A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds.

BACKGROUND: The management of open fractures requires wound irrigation and débridement to remove contaminants, but the effectiveness of various pressures and solutions for irrigation remains controversial. We investigated the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low irrigation pressure. METHODS: In this study with a 2-by-3 factorial design, conducted at 41 clinical centers, we randomly assigned patients who had an open fracture of an extremity to undergo irrigation with one of three irrigation pressures (high pressure [>20 psi], low pressure [5 to 10 psi], or very low pressure [1 to 2 psi]) and one of two irrigation solutions (castile soap or normal saline). The primary end point was reoperation within 12 months after the index surgery for promotion of wound or bone healing or treatment of a wound infection. RESULTS: A total of 2551 patients underwent randomization, of whom 2447 were deemed eligible and included in the final analyses. Reoperation occurred in 109 of 826 patients (13.2%) in the high-pressure group, 103 of 809 (12.7%) in the low-pressure group, and 111 of 812 (13.7%) in the very-low-pressure group. Hazard ratios for the three pairwise comparisons were as follows: for low versus high pressure, 0.92 (95% confidence interval [CI], 0.70 to 1.20; P=0.53), for high versus very low pressure, 1.02 (95% CI, 0.78 to 1.33; P=0.89), and for low versus very low pressure, 0.93 (95% CI, 0.71 to 1.23; P=0.62). Reoperation occurred in 182 of 1229 patients (14.8%) in the soap group and in 141 of 1218 (11.6%) in the saline group (hazard ratio, 1.32, 95% CI, 1.06 to 1.66; P=0.01). CONCLUSIONS: The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group. (Funded by the Canadian Institutes of Health Research and others; FLOW ClinicalTrials.gov number, NCT00788398.).

A cohort study of 4,190 patients treated with low-intensity pulsed ultrasound (LIPUS): findings in the elderly versus all patients.

BACKGROUND: Patient age is one of many potential risk factors for fracture nonunion. Our hypothesis is that older patients (≥ 60) with fracture risk factors treated with low-intensity pulsed ultrasound (LIPUS) have similar heal rate (HR) to the population as a whole. We evaluate the impact of age in conjunction with other risk factors on HR in LIPUS-treated patients with fresh fracture (≤ 90 days old). METHODS: The Exogen Bone Healing System is a LIPUS device approved in 1994 to accelerate healing of fresh fracture. After approval, the FDA required a Post-Market Registry to assess performance. Patient data collected from October 1994 until October 1998 were individually reviewed and validated by a registered nurse. Four distinct data elements were required to report a patient: date fracture occurred; date treatment began; date treatment ended; and a dichotomous outcome of healed v. failed, by clinical and radiological criteria. Data were used to calculate two derived variables; days to treatment (DTT) and days on treatment (DOT). Every validated fresh fracture patient with DTT, DOT, and outcome is reported. RESULTS: The validated registry had 5,765 patients with fresh fracture; 73% (N = 4,190) are reported, while 13% of patients were lost to follow-up, 11% withdrew or were non-compliant, and 3% died or are missing outcome. Among treatment-compliant patients, HR was 96.2%. Logistic estimates of the odds ratio for healing are equivalent for patients age 30 to 79 years and all age cohorts had a HR > 94%. Open fracture, current smoking, diabetes, vascular insufficiency, osteoporosis, cancer, rheumatoid arthritis, and prescription NSAIDs all reduced HR, but older patients (≥ 60) had similar HRs to the population as a whole. DTT was significantly shorter for patients who healed (p < 0.0001). CONCLUSIONS: Comorbid conditions in conjunction with aging can reduce fracture HR. Patients with fracture who used LIPUS had a 96% HR, whereas the expected HR averages 93%. Time to treatment was significantly shorter among patients who healed (p < 0.0001), suggesting that it is beneficial to begin LIPUS treatment early. Older patients (≥ 60) with fracture risk factors treated with LIPUS exhibit similar heal rates to the population as a whole.

Prevalence of abuse and intimate partner violence surgical evaluation (PRAISE) in orthopaedic fracture clinics: a multinational prevalence study.

BACKGROUND: Intimate partner violence (IPV) is the leading cause of non-fatal injury to women worldwide. Musculoskeletal injuries, which are often seen by orthopaedic surgeons, are the second most common manifestation of IPV. We aimed to establish the 12-month and lifetime prevalence of IPV in women presenting to orthopaedic fracture clinics. METHODS: The PRAISE team of 80 investigators did a cross-sectional study of a consecutive sample of 2945 female participants at 12 orthopaedic fracture clinics in Canada, the USA, the Netherlands, Denmark, and India. Participants who met the eligibility criteria anonymously answered direct questions about physical, emotional, and sexual IPV, and completed two previously developed questionnaires (Women Abuse Screening Tool [WAST] and Partner Violence Screen [PVS]). We did a multivariable logistic regression analysis to investigate the risk factors associated with IPV. FINDINGS: The overall response rate was 85% (2344 of 2759 patients provided informed consent). One in six women (455/2839, 16·0%, 95% CI 14·7-17·4%) disclosed a history of IPV within the past year, and one in three (882/2550, 34·6%, 32·8-36·5%) had experienced IPV in their lifetime. 49 women (1·7%, 1·3-2·2%) attended their clinic visit as a direct consequence of IPV, only seven of whom (14%) had ever been asked about IPV in a health-care setting. Women in short-term relationships (OR 0·584, 99% CI 0·396-0·860, p=0·0001) were at increased risk of IPV and physical abuse in the past 12 months in this study. Compared with women in Canada and the USA, those in the Netherlands and Denmark were at reduced risk of any abuse in the past 12 months, physical abuse in lifetime, and any abuse in lifetime (OR 0·595, 99% CI 0·427-0·830, p<0·0001; 0·630, 0·445-0·890, p=0·001; and 0·464, 0·352-0·612, p<0·0001, respectively). INTERPRETATION: PRAISE is the largest prevalence study done so far in orthopaedics. Orthopaedic surgeons should be confident in the assumption that one in six women have a history of physical abuse, and that one in 50 injured women will present to the clinic as a direct result of IPV. Our findings warrant serious consideration for fracture clinics to improve identification of, respond to, and provide referral services for, victims of IPV. FUNDING: Orthopaedic Trauma Association, Canadian Orthopaedic Foundation, and the McMaster University Surgical Associates. MB is partly funded by a Canada Research Chair.

Orthopaedic surgeons' knowledge and misconceptions in the identification of intimate partner violence against women.

BACKGROUND: Intimate partner violence (IPV)-physical, sexual, psychologic, or financial abuse between intimate partners-is the most common cause of nonfatal injury to women in North America. As many IPV-related injuries are musculoskeletal, orthopaedic surgeons are well positioned to identify and assist these patients. However, data are lacking regarding surgeons' knowledge of the prevalence of IPV in orthopaedic practices, surgeons' screening and management methods, and surgeons' perceptions about IPV. QUESTIONS/PURPOSES: We aimed to identify (1) surgeon attitudes and beliefs regarding victims of IPV and batterers and (2) perceptions of surgeons regarding their role in identifying and assisting victims of IPV. METHODS: We surveyed 690 surgeon members of the Orthopaedic Trauma Association. The survey had three sections: (1) general perception of orthopaedic surgeons regarding IPV; (2) perceptions of orthopaedic surgeons regarding victims and batterers; and (3) orthopaedic relevance of IPV. One hundred fifty-three surgeons responded (22%). RESULTS: Respondents manifested key misconceptions: (1) victims must be getting something out of the abusive relationships (16%); (2) some women have personalities that cause the abuse (20%); and (3) the battering would stop if the batterer quit abusing alcohol (40%). In the past year, approximately ½ the respondents (51%) acknowledged identifying a victim of IPV; however, only 4% of respondents currently screen injured female patients for IPV. Surgeons expressed concerns regarding lack of knowledge in the management of abused women (30%). CONCLUSION: Orthopaedic surgeons had several misconceptions about victims of IPV and batterers. Targeted educational programs on IPV are needed for surgeons routinely caring for injured women.

Periprosthetic fractures about the knee - an overview.

Several factors are conspiring to cause a dramatic increase in the incidence of periprosthetic fractures. First, the incidence of arthroplasty is increasing as the population ages. Second, arthroplasty is being performed in younger, more active patients, who live longer after their arthroplasty and are more likely to have subsequent trauma to their previously operated limb. Third, following lower extremity surgery, disuse osteopenia of the limb often occurs, increasing the risk of subsequent fracture in that same limb. This increased risk of later fracture is further aggravated by the implant placed at the previous surgery, which often functions as a mechanical stress riser. Careful attention to detail during knee arthroplasty or during fracture repair in which fixation is placed close to the knee is beneficial for minimizing the risk of subsequent periprosthetic fracture. Intraoperative vigilance, judicious use of force when inserting implants, and meticulous technical execution of the procedure may all reduce fracture complications postoperatively. This article reviews the prevalence of periprosthetic fractures about knee arthroplasties and fracture fixation constructs, and also provides a description of common recommendations intended to reduce the risk of periprosthetic fracture.

Displaced patella fractures.

Displaced patella fractures often result in disruption of the extensor mechanism of the knee. An intact extensor mechanism is a requirement for unassisted gait. Therefore, operative treatment of the displaced patella fracture is generally recommended. The evaluation of the patella fracture patient includes examination of extensor mechanism integrity. Operative management of patella fractures normally includes open reduction with internal fixation, although partial patellectomy is occasionally performed, with advancement of quadriceps tendon or patellar ligament to the fracture bed. Open reduction with internal fixation has historically been performed utilizing anterior tension band wiring, although comminution of the fracture occasionally makes this fixation construct inadequate. Supplementation or replacement of the tension band wire construct with interfragmentary screws, cerclage wire or suture, and/or plate-and-screw constructs may add to the stability of the fixation construct. Arthrosis of the patellofemoral joint is very common after healing of patella fractures, and substantial functional deficits may persist long after fracture healing has occurred.

Orthopaedic injuries from deer stands and their functional outcomes.

Hunters who fall from deer stands can sustain a variety of injuries. A retrospective review was conducted at a single institution to gauge the experience in treating patients injured in falls from deer stands from 2002 to 2008. Medical records were analyzed for patient demographics, tree stand characteristics, and injury details. Patients were contacted to complete a SF-12 health survey to assess their functional outcome following their injuries. Of the 30 patients who sustained a fracture, an average of 2.08 fractures were sustained per patient. Sixteen patients sustained a spinal column fracture, and four of these sustained a spinal cord injury. Twenty-one patients underwent at least one surgical procedure by the trauma surgery (two), neurosurgery (four), or orthopaedic surgery (15) teams. The importance of understanding deer stand instructions should be emphasized during hunting education classes, and all hunters should follow safe hunting recommendations pertaining to firearms and tree stands.

American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary on the Treatment of Clavicle Fractures.

Treatment of Clavicle Fractures Evidence-Based Clinical Practice Guideline is based on a systematic review of published studies examining the diagnosis and treatment of clavicle fractures. This guideline contains four recommendations and 10 options to assist orthopaedic surgeons and any other qualified healthcare professionals with determining the treatment of isolated clavicle fractures based on the best current available evidence. It is also intended to serve as an information resource for healthcare professionals and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development. This guideline has been endorsed by the Orthopaedic Trauma Association, the American Shoulder and Elbow Surgeons, and the American Society of Shoulder and Elbow Therapists.

A prospective randomized double-blind clinical trial to assess the effects of leukocyte-reduced platelet-rich plasma on pro-inflammatory, degradative, and anabolic biomarkers after closed pilon fractures.

Posttraumatic osteoarthritis (PTOA) significantly affects patients with pilon fractures even after adequate anatomical reduction, and treatment strategies targeting the biologic mediators of PTOA are needed. This study was designed to determine the effects of intra-articular injection of platelet-rich plasma (PRP) on synovial fluid (SF) biomarkers for patients undergoing open reduction and internal fixation (ORIF) of pilon fractures. Patients undergoing staged management of pilon fractures were enrolled in a prospective, double-blinded, randomized, and placebo-controlled clinical trial to determine the effects of a single intra-articular injection of leukocyte-reduced PRP on SF biomarkers. Arthrocentesis of the injured and uninjured ankles was performed at the time of external skeletal fixation (ESF) and ORIF. Patients were randomized to receive either autogenous leukocyte-reduced PRP or saline (control) via intra-articular injection into the injured ankle at the time of ESF. SF biomarker concentrations were compared-uninjured, injured pretreatment, and saline-injected or PRP-injected. Eleven patients (PRP, n = 5; saline, n = 6) completed the study. Twenty-one uninjured, and 11 injured pretreatment, five PRP-treated, and six saline-treated SF samples were analyzed. PRP-treated SF contained significantly higher levels of PDGF-AA (p = 0.046) and significantly lower levels of MMP-3 (p = 0.042), MMP-9 (p = 0.009), IL-1ß (p = 0.049), IL-6 (p < 0.01), IL-8 (p = 0.048), and PGE2 (p < 0.04). This study provided mechanistic data to suggest that a single intraarticular injection of leukocyte-reduced PRP is associated with anti-inflammatory, anti-degradative, and anabolic responses compared with saline control. These findings provide the impetus for investigating long-term clinical outcomes after PRP injection as an orthobiologic adjunct to ORIF for mitigating the incidence and severity of PTOA after pilon fractures.

Pilon fractures: advances in surgical management.

Pilon fractures are challenging to manage because of the complexity of the injury pattern and the risk of significant complications. Variables such as fracture pattern, soft-tissue injury, and preexisting patient factors can lead to unpredictable outcomes. Avoiding complications associated with the soft-tissue envelope is paramount to optimizing outcomes. In persons with soft-tissue compromise, the use of temporary external fixation and staged management is helpful in reducing further injury and complications. Evidence in support of new surgical approaches and minimally invasive techniques is incomplete. Soft-tissue management, such as negative-pressure dressings, may be helpful in preventing complications.

Optimal Prosthesis Sizing for Radial Head Arthroplasty: A Review of Current Evidence and Guidelines.

¼: Radial head arthroplasty is a viable surgical option when a radial head fracture cannot be reconstructed. Radial head arthroplasty provides a load-bearing articular structure against the capitellum in unstable fractured elbows. ¼: Studies have emphasized the importance of choosing the correct implant size to replicate the native radial head anatomy, citing various consequences of improperly sized radial head prostheses. Overstuffing of the radiocapitellar joint, or lengthening of the radius, has been extensively studied because of its detrimental effects on elbow biomechanics, but other types of improper sizing also have negative consequences. ¼: In the setting of severe fracture-dislocation or revision surgery, anatomic landmarks that are useful for prosthesis sizing often are missing. Various methods have been described to provide guidance for the accurate sizing of a prosthetic radial head; a retrieved radial head, the proximal edge of the lesser sigmoid notch, the radiocapitellar synovial fold, and the ulnohumeral joint space all represent useful references. ¼: Intraoperative radiographic examination is an important step while assessing implant size, including the height of the prosthetic radial head. ¼: Since no single method is perfect on its own, the surgeon should combine as many reference measures as possible, both before and during the procedure, for accurate prosthesis sizing in order to achieve successful outcomes.

Variability of human femoral geometry and its implications on nail design.

OBJECTIVES: The objectives of this study are to present a new method of quantifying variability in human femoral geometry and to use this data to optimize intramedullary nail geometry for a better fit within the femoral canal. METHODS: Computed tomography (CT) scans of forty intact adult human femora were divided according to race, sex, and age, and were reconstructed digitally into three-dimensional solid models. Geometric features were then measured and compared among groups using ANOVA. An average geometric model was generated, from which an optimal intramedullary (IM) nail curvature function was derived. Insertion of the derived optimal nail and of two currently-available commercial nails into the femur having the highest degree of curvature was then simulated via finite element methods. RESULTS: Substantial variability in femoral curvature was observed among the population sample. Sex was found to correlate most strongly with femoral size; males tend to have larger femora than females. Although the average femoral radius of curvature for African Americans was slightly higher than for Caucasians, the difference was not statistically significant. Curvature did not vary across the sample by age, sex or race. Finite element analysis results simulating IM nail insertion using the geometrically-optimized nail showed a substantial decrease in von Mises stress when compared to tested commercially-available IM nails. Fracture was predicted within the posterior canal wall for commercially available nails, as the generated stresses exceeded the allowable stress of cortical bone, but not for the geometrically-optimized nail. CONCLUSIONS: Considering variation in femoral geometry among patients when designing implantable fixation devices may be important. Femoral size differs between adults by sex, with males being larger than females. Pattern of curvature, however, did not differ, although there may be slight differences between European and African Americans. As such, the proposed average femoral curvature function calculated here may be sufficient for the entire population. According to finite element analysis, insertion-induced stresses in the femur were within the allowable range for the geometrically-optimized nail and appear more desirable than in other common nail designs.

Definition of long-bone nonunion: A scoping review of prospective clinical trials to evaluate current practice.

AIM: Although nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures. METHODS: A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database. RESULTS: Although 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months. CONCLUSION: In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria.

Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH-2): The Exploratory Health-Related Quality of Life and Patient-Reported Functional Outcomes of a Multi-Centre 2 × 2 Factorial Randomized Controlled Pilot Trial in Young Femoral Neck Fracture Patients.

PURPOSE: Femoral neck fractures in young patients are typically managed with internal fixation using either cancellous screws or a sliding hip screw (SHS). Although fixation preserves the hip joint, patients are still at risk of complications and poor clinical outcomes which lead to diminished function and health related quality of life (HRQL). The Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH-2) pilot randomized controlled factorial trial evaluated the effect of surgical fixation (cancellous screws vs. SHS) and vitamin D supplementation vs. placebo on patient-reported function and HRQL. METHODS: Patients between the ages of 18-60 years with a femoral neck fracture requiring surgical fixation were eligible. Eligible patients were randomized to receive either a sliding hip screw or cancellous screws for fracture fixation AND vitamin D3 4,000 IU or placebo daily for 6 months. Patient-reported function (Hip Outcome Score) and HRQL (Short Form-12) were assessed at standardized time points in the 12 months following their fixation surgery. Patient-reported function and HRQL were summarized using means, SD, and 95% confidence intervals (CIs), or percentages and counts. Longitudinal data analysis with mixed models was used to explore the effect of treatment group and time on the patient-reported function and HRQL. RESULTS: 86 of the 91 patients randomized into the FAITH-2 pilot study were deemed eligible. There were no significant differences in patient-reported function or HRQL between the treatment groups at 12 months post-fracture. At the 6- and 9-month assessments, a potential benefit in hip function was seen in the cancellous screw group. In all treatment groups, participants reported lower function and HRQL at 12 months post-fracture as compared to their pre-injury assessment. CONCLUSIONS: Few differences were found in function and HRQL among the treatment groups in the FAITH-2 pilot study. Despite modern implants and vitamin D supplementation, neither function nor HRQL returns to baseline in this population. Additional efforts to improve the outcomes of these challenging injuries are still needed. LEVEL OF EVIDENCE: Therapeutic Level II.

Compartment syndrome surgical management techniques associated with tibial plateau fractures.

Compartment syndrome is an orthopaedic emergency that can be challenging to diagnose and manage when associated with a tibial plateau fracture. This technique article discusses one- and two-incision fasciotomy surgical techniques, and the surgical decision making and technique modifications when there is an associated tibial plateau fracture.

Biomechanical assessment of lateral ulnar collateral ligament repair and reconstruction with or without internal brace augmentation.

BACKGROUND: Surgical treatment of posterolateral rotatory instability (PLRI) using primary repair or reconstruction of the lateral collateral ligament complex have proven inconsistent. This study aimed to test the hypothesis that augmentation of LUCL repair or palmaris longus tendon reconstruction using a suture tape augmentation would be associated with less rotational displacement and greater torque load to failure (LTF) compared with nonaugmented constructs. METHODS: Cadaveric elbows (n = 12 matched pairs) were used. Baseline stiffness and displacement values were obtained. The LUCL was transected followed by repair alone, repair with augmentation, reconstruction with palmaris longus graft, or reconstruction with augmentation. Specimens were retested including torque LTF. Paired t tests were performed to assess the biomechanical effects of augmentation. RESULTS: Augmentation was associated with higher LTF than repair and reconstruction alone (P = .008 and .047, respectively). Displacement was less with augmentation in reconstruction groups (P = .048) but not in repair groups. Suture tape augmentation maintained rotational stiffness better than repair alone (P = .01). Although reconstruction with augmentation maintained rotational stiffness better than nonaugmented reconstruction, the differences were not statistically significant (P = .057). Mode of failure for repair alone was predominantly suture pulling through repaired ligament. Augmented repairs primarily failed at the anchor-bone interface. Modes of failure for both reconstruction groups were similar, including graft tearing and/or slipping at the anchor. CONCLUSION: When positioned in neutral forearm rotation and 90o of flexion to simulate postoperative conditions, augmentation of LUCL repair or tendon reconstruction using suture tape is associated with better resistance to rotational loads compared with nonaugmented repair or reconstruction, while maintaining near-native rotational stiffness.

Risk Factors Associated With Infection in Open Fractures of the Upper and Lower Extremities.

INTRODUCTION: Open fractures are associated with a high risk of infection. The prevention of infection is the single most important goal, influencing perioperative care of patients with open fractures. Using data from 2,500 participants with open fracture wounds enrolled in the Fluid Lavage of Open Wounds trial, we conducted a multivariable analysis to determine the factors that are associated with infections 12 months postfracture. METHODS: Eighteen predictor variables were identified for infection a priori from baseline data, fracture characteristics, and surgical data from the Fluid Lavage of Open Wounds trial. Twelve predictor variables were identified for deep infection, which included both surgically and nonoperatively managed infections. We used multivariable Cox proportional hazards regression analyses to identify the factors associated with infection. Irrigation solution and pressure were included as variables in the analysis. The results were reported as adjusted hazard ratios (HRs), 95% confidence intervals (CIs), and associated P values. All tests were two tailed with alpha = 0.05. RESULTS: Factors associated with any infection were fracture location (tibia: HR 5.13 versus upper extremity, 95% CI 3.28 to 8.02; other lower extremity: HR 3.63 versus upper extremity, 95% CI 2.38 to 5.55; overall P < 0.001), low energy injury (HR 1.64, 95% CI 1.08 to 2.46; P = 0.019), degree of wound contamination (severe: HR 2.12 versus mild, 95% CI 1.35 to 3.32; moderate: HR 1.08 versus mild, 95% CI 0.78 to 1.49; overall P = 0.004), and need for flap coverage (HR 1.82, 95% CI 1.11 to 2.99; P = 0.017). DISCUSSION: The results of this study provide a better understanding of which factors are associated with a greater risk of infection in open fractures. In addition, it can allow for surgeons to better counsel patients regarding prognosis, helping patients to understand their individual risk of infection.

Pressure reducing skin pie-crusting in extremity trauma: An in-vitro biomechanical study and human case series.

BACKGROUND: Multiple small relaxing skin incisions oriented parallel to the longitudinal axis (so-called "pie-crusting") near traumatic lacerations or surgical incisions in edematous tissue beds have been utilized to achieve primary closure when edema or skin loss would otherwise have made this difficult. Our study hopes to demonstrate (1) biomechanical evidence that pie-crusting decreases wound closure tension and (2) provide a case series with data showing clinical results. MATERIALS AND METHODS: This study is a biomechanical cadaveric study and retrospective small series cohort using 16 porcine limbs and 7 patients with 8 wounds in which pie-crusting was performed. An elliptical incision was made on the porcine limbs and the wound closure tension was measured with a hydraulic test machine before and after pie-crusting. The retrospective patient cohort had pie-crusting performed on traumatic wounds that were difficult to primarily close. The patient cohort was assessed by retrospective chart review examining wound dimensions before and after pie-crusting, and wound healing at final follow-up. RESULTS: The biomechanical data showed that pie-crusting the wound with both a single and double row of incisions significantly decreased the closing tension. A single row decreased wound tension by an average of 34%. Using an average of 3.5 parallel layers of pie-crusting at the time of definitive closure all wounds in the patient cohort closed and healed well with no complications at average follow-up (average 18 months). CONCLUSION: Pie-crusting may allow for easier wound closure and decrease the need for skin-grafting in edematous extremity wounds, with minimal patient morbidity.

Fixation Using Alternative Implants for the Treatment of Hip Fractures (FAITH-2): The Clinical Outcomes of a Multicenter 2 × 2 Factorial Randomized Controlled Pilot Trial in Young Femoral Neck Fracture Patients.

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.