Area Deprivation Index as a proxy for socioeconomic status in outpatient orthopaedic surgery patients - A prospective registry cross sectional study.

Background: We aimed to determine if Area Deprivation Index (ADI) is associated with self-reported metrics socioeconomic status (SES), and to assess the relationship between ADI and preoperative score on common patient reported outcome scores (PROS). Methods: Patients presenting for outpatient orthopaedic surgery completed Patient-Reported Outcome Metric Information System (PROMIS) and joint-specific PROS. ADI was determined from geocoded home address. Sociodemographic data was collected from self-reported survey. Tests of association were used to describe the relationship between ADI and sociodemographic factors as well as the correlation between ADI and PROS. Extreme group analysis was used to examine which PROS may be subject to clinically meaningful variation. Results: ADI was associated with self-reported SES. ADI was correlated with score on all baseline PROS. Extreme group analysis showed that low SES was associated with clinically meaningful differences in some, but not all, PROS. Conclusion: ADI is associated with self-reported measures of SES in an orthopaedic outpatient surgical population. Lower SES correlates with worse function to a clinically significant degree for some PROS. SES should be considered in the context of preoperative symptom severity in outpatient orthopaedic surgery patients. ADI may be a useful adjunct to self-reported measures of SES for this purpose.

Timing of radiographic healing for distal femur fractures treated with intramedullary nails.

OBJECTIVES: This study aimed to profile modified Radiographic Union Scale for Tibia (mRUST) scores over time in distal femur fractures treated with intramedullary nails and identify predictors of radiographic union timing and delayed progression. METHODS: Design: Multicenter retrospective cohort study. SETTING: Ten Level I Trauma Centers. PATIENT SELECTION CRITERIA: The inclusion criteria were patients with distal femur fractures (OTA/AO 33A and 33C) treated with intramedullary nails, with a minimum follow-up of one year or until radiographic union or reoperation. The exclusion criteria were fractures treated with combination nail-plate constructs, pathologic fractures, and patients under 18 years old.Outcome Measures and Comparisons: The primary outcome was the mRUST score at 3, 6, and 12 months post-operatively. Receiver operating characteristic (ROC) curve analysis identified the optimal 3-month mRUST score predicting reoperation. Multivariable models were used to identify predictors of radiographic union timing and delayed progression. RESULTS: The study included 155 fractures in 152 patients, with a mean patient age of 51 and a mean follow-up of 17 months. A 3-month mRUST score of ≤8 predicted reoperation with a PPV of 25%, and a NPV of 99%. The timing of radiographic union was associated with tobacco use (1.2 months later; p = 0.04), open fracture (1.4 months later; p = 0.04), and the use of topical antibiotics (2.1 months longer; 95% CI: 0.33 - 3.84; p = 0.02), however topical antibiotics was at high risk of being confounded by injury severity. Delayed progression to fracture healing, wherein the most rapid radiographic healing occurs more than 3 months post-operatively, was predicted by chronic kidney disease (p < 0.01). CONCLUSIONS: A 3-month mRUST score >8 suggests a very high likelihood of avoiding reoperation for nonunion.Tobacco use and open fractures were associated with a longer time to radiographic union. Chronic kidney disease is associated with a delayed radiographic progression, suggesting a need for adjusted expectations and management strategies in these patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Venous thromboembolism prophylaxis prescribing patterns for patients with orthopedic trauma: a clinical vignette survey.

Background: A recent clinical trial suggested aspirin is a viable alternative to enoxaparin for venous thromboembolism (VTE) prophylaxis in patients after orthopedic trauma. The initial impact of these findings on VTE prophylaxis prescribing is unknown. The study aimed to evaluate stated VTE prophylaxis prescribing patterns among clinicians who treat patients after orthopedic trauma. Methods: For this clinical vignette survey, we recruited surgeons and advanced practice providers who prescribed VTE prophylaxis to patients with orthopedic trauma across 40 states. Clinicians were shown seven clinical vignettes describing hypothetical patients with orthopedic trauma based on their fracture type, treatment, VTE risk factors, additional injuries and health insurance status. We assessed the stated VTE prophylaxis medications prescribed in-hospital and at discharge, patient factors associated with changes in medication prescribing preferences and practice variation by specialty and provider training. Results: Among the 287 respondents, the median age was 43 years (IQR, 38-50), and 154 (weighted average, 63%) were men. For in-hospital VTE prophylaxis, enoxaparin was prescribed in 83% of the presented scenarios, and aspirin was prescribed in 13% (p<0.001). At discharge, aspirin was prescribed more frequently than enoxaparin (50% vs 41%, p<0.001). Healthcare providers with an aspirin discharge preference were 12% more likely to switch to enoxaparin if the patient had additional VTE risk factors, such as obesity (95% CI 4% to 19%, p=0.005). Conclusions: Despite new clinical evidence, in-hospital VTE prophylaxis prescribing practices for patients with orthopedic trauma remain consistent with those reported a decade ago. However, compared with historical data, clinicians have significantly increased their preference for aspirin for thromboprophylaxis at discharge-unless the patient has additional thromboembolic risk factors. Level of evidence: 5-expert opinion.

Positive Cutibacterium acnes Intervertebral Discs Are Not Associated with Subsidence Following Anterior Cervical Discectomy and Fusion at 3 or 6 Months.

Background/Objectives:Cutibacterium acnes (C. acnes), formerly known as Propionibacterium acnes (P. acnes), is an anaerobic, low-virulent bacterium that has been associated with postoperative infections of the shoulder, knee, and cervical spine. Recent studies have highlighted an association between C. acnes and the development of degenerative disc disease (DDD). The aim of this study is to ascertain whether C. acnes increases the risk of subsidence following anterior cervical discectomy and fusion (ACDF). Methods: After IRB approval, consecutive patients undergoing elective ACDF for DDD from 2017 to 2018 were enrolled in this prospective cohort study. Intervertebral disc samples were taken at each affected level and cultured. A total of 66 patients with radiographic follow-ups were included in the final analysis. The extent of subsidence and cervical lordosis was determined immediately postoperatively and at the 3- and 6-month follow-ups. Results: No significant difference in subsidence was observed at 3 months (p = 0.07) or 6 months (p = 0.11) between culture-positive and -negative cohorts. Additionally, there was no significant difference detected in the change in cervical lordosis observed at 3 months (p = 0.16) or 6 months (p = 0.27) between culture-positive and -negative cohorts. For the most inferiorly fused segment, there was a significant difference in subsidence observed at 3 months (1.5 mm, 95% CI: 0.2-2.7 mm, p = 0.02) but not at 6 months (p = 0.17). Conclusions: Intervertebral discs with a positive C. acnes culture were not associated with greater levels of subsidence at 3 or 6 months following ACDF for DDD. Further research is necessary to endorse these results and to gauge the clinical significance of C. acnes infection.

External Validation of a Predictive Score for Fracture-Related Infections in Orthopedic Trauma Surgery.

BACKGROUND: The purpose of this study was to externally validate a predictive score for fracture-related infections, establishing generalizability for absolute and relative risk of infection in the setting of orthopedic fracture surgery. MATERIALS AND METHODS: This was a retrospective, case-control study performed at a level I academic trauma center that included 147 patients with fracture-related infection in the study group and 300 control patients. We analyzed the same 8 independent predictors of fracture-related infection cited by a previous study. We then used the area under the receiver operating characteristics curve (AUC) to compare the derivation and validation cohorts. The validation and derivation cohorts were then compared by grouping patients into 4 strata of Wise score groups. This allowed for comparison of AUC and risk of fracture-related infection in our institution with those in the previously studied institution. RESULTS: The resulting data yielded an AUC (0.74) nearly identical to that of the previously studied institution. It was also found that the relative risk of infection correlated with the Wise score in the same way the initial model did with the absolute risks being similar. CONCLUSION: The previous predictive model was externally validated and shown to be generalizable to a different patient population. The relative risk of a fracture-related infection can be determined using this scoring model preoperatively with the goal of aiding in patient counseling and surgical decision-making, giving a quantitative value to patient risk factors. [Orthopedics. 2024;47(5):e268-e272.].

Is the Orthopaedic Trauma Association-Open Fracture Classification (OTA-OFC) Better than the Gustilo-Anderson Classification at Predicting Fracture-Related Infections in the Tibia?

OBJECTIVES: To investigate and compare the predictive ability of the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) and the Gustilo-Anderson classification systems for fracture-related infections (FRI) in patients with open tibia fractures. METHODS: Design: Retrospective cohort study. SETTING: Academic trauma center. PATIENT SELECTION CRITERIA: Patients aged 16 years or older with an operatively treated open tibia fracture (OTA-OTA 41, 42, and 43) between 2010 and 2021. OUTCOME MEASURES AND COMPARISONS: The primary outcome was FRI. The OTA-OFC and the Gustilo-Anderson classifications were compared in their ability to predict FRI. RESULTS: 890 patients (mean age, 43 years [range, 17 to 96]; 75% male) with 912 open tibia fractures were included. 142 (16%) had an infection. The OTA-OFC was not significantly better at predicting FRI than the Gustilo-Anderson classification (area under the curve, 0.66 vs. 0.66; P = 0.89). The Gustilo-Anderson classification was a stronger predictor of FRI than any single OTA-OFC domain, explaining 72% of FRI variance. Only the addition of the OTA-OFC wound contamination domain to Gustilo-Anderson significantly increased the variance explained (72% vs. 84%, P = 0.04). Embedded contamination increased the risk of FRI by approximately 10% as the risk of FRI with embedded contamination was 16% for Type I or IIs, 26% for Type IIIAs, 45% for Type IIIBs, and 46% for Type IIICs. CONCLUSIONS: The more complex OTA-OFC system was not better than the Gustilo-Anderson classification system in predicting FRIs in patients with open tibia fractures. Adding embedded wound contamination to the Gustilo-Anderson classification system significantly improved its prognostic ability. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for infection in severe open tibial shaft fractures.

OBJECTIVE: To evaluate risk factors for infection in severe open tibial shaft fractures. METHODS: A secondary analysis of a multicenter prospective study investigated internal versus external fixation of severe open tibia fractures at 20 US Level I trauma centers. Adult patients, aged <65 years, with a Gustilo-Anderson Type IIIB or severe IIIA metaphyseal or diaphyseal tibia fracture were included. All fractures underwent definitive fixation with either a modern ring external fixator, intramedullary device, and/or plate. Fourteen variables previously identified as risk factors for infection were included in the analysis. Deep surgical site infection was defined as an infection treated with surgical debridement within 1 year of index surgery. RESULTS: The study cohort included 430 patients. Deep surgical site infection requiring reoperation occurred in 108 (25 %) patients. The final model identified four risk factors for infection: age >40 years (OR, 2.00; 95 % CI, 1.3-3.1), Gustilo-Anderson Type IIIB (OR, 1.80; 95 % CI, 1.1-3.0), embedded wound contamination (OR, 1.69; 95 % CI, 1.1-2.7), and wound length (OR, 1.02/cm; 95 % CI, 1.0-1.05). The model performed poorly at distinguishing infected from uninfected patients (Area Under the Curve=0.57; 95 % CI, 0.51-0.63). CONCLUSIONS: Surgeons can now counsel patients with these risk factors that they are at a markedly higher risk of infection. The identification of these risk factors may direct future research aimed at mitigating the risk of deep surgical site infection in this patient population.

What outcomes do patients value after orthopaedic trauma: A best-worst scaling choice experiment.

INTRODUCTION: Patient-centered treatment and research should focus on the outcomes that matter to patients. The primary aim of this study was to determine the outcome preferences of patients after musculoskeletal trauma. The secondary aim was to identify discrepancies between outcome preferences of surgeons and patients. METHODS: A Best-worst scaling choice experiment survey was administered to patients with operative lower extremity injuries and orthopaedic surgeons who take trauma call. Participants completed 13 choice sets of 3 randomly-ordered outcomes, including: a full recovery (back to normal) without any problems; a problem that requires additional surgery or hospital stay versus medication or treatment in clinic/emergency department; minimal to moderate versus severe pain for 6 weeks; need for crutches/walker versus wheelchair for 6-12 weeks; being unable to work for 6-12 weeks; requiring 2-4 weeks in a facility; a perfect versus poor or worst-possible EuroQol 5 Dimension (EQ-5D) score at 1 year; and death. Within each set, participants ranked their "most-preferred" to "least-preferred" outcomes. Responses were aggregated to calculate the relative importance, or marginal utility, of each outcome stratified by respondent type. RESULTS: Fifty-five patients and 65 surgeons participated. The most preferred outcome for patients and surgeons was a full recovery (back to normal) without any problems, followed by minimal to moderate pain for 6 weeks and a perfect EQ-5D score. The least preferred outcomes were death and the worst EQ-5D score, which had similar marginal utility, followed by a poor EQ-5D score and a problem that needs another surgery or stay at a hospital, which also had similar marginal utility. Surgeons, in comparison to patients, assigned a higher marginal utility to perfect EQ-5D scores at one year (3.55 vs. 2.03; p < 0.0001) and a 2-4 week stay in a facility (0.52 vs. -0.21; p = 0.001), and a lower marginal utility to severe pain for 6 weeks (-0.58 vs. -0.08; p = 0.04) and a poor EQ-5D score (-1.88 vs. -1.03; p = 0.02). CONCLUSIONS: A full recovery (back to normal) without any problems was the most-preferred outcome for both patients and surgeons. Patient-centered care and research should focus on both patients' return to baseline and the avoidance of complications. LEVEL OF EVIDENCE: N/A.

Healthcare personnel opinions regarding the feasibility of a risk-tailored approach to contact precautions for methicillin-resistant Staphylococcus aureus in the acute care setting.

"All or none" approaches to the use of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) both fail to recognize that transmission risk varies. This qualitative study assessed healthcare personnel perspectives regarding the feasibility of a risk-tailored approach to use contact precautions for MRSA more strategically in the acute care setting.

Factors that Promote and Protect Against Financial Toxicity after Orthopaedic Trauma: A Qualitative Study.

INTRODUCTION: Financial toxicity is highly prevalent in patients after an orthopaedic injury. However, little is known regarding the conditions that promote and protect against this financial distress. Our objective was to understand the factors that cause and protect against financial toxicity after a lower extremity fracture. METHODS: A qualitative study was conducted using semi-structured interviews with 20 patients 3 months after surgical treatment of a lower extremity fracture. The interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis to identify themes and subthemes. Data saturation occurred after 15 interviews. The percentage of patients who described the identified themes are reported. RESULTS: A total of 20 patients (median age, 44 years [IQR, 38 to 58]; 60% male) participated in the study. The most common injury was a distal tibia fracture (n = 8; 40%). Eleven themes that promoted financial distress were identified, the most common being work effects (n = 14; 70%) and emotional health (n = 12; 60%). Over half (n = 11; 55%) of participants described financial toxicity arising from an inability to access social welfare programs. Seven themes that protected against financial distress were also identified, including insurance (n = 17; 85%) and support from friends and family (n = 17; 85%). Over half (n = 13; 65%) of the participants discussed the support they received from their healthcare team, which encompassed expectation setting and connections to financial aid and other services. Employment protection and workplace flexibility were additional protective themes. CONCLUSION: This qualitative study of orthopaedic trauma patients found work and emotional health-related factors to be primary drivers of financial toxicity after injury. Insurance and support from friends and family were the most frequently reported protective factors. Many participants described the pivotal role of the healthcare team in establishing recovery expectations and facilitating access to social welfare programs.

Venous thromboembolism testing practices after orthopaedic trauma: prophylaxis regimen does not influence testing patterns.

Objectives: To determine venous thromboembolism (VTE) testing patterns in an orthopaedic trauma population and to evaluate for differences in VTE surveillance by prophylaxis regimen through a secondary analysis of the ADAPT trial. Design: Prospective randomized trial. Setting: Level I trauma center. Patients: Three hundred twenty-nine adult (18 years and older) trauma patients presenting with an operative extremity fracture proximal to the metatarsals/carpals or any pelvic or acetabular fracture requiring VTE prophylaxis. Intervention: VTE imaging studies recorded within 90 days post injury. Main Outcome Measurements: Percentage of patients tested for VTE were compared between treatment groups using Fisher's exact test. Subsequently, multivariable regression was used to determine patient factors significantly associated with risk of receiving a VTE imaging study. Results: Sixty-seven patients (20.4%) had VTE tests ordered during the study period. Twenty (29.9%) of these 67 patients with ordered VTE imaging tests had a positive finding. No difference in proportion of patients tested for VTE by prophylaxis regimen (18.8% on aspirin vs. 22.0% on LMWH, P = 0.50) was observed. Factors associated with increased likelihood of VTE testing included White race (adjusted odds ratio [aOR]: 2.61, 95% CI: 1.26-5.42), increased Injury Severity Score (aOR for every 1-point increase: 1.10, 95% CI: 1.05-1.15), and lower socioeconomic status based on the Area Deprivation Index (aOR for every 10-point increase: 1.14, 95% CI: 1.00-1.30). Conclusions: VTE surveillance did not significantly differ by prophylaxis regimen. Patient demographic factors including race, injury severity, and socioeconomic status were associated with differences in VTE surveillance. Level of Evidence: Level I, Therapeutic.

Patient Preferences for Operative Versus Nonoperative Treatment of LC1 Pelvis Fracture: A Discrete Choice Experiment.

OBJECTIVES: To quantify how patients with lateral compression type 1 (LC1) pelvis fracture value attributes of operative versus nonoperative treatment. DESIGN: Discrete choice experiment. SETTING: Three US Level 1 trauma centers. PATIENT SELECTION CRITERIA: Adult survivors of an LC1 pelvis treated between June 2016 and March 2023 were identified from institutional registries. The choice experiment was administered as a survey from March through August 2023. OUTCOME MEASURES AND COMPARISONS: Participants chose between 12 hypothetical comparisons of treatment attributes including operative or nonoperative care, risk of death, severity of pain, risk of secondary surgery, shorter hospital stay, discharge destination, and independence in ambulation within 1 month of injury. The marginal utility of each treatment attribute, for example, the strength of participants' aggregate preference for an attribute as indicated by their survey choices, was estimated by multinomial logit modeling with and without stratification by treatment received. RESULTS: Four hundred forty-nine eligible patients were identified. The survey was distributed to 182 patients and collected from 72 patients (39%) at a median 2.3 years after injury. Respondents were 66% female with a median age of 59 years (IQR, 34-69 years). Before injury, 94% ambulated independently and 75% were working; 41% received operative treatment. Independence with ambulation provided the highest relative marginal utility (21%, P < 0.001), followed by discharge to home versus skilled nursing (20%, P < 0.001), moderate versus severe postdischarge pain (17%, P < 0.001), shorter hospital stay (16%, P < 0.001), secondary surgery (15%, P < 0.001), and mortality (10%, P = 0.02). Overall, no relative utility for operative versus nonoperative treatment was observed (2%, P = 0.54). However, respondents strongly preferred the treatment they received: operative patients valued operative treatment (utility, 0.37 vs. -0.37, P < 0.001); nonoperative patients valued nonoperative treatment (utility, 0.19 vs. -0.19, P < 0.001). CONCLUSIONS: LC1 pelvis fracture patients valued independence with ambulation, shorter hospital stay, and avoiding secondary surgery and mortality in the month after their injury. Patients preferred the treatment they received rather than operative versus nonoperative care.

Fix or Replace? Patient Preferences for the Treatment of Geriatric Lower Extremity Fractures: A Discrete Choice Experiment.

Introduction: When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture. Materials and Methods: We administered a discrete choice experiment survey to 150 patients who were at least 60 years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24 months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling. Results: The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6 months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively). Discussion: After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes. Conclusions: Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.

Effect of Aspirin Versus Low-Molecular-Weight Heparin Thromboprophylaxis on Medication Satisfaction and Out-of-Pocket Costs: A Secondary Analysis of a Randomized Clinical Trial.

BACKGROUND: Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin. METHODS: This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales. RESULTS: The trial enrolled 12,211 patients (mean age and standard deviation [SD], 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio [OR]: 2.59; 95% confidence interval [CI]: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001). CONCLUSIONS: Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis. LEVEL OF EVIDENCE: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Risk Factors of Failure in 228 Periprosthetic Distal Femur Fractures: A Multicenter Study.

OBJECTIVES: To identify risk factors of reoperation to promote union or to address deep surgical-site infection (DSSI) in periprosthetic distal femur fractures treated with lateral distal femoral locking plates (LDFLPs). DESIGN: Multicenter retrospective cohort study. SETTING: Ten level-I trauma centers. PATIENT SELECTION CRITERIA: Patients with Orthopaedic Trauma Association/Association of Osteosynthesis (OTA/AO) 33A or 33C periprosthetic distal femur fractures who underwent surgical fixation between January 2012 and December 2019 exclusively using LDFLPs were eligible for inclusion. Patients with pathologic fractures or with follow-up less than 3 months without an outcome event (unplanned reoperation to promote union or for deep surgical infection) before this time point were excluded. Fracture fixation constructs used medial plates, intramedullary nails, or hybrid fixation constructs were excluded from analysis. OUTCOME MEASURES AND COMPARISONS: To examine the influence of patient demographics, injury characteristics, and features of the fracture fixation construct on the occurrence of unplanned reoperation to promote union or to address a DSSI. RESULTS: There was an 8.3% rate (19/228) of unplanned reoperation to promote union. Predictive factors for the need for reoperation to promote union included increasing body mass index (odds ratio [OR] = 1.09; 95% confidence interval [CI]: 1.02-1.16; P = 0.01), increasing number of screws in the distal fracture segment (OR = 1.73; 95% CI: 1.06-2.95; P = 0.03), and decreasing proportion of proximal segment screws that are locking (OR = 0.17; 95% CI: 0.03-0.70; P = 0.02) There was a 4.8% rate (11/228) of reoperation to address DSSI. There were no statistically significant predictive factors identified as risk factors of the need for reoperation to address DSSI ( P > 0.05). CONCLUSIONS: 8.3% of periprosthetic distal femur fractures treated at 10 centers with LDFLPs underwent unplanned reoperation to promote union. Increasing patient body mass index and increasing number of screws in the distal fracture segment were found to be predictive factors, whereas increased locking screws in the proximal segment were found to be protective. 4.8% of patients in this cohort underwent reoperation to address DSSI. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Does the OTA Open Fracture Classification Align With the Gustilo-Anderson Classification? A Study of 2215 Open Fractures.

OBJECTIVES: To characterize the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) and Gustilo-Anderson classification of open extremity fractures and determine if there is meaningful alignment between these grading systems. DESIGN: Retrospective case series. SETTING: Level I academic trauma center. PATIENT SELECTION CRITERIA: Adult patients with at least 1 operatively treated open extremity fracture and surgeon-assigned OTA-OFC and Gustilo-Anderson classification. OUTCOME MEASURES AND COMPARISONS: Frequency, distribution, and association measures of OTA-OFC category scores and Gustilo-Anderson classification types. RESULTS: Two thousand twenty-seven patients (mean age, 43.1 ± 17.5 years) with 2215 fractures were included. Gustilo-Anderson type I or II fractures (n = 961; 43%) most frequently had the least severe scores for all OTA-OFC categories. Type IIIA fractures (n = 978; 44%) were most often assigned intermediate scores for OTA-OFC Bone Loss (n = 564; 58%). Type IIIB fractures (n = 204, 9%) were most often assigned intermediate OTA-OFC Skin scores (n = 120; 59%). Type IIIC fractures (n = 72; 3%) were most often assigned the most severe OTA-OFC Arterial score (n = 60; 83%). In the multivariable model, OTA-OFC Contamination scores showed little association (ß = 0.05; 95% confidence interval [CI], 0.01-0.09) with Gustilo-Anderson classification severity. Conversely, higher OTA-OFC Arterial (ß = 0.50; 95% CI 0.44-0.56) and Skin (ß = 0.46; 95% CI, 0.40-0.51) scores were strongly associated with more severe Gustilo-Anderson classifications. CONCLUSIONS: OTA-OFC Contamination scores were weakly associated with Gustilo-Anderson classification severity for open fractures. The study findings suggest that the current Gustilo-Anderson classification does not adequately account for injury contamination, a known predictor of infection. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.