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Objectives To determine whether using topical vancomycin powder in fracture surgery may result in low levels of vancomycin in the serum and not result in nephrotoxicity. Design Prospective observational at a single site as a substudy of the VANCO trial. Setting Single, large urban level I trauma center. Patients/participants Fifty-eight patients with tibial plateau and pilon fractures randomized to the treatment arm at the principal investigator's site. Intervention Topical vancomycin powder (1000 mg) applied directly in the wound over all metal implants at the time of wound closure. Main outcome measurements Serum vancomycin levels at 1 hour and 6-8 hours after surgery. Secondary outcomes included serum creatinine before surgery, a day after surgery, and at 2 weeks postoperatively and complete blood count at 2 weeks postoperatively. Results Except in 2 patients who also received intravenous vancomycin, none of the study patients had detectable (>5 µg/mL) serum vancomycin levels at 1 hour and 6-8 hours after surgery. One patient with a history of elevation of serum creatinine had a minor increase of serum creatinine but had undetectable vancomycin levels. None of the other patients had a clinically significant increase in creatinine levels. Conclusions Despite its relatively widespread usage, little data exist regarding the systemic levels and nephrotoxicity associated with the topical use of vancomycin powder in orthopaedic fracture surgery. These prospective data indicate that there seems to be little clinical concern regarding toxicity associated with systemic absorption of vancomycin powder in this specific clinical application. Level of evidence Therapeutic Level IV. See instructions for authors for a complete description of levels of evidence.

OBJECTIVE To determine the risk factors for knee stiffness surgery after tibial plateau fixation. DESIGN Retrospective observational cohort study. SETTING Academic Level I trauma center. PATIENTS/PARTICIPANTS A study group of 110 patients who underwent knee stiffness surgery (manipulation while under anesthesia, arthroscopic lysis of adhesion, or quadricepsplasty) at a time remote from open reduction and internal fixation of tibial plateau fractures and a control group of 319 patients with tibial plateau fractures treated with open reduction and internal fixation who did not undergo knee stiffness surgery and who had either a minimum of 1 year of follow-up or clearly documented range of motion ≥110 degrees with a minimum of 90 days of follow-up. INTERVENTION Each case was assessed from the time of index admission through study event, end of minimum follow-up, or achievement of ≥110 degrees range of motion. MAIN OUTCOME MEASUREMENTS Knee stiffness surgery. RESULTS Total number of weeks in an external fixator (odds ratio, 1.5 per week; 95% confidence interval, 1.3-1.7; P < 0.001) and the presence of bilateral tibial plateau fractures (odds ratio, 3.3; 95% confidence interval, 1.2-9.1; P = 0.02) were significant predictors of knee stiffness intervention. CONCLUSION Clinicians should be aware that the time spent in external fixation and the presence of bilateral tibial plateau injuries are strong risk factors for requiring subsequent surgery to treat knee stiffness. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.