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To determine the outcomes of high-risk patients treated with tibiotalocalcaneal hindfoot fusion nails.Retrospective case series.Level I trauma center.Between January 2007 and December 2016, 50 patients with significant medical comorbidities treated with a tibiotalocalcaneal hindfoot fusion nail in the setting of acute distal tibia and ankle trauma considered to be limb-threatening.Tibiotalocalcaneal hindfoot fusion nail.Two-year cumulative incidence of unplanned reoperation and estimated survival with limb salvage at 2 years.Of the 50 patients, 20 (38%) had an unplanned reoperation (mean: 2.5 reoperations), including 19 for implant removal, 11 for irrigation and debridement and/or placement of an antibiotic delivery device, and 4 for revision fusion. Three patients required amputation and 3 patients died within 2 years of injury, resulting in an estimated survival with limb salvage at 2 years of 79% (95% confidence interval: 67%-91%). After accounting for the competing risk of death and incomplete follow-up, the 2-year cumulative incidence of unplanned reoperation was 64% (95% confidence interval: 62%-67%).Patients in this series experienced a high rate of return to the operating room but a relatively low rate of amputation. Because patients were indicated for this course of treatment on the basis of comorbidities felt to put them at high risk of loss of limb with traditional treatment, acute hindfoot fusion nailing might represent a viable option in select high-risk patients and injuries. Clinicians should be aware that complications are still common.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.Retrospective cohort study.Urban academic level-I trauma center.Seven hundred ninety-five patients who underwent an open reduction internal fixation for an acetabular fracture.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.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.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Describe co-occurrence or clustering of microbial taxa in fracture-related infections to inform further exploration of infection-related interactions among them.Retrospective review.Level 1 trauma center.Four hundred twenty-three patients requiring surgical intervention for deep surgical site infection between January 2006 and December 2015.None.Connection between microbial taxa.Methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, and coagulase-negative Staphylococcus represented the majority of monomicrobial observations (71%). Gram-negative rods, gram-positive rods, and anaerobes presented more frequently in polymicrobial infections. Enterobacter, vancomycin-sensitive Enterococcus, and Pseudomonas are present in polymicrobial infections with the highest frequencies and represent the top 3 most important nodes within the microorganism framework, with the highest network centrality scores.The present study indicates that there are common microbial taxa (Enterobacter, Enterococcus, and Pseudomonas) that tend to co-occur with other microbes greater than 75% of the time. These commonly co-occurring microbes have demonstrated interactive relationships in other disease pathologies, suggesting that there may be similar important interactions in fracture-related infections. It is possible that these microbial communities play a role in the persistently high failure rate associated with management of infection after trauma. Future studies are needed to study the intermicrobial interactions that explain the frequency at which taxa co-occur. Understanding and potentially disrupting these intermicrobial relationships could inform improvements in the treatment of established infections and in the prevention of infection in high-risk patients.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury.Retrospective cohort study.Level I trauma center.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.Pelvic ring management, years 1999-2006 versus years 2007-2018.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.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%; P0.01). 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%; P0.01).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.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Next-generation DNA sequencing (NGS) detects bacteria-specific DNA corresponding to the 16S ribosomal RNA gene and can identify bacterial presence with greater accuracy than traditional culture methods. The clinical relevance of these findings is unknown. The purpose of the present study was to compare the results from bacterial culture and NGS in order to characterize the potential use of NGS in orthopaedic trauma patients.A prospective cohort study was performed at a single academic, level-I trauma center. Three patient groups were enrolled: (1) patients undergoing surgical treatment of acute closed fractures (presumed to have no bacteria), (2) patients undergoing implant removal at the site of a healed fracture without infection, and (3) patients undergoing a first procedure for the treatment of a fracture nonunion who might or might not have subclinical infection. Surgical site tissue was sent for culture and NGS. The proportions of culture and NGS positivity were compared among the groups. The agreement between culture and NGS results was assessed with use of the Cohen kappa statistic.Bacterial cultures were positive in 9 of 111 surgical sites (110 patients), whereas NGS was positive in 27 of 111 surgical sites (110 patients). Significantly more cases were positive on NGS as compared with culture (24% vs. 8.1%; p = 0.001), primarily in the acute closed fracture group. No difference was found in terms of the percent positivity of NGS when comparing the acute closed fracture, implant removal, and nonunion groups. With respect to bacterial identification, culture and NGS agreed in 73% of cases (κ = 0.051; 95% confidence interval, -0.12 to 0.22) indicating only slight agreement compared with expected chance agreement of 50%.NGS identified bacterial presence more frequently than culture, but with only slight agreement between culture and NGS. It is possible that the increased frequency of bacterial detection with molecular methods is reflective of biofilm presence on metal or colonization with nonpathogenic bacteria, as culture methods have selection pressure posed by restrictive, artificial growth conditions and there are low metabolic activity and replication rates of bacteria in biofilms. Our data suggest that NGS should not currently substitute for or complement conventional culture in orthopaedic trauma cases with low suspicion of infection.Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE To identify the patient, injury and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multi-center retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction. DESIGN Multi-center Retrospective Review. SETTING Sixteen Trauma Centers. PATIENTS One thousand and three consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures. MAIN OUTCOME MEASURES Fracture-related infection (FRI) in open ankle fractures. RESULTS The charts of 1,003 consecutive patients were reviewed and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction and/or implant failure; FRI was associated with higher rates of these complications (p=0.01). CONCLUSION Several patient, injury and surgical factors were associated with fracture-related infection in the treatment of open ankle fractures. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Patient-Reported Outcomes Measurement Information System (PROMIS) has developed item banks, short forms and computer-adaptive tests (CATs) to help standardize measurement for important patient reported outcome (PRO) domains. These tools have the potential to revolutionize outcome measurement in clinical research through greater assessment precision while reducing response burden. Perceived implementation challenges include the need for CAT software, mobile technology and internet access. Here, we present preliminary results examining the feasibility of using PROMIS tools within a large, multi-center clinical trials consortium. The assessment of 10 PROMIS domains was incorporated into the longitudinal data collection of six ongoing orthopaedic trauma clinical trials for participants being evaluated at 3, 6 and 12 months following an orthopaedic injury. Twelve-month assessments included both CAT assessments as well as completion of full item banks for a subset of domains. Data were collected for 1,000 trauma patients at 43 trauma centers using a custom-built application which included an interface with our primary data capture system. Paper short forms were available as backup instruments and used infrequently. Six and 12-month study assessments were conducted for 83% and 77% of patients, respectively. It was feasible to use PROMIS tools in a large multi-center, trauma orthopaedics research setting. The ability to efficiently assess a wide spectrum of domains is critically important to the successful completion of future large-scale trials.

OBJECTIVES: Laser-assisted Indocyanine Green Angiography (LA-ICGA) is a novel method for objectively quantifying soft tissue perfusion. The primary aim of this study was to determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol. DESIGN: Prospective cohort study SETTING: Academic trauma centre PATIENTS: Eight pilon fracture patients and 19 tibial plateau fracture patients that underwent open reduction internal fixation MAIN OUTCOME MEASUREMENTS: Skin perfusion (fluorescence units) as measured by LA-ICGA RESULTS: Six patients were classified as Tscherne grade 0, nine as grade 1, ten as grade 2, and two as grade 3. Perfusion decreased by 14 fu (95% CI: −21, −6, p

Objective To evaluate rates of complications in patients with bilateral femur fractures treated with intramedullary nailing (IMN) during either 1 single procedure or 2 separate procedures. Design A multicenter retrospective review of patients sustaining bilateral femur fractures, treated with IMN in single or 2-stage procedure, from 1998 to 2018 was performed at 10 Level-1 trauma centers. Setting Ten Level-1 trauma centers. Patients/participants Two hundred forty-six patients with bilateral femur fractures. Interventions Intramedullary nailing. Main outcome measures Incidence of complications. Results A total of 246 patients were included, with 188 single-stage and 58 two-stage patients. Gender, age, injury severity score, abbreviated injury score, secondary injuries, Glasgow coma scale, and proportion of open fractures were similar between both groups. Acute respiratory distress syndrome (ARDS) occurred at higher rates in the 2-stage group (13.8% vs. 5.9%; P value = 0.05). When further adjusted for age, gender, injury severity score, abbreviated injury score, Glasgow coma scale, and admission lactate, the single-stage group had a 78% reduced risk for ARDS. In-hospital mortality was higher in the single-stage cohort (2.7% compared with 0%), although this did not meet statistical significance (P = 0.22). Conclusions This is the largest multicenter study to date evaluating the outcomes between single- and 2-stage IMN fixation for bilateral femoral shaft fractures. Single-stage bilateral femur IMN may decrease rates of ARDS in polytrauma patients who are able to undergo simultaneous definitive fixation. However, a future prospective study with standardized protocols in place will be required to discern whether single- versus 2-stage fixation has an effect on mortality and to identify those individuals at risk. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To compare the volume of embolic load during intramedullary fixation of femoral and tibial shaft fractures. Our hypothesis was that tibial intramedullary nails (IMNs) would be associated with less volume of intravasation of marrow than IM nailing of femur fractures. DESIGN Prospective observational study. SETTING Urban Level I trauma center. PATIENTS/PARTICIPANTS Twenty-three patients consented for the study: 14 with femoral shaft fractures and 9 with tibial shaft fractures. INTERVENTION All patients underwent continuous transesophageal echocardiography, and volume of embolic load was evaluated during 5 distinct stages: postinduction, initial guide wire, reaming (REAM), nail insertion, and postoperative. MAIN OUTCOME MEASUREMENTS Volume of embolic load was measured based on previously described luminosity scores. The embolic load based on fracture location and procedure stage was evaluated using a mixed effects model. RESULTS The IMN procedure increased the embolic load by 215% (-12% to 442%, P = 0.07) in femur patients relative to tibia patients after adjusting for baseline levels. Of the 5 steps measured, REAM was associated with the greatest increase in embolic load relative to the guide wire placement and controlling for fracture location (421%, 95% confidence interval: 169%-673%, P < 0.01). CONCLUSIONS Femoral shaft IMN fixation was associated with a 215% increase in embolic load in comparison with tibial shaft IMN fixation, with the greatest quantitative load during the REAM stage; however, both procedures produce embolic load. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES Determine if extended inpatient counseling increases smoking cessation. DESIGN Prospective randomized trial. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Current smokers with an operative fracture. INTERVENTION Randomly assigned to control (no counseling), brief counseling (inpatient counseling), or extended counseling (brief counseling plus follow-up counseling) groups in a 1:3:3 ratio. MAIN OUTCOME MEASUREMENTS Smoking cessation confirmed by exhaled carbon monoxide at 3 and 6 months. Secondary outcomes are proportion accepting services from a nationally based quitline. RESULTS Overall, 266 patients participated, with 40, 111, and 115 patients in the control and 2 treatment groups, respectively. At 3 months, 17% of control patients versus 11% in the brief counseling and 10% in the extended counseling groups quit smoking, respectively (P = 0.45, 0.37). At 6 months, 15% of control, and 10% and 5% of the respective counseling groups quit (P = 0.45, 0.10). Extended counseling patients were 3 times more likely to accept referral to a quitline [odds ratio (OR), 3.1; 95% confidence interval (CI), 1.4-6.9], and brief counseling patients were more than 2 times as likely to accept referral (OR, 2.3; 95% CI, 1.0-5.1) than the control group. Extended counseling (OR, 8.2; 95% CI, 1.0-68.5) and brief counseling (OR, 5.3; 95% CI, 0.6-44.9) patients were more likely to use quitline services than the control group. CONCLUSION Increasing levels of inpatient counseling can improve successful referral to a smoking quitline, but it does not seem to influence quit rates among orthopaedic trauma patients. Extended counseling does not appear to provide substantial benefit over brief counseling. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Objectives To assess the reliability of the current computed tomography (CT) based technique for determining femoral anteversion, and quantify the prevalence and magnitude of side-to-side differences. Design Cross-sectional cohort study. Setting Academic trauma center. Patients We reviewed CT scans from 120 patients with bilateral full-length axial cuts of both femurs. Two hundred forty femurs with no fractures or other identifying features in their femora were included. Ten unique data sets were created to measure anteversion of the left and right sides. Main outcome measurements Intraobserver and interobserver reliability were calculated using intraclass correlation coefficients (ICC) and pooled absolute differences. The mean absolute difference between the sides was determined using a fixed-effects model. Results Interobserver reliability was high (ICC: 0.85, 95% confidence interval [CI]: 0.83-0.88). The pooled mean absolute magnitude of variation between reviewers was small at 1.6 degrees (95% CI: 1.4-1.8 degrees) per scan. The intraobserver reproducibility was high (ICC: 0.91, 95% CI: 0.88-0.93) with a mean error of 2.7 degrees (95% CI: 2.2-3.1 degrees) per repeat viewing of the same scan by the same person. The magnitude of side-to-side variation was 2.0 degrees (95% CI: 1.5-2.6 degrees). Twenty-one subjects (18%, 95% CI: 12-25%) had a mean side-to-side calculated femoral anteversion difference of ≥10 degrees, while 6 (5%, 95% CI: 2-10) subjects had a calculated mean side-to-side difference ≥15 degrees. Conclusions CT based femoral anteversion measurement techniques demonstrate good precision. Only 1 in 20 patients had side-to-side differences of 15 degrees or more. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives To analyze the effectiveness of an implant stewardship program on implant cost containment and to estimate surgeon responsiveness to implant price changes. Design Interrupted time series. Setting Level I trauma center. Patients/participants Monitored usage of 5 trauma constructs by 10 surgeons over a 5-year period. Intervention Red-Yellow-Green (RYG) implant pricing comparison chart. Main outcome measurements Primary outcomes were changes in the mean price, minimum price, and the number of price changes. The secondary outcome was surgeon responsiveness to RYG/cost changes. Results The study consisted of 2468 procedures. A mean construct price decrease of $66 per year (95% confidence interval [CI], $-170 to $-151), with distal femoral plates demonstrating the largest mean annual price decline ($486; 95% CI, $-540 to $-432). The minimum construct price decreased by $131 per year (95% CI, $-155 to $-111), with the largest reductions observed for distal femoral plates (-$436 per year; 95% CI, $-516 to $-354) and external fixators (-$122 per year; 95% CI, $-258 to $-136). The median price decrease was $407 (range: $6 to $2491), or 12.5% of the previous price. Positive changes in RYG levels increased surgeon usage of tibial nails by 115%, femoral nails by 106%, and external fixators by 104%. Surgeon implant selection was insensitive to RYG changes for distal femoral plates (RYG elasticity [ERYG]: -0.74) and proximal tibia plates (ERYG: -0.21). Conclusions The implant stewardship program was associated with substantial implant price reductions. Surgeon implant selection was especially sensitive to price changes for intramedullary nails and external fixators. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Describe patient-reported pain and function within 24 months of a pelvic fracture treated with posterior screw fixation and identify factors associated with increased pain.Prospective case series.Academic trauma center.Eighty-eight patients with adult pelvic fracture treated with sacroiliac or transiliac screws.Average pain measured with the Brief Pain Inventory (BPI); function measured with the Majeed Pelvic Outcome Score from 6 to 24 months postinjury.The mean pain from 6 to 24 months postinjury was 2.22 on the 10-point BPI scale (95% CI, 0.64-3.81). Sixty-nine patients (78.4%) reported mild to no pain at 6 months; 12 (13.6%) patients had severe pain. Two years after injury, 71 patients (80.6%) exhibited mild to no pain. Within 24 months of injury, the mean pelvic function was 71 on the 100-point Majeed scale (95% CI, 60-82). Half of the sample (n = 44) had good to excellent pelvis function by 6 months postinjury; 55 patients (62.5%) attained this level of function by 24 months. A history of chronic pain (1.31; 95% CI, 0.26-2.37; P = 0.02), initial fracture displacement (≥5 mm) (0.99; 95% CI, 0.23-1.69; P = 0.01), and socioeconomic deprivation (0.28; 95% CI, 0.11-0.44; P0.01) were significantly associated with increased pain.Our findings suggest that most patients with unstable pelvic ring fractures treated with posterior screw fixation achieve minimal to no pelvis pain and good to excellent pelvic function 6-24 months after injury.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To evaluate the efficacy of intraoperative tobramycin powder in preventing surgical site infection (SSI) and implant colonization with Enterobacter cloacae in a rabbit fixation model. Gram-negative rods, particularly Enterobacter species, comprise an increasing percentage of SSI at our institution. METHODS Eighteen New Zealand White rabbits underwent surgical fixation of the left tibia with implantation of a plate and screws. The surgical site and implant were inoculated with 1 × 107 CFUs E. cloacae. The selected E. cloacae isolate was resistant to tobramycin and capable of forming biofilms. Nine rabbits received 125 mg tobramycin powder directly into the surgical site, overlying the implant. The control group was untreated. Fourteen days postinfection, the tibiae and implants were explanted. Radiographs were taken with and without the implants in place. One tibia from each group was examined after hematoxylin and eosin staining. The remaining tibiae and implants were morselized or sonicated, respectively, and plated on agar to determine infection burden. Data were analyzed with Fisher exact tests and Mann-Whitney U tests. RESULTS No bone infection or implant colonization occurred in the tobramycin-treated group. In the control group, 7 of 8 rabbits developed bone infections (P = 0.001), and 4 of 8 implants were colonized (P = 0.07). No gross disruption of the normal bone architecture was observed in either group. CONCLUSIONS Intraoperative tobramycin powder applied at the time of contamination prevented bone infection with E. cloacae in this rabbit fixation model. The results are encouraging because the E. cloacae isolate was tobramycin-resistant, demonstrating the utility of intraoperative powdered antibiotics.

OBJECTIVE To determine whether fully threaded transiliac-transsacral (TI-TS) fixation is biomechanically superior to partially threaded TI-TS fixation of vertically unstable transforaminal sacral fractures. METHODS Vertically unstable zone 2 sacral fractures were created in 20 human cadaveric pelves with a unilateral osteotomy and resection of 1 cm of bone through the foramen of the sacrum to represent comminution. Ten specimens received either 2 7.3-mm fully threaded or 2 7.3-mm partially threaded TI-TS screw fixation at the S1 and S2 body, and every specimen received standard 3.5-mm 8-hole parasymphyseal plating anteriorly. Each pelvis was loaded to 250 N at 3 Hz for 100,000 cycles and then loaded to failure. The primary outcome was fracture displacement at the S1 foramen, which was measured at 25,000, 50,000, 75,000, and 100,000 cycles. Secondary outcomes were simulated clinical failure of ≥1 cm displacement at the S1 foramen to determine occurrence probability of failure, and load at failure was defined as 2.5 cm of the linear loading system displacement. Specimens in the fully threaded and partially threaded cohorts were otherwise respectively comparable in regards to age, gender, and bone density. RESULTS Five of the 10 TI-TS partially threaded specimens experienced simulated clinical failure with >1 cm displacement at the S1 foramen compared with 0 of the 10 TI-TS fully threaded cohort (50% vs. 0%, P = 0.03). The mean maximal displacement at the S1 foramen was greater in the partially threaded cohort (9.3 mm) compared with the fully threaded cohort (3.6 mm; P = 0.004). Fully threaded specimens also demonstrated greater mean force to failure than the partially threaded specimens (461 N vs. 288 N; P = 0.0001). CONCLUSIONS Fully threaded TI-TS screw fixation seems to be mechanically superior to partially threaded fixation in a cadaveric vertically unstable transforaminal sacral fracture model with significantly less displacement of the posterior pelvic ring and greater load to failure.

Objectives To determine if the use of intrawound vancomycin powder reduces surgical-site infection after open reduction and internal fixation of bicondylar tibial plateau, tibial pilon, and calcaneus fractures. Design Retrospective analysis. Setting Level I trauma center. Patients All fractures operatively treated from January 2011 to February 2015 were reviewed; 583 high-risk fractures were included, of which 35 received topical vancomycin powder. A previously published prospectively collected cohort of 235 similar high-risk fractures treated at our center from 2007 through 2010 served as a second comparison group. Intervention Topical vancomycin powder at wound closure. Main outcome measurements Deep surgical-site infection. Analyses used both univariate comparison of all patients and 1:2 matching analysis using both nearest neighbor and propensity-based matching. Results Compared with a control group of fractures treated during the same time period without vancomycin powder, the infection rate with vancomycin powder was significantly lower [0% (0/35) vs. 10.6% (58/548), P = 0.04]. Compared with our previously published historical infection rate of 13% for these injuries, vancomycin powder was also associated with significantly decreased deep surgical-site infection (0% vs. 13%, P = 0.02). These results agreed with the matched analyses, which also showed lower infection in the vancomycin powder group (0% vs. 11%-16%, P ≤ 0.05). Conclusions Vancomycin powder may play a role in lowering surgical-site infection rates after fracture fixation. A larger randomized controlled trial is needed to validate our findings. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

We describe the novel quantitative lesser trochanter profile (QLTP) technique to determine the magnitude and direction of femoral malrotation and to compare its performance with the cortical step sign technique. For this assessment, 9 orthopaedic surgeons estimated the magnitude and direction of femoral malrotation with each technique in 198 anteroposterior view images of the proximal cadaveric femur and osteotomy sites. Based on the results, the main benefit of the QLTP technique over the cortical step sign technique is the ability to determine the direction of femoral malrotation. The QLTP technique was also more accurate in measuring malrotation and had less error. However, the QLTP technique requires additional imaging, and the mean difference in error between the 2 techniques might not be clinically meaningful.

OBJECTIVE To evaluate the diagnostic performance of perfusion pressure (PP) thresholds for fasciotomy. DESIGN Prospective observational study. SETTING Seven Level-1 trauma centers. PATIENTS/PARTICIPANTS One hundred fifty adults with severe leg injuries and ≥2 hours of continuous PP data who had been enrolled in a multicenter observational trial designed to develop a clinical prediction rule for acute compartment syndrome (ACS). MAIN OUTCOME MEASUREMENTS For each patient, a given PP criterion was positive if it was below the specified threshold for at least 2 consecutive hours. The diagnostic performance of PP thresholds between 10 and 30 mm Hg was determined using 2 reference standards for comparison: (1) the likelihood of ACS as determined by an expert panel who reviewed each patient's data portfolio or (2) whether the patient underwent fasciotomy. RESULTS Using the likelihood of ACS as the diagnostic standard (ACS considered present if median likelihood ≥70%, absent if

Background Periprosthetic fracture is a leading reason for readmission following total hip arthroplasty. Most of these fractures occur during the early postoperative period before bone ingrowth. Before ingrowth occurs, the femoral component can rotate relative to the femoral canal, causing a spiral fracture pattern. We sought to evaluate, in a paired cadaver model, whether the torsional load to fracture was higher in collared stems. The hypothesis was that collared stems have greater load to fracture under axial and torsional loads compared with collarless stems. Methods Twenty-two cadaveric femora (11 matched pairs) with a mean age of 77 ± 10.2 years (range, 54 to 90 years) were harvested. Following dissection, the femora were evaluated with use of a dual x-ray absorptiometry scanner and T scores were recorded. We utilized a common stem that is available with the same intraosseous geometry with and without a collar. For each pair, 1 femur was implanted with a collared stem and the contralateral femur was implanted with a collarless stem with use of a standard broaching technique. A compressive 68-kg load was applied to simulate body weight during ambulation. A rotational displacement was then applied until fracture occurred. Peak torque prior to fracture was measured with use of a torque meter load cell and data acquisition software. Results The median torque to fracture was 65.4 Nm for collared stems and 43.1 Nm for uncollared stems (p = 0.0014, Wilcoxon signed-rank test). The median T score was -1.95 (range, -4.1 to -0.15). The median difference in torque to fracture was 29.18 Nm. As expected in each case, the mode of failure was a spiral fracture around the implant. Conclusions Collared stems seemed to offer a protective effect in torsional loading in this biomechanical model comparing matched femora. Clinical relevance These results may translate into a protective effect against early periprosthetic Vancouver B2 femoral fractures that occur before osseous integration has occurred.

To compare duration of mechanical ventilation and pulmonary outcomes in patients treated with intramedullary nail (IMN) fixation of the tibia versus the femur.Retrospective cohort study.Level I trauma center.One thousand thirty patients were categorized based on treatment: those treated with IMN of the tibia (n = 515) and those treated with IMN of the femur (n = 515).IMN fixation of tibial and femoral fractures.The primary outcome was duration of mechanical ventilation. Secondary outcomes included length of intensive care unit (ICU) stay and risk of tracheostomy, pulmonary embolism (PE), acute respiratory distress syndrome (ARDS), and mortality.In an unadjusted analysis, femoral fractures were associated with increase in ventilator days (mean difference, 1.4; P0.001), ICU days (mean difference, 1.8; P0.001), and odds of tracheostomy (odds ratio, 1.7; P0.01). No difference was shown in likelihood of PE, ARDS, or mortality (P0.2). Propensity score-matched estimates showed no differences in any measured outcomes (P0.40). In patients with Injury Severity Scores17, we found no difference in length of ventilator or ICU days or likelihood of tracheostomy, PE, ARDS, or mortality in the unadjusted (P0.2) or propensity score-matched estimates (P0.3).These findings suggest that IMN fixation of the tibia is associated with duration of mechanical ventilation and risk of poor pulmonary outcomes similar to those of femoral nailing, after adjustment for baseline characteristics.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

At the initiation of the COVID-19 pandemic, restrictions forced researchers to decide whether to continue their ongoing clinical trials. The PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities) trial is a pragmatic cluster-randomized crossover trial in patients with open and closed fractures. PREPARE was enrolling over 200 participants per month at the initiation of the pandemic. We aim to describe how the COVID-19 research restrictions affected participant enrollment.The PREPARE protocol permitted telephone consent, however, sites were obtaining consent in-person. To continue enrollment after the initiation of the restrictions participating sites obtained ethics approval for telephone consent scripts and the waiver of a signature on the consent form. We recorded the number of sites that switched to telephone consent, paused enrollment, and the length of the pause. We used t-tests to compare the differences in monthly enrollment between July 2019 and November 2020.All 19 sites quickly implement telephone consent. Fourteen out of nineteen (73.6%) sites paused enrollment due to COVID-19 restrictions. The median length of enrollment pause was 46.5 days (range, 7-121 days; interquartile range, 61 days). The months immediately following the implementation of restrictions had significantly lower enrollment.A pragmatic design allowed sites to quickly adapt their procedures for obtaining informed consent via telephone and allowed for minimal interruptions to enrollment during the pandemic.

Severe lower extremity trauma among working-age adults is highly consequential for returning to work; however, the economic impact attributed to injury has not been fully quantified. The purpose of this study was to examine work and productivity loss during the year following lower extremity trauma and to calculate the economic losses associated with lost employment, lost work time (absenteeism), and productivity loss while at work (presenteeism).This is an analysis of data collected prospectively across 3 multicenter studies of lower extremity trauma outcomes in the United States. Data were used to construct a Markov model that accumulated hours lost over time due to lost employment, absenteeism, and presenteeism among patients from 18 to 64 years old who were working prior to their injury. Average U.S. wages were used to calculate economic loss overall and by sociodemographic and injury subgroups.Of 857 patients working prior to injury, 47.2% had returned to work at 1 year. The average number of productive hours of work lost was 1,758.8/person, representing 84.6% of expected annual productive hours. Of the hours lost, 1,542.3 (87.7%) were due to working no hours or lost employment, 71.1 (4.0%) were due to missed hours after having returned, and 145.4 (8.3%) were due to decreased productivity while working. The 1-year economic loss due to injury totaled $64,427/patient (95% confidence interval [CI], $63,183 to $65,680). Of the 1,758.8 lost hours, approximately 88% were due to not being employed (working zero hours), 4% were due to absenteeism, and 8% were due to presenteeism. Total productivity loss was higher among older adults (≥40 years), men, those with a physically demanding job, and the most severe injuries (i.e., those leading to amputation as well as Gustilo type-IIIB tibial fractures and type-III pilon/ankle fractures).Patients with severe lower extremity trauma carry a substantial economic burden. The costs of lost productivity should be considered when evaluating outcomes.

To characterize long-term outcomes of multiligament knee injuries (MLKIs) using patient-reported outcome measures, physical examination, and knee radiographs.Retrospective clinical follow-up.Twenty knees (18 patients) were evaluated at a mean follow-up of 13.1 years (range 11-15 years). The primary outcome measure was the Internal Knee Documentation Committee score. Patients also completed secondary patient-based outcome assessments including Patient-Reported Outcomes Measurement Information System computer adaptive testing, Short Form-36, and Tegner activity score. Sixteen knees (14 patients) also had physical examination and bilateral knee radiographs assessed with the Kellgren-Lawrence score.The mean Internal Knee Documentation Committee score was 56 points, which was significantly lower than the age-matched normative value of 77 ( P = 0.004) and exceeds the minimum clinically important difference of 12 points. Most secondary outcome scores were worse than normative population values. Posttraumatic arthritis was present in 100% of MLKIs that had radiographs. Comparing operative versus nonoperative management, there were no statistical differences in patient demographics, injury characteristics, physical examination, or imaging, but surgical patients had better Short Form-36 Social Functioning (89 vs. 63, P = 0.02) and Tegner scores (4.5 vs. 2.9, P = 0.05).The long-term outcomes of MLKIs are generally poor, and posttraumatic radiographic evidence of arthritis seems to be universal . Operative management of these injuries may improve long-term outcomes. Clinicians should be aware of these results when counseling patients.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Limited data are available on the longer-term physical and psychosocial consequences after major extremity trauma apart from literature on the consequences after major limb amputation. The existing literature suggests that although variations in outcome exist, a significant proportion of service members and civilians sustaining major limb trauma will have less than optimal outcomes or health and rehabilitation needs over their life course. The proposed pilot study will address this gap in current research by locating and consenting METRC participants with the period of 5-7 years postinjury, identifying potential participation barriers and appropriate use of incentives, and conducting the follow-up examination at several data collection sites. The resulting data will inform the primary objective of refining and developing specific hypotheses to determine the design, scope, and feasibility of the main long-term consequences of major extremity trauma. Three METRC enrollment centers will contact past participants to achieve the goal of completing an interview, select patient-reported outcomes, perform a medical record review, and conduct an in-person clinic visit that will consist of a physical examination, blood draw, and x-ray of the study injury area. If successful, it will be possible to design studies to further examine these effects and develop future therapeutic interventions.

To compare the retrospective decision of an expert panel who assessed likelihood of acute compartment syndrome (ACS) in a patient with a high-risk tibia fracture with decision to perform fasciotomy.Prospective observational study.Seven Level 1 trauma centers.One hundred eighty-two adults with severe tibia fractures.Diagnostic performance (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver-operator curve) of an expert panel's assessment of likelihood ACS compared with fasciotomy as the reference diagnostic standard.The interrater reliability of the expert panel as measured by the Krippendorff alpha. Expert panel consensus was determined using the percent of panelists in the majority group of low (expert panel likelihood of ≤0.3), uncertain (0.3-0.7), or high (0.7) likelihood of ACS.Comparing fasciotomy (the diagnostic standard) and the expert panel's assessment as the diagnostic classification (test), the expert panel's determination of uncertain or high likelihood of ACS (threshold0.3) had a sensitivity of 0.90 (0.70, 0.99), specificity of 0.95 (0.90, 0.98), PPV of 0.70 (0.50, 0.86), and NPV of 0.99 (0.95, 1.00). When a threshold of0.7 was set as a positive diagnosis, the expert panel assessment had a sensitivity of 0.67 (0.43, 0.85), specificity of 0.98 (0.95, 1.00), PPV of 0.82 (0.57, 0.96), and NPV of 0.96 (0.91, 0.98).In our study, the retrospective assessment of an expert panel of the likelihood of ACS has good specificity and excellent NPV for fasciotomy, but only low-to-moderate sensitivity and PPV. The discordance between the expert panel-assessed likelihood of ACS and the decision to perform fasciotomy suggests that concern regarding potential diagnostic bias in studies of ACS is warranted.Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

To quantify patient preferences towards time to return to driving relative to compromised reaction time and potential complication risks.Cross-sectional discrete choice experiment.Academic trauma center.Ninety-six adult patients with an operative lower extremity fracture from December 2019 through December 2020.None.Patient completed a discrete choice experiment survey consisting of 12 hypothetical return to driving scenarios with varied attributes: time to return to driving (range: 1 to 6 months), risk of implant failure (range: 1% to 12%), pain upon driving return (range: none to severe), and driving safety measured by braking distance (range: 0 to 40 feet at 60 mph). The relative importance of each attribute is reported on a scale of 0% to 100%.Patients most valued a reduced pain level when resuming driving (62%), followed by the risk of implant failure (17%), time to return to driving (13%), and braking safety (8%). Patients were indifferent to returning to driving at 1 month (median utility: 28, interquartile range [IQR] -31 to 80) or 2 months (median utility: 59, IQR: 41 to 91) postinjury.Patients with lower extremity injuries demonstrated a willingness to forego earlier return to driving if it might mean a decrease in their pain level. Patients are least concerned about their driving safety, instead placing higher value on their own pain level and chance of implant failure. The findings of this study are the first to rigorously quantify patient preferences toward a return to driving and heterogeneity in patient preferences.V.

OBJECTIVES To determine whether knowledge-based deficiencies are adequately addressed at the AO North America Basic Principles of Fracture Management course. DESIGN Pretest, posttest. SETTING Eighteen national trauma courses. PARTICIPANTS Two thousand one hundred forty-nine learners. INTERVENTION Pre- and postcourse 20-item tests of basic fracture knowledge, including 14 trauma topics. MAIN OUTCOME MEASURES Deficiencies were defined as

To determine factors predictive of postoperative surgical site infection (SSI) after fracture fixation and create a prediction score for risk of infection at time of initial treatment.Retrospective cohort study.Level I trauma center.Study group, 311 patients with deep SSI; control group, 608 patients.We evaluated 27 factors theorized to be associated with postoperative infection. Bivariate and multiple logistic regression analyses were used to build a prediction model. A composite score reflecting risk of SSI was then created.Risk of postoperative infection.The final model consisted of 8 independent predictors: (1) male sex, (2) obesity (body mass index ≥ 30) (3) diabetes, (4) alcohol abuse, (5) fracture region, (6) Gustilo-Anderson type III open fracture, (7) methicillin-resistant Staphylococcus aureus nasal swab testing (not tested or positive result), and (8) American Society of Anesthesiologists classification. Risk strata were well correlated with observed proportion of SSI and resulted in a percent risk of infection of 1% for ≤3 points, 6% for 4-5 points, 11% for 6 to 8-9 points, and 41% for ≥10 points.The proposed postoperative infection prediction model might be able to determine which patients have fractures at higher risk of infection and provides an estimate of the percent risk of infection before fixation.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

To evaluate the outcomes of patients with pelvic ring injuries managed with resuscitative endovascular balloon occlusion of the aorta (REBOA).Retrospective case series.Academic, Level 1 trauma center in North America.Twenty-five patients with disruption of the pelvic ring and hemodynamic instability.Placement of a REBOA device as an adjuvant treatment to trauma resuscitation.Death and ischemic-related complications.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.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.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Gunshot injuries of the extremities are common in the United States, especially among people with nonfatal gunshot wounds. Controversy persists regarding the proper management for low-energy gunshot-induced fractures, likely stemming from varying reports on the likelihood of complications. There has yet to be published a study on a large cohort of patients with gunshot-induced tibia fractures on which to base our understanding of complications after this injury. Questions/purposes (1) What percentage of patients with low-energy gunshot-induced tibia fractures developed complications? (2) Was there an association between deep infection and fracture location, injury characteristics, debridement practices, or antibiotic use? Methods This was a multicenter retrospective study. Between January 2009 and December 2018, we saw 201 patients aged 16 years or older with a gunshot-induced fracture who underwent operative treatment; 2% (4 of 201) of those screened had inadequate clinical records, and 38% (76 of 201) of those screened had inadequate follow-up for inclusion. In all, 121 patients with more than 90 days of follow-up were included in the study. Nonunion was defined as a painful fracture with inadequate healing (fewer than three cortices of bridging bone) at 6 months after injury, resulting in revision surgery to achieve union. Deep infection was defined according to the confirmatory criteria of the Fracture-Related Infection Consensus Group. These results were assessed by a fellowship-trained orthopaedic trauma surgeon involved with the study. Complication proportions were tabulated. A Kaplan-Meier chart demonstrated presentations of deep infection by fracture location (proximal, shaft, or distal). Univariate statistics and multivariate Cox regression were used to examine the association between deep infection and fracture location, entry wound size, vascular injury, intravenous (IV) antibiotics in the emergency department (ED), deep and superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics, while adjusting for age, race/ethnicity, smoking status, and BMI. A power analysis for the result of deep infection demonstrated that we would have had to observe a hazard ratio of 4.28 or greater for shaft versus proximal locations to detect statistically significant results at 80% power and alpha = 0.05. Results The overall complication proportion was 49% (59 of 121), with proportions of 14% (17 of 121) for infection, 27% (33 of 121) for wound complications, 20% (24 of 121) for nonunion, 9% (11 of 121) for hardware breakage, and 26% (31 of 121) for revision surgery. A positive association was present between deep infection and deep debridement (HR 5.51 [95% confidence interval 1.12 to 27.9]; p = 0.04). With the numbers available, we found no association between deep infection and fracture location, entry wound size, vascular injury, IV antibiotics in the ED, superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics. Conclusion In this multicenter study, we found a higher risk of complications in operative gunshot-induced tibia fractures than prior studies have reported. Infection, in particular, was much more common than expected based on prior studies. Consequently, surgeons might consider adopting the general management principles for nongunshot-induced open tibia fractures with gunshot-induced fractures, such as the use of IV antibiotics both initially and after surgery. Further research is needed to test and validate these approaches. Level of evidence Level IV, therapeutic study.

OBJECTIVE To compare the early pain and functional outcomes of operative fixation versus nonoperative management for minimally displaced complete lateral compression (LC; OTA/AO 61-B1/B2) pelvic fractures. DESIGN Prospective clinical trial. SETTING Two academic trauma centers. PATIENTS Forty-eight adult patients with LC pelvic ring injuries with

Introduction Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. Methods and analysis PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. Ethics and dissemination The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. Trial registration number NCT02984384.

OBJECTIVES To evaluate the association of admission blood glucose ≥200 mg/dL and surgical site infection in orthopaedic trauma surgery. DESIGN Retrospective, case control study. SETTING Academic trauma center. PATIENTS Four hundred sixty-five nondiabetic, noncritically ill orthopaedic trauma patients with an extremity, pelvic, or acetabular fracture and requiring open reduction and internal fixation or intramedullary nailing. INTERVENTION None. MAIN OUTCOME MEASUREMENTS Ninety-day deep surgical site infection. RESULTS Admission blood glucose ≥200 mg/dL was significantly associated with the primary outcome (8/128, 6.3% vs. 35/337, 1.8%; P = 0.01). Multivariable logistic regression modeling demonstrated that admission blood glucose ≥200 mg/dL was a significant risk factor for deep surgical site infections [odds ratio (OR): 4.7, 95% confidence interval (CI) 1.4-15.7], after controlling for male gender (OR: 1.8, 95% CI: 1.1-3.1), prior drug or alcohol abuse (OR: 1.9, 95% CI 0.9-4.0), open fracture (OR: 6.4, 95% CI 3.7-11.0), and fracture region (upper extremity OR: reference; pelvis/hip OR: 3.9, 95% CI 1.6-9.7; femur OR: 2.0, 95% CI 0.88-4.8; tibia/ankle OR: 3.3, 95% CI 1.7-6.2; and foot OR: 2.7, 95% CI 1.2-6.3). CONCLUSIONS Admission glucose ≥200 mg/dL was a significant independent risk factor for 90-day deep surgical site infections in orthopaedic trauma patients and may serve as an important marker for infection risk. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Prompt administration of antibiotics is a critical component of open fracture treatment. Traditional antibiotic recommendations have been a first-generation cephalosporin for Gustilo Type-I and Type-II open fractures, with the addition of an aminoglycoside for Type-III fractures and penicillin for soil contamination. However, concerns over changing bacterial patterns and the side effects of aminoglycosides have led to interest in other regimens. The purpose of the present study was to describe the adherence to current prophylactic antibiotic guidelines. Methods We evaluated the antibiotic-prescribing practices of 24 centers in the U.S. and Canada that were participating in 2 randomized controlled trials of skin-preparation solutions for open fractures. A total of 1,234 patients were evaluated. Results All patients received antibiotics on the day of admission. The most commonly prescribed antibiotic regimen was cefazolin monotherapy (53.6%). Among patients with Type-I and Type-II fractures, there was 61.1% compliance with cefazolin monotherapy. In contrast, only 17.2% of patients with Type-III fractures received the recommended cefazolin and aminoglycoside therapy, with an additional 6.7% receiving piperacillin/tazobactam. Conclusions There is moderate adherence to the traditional antibiotic treatment guidelines for Gustilo Type-I and Type-II fractures and low adherence for Type-III fractures. Given the divergence between current practice patterns and prior recommendations, high-quality studies are needed to determine the most appropriate prophylactic protocol.

OBJECTIVES To determine the reliability of self-reported smoking status in the orthopaedic trauma population and determine if certain patient factors might predispose inaccurate self-reported smoking cessation. DESIGN Prospective. SETTING Level I trauma center. PATIENTS Two hundred forty-seven orthopaedic trauma patients were included in the study. INTERVENTION In-office measurement of exhaled carbon monoxide (CO). MAIN OUTCOME MEASUREMENTS Self-reported smoking cessation with exhaled CO measurements. RESULTS A total of 906 self-reported surveys were completed over 4 follow-up visits. Of the responses indicating smoking cessation (n = 174), 12.6% [95% confidence interval (CI), 0.081-0.185] reported smoking cessation with positive CO readings, suggesting inaccurate self-reporting of smoking status. Over 20% of those patients inaccurately reporting abstinence did so more than once. The odds of inaccurate self-reporting was 3 times higher in patients with no insurance or government insurance [odds ratio (OR), 3.5; 95% CI, 1.1-11.0; P = 0.043] and in the unemployed (OR, 3.3; 95% CI, 0.97-8.57; P = 0.049). CONCLUSIONS Self-reported smoking status in the orthopaedic population is fairly reliable, with 13% of patient's inaccurately self-reporting smoking cessation despite knowing their smoking status was being measured. Clinicians should be aware of the potential for inaccuracy in self-reported smoking cessation, particularly in patients with the identified socioeconomic factors. Point-of-care testing before elective trauma procedures to confirm smoking status might have a role if the procedure outcome is highly dependent on smoking status. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

ObjectiveOccupational therapy is often prescribed after the acute treatment of upper extremity fractures. However, high out-of-pocket expenses and logistical constraints can reduce access to formal therapy services. We aimed to quantify preferences of patients with upper extremity fracture for attending occupational therapy, when considering possible differences in clinical outcomes.DesignDiscrete choice experiment.SettingLevel 1 trauma centre in Baltimore, Maryland, USA.Participants134 adult patients with upper extremity fractures.Primary outcome measuresThe scenarios were described with five attributes: cost, duration of therapy session, location of therapy, final range of motion and pain. We report the relative importance of each attribute as a proportion of total importance, and the willingness to pay for benefits of the therapy services.ResultsOf the 134 study participants, the mean age was 47 years and 53% were men. Cost (32%) and range of motion (29%) were the attributes of greatest relative importance. Pain (17%), duration of therapy (13%) and location of therapy (8%) were of lesser importance. Patients were willing to pay $85 more per therapy session for a 40% improvement in their range of motion. Patients were willing to pay $43 more per therapy session to improve from severe pain to mild pain. Patients were indifferent to whether the therapy treatment was home-based or in a clinical environment.ConclusionsWhen deciding on an upper extremity fracture therapy programme, out-of-pocket costs are a paramount consideration of patients. Improvements in range of motion are of greater importance than residual pain, the duration of therapy sessions and the location of service provision. Patients with upper extremity fracture should be prescribed occupational therapy services that align with these patients’ preferences.

Objective To assess whether the fixation method and vitamin D supplementation affect the risk of patient-important outcomes within 12 months of injury in nongeriatric femoral neck fracture patients. Design A pilot factorial randomized controlled trial. Setting Fifteen North American clinical sites. Participants Ninety-one adults 18-60 years of age with a femoral neck fracture requiring surgical fixation. Intervention Participants were randomized to a surgical intervention (sliding hip screw or cancellous screws) and a vitamin D intervention (vitamin D3 4000 IU daily vs. placebo for 6 months). Main outcome measurements The primary clinical outcome was a composite of patient-important complications (reoperation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion). Secondary outcomes included fracture-healing complications and radiographic fracture healing. Results Eighty-six participants with a mean age of 41 years were included. We found no statistically significant difference in the risk of patient-important outcomes between the surgical treatment arms (hazard ratio 0.90, 95% confidence interval 0.40-2.02, P = 0.80) and vitamin D supplementation treatment arms (hazard ratio 0.96, 95% confidence interval 0.42-2.18, P = 0.92). Conclusions These pilot trial results continue to describe the results of current fixation implants, inform the challenges of improving outcomes in this fracture population, and may guide future vitamin D trials to improve healing outcomes in young fracture populations. Although the pilot trial was not adequately powered to detect treatment effects, publishing these results may facilitate future meta-analyses on this topic. Level of evidence Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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 2 times the femoral radius had 32 times the odds (95% confidence interval, 2-752) of motion surgery compared with patients with distance ratios

Objectives To determine whether using topical vancomycin powder in fracture surgery may result in low levels of vancomycin in the serum and not result in nephrotoxicity. Design Prospective observational at a single site as a substudy of the VANCO trial. Setting Single, large urban level I trauma center. Patients/participants Fifty-eight patients with tibial plateau and pilon fractures randomized to the treatment arm at the principal investigator's site. Intervention Topical vancomycin powder (1000 mg) applied directly in the wound over all metal implants at the time of wound closure. Main outcome measurements Serum vancomycin levels at 1 hour and 6-8 hours after surgery. Secondary outcomes included serum creatinine before surgery, a day after surgery, and at 2 weeks postoperatively and complete blood count at 2 weeks postoperatively. Results Except in 2 patients who also received intravenous vancomycin, none of the study patients had detectable (>5 µg/mL) serum vancomycin levels at 1 hour and 6-8 hours after surgery. One patient with a history of elevation of serum creatinine had a minor increase of serum creatinine but had undetectable vancomycin levels. None of the other patients had a clinically significant increase in creatinine levels. Conclusions Despite its relatively widespread usage, little data exist regarding the systemic levels and nephrotoxicity associated with the topical use of vancomycin powder in orthopaedic fracture surgery. These prospective data indicate that there seems to be little clinical concern regarding toxicity associated with systemic absorption of vancomycin powder in this specific clinical application. Level of evidence Therapeutic Level IV. See instructions for authors for a complete description of levels of evidence.

Objectives To determine whether patients with operatively treated fractures and surgical site infection after use of topical vancomycin powder have a lower proportion of Staphylococcus aureus infections than patients who did not receive topical vancomycin powder. Design Retrospective cohort study. Setting Level I trauma center. Patients Treatment group: 10 of 133 patients (145 fractures) with surgical site infections who received intrawound vancomycin powder at the time of wound closure for fracture fixation. Control group: 175 patients who sustained deep surgical site infections during the same period but did not receive vancomycin powder. Intervention Vancomycin powder or no vancomycin powder. Main outcome measurement Proportion of patients' cultures positive for S. aureus. Results The proportion of cultures positive for S. aureus was significantly lower in patients with surgical site infection who received vancomycin powder than in those who did not receive vancomycin powder (10% [1 of 10 patients in the treatment group] vs. 50% [87 of 175 patients in the control group]; P = 0.02). A trend was observed for a lower proportion of methicillin-resistant S. aureus (0% vs. 23%; P = 0.12). Conclusions Vancomycin powder might alter the bacteriology of surgical site infections and decrease the proportion in culture of the most common organism typically present after fracture surgery infection. These findings suggest that the application of vancomycin powder might change the bacteriology of surgical site infections when they occur, regardless of the effect on overall infection rates. Although our bacteriology results are clinically and statistically significant, these findings must be confirmed in larger randomized controlled trials. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To determine whether Hounsfield units (HUs) measured on perioperative computed tomographic scans are associated with radiographic outcomes and reoperations after femoral neck fracture fixation. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS One hundred fourteen patients age ≥18 years, who presented to a Level I trauma center, and who underwent surgical fixation of intracapsular femoral neck fracture and had perioperative computed tomographic scans and adequate follow-up. INTERVENTION None. MAIN OUTCOME MEASUREMENTS Screw penetration, femoral neck shortening >5 mm, and revision surgery. RESULTS A median follow-up was 23 months. An HU measurement of the femoral head was significantly associated with screw penetration and femoral neck shortening but not revision surgery. Patients with middle femoral head HU measurements