Workplace Hazards in Orthopaedic Surgery Training: A Nationwide Resident Survey Involving Sharps-related Injuries.

INTRODUCTION: Surgical specialties are at an increased risk for occupational hazards, including sharps-related injuries. The objective of this study was to report the frequency of sharps injuries and evaluate which characteristics influence the number of injuries and reporting behaviors. METHODS: A web-based, anonymous survey was available for 10 weeks to 46 US orthopaedic surgery residency programs (1,207 potential residents) participating in an education research collaborative. The survey was divided into the following areas: demographics, training and attitudes concerning occupational hazards, and sharps injuries and reporting. Logistic regression was used to evaluate the association between the above variables on experiencing sharps injuries with significance threshold set at P < 0.05. RESULTS: In this study, 518 surveys were included yielding a response rate of 42.9% (518/1,207). Nearly 80% of the residents recalled some form of safety training during intern orientation and 62% of the respondents felt that they received adequate occupation safety training specifically related to orthopaedic surgery. Four hundred seventeen residents (80.5%) experienced a sharps injury (mean 2.8). Nearly 20% of the respondents experienced ≥5 sharps injuries. Needle sticks (38.8%) were responsible for the greatest percentage of injuries, followed by Kirschner wires (33.6%), scalpel (22.5%), and bone (17.3%). Only 42% of the residents consistently reported all injuries. Reasons included feelings of no risk (63.1%), too much hassle (58.9%), embarrassment (14.5%), other (8.7%), forgot (5.8%), and unclear what to do (3.3%). Inadequate safety training specific to orthopaedic surgery (odds ratio, 2.32 [95% confidence interval, 1.20 to 4.46]; P = 0.012) and greater training seniority (odds ratio, 2.04 [95% confidence interval, 1.64 to 2.52]; P < 0.0001) were associated with acquiring five or more sharps injuries. DISCUSSION: Sharps injuries are a prevalent and concerning reality for orthopaedic surgical trainees. Despite this common occurrence, only 42% of the residents always reported their injuries. Inadequate training specific to orthopaedic surgery and each subsequent year of postgraduate training are associated with increased sharps injuries. STUDY TYPE: Level III, retrospective observational survey.

Percutaneous Intramedullary Nailing of Complex Humeral Shaft Fractures: A Retrospective Case Series.

BACKGROUND: Humeral diaphyseal fractures have been traditionally stabilized with plates and screws. However, surgical morbidity can be quite extensive, particularly in more complex segmental and comminuted fracture patterns. An intramedullary nail (IMN) has the biomechanical advantage of being a load-sharing device and can be placed with a more minimally invasive technique. The purpose of this study was to evaluate the clinical and radiographic outcomes of complex humeral shaft fractures treated with an IMN utilizing a percutaneous surgical technique. METHODS: A retrospective review was performed on a consecutive series of patients who underwent treatment of a complex humeral shaft fracture with an IMN placed with a percutaneous technique. Clinical outcome scores and radiographic analysis were performed at a minimum one-year follow-up. RESULTS: Of the 14 patients included, 12 had clinical and radiographic follow-ups at one year. The majority (64%) were obese and involved polytrauma (50%), and 79% were AO Foundation/Orthopaedic Trauma Association (AO/OTA) type C fractures. Union after the index procedure was 93%, with one nonunion requiring a secondary operation. The average operative time was 103 minutes. There were no other complications or additional procedures. The mean clinical outcome scores included American Shoulder and Elbow Society (ASES): 78.2, Constant Score: 72.1, Single Assessment Numerical Evaluation (SANE): 81.9, and Penn Shoulder Score: 82.7. CONCLUSION: This study demonstrates complex comminuted and segmental humeral shaft fractures in a higher-risk patient population can be effectively managed with IMN. Percutaneous placement of an IMN should be considered as a treatment option in complex humeral shaft fractures, particularly in patients with secondary comorbidities such as obesity and polytrauma.

Distal clavicle autograft for anterior-inferior glenoid augmentation: A comparative cadaveric anatomic study.

INTRODUCTION: The aim of this study was to anatomically compare distal clavicle and coracoid autografts and their potential to augment anterior-inferior glenoid bone loss. METHODS: Ten millimeters of distal clavicle and 20 mm of coracoid were harvested bilaterally from 32 cadavers. Length, weight, and height were measured and surface area and density were calculated. For each graft, ipsilateral measurements were compared and the ability to restore corresponding glenoid bone loss was calculated. RESULTS: Distal clavicle grafts were larger than coracoid grafts with respect to length (22.3 mm versus 17.7 mm; p < 0.001), height (12.49 mm versus 9.65 mm; p < 0.001), mass (2.72 g versus 2.45 g; p = 0.0437), and volume (2.36 cm3 versus 1.96 cm3; p = 0.002). Coracoid grafts had larger widths (14.56 mm versus 10.52 mm; p < 0.001) and greater density (1.24 g/cm3 versus 1.18 g/cm3; p < 0.001). Distal clavicle surface area was greater on both the articular (2.93 cm2 versus 1.5 cm2; p < 0.001) and superior surfaces (2.76 cm2 versus 1.5 cm2; p < 0.001) when compared to lateral coracoid surface area. DISCUSSION: Distal clavicle grafts were larger and restored larger bony defects but had greater variability and lower density than coracoid grafts. Clinical studies are needed to compare these graft options.

Acute Workplace Hazards in Orthopedic Surgery: Resident Survey Regarding Splash and Workplace Violence Events.

INTRODUCTION: Orthopedic surgery residents are at risk for daily work-related hazards and exposures. Hazards related specific to this specialty includes radiation exposure, smoke inhalation (from electrocautery), and disease transmission through contact with surgical instruments or sharps during procedures. However, minimal research has been focused on other occupational hazard risks in orthopedic surgery including surgical splash events and workplace violence. This study focused on determining (1) whether or not use of protective eyewear in the workplace would be related to the availability of personal protective equipment (PPE); (2) resident education; and (3) the rate of workplace violence toward orthopedic surgery residents during their training. METHODS: An invitation to participate in a web-based, anonymous survey to 46 US allopathic orthopedic surgery residency programs (1207 potential resident respondents). The survey was conceptually divided into the following areas: (1) demographics; (2) training and attitudes concerning occupational hazards; (3) PPE provision and use; (4) sharps injuries and reporting; and (5) general safety knowledge and violence in the workplace. Those who answered yes to having a splatter event or receiving a threat at the hospital were compared to those who did not. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between these outcomes and selected independent variables of interest. p-Values of <0.05 were considered statistically significant. RESULTS: From January 18 to March 31, 2016, 518 surveys were received and included for analysis for a response rate of 42.9% (518/1207). One survey was excluded from analysis due to <50% completed response items. Self-reported program types were 64.5% (334/518) public university-affiliated, 23.2% (120/518) private university affiliated, 7.1% (37/518) community, and 5.2% (27/518) military. Residents were 83.0% = male and 17.0% = female. Overall, reported eye protection usage was 95% amongst all residents and 22% of residents reported experiencing a violent threat in the workplace. The risk of experiencing a splatter event was not statistically associated with residency type, gender, or geographic region. Senior residents were at an increased likelihood of experiencing a splatter event (OR 1.22, [95% CI 1.06-1.41], p = 0.006) when compared to PGY-1 residents. The risk of a violent experience at work was not statistically associated with residency type, year of residency training, or gender. Residents in the Northeast were more likely to have a violent experience (OR 2.78 [95% CI 1.41-5.49] p = 0.003). Overall, residents felt that they had adequate training to prevent occupational hazards (mean of 3.9/5 on Likert scale) and respond to hazards (mean of 3.7/5 Likert). CONCLUSIONS: Occupational hazards are not uncommon in orthopedic surgery training with high rates of improper eyewear PPE use and poor awareness of Occupational Safety and Health Administration and AAOS guidelines. Violence in the workplace impacts over one in 4 residents and training programs and hospitals should improve education and report efforts. Continual yearly PPE training and awareness of AAOS guidelines could be intertwined with duty hour and/or case logs in order to ensure residents are exposed to this material on a regular basis.

Check-in Kiosks in the Outpatient Clinical Setting: Fad or the Future?

OBJECTIVES: Check-in kiosks are increasingly used in health care. This project aims to assess the effects of kiosk use upon check-in duration, point of service (POS) financial returns, and patient satisfaction. METHODS: Six kiosks were implemented in a large academic orthopedic clinic, and check-in duration for 8.5 months following implementation and POS returns for 10.5 months before and after implementation were analyzed. Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey and self-devised surveys recorded patient satisfaction. RESULTS: Cumulatively, 28,636 kiosk-based patient encounters were analyzed. Compared with historical norms, check-in duration decreased 2 minutes, 47 seconds (P < 0.001). Daily gross and individual POS returns increased $532.13 and $1.89, respectively (P < 0.001). Satisfaction surveys were completed by 719 of 1376 consecutive patients (52% response rate), revealing 12% improvement (P < 0.001), but Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey responses demonstrated no change (P = 0.146, 0.928, and 0.336). CONCLUSIONS: Kiosks offer to reduce check-in duration and increase POS revenue without negatively affecting patient satisfaction.

Adoption of Intramedullary Nail Fixation for Proximal Humerus Fractures: Assessment of Surgical Efficiency and Complications.

Fixation of proximal humerus fractures (PHFs) with intramedullary (IM) nails potentially is a newer, less invasive technique. The purpose of this study was to report on the early adoption results of IM nail use for PHF. Retrospective chart reviews were performed on the first 60 patients treated with IM nails for acute PHFs by two shoulder surgeons. The first 15 patients treated by each surgeon were compared with the subsequent 15 patients. Surgical and fluoroscopic times, fracture type, union, and varus collapse were compared. The average operating time decreased (p = .002). Fluoroscopy time, radiographic alignment, union rate, complications, and reoperations were not influenced. Three- and four-part fractures had a higher complication rate than two-part fractures (53% vs. 20%). When considering implementing use of IM nails for treatment of PHFs, initial cases can have outcomes and complications similar to those performed with greater experience. IM nailing appears a good treatment option for two-part PHFs. (Journal of Surgical Orthopaedic Advances 28(2):121-126, 2019).

Trends and Characteristics of Highly Cited Articles in Shoulder Arthroplasty.

Citation calculations measure academic influence. This study sought to analyze highly cited shoulder arthroplasty articles and determine the best measure to assess their impact. Scopus identified the 50 most cited articles, and each was analyzed for citation number, authors, institution, country of origin, and journal of publication. SPSS 23 was used for descriptive statistics, and a Pearson correlation coefficient assessed the relationship between citation measures. The results revealed an average citation count of 259 ± 108 and a citation density (citation count/years since publication) of 18 ± 10 annually. Most articles originated in the United States (31) and France (9). Twelve surgeons were included on three or more articles. Forty-one studies were clinically based. Finally, correlation was demonstrated between citation count and citation density (r = 0.486, p < .001). In conclusion, this study revealed the trends of highly cited shoulder arthroplasty articles and found citation count and citation density to be acceptable measures of academic influence. (Journal of Surgical Orthopaedic Advances 28(1):10-17, 2019).

A comparison of union rates and complications between single screw and double screw fixation of sliding calcaneal osteotomy.

BACKGROUND: The number of screws used for sliding calcaneal osteotomy fixation has not been examined in the literature. The purpose of this paper is to examine this topic. METHODS: Retrospective chart review was performed on 190 patients who met selection criteria. We compared complication risk for single versus double screw, headed versus headless screw, and short versus longitudinal incision cases. RESULTS: The mean age was 48.4 (18-83) years and average follow up was 28 (12-150) weeks. All cases achieved radiographic union. Overall complication rate was 19.5% (37/190). Risk of complication did not differ significantly between single and double screw (RR: 1.170; 95% CI: 0.66-2.09; p=0.594) or short and extended incision groups (RR: 0.868; 95% CI: 0.42-1.80; p=0.704). Risk of complication differed significantly between headed and headless screw fixation (RR: 5.558; 95% CI: 2.69-11.50; p<0.0001). CONCLUSIONS: Single screw fixation of sliding calcaneal osteotomy achieves similar outcomes as double screw fixation. Headless screws are advantageous for minimizing hardware pain and subsequent hardware removal.

Blood Transfusion During Total Ankle Arthroplasty Is Associated With Increased In-Hospital Complications and Costs.

INTRODUCTION: Total ankle arthroplasty (TAA) is an increasingly used, effective treatment for end-stage ankle arthritis. Although numerous studies have associated blood transfusion with complications following hip and knee arthroplasty, its effects following TAA are largely unknown. This study uses data from a large, nationally representative database to estimate the association between blood transfusion and inpatient complications and hospital costs following TAA. METHODS: Using the Nationwide Inpatient Sample (NIS) database from 2004 to 2014, 25 412 patients who underwent TAA were identified, with 286 (1.1%) receiving a blood transfusion. Univariate analysis assessed patient and hospital factors associated with blood transfusion following TAA. RESULTS: Patients requiring blood transfusion were more likely to be female, African American, Medicare recipients, and treated in nonteaching hospitals. Average length of stay for patients following transfusion was 3.0 days longer, while average inpatient cost was increased by approximately 50%. Patients who received blood transfusion were significantly more likely to suffer from congestive heart failure, peripheral vascular disease, hypothyroidism, coagulation disorder, or anemia. Acute renal failure was significantly more common among patients receiving blood transfusion ( P < .001). CONCLUSION: Blood transfusions following TAA are infrequent and are associated with multiple medical comorbidities, increased complications, longer hospital stays, and increased overall cost. LEVELS OF EVIDENCE: Level III: Retrospective, comparative study.

Outcomes With Overlapping Surgery at a Large Academic Medical Center.

OBJECTIVE: The aim of the study was to evaluate the efficiency and safety of overlapping surgery (OS) at a training institution by comparing it with nonoverlapping surgery (NO) with respect to operative time, mortality, readmissions, and complications. BACKGROUND: OS is the practice of an attending physician providing supervision to 2 surgeries that are scheduled at overlapping times. Recent media and government attention have raised concerns about this practice and the need for informed patient consent. METHODS: A population-based, retrospective, cohort study was conducted using data on operative procedures from January 1, 2014 to December 31, 2015 at a large tertiary academic center. Patients who had undergone surgery by attending surgeons who performed ≥10% of their cases overlapping were selected. Thirty-day mortality, readmission within 30 days, and 7 patient safety indicators (PSIs) were recorded. RESULTS: A total of 26,260 cases met our criteria for analysis for surgical time and 15,106 cases for outcomes. OS patients had an average case length of 2.18 hours compared with 1.64 hours among NO patients (P < 0.0001), a decreased risk of mortality [relative risk (RR) 0.42, 95% confidence interval (CI), 0.34-0.52, P < 0.0001), a decreased risk of readmission (RR 0.92, 95% CI, 0.86-0.98, P = 0.0148), and a decreased risk of experiencing any PSI (RR 0.67, 95% CI, 0.55-0.83, P = 0.0002). CONCLUSIONS: The present study confirms prior reports and addresses gaps in the literature regarding OS, such as the effect of resident involvement and the individual effect of OS in 13 different surgical specialties. The findings highlight the need for additional investigation and suggest that the practice of OS does not expose patients to increased risk of negative outcomes.

Subscapularis-Sparing Rotator Interval Approach for Anatomic Total Shoulder Arthroplasty.

BACKGROUND: A subscapularis-sparing approach to anatomic total shoulder arthroplasty (TSA) is used for patients with glenohumeral osteoarthritis who have an intact rotator cuff and sufficient bone volume. DESCRIPTION: A 7 to 10-cm anterosuperior incision is made with the patient in the beach chair position. The anterolateral deltoid muscle raphe is split, and the shoulder is externally rotated to bring the rotator interval to the field. A flap of interval tissue is incised, tenodesis of the biceps tendon is performed, and the interval tissue is incised straight back to the glenoid from the upper edge of the subscapularis, creating a triangular piece of tissue referred to as a "trapdoor." Two Darrach retractors are placed to expose the humeral head. An intramedullary guide is placed, and a humeral head osteotomy is performed. The glenoid is exposed, and the glenoid component is placed after sizing, preparation, drilling, and insertion of trial components per the surgical technique. The humeral head size is estimated by measuring, and the humeral stem size is decided by sequentially inserting the trial components. The permanent humeral stem is inserted, and the permanent humeral head is implanted after insertion of trial components. The trapdoor is sutured, the deltoid is reattached, and subcutaneous tissue and skin are sutured. ALTERNATIVES: The traditional surgical approach for anatomic TSA involves release and reattachment of the subscapularis tendon. RATIONALE: Nearly all anatomic TSA techniques require the subscapularis to be released, with a peel, tenotomy, or osteotomy, and then repaired on completion of the arthroplasty. Failure of the subscapularis to heal is an unfortunate and potentially devastating complication following anatomic TSA that has been linked to decreased function, instability, and pain1-4. Subscapularis dysfunction following anatomic TSA is seen in one-third to two-thirds of patients, with evidence of complete tears in up to 50% of asymptomatic patients using ultrasound examinations1-5.Sling immobilization with avoidance of excessive passive external rotation and active internal rotation is recommended to help prevent postoperative rupture of the subscapularis repair6-8. However, postoperative motion restrictions to protect the subscapularis may lead to stiffness and may negatively impact function and satisfaction.We describe a subscapularis-sparing TSA, in which we address and improve on 3 technical difficulties identified by Lafosse et al.9: (1) difficulty ensuring an anatomic humeral neck cut because of the difficulty visualizing the anterior aspect of the shoulder, (2) inadequate resection of inferior humeral neck osteophytes, and (3) undersizing of the humeral head.

Preoperative Assessment of the Peroneal Tendons in Lateral Ankle Instability: Examining Clinical Factors, Magnetic Resonance Imaging Sensitivity, and Their Relationship.

The purpose of our study was to examine the preoperative clinical factors and magnetic resonance imaging (MRI) findings associated with peroneal pathology in chronic lateral ankle instability patients, as well as the clinical factors associated with peroneal lesions being detected on MRI. Peroneal pathology was determined from intraoperative findings. Patients with/without peroneal pathology were compared regarding their preoperative clinical findings. MRI reports were examined to determine the sensitivity of detecting peroneal pathologies. Clinical factors were compared between patients (N = 238) with undetected and detected peroneal lesions on MRI. Conservative treatment, preoperative physical therapy, and lack of a traumatic inciting event were associated with peroneal pathology. MRI had a sensitivity of 61.11% for detecting peroneal pathology. No clinical factors were significantly different between "detected" and "undetected" cases. Certain historical factors were associated with peroneal pathology in patients with chronic lateral ankle instability, and MRI had a high false-negative rate. Surgeons should exercise caution when ruling out peroneal pathology based on preoperative physical examination or MRI.

Sternoclavicular joint palpation pain: the shoulder's Waddell sign?

BACKGROUND: Pain is a complex and subjective reality and can be magnified by nonorganic or nonanatomic sources. Multiple studies have demonstrated a correlation between psychological factors and patients' perceptions of musculoskeletal pain and disability. In addition, nonorganic findings as part of the physical examination are well and long recognized. The purpose of this study was to analyze the relationship between a shoulder examination test, palpation of the sternoclavicular joint (SCJ), and psychosocial conditions including chronic pain, depression, and anxiety. METHODS: From June until October 2016, all new patients of 2 sports/shoulder fellowship-trained surgeons at an academic practice were screened for study enrollment. After their consent was obtained, patients were given a set of 5 surveys (Pain Catastrophizing Scale; Patient-Health Questionnaire 2; Pain Self-Efficacy Questionnaire; shortened Disabilities of the Arm, Shoulder and Hand questionnaire; and Shoulder Pain and Disability Index) to complete. The physician then completed a comprehensive standardized physical examination, with the examining physician being blinded to the patient's survey responses. Palpation of the SCJ was done with the examiner's thumbs and was accompanied by the question "Does this hurt?" If a positive pain response was given, clarification as to the correct side of the pain was made. RESULTS: A total of 132 patients were enrolled and completed the surveys and physical examination. Of the patients, 26 (19.7%) reported SCJ pain with SCJ palpation. Patients with and without confirmed pain on SCJ palpation had significantly different (P < .001) mean scores for all 5 surveys. A review of the medical histories between the 2 groups identified a significantly increased prevalence of chronic pain and mental health disorders, such as anxiety and depression, in SCJ palpation-positive patients. CONCLUSIONS: Patients who confirmed pain on SCJ palpation had significantly higher scores on various psychological surveys than those who denied pain on palpation, indicating that a portion of their pain was stemming from a nonorganic source. Inclusion of SCJ palpation during a routine shoulder or upper extremity physical examination may improve selection of treatment options for patients.

What Leads to Lead: Results of a Nationwide Survey Exploring Attitudes and Practices of Orthopaedic Surgery Residents Regarding Radiation Safety.

BACKGROUND: Excessive radiation to health-care providers has been linked to risks of cancer and cataracts, but its negative effects can be substantially reduced by lead aprons, thyroid shields, and leaded glasses. Hospitals are required to provide education and proper personal protective equipment, yet discrepancies exist between recommendations and compliance. This article presents the results of a survey of U.S. orthopaedic surgery residents concerning attitudes toward radiation exposure and personal protective equipment behavior. METHODS: An invitation to participate in a web-based, anonymous survey was distributed to 46 U.S. allopathic orthopaedic surgery residency programs (1,207 potential resident respondents). The survey was conceptually divided into the following areas: demographic characteristics, training and attitudes concerning occupational hazards, personal protective equipment provision and use, and general safety knowledge. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated for the association between these characteristics and compliance with thyroid shield or lead gown wear. RESULTS: In this study, 518 surveys were received, with 1 survey excluded because of insufficient response, leaving 517 surveys for analysis (42.8% response rate). Ninety-eight percent of residents believed that personal protective equipment should be provided by the hospital or residency program. However, provision of personal protective equipment was not universal, with 33.8% reporting none and 54.2% reporting provision of a gown and thyroid shield. The prevalence of leaded glasses usage was 21%. Poor lead gown compliance and thyroid shield wear were associated with difficulty finding the corresponding equipment: PR, 2.51 (95% CI, 1.75 to 3.62; p < 0.001) for poor lead gown compliance and PR, 2.14 (95% CI, 1.46 to 3.16; p < 0.0001) for poor thyroid shield wear. Not being provided with personal protective equipment was also significantly associated with low compliance with both lead gowns (PR, 1.47 [95% CI, 1.04 to 2.08]; p = 0.03) and thyroid shields (PR, 1.69 [95% CI, 1.18 to 2.41]; p = 0.004). Respondents from the Southeast, West, or Midwest had lower compliance with lead gown usage. Forgetting was the number 1 reason to not wear a lead apron (42%). CONCLUSIONS: Radiation exposure is associated with increased risk of serious health problems. Our findings identified that the availability of lead personal protective equipment leads to increased compliance among residents surveyed. In addition to yearly occupational hazard training specific to orthopaedic surgery, greater efforts by residency programs and hospitals are needed to improve access to lead personal protective equipment and compliance for orthopaedic residents.

A Retrospective Case Series of Carbon Fiber Plate Fixation of Ankle Fractures.

Distal fibula fractures represent a common problem in orthopaedics. When fibula fractures require operative fixation, implants are typically made from stainless steel or titanium alloys. Carbon fiber implants have been used elsewhere in orthopaedics for years, and their advantages include a modulus of elasticity similar to that of bone, biocompatibility, increased fatigue strength, and radiolucency. This study hypothesized that carbon fiber plates would provide similar outcomes for ankle fracture fixation as titanium and steel implants. A retrospective chart review was performed of 30 patients who underwent fibular open reduction and internal fixation (ORIF). The main outcomes assessed were postoperative union rate and complication rate. The nonunion or failure rate for carbon fiber plates was 4% (1/24), and the union rate was 96% (23/24). The mean follow-up time was 20 months, and the complication rate was 8% (2/24). Carbon fiber plates are a viable alternative to metal plates in ankle fracture fixation, demonstrating union and complication rates comparable to those of traditional fixation techniques. Their theoretical advantages and similar cost make them an attractive implant choice for ORIF of the fibula. However, further studies are needed for extended follow-up and inclusion of larger patient cohorts. LEVELS OF EVIDENCE: Level IV: Retrospective Case series.

Arthroscopic Versus Open Rotator Cuff Repair: Which Has a Better Complication and 30-Day Readmission Profile?

PURPOSE: To provide a comparative 30-day postoperative analysis of complications and unplanned readmission rates, using the National Surgical Quality Improvement Program database, after open or arthroscopic rotator cuff repair (RCR). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for postoperative complications after open or arthroscopic RCR over an 8-year period, from 2007 through 2014. Patients were identified by use of Current Procedural Terminology codes. The open group contained 3,590 cases (21.8%) and the arthroscopic group had 12,882 cases (78.2%), for a total of 16,472 patients undergoing RCR. The risk of complications was compared between the 2 groups, along with patient demographic characteristics, operative time, length of stay, and unplanned readmission within 30 days. We compared dichotomous variables using the Fisher exact test and continuous variables with 1-way analysis of variance. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated when appropriate. RESULTS: The open RCR group had a higher prevalence of patients aged 65 years or older and comorbidities such as hypertension, diabetes, chronic obstructive pulmonary disease, smoking, and alcoholism (P < .05). Patients undergoing open RCR had a higher risk of any adverse event when compared with arthroscopic RCR patients (1.48% vs 0.84%; RR, 1.17; 95% CI, 1.05-1.30; P = .0010). They were also at higher risk of return to the operating room within 30 days (0.70% vs 0.26%; RR, 1.36; 95% CI, 1.09-1.69; P = .0004). Open RCR was associated with a longer average hospital stay (0.48 ± 2.7 days vs 0.23 ± 4.2 days, P = .0007), whereas arthroscopic RCR had a longer average operative time (90 ± 45 minutes vs 79 ± 45 minutes, P < .0001). CONCLUSIONS: Although both open and arthroscopic approaches to RCR had low morbidity, arthroscopy was associated with lower risks of any adverse event and return to the operating room during the initial 30-day postoperative period. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Intraoperative Topical Antibiotics for Infection Prophylaxis in Pelvic and Acetabular Surgery.

OBJECTIVES: To determine if topical vancomycin and tobramycin powder reduces the incidence of surgical site infection after pelvic ring and acetabulum fracture surgery. DESIGN: Retrospective cohort study. SETTING: University of Alabama at Birmingham, Academic Level I Trauma Center. PATIENTS/PARTICIPANTS: Two hundred nineteen patients (140 meeting inclusion criteria) with pelvic and acetabular fractures who underwent open reduction and internal fixation from March 2012 to November 2013. INTERVENTION: One gram vancomycin and 1.2 g tobramycin powder applied deep in the surgical wound of the treatment group. MAIN OUTCOME MEASUREMENTS: Postoperative infection rate. RESULTS: One hundred forty patients were included. Control group (n = 69) and treatment group (n = 71) were similar for sex, age, ethnicity, and body mass index. There was no difference between groups with regards to renal function postoperative day 2 (P = 0.24). The risk of infection was 14.5% and 4.2% (P = 0.04) for the control and treatment groups, respectively. No significant effect of antibiotic treatment was observed overall after adjusting for EBL (odds ratio 0.20, 95% confidence interval, 0.02-1.06). Of note, a nonsignificant 71% increase was observed among those with ≥1 L EBL (odds ratio 1.71, 95% confidence interval, 0.02-147.02). CONCLUSIONS: Topical antibiotics possibly reduce the incidence of surgical site infection after open pelvic and acetabulum fixation without increasing risk of renal impairment. The protective effect of topical antibiotics may be limited to patients with minimal intraoperative blood loss. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.