Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Hemoglobin A1c as a Predictor of Surgical Site Infection in Patients With Orthopaedic Trauma.

INTRODUCTION: Previous research involving diabetes mellitus (DM), glycemic control, and complications in orthopaedic patients has primarily focused on elective procedures. The purpose of this study was to evaluate hemoglobin A1c (A1c) as a predictor of postoperative surgical site infection (SSI) in patients with orthopaedic trauma. METHODS: Patients aged 18 years or older treated surgically for an acute fracture by a fellowship-trained orthopaedic trauma surgeon at a single academic tertiary referral center with a laboratory value for A1c available within 3 months of their surgery were identified retrospectively. Postoperative SSI was defined according to 'Fracture related infection: A consensus on definition from an international expert group,' by Metsemakers et al. RESULTS: A total of 925 patients met criteria for analysis. A receiver operating characteristic curve was calculated using A1c as a predictor for signs suggestive and confirmatory of SSI and demonstrated an area under the curve of 0.535 and 0.539, respectively. No significant difference was found in the rate of signs suggestive or confirmatory of SSI in patients with normal A1c levels (<6.5) compared with patients with A1c levels consistent with a diagnosis of DM (>6.5), P-value = 0.199 and P-value = 0.297, respectively. No significant difference was found in the rate of signs suggestive or confirmatory of SSI in patients with completely uncontrolled DM (A1c > 10) compared with patients with A1c levels <10, P-value 0.528 and P-value = 0.552, respectively. CONCLUSION: Existing literature has demonstrated an association with postoperative infection in orthopaedic patients who have elevated A1c values. In this cohort of patients with orthopaedic trauma, hemoglobin A1c was not a valuable tool to predict postoperative SSI. Given these findings, routine A1c monitoring is not a reliable predictor of SSI criteria in patients with orthopaedic trauma based on the current consensus definition of SSI in fracture surgery.

Pragmatic design and inclusion of patient-partner representatives improves participant experience in clinical research.

Objectives: Patient engagement in the design and implementation of clinical trials is necessary to ensure that the research is relevant and responsive to patients. The PREP-IT trials, which include 2 pragmatic trials that evaluate different surgical preparation solutions in orthopaedic trauma patients, followed the patient-centered outcomes research (PCOR) methodology throughout the design, implementation, and conduct. We conducted a substudy within the PREP-IT trials to explore participants' experiences with trial participation. Methods: At the final follow-up visit (12 months after their fracture), patients participating in the PREP-IT trials were invited to participate in the substudy. After providing informed consent, participants completed a questionnaire that asked about their experience and satisfaction with participating in the PREP-IT trials. Descriptive statistics are used to report the findings. Results: Four hundred two participants participated in the substudy. Most participants (394 [98%]) reported a positive experience, and 376 (94%) participants felt their contributions were appreciated. The primary reasons for participation were helping future patients with fracture (279 [69%]) and to contribute to science (223 [56%]). Two hundred seventeen (46%) participants indicated that their decision to participate was influenced by the minimal time commitment. Conclusions: Most participants reported a positive experience with participating in the PREP-IT trials. Altruism was the largest motivator for participating in this research. Approximately half of the participants indicated that the pragmatic, low-participant burden design of the trial influenced their decision to participate. Meaningful patient engagement, a pragmatic, and low-burden protocol led to high levels of participant satisfaction.

Use of Computed Tomography Angiography to Predict Complications in Tibia Fractures: A Multicenter Retrospective Analysis.

OBJECTIVES: To assess the ability of computed tomography angiography identified infrapopliteal vascular injury to predict complications in tibia fractures that do not require vascular surgical intervention. DESIGN: Multicenter retrospective review. SETTING: Six Level I trauma centers. PATIENTS AND INTERVENTION: Two hundred seventy-four patients with tibia fractures (OTA/AO 42 or 43) who underwent computed tomography angiography maintained a clinically perfused foot not requiring vascular surgical intervention and were treated with an intramedullary nail. Patients were grouped by the number of vessels below the trifurcation that were injured. MAIN OUTCOME MEASUREMENTS: Rates of superficial and deep infection, amputation, unplanned reoperation to promote bone healing (nonunion), and any unplanned reoperation. RESULTS: There were 142 fractures in the control (no-injury) group, 87 in the one-vessel injury group, and 45 in the two-vessel injury group. Average follow-up was 2 years. Significantly higher rates of nerve injury and flap coverage after wound breakdown were observed in the two-vessel injury group. The two-vessel injury group had higher rates of deep infection (35.6% vs. 16.9%, P = 0.030) and unplanned reoperation to promote bone healing (44.4% vs. 23.9%, P = 0.019) compared with controls, as well as increased rates of any unplanned reoperation compared with control and one-vessel injury groups (71.1% vs. 39.4% and 51.7%, P < 0.001), respectively. There were no significant differences in rates of superficial infection or amputation. CONCLUSIONS: Tibia fractures with two-vessel injuries were associated with higher rates of deep infection and unplanned reoperation to promote bone healing compared with those without vascular injury, as well as increased rates of any unplanned reoperation compared with controls and fractures with one-vessel injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Local administration of vancomycin powder in orthopaedic fracture surgery: current practice and trends.

Objectives: Surgical site infections in orthopaedic trauma are a significant problem with meaningful patient and health care system-level consequences. Direct application of antibiotics to the surgical field has many potential benefits in reducing surgical site infections. However, to date, the data regarding the local administration of antibiotics have been mixed. This study reports on the variability of prophylactic vancomycin powder use in orthopaedic trauma cases across 28 centers. Methods: Intrawound topical antibiotic powder use was prospectively collected within three multicenter fracture fixation trials. Fracture location, Gustilo classification, recruiting center, and surgeon information were collected. Differences in practice patterns across recruiting center and injury characteristics were tested using chi-square statistic and logistic regression. Additional stratified analyses by recruiting center and individual surgeon were performed. Results: A total of 4941 fractures were treated, and vancomycin powder was used in 1547 patients (31%) overall. Local administration of vancomycin powder was more frequent in open fractures 38.8% (738/1901) compared with closed fractures 26.6% (809/3040) (P < 0.001). However, the severity of the open fracture type did not affect the rate at which vancomycin powder was used (P = 0.11). Vancomycin powder use varied substantially across the clinical sites (P < 0.001). At the surgeon level, 75.0% used vancomycin powder in less than one-quarter of their cases. Conclusions: Prophylactic intrawound vancomycin powder remains controversial with varied support throughout the literature. This study demonstrates wide variability in its use across institutions, fracture types, and surgeons. This study highlights the opportunity for increased practice standardization for infection prophylaxis interventions. Level of Evidence: Prognostic-III.

Risk Factors for Early Conversion Total Hip Arthroplasty After Pipkin IV Femoral Head Fracture.

OBJECTIVES: To determine risk factors for early conversion total hip arthroplasty (THA) in Pipkin IV femoral head fractures. DESIGN: Retrospective cohort. SETTING: Two level I trauma centers. PATIENTS AND INTERVENTION: One hundred thirty-seven patients with Pipkin IV fractures meeting inclusion criteria with 1 year minimum follow-up managed from 2009 to 2019. MAIN OUTCOME MEASUREMENT: Patients were separated into groups by the Orthopaedic Trauma Association/AO Foundation (OTA/AO) classification of femoral head fracture: 31C1 (split-type fractures) and 31C2 (depression-type fractures). Multivariable regression was performed after univariate analysis comparing patients requiring conversion THA with those who did not. RESULTS: We identified 65 split-type fractures, 19 (29%) underwent conversion THA within 1 year. Surgical site infection ( P = 0.002), postoperative hip dislocation ( P < 0.0001), and older age ( P = 0.049) resulted in increased rates of conversion THA. However, multivariable analysis did not identify independent risk factors for conversion. There were 72 depression-type fractures, 20 (27.8%) underwent conversion THA within 1 year. Independent risk factors were increased age ( P = 0.01) and posterior femoral head fracture location ( P < 0.01), while infrafoveal femoral head fracture location ( P = 0.03) was protective against conversion THA. CONCLUSION: Pipkin IV fractures managed operatively have high overall risk of conversion THA within 1 year (28.5%). Risk factors for conversion THA vary according to fracture subtype. Hip joint survival of fractures subclassified OTA/AO 31C1 likely depends on patient age and postoperative outcomes such as surgical site infection and redislocation. Pipkin IV fractures subclassified to OTA/AO 31C2 type with suprafoveal and posterior head impaction and older age should be counseled of high conversion risk with consideration for alternative management options. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bicondylar tibial plateau fracture dislocations with an intact anterolateral cortical rim: A surgical technique.

A displaced medial tibial plateau fracture with central and lateral impaction, but an intact anterolateral cortical rim, is an uncommon variant of bicondylar tibial plateau fracture that presents a number of challenges. Without a lateral metaphyseal fracture line to work through, it is challenging to address central and lateral impaction. Previously published techniques for addressing this fracture pattern describe an intra-articular osteotomy of the lateral plateau to aid visualization and reduction, or use a posterolateral approach to the proximal tibia with or without an osteotomy of the proximal fibula. This study presents a technique which utilizes standard dual incision approaches and does not involve an intra-articular osteotomy of the lateral tibial plateau or a posterolateral approach. A case series was conducted evaluating radiographic and functional outcomes of 8 patients.

The Prevalence of Metabolic and Endocrine Disturbances on Fracture Nonunion.

OBJECTIVE: This study aims to determine the prevalence of metabolic disturbance in all fracture nonunion cases and identify the most common endocrine abnormalities seen using a simple screening algorithm. METHODS: A retrospective review study was performed evaluating patients who underwent operative intervention for nonunion from January 2010 to December 2018 at 2 level-1 trauma centers. Preoperative laboratory values were recorded for a 9-test "nonunion panel." A metabolic or endocrine abnormality, specifically an abnormality in the thyroid or parathyroid axis, was evaluated. RESULTS: 42% of patients had an undiagnosed metabolic laboratory abnormality. When multiple tests were used, the rate of metabolic dysfunction was between 60% and 75%, depending on the definition of vitamin D insufficiency vs deficiency used. CONCLUSION: Results indicate a relatively high prevalence of metabolic disturbance in patients with nonunion and suggest metabolic screening for all nonunion patients not only those without a mechanical or infectious cause. LEVEL OF EVIDENCE: IV, retrospective case series.

Tibial Shaft and Pilon Fractures With Associated Syndesmotic Injury: A Matched Cohort Assessment.

OBJECTIVE: To determine the outcomes of pilon and tibial shaft fractures with syndesmotic injuries compared with similar fractures without syndesmotic injury. DESIGN: Retrospective case-control study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: All patients over a 5-year period (2012-2017) with tibial shaft or pilon fractures with a concomitant syndesmotic injury and a control group without a syndesmotic injury matched for age, OTA/AO fracture classification, and Gustilo-Anderson open fracture classification. INTERVENTION: Preoperative or intraoperative diagnosis of syndesmotic injury with reduction and fixation of both fracture and syndesmosis. MAIN OUTCOME MEASUREMENT: Rates of deep infection, nonunion, unplanned reoperation, and amputation in patients with a combined syndesmotic injury and tibial shaft or pilon fracture versus those without a syndesmotic injury. RESULTS: A total of 30 patients, including 15 tibial shaft and 15 pilon fractures, were found to have associated syndesmotic injuries. The matched control group comprised 60 patients. The incidence of syndesmotic injury in all tibial shaft fractures was 2.3% and in all pilon fractures was 3.4%. The syndesmotic injury group had more neurologic injuries (23.3% vs. 8.3% P = 0.02), more vascular injuries not requiring repair (30% vs. 15%, P = 0.13), and a higher rate compartment syndrome (6.7% vs. 0%, P = 0.063). Segmental fibula fracture was significantly more common in patients with a syndesmotic injury (36.7% vs. 13.3%, P = 0.04). Fifty percent of the syndesmotic injury group underwent an unplanned reoperation with significantly more unplanned reoperations (50% vs. 27.5%, P = 0.04). The syndesmotic group had a significantly higher deep infection rate (26.7% vs. 8.3% P = 0.047) and higher rate of amputation (26.7% vs. 3.3% P = 0.002) while the nonunion rate was similar (17.4% vs. 16.7% P = 0.85). CONCLUSIONS: Although syndesmotic injuries with tibial shaft or pilon fractures are rare, they are a marker of a potentially limb-threatening injury. Limbs with this combined injury are at increased risk of deep infection, unplanned reoperation, and amputation. The presence of a segmental fibula fracture should raise clinical suspicion to evaluate for syndesmotic injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Complications of Morbid Obesity in the Treatment of Acetabular Fractures: Re-evaluating Outcomes a Decade Later.

OBJECTIVES: To determine the rate of perioperative complications between morbidly obese (body mass index greater than 40 kg/m2) and nonmorbidly obese patients undergoing operative treatment of acetabular fractures across 2 periods (2000-2005 and 2012-2019). DESIGN: Retrospective, case-control study. SETTING: Level I academic trauma center. PATIENTS: Four hundred thirty-five consecutive patients from 2000 to 2005 and 216 consecutive patients from 2012 to 2019 with acetabular fractures treated by a single surgeon. INTERVENTION: Operative fixation of acetabular fracture. MAIN OUTCOME MEASUREMENTS: Outcome variables include positioning time, operative time, estimated blood loss, hospital stay, wound complications, and perioperative complications. RESULTS: Twenty-eight morbidly obese and 188 nonmorbidly obese patients from 2012 to 2019, as well as 41 morbidly obese patients and 394 nonmorbidly obese patients from 2000 to 2005 were included in the study. The relative risk (RR) of wound complications between 2012 and 2019 groups was significantly higher for morbidly obese patients (RR = 5.31, P = 0.009) but has decreased significantly for morbidly obese patients between 2000-2005 and 2012-2019 (RR = 0.31, P = 0.017). The rate of total perioperative complications was similar between morbidly obese and nonmorbidly obese groups from 2012 to 2019 (21% vs. 8%, P = 0.230). For morbidly obese patients, the rate of total perioperative complications decreased significantly between 2000-2005 and 2012-2019 (63% vs. 21% P = 0.010). CONCLUSION: Acetabular fracture surgery can be safely performed in morbidly obese patients. Although obesity remains a significant risk factor for wound complications, the risk for morbidly obese patients has decreased significantly since our initial investigation because of adaptations to surgical techniques and surgeon's experience. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Geriatric Acetabular Fractures and Femoral Head Protrusio: Methods of Fixation and the Option of Total Hip Arthroplasty.

SUMMARY: Currently, the literature is unclear regarding the optimal treatment algorithm for geriatric acetabular fractures. In a recent epidemiological study, 70% of all acetabular fractures in patients older than 65 years were classified as either associated both column or anterior column/posterior hemitransverse. Within the subset of these fractures, variants with significant femoral head protrusio, which is defined as the displacement of the femoral head medial to the ilioischial line, present with unique challenges. Goals of treatment in these cases should include surgical techniques that minimize the physiologic insult for the patient yet restore hip congruity and stability. "Fix and replace" is becoming an increasingly popular approach in the acute setting; however, its indications are not yet well-established. At our institution, we often favor open reduction and internal fixation alone as an effective and efficient way to treat the protrusio variant, even at the expense of protected weight-bearing. In the following article, we present a systematic approach for the management of geriatric acetabular fracture femoral head protrusio along with specific case examples.

Is Obesity Associated With an Increased Risk of Complications After Surgical Management of Acetabulum and Pelvis Fractures? A Systematic Review.

BACKGROUND: When considering surgical fixation of acetabulum and pelvis fractures in patients with obesity, a thorough understanding of the risks of potential complications is important. We performed a systematic review to evaluate whether obesity is associated with an increased risk of complications after surgical management of acetabulum and pelvis fractures. METHODS: We searched PubMed/MEDLINE, EMBASE, and the Cochrane Library for studies published through December 2020 that reported the effect of increased body mass index (BMI) or obesity on the risk of complications after surgical treatment of acetabulum and pelvis fractures. RESULTS: Fifteen studies were included. Eight of the 11 studies that included infection or wound complication as end points found that increased BMI or some degree of obesity was a significant risk factor for these complications. Two studies found that obesity was significantly associated with loss of reduction. Other complications that were assessed in a few studies each included venous thromboembolism, nerve palsy, heterotopic ossification, general systemic complications, and revision surgery, but obesity was not clearly associated with those outcomes. CONCLUSIONS: Obesity (or elevated BMI) was associated with an increased risk of complications-infection being the most commonly reported-after surgical management of acetabulum and pelvis fractures, which suggests the need for increased perioperative vigilance.

Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications?

BACKGROUND: Gunshot injuries of the extremities are common in the United States, especially among people with nonfatal gunshot wounds. Controversy persists regarding the proper management for low-energy gunshot-induced fractures, likely stemming from varying reports on the likelihood of complications. There has yet to be published a study on a large cohort of patients with gunshot-induced tibia fractures on which to base our understanding of complications after this injury. QUESTIONS/PURPOSES: (1) What percentage of patients with low-energy gunshot-induced tibia fractures developed complications? (2) Was there an association between deep infection and fracture location, injury characteristics, debridement practices, or antibiotic use? METHODS: This was a multicenter retrospective study. Between January 2009 and December 2018, we saw 201 patients aged 16 years or older with a gunshot-induced fracture who underwent operative treatment; 2% (4 of 201) of those screened had inadequate clinical records, and 38% (76 of 201) of those screened had inadequate follow-up for inclusion. In all, 121 patients with more than 90 days of follow-up were included in the study. Nonunion was defined as a painful fracture with inadequate healing (fewer than three cortices of bridging bone) at 6 months after injury, resulting in revision surgery to achieve union. Deep infection was defined according to the confirmatory criteria of the Fracture-Related Infection Consensus Group. These results were assessed by a fellowship-trained orthopaedic trauma surgeon involved with the study. Complication proportions were tabulated. A Kaplan-Meier chart demonstrated presentations of deep infection by fracture location (proximal, shaft, or distal). Univariate statistics and multivariate Cox regression were used to examine the association between deep infection and fracture location, entry wound size, vascular injury, intravenous (IV) antibiotics in the emergency department (ED), deep and superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics, while adjusting for age, race/ethnicity, smoking status, and BMI. A power analysis for the result of deep infection demonstrated that we would have had to observe a hazard ratio of 4.28 or greater for shaft versus proximal locations to detect statistically significant results at 80% power and alpha = 0.05. RESULTS: The overall complication proportion was 49% (59 of 121), with proportions of 14% (17 of 121) for infection, 27% (33 of 121) for wound complications, 20% (24 of 121) for nonunion, 9% (11 of 121) for hardware breakage, and 26% (31 of 121) for revision surgery. A positive association was present between deep infection and deep debridement (HR 5.51 [95% confidence interval 1.12 to 27.9]; p = 0.04). With the numbers available, we found no association between deep infection and fracture location, entry wound size, vascular injury, IV antibiotics in the ED, superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics. CONCLUSION: In this multicenter study, we found a higher risk of complications in operative gunshot-induced tibia fractures than prior studies have reported. Infection, in particular, was much more common than expected based on prior studies. Consequently, surgeons might consider adopting the general management principles for nongunshot-induced open tibia fractures with gunshot-induced fractures, such as the use of IV antibiotics both initially and after surgery. Further research is needed to test and validate these approaches. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Acute Femoral Nailing and Ipsilateral Knee-Spanning External Fixation: Improved Early Stability for Floating Knee Injuries Involving the Tibial Plateau.

SUMMARY: Ipsilateral femoral shaft and tibial plateau fractures, termed a "floating knee," are rare and challenging injuries. There is limited literature guiding the operative technique and the outcomes associated with these injuries. The author's preferred technique is early intramedullary of the femoral shaft fracture with knee-spanning external fixation of any length unstable plateau fractures in the same operative setting. Early fixation of the femur fracture allows for improved hemodynamic and inflammatory stability. External fixation of the tibial plateau restores length and alignment and allows for soft tissue rest until definitive fixation. The purpose of this study is to describe this operative technique and determine the infection rate and complications requiring return to the operating room in patients with femoral shaft fractures and length unstable plateau fractures.

Open Fractures: Are We Still Treating the Same Types of Infections?

Background: To analyze the rate of methicillin-resistant Staphylococcus aureus (MRSA), gram-negative, and polymicrobial infections in open fractures, measure the efficacy of the current open fracture antibiotic regimen against these infections, identify the most effective agent(s) to cover these infections, and analyze risk factors for infection. Methods: We examined retrospectively 451 patients with open fractures from January 2008 to December 2012 who were treated at our facility. Positive cultures during surgical debridement after wound closure defined an infection. Infecting organisms and their antibiotic sensitivities were identified through microbiology culture reports. Rates of MRSA, gram-negative, and polymicrobial infections were determined. The efficacy of the current regimen (cefazolin and gentamicin) was calculated against gram-positive and gram-negative organisms. Efficacy profiles against infectious organisms were calculated for all commonly tested antibiotics. Patient factors, injury characteristics, and treatment options were analyzed to determine risk factors for infection. Results: Ninety patients (20%) were identified as infected at surgical debridement. Of those 90, 21 (23.3%) were diagnosed with MRSA, 56 (62.2%) were found to have a gram-negative infection, and 46 (51.1%) had polymicrobial infections. Cephalosporins and ß-lactam agents had a 59.2% efficacy rate against gram-positive bacteria and gentamicin showed a 94% sensitivity rate against gram-negative bacteria. Vancomycin (95.8% sensitivity) demonstrated the highest sensitivity for all gram-positive organisms. Amikacin (98.8% sensitivity), meropenem (96.3% sensitivity), and gentamicin (94.2% sensitivity) demonstrated excellent efficacy for all gram-negative organisms. Immuno-compromised status and Gustilo-Anderson type were the only independently predictive risk factors for infection in a multivariable model. Conclusions: Based on this analysis, the rate of MRSA, gram-negative, and polymicrobial infections in open fractures is high and increasing compared with historical cohorts. With the sensitivity of early generation cephalosporins being relatively poor against gram-positive organisms, the present antibiotic regimen for open, long-bone fractures may need to be reconsidered with these emerging trends.

The rising use of total hip arthroplasty for femoral neck fractures in the United States.

BACKGROUND: We examined the trends in the treatment of femoral neck fractures with arthroplasty in the United States from 2004-2013. METHODS: We used the National Inpatient Sample database in conjunction with codes from the International Classification of Diseases, Ninth Revision, to identify patients receiving hemiarthroplasty (HA) or total hip arthroplasty (THA) for the treatment of closed femoral neck fracture from 2004-2013. We evaluated the trend of these 2 treatments along with demographics, comorbidities, length of stay and same admission mortality. RESULTS: Our study identified 1,059,414 patients who underwent arthroplasty for the treatment of femoral neck fracture. We found a 42% increase in the use of THA during the study period from 8.4% in 2004 to 12.9% in 2013. While the large majority of patients received HA (87.1%), there was an overall decline in the use of HA (89,132 in 2004 to 85,635 in 2013) and increase in the use of THA (8,177 in 2004 to 11,375 in 2013). Patients receiving THA were younger (mean age 74.7 THA vs. 80.4 HA, p < 0.001) with fewer comorbidities, higher likelihood of discharge to home (24% THA vs. 10% HA, p < 0.001) and lower inpatient mortality rates (1.5 % THA vs. 2.4 % HA, p < 0.001) in comparison to HA. CONCLUSION: There has been a significant increase in the use of THA over the last decade. Patients receiving THA were younger and healthier with fewer comorbidities, less likely to sustain a same admission mortality and more likely to discharge to home in comparison to HA patients.

What are the Risk Factors for Deep Infection in OTA/AO 43C Pilon Fractures?

OBJECTIVES: To determine the risk factors for deep infection in OTA/AO 43C pilon fractures. DESIGN: Retrospective, case-control study. SETTING: Single institution, Level 1 trauma center. PARTICIPANTS: All patients with 43C pilon fractures treated over a 5-year period with follow-up to bony union. One hundred fifty of 169 of identified patients met inclusion criteria. INTERVENTION: Operative treatment of tibial pilon fracture. MAIN OUTCOME MEASUREMENTS: Deep infection; patient demographics, Gustilo-Anderson classification, location of open fracture wounds, surgical approaches. RESULTS: The overall rate of deep infection was 16.7%. Body mass index, tobacco use, and diabetes were not associated with deep infection. The rate of Gustilo-Anderson type 3A and 3B fractures was significantly higher in those with infection, but the overall open fracture rate was not significantly different between the groups. Medial and anterior open fracture wound location was significantly associated with deep infection, whereas lateral open fracture wound location was not. In closed fractures, anteromedial and anterolateral approaches were not significantly associated with infection, but posterolateral approach was associated with deep infection. Segmental bone loss and the need for soft tissue coverage were the only independent risk factors for deep infection. CONCLUSIONS: High-grade open pilon fractures are at risk of deep infection, and medial/anterior open fracture wounds are particularly vulnerable to developing deep infection. The anteromedial/anterolateral surgical approaches should be selected based on a complete understanding of the fracture pattern and soft tissue injury; however, the posterolateral approach to the tibia should be used with some caution. Ultimately injury factors (segmental bone loss and need for soft tissue coverage) seem to be the most important variables in driving deep infection, and a complete understanding of the bone and soft tissue injury is needed to manage these injuries effectively. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Distal Femur Fractures With the DePuy-Synthes Variable Angle Locking Compression Plate.

OBJECTIVES: To determine the failure rate of the DePuy-Synthes variable angle locking compression curved condylar plate (VA-LCP) and quantify failure modes. DESIGN: Retrospective review. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: One hundred thirteen patients with 118 OTA/AO classification 33A and 33C distal femoral fractures were included in the study. INTERVENTION: Internal fixation using only the DePuy-Synthes VA-LCP plate. MAIN OUTCOME MEASUREMENTS: Primary outcomes included mechanical failure rate of the DePuy-Synthes VA-LCP plate in open and closed fractures. Secondary outcomes included overall failure rate of treatment, risk factors for mechanical failure, and the specific location of failure: loss of fixation in the proximal segment, implant failure over the working length, or failure of locking screw fixation distally. RESULTS: There were 11 total failures (9.3%) in 118 fractures. Failure rates for the closed and open fracture groups were 5.4% and 15.9%, respectively. Twenty patients (16.9%) required reoperation to promote union. Open fractures (P = 0.00475), the presence of medial metaphyseal comminution (P = 0.037), the length of the zone of comminution (P = 0.037), and plate length (P = 0.0096) were significantly higher in those with implant failure. Most failures (63.6%) were in the working length of the implant. CONCLUSIONS: The use of the Synthes VA-LCP is a viable option in distal femoral fractures and has an acceptable failure rate and reoperation to promote union rate. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Optimizing the Host in Fracture Surgery.

Multiple factors impact fracture healing; thus, endocrine optimization and nutritional optimization warrant investigation in the acute fracture and nonunion patient. This article presents current evidence regarding the role of the endocrinologists and the dietician in the fracture patient as well as the most recent data assessing the vitamin D axis in these populations. Similarly, the most recent information regarding the use and risks of NSAIDs in fracture healing are presented. The fracture surgeon must consider each individual patient and weigh the benefits versus the costs of host optimization.

Planning C2 pedicle screw placement with multiplanar reformatted cervical spine computed tomography.

OBJECT: Careful preoperative planning with thin-slice computed tomography (CT) scan is useful for hardware placement at C2. Prior studies have shown considerable variability in the proportion of C2 vertebrae considered safe for pedicle screw placement, depending on the imaging technique used. Our work sought to more carefully define that proportion using a refined imaging technique on a large number of submillimeter CT scans. MATERIALS AND METHODS: We reviewed 150 submillimeter cervical spine studies randomly selected from CT scans performed at a Level 1 trauma center. OsiriX™ image analysis software was used to propagate a 5-mm cylinder through the plane of the pedicle on paracoronal reformatted CT scans. Hounsfield unit attenuation was used to determine whether the cylinder violated the pedicle. Binomial data were generated to determine the proportion of pedicles that would allow safe screw placement. RESULTS: We analyzed 300 pedicles in 150 patients. Using a standard C2 pedicle starting point, 32% of pedicles were breached by the 5-mm diameter cylinder. When screw trajectory was adjusted by moving the cylinder to fit the pedicle isthmus, establishing an optimized starting point, only 14% of pedicles were breached. Average pedicle length was 27.3 mm for screws that would have crossed the isthmus versus 13.2 mm for screws that would have stopped short due to potential breach. CONCLUSIONS: Findings of the current work suggest that preoperative imaging analysis or navigation can be useful adjuncts when anatomical variants are present.