Single dose IV Antibiotic for Low-Energy Extremity Gunshot Wounds: A Prospective Protocol.

Objective: To prospectively determine infection rate following low-energy extremity GSWs with a single dose IV antibiotic protocol. Summary Background Data: Previous work suggests that a single IV antibiotic dose, without formal surgical debridement, mitigates infection risk. Methods: Over 35 months 530 adults with low-energy GSWs to the extremities were included. Three hundred fifty-two patients (66%) had ≥30 days follow-up. Patients were administered a single dose of first-generation IV cephalosporin antibiotics, and those with operative fractures received 24-hour perioperative antibiotics. Injury characteristics, treatment, protocol adherence, and outcomes (infection) were assessed between the protocol group (single-dose antibiotics) and the non-protocol group (no antibiotics or extra doses of antibiotics). Results: Compliance with the single-dose protocol occurred in 66.8%, while 33.2% received additional antibiotics or no antibiotics. The deep infection rate requiring surgical debridement was 0.8%, while the combined rate of all infections was 11.1%. Age, sex, injury location, multiple injuries, fracture presence, and type of surgery did not affect infection rate. Adherence to the antibiotic protocol was associated with a reduction in infection risk (odds ratio = 0.39, 95% confidence interval 0.19-0.83, P = 0.01). Receipt of additional antibiotics outside of our single-dose protocol did not predict further reduction in rate of infection (P = 0.64). Conclusions: A standardized protocol of single-dose IV antibiotic appears effective in minimizing infection after low-energy GSW to the extremities. Level of Evidence: Therapeutic Level II.

Minimizing Nonessential Follow-up for Hip Fracture Patients.

INTRODUCTION: Hip fractures pose a significant burden to patients and care providers. The optimal protocol for postoperative care across all surgically treated hip fracture patients is unknown. The purpose of this study was to investigate the effect that routine follow-up had on changing the clinical course. METHODS: This was a retrospective review of all low-energy hip fractures (ie, femoral neck fractures, pertrochanteric hip fractures, and subtrochanteric fractures) treated surgically from January 2018 through December 2019. Charts were reviewed for demographic information; the procedure performed; the number of postoperative follow-up visits each patient had with the orthopaedic surgery team; the number of sets of postoperative radiographic images obtained; and postoperative complications. RESULTS: Eight hundred eleven patients with 835 hip fractures were included in the study. The overall number of patient visits was 1,788, and the number of radiograph sets was 1,537. The median number of follow-up visits was two visits/fracture (interquartile range: 1 to 3 visits, maximum = 9 visits), with the median follow-up length of 54 days (interquartile range: 33 to 97 days) with the treating orthopaedic surgeons. Sixty-two (7.6%) patients had 81 (4.5%) postoperative visits and 26 (1.7%) sets of images that led to treatment changes. Among them, 48 (77.4%) patients had concerns that were initiated by the patients and/or care provider. Fourteen standard patient visits led to treatment changes that were not initiated as concerns by the patient and/or care provider. DISCUSSION: Most clinic visits and radiographs did not lead to a change in the care plan. We recommend that emphasis be placed on comprehensive orthogeriatric care of these patients, and we believe that these data provide the impetus to work toward improving the care pathways for elderly patients with hip fractures.

Gunshot Fractures of the Forearm: A Multicenter Evaluation.

OBJECTIVES: To evaluate a large series of open fractures of the forearm after gunshot wounds (GSWs) to determine complication rates and factors that may lead to infection, nonunion, or compartment syndrome. DESIGN: Multicenter retrospective review. SETTING: Nine Level 1 Trauma Centers. PATIENTS/PARTICIPANTS: One hundred sixty-eight patients had 198 radius and ulna fractures due to firearm injuries. All patients were adults, had a fracture due to a firearm injury, and at least 1-year clinical follow-up or follow-up until union. The average follow-up was 831 days. INTERVENTION: Most patients (91%) received antibiotics. Formal irrigation and debridement in the operating room was performed in 75% of cases along with either internal fixation (75%), external fixation (6%), or I&D without fixation (19%). MAIN OUTCOME MEASURES: Complications including neurovascular injuries, compartment syndrome, infection, and nonunion. RESULTS: Twenty-one percent of patients had arterial injuries, and 40% had nerve injuries. Nine patients (5%) developed compartment syndrome. Seventeen patients (10%) developed infections, all in comminuted or segmental fractures. Antibiotics were not associated with a decreased risk of infection. Infections in the ulna were more common in fractures with retained bullet fragments and bone loss. Twenty patients (12%) developed a nonunion. Nonunions were associated with high velocity firearms and bone defect size. CONCLUSIONS: Open fractures of the forearm from GSWs are serious injuries that carry high rates of nonunion and infection. Fractures with significant bone defects are at an increased risk of nonunion and should be treated with stable fixation and proper soft-tissue handling. Ulna fractures are at a particularly high risk for deep infection and septic nonunion and should be treated aggressively. Forearm fractures from GSWs should be followed until union to identify long-term complications. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Implementation of a Multidisciplinary "Code Hip" Protocol is Associated with Decreased Time to Surgery and Improved Patient Outcomes.

BACKGROUND: The purpose of this study is to report outcomes data based on the implementation of a "Code Hip" protocol, a multidisciplinary approach to the care of fragility hip fracture patients focussing on medical optimization and early operative intervention. We hypothesized that implementation of this protocol would decrease time from presentation to surgical intervention and improve outcomes based on short term post-operative data. METHODS: A retrospective chart review was performed on all patients aged greater than 65 years old with a fragility hip fracture from October 2015 through June 2018. In addition to demographic and patient factors, we recorded time to surgery, type of surgical interventions performed, ability to ambulate in the post-operative period, 90-day post-operative complications and overall hospital cost. RESULTS: There were 114 patients in the pre-Code Hip cohort and 132 patients in the post-Code Hip cohort. Demographic factors were not different between the 2 cohorts. Time from presentation to surgery in the post-Code Hip cohort was shorter at 23.1 ± 16.4 hours versus 33.2 ± 27.2 hours (p < 0.001). 30.3% of patients in the post-Code Hip cohort had at least one post-operative complication compared to 42.1% in the pre-Code Hip cohort (RR = 0.72, CI = 0.51 -1.01, p = 0.05). The post-Code Hip cohort had a significantly lower rate of hospital readmission (p = 0.04), unplanned reoperation (p = 0.02), surgical site infection (p = 0.03), and sepsis (p = 0.05). Total hospital cost per patient decreased from an average of $14,079 +/- $10,305 pre-Code Hip cohort to $11,744 +/- $4,174 per patient in the post-Code Hip cohort (p = 0.02). CONCLUSIONS: Implementation of our Code Hip protocol, which invokes a multidisciplinary approach to the elderly patient with a fragility hip fracture, is associated with shorter times from presentation to surgery, increased ability to ambulate post-operatively, decreased short term post-operative complication, and decreased hospital costs. LEVEL OF EVIDENCE: Therapeutic Level III.

Costs of Care for Low-Energy Extremity Gunshot Injuries are Reduced With Standardized Treatment.

OBJECTIVES: (1) To determine the overall treatment costs associated with isolated low-energy gunshot wounds (GSWs) to the extremity and (2) to estimate cost savings associated with a single-dose IV antibiotic strategy administered in the emergency room for patients with simple GSWs. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Patients (N = 380) with extremity-only GSW injuries from 2010 to 2015 were retrospectively reviewed. Treatment was recorded including type and duration of antibiotics, admission, and surgical intervention. MAIN OUTCOME MEASURES: Costs were calculated including facility services in the operating room and hospital. RESULTS: There were 460 GSWs in 380 patients with a mean age of 30 years old. There were 309 admissions, 273 operations performed, and 1010 days of antibiotics prescribed. The total inpatient facility cost to treat all patients was $1,701,154. Among 179 patients who could be treated by the single-dose antibiotic care pathway for simple GSWs, 132 patients (73%) received additional treatment with 108 hospital admissions, 26 debridement surgeries, and 322 days of additional oral and/or IV antibiotics. The single-dose antibiotic care pathway would have saved an average of $1436 per patient with simple GSWs in actual facility expenses. CONCLUSIONS: The overall cost associated with isolated low-energy GSWs to the extremity is high. Limiting antibiotics to a single IV dose in the emergency room can reduce treatment expenses substantially for patients with simple GSWs. LEVEL OF EVIDENCE: Economic Level IV. See instructions for authors for a complete description of levels of evidence.

Walking Greater Than 5 Feet After Hip Fracture Surgery Is Associated With Fewer Complications, Including Death.

INTRODUCTION: Hip fractures in the elderly are associated with notable morbidity. The influence of postoperative ambulation on outcomes is not well described. We hypothesized that patients who mobilize faster after surgical intervention would demonstrate fewer postoperative complications. METHODS: A retrospective review was performed on patients with hip fractures from October 2015 through September 2017. All ambulatory patients at least 65 years old (y/o), with a low-energy mechanism of injury, and who underwent surgical treatment were included. Physical therapy notes were used to track postoperative ambulation, and medical records were reviewed for 90-day postoperative complications. RESULTS: One hundred sixty-three patients were included (64 femoral neck, 88 intertrochanteric, and 11 subtrochanteric fractures). Eighty patients had postoperative complication(s). Walking >5 feet by 72 hours postoperatively was associated with decreased morbidity (complication rate: 31% versus 77% (≤5 feet ambulation), P < 0.001). Walking >5 feet by 72 hours postoperatively decreased the likelihood of myocardial infarction (P = 0.003), pneumonia (P = 0.021), intensive care unit admission (P < 0.001), and death or hospice transfer (P < 0.001). DISCUSSION: Ambulating >5 feet within 72 hours postoperatively is associated with a lower postoperative complication rate. To our knowledge, this study is the first to quantify the relationship between postoperative hip fracture mobilization and morbidity and mortality. LEVEL OF EVIDENCE: Prognostic, Level III.

Impact of the Fascia Iliaca Block on Pain, Opioid Consumption, and Ambulation for Patients With Hip Fractures: A Prospective, Randomized Study.

OBJECTIVES: To determine the effect of the fascia iliaca block (FIB) on patients undergoing surgery for hip fractures. DESIGN: Prospective, randomized controlled trial. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Patients (N = 97) undergoing surgery for hip fractures were prospectively randomized to receive either a perioperative FIB (FIB group) or no block (control group) from February 2018 to April 2019. MAIN OUTCOME MEASURES: Visual analog scale (VAS) score, morphine milligram equivalents, and postoperative ambulatory distance. RESULTS: Fifty-seven patients were randomized to the FIB group, and 40 patients were randomized to the control group. Eighteen patients crossed over from the FIB to the control group, and 12 patients crossed over from the control to the FIB group. In the intent-to-treat analysis, demographic data, mechanism of injury, radiographic fracture classification, and surgical procedure were similar between the 2 groups. The FIB group consumed fewer morphine milligram equivalents before surgery (13 vs. 17, P = 0.04), had a trend toward an improved visual analog scale score on postoperative day 2 (0 vs. 2 P = 0.06), and walked a farther distance on postoperative day 2 (25' vs. 2', P = 0.09). A greater proportion of the FIB group were discharged home (50.9% vs. 32.5%, P = 0.05). There were no differences in opioid-related, block-related, or medical complications between groups. In the as-treated and per-protocol analyses, there were no significant differences. CONCLUSIONS: A single perioperative FIB for patients with hip fractures undergoing surgery may decrease opioid consumption and increase the likelihood that a patient is discharged home. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Six-Week Interval Between Preoperative Radiation and Surgery Is Associated With Fewer Major Wound Complications in Soft Tissue Sarcoma.

OBJECTIVES: A total of 30% to 40% of soft tissue sarcoma (STS) patients develop major wound complications (MWCs) after preoperative radiation (preRT). The optimal preRT-surgery interval and its association with MWCs is unknown. This study investigated whether a longer preRT-surgery interval is associated with fewer MWCs compared with historical controls. METHODS: All patients treated by a single surgeon after preRT with limb-sparing wide resection for extremity and trunk STS were retrospectively reviewed from 2004 to 2014. The primary outcome was MWCs defined as a secondary operation, invasive procedure, wound packing, or readmission for wound care. Secondary outcomes of local recurrence and survival were followed and independent variables were analyzed for an association with MWCs. RESULTS: Fifty-four patients were included with a median follow-up of 32 months and age of 61 years. The majority of tumors were deep (91%), large (median size of 11 cm), high grade (78%) and within the lower extremity (78%). The median preRT-surgery interval was 43 days and 80% of patients received surgery 35 to 49 days after radiation. MWCs were observed in 15% of patients and 88% occurred within 40 days. Predictors for MWCs on multivariate analysis were peripheral vascular disease (P=0.03), location in the medial compartment of the thigh (P=0.03), and neurovascular involvement (P=0.03). CONCLUSIONS: This study presents a cohort of STS patients with an extended preRT-surgery interval of ~6 weeks. MWCs in this population occurred at a lower rate than historical controls. Overall these findings support the exploration of a longer interval to reduce MWCs and their associated morbidity.

Alleviation of Pain After Femur and Tibia Shaft Fractures Using Nothing Stronger Than Codeine and Tramadol.

OBJECTIVE: To determine whether using nothing stronger than codeine and tramadol provides adequate pain alleviation in people recovering from fixation of a fracture of the femur or tibia shaft. DESIGN: Retrospective case series. SETTING: Level 1 trauma center in the United States. PATIENTS: All adult patients from October 2016 to October 2018 with femur (OTA/AO 32) and tibial (OTA/AO 42) shaft fractures who were treated surgically were included. A nurse counseled patients on safe and effective alleviation of pain. Charts were reviewed for pain medication prescribed, noting utilization of schedule II opioid medications. MAIN OUTCOME MEASURES: Frequency of schedule II pain medication prescription on discharge or during follow-up, emergency department presentation for pain, or readmission for pain. RESULTS: One hundred fifty patients with 162 fractures were treated for femoral (N = 73 fractures) or tibial (N = 89 fractures) shaft fractures. Sixty patients (40%) were multiple injured patients. Thirteen (8.7%) patients were discharged with hydrocodone, oxycodone, or fentanyl. Of the remaining patients with adequate follow-up (N = 109), 6.4% requested hydrocodone, oxycodone, or fentanyl after discharge. There was 1 patient presentation to the emergency department for pain, and there were no pain-related readmissions. CONCLUSIONS: Alleviation of pain can be achieved in most patients with femoral and tibial shaft fractures, including multiply injured patients, with one-on-one patient support and by using nothing stronger than codeine and tramadol. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reducing the "Irreducible" Total Hip Arthroplasty Dislocation with a Fracture Table: A Case Report.

CASE: Reduction of dislocated total hip arthroplasty components is a challenging clinical scenario. Although component revision is recommended as a definitive treatment for those with recurrent instability, immediate reduction is required after an acute dislocation. We describe the case of a dislocated total hip arthroplasty and present a novel method for obtaining reduction after other closed techniques had failed. CONCLUSIONS: Based on this case, utilization of a fracture table to generate adequate axial traction can aid orthopedic surgeons in obtaining reduction of a challenging dislocated hip prosthesis.

Abstracts Accepted for Presentation at Orthopaedic Trauma or Arthroplasty Conferences: Which Conference Is the Best Indicator of Future Publication?

Time and financial resources pose limitations to orthopaedic surgeons wishing to advance their orthopaedic knowledge, and surgeons frequently must choose one meeting to attend. We sought to determine whether abstracts presented at the American Academy of Orthopaedic Surgeons (AAOS) annual meeting or the trauma (Orthopaedic Trauma Association [OTA]) or arthroplasty (American Association of Hip and Knee Surgeons [AAHKS]) subspecialty meetings, respectively, were higher yield with respect to material ultimately being published. We hypothesized that papers accepted by AAOS would demonstrate higher conversion to publication compared with OTA and AAHKS but expected abstract publication rates from OTA and AAHKS to be similar. METHODS: All clinical and preclinical abstracts from the trauma and total joint arthroplasty subspecialties presented at the AAOS, OTA, and AAHKS annual meetings in 2015 were evaluated. Data collected included the current status of the publication, journal and publication date, time to publication, and country of origin (United States or international). RESULTS: There were 516 (N = 213, AAOS; N = 303, OTA) trauma and 711 (N = 470, AAOS; N = 241 AAHKS) arthroplasty poster and podium presentations. When comparing publication rates in trauma, no significant difference was observed in overall publication rates between AAOS and OTA at 57.2% (N = 122 published) and 60.4% (N = 183 published), respectively (P = 0.54). In addition, no significant difference was observed in overall publication rates in arthroplasty between AAOS and AAHKS, with publication rates of 65.3% (N = 307 published) and 59.8% (N = 144 published), respectively (P = 0.17). Of abstracts that were published, AAHKS arthroplasty abstracts were more likely to be published in The Journal of Arthroplasty (JOA, 69.4%) compared with OTA trauma abstracts published in the Journal of Orthopaedic Trauma (JOT, 33.3%), P < 0.001. CONCLUSION: The overall publication rates, along with publication rates to premiere subspecialty journals, is indicative of forefront research being presented at the three annual meetings. Given the comparable research quality of OTA and AAHKS abstracts, the AAOS meeting appears to provide the highest yield for surgeons with more generalized practices or practices spanning multiple subspecialties.

Chronic Systemic Metal Ion Toxicity from Wear on a Revised Cobalt-chromium Trunnion.

INTRODUCTION: Metal toxicity secondary to corrosion and wear has been reviewed in the arthroplasty literature with evidence supporting dermatologic, neurologic, and cardiac involvement. This is the first report of a novel case with the occurrence of systemic pathology with only mildly elevated serum cobalt (Co) and chromium (Cr) levels due to trunnion wear in a metal-on-polyethylene articulation. CASE REPORT: A 45-year-old female who had undergone a revision total hip arthroplasty developed concerning dermatologic, neurologic, and cardiac symptoms. Symptoms were initially attributed to an unknown autoimmune etiology. She had mildly elevated cobalt and chromium levels and subsequently underwent a second revision, this time with complete exchange of the cobalt/chromium components. By her 2-month follow-up, she reported partial resolution of symptoms. She continues to improve more than a year postoperatively. CONCLUSION: Consideration should be given to metal ion toxicity due to trunnion wear in patients with cobalt/chromium femoral components, even with relatively low ion levels.

Diabetic Control Predicts Surgical Site Infection Risk in Orthopaedic Trauma Patients.

OBJECTIVES: (1) To determine the incidence of surgical site infections (SSIs) in diabetic orthopaedic trauma patients and (2) to establish a protocol for managing diabetes mellitus (DM) in orthopaedic trauma patients. DESIGN: Retrospective cohort study. SETTING: Level 1 Trauma Center. PATIENTS: All diabetic orthopaedic trauma patients who underwent surgical intervention with at least 1 month follow-up. Patients were classified as poorly controlled or controlled diabetic patients based on admission hemoglobin A1c and blood glucose (BG) levels. INTERVENTIONS: Orthopaedic surgical intervention in accordance with fracture type and a standardized diabetes management protocol with internal medicine comanagement. MAIN OUTCOME MEASUREMENT: SSI incidence. RESULTS: There were 260 patients during the study period. Two hundred two (77.7%) were included in the final analysis. Seventy-five (37.1%) patients met the criteria for poorly controlled DM. The overall rate of SSI was 20.8%; 32.0% for poorly controlled diabetic patients, and 14.2% for controlled diabetic patients (P < 0.01). The admission blood glucose level (BG, P = 0.05), but not discharge BG, was associated with SSI incidence. CONCLUSIONS: Trauma patients with poorly controlled DM have a higher rate of SSIs than patients with controlled DM. Perioperative diabetes control does not seem to decrease infection rates in these patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Activity-related Changes in Cobalt Levels in a Total Hip with a Modular Femoral Stem: A Case Report.

INTRODUCTION: Femoral neck modularity in total hip arthroplasty (THA) affords the surgeon the ability to optimize femoral neck length, offset, and version, thereby theoretically improving restoration of patient anatomy and biomechanics. The effect of activity on serum metal ion levels in patients with a THA with a mixed-metal modular neck design has not yet been described. CASE REPORT: A 63-year-old male underwent THA utilizing a femoral stem with a mixed-metal modular femoral neck. After the stem was voluntarily recalled, he was indicated to be monitored for manifestations ofmodular junction corrosion and development of adverse local tissue reactions (ALTR). An association between activity levels and serial serum cobalt levels was demonstrated. CONCLUSION: In this patient with a THA incorporating a mixed-metal modular femoral neck, modification of activity intensity may have played a role in altered corrosion generation, as indicated by serum metal ion levels. In turn, this may play a role in the progression of ALTR.

Are Radiographic and Direct Measures of Acetabular Polyethylene Wear Comparable?

BACKGROUND: All polyethylene acetabular liners wear over time, and numerous methods for calculating linear wear rates exist. The objective of this study was to compare 2-dimensional wear rates between direct, micrometer measurements and the computerized, edge-detection method using Hip Analysis Suite (HAS) 8.0.4.3. METHODS: Two groups of retrieved acetabular liners from Harris-Galante Prosthesis I and Harris-Galante Prosthesis II implants in situ for more than 10 years were evaluated. Group 1 (n = 18) contained liners with both early postoperative (<6 months) and prerevision radiographs taken within 1 month of explantation. Group 2 (n = 55) included liners with only prerevision X-rays (ie, 1 radiograph for wear assessment). Average and maximum direct linear wear was calculated from thicknesses measured at 6 consistent, well-separated locations (3 in the worn and 3 in the unworn regions) using a calibrated, digital micrometer. HAS 8.0.4.3 was used to calculate 2-dimensional wear from anteroposterior pelvic radiographs. RESULTS: Aggregate wear rates calculated by HAS were higher than those calculated by the average of direct measurements for group 1 (P = .020) and group 2 (P < .001). However, comparing the maximum direct micrometer measurements to HAS showed no difference for either group 1 (P = .351) or group 2 (P = .451). Linear regression analysis showed a strong correlation between HAS and both average and maximum direct wear measures for both groups, though the coefficient for the direct maximum measurement comparisons were closer to one, indicating a better one-to-one correspondence between HAS and direct maximum wear. CONCLUSION: To our knowledge, this is the first study to compare and validate 2-dimensional wear rates in polyethylene acetabular liners between direct measurements from retrieved components and a radiographic computer-assisted technique (as opposed to comparison against a phantom component). Wear rates determined by direct measurements from retrievals were consistent with computer-assisted 2-dimensional methods when comparing maximum wear measurements. In addition, a single prerevision radiograph appears to be sufficient to assess 2-dimensional in vivo wear.

A nonsurgical protocol for management of postarthroplasty wound drainage.

Persistent wound drainage after total joint arthroplasty can potentiate periprosthetic joint infection. Although current recommendations are to treat persistent wound drainage with surgical debridement, we believe nonoperative treatment may be successful in selected patients. We performed a retrospective analysis of 25 persistently draining hip and knee arthroplasty wounds treated with a protocol consisting of a combination of surgical site aspiration, closure of open wound edges, cessation of anticoagulants, activity modification, and antibiotics (in select patients). Wound drainage ceased in 24 of 25 wounds treated with this protocol. One patient who continued to drain for 3 more days was successfully treated with surgical debridement and evacuation of hematoma. No patient developed infection. We believe this protocol can be successful in many arthroplasty patients.

Variation in treatment of low energy gunshot injuries - A survey of OTA members.

The purpose of this study was to determine current practice patterns in the treatment of low energy gunshot wounds involving bones and joints. One hundred seventy-three Orthopaedic Trauma Association (OTA) members completed a web-based survey. The survey included practices for antibiotic therapy and operative treatment for different types of low-energy gunshot injuries. Six different scenarios of soft tissue injury, intra-articular injury, and fractures were described. Several permutations of antibiotic therapy and operative or non-operative management options were given as choices on the survey. Survey responses had a high degree of heterogeneity with only two treatment options receiving more than 50% agreement among responders: 54% agreed on joint exploration with perioperative antibiotics for gunshot wounds (GSWs) traversing a joint and 55% agreed on treating operative tibial shaft fractures from GSWs with fixation, along with debridement and irrigation of the GSW tract, and perioperative antibiotics. The majority of participants (69%) were either not aware of or not sure of an established protocol for treatment of GSW to bones and joints at their institution. Moreover, there is still wide variation in treatments among 31% of the participants who reported a protocol in place at their institutions. We conclude there is wide variation among orthopaedic surgeons in the antimicrobial prophylaxis and treatment of GSWs. Opportunity exists to develop standardized practices to minimize related infections, other complications, and costs.

Perioperative Considerations When Treating Isolated Periprosthetic Distal Femur Fractures.

BACKGROUND: Periprosthetic distal femur (PPDF) fractures occur most frequently via low energy mechanisms in elderly patients. This population is often frail and ill-suited to the physiologic burden of trauma and surgery. Here, we describe the perioperative and early hospital course for patients with PPDF fractures, and identify risk factors for poor outcomes. METHODS: Consecutive patients with isolated PPDF fractures from 2005 - 2015 were treated operatively at a Level I trauma center. Perioperative records were reviewed. Complications included wound complications, cardiac complications, pneumonia, thromboembolic events, urinary tract infections (UTIs), sepsis, multiple organ failure, death, and 90-day readmissions. RESULTS: Thirty-nine patients were treated operatively for isolated PPDF fractures. Mean age was 75.1 years old, 87.2% were women, and 92.3% occurred after falls from standing. Average American Society of Anesthesiologists score was 3.0. Thirty-six patients underwent open reduction and internal fixation with a mean operative time of 108 minutes. Excluding outliers, mean LOS was 4.6 days. Patients admitted to the ICU had longer LOS (p=0.03). Complications occurred in 17.9% of patients, including cardiac events (12.8%) and (5.1%) deaths. CONCLUSIONS: Patients with PPDF fractures frequently have underlying medical comorbidities. A complicated and/or protracted hospital course is not uncommon. Further study to optimize treatment appears warranted. Level of evidence: Prognostic, level 4.