Medicaid and Indigent Patients Experience Delayed Fixation of Distal Radius Fractures, Resulting in Worse Consequential Radiographic Outcomes.

Distal radius fractures are the most common upper extremity injury. Patients referred to safety-net tertiary facilities following a fracture experience significant delays in treatment because of financial and language barriers as well as poor access to care at outlying community hospitals. This delay in treatment can affect postoperative functional outcomes and complication rates because of failure to restore anatomic alignment. The purpose of this multicenter study was to assess for risk factors associated with delayed fixation of distal radius fractures and evaluate the impact of delayed treatment on radiographic alignment. Patients with a distal radius fracture treated surgically during a 2-year period were identified. Measures included time from injury to surgery, demographic information, fracture classification, and radiographic parameters. The effect of surgery delay on radiographic outcomes was assessed with delayed surgery defined as 11 or more days out from injury. A total of 183 patients met study inclusion criteria. Medicaid and indigent patients were more likely to experience a delay in surgical treatment. Specifically, 70% of these patients were treated in a delayed fashion. Delayed treatment of 11 days or more was associated with worse radial height and inclination on postoperative radiographic imaging. Medicaid and indigent patients are more likely to experience delayed fixation in the treatment of distal radius fractures. This delayed surgery negatively affects postoperative radiographic outcomes. These findings suggest a need to improve access to care for Medicaid and indigent patients and to proceed with operative intervention within 10 days for distal radius fractures. [Orthopedics. 2024;47(2):e93-e97.].

Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation.

OBJECTIVES: To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population. DESIGN: Retrospective case series. SETTING: Eight, academic, level 1 trauma centers. PATIENTS SELECTION CRITERIA: Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019. OUTCOME MEASURES AND COMPARISONS: Success rate of nonunion surgery. RESULTS: Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate. CONCLUSIONS: This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

High Return to Play and Low Reinjury Rates in National Collegiate Athletic Association Division I Football Players Following Anterior Cruciate Ligament Reconstruction Using Quadrupled Hamstring Autograft.

PURPOSE: The purpose of this study was to examine the outcomes of anterior cruciate ligament (ACL) reconstruction using quadrupled hamstring (QH) autograft in a cohort of National Collegiate Athletic Association (NCAA) Division I football players. METHODS: A retrospective analysis was performed on NCAA Division I football players at a single institution who had transtibial ACL reconstruction using QH autograft between 2001 and 2016. Primary outcomes were ACL reinjury and return to play (RTP). Secondary outcomes were position, percent of eligibility used after surgery, graft diameter, Tegner-Lysholm scores, concomitant injuries/surgeries, and postcollegiate professional play. RESULTS: Between 2001 and 2016, 34 players had QH autograft ACL reconstruction, and 29 players achieved RTP. Of the 29, 2 (6.9%) sustained ACL reinjuries. The average RTP was 318 days (range 115-628) after surgery. Players used 79.5% of their remaining collegiate eligibility after surgery. Nine players sustained multiligamentous knee injuries. This did not have a significant effect on RTP (P = 0.709; mean 306±24 days for isolated ACL, mean of 353±51 for 2 ligaments, mean of 324±114 for 3 + ligaments) and none sustained reinjury. Associated meniscal injuries were sustained by 28, and 8 sustained chondral injuries. The mean postoperative Tegner-Lysholm score was 90.7 of 100, with mean follow-up of 102 months. Of these players, 18 went on to play professionally, with 17 joining National Football League rosters and 1 an arena team roster. CONCLUSION: QH demonstrated an ACL reinjury and RTP rates similar to those in previously published, predominantly bone-patella tendon-bone ACL reinjury data in elite athletes. This study demonstrates that QH autograft may be a viable option in elite athletes. LEVEL OF EVIDENCE: IV, case series.

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.

Heterotopic Ossification Following Arthroplasty for Femoral Neck Fracture.

BACKGROUND: Heterotopic ossification (HO) is a frequent complication following hip surgery. Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we aimed to (1) determine the prevalence of HO following total hip arthroplasty (THA) for femoral neck fracture in patients ≥50 years of age, (2) identify whether HO is associated with an increased risk of revision surgery within 24 months after the fracture, and (3) determine the impact of HO on functional outcomes. METHODS: We performed a multivariable Cox regression analysis using revision surgery as the dependent variable and HO as the independent variable. We compared Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores between participants with and those without HO at 24 months. RESULTS: Of 1,441 participants in the study, 287 (19.9%) developed HO within 24 months. HO was not associated with subsequent revision surgery. Grade-III HO was associated with statistically significant and clinically relevant deterioration in the total WOMAC score, which was mainly related to the function component of the score, compared with grade I or II. CONCLUSIONS: The impact of grade-III HO on the functional outcomes and quality of life after THA for hip fracture is clinically important, and HO prophylaxis for selected high-risk patients may be appropriate. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of COVID-19 on orthopaedic care: a call for nonoperative management.

BACKGROUND: Surgical specialties face unique challenges caused by SARS-COV-2 (COVID-19). These disruptions will call on clinicians to have greater consideration for non-operative treatment options to help manage patient symptoms and provide therapeutic care in lieu of the traditional surgical management course of action. This study aimed to summarize the current guidance on elective surgery during the COVID-19 pandemic, assess how this guidance may impact orthopaedic care, and review any recommendations for non-operative management in light of elective surgery disruptions. METHODS: A systematic search was conducted, and included guidance were categorized as either "Selective Postponement" or "Complete Postponement" of elective surgery. Selective postponement was considered as guidance that suggested elective cases should be evaluated on a case-by-case basis, whereas complete postponement suggested that all elective procedures be postponed until after the pandemic, with no case-by-case consideration. In addition, any statements regarding conservative/non-operative management were summarized when provided by included reports. RESULTS: A total of 11 reports from nine different health organizations were included in this review. There were seven (63.6%) guidance reports that suggested a complete postponement of non-elective surgical procedures, whereas four (36.4%) reports suggested the use of selective postponement of these procedures. The guidance trends shifted from selective to complete elective surgery postponement occurred throughout the month of March. The general guidance provided by these reports was to have an increased consideration for non-operative treatment options whenever possible and safe. As elective surgery begins to re-open, non-operative management will play a key role in managing the surgical backlog caused by the elective surgery shutdown. CONCLUSION: Global guidance from major medical associations are in agreement that elective surgical procedures require postponement in order to minimize the risk of COVID-19 spread, as well as increase available hospital resources for managing the influx of COVID-19 patients. It is imperative that clinicians and patients consider non-operative, conservative treatment options in order to manage conditions and symptoms until surgical management options become available again, and to manage the increased surgical waitlists caused by the elective surgery shutdowns.

Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture.

BACKGROUND: Globally, hip fractures are among the top 10 causes of disability in adults. For displaced femoral neck fractures, there remains uncertainty regarding the effect of a total hip arthroplasty as compared with hemiarthroplasty. METHODS: We randomly assigned 1495 patients who were 50 years of age or older and had a displaced femoral neck fracture to undergo either total hip arthroplasty or hemiarthroplasty. All enrolled patients had been able to ambulate without the assistance of another person before the fracture occurred. The trial was conducted in 80 centers in 10 countries. The primary end point was a secondary hip procedure within 24 months of follow-up. Secondary end points included death, serious adverse events, hip-related complications, health-related quality of life, function, and overall health end points. RESULTS: The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to total hip arthroplasty and 60 of 723 patients (8.3%) who were randomly assigned to hemiarthroplasty (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; P = 0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemiarthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, pain score, stiffness score, and function score, modestly favored total hip arthroplasty over hemiarthroplasty. Mortality was similar in the two treatment groups (14.3% among the patients assigned to total hip arthroplasty and 13.1% among those assigned to hemiarthroplasty, P = 0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to total hip arthroplasty and in 265 patients (36.7%) assigned to hemiarthroplasty. CONCLUSIONS: Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo total hip arthroplasty and those who were assigned to undergo hemiarthroplasty, and total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00556842.).

Obese Patients Have Fewer Wound Complications Following Fixation of Ankle Fractures.

Outcomes following ankle fracture surgery have been well studied; however, factors associated with surgical wound healing specifically are less clear. We aimed to study the relationship between wound healing and body mass index, as well as other variables following surgical treatment of ankle fractures. There were 127 consecutive, isolated, closed, malleolar ankle fractures treated with open reduction and internal fixation at a level-1 trauma center from 2008 to 2012. Patient, injury, and treatment variables were recorded and clinical records were reviewed to identify wound complications. There were 6 major and 18 minor wound complications. The overall rate of wound complication of any type was significantly lower in obese patients at 11.7% (7/60) compared with 25.4% (17/67, P < .05) in nonobese patients. When controlling for other variables obesity was associated with a significantly lower risk of developing a wound complication (OR 0.267, 95% CI 0.087-0.822), as was low energy mechanism (OR 0.246, 95% CI 0.067-0.906). No other covariates tested were associated with an increased risk of a wound infection. Ankle anatomy may present a unique situation whereby obesity may be protective against wound complications. Further studies are needed to confirm this clinical observation, and to demonstrate the mechanism through which this may occur. LEVELS OF EVIDENCE: Therapeutic, Level IV: Retrospective.

Novel Technique for Treatment of Calcaneal Tuberosity Fractures.

Calcaneal tuberosity fractures comprise only 1% to 2% of all calcaneal fractures. Treatment of these injuries has traditionally included open reduction and internal fixation with various means including lag screws, suture anchors, and K-wires. This article reports on a series of cases treated with excision of the tuberosity fragment with repair of the Achilles tendon supplemented by a flexor hallucis longus tendon transfer.

Glenohumeral arthritis as a risk factor for proximal humerus nonunion.

BACKGROUND: Proximal humerus fractures are common injuries and nonsurgical treatment has proven to yield good to excellent clinical results. A small percentage of these fractures go on to delayed or nonunion and the incidence and risk factors for this complication are poorly understood. We hypothesize that adjacent joint stiffness of the glenohumeral joint might lead to an increased rate of nonunion for proximal humerus fractures. METHODS: A search of the entire Medicare database from 2005 to 2011 was performed to identify 38,754 patients who sustained a proximal humerus fracture including 13,802 with co-existing ipsilateral shoulder osteoarthritis (OA) and 24,952 with co-existing diagnosis of rheumatoid arthritis (RA). A cohort of 301,987 patients served as a control. Medical co-morbidities and fracture complications were compared between the cohorts. RESULTS: The incidence of delayed union at 3 and 6 months for OA and RA groups were significantly increased compared to control at 0.79% and 1.74%, and 0.67% and 1.86%, respectively (p < 0.001). Nonunion rates were also significantly increased (p < 0.001) in the OA and RA cohorts at 9 months and 1 year with incidences of 2.39%, 2.89% and 2.59% and 3.08%, Respectively. The incidence of nonunion in the control cohort at the same time points was 1.13% and 1.35%. CONCLUSIONS: The coexistence of shoulder OA or a diagnosis of RA nearly doubled in the incidence of proximal humerus nonunion. This is the first study investigating this association in the shoulder and should be considered along with traditional nonunion risk factors in the treatment algorithm.

Xanthine oxidase injurious response in acute joint injury.

BACKGROUND: While acute trauma is a major cause of osteoarthritis, its etiology is poorly understood. We sought to determine whether xanthine oxidase (XO), a major producer of reactive oxygen species, plays a role in the early events of acute joint injury. METHODS: We analyzed synovial fluid from 23 subjects with recent severe acute knee injury. As a control we evaluated SF from 23 individuals with no or minimal knee osteoarthritis. We measured XO activity, reactive oxygen+reactive nitrogen species (ROS+RNS), protein oxidative damage (carbonyl), the type II collagen synthesis marker procollagen II c-propeptide (CPII) and the type II collagen degradation marker collagen type II telopeptide (CTx-II). We also measured the proinflammatory cytokine IL-6. RESULTS: XO and ROS+RNS were higher (p=0.02 and p=0.001 respectively) in acute injury than control and were strongly positively associated (r=0.62, p=0.004). Carbonyl was higher in acute injury than control (p=0.0002) and was positively correlated with XO (r=0.68, p=0.0007) as well as with ROS+RNS (r=0.71, p=0.004). CPII was higher in acute injury than control (p<0.0001) and was negatively correlated with XO (r=-0.49, p=0.017). While CTxII was not significantly higher in acute injury than control, it was positively correlated with CPII (r=0.71, p=0.0002). IL-6 was higher in acute injury than control (p<0.0001). CONCLUSIONS: These results are consistent with a potentially injurious effect of XO activity in acute joint injury characterized by excess free radical production and oxidative damage. These effects are associated with an inhibition of type II collagen production that may impede the ability of the injured joint to repair.

Pubic symphysis osteomyelitis in the prostate cancer survivor: clinical presentation, evaluation, and management.

OBJECTIVE: To describe pelvic bone osteomyelitis in the prostate cancer survivor, to report on clinical presentation and treatment, and to suggest an algorithmic approach to managing this syndrome complex. MATERIALS AND METHODS: A retrospective chart review from January 2011 to June 2014 was performed to identify prostate cancer patients with pubic symphysis osteomyelitis at a tertiary-care academic medical center with emphasis on genitourinary cancer survivorship. Data on clinical presentation and outcomes were reviewed. RESULTS: Ten patients were diagnosed with having osteomyelitis of the pubic symphysis with or without extension into the pubic rami. Three patients had associated rectal fistulas. Four patients had radical prostatectomy, 5 patients received radiotherapy, and 1 patient received high-intensity focused ultrasound as the primary treatment for prostate cancer. The most common presenting symptoms were pelvic and suprapubic pain, difficulty in walking, and recurrent urinary infections at a median of 7 years after prostate cancer treatment (range, 1.5-16 years). Eight of the 10 patients underwent pubic bone debridement with urinary and fecal diversion when needed. Two patients continue to be managed conservatively with suppressive antibiotics owing to low disease burden. Complete resolution of symptoms was noted in patients undergoing operative intervention, without any pelvic ring instability due to pubic bone resection. CONCLUSION: The combination of pelvic pain, difficulty with ambulation, and recurrent infections in a prostate cancer survivor should prompt investigation for pubic bone osteomyelitis-a poorly recognized syndrome complex that is best managed in a multidisciplinary setting.

Articular ankle fracture results in increased synovitis, synovial macrophage infiltration, and synovial fluid concentrations of inflammatory cytokines and chemokines.

OBJECTIVE: The inflammatory response following an articular fracture is thought to play a role in the development of posttraumatic arthritis (PTA) but has not been well characterized. The objective of this study was to characterize the acute inflammatory response, both locally and systemically, in joint synovium, synovial fluid (SF), and serum following articular fracture of the ankle. We hypothesized that intraarticular fracture would alter the synovial environment and lead to increased local and systemic inflammation. METHODS: Synovial tissue biopsy specimens, SF samples, and serum samples were collected from patients with an acute articular ankle fracture (n = 6). Additional samples (normal, ankle osteoarthritis [OA], and knee OA [n = 6 per group]) were included for comparative analyses. Synovial tissue was assessed for synovitis and macrophage count. SF and serum were assessed for cytokines (interferon-γ [IFNγ], interleukin-1ß [IL-1ß], IL-6, IL-8, IL-10, IL-12p70, and tumor necrosis factor α) and chemokines (eotaxin, eotaxin 3, IFNγ-inducible 10-kd protein, monocyte chemotactic protein 1 [MCP-1], MCP-4, macrophage-derived chemokine, macrophage inflammatory protein 1ß, and thymus and activation-regulated chemokine). RESULTS: Synovitis scores were significantly higher in ankle fracture tissue compared with normal ankle tissue (P = 0.007), and there was a trend toward an increased abundance of CD68+ macrophages in ankle fracture synovium compared with normal knee synovium (P = 0.06). The concentrations of all cytokines and chemokines were elevated in the SF of patients with ankle fracture compared with those in SF from OA patients with no history of trauma. Only the concentration of IL-6 was significantly increased in the serum of patients with ankle fracture compared with normal serum (P = 0.027). CONCLUSION: Articular fracture of the ankle increased acute local inflammation, as indicated by increased synovitis, increased macrophage infiltration into synovial tissue, and increased SF concentrations of biomarkers of inflammation. Characterizing the acute response to articular fracture provides insight into the healing process and may help to identify patients who may be at greater risk of PTA.

Computer-assisted reduction method for periprosthetic distal femur fracture.

The purpose of this case report is to describe a novel use of computer assistance in identifying and restoring the mechanical axis in the treatment of a periprosthetic distal femur fracture in a 76-year-old female patient with a total knee arthroplasty.

Outcome of intramedullary fixation of clavicular fractures.

We conducted a retrospective, single-center (tertiary referral center with associated level I trauma center) review to evaluate the outcome of open reduction and internal fixation (ORIF) with intramedullary (IM) clavicle pin of displaced clavicular fractures. Sixty-eight displaced midshaft clavicle fractures in 68 patients underwent ORIF with IM clavicle pins. Patients were identified through a perioperative database by searching for Current Procedural Terminology (CPT) codes. Union was the primary outcome. Secondary outcomes included time to union, pain, incidence of nonunion and delayed union, postoperative range of motion, and incidence of complications. Sixty-six fractures (97%) went on to union. Complications included painful hardware (44%), deep and superficial wound infections (10%), and hardware failure (4%), including pin breakage and extrusion. Postoperative shoulder pain was present in 10% of patients and limited shoulder range of motion in 12%. IM pin fixation can provide good outcomes, even for fractures with a significant amount of shortening and comminution.

Case report: lead toxicity associated with an extra-articular retained missile 14 years after injury.

Lead toxicity associated with extra-articular retained missiles (EARMs) is an uncommon yet potentially devastating complication of gunshot wounds. While the risk of lead toxicity with intra-articular retained missiles is well-known, EARMs are routinely permitted to remain in tissues indefinitely without surveillance for lead toxicity. We present a 34 year-old man who was found to have symptomatic lead toxicity 14 years after sustaining a gunshot-associated femoral fracture with retention of lead bullet fragments. A fluid-filled cyst containing two large lead bullet fragments was identified intraoperatively. Whole-blood lead concentration decreased after removal of the lead-filled cyst. Cyst formation and concomitant bone fracture are two of the risk factors for lead toxicity in patients with EARMs after gunshot wounds. Recognizing risk factors for EARM-associated elevation in lead levels is important as the adverse effects of increased lead burden may be asymptomatic and difficult to diagnose, yet debilitating and potentially lethal.

Femoral neck fracture in association with low-energy pelvic ring fractures in an elderly patient.

Concomitant fractures of the pelvic ring and proximal femur in the setting of low-energy trauma are rare but not mutually exclusive. An 82-year-old woman, without prior hip pain, presented to our institution after a fall from standing height. Ipsilateral pubic rami and sacral ala fractures were diagnosed with plain radiographs and computed tomography scanning, respectively, and corroborated by physical examination. No further imaging was performed in the emergency department. However, with adequate in-house pain control, the patient's complaints and physical examination were also indicative of a hip fracture. A subsequent magnetic resonance imaging study revealed a nondisplaced ipsilateral intertrochanteric femur fracture. Previously, it has been reported that occult fractures of the hip and pelvic ring appear to be mutually exclusive. Moreover, if acute fractures of the pubic ramus are identified, it has been recommended that no further investigation is warranted to rule out fracture of the hip. This case report demonstrates that low-energy pelvic ring and hip fractures can occur together. Sound clinical acumen is imperative and must supercede literature reports when providing patient care.

Timing of definitive fixation of severe tibial plateau fractures with compartment syndrome does not have an effect on the rate of infection.

BACKGROUND: Tibial plateau fractures with associated compartment syndrome are severe injuries with elevated infection rates. The objective of this article was to analyze whether there is an association between infection and the timing of definitive fracture fixation in relation to fasciotomy closure or coverage. METHODS: Eighty-one tibial plateau fractures, complicated by compartment syndrome, were treated with four-compartment fasciotomies and definitive fracture fixation before, at, or after fasciotomy closure or coverage. RESULTS: Thirty extremities were treated with definitive fixation before fasciotomy closure. Seven (23%) of these extremities developed an infection. Twenty-six extremities were treated with definitive internal fixation at the time of fasciotomy closure of which three (12%) developed an infection. Twenty-five extremities were treated definitively after fasciotomy closure of which four (16%) developed an infection. There was no significant difference in the rate of infection among the groups (p = 0.5012). CONCLUSIONS: This study demonstrated no statistical difference in the rate of infection when tibial plateau fractures with four-compartment fasciotomies were treated with open reduction and internal fixation before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure. Based on the data presented herein, it seems that definitive fracture treatment can be determined by the condition of patient and by surgeon preference and experience without exposing the patient to the additional risk of infection.