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.).

The Prevalence of Metabolic and Endocrine Disturbances on Fracture Nonunion.

OBJECTIVE: This study aims to determine the prevalence of metabolic disturbance in all fracture nonunion cases and identify the most common endocrine abnormalities seen using a simple screening algorithm. METHODS: A retrospective review study was performed evaluating patients who underwent operative intervention for nonunion from January 2010 to December 2018 at 2 level-1 trauma centers. Preoperative laboratory values were recorded for a 9-test "nonunion panel." A metabolic or endocrine abnormality, specifically an abnormality in the thyroid or parathyroid axis, was evaluated. RESULTS: 42% of patients had an undiagnosed metabolic laboratory abnormality. When multiple tests were used, the rate of metabolic dysfunction was between 60% and 75%, depending on the definition of vitamin D insufficiency vs deficiency used. CONCLUSION: Results indicate a relatively high prevalence of metabolic disturbance in patients with nonunion and suggest metabolic screening for all nonunion patients not only those without a mechanical or infectious cause. LEVEL OF EVIDENCE: IV, retrospective case series.

Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications?

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.

The effects of obesity in orthopaedic care.

Obesity is a costly, difficult, and increasingly prevalent challenge facing orthopaedic care. It adds complexity to caring for patients throughout all types and stages of treatment in all orthopaedic subspecialties. There are medical complications to mitigate, anesthetic challenges to meet, and surgical complexities to overcome. The financial implications of treating patients who are obese will continue to challenge surgeons, especially as new payment models are encountered. Research continues to provide more evidence of the unfavorable effects of obesity on outcomes after various orthopaedic procedures. An increasing awareness of the effects of obesity on patients undergoing orthopaedic procedures and educating orthopaedic providers on methods of countering the challenges associated with obesity should ultimately benefit both the provider and the patient.

Modifier 22 for acetabular fractures in morbidly obese patients: does it affect reimbursement?

BACKGROUND: Modifier 22 in the American Medical Association's Current Procedural Terminology (CPT®) book is a billing code for professional fees used to reflect an increased amount of skill, time, and work required to complete a procedure. There is little disagreement that using this code in the setting of surgery for acetabulum fractures in the obese patient is appropriate; however, to our knowledge, the degree to which payers value this additional level of complexity has not been determined. QUESTIONS/PURPOSES: We asked whether (1) the use of Modifier 22 increased reimbursements in morbidly obese patients and (2) there was any difference between private insurance and governmental payer sources in treatment of Modifier 22. METHODS: Over a 4-year period, we requested immediate adjudication with payers when using Modifier 22 for morbidly obese patients with acetabular fractures. We provided payers with evidence of the increased time and effort required in treating this population. Reimbursements were calculated for morbidly obese and nonmorbidly obese patients. Of the 346 patients we reviewed, 57 had additional CPT® codes or modifiers appended to their charges and were excluded, leaving 289 patients. Thirty (10%) were morbidly obese and were billed with Modifier 22. Fifty-three (18%) were insured by our largest private insurer and 69 (24%) by governmental programs (Medicare/Medicaid). Eight privately insured patients (15%) and seven governmentally insured patients (10%) were morbidly obese and were billed with Modifier 22. For our primary question, we compared reimbursement rates between patients with and without Modifier 22 for obesity within the 289 patients. We then performed the same comparison for the 53 privately insured patients and the 69 governmentally insured patients. RESULTS: Overall, there was no change in mean reimbursement when using Modifier 22 in morbidly obese patients, compared to nonmorbidly obese patients (USD 2126 versus USD 2149, p < 0.94). There was also no difference in mean reimbursements with Modifier 22 in either the privately insured patients (USD 3445 versus USD 2929, p = 0.16) or the governmentally insured patients (USD 1367 versus USD 1224, p=0.83). CONCLUSIONS: Despite educating payers on the increased complexity and time needed to deal with morbidly obese patients with acetabular fractures, we have not seen an increased reimbursement in this challenging patient population. This could be a disincentive for many centers to treat these challenging injuries. Further efforts are needed to convince government payer sources to increase compensation in these situations. LEVEL OF EVIDENCE: Level IV, economic and decision analyses. See Instructions for Authors for a complete description of levels of evidence.

Direct anterior total hip arthroplasty.

The direct anterior approach to hip arthroplasty has become a popular technique. This technique, which was described almost 70 years ago, allows the surgeon to approach the hip through an internervous and intermuscular plane. Preliminary studies show that direct anterior hip arthroplasty may allow patients to recover faster with a lower dislocation rate. It is helpful to understand the history, scientific basis, and surgical technique of direct anterior hip arthroplasty.

Influence of connection design and material properties on stress distribution and fatigue lifetime of zygomatic implants: A finite element analysis.

Zygomatic implants (ZIs) were developed as a graftless alternative to rehabilitate severely reabsorbed maxillae. This study aims to employ three-dimensional finite element analysis (FEA) to simulate the impact of external hexagonal implant connection (EHC) and internal hexagonal implant connection (IHC) on the stress distribution and fatigue lifetime within the ZI systems using parameters defined in ISO 14801:2016. Two ZI assemblies (Nobel Biocare and Noris Medical) were scanned in a micro-CT scanner and reconstructed using Nrecon software. Three-dimensional models were generated by Simpleware ScanIP Medical software. All models were exported to FEA software (ABAQUS) and subsequently to a fatigue analysis software (Fe-safe). A compressive 150 N load was applied at a 40° angle on the cap surface. A 15 Hz frequency was applied in the in silico cyclic test. The implant components had material properties of commercially pure grade 4 titanium (CPTi) and Titanium-6Aluminum-4Vanadium alloy (Ti64). Von Mises stress data, contour plots, and fatigue limits were collected and analyzed. EHC models exhibited higher peak stresses in implant components for both materials compared to IHC models. However, simulated bone support results showed the opposite trend, with higher stresses on IHCthan EHC models. The fatigue analysis revealed that assemblies with both designs exceeded ISO 14801:2016 number of cycles limits using Ti64, while CPTi groups exhibited comparatively lower worst life-repeats. In conclusion, ZIs with IHC were found to have a more homogeneous and advantageous stress distribution within both materials tested. Ti64 demonstrates a prolonged service life for both design connections.

Haves and have-nots: socioeconomic position improves accuracy of machine learning algorithms for predicting high-impact chronic pain.

ABSTRACT: Lower socioeconomic position (SEP) is associated with increased risk of developing chronic pain, experiencing more severe pain, and suffering greater pain-related disability. However, SEP is a multidimensional construct; there is a dearth of research on which SEP features are most strongly associated with high-impact chronic pain, the relative importance of SEP predictive features compared to established chronic pain correlates, and whether the relative importance of SEP predictive features differs by race and sex. This study used 3 machine learning algorithms to address these questions among adults in the 2019 National Health Interview Survey. Gradient boosting decision trees achieved the highest accuracy and discriminatory power for high-impact chronic pain. Results suggest that distinct SEP dimensions, including material resources (eg, ratio of family income to poverty threshold) and employment (ie, working in the past week, number of working adults in the family), are highly relevant predictors of high-impact chronic pain. Subgroup analyses compared the relative importance of predictive features of high-impact chronic pain in non-Hispanic Black vs White adults and men vs women. Whereas the relative importance of body mass index and owning/renting a residence was higher for non-Hispanic Black adults, the relative importance of working adults in the family and housing stability was higher for non-Hispanic White adults. Anxiety symptom severity, body mass index, and cigarette smoking had higher relevance for women, while housing stability and frequency of anxiety and depression had higher relevance for men. Results highlight the potential for machine learning algorithms to advance health equity research.

Preoperative Blood Loss of Isolated Acetabular Fractures.

OBJECTIVE: To quantify preoperative blood loss in isolated acetabular fractures and identify any fracture or patient characteristics associated with increased blood loss or blood transfusion. DESIGN: Retrospective cohort study. SETTING: Two level 1 trauma centers. PATIENTS/PARTICIPANTS: All patients with operative, isolated acetabular fractures from January 2010 to December 2018. INTERVENTION: Operative management of an acetabular fracture. MAIN OUTCOME MEASUREMENTS: Volume of preoperative blood loss and transfusion rates associated with isolated acetabular fracture patterns. RESULTS: A total of 598 patients were included. The mean preoperative blood loss of all fractures was 1172.6 mL. The 3 fracture patterns with the greatest average preoperative blood loss were associated both column (1454.9 mL), T-type (1374.8 mL), and anterior column posterior hemitransverse fractures (1317.7 mL). The acetabular fracture pattern had a significant association with preoperative blood loss and preoperative transfusion. The timing from injury to surgery and body mass index were significantly associated with preoperative blood loss. CONCLUSIONS: In conclusion, operatively treated isolated acetabular fractures surprisingly lose an average of greater than 1 liter of blood in the preoperative setting. Surgeons must carefully assess patient's physiology, ensuring they are adequately resuscitated before surgery and remain aware that increasing body mass index is associated with increased preoperative blood loss. However, as patients await surgery, unreduced acetabular fractures continue to contribute to ongoing blood loss beyond the first 24 hours from injury. We believe the best hemostasis after initial resuscitation is provided by surgical reduction and fixation, and we recommend a continued early surgical intervention to prevent continued bleeding from fracture surfaces. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Early Conversion Total Hip Arthroplasty After Pipkin IV Femoral Head Fracture.

OBJECTIVES: To determine risk factors for early conversion total hip arthroplasty (THA) in Pipkin IV femoral head fractures. DESIGN: Retrospective cohort. SETTING: Two level I trauma centers. PATIENTS AND INTERVENTION: One hundred thirty-seven patients with Pipkin IV fractures meeting inclusion criteria with 1 year minimum follow-up managed from 2009 to 2019. MAIN OUTCOME MEASUREMENT: Patients were separated into groups by the Orthopaedic Trauma Association/AO Foundation (OTA/AO) classification of femoral head fracture: 31C1 (split-type fractures) and 31C2 (depression-type fractures). Multivariable regression was performed after univariate analysis comparing patients requiring conversion THA with those who did not. RESULTS: We identified 65 split-type fractures, 19 (29%) underwent conversion THA within 1 year. Surgical site infection ( P = 0.002), postoperative hip dislocation ( P < 0.0001), and older age ( P = 0.049) resulted in increased rates of conversion THA. However, multivariable analysis did not identify independent risk factors for conversion. There were 72 depression-type fractures, 20 (27.8%) underwent conversion THA within 1 year. Independent risk factors were increased age ( P = 0.01) and posterior femoral head fracture location ( P < 0.01), while infrafoveal femoral head fracture location ( P = 0.03) was protective against conversion THA. CONCLUSION: Pipkin IV fractures managed operatively have high overall risk of conversion THA within 1 year (28.5%). Risk factors for conversion THA vary according to fracture subtype. Hip joint survival of fractures subclassified OTA/AO 31C1 likely depends on patient age and postoperative outcomes such as surgical site infection and redislocation. Pipkin IV fractures subclassified to OTA/AO 31C2 type with suprafoveal and posterior head impaction and older age should be counseled of high conversion risk with consideration for alternative management options. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Induced Membrane Technique Is Effective for the Management of Acute Traumatic Bone Loss in Both Diaphyseal and Metaphyseal Lower Extremity Fractures.

OBJECTIVE: To compare outcomes of Masquelet-induced membrane technique (IMT) in metaphyseal and diaphyseal fractures with acute bone loss. DESIGN: Retrospective cohort study. SETTING: Four Level 1 Academic Trauma Centers. PATIENTS/PARTICIPANTS: Patients acutely treated with IMT for traumatic lower extremity bone loss at 4 Level 1 trauma centers between 2010 and 2020. INTERVENTION: Operative treatment with placement of cement spacer within 3 weeks of initial injury followed by staged removal and bone grafting to the defect. MAIN OUTCOME MEASUREMENTS: Fracture union, infection, revision grafting, time to union, and amputation. RESULTS: One hundred twenty fractures met inclusion criteria, including 43 diaphyseal fractures (DIM) and 77 metaphyseal fractures (MIM). Demographic characteristics were not significantly different, except for age (DIM 34 years vs. MIM 43 years, P < 0.001). Union after treatment with IMT was 89.2% overall. After controlling for age, this was not significantly different between DIM (41/43, 95.3%) and MIM (66/77, 85.7%) ( P = 0.13) nor was the rate of infection between groups. There was no difference in any secondary outcomes. CONCLUSIONS: The overall union rate in the current series of acute lower extremity fractures treated with the induced membrane technique was 89%. There was no difference in successful union between patients with diaphyseal bone loss or metaphyseal bone loss treated with IMT. Similarly, there was no difference in patients with tibial or femoral bone loss treated with induced membrane. Defect size after debridement may be more prognostic for secondary operations rather than the limb segment involved or the degree of soft-tissue injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bicondylar tibial plateau fracture dislocations with an intact anterolateral cortical rim: A surgical technique.

A displaced medial tibial plateau fracture with central and lateral impaction, but an intact anterolateral cortical rim, is an uncommon variant of bicondylar tibial plateau fracture that presents a number of challenges. Without a lateral metaphyseal fracture line to work through, it is challenging to address central and lateral impaction. Previously published techniques for addressing this fracture pattern describe an intra-articular osteotomy of the lateral plateau to aid visualization and reduction, or use a posterolateral approach to the proximal tibia with or without an osteotomy of the proximal fibula. This study presents a technique which utilizes standard dual incision approaches and does not involve an intra-articular osteotomy of the lateral tibial plateau or a posterolateral approach. A case series was conducted evaluating radiographic and functional outcomes of 8 patients.

Hemoglobin A1c as a Predictor of Surgical Site Infection in Patients With Orthopaedic Trauma.

INTRODUCTION: Previous research involving diabetes mellitus (DM), glycemic control, and complications in orthopaedic patients has primarily focused on elective procedures. The purpose of this study was to evaluate hemoglobin A1c (A1c) as a predictor of postoperative surgical site infection (SSI) in patients with orthopaedic trauma. METHODS: Patients aged 18 years or older treated surgically for an acute fracture by a fellowship-trained orthopaedic trauma surgeon at a single academic tertiary referral center with a laboratory value for A1c available within 3 months of their surgery were identified retrospectively. Postoperative SSI was defined according to 'Fracture related infection: A consensus on definition from an international expert group,' by Metsemakers et al. RESULTS: A total of 925 patients met criteria for analysis. A receiver operating characteristic curve was calculated using A1c as a predictor for signs suggestive and confirmatory of SSI and demonstrated an area under the curve of 0.535 and 0.539, respectively. No significant difference was found in the rate of signs suggestive or confirmatory of SSI in patients with normal A1c levels (<6.5) compared with patients with A1c levels consistent with a diagnosis of DM (>6.5), P-value = 0.199 and P-value = 0.297, respectively. No significant difference was found in the rate of signs suggestive or confirmatory of SSI in patients with completely uncontrolled DM (A1c > 10) compared with patients with A1c levels <10, P-value 0.528 and P-value = 0.552, respectively. CONCLUSION: Existing literature has demonstrated an association with postoperative infection in orthopaedic patients who have elevated A1c values. In this cohort of patients with orthopaedic trauma, hemoglobin A1c was not a valuable tool to predict postoperative SSI. Given these findings, routine A1c monitoring is not a reliable predictor of SSI criteria in patients with orthopaedic trauma based on the current consensus definition of SSI in fracture surgery.

Pragmatic design and inclusion of patient-partner representatives improves participant experience in clinical research.

Objectives: Patient engagement in the design and implementation of clinical trials is necessary to ensure that the research is relevant and responsive to patients. The PREP-IT trials, which include 2 pragmatic trials that evaluate different surgical preparation solutions in orthopaedic trauma patients, followed the patient-centered outcomes research (PCOR) methodology throughout the design, implementation, and conduct. We conducted a substudy within the PREP-IT trials to explore participants' experiences with trial participation. Methods: At the final follow-up visit (12 months after their fracture), patients participating in the PREP-IT trials were invited to participate in the substudy. After providing informed consent, participants completed a questionnaire that asked about their experience and satisfaction with participating in the PREP-IT trials. Descriptive statistics are used to report the findings. Results: Four hundred two participants participated in the substudy. Most participants (394 [98%]) reported a positive experience, and 376 (94%) participants felt their contributions were appreciated. The primary reasons for participation were helping future patients with fracture (279 [69%]) and to contribute to science (223 [56%]). Two hundred seventeen (46%) participants indicated that their decision to participate was influenced by the minimal time commitment. Conclusions: Most participants reported a positive experience with participating in the PREP-IT trials. Altruism was the largest motivator for participating in this research. Approximately half of the participants indicated that the pragmatic, low-participant burden design of the trial influenced their decision to participate. Meaningful patient engagement, a pragmatic, and low-burden protocol led to high levels of participant satisfaction.

Local administration of vancomycin powder in orthopaedic fracture surgery: current practice and trends.

Objectives: Surgical site infections in orthopaedic trauma are a significant problem with meaningful patient and health care system-level consequences. Direct application of antibiotics to the surgical field has many potential benefits in reducing surgical site infections. However, to date, the data regarding the local administration of antibiotics have been mixed. This study reports on the variability of prophylactic vancomycin powder use in orthopaedic trauma cases across 28 centers. Methods: Intrawound topical antibiotic powder use was prospectively collected within three multicenter fracture fixation trials. Fracture location, Gustilo classification, recruiting center, and surgeon information were collected. Differences in practice patterns across recruiting center and injury characteristics were tested using chi-square statistic and logistic regression. Additional stratified analyses by recruiting center and individual surgeon were performed. Results: A total of 4941 fractures were treated, and vancomycin powder was used in 1547 patients (31%) overall. Local administration of vancomycin powder was more frequent in open fractures 38.8% (738/1901) compared with closed fractures 26.6% (809/3040) (P < 0.001). However, the severity of the open fracture type did not affect the rate at which vancomycin powder was used (P = 0.11). Vancomycin powder use varied substantially across the clinical sites (P < 0.001). At the surgeon level, 75.0% used vancomycin powder in less than one-quarter of their cases. Conclusions: Prophylactic intrawound vancomycin powder remains controversial with varied support throughout the literature. This study demonstrates wide variability in its use across institutions, fracture types, and surgeons. This study highlights the opportunity for increased practice standardization for infection prophylaxis interventions. Level of Evidence: Prognostic-III.

Use of Computed Tomography Angiography to Predict Complications in Tibia Fractures: A Multicenter Retrospective Analysis.

OBJECTIVES: To assess the ability of computed tomography angiography identified infrapopliteal vascular injury to predict complications in tibia fractures that do not require vascular surgical intervention. DESIGN: Multicenter retrospective review. SETTING: Six Level I trauma centers. PATIENTS AND INTERVENTION: Two hundred seventy-four patients with tibia fractures (OTA/AO 42 or 43) who underwent computed tomography angiography maintained a clinically perfused foot not requiring vascular surgical intervention and were treated with an intramedullary nail. Patients were grouped by the number of vessels below the trifurcation that were injured. MAIN OUTCOME MEASUREMENTS: Rates of superficial and deep infection, amputation, unplanned reoperation to promote bone healing (nonunion), and any unplanned reoperation. RESULTS: There were 142 fractures in the control (no-injury) group, 87 in the one-vessel injury group, and 45 in the two-vessel injury group. Average follow-up was 2 years. Significantly higher rates of nerve injury and flap coverage after wound breakdown were observed in the two-vessel injury group. The two-vessel injury group had higher rates of deep infection (35.6% vs. 16.9%, P = 0.030) and unplanned reoperation to promote bone healing (44.4% vs. 23.9%, P = 0.019) compared with controls, as well as increased rates of any unplanned reoperation compared with control and one-vessel injury groups (71.1% vs. 39.4% and 51.7%, P < 0.001), respectively. There were no significant differences in rates of superficial infection or amputation. CONCLUSIONS: Tibia fractures with two-vessel injuries were associated with higher rates of deep infection and unplanned reoperation to promote bone healing compared with those without vascular injury, as well as increased rates of any unplanned reoperation compared with controls and fractures with one-vessel injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Aseptic loosening rates in distal femoral endoprostheses: does stem size matter?

BACKGROUND: Long-term survival of distal femoral endoprosthetic replacements is largely affected by aseptic loosening. It is unclear whether and to what degree surgical technique and component selection influence the risk of loosening. QUESTIONS/PURPOSES: We (1) established the overall failure and aseptic loosening rates in a tumor population and asked (2) whether stem diameter and specifically the diaphysis-to-stem ratio predicts loosening, and (3) whether resection percentage correlates with failure. METHODS: We retrospectively reviewed the charts of all 93 patients in whom 104 distal femoral replacements had been performed from 1985 to 2008. We extracted the following data: age, need for revision surgeries, tumor diagnosis, adjunct treatment, and implant characteristics. We reviewed radiographs and determined stem size, bone diaphyseal width, and resection percentage of the femur. Kaplan-Meier survivorship was calculated for all implant failures and failures resulting from aseptic loosening. We evaluated radiolucent lines in patients with radiographic followup over 5 years. We identified independent risk factors for loosening. The minimum followup for radiographic evaluation was 5 years (mean, 12.7 years; range, 5.4-23.5 years). RESULTS: Overall implant survival for 104 stems in 93 patients was 73.3% at 10 years, 62.8% at 15 years, and 46.1% at 20 years. Survival from aseptic loosening was 94.6% at 10 and 15 years and 86.5% at 20 years. Of the variables analyzed, only bone:stem ratio independently predicted aseptic failure. Patients with stable implants had larger stem sizes and lower bone:stem ratios than those with loose implants (14.5 mm versus 10.7 mm and 2.02 versus 2.81, respectively). CONCLUSIONS: Our data suggest durability relates to selecting stems that fill the canal. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Complications of anterior subcutaneous internal fixation for unstable pelvis fractures: a multicenter study.

BACKGROUND: Stabilization after a pelvic fracture can be accomplished with an anterior external fixator. These devices are uncomfortable for patients and are at risk for infection and loosening, especially in obese patients. As an alternative, we recently developed an anterior subcutaneous pelvic internal fixation technique (ASPIF). QUESTIONS/PURPOSES: We asked if the ASPIF (1) allows for definitive anterior pelvic stabilization of unstable pelvic injuries; (2) is well tolerated by patients for mobility and comfort; and (3) has an acceptable complication rate. METHODS: We retrospectively reviewed 91 patients who incurred an unstable pelvic injury treated with an anterior internal fixator and posterior fixation at four Level I trauma centers. We assessed (1) healing by callous formation on radiographs and the ability to weightbear comfortably; (2) patient function by their ability to sit, stand, lie on their sides, and how well they tolerated the implants; and (3) complications during the observation period. The minimum followup was 6 months (mean, 15 months; range, 6-40 months). RESULTS: All 91 patients were able to sit, stand, and lie on their sides. Injuries healed without loss of reduction in 89 of 91 patients. Complications included six early revisions resulting from technical error and three infections. Irritation of the lateral femoral cutaneous nerve was reported in 27 of 91 patients and resolved in all but one. Heterotopic ossification around the implants, which was asymptomatic in all cases, occurred in 32 of 91 patients. CONCLUSIONS: The anterior internal fixator provided high rates of union for the anterior injury in unstable pelvic fractures. Patients were able to sit, stand and ambulate without difficulty. Infections and aseptic loosening were reduced but heterotopic ossification and irritation of the LFCN are common. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Inpatient soft tissue protocol and wound complications in calcaneus fractures.

BACKGROUND: Operative treatment of calcaneus fractures is associated with the risk of early wound complications. Though accepted practice dictates surgery should be delayed until soft tissues recover from the initial traumatic insult, optimal timing of surgery has not been delineated. METHODS: A retrospective chart and radiographic review at a level I trauma center was performed to determine if an aggressive inpatient soft tissue management protocol designed to decrease the time delay from injury to surgery is effective at reducing complications. Ninety-seven patients (17 female, 80 male; mean age, 39.7±14.0 years) with 102 calcaneus fractures treated between October 1995 and January 2005 were identified. Differences in complication rates and quality of reduction between the inpatient and outpatient treatment groups were analyzed. Quality of reduction was determined by measuring postoperative Bohler's angle and posterior facet articular step-off. RESULTS: Mean time from injury to surgery was 6.2 days for the inpatient group and 10.8 days for the outpatient group (p<0.0001). The overall complication rate was over twice as high in the outpatient group (27 versus 12%, p=0.04) and the serious complication rate was 6.5 times higher when patients were managed as outpatients (9% versus 1%, p=0.09). With the numbers available, there were no significant differences in the quality of reduction obtained at surgery. CONCLUSION: This study suggests that this inpatient soft tissue management protocol of calcaneal fractures is a feasible treatment option when a patient is kept in the hospital that offers a reduction in postoperative wound complications while enabling surgery 4 days earlier on average.

Complications of Morbid Obesity in the Treatment of Acetabular Fractures: Re-evaluating Outcomes a Decade Later.

OBJECTIVES: To determine the rate of perioperative complications between morbidly obese (body mass index greater than 40 kg/m2) and nonmorbidly obese patients undergoing operative treatment of acetabular fractures across 2 periods (2000-2005 and 2012-2019). DESIGN: Retrospective, case-control study. SETTING: Level I academic trauma center. PATIENTS: Four hundred thirty-five consecutive patients from 2000 to 2005 and 216 consecutive patients from 2012 to 2019 with acetabular fractures treated by a single surgeon. INTERVENTION: Operative fixation of acetabular fracture. MAIN OUTCOME MEASUREMENTS: Outcome variables include positioning time, operative time, estimated blood loss, hospital stay, wound complications, and perioperative complications. RESULTS: Twenty-eight morbidly obese and 188 nonmorbidly obese patients from 2012 to 2019, as well as 41 morbidly obese patients and 394 nonmorbidly obese patients from 2000 to 2005 were included in the study. The relative risk (RR) of wound complications between 2012 and 2019 groups was significantly higher for morbidly obese patients (RR = 5.31, P = 0.009) but has decreased significantly for morbidly obese patients between 2000-2005 and 2012-2019 (RR = 0.31, P = 0.017). The rate of total perioperative complications was similar between morbidly obese and nonmorbidly obese groups from 2012 to 2019 (21% vs. 8%, P = 0.230). For morbidly obese patients, the rate of total perioperative complications decreased significantly between 2000-2005 and 2012-2019 (63% vs. 21% P = 0.010). CONCLUSION: Acetabular fracture surgery can be safely performed in morbidly obese patients. Although obesity remains a significant risk factor for wound complications, the risk for morbidly obese patients has decreased significantly since our initial investigation because of adaptations to surgical techniques and surgeon's experience. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.