Search

AIM: Although nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures. METHODS: A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database. RESULTS: Although 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months. CONCLUSION: In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria. pmid: 34531088 ispartof: INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED vol:52 issue:11 pages:3200-3205 ispartof: location:Netherlands status: published

Posttraumatic osteoarthritis (PTOA) significantly affects patients with pilon fractures even after adequate anatomical reduction, and treatment strategies targeting the biologic mediators of PTOA are needed. This study was designed to determine the effects of intra-articular injection of platelet-rich plasma (PRP) on synovial fluid (SF) biomarkers for patients undergoing open reduction and internal fixation (ORIF) of pilon fractures. Patients undergoing staged management of pilon fractures were enrolled in a prospective, double-blinded, randomized, and placebo-controlled clinical trial to determine the effects of a single intra-articular injection of leukocyte-reduced PRP on SF biomarkers. Arthrocentesis of the injured and uninjured ankles was performed at the time of external skeletal fixation (ESF) and ORIF. Patients were randomized to receive either autogenous leukocyte-reduced PRP or saline (control) via intra-articular injection into the injured ankle at the time of ESF. SF biomarker concentrations were compared-uninjured, injured pretreatment, and saline-injected or PRP-injected. Eleven patients (PRP, n = 5; saline, n = 6) completed the study. Twenty-one uninjured, and 11 injured pretreatment, five PRP-treated, and six saline-treated SF samples were analyzed. PRP-treated SF contained significantly higher levels of PDGF-AA (p = 0.046) and significantly lower levels of MMP-3 (p = 0.042), MMP-9 (p = 0.009), IL-1β (p = 0.049), IL-6 (p < 0.01), IL-8 (p = 0.048), and PGE2 (p < 0.04). This study provided mechanistic data to suggest that a single intraarticular injection of leukocyte-reduced PRP is associated with anti-inflammatory, anti-degradative, and anabolic responses compared with saline control. These findings provide the impetus for investigating long-term clinical outcomes after PRP injection as an orthobiologic adjunct to ORIF for mitigating the incidence and severity of PTOA after pilon fractures.

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Cephalomedullary nails (CMN) have proven to be effective for the fixation of unstable pertrochanteric hip fractures, but limited data exists regarding the degree of shortening that occurs with nailing systems that offer "dynamically" versus "statically" locked helical blades. This study aimed to determine the incidence, timing, and amount of postoperative fracture shortening in patients with pertrochanteric hip fractures treated with "dynamically" versus "statically" locked helical blades.A retrospective review was performed on patients requiring operative fixation of pertrochanteric fractures. Inclusion criteria were patients aged 55 or older, low energy mechanism of injury, primary surgical open reduction and internal fixation of the injury, surgery performed by a fellowship-trained orthopaedic traumatologist, and radiographic follow up until healing or failure (minimum of 3 months). Quantification of fracture shortening was determined using the lateral screw protuberance method. Fracture shortening measurements were calculated from immediate post-operative films and subsequent radiographs at each follow-up visit.222 patients met inclusion criteria (123 using Depuy Synthes Trochanteric Fixation Nail proximal femoral nailing system (TFN) with static locking; 65 TFN with dynamic locking; 23 using Depuy Synthes Trochanteric Fixation Nail-Advanced proximal nailing system (TFNA) with static locking; and 11 TFNA with dynamic locking). When comparing the final screw protuberance, the TFN dynamic (10.31 mm), TFNA static (9.52 mm), and TFNA dynamic (7.02 mm) groups were found to be significantly less compared to the TFN static cohort (11.67 mm; p 0.001). The distribution of fracture shortening was found to be significant (p 0.01). Interval measurements of fracture shortening by repeated measures of ANOVA within groups showed statically significant increases in screw protuberance for the TFN static (p 0.001), TFN dynamic (p 0.001), and TFNA static (p 0.01) cohorts within the first 60 days postoperatively. The TFNA with dynamic locking group was found to have statically significant increases until the first 100 days post-operatively (p 0.02).The incidence of fracture shortening remains high even with the use of cephalomedullary nails, regardless of dynamization status. Current pertrochanteric fixation constructs continue to favor fracture healing at the direct expense of fracture shortening.

Objectives The objectives of this study are to present a new method of quantifying variability in human femoral geometry and to use this data to optimize intramedullary nail geometry for a better fit within the femoral canal. Methods Computed tomography (CT) scans of forty intact adult human femora were divided according to race, sex, and age, and were reconstructed digitally into three-dimensional solid models. Geometric features were then measured and compared among groups using ANOVA. An average geometric model was generated, from which an optimal intramedullary (IM) nail curvature function was derived. Insertion of the derived optimal nail and of two currently-available commercial nails into the femur having the highest degree of curvature was then simulated via finite element methods. Results Substantial variability in femoral curvature was observed among the population sample. Sex was found to correlate most strongly with femoral size; males tend to have larger femora than females. Although the average femoral radius of curvature for African Americans was slightly higher than for Caucasians, the difference was not statistically significant. Curvature did not vary across the sample by age, sex or race. Finite element analysis results simulating IM nail insertion using the geometrically-optimized nail showed a substantial decrease in von Mises stress when compared to tested commercially-available IM nails. Fracture was predicted within the posterior canal wall for commercially available nails, as the generated stresses exceeded the allowable stress of cortical bone, but not for the geometrically-optimized nail. Conclusions Considering variation in femoral geometry among patients when designing implantable fixation devices may be important. Femoral size differs between adults by sex, with males being larger than females. Pattern of curvature, however, did not differ, although there may be slight differences between European and African Americans. As such, the proposed average femoral curvature function calculated here may be sufficient for the entire population. According to finite element analysis, insertion-induced stresses in the femur were within the allowable range for the geometrically-optimized nail and appear more desirable than in other common nail designs.

Background Surgical treatment of posterolateral rotatory instability (PLRI) using primary repair or reconstruction of the lateral collateral ligament complex have proven inconsistent. This study aimed to test the hypothesis that augmentation of LUCL repair or palmaris longus tendon reconstruction using a suture tape augmentation would be associated with less rotational displacement and greater torque load to failure (LTF) compared with nonaugmented constructs. Methods Cadaveric elbows (n = 12 matched pairs) were used. Baseline stiffness and displacement values were obtained. The LUCL was transected followed by repair alone, repair with augmentation, reconstruction with palmaris longus graft, or reconstruction with augmentation. Specimens were retested including torque LTF. Paired t tests were performed to assess the biomechanical effects of augmentation. Results Augmentation was associated with higher LTF than repair and reconstruction alone (P = .008 and .047, respectively). Displacement was less with augmentation in reconstruction groups (P = .048) but not in repair groups. Suture tape augmentation maintained rotational stiffness better than repair alone (P = .01). Although reconstruction with augmentation maintained rotational stiffness better than nonaugmented reconstruction, the differences were not statistically significant (P = .057). Mode of failure for repair alone was predominantly suture pulling through repaired ligament. Augmented repairs primarily failed at the anchor-bone interface. Modes of failure for both reconstruction groups were similar, including graft tearing and/or slipping at the anchor. Conclusion When positioned in neutral forearm rotation and 90o of flexion to simulate postoperative conditions, augmentation of LUCL repair or tendon reconstruction using suture tape is associated with better resistance to rotational loads compared with nonaugmented repair or reconstruction, while maintaining near-native rotational stiffness.

Background Multiple small relaxing skin incisions oriented parallel to the longitudinal axis (so-called "pie-crusting") near traumatic lacerations or surgical incisions in edematous tissue beds have been utilized to achieve primary closure when edema or skin loss would otherwise have made this difficult. Our study hopes to demonstrate (1) biomechanical evidence that pie-crusting decreases wound closure tension and (2) provide a case series with data showing clinical results. Materials and methods This study is a biomechanical cadaveric study and retrospective small series cohort using 16 porcine limbs and 7 patients with 8 wounds in which pie-crusting was performed. An elliptical incision was made on the porcine limbs and the wound closure tension was measured with a hydraulic test machine before and after pie-crusting. The retrospective patient cohort had pie-crusting performed on traumatic wounds that were difficult to primarily close. The patient cohort was assessed by retrospective chart review examining wound dimensions before and after pie-crusting, and wound healing at final follow-up. Results The biomechanical data showed that pie-crusting the wound with both a single and double row of incisions significantly decreased the closing tension. A single row decreased wound tension by an average of 34%. Using an average of 3.5 parallel layers of pie-crusting at the time of definitive closure all wounds in the patient cohort closed and healed well with no complications at average follow-up (average 18 months). Conclusion Pie-crusting may allow for easier wound closure and decrease the need for skin-grafting in edematous extremity wounds, with minimal patient morbidity.

» Radial head arthroplasty is a viable surgical option when a radial head fracture cannot be reconstructed. Radial head arthroplasty provides a load-bearing articular structure against the capitellum in unstable fractured elbows. » Studies have emphasized the importance of choosing the correct implant size to replicate the native radial head anatomy, citing various consequences of improperly sized radial head prostheses. Overstuffing of the radiocapitellar joint, or lengthening of the radius, has been extensively studied because of its detrimental effects on elbow biomechanics, but other types of improper sizing also have negative consequences. » In the setting of severe fracture-dislocation or revision surgery, anatomic landmarks that are useful for prosthesis sizing often are missing. Various methods have been described to provide guidance for the accurate sizing of a prosthetic radial head; a retrieved radial head, the proximal edge of the lesser sigmoid notch, the radiocapitellar synovial fold, and the ulnohumeral joint space all represent useful references. » Intraoperative radiographic examination is an important step while assessing implant size, including the height of the prosthetic radial head. » Since no single method is perfect on its own, the surgeon should combine as many reference measures as possible, both before and during the procedure, for accurate prosthesis sizing in order to achieve successful outcomes.

Objective To assess whether the fixation method and vitamin D supplementation affect the risk of patient-important outcomes within 12 months of injury in nongeriatric femoral neck fracture patients. Design A pilot factorial randomized controlled trial. Setting Fifteen North American clinical sites. Participants Ninety-one adults 18-60 years of age with a femoral neck fracture requiring surgical fixation. Intervention Participants were randomized to a surgical intervention (sliding hip screw or cancellous screws) and a vitamin D intervention (vitamin D3 4000 IU daily vs. placebo for 6 months). Main outcome measurements The primary clinical outcome was a composite of patient-important complications (reoperation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion). Secondary outcomes included fracture-healing complications and radiographic fracture healing. Results Eighty-six participants with a mean age of 41 years were included. We found no statistically significant difference in the risk of patient-important outcomes between the surgical treatment arms (hazard ratio 0.90, 95% confidence interval 0.40-2.02, P = 0.80) and vitamin D supplementation treatment arms (hazard ratio 0.96, 95% confidence interval 0.42-2.18, P = 0.92). Conclusions These pilot trial results continue to describe the results of current fixation implants, inform the challenges of improving outcomes in this fracture population, and may guide future vitamin D trials to improve healing outcomes in young fracture populations. Although the pilot trial was not adequately powered to detect treatment effects, publishing these results may facilitate future meta-analyses on this topic. Level of evidence Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To conduct a pilot trial for the Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH-2) protocol to assess feasibility of a definitive trial. Design: Pilot trial. Setting: Twenty-five clinical sites across North America and Australia were initiated, but enrolment occurred in only 15 North American sites. Patients/Participants: Ninety-one randomized adults aged 18 to 60 years with a femoral neck fracture requiring surgical fixation. Intervention: Eligible patients were randomized to receive surgical treatment (sliding hip screw or cancellous screws) AND nutritional supplementation (4000 IU of vitamin D or placebo) for 6 months postfracture. Main Outcome Measurements: Feasibility outcomes included: clinical site initiation, participant enrolment rate, proportion of participants with complete 12-month follow-up, level of data quality, and rate of protocol adherence (number of randomization errors, crossovers between treatment groups, and daily supplementation adherence). Results: Eighty-six of 91 participants randomized into the pilot trial from 15 North American hospitals were deemed eligible. Four of five primary feasibility criteria were not achieved as we were unable to initiate clinical sites outside of North America and Australia due to feasibility constraints, slow participant enrolment (60 participants recruited over 36 mo), low adherence with daily nutritional supplementation at the 6-week (72.1%), 3-month (60.5%), and 6-month (54.7%) follow-up visits, and a high loss to follow-up rate of 22.1% at 12 months. Conclusions: Despite not meeting key feasibility criteria, we increased our knowledge on the logistics and anticipated barriers when conducting vitamin D supplementation trials in this trauma population, which can be used to inform the design and conduct of future trials on this topic.

Author(s): Pogorzelski, David; Nguyen, Uyen; McKay, Paula; Thabane, Lehana; Camara, Megan; Ramsey, Lolita; Seymour, Rachel; Goodman, J Brett; McGee, Sheketha; Fraifogl, Joanne; Hudgins, Andrea; Tanner, Stephanie L; Bhandari, Mohit; Slobogean, Gerard P; Sprague, Sheila; PREP-IT Investigators Executive Committee:; Steering Committee; Adjudication Committee; Data and Safety Monitoring Committee; Research Methodology Core; Patient Centred Outcomes Core; Orthopaedic Surgery Core; Operating Room Core; Infectious Disease Core; Military Core; McMaster University Methods Center; University of Maryland School of Medicine Administrative Center; University of Maryland School of Pharmacy, The PATIENTS Program; PREP-IT Clinical Sites: Lead Clinical Site (Aqueous-PREP and PREPARE); Aqueous-PREP and PREPARE; Aqueous-PREP; PREPARE; PREP-IT Investigators Executive Committee | Abstract: IntroductionPragmatic trials in comparative effectiveness research assess the effects of different treatment, therapeutic, or healthcare options in clinical practice. They are characterized by broad eligibility criteria and large sample sizes, which can lead to an unmanageable number of participants, increasing the risk of bias and affecting the integrity of the trial. We describe the development of a sampling strategy tool and its use in the PREPARE trial to circumvent the challenge of unmanageable work flow.MethodsGiven the broad eligibility criteria and high fracture volume at participating clinical sites in the PREPARE trial, a pragmatic sampling strategy was needed. Using data from PREPARE, descriptive statistics were used to describe the use of the sampling strategy across clinical sites. A Chi-square test was performed to explore whether use of the sampling strategy was associated with a reduction in the number of missed eligible patients.Results7 of 20 clinical sites (35%) elected to adopt a sampling strategy. There were 1539 patients excluded due to the use of the sampling strategy, which represents 30% of all excluded patients and 20% of all patients screened for participation. Use of the sampling strategy was associated with lower odds of missed eligible patients (297/4545 (6.5%) versus 341/3200 (10.7%) p l 0.001).ConclusionsImplementing a sampling strategy in the PREPARE trial has helped to limit the number of missed eligible patients. This sampling strategy represents a simple, easy to use tool for managing work flow at clinical sites and maintaining the integrity of a large trial.

Modern intramedullary nailing began in the World War II era with Gerhard Kuntscher’s intramedullary implants. Multiple design advances have followed, and medullary nailing has become the workhorse in the armamentarium of the orthopedic trauma surgeon for long bone fracture and deformity care. Current nail design features that have an effect on nail biomechanics include the following: material (metal) properties, cross-sectional shape, diameter, curvature of the nail, and the ability to place interlocking devices (such as bolts). Extrinsic factors, such as reaming of the medullary canal, inherent fracture stability (fracture pattern, including comminution or spiral configuration), and the use of adjuncts for stability (such as blocking or “poller” screws), also affect biomechanics of fracture fixation. This chapter will describe biomechanics of intramedullary nailing, with illustrative examples.

Background: Pelvic ring–comminuted transforaminal sacral fracture injuries are rotationally and vertically unstable and have a high rate of failure. Objective: Our study purpose was to use three-dimensional (3D) optical tracking to detect onset location of bone–implant interface failure and measure the distances and angles between screws and line of applied force for correlation to strength of pelvic fracture fixation techniques. Methods: 3D relative motion across sacral–rami fractures and screws relative to bone was measured with an optical tracking system. Synthetic pelves were used. Comminuted transforaminal sacral–rami fractures were modelled. Each pelvis was stabilised by either (1) two iliosacral screws in S1, (2) one transsacral screw in S1 and one iliosacral screw in S1 and (3) one trans-alar screw in S1 and one iliosacral screw in S1; groups 4–6 consisted of fixation groups with addition of anterior inferior iliac pelvic external fixator. Eighteen-instrumented pelvic models with right ilium fixed simulate single-leg stance. Load was applied to centre of S1 superior endplate. Five cycles of torque was initially applied, sequentially increased until permanent deformation occurred. Five cycles of axial load compression was next applied, sequentially increased until permanent deformation occurred, followed by axial loading to catastrophic failure. A Student t test was used to determine significance (p

Copyright © 2018 by the American Society of Plastic Surgeons. Background: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer. Methods: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders. Results: Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm2 was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm2 were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room. Conclusion: The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates.

Orthopaedic surgeons commonly have the misconception that patients with tibial plateau fractures will likely go on to posttraumatic knee arthritis requiring total knee arthroplasty (TKA). In younger patients, osteochondral allograft (OCA) transplantation is an alternative method to address posttraumatic knee arthritis. The purpose of this study was (1) to identify our institutional failure rate following tibial plateau open reduction and internal fixation (ORIF) (failure was defined as conversion to TKA or OCA); (2) to determine if there are patient- or injury-related risk factors predictive of failure; and (3) to characterize differences between patients treated with TKA versus those treated with OCA transplantation. A 10-year retrospective review was conducted to identify patients treated at our institution with a tibial plateau fracture. Patients included in the final analysis were at least 18 years of age with an articular fracture (AO/OTA 41 B/C). The primary outcome was subsequent ipsilateral OCA or TKA. There were 350 patients (359 tibial plateau fractures) with a mean follow-up of 22.3 months (range, 6–133 months) who met inclusion criteria. Twenty-seven fractures (7.5%) were subsequently converted to a TKA or OCA at an average of 3.75 ± 3.1 years following their initial surgery. Patients who consumed tobacco were 2.3 times more likely to require a joint replacement (confidence interval [CI], 1.0–5.2; p = 0.04). Those patients who received an OCAs were significantly younger as compared with their TKA peers, both at time of initial injury (37 vs. 51 years, p = 0.02) and at time of surgery (41 vs. 55 years, p = 0.009). The joint replacement rate in this study is similar to those studies in the published literature that focused solely on the prevalence of conventional TKA. Tobacco is a risk factor for failure following tibial plateau ORIF. Patients who were treated with an OCA were younger at time of injury and failure.

OBJECTIVES The purpose of this study was to review the treatment of patients with ipsilateral acetabular and femur fractures to provide descriptive demographic data, injury pattern classification, treatment, and evaluate the complication profile reflective of current practices. STUDY DESIGN Multicenter retrospective cohort. SETTING Eight Level 1 Trauma Centers. PATIENTS/PARTICIPANTS One hundred one patients met inclusion criteria. INTERVENTION Surgical treatment of both the acetabular and femur fractures. MAIN OUTCOME MEASUREMENTS The complications evaluated include avascular necrosis, heterotopic ossification, posttraumatic arthritis, deep venous thrombosis, pulmonary embolism and superficial/deep infection, fracture union, and secondary surgeries. RESULTS Forty-three patients had 31 type fractures (29A; 11B, and 3C), 60 had 32 type (37A, 8B; 15C), and 8 had 33 type (1A, 4B, 3C) femur fractures; 10 patients had combinations involving more than 1 femur fracture pattern. There were 35 62A type fractures, 47 62B, and 19 62C acetabular fractures. Age of 45 or older was associated with marginal impaction (P = 0.001). The aggregate infection rate was 17%. More than 30% of patients required secondary surgeries. The rate of avascular necrosis was higher in acetabular fractures combined with proximal femur fractures (P < 0.05). The rate of deep venous thrombosis was associated with increased age and time to surgical fixation (P < 0.05). CONCLUSIONS We report the largest review of the surgical treatment and complications of ipsilateral acetabular and femoral fractures. This study provides useful information regarding the complications and provides some treatment recommendations regarding these injuries. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background The study purpose is to evaluate the working length, proximal screw density, and diaphyseal fixation mode and the correlation to fracture union after locking plate osteosynthesis of distal femoral fractures using bridge-plating technique. Methods A four-year retrospective review was performed to identify patients undergoing operative fixation of distal femur fractures with a distal femoral locking plate using bridge-plating technique for the metadiaphyseal region. Primary variables included fracture union, secondary surgery for union, plate working length, and diaphyseal screw technique and configuration. Multiple secondary variables including plate metallurgy and coronal plane fracture alignment were also collected. Results Ninety-six patients with distal femur fractures with a mean age 60 years met inclusion criteria. None of the clinical parameters were statistically significant indicators of union. Likewise, none of the following surgical technique parameters were associated with fracture union: plate metallurgy, the mean working length, screw density and number of proximal screws and screw cortices. However, diaphyseal screw technique did show statistical significance. Hybrid technique had a statistically significant higher chance of union when compared to locking (p = 0.02). All proximal locking screw constructs were 2.9 times more likely to lead to nonunion. Conclusions Plating constructs with all locking screws used in the diaphysis when bridge-plating distal femur locking plates were 2.9 times more likely to incur a nonunion. However, other factors associated with more flexible fixation constructs such as increased working length, decreased proximal screw number, and decreased proximal screw density were not significantly associated with union in this study.

Background Negative pressure wound therapy use over closed surgical incisions (iNPWT) has proven to be effective at reducing hematoma, wound drainage and infection in high-risk wounds. The purpose of this study was to determine if iNPWT decreased the risk of infection in patients undergoing open reduction internal fixation (ORIF) for acetabular fractures. Methods 71 patients who underwent operative intervention for an acetabular fracture between March 2008 and September 2012 consented and prospectively randomized to iNPWT or a standard postoperative (dry gauze) dressing. The primary endpoint was deep infection, i.e. necessitating surgical debridement. Patients were followed until fracture union. Results 33 patients were randomized to treatment with a standard gauze dressing and 33 patients were randomized to the iNPWT cohort. There were no statistically significant differences between the groups with respect to patient demographics, clinical, or surgery characteristics. Overall, seven patients (10.6%) were diagnosed with infections; two patients (6.1%) in the placebo group and 5 (15.2%) in the treatment group. Conclusions In this randomized prospective trial, iNPWT did not decrease the incidence of deep infections when compared to gauze dressings in patients with acetabular fractures. Although not statistically significant, patients in the iNPWT cohort were 2.77 times more likely to develop a deep infection.

BackgroundFracture nonunion risk is related to severity of injury and type of treatment, yet fracture healing is not fully explained by these factors alone. We hypothesize that patient demographic factors assessable by the clinician at fracture presentation can predict nonunion.MethodsA prospective cohort study design was used to examine ~2.5 million Medicare patients nationwide. Patients making fracture claims in the 5% Medicare Standard Analytic Files in 2011 were analyzed; continuous enrollment for 12months after fracture was required to capture the ICD-9-CM nonunion diagnosis code (733.82) or any procedure codes for nonunion repair. A stepwise regression analysis was used which dropped variables from analysis if they did not contribute sufficient explanatory power. In-sample predictive accuracy was assessed using a receiver operating characteristic (ROC) curve approach, and an out-of-sample comparison was drawn from the 2012 Medicare 5% SAF files.ResultsOverall, 47,437 Medicare patients had 56,492 fractures and 2.5% of fractures were nonunion. Patients with healed fracture (age 75.0±12.7SD) were older (p

Ongoing studies investigating fracture healing have uncovered and allowed investigators to gain a better understanding of where the variety of cells, which participate in this process, originate, and how they communicate as well as how they can be enhanced to successfully heal a fracture when the process has slowed or failed completely. This brief review will highlight some of the recent findings regarding the role the immune system in fracture healing and how these cells communicate with each other during the healing process. In addition, two 2 methods that have recently been shown to be promising techniques in supporting fracture when it stalls or reversing the process, when the fracture has failed to heal, will also be described.

Importance The risk of developing a surgical site infection after extremity fracture repair is nearly 5 times greater than in most elective orthopedic surgical procedures. For all surgical procedures, it is standard practice to prepare the operative site with an antiseptic solution; however, there is limited evidence to guide the choice of solution used for orthopedic fracture repair. Objective To compare the effectiveness of iodophor vs chlorhexidine solutions to reduce surgical site infections and unplanned fracture-related reoperations for patients who underwent fracture repair. Design, Setting, and Participants The PREP-IT (Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma) master protocol will be followed to conduct 2 multicenter pragmatic cluster randomized crossover trials, Aqueous-PREP (Pragmatic Randomized Trial Evaluating Pre-Operative Aqueous Antiseptic Skin Solution in Open Fractures) and PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities). The Aqueous-PREP trial will compare 4% aqueous chlorhexidine vs 10% povidone-iodine for patients with open extremity fractures. The PREPARE trial will compare 2% chlorhexidine in 70% isopropyl alcohol vs 0.7% iodine povacrylex in 74% isopropyl alcohol for patients with open extremity fractures and patients with closed lower extremity or pelvic fractures. Both trials will share key aspects of study design and trial infrastructure. The studies will follow a pragmatic cluster randomized crossover design with alternating treatment periods of approximately 2 months. The primary outcome will be surgical site infection and the secondary outcome will be unplanned fracture-related reoperations within 12 months. The Aqueous-PREP trial will enroll a minimum of 1540 patients with open extremity fractures from at least 12 hospitals; PREPARE will enroll a minimum of 1540 patients with open extremity fractures and 6280 patients with closed lower extremity and pelvic fractures from at least 18 hospitals. The primary analyses will adhere to the intention-to-treat principle and account for potential between-cluster and between-period variability. The patient-centered design, implementation, and dissemination of results are guided by a multidisciplinary team that includes 3 patients and other relevant stakeholders. Discussion The PREP-IT master protocol increases efficiency through shared trial infrastructure and study design components. Because prophylactic skin antisepsis is used prior to all surgical procedures and the application, cost, and availability of all study solutions are similar, the results of the PREP-IT trials are poised to inform clinical guidelines and bring about an immediate change in clinical practice. Trial Registration ClinicalTrials.gov Identifiers:NCT03385304andNCT03523962

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic disruption occurs in 10 to 13% of all ankle fractures. It is present in 15 cases per 100,000 of the general population. There has been debate on the best treatment for syndesmotic injuries. The typical surgical treatments include fixation with either screws or suture button devices. The purpose of this study is to compare clinical outcomes of syndesmotic injuries treated surgically with either screws or suture button devices. It was hypothesized that suture button fixation would provide equal clinical results with less need for hardware removal. Methods: This was a multi-center, randomized, prospective clinical trial comparing two surgical interventions for treatment of acute syndesmotic injury. Subjects were placed into either screw fixation or the Suture-button device group. Subjects with clinical signs or radiographic evidence of syndesmotic injury were asked to participate in this study. Inclusion criteria was ages 18 to 65 years old with confirmed syndesmotic instability. The primary outcomes of the study were VAS scores (activity, pain, satisfaction) and FFI scores (pain, disability, activity) which were collected at preoperative state, 6 weeks, and 12 months postoperatively. Results: Sixty-five subjects were enrolled in this study. Thirty-two subjects received Suture-button fixation (49%) and 33 received screw fixation (51%). VAS scores and FFI scores for subjects treated with the Suture-button device or screw fixation comparing preoperative, six-week, and 12-month scores all showed clinical improvement. There was no significant difference between the two treatment groups (p >0.05).Nine subjects (27%) in the syndesmotic screw fixation group experienced adverse events, and only one subject (3%) in the suture-button group had adverse event. Conclusion: The short-term clinical outcomes suggest that both syndesmotic screws and suture-button devices are effective treatment options to address acute syndesmotic injuries. In the short-term (12-months), suture-button fixation resulted in significantly less adverse events compared to syndesmotic screw fixation group.

Objective To assess the "Dedicated Orthopaedic Trauma Operating Room" (DOTOR) effect on management and outcomes of open tibia and femur fractures. Design Retrospective chart review. Location University Level I Trauma Center. Methods Patients categorized into those managed in the DOTOR versus those managed in a standard on-call operating room (OCOR). Data collected include patient and injury characteristics, time to debridement, and patient outcomes. Results A total of 297 patients with 347 open tibia and femur fractures were included; 154 patients (174 fractures) were managed in the DOTOR group and 143 patients (170 fractures) were managed in the OCOR group. The average time to debridement was significantly longer for DOTOR (12.9 hours) versus OCOR (5.4 hours). The DOTOR group was 9 times less likely to undergo debridement within 6 hours. The number of patients debrided within 24 hours was similar (90% for DOTOR vs. 96% OCOR). The rate of primary fracture union was significantly higher in the DOTOR (73.2% vs. 56.6%). OCOR patients were twice as likely to have an unplanned surgery. Rates of infection, nonunion, and amputation were similar. Conclusion Despite earlier access to the Operating room for debridement in the OCOR group, there was no difference in the infection rate compared with the DOTOR group. However, patients managed in the DOTOR group were more likely to go on to uncomplicated fracture union and less likely to have an unplanned surgery. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The importance of timely pre-operative antibiotic agents for effective surgical prophylaxis has been established but the optimal duration of antimicrobial coverage post-operatively has not yet been defined clearly. The purpose of this study was to determine if prophylactic post- operative cefazolin for 23 hours decreases the risk of surgical site infection (SSI) after open reduction internal fixation (ORIF) of closed extremity fractures.After Institutional Reviews Board approval, patients undergoing ORIF of closed extremity fractures who had a planned post-operative stay of at least 23 hours were randomly assigned to either receive 23 hours of cefazolin or a placebo. Both groups received weight-based pre-operative cefazolin and intra-operative re-dosing at three-hour intervals until surgery completion. The primary end point was infection. Patients were followed clinically until bony union. Published risk factors were accumulated as a risk score to help determine risk of SSI.A total of 227 patients were randomized to either receive post-operative cefazolin or placebo and 160 patients completed clinical follow-up to bony union. There were 83 patients in the cefazolin group and 77 in the placebo group. Surgical site infections occurred in a total of 15 patients (9.4%) in this trial without any differences between the cefazolin and placebo groups. Patients with diabetes mellitus were 4.33 times more likely to develop an SSI (95% confidence interval [CI], 1.30-14.38; p = 0.02). Patients with a risk score of two or more were 3.14 times more likely to develop an infection (95% CI, 1.02-9.68; p 0.05).Although not statistically significant, in a randomized double-blinded placebo-controlled trial, patients who were treated with a 23-hour post-operative regimen of antibiotics after ORIF were less likely to develop SSIs. Patients with diabetes mellitus and those with a risk score of two or greater were more likely to develop an SSI.

Certain common medications are associated with an elevated risk of fracture and recent data suggests that medications can also increase nonunion risk. Medication use is a modifiable nonunion risk factor, but it is unknown whether risk accrues solely to chronic medication use or whether there is also risk inherent to acute use.Multivariate logistic regression was used in an inception cohort to calculate odds ratios (OR) for fracture nonunion associated with medication use, in context with other risk factors demonstrated to influence nonunion. Patient-level health claims for medical and drug expenses were compiled from a payer database. Patients were included if they had a fracture coded in 2011, with continuous enrollment for 1 month prior to and 12 months after fracture. The database contained demographic descriptors, treatment procedures per CPT codes, co-morbidities per ICD-9 codes, and prescriptions per National Drug Codes. Chronic medication use was defined as ≥30 days of prescription prior to fracture with ≥1 day afterward; acute use was any other prescription.Most non-analgesic medications were safe in acute or chronic use, but risk of nonunion was elevated for a wide range of analgesics. Overall, 45,085 fractures (14.6% of fractures) affected patients using chronic opioids. Nonunion OR was elevated for acute and chronic use of Schedule 2 opioids including acetaminophen/oxycodone, hydromorphone, oxycodone, and acetaminophen/hydrocodone bitartrate, as well as Schedule 3-5 opioids including tramadol (all, p 0.0001). The highest ORs were associated with chronic administration of Schedule 2 opioids.Most medications do not increase nonunion risk, but acute and chronic use of NSAIDs or opioids was associated with impaired fracture healing. There is particular risk in prescribing opioid analgesics for fracture, though literature suggests that roughly half of opioid-naïve patients receive such a prescription.Patients evaluated in this study were not a random sample of Americans; they may approximate a random sample of the Emergency Department population in the United States. Thus, trauma patients may represent a population enriched for nonunion risk factors. Opioids impair recovery from injury; if they also predispose to injury, the ongoing opioid epidemic could presage an increase in nonunion prevalence.

The objective of this study was to compare a cohort of geriatric patients with operatively managed isolated fractures below the hip to a cohort of geriatric patients with operatively managed isolated hip fractures. All patients greater than 59 years of age admitted to our institution for surgical care of an isolated lower extremity fracture during a 3-year period were included. Patients were divided into 2 cohorts: BTH (fracture below the subtrochanteric region of the femur) and HIP (proximal femoral fracture at subtrochanteric region or proximal). We identified 141 patients included in cohort BTH and 205 patients included in cohort HIP. HIP patients were older ( P < .01) and less obese ( P < .01) but were otherwise very similar. An extensive comorbidity review revealed that the 2 cohorts were similar, with the exception of an increased incidence of dementia ( P = .012) or glaucoma ( P = .04) in HIP patients and of peripheral neuropathy ( P = .014) in BTH patients. HIP patients were more likely to be under active antiosteoporotic medication management and were more likely to be receiving pharmacological anticoagulation at the time of admission. HIP patients and BTH patients were similar with regard to necessity of assistance with ambulation preinjury, but HIP patients were less likely to reside independently at home than were BTH patients ( P < .001). HIP patients were also less likely to be discharged directly home from the hospital ( P < .001). Geriatric patients with fractures below the hip are medically similar to geriatric patients with hip fracture. Medical comanagement protocols have been extensively published that improve care of geriatric patients with hip fracture; consideration should be given to similar protocol-driven medical comanagement programs for geriatric patients with fractures below the hip.

OBJECTIVE The purpose of this study was to determine the effectiveness of our vitamin D treatment protocol in managing low serum vitamin D levels in orthopaedic trauma patients. METHODS A retrospective review was conducted of all orthopaedic trauma patients at a university level I trauma center over 20 months. Patients were included if they had an initial and repeat 25-hydroxy (OH) vitamin D serum level available. Vitamin D deficiency was defined as serum 25-hydroxy vitamin D level with less than 20 ng/mL. Vitamin D insufficiency was defined as serum 25-hydroxy vitamin D level between 20 and 32 ng/mL. The standard regimen for all patients was over-the-counter vitamin D3 1000 IU and 1500 mg of calcium daily. Patients with vitamin D deficiency or insufficiency also received 50,000 IU of ergocalciferol (D2) weekly until their 25-hydroxyvitamin D level normalized or their fracture healed. No compliance monitoring was performed except for questioning at each clinic visit. RESULTS A total of 201 patients met the inclusion criteria. Thirty-two patients had a normal initial 25-hydroxyvitamin D level, and 84% maintained their normal level, whereas 16% became insufficient or deficient. There were 88 patients insufficient initially and 54.5% improved to normal and 8% became deficient. In the vitamin D deficiency group (81), 26% remained deficient and 74% improved to insufficient. The average increase in serum 25-OH vitamin D with treatment (in nanograms per milliliter) was statistically significant for both the insufficient and deficient groups. CONCLUSIONS Vitamin D therapy improved the majority of the patients' vitamin D-25-OH level but did not normalize most. Patients with initial deficiency had the largest improvement. This study indicates that vigilance is required to adequately treat a low serum vitamin D-25-OH level.

The epidemiology of fracture nonunion has been characterized so it is potentially possible to predict nonunion using patient-related risk factors. However, prediction models are currently too cumbersome to be useful. We test a hypothesis that nonunion can be predicted with ≤10 variables, retaining the predictive accuracy of a full model with 42 variables.We sought to predict nonunion with prospectively-acquired inception cohort data for 18 different bones, using the smallest possible number of variables that did not substantially decrease prediction accuracy. An American nationwide claims database of ∼90.1 million participants was used, which included medical and drug expenses for 2011-2012. Continuous enrollment was required for 12 months after fracture, to allow sufficient time to capture a nonunion diagnosis. Health claims were evaluated for 309,330 fractures. A training dataset used a random subset of 2/3 of these fractures, while the remaining fractures formed a validation dataset. Multivariate logistic regression and stepwise logistic regression were used to identify variables predictive of nonunion. P value and the Akaike Information Criterion (AIC) were used to select variables for reduced models. Area-under-the-curve (AUC) was calculated to characterize the success of prediction.Nonunion rate in 18 fracture locations averaged 4.93%. Algorithms to predict nonunion in 18 locations in the full-model validation set had average AUC=0.680 (±0.034). In the reduced models, average validation set AUC=0.680 (±0.033) and the average number of risk factors required for prediction was 7.6. There was agreement across training set, validation set, and reduced set; in tibia, reduced model validation AUC=0.703, while the full-model validation AUC=0.709. Certain risk factors were important for predicting nonunion in ≥10 bones, including open fracture, multiple fracture, osteoarthritis, surgical treatment, and use of certain medications, including anticoagulants, anticonvulsants, or analgesics.Nonunion can be predicted in 18 fracture locations using parsimonious models with10 patient demography-related risk factors. The model reduction approach used results in simplified models that have nearly the same AUC as the full model. Reduced algorithms can predict nonunion because risk factors important in the full models remain important in the reduced models. This prognostic inception cohort study provides Level I evidence.

OBJECTIVE The clinical value of low-intensity pulsed ultrasound (LIPUS) for fresh fracture is known. Yet, in the absence of a definition of what "fresh" is, payers have adopted study inclusion criteria drawn from randomized clinical trials as de facto definitions of which patients should be treated, with "fresh" defined as