Early Acetabular Fracture Repair Through an Anterior Approach Is Associated With Increased Blood Loss.

OBJECTIVES: To determine whether the timing of acetabular fracture fixation through an anterior approach influences estimated and calculated perioperative blood loss. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center from 2013 to 2021. PATIENT SELECTION CRITERIA: Patients aged ≥18 years treated with acetabular fracture fixation through an anterior-based approach. OUTCOME MEASURES AND COMPARISONS: The primary outcome was calculated blood loss (CBL). Secondary outcomes were estimated blood loss reported by surgeon and anesthesia, and blood transfusion requirements. Comparisons of blood loss were made at discrete postinjury time thresholds (24, 36, and 48 hours) and on a continuous basis. RESULTS: One hundred eight patients were studied. The mean age was 65 years, and 73% of patients were male. Earlier fixation of acetabular fractures resulted in greater CBL and estimated blood loss (surgeon and anesthesia) compared with later fixation when analyzed on a continuum and at specific time points (24, 36, and 48 hours). Mean CBL in patients treated earlier (<48 hours, 2539 ± 1194 mL) was significantly greater than those treated later (≥48 hours, 1625 ± 909 mL; P < 0.001). Fracture repair before 48 hours postinjury was associated with a 3 times greater risk of >2000 mL of CBL ( P = 0.006). This did not result in differences in transfusion rates between groups at 24 hours ( P = 0.518), 36 hours ( P = 1.000), or 48 hours ( P = 0.779). CONCLUSIONS: Delaying fixation of acetabular fractures treated through an anterior approach for 48 hours postinjury may significantly reduce perioperative blood loss. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Wound care practices after orthopaedic trauma surgery are highly variable and not evidence based.

OBJECTIVE: Given the tremendous medical, social and financial costs of surgical site infections, the pressure to minimize these complications has been mounting. There remains a substantial gap in evidence-based practice for postoperative wound care after orthopaedic trauma surgery. The purpose of this study is to determine what standards are currently in practice for postoperative wound management. METHODS: A 16-question web-based survey was published on the Orthopaedic Trauma Association website and disseminated to members through the association's quarterly email. The survey gathered data on postoperative wound care practices; specifically, when wound checks are performed, and when providers allow patients to get the incisions wet. RESULTS: 102 Orthopaedic surgeons completed the survey. Ninety-one percent were trauma fellowship trained, and 95% worked at either a Level I (76%) or Level II (19%) trauma center. There were over 100 different proposed protocols captured by the survey. The majority of surgeons (54%) perform a wound check within the first three days after surgery. Additionally, half of surgeons (50%) do not permit patients to get their incisions wet until sutures and staples are removed. CONCLUSION: Wound care routines following surgical management of orthopaedic trauma injuries are highly variable. Diverse protocols are performed at the discretion of the treating surgeon without scientific basis. This study defines immense variability in one aspect of peri-operative care that could play an important role in surgical site infections and provides a foundation for future studies to explore the potential influence of standardized wound care routines on post-operative infections and wound healing.

Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial.

Importance: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. Objective: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. Design, Setting, and Participants: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. Interventions: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. Main Outcomes and Measures: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. Results: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. Conclusions and Relevance: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. Trial Registration: ClinicalTrials.gov Identifier: NCT02227446.

Mechanisms of failure of locked-plate fixation of the proximal humerus: acoustic emissions as a novel assessment modality.

OBJECTIVES: Locking plates are the predominant implants used for proximal humerus fractures. Despite a preponderance of good clinical outcomes, failures continue to occur. The purpose of this study was to investigate the failure mechanism of locked proximal humeral plate fixation and its relationship with bone density and screw length. METHODS: Human cadaveric humeri were subjected to cyclic bending loads after an unstable 2-part fracture (Orthopedic Trauma Association classification 11 A-3) was created and stabilized with a locking proximal humeral plate. Acoustic emission (AE) sensors were mounted on the specimens to detect fracture displacement and generation of microcracks. The data were analyzed to evaluate construct failure. RESULTS: Eight of 10 locking plate constructs in cadaver specimens failed in varus collapse. The primary influences on failure were cancellous bone density and cancellous bone screw length. AE monitoring demonstrated patterns of microcrack progression, predominantly along the inferior screws. The progression trends according to AE were similar to their respective actuator displacement versus time curves. CONCLUSIONS: Cancellous bone density and total cancellous screw depth penetration seem to be critical variables. Although the patients' bone density cannot be controlled, surgeons may decrease the risk of failure by maximizing the length of the screws within the cancellous bone. Analysis of microcrack formation revealed that failures begin at the midportion and tips of the inferior screws and at the bone-plate interface of the inferior screws.

Pelvic ring fractures are an independent risk factor for death after blunt trauma.

BACKGROUND: It is unknown whether pelvic ring fracture is an independent predictor of death after blunt trauma. Few previous studies have attempted to analyze whether the high death rate observed in association with pelvic ring injury is secondary to the pelvic ring injury or merely related to many other injuries that typically are sustained in such cases. Our hypothesis was that pelvic ring fracture is an independent risk factor for death, even after accounting for the risk of death from other associated injuries. METHODS: We reviewed the records of 31,550 patients who presented with blunt trauma at our Level I trauma center from 1995 to 2002. We analyzed our prospectively collected database and excluded any patient who was missing more than one demographic parameter (n = 414, 1.3% of the data set). Our study group consisted of 1,017 patients with pelvic ring fractures and 30,119 patients with blunt trauma without pelvic ring fractures. Multiple logistic regression analysis was conducted to account for the relative contribution of associated clinical criteria to mortality. A mortality model was then designed by using the regression analysis, allowing us to compare a calculated chance of death for each patient in the study group. We then compared the expected number of deaths of patients with pelvic injury with the actual number of observed deaths in that data set. Additionally, we conducted a second statistical analysis with which we compared the death rate of our pelvic ring fracture population (n = 1,017) with a matched subgroup (n = 1,017) from our patient population without pelvic ring fractures (n = 30,119). RESULTS: The presence of pelvic ring fracture was found to be an independent risk factor for mortality in the blunt trauma population based on both statistical methods (odds ratios, 1.9 [p < 0.001] and 2.1 [p < 0.0007]). Other significant predictors of mortality included patient age, Injury Severity Score, Glasgow Coma Scale score, systolic blood pressure and respiratory rate at admission, and several medical comorbidities. CONCLUSION: The presence of pelvic ring fracture seems to represent a clinically significant independent risk factor for mortality, even after accounting for the association with potentially severe additional body system injuries.

Effective osteoporosis education in the outpatient orthopaedic setting.

BACKGROUND: The orthopaedic surgeon may be the first medical specialist to interact with a patient with clinically important osteoporosis, providing an opportunity to educate that patient about this disease. The purpose of the present study was to investigate whether patients could be effectively educated with regard to osteoporosis and lifestyle modification during their outpatient visits to an orthopaedic surgeon's office. METHODS: Eighty female patients ranging from fifteen to seventy-three years of age completed an eleven-question quiz that included items regarding their knowledge of osteoporosis, calcium intake, menopausal status, exercise, smoking, and whether or not they had had a bone mineral density scan. The quiz was completed during a visit to an outpatient sports medicine/general orthopaedic clinic. After the quiz, an educational intervention was performed by providing the patients with an informational handout. The patients were followed at an average interval of six months and were reassessed either in the office or over the telephone with use of the same quiz to evaluate increases in knowledge and modification of lifestyle. RESULTS: Fifty-four premenopausal and twenty-six postmenopausal patients were available for follow-up. The premenopausal and postmenopausal groups differed at the beginning of the study, with premenopausal patients having a higher daily calcium intake (p = 0.008) and a better ability to define osteoporosis (p = 0.004) and postmenopausal patients having a higher rate of having had a prior bone mineral density scan (p < 0.001). In response to the educational intervention, significant improvements were seen in terms of the patients' ability to define osteoporosis (p = 0.004), the ability to identify being female as a major risk factor (p < 0.001), and the understanding that females should begin adequate calcium intake at a young age (p < 0.001). Significant increases in daily calcium intake (p < 0.001) and exercise level also occurred (p < 0.003). The postmenopausal group demonstrated a less robust response to the educational intervention. CONCLUSIONS: The outpatient orthopaedic sports medicine office setting represents a prime opportunity for education regarding osteoporosis prevention and lifestyle modification that can be performed in an inexpensive fashion and that can be easily replicated in most offices both in the community and in academic settings.