007-2018., Main Outcome Measurements: In hospital mortality. Other examined variables included change in patient demographics, fracture characteristics, date of injury, associated injuries, length of hospital stay, Abbreviated Injury Severity Score., Results: The composite mortality rate was 6.5% (214/3314). The earliest cohort presented a mortality rate of 9.1% [111/1224; 95% confidence interval (CI), 7.6%-10.8%] compared with the more recent cohort mortality rate of 4.9% (103/2090; 95% CI, 4.1%-5.9%). Overall mortality was significantly lower in the more recent period, a risk difference of 4.1% (95% CI, 2.3%-6.1%; P < 0.01). After adjusting for age and Abbreviated Injury Severity Score of the brain, chest, and abdomen, the mortality reduction was more pronounced with an adjusted risk difference of 6.4% (95% CI, 4.7%-8.1%; P < 0.01)., Conclusion: Significant improvement in the mortality rate of pelvic ring injuries has been demonstrated in recent years (4.9% vs. 9.1%) and the difference is even large when accounting for known confounders. Improvement appears to coincide chronologically with changes in trauma resuscitation and implementation of adjuvant treatments for managing patients with severe hemorrhagic shock. Although the exact benefit of each treatment awaits further research, these data might indicate improved care over time for these difficult patients., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: R. V. O'Toole is a paid consultant for Lincotek and Smith & Nephew, receives stock options from Imagen, and receives royalties from Lincotek, all unrelated to this work. The remaining authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the outcomes of patients with pelvic ring injuries managed with resuscitative endovascular balloon occlusion of the aorta (REBOA)., Design: Retrospective case series., Setting: Academic, Level 1 trauma center in North America., Patients: Twenty-five patients with disruption of the pelvic ring and hemodynamic instability., Intervention: Placement of a REBOA device as an adjuvant treatment to trauma resuscitation., Main Outcome Measure: Death and ischemic-related complications., Results: The average age of patients was 43 years (range: 17-85). Patients presented with a median lactate of 6.3 mmol/L, systolic blood pressure of 116 mm Hg, heart rate of 121 beats/minute, and injury severity score of 34. The median unit of packed red blood cells received through transfusion in the first 24 hours of hospital admission was 13 (interquartile range: 8-28). Young-Burgess injury patterns included fractures of the following types: 5 lateral compression (LC)-1, 1 LC-2, 8 LC-3, 4 anteroposterior compression-2, and 7 anteroposterior compression-3. Angiography and embolization were performed in 24 (96%) patients. Selective embolization occurred in 18 (72%) patients, with nonselective angiography of the iliac system occurring in 7 (24%) patients. There were 12 (48%) deaths, 7 (28%) patients requiring lower extremity fasciotomy, and 5 (20%) patients requiring lower extremity amputations, and there was 1 (4%) patient requiring thrombectomy., Conclusions: REBOA use in pelvic ring injuries is rare and most frequently used in critically ill patients with polytrauma. Successful pelvic embolization can occur in concert with REBOA use; however, the severity of injury is associated with a high complication profile. In this series of 25 patients, in-hospital mortality was 48%. For those patients who survived, 54% experienced a major complication (fasciotomy, amputation, and deep infection). Further investigation is required to evaluate the role REBOA may play in managing these patients., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine the association between displaced femoral shaft bone fragments ("spikes") seen on radiographs after intramedullary nail insertion and the need for future motion surgery., Design: Retrospective case-control study., Setting: Academic trauma center., Patients: We included patients with femoral shaft fractures treated with intramedullary nail insertion. Case patients (n = 22) had developed knee stiffness treated with motion surgery. The control group was a randomly selected sample (1:3 ratio)., Main Outcome Measures: Motion surgery to address knee stiffness. We defined a "spike distance ratio" and "spike area ratio" from initial postoperative anteroposterior and lateral radiographs. Multivariable logistic regression determined the effect of spike distance and area ratios on the likelihood of need for motion surgery, controlling for polytraumatic injuries and bilateral fractures., Results: The case group had a median femoral spike distance ratio of 1.9 [interquartile range (IQR), 1.6-2.5] compared with 1.5 (IQR, 1.2-1.8) in the control group. An increased femoral spike distance ratio was associated with increased odds of motion surgery (P < 0.01). A femoral spike distance >2 times the femoral radius had 32 times the odds (95% confidence interval, 2-752) of motion surgery compared with patients with distance ratios <1.25. Median femoral spike area ratios were similar between the case (0.2; IQR, 0.1-0.5) and control (0.2; IQR, 0.0-0.5) groups and were not associated with increased odds of motion surgery (P = 0.34)., Conclusions: A larger spike distance ratio is associated with increased odds of subsequent motion surgery., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: R. V. O’Toole is a paid consultant for CoorsTek, Imagen, and Smith & Nephew, receives stock options from Imagen, and receives royalties from CoorsTek, unrelated to this study. The remaining authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)