Do Long-Segment Blocking Screws Increase the Stability of Intramedullary Nail Fixation in Proximal Tibia Fractures, Eliminating the "Bell-Clapper Effect?"

OBJECTIVES: To determine change in stiffness and horizontal translation of a geriatric extra-articular proximal tibia fracture model after intramedullary nailing with distal (long)-segment blocking screws versus proximal (short)-segment blocking screws. METHODS: Unstable extra-articular proximal tibia fractures (OTA/AO 41-A3) were created in 12 geriatric cadaveric tibias. Intramedullary nails were locked with a standard construct (4 proximal screws and 2 distal screws). Specimens were then divided into 2 groups (6 matched pairs per group). Group 1 had a blocking screw placed lateral to the nail in the proximal segment (short segment). Group 2 had a blocking screw placed 1 cm distal to the fracture and medial to the nail (long segment). Specimens were then axially loaded and cycled to failure or cycle completion (50,000 cycles). RESULTS: Long-segment blocking screws significantly decreased the amount of horizontal translation at the fracture site compared with short-segment screws (0.77 vs. 2.0 mm, P = 0.039). They also resulted in a greater trend towards greater baseline stiffness, (807.32 ± 216.95 N/mm vs. 583.12 ± 130.1 N/mm, P = 0.072). There was no difference in stiffness after cyclic loading or survival through 50,000 cycles between the long-segment and short-segment groups. CONCLUSION: Long-segment blocking screws added to an intramedullary nail construct resulted in decreased horizontal translation at the fracture site compared with short-segment screws in this model of a geriatric proximal tibia fracture. CLINICAL RELEVANCE: Blocking screws are commonly used to aid in fracture alignment during intramedullary nailing of proximal tibia fractures. Even when not required to attain or maintain alignment, the addition of a blocking screw in either the proximal or the distal (long) segment may help mitigate the "Bell-Clapper Effect" in geriatric patients.

Outcomes After Acute Versus Staged Fixation of Complete Articular Tibial Plafond Fractures.

OBJECTIVE: To determine the outcomes after acute versus staged fixation of complete articular tibial plafond fractures. DESIGN: Retrospective cohort study. SETTING: Single Level 1 Trauma center. PARTICIPANTS: 98 skeletally mature patients with OTA/AO 43C type fractures who underwent definitive fixation with plate and screw constructs and had a minimum 6 months of follow-up. INTERVENTION: Acute open reduction internal fixation (aORIF) versus staged (sORIF) definitive fixation. MAIN OUTCOME MEASUREMENT: Rates of wound dehiscence/necrosis and deep infection. RESULTS: Acute (N = 40) versus staged (N = 58) ORIF groups had comparable rates of vascular disease, renal disease, and substance/nicotine use, but aORIF patients had higher rates of diabetes mellitus (10% vs. 0%, P < 0.001), which correlated with higher American Society of Anaesthesiologist scores (>American Society of Anaesthesiologist 3: 37.5% vs. 13.8%, P = 0.02). Both groups achieved anatomic/good reductions, as determined by postoperative CT scans, at rates greater than 90%; however, the sORIF group required modestly longer operative times to achieve this outcome (aORIF vs. sORIF: 121 vs. 146 minutes, P = 0.02). Postoperatively, both groups had similar rates of wound dehiscence (2.5% vs. 6.9%, P = 0.65), superficial infections (10% vs. 17.2%, P = 0.39), and deep infections (10% vs. 8.6%, P = 0.99). While the injury pattern itself required free flap coverage in 1 patient in each group, unplanned free flap coverage occurred in 10.0% and 10.3% of aORIF and sORIF groups, respectively. Overall, rates of unplanned reoperations, excluding ankle arthrodesis, did not differ between groups (aORIF vs. sORIF:12.5% vs. 25.9%, P = 0.13). CONCLUSIONS: In select patients managed by fellowship-trained orthopaedic traumatologists, acute definitive pilon fixation can produce acceptable outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

High- Versus Low-Energy Intertrochanteric Hip Fractures in Young Patients: Injury Characteristics and Factors Associated With Complications.

OBJECTIVE: To compare fracture patterns and associated injuries for young patients with high- versus low-energy intertrochanteric hip fractures and to report on factors associated with complications after surgical fixation of high-energy fractures. DESIGN: Retrospective comparative study. SETTING: Academic Level 1 Trauma Center. PATIENTS: A total of 103 patients 50 years of age or younger were included: 80 high-energy fractures and 23 low-energy fractures. INTERVENTION: Cephalomedullary nailing (N = 92) or a sliding hip screw (N = 11). MAIN OUTCOME MEASURES: Radiographic characteristics of fracture morphology, implant position, and reduction quality and postoperative complications were the main outcome measures. RESULTS: Compared with young patients with low-energy fractures, those with high-energy fractures had more fracture comminution ( P = 0.013) and higher ISS scores ( P < 0.003) and were more likely to require open reduction ( P < 0.001). Patients with low-energy fractures from a ground-level fall had higher rates of alcohol abuse (0.032), cirrhosis (0.010), and chronic steroid use (0.048). Overall reoperation rate for high-energy fractures was 7%, including 2 IT fracture nonunions (5%) and 1 deep infection (2%). For high-energy fractures, ASA class ( P = 0.026), anterior lag screw position ( P = 0.001), and varus malreduction ( P < 0.001) were associated with malunion. Four-part fracture (OTA/AO 31A2.3/Jensen 5) ( P = 0.028) and residual calcar gap >3 mm ( P = 0.03) were associated with reoperation. CONCLUSIONS: Surgical treatment of high-energy IT fractures in young patients is technically demanding with potential untoward outcomes. Injury characteristics and severity are significantly different for young patients with high-energy IT fractures compared with low-energy fractures. For young patients with a high-energy IT fracture, surgeons can anticipate a high rate of associated injuries and complex fracture patterns requiring open reduction. For young patients with a low-energy IT fracture, comanagement with a hospitalist or a geriatrician should be considered because they may be physiologically older. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Immediate Weight Bearing as Tolerated Is Safe Following Intramedullary Fixation of Extra-articular Metaphyseal Proximal Tibia Fractures (OTA/AO 41-A).

OBJECTIVES: To determine whether immediate weight bearing after intramedullary fixation of extra-articular proximal tibia fractures (OTA/AO 41A) results in change of alignment before union. DESIGN: Retrospective Review. SETTING: Level I and Level II Trauma Center. PATIENTS/PARTICIPANTS: Thirty-seven patients with 37 proximal tibial fractures, all whom could bear weight as tolerated postoperatively. Eighteen fractures were OTA/AO 41-A2, and 19 were OTA/AO 41-A3. INTERVENTION: Intramedullary nailing of extra-articular proximal tibia fractures. MAIN OUTCOME MEASUREMENTS: Change in fracture alignment or loss of reduction. RESULTS: The average change in coronal alignment at the final follow-up was 1.22 ± 1.28 degrees of valgus and 1.03 ± 1.05 degrees of extension in the sagittal plane. Twenty-five patients demonstrated excellent initial alignment, 10 patients demonstrated acceptable initial alignment, and 2 patients demonstrated poor initial alignment. Five patients demonstrated a change in alignment from excellent to acceptable at the final follow-up. No patient went from excellent or acceptable initial alignment to poor final alignment. Five patients required unplanned secondary surgical procedures. Two patients required return to the operating room for soft-tissue coverage procedures, 2 patients required surgical debridement of a postoperative infection, and 1 patient underwent debridement and exchange nailing of an infected nonunion. No patient underwent revision for implant failure or loss of reduction. CONCLUSION: Immediate weight bearing after intramedullary fixation of extra-articular proximal tibia fractures (OTA/AO 41A) led to minimal change in alignment at final postoperative radiographs. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does a Reduced Secondary Operation Rate Offset Higher Implant Charges when Utilizing Suture Button Fixation for Syndesmotic Injuries?

OBJECTIVE: To determine whether a reduced secondary operation rate offsets higher implant charges when using suture button fixation for syndesmotic injuries. DESIGN: Retrospective cohort study. SETTING: Single, urban, Level 1 trauma center. PARTICIPANTS: Three-hundred twenty-seven (N = 327) skeletally mature patients with rotational ankle fractures (OTA/AO type 44) necessitating concurrent syndesmotic fixation. INTERVENTION: Suture button or solid 3.5-mm screw syndesmotic fixation. MAIN OUTCOME MEASUREMENTS: To compare implant charges with secondary operation charges based on differential implant removal rates between screws and suture buttons. RESULTS: Patients undergoing screw fixation were older (48.8 vs. 39.6 years, P < 0.01), had more ground-level fall mechanisms (59.3% vs. 51.1%, P = 0.026), and sustained fewer 44C type injuries (34.7% vs. 56.8%, P = 0.01). Implant removal occurred at a higher rate in the screw fixation group (17.6% vs. 5.7%, P = 0.005). Binomial logistic regression identified nonsmoker status (B = 1.03, P = 0.04) and implant type (B = 1.41, P = 0.008) as factors associated with implant removal. Adjusting for age, the NNT with a suture button construct to prevent one implant removal operation was 9, with mean resulting additional implant charges of $9747 ($1083/case). Backward calculations using data from previous large studies estimated secondary operation charges at approximately $14220, suggesting a potential 31.5% cost savings for suture buttons when considering reduced secondary operation rates. CONCLUSIONS: A reduced secondary operation rate may offset increased implant charges for suture button syndesmotic fixation when considering institutional implant removal rates for operations occurring in tertiary care settings. Given these offsetting charges, surgeons should use the syndesmotic fixation strategy they deem most appropriate in their practice setting. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Various Antibiotic Cement-Coated Intramedullary Implants on the Treatment of Long Bone Septic Nonunion.

OBJECTIVE: To determine the effectiveness of various types of antibiotic-coated intramedullary implants in the treatment of septic long bone nonunion. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PARTICIPANTS: Forty-one patients with septic long bone nonunion treated with an antibiotic cement-coated intramedullary implant. INTERVENTION: Surgical debridement and placement of a type of antibiotic-coated intramedullary implant. MAIN OUTCOME MEASUREMENTS: Union and need for reoperation. RESULTS: At an average 27-month follow-up (6-104), 27 patients (66%) had a modified radiographic union score of the tibia of 11.5 or greater, 12 patients (29%) a score lower than 11.5, and 2 patients (5%) underwent subsequent amputation. Six patients underwent no further surgical procedures after the index operation. Patients treated with a rigid, locked antibiotic nail achieved earlier weight-bearing (P = 0.001), less frequently required autograft (P = 0.005), and underwent fewer subsequent procedures (average 0.38 vs. 3.60, P = 0.004) than those treated with flexible core antibiotic rods. CONCLUSIONS: Antibiotic-coated intramedullary implants are successful in the treatment of septic nonunions in long bones. In our cohort, rigid, statically locked nails allowed faster rehabilitation, decreased the need for autograft, and decreased the number of additional surgical procedures. Further study is needed to confirm these findings. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

"Unstable" Pediatric Femoral Shaft Fractures Treated With Flexible Elastic Nails Have Few Complications.

OBJECTIVES: To determine our complication rate in pediatric femoral shaft fractures treated with flexible elastic nailing and to determine fracture characteristics that may predict complications. DESIGN: Retrospective cohort study. SETTING: One Level 1 and One Level 2 academic trauma centers. PATIENTS/PARTICIPANTS: One hundred one pediatric femoral shaft fractures treated from 2006 to 2018. MAIN OUTCOME MEASUREMENT: Major and minor complications. RESULTS: One hundred one femurs met inclusion criteria. The average age was 7 years (range 3-12 years). The average weight was 29.0 kg (range 16-55 kg). The average follow-up was 11 months (6-36 months). Ninety-three patients underwent elective implant removal at our institution. Fifty-one of the 101 (50%) fractures were "unstable" patterns. Ninety-three percent had implants that filled >80% of the canal (69 titanium and 32 stainless steel). Seventeen percent (18) had cast immobilization. All fractures went on to union. No patient required revision surgery for malunion as follows: 6 had coronal/sagittal malalignment >10 degrees, 3 had malrotation >15 degrees, and none had a leg length inequality >1 cm. Three patients had an unplanned surgery as follows: 2 for prominent implants and 1 for refracture after a second injury. There were no patient, fracture, or treatment characteristics that were predictive of complications or unplanned surgery, including "unstable" fractures (P = 0.78). CONCLUSION: Our study demonstrates that flexible elastic nailing can be safely used in most pediatric femoral shaft fractures, including those previously described as "unstable." LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Quality of Reduction of Displaced Intra-articular Calcaneal Fractures Using a Sinus Tarsi Versus Extensile Lateral Approach.

OBJECTIVE: To evaluate the difference in the quality of fracture reduction between the sinus tarsi approach (STA) and extensile lateral approach (ELA) using postoperative Computed Tomography (CT) scans in displaced intra-articular calcaneal fractures (DIACFs). DESIGN: Retrospective. SETTING: Level 1 and level 2 academic centers. PATIENTS: Consecutive patients undergoing operative fixation of DIACFs with postoperative CT scans and standard radiographs. METHODS: Patients were identified based on Current Procedural Terminology code and chart review. All operative calcaneal fractures treated between 2012 and 2018 by fellowship-trained orthopaedic trauma surgeons were evaluated. Those with both postoperative CT scans and radiographs were included. Exclusion criteria included extra-articular fractures, malunions, percutaneous fixation, ORIF and primary fusion, and those patients without a postoperative CT scan. The Sanders classification was used. Cases were divided into 2 groups based on ELA versus STA. Bohler angle and Gissane angle were evaluated on plain radiographs. CT reduction quality grading included articular step off/gap within the posterior facet, and varus angulation of the tuberosity: CT reduction grading included: excellent (E): no gap, no step, and no angulation; good (G): <1 mm step, <5 mm gap, and/or <5° of angulation, fair (F): 1-3 mm step, 5-10 mm gap, and/or 5-15° angulation; and poor (P): >3 mm step, >10 mm gap, and/or >15° angulation. RESULTS: Seventy-seven patients with 83 fractures were included. Average age was 42 years (range, 18-74 years), with 57 men. Four fractures were open. There were 37 Sanders II and 46 Sanders III fractures; 36 fractures were fixed using the STA, whereas 47 used the ELA. Average days to surgery were 5 for STA and 14 for ELA (P < 0.001). A normal Bohler angle was achieved more often with the ELA (91.5%) than with STA (77.8%) (P < 0.001). There was no difference by approach for Gissane angle (P = 0.5). ELA had better overall reduction quality (P = 0.02). For Sanders II, there was no difference in reduction quality with STA versus ELA (P = 0.51). For Sanders III, ELA trended toward better reduction quality (P = 0.06). CONCLUSIONS: The ELA had a better overall reduction of Bohler angle on plain radiographs and of the posterior facet and tuberosity on postoperative CT scans. For Sanders type II DIACFs, there was no difference between STA and ELA. Importantly, for Sanders III DIACFs, ELA trended toward better reduction quality. In addition to fracture reduction, surgeon learning curve, early wound complications, and long-term outcomes must be considered in future studies comparing the ELA and STA. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Primary Care Answer to a Pandemic: Keeping a Population of Patients Safe at Home through Chronic Care Management and Remote Patient Monitoring.

The pandemic caused by the coronavirus disease of 2019 (COVID-19) challenged primary care providers (PCPs) to continue to deliver care for their patients, while also remaining financially stable. Most practices have experienced declining revenue due to fewer in-person patient visits. To help offset this and to continue to provide safe patient care, practices have shifted toward using remote options. Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) are benefits available to Medicare fee-for-service patients, which allow a medical practice to deliver expanded care and generate much-needed revenue. These services can be delivered by clinical staff called care managers. A top health priority for most seniors is to effectively self-isolate to reduce risk of COVID-19, while maintaining mental and physical health. We developed a Safe at Home program, designed to be run by care managers through CCM and RPM, with the use of a remote monitoring technology. Safe at Home tracks signs and symptoms of COVID-19, mental and physical health, and lifestyle behaviors that can affect immune function. We project that this service can complement regular telehealth PCP visits and deliver population health monitoring services, while generating substantial revenue for the practice.

Formation of a National Lifestyle Medicine Network to Benefit Patients and Lifestyle Medicine Providers.

The American College of Lifestyle Medicine (ACLM) is forming a Lifestyle Medicine Provider Network (LMPN). The goal of this network is 2-fold: (1) to provide significant benefits to patients by focusing on the adoption of intensive evidence-based lifestyle medicine (LM) therapies to treat and reverse chronic disease and (2) to benefit LM providers by supporting their practice operations and optimizing contracting and reimbursement opportunities. The 2 phases of the network development will include (1) network formation and practice standardization and (2) deployment for group contracting. LMPN will be organized as a special project of the ACLM, with leadership provided through the ACLM LMPN Task Force. As part of this first phase, ACLM will devote the necessary resources to establish the network and promote LM training, certification, and sharing of best practices across the network. The second phase will necessitate the establishment of a separate corporate entity, enabling the acquisition of the required capital and expertise to fully realize the potential of LMPN deployment. Strategic direction will be provided by a LMPN Board of Advisors, consisting of select network members as well as select members of ACLM's Board of Directors. The first priority of the LMPN will be to recruit interested and qualifying LM practitioners and standardize the LM approach and process of care delivery, starting with high-value services, such as chronic care management. The focus on maximizing existing provider program incentives avails the LMPN the fastest and most efficient path to demonstrating value to its members and to its client base.

Long Segment Blocking Screws Increase the Stability of Retrograde Nail Fixation in Geriatric Supracondylar Femur Fractures: Eliminating the "Bell-Clapper Effect".

OBJECTIVES: To determine the change in stiffness and horizontal translations of a geriatric supracondylar femur fracture model with the addition of distal segment blocking screws versus proximal (long) segment blocking screws to the standard retrograde intramedullary nail construct. METHODS: Unstable supracondylar femur fractures (OTA/AO 33-A3) were created; all specimens were instrumented with a retrograde intramedullary nail. Specimens were divided into 2 groups (6 matched pairs per group). Group 1 compared the standard construct (1 proximal screw and 3 distal screws) to a distally augmented construct, with blocking screws placed in the distal metaphyseal segment. Group 2 compared the distally augmented construct to one in which blocking screws were placed just proximal to the fracture (long segment blocking screws). Specimens were then axially loaded and cycled to failure or run-out. RESULTS: There was no significant difference in baseline stiffness, survival through cyclic loading, stiffness after cyclic loading, or cycles to failure between femurs treated with distal blocking screws and femurs treated without blocking screws (group 1). Femurs with blocking screws in the long proximal segment had significantly greater baseline stiffness, stiffness after cyclic loading, and less horizontal translation at the fracture site (group 2). There was no difference in survival through cyclic loading or cycles to failure. CONCLUSION: Long segment blocking screws are biomechanically superior to blocking screws in the distal segment or no blocking screws initially and after cyclic loading in an unstable geriatric supracondylar femur fracture model treated with intramedullary nail. CLINICAL RELEVANCE: Surgeons may use blocking screws to aid in fracture alignment during retrograde nail fixation. In addition, the placement of long segment blocking screws can help resist failure of fixation in geriatric patients by eliminating the "Bell-clapper effect."

Opportunistic CT Screening for Osteoporosis in Patients With Pelvic and Acetabular Trauma: Technique and Potential Clinical Impact.

OBJECTIVES: To present a technique for the use of computed tomography (CT) scans in opportunistic screening for osteoporosis in patients with pelvic and acetabular fractures and to quantify the potential clinical impact in a geriatric trauma population. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS: A total of 335 patients older than 60 years of age who presented to a Level 1 trauma center with a diagnosis of pelvic or acetabular fracture and were evaluated with a CT scan between the years 2010 and 2016. A subset of 255 patients were evaluated with a dual-energy x-ray absorptiometry scan within 6 months of the CT scan. INTERVENTION: Measurement of Hounsfield units (HU) was performed at the midpoint of the femoral neck using a standardized, ovoid section, followed by Livewire measurement. Application of this technique retrospectively to a population of geriatric patients with pelvic or acetabular fractures. MAIN OUTCOME MEASUREMENTS: (1) HUs were measured in a cross section at the midpoint of the femoral neck and, discriminant function analysis was used to establish thresholds for normal bone mineral density, osteopenia, and osteoporosis. (2) Change in the number of diagnoses of osteoporosis after application of the protocol the geriatric trauma cohort. RESULTS: Patients with osteopenia were identified correctly 67.5% of the time (14.3% were incorrectly grouped as normal, and 18.3% were grouped as having osteopenia). Patients with osteoporosis were identified correctly 88.9% of the time (the remaining 11.1% were assigned to osteopenic). The results of discriminant function analysis were used to establish CT thresholds for osteopenia (345 HUs) and osteoporosis (262 HUs). CONCLUSION: CT imaging obtained for pelvic and acetabular fractures can identify patients with osteoporosis without additional radiation exposure or cost. The fitted ovoid region of interest is a standard feature in most CT scan platforms and is quite simple to perform. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical Comparison of 3 Inferiorly Directed Versus 3 Superiorly Directed Locking Screws on Stability in a 3-Part Proximal Humerus Fracture Model.

OBJECTIVE: To quantify the stability of 3 points of inferiorly directed versus 3 points of superiorly directed locking screw fixation compared with the full contingent of 6 points of locked screw fixation in the treatment of a 3-part proximal humerus fracture. METHODS: A standardized 3-part fracture was created in 10 matched pairs (experimental groups) and 10 nonmatched humeri (control group). Osteosynthesis was performed using 3 locking screws in the superior hemisphere of the humeral head (suspension), 3 locking screws in the inferior hemisphere (buttress), or the full complement of 6 locking screws (control). Specimens were tested in varus cantilever bending (7.5 Nm) to 10,000 cycles or failure. Construct survival (%) and the cycles to failure were compared. RESULTS: Seven of 10 controls survived the 10,000-cycle runout (70%: 8193 average cycles to failure). No experimental constructs survived the 10,000-cycle runout. Suspension and buttress screw groups failed an average of 331 and 516 cycles, respectively (P = 1.00). The average number of cycles to failure and the number of humeri surviving the 10,000-cycle runout were greater in the control group than in the experimental groups (P ≤ 0.006). CONCLUSION: Data support the use of a full contingent of 6 points of locking screw fixation over 3 superior or 3 inferior points of fixation in the treatment of a 3-part proximal humerus fracture with a locking construct. No biomechanical advantage to the 3 buttress or 3 suspension screws used in isolation was observed.

Institutional and Seasonal Variations in the Incidence and Causative Organisms for Posttraumatic Infection following Open Fractures.

OBJECTIVES: The current literature focuses on wound severity, time to debridement, and antibiotic administration with respect to risk of infection after open fracture. The purpose of this analysis was to determine if either the incidence of posttraumatic infection or causative organism varies with treating institution or the season in which the open fracture occurred. DESIGN: Retrospective review. SETTING: Seven level 1 regional referral trauma centers located in each of the 7 climatic regions of the continental United States (Northwest, High Plains, Midwest/Ohio Valley, New England/Mid-Atlantic, Southeast, South, and Southwest). PATIENTS/PARTICIPANTS: Five thousand one hundred twenty-seven skeletally mature patients with open extremity fractures treated between 2008 and 2012 at one of the 7 institutions. INTERVENTION: Open reduction and internal fixation of fracture following institutional protocol for antibiotic prophylaxis, debridement, and soft-tissue management. MAIN OUTCOME MEASUREMENTS: Seasonal variation on the incidence of infection and the causative organism after treatment for open fracture as recorded by each individual treating institution. Charts were analyzed to extract information regarding date of injury, Gustilo-Anderson type of open fracture, subsequent treatment for a posttraumatic wound infection, and the causative organisms. Patients were placed into one of the 4 groups based on the time of year that the injury occurred: spring (March-May), summer (June-August), fall (September-November), and winter (December-February). Univariate/multivariate analyses and Fisher test were used to assess whether any observed differences were of statistical significance. RESULTS: The overall incidence of infection for all open fractures across the 7 different institutions was 7.6% and this did not vary significantly by season. There were, however, significant differences in overall infection rates between the different institutions: Southeast 4.3%, Northwest 13%, Northeast 7.7%, Southwest 9.3%, Midwest/Ohio Valley 5.5%, High Plains 14.6%, and South 7.4%. The following institutions demonstrated a significant seasonal variation in the incidence of infection: Northwest = fall 11% versus winter 18.5%, Southwest = winter 1.5% and fall 17.3%, Northeast = winter 5.2% and spring 9.7%, and Southeast = fall 2.8% and spring 6.0%. The High Plains, Midwest/Ohio Valley, and Southern institutions did not demonstrate a significant seasonal variation in infection rates. Finally, the most commonly encountered causative organism varied not only by region, but by season as well. Staphylococcus aureus (both methicillin sensitive and resistant) continues to be the most prevalent organism in the continental United States. CONCLUSIONS: A substantial seasonal and institutional variation exists regarding the incidence of infection and causative organisms for posttraumatic wound infection after open fractures. Although this may represent a difference in treatment regimens between individual surgeons and institutions, a decades-old general nation-wide empiric antibiotic prophylaxis regimen for all open fractures may in fact be outdated and suboptimal. We recommend that surgeons consult with their infectious disease colleagues to better understand the seasonal variation of infection and causative organism for their individual hospital, and adjust their prophylactic and treatment regimens accordingly. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Ketorolac Administered in the Recovery Room for Acute Pain Management Does Not Affect Healing Rates of Femoral and Tibial Fractures.

OBJECTIVES: To determine whether ketorolac administered in the immediate perioperative period affects the rate of nonunion in femoral and tibial shaft fractures. DESIGN: Retrospective comparative study. SETTING: Single Institution, Academic Level 1 Trauma Center. PATIENTS: Three hundred and thirteen skeletally mature patients with 137 femoral shaft (OTA 32) and 191 tibial shaft (OTA 42) fractures treated with intramedullary rod fixation. INTERVENTION: Eighty patients with 33 femoral shaft and 52 tibial shaft fractures were administered ketorolac within the first 24 hours after surgery (group 1-study group). Two-hundred thirty-three patients with 104 femoral shaft and 139 tibial shaft fractures were not (group 2-control group). MAIN OUTCOME MEASUREMENTS: Rate of reoperation for repair of a nonunion and time to union. RESULTS: Average time to union of the femur was 147 days for group 1 and 159 days for group 2 (P = 0.57). Average time to union of the tibia was 175 days for group 1 and 175 days for group 2 (P = 0.57). There were 3 femoral nonunions (9%) in group 1 and eleven femoral nonunions (11.6%) in group 2 (P = 1.00). There were 3 tibial nonunions (5.8%) in group 1 and 17 tibial nonunions (12.2%) in group 2 (P = 0.29). The average dose of ketorolac for patients who healed their fracture was 85 mg, whereas it was 50 mg for those who did not (P = 0.27). All patients with a nonunion in the study group were current smokers. CONCLUSIONS: Ketorolac administered in the first 24 hours after fracture repair for acute pain management does not seem to have a negative impact on time to healing or incidence of nonunion for femoral or tibial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Production and characterization of plutonium dioxide particles as a quality control material for safeguards purposes.

Plutonium (Pu) dioxide particles were produced from certified reference material (CRM) 136 solution (CRM 136-plutonium isotopic standard, New Brunswick Laboratory, Argonne, IL, U.S.A., 1987) using an atomizer system on December 3, 2009 after chemical separation of americium (Am) on October 27, 2009. The highest density of the size distribution of the particles obtained from 312 particles on a selected impactor stage was in the range of 0.7-0.8 µm. The flattening degree of 312 particles was also estimated. The isotopic composition of Pu and uranium (U) and the amount of Am were estimated by thermal ionization mass spectrometry (TIMS), inductively coupled plasma mass spectrometry (ICPMS), and α-spectrometry. Within uncertainties the isotopic composition of the produced particles is in agreement with the expected values, which were derived from the decay correction of the Pu isotopes in the CRM 136. The elemental ratio of Am to Pu in the produced particles was determined on the 317th and 674th day after Am separation, and the residual amount of Am in the solution was estimated. The analytical results of single particles by micro-Raman-scanning electron microscopy (SEM)-energy-dispersive X-ray spectrometry (EDX) indicate that the produced particles are Pu dioxide. Our initial attempts to measure the density of two single particles gave results with a spread value accompanied by a large uncertainty.