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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.

Exposure to retained metal fragments from war-related injuries can result in increased systemic metal concentrations, thereby posing potential health risks to target organs far from the site of injury. Given the large number of veterans who have retained fragments and the lack of clear guidance on how to medically manage these individuals, the Department of Veterans Affairs (VA) convened a meeting of chelation experts and clinicians who care for embedded fragment patients to discuss current practices and provide medical management guidance. Based on this group's clinical expertise and review of published literature, the evidence presented suggests that, at least in the case of lead fragments, short-term chelation therapy may be beneficial for embedded fragment patients experiencing acute symptoms associated with metal toxicity; however, in the absence of clinical symptoms or significantly elevated blood lead concentrations (greater than 80 µg/dL), chelation therapy may offer little to no benefit for individuals with retained fragments and pose greater risks due to remobilization of metals stored in bone and other soft tissues. The combination of periodic biomonitoring to assess metal body burden, longitudinal fragment imaging, and selective fragment removal when metal concentrations approach critical injury thresholds offers a more conservative management approach to caring for patients with embedded fragments.

Case We present a case of a pure superior wall acetabular fracture in an US soldier, caused by a collapsing wall. Although Letournel and Judet classified this pattern as a rare variant of a posterior-superior wall acetabular fracture, it shares features of several patterns and the treatment more closely follows that of the anterior-based elementary patterns. Conclusion The mechanism, incidence, and long-term outcomes of this fracture remain unknown, but improved recognition and proper classification may help to guide treatment. This case highlights 1 patient with this unique pattern and outlines its management and short- to mid-term outcome.

To compare the outcomes of elderly patients with nondisplaced and minimally displaced femoral neck fractures treated with internal fixation versus arthroplasty.A comprehensive search of the MEDLINE, Embase, and central databases was conducted through June 25, 2019.Studies were included if the sample population was (1) 60 years of age or older, (2) had nondisplaced or minimally displaced (Garden I or II) femoral neck fractures, and (3) if the study compared internal fixation versus arthroplasty. Only full-text English manuscripts were included. The primary outcome was reoperation. Secondary outcomes included mortality, patient-reported outcomes, length of hospital stay, infection, and blood transfusions.Two authors independently extracted data from the included studies. Each study was independently evaluated for quality using the Cochrane risk of bias assessment.Of the 1597 identified articles, 4 manuscripts met the eligibility criteria with a total of 579 patients (236 treated with hemiarthroplasty and 343 treated with internal fixation). Patients treated with arthroplasty had a significantly lower risk of reoperation when compared with those treated with internal fixation [relative risk: 0.30 (95% CI, 0.16-0.55, P0.01)]. There was no significant difference detected in 1-year mortality risk between the 2 treatment groups.In elderly patients with nondisplaced and minimally displaced femoral neck fractures, treatment with hemiarthroplasty may reduce the relative risk of reoperation by 70% when compared with internal fixation.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE At this time, there is no validated tool for describing heterotopic ossification (HO) severity or measuring efficacy of therapies after amputation. This study aims to validate the Walter Reed classification system for reliable characterization of HO burden in residual limbs. DESIGN Descriptive, Level IV. SETTING US Military Trauma Referral Center. STUDY POPULATION Five orthopaedic surgeon raters with varying experience levels assessed orthogonal radiographs of 100 randomly selected residual upper and lower limbs after combat-related amputation. INTERVENTION A standardized education session on the Walter Reed HO classification system followed by 2 grading sessions, separated by a 2-week waiting period. MAIN OUTCOME MEASURES Scores were analyzed for interobserver and intraobserver reliability using weighted Cohen's kappa, intraclass correlation coefficient, and Krippendorff's alpha for ordinal variables. RESULTS After the waiting period, 89% of HO was rated the same by observers with an intraobserver kappa = 0.83 (95% confidence interval [CI] 0.75-0.92). Interobserver reliability was evaluated using group-wise comparison among observers, resulting in an overall Krippendorff's alpha = 0.78 (95% CI 0.76-0.80). Using intraclass correlation coefficient, interrater consistency was 0.94 (95% CI 0.91-0.96). CONCLUSIONS The Walter Reed HO classification system is substantially reliable for use by raters with any level of orthopaedic training. In addition, it is reliable for evaluation of both through bone and disarticulation type amputations in the upper and lower extremities. However, in 11% of cases, a secondary read may vary, suggesting that this system is useful for understanding HO and developing interventions but may benefit from further refinement, including advanced imaging and clinical correlation.

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

Blast injuries to the pelvis are uncommon but devastating injuries typically associated with lower extremity amputations, intra-abdominal injuries, and genitourinary trauma. The majority of patients with a blast-injured pelvis will die at the point of injury. Maximizing chances of survival depends on rapid hemodynamic stabilization through the use of a pelvic binder or external fixator, resuscitation with crystalloids and blood products, and often pelvic packing or proximal arterial control. Once hemodynamically stable, debridement of traumatic wounds is challenging due to the multiple potential spaces of the open pelvis. Patients with a blast-injured pelvis are at high risk of both bacterial and fungal deep space infections. Antibiotic-impregnated beads and negative pressure wound therapy are useful adjuncts in preventing or mitigating infection. Late reconstructive care relies on local flaps of opportunity and the use of regenerative medicine adjuncts such as dermal regeneration templates. Survivors typically require extensive rehabilitation but are usually able to regain the ability to function independently.

This article summarizes the evolution of literature and practice related to fracture care in polytrauma patients. Particular emphasis is given to the management of femoral shaft fractures and the concept of damage control in these complex patients. The application of these guidelines in common clinical practice is also discussed.

BackgroundNonoperative treatment of traumatic shoulder dislocations leads to a high rate of recurrent dislocations.HypothesisEarly arthroscopic treatment for shoulder dislocation will result in a lower recurrence rate than nonoperative treatment.Study DesignProspective, randomized clinical trial.MethodsTwo groups of patients were studied to compare nonoperative treatment with arthroscopic Bankart repair for acute, traumatic shoulder dislocations in young athletes. Fourteen nonoperatively treated patients underwent 4 weeks of immobilization followed by a supervised rehabilitation program. Ten operatively treated patients underwent arthroscopic Bankart repair with a bioabsorbable tack followed by the same rehabilitation protocol as the nonoperatively treated patients. The average follow-up was 36 months.ResultsThree patients were lost to follow-up. Twelve nonoperatively treated patients remained for follow-up. Nine of these (75%) developed recurrent instability. Six of the nine have required subsequent open Bankart repair for recurrent instability. Of the nine operatively treated patients available for follow-up, only one (11.1%) developed recurrent instability.ConclusionsArthroscopic stabilization of traumatic, first-time anterior shoulder dislocations is an effective and safe treatment that significantly reduces the recurrence rate of shoulder dislocations in young athletes when compared with conventional, nonoperative treatment.

A 23-year-old male athlete reported both feeling and hearing a pop in his anterior thigh while sprinting. This was followed by immediate pain and an inability to walk. He had swelling and tenderness in his inguinal region. Radiographs were normal. An magnetic resonance imaging revealed a complete avulsion of the rectus femoris from its origin on the anterior inferior iliac spine. Following discussions of his treatment options, the patient chose to undergo operative management of the injury. A surgical repair was performed of the tendon of the direct head to the anterior inferior iliac spine through bone tunnels. He had a full recovery over the next 6 months and subsequently returned to unrestricted active military duty.

The 2013 Extremity War Injury symposium focused on the sequelae of combat-related injuries, including posttraumatic osteoarthritis, amputations, and infections. Much remains to be learned about posttraumatic arthritis, and there are few circumstances in which a definitive arthroplasty should be performed in an acutely injured and open joint. Although the last decade has seen tremendous advances in the treatment of combat upper extremity injuries, many questions remain unanswered, and continued research focusing on improving reconstruction of large segmental defects remains critical. Discussion of infection centered on the need for novel methods to reduce the bacterial load following the initial debridement procedures. Novel methods of delivering antimicrobial therapy and anti-inflammatory medications directly to the wound were discussed as well as the need for near real-time assessment of bacterial and fungal burden and further means of prevention and treatment of biofilm formation and the importance of animal models to test therapies discussed. Moderators and lecturers of focus groups noted the continuing need for improved prehospital care in the management of junctional injuries, identified optimal strategies for both surgical repair and/or reconstruction of the ligaments in multiligamentous injuries, and noted the need to mitigate bone mineral density loss following amputation and/or limb salvage as well as the necessity of developing better methods of anticipating and managing heterotopic ossification.

This article summarizes the evolution of literature and practice related to fracture care in polytrauma patients. Particular emphasis is given to the management of femoral shaft fractures and the concept of damage control in these complex patients. The application of these guidelines in common clinical practice is also discussed.

Symptomatic distal tibiofibular instability is a known complication of trauma-related transtibial amputations. Overt proximal tibiofibular dislocations, which are easily recognized on routine radiographs, may occur concurrently with the traumatic injury or amputation. More commonly, however, the proximal tibiofibular joint remains structurally intact in the presence of distal instability due to the loss of the distal syndesmotic structures and damage to the interosseous membrane, resulting in fibular angulation and distal tibiofibular diastasis. Some authors have espoused treating this instability with the creation of a distal tibiofibular bridge synostosis (the so-called Ertl procedure or modifications there of) to prevent potentially painful discordant motion and to minimize the prominence of the residual distal fibula. Recent studies, however, have suggested an increase in complication and reoperation rates in transtibial amputations that received a bridge synostosis compared with standard transtibial amputations. Additionally, although there are several described techniques for bridge synostosis creation, most are dependent on having sufficient remaining fibula to construct the bone bridge without unnecessary shortening of the tibia; however, sufficient residual fibula is not always available after traumatic and trauma-related amputations. We propose a technique utilizing a suture bridge to restore tibiofibular stability when performing transtibial amputations in patients with proximal tibiofibular dislocations or distal diastasis, avoiding the potential need for a distal bridge synostosis.

Experiences in treating wartime casualties in Iraq and Afghanistan have already led to changes in civilian trauma care practices. While advances in the care of civilian musculoskeletal injuries are likely as a result of ongoing military basic and clinical research, major advances in resuscitative care have already been realized. Early liberal use of tourniquets to control bleeding from combat-associated extremity trauma has led to decreased mortality. Military experience has demonstrated that use of temporary intravascular shunts is effective for mitigating ischemic injury from vascular trauma until definitive repair can be accomplished. Hemostatic dressings have improved the surgeon's hemorrhage control armamentarium. Clinical experience with hypotensive resuscitation has led to refinement and improvement in the technique. Use of recombinant factor VIIa has improved hemorrhage control in the context of brain injury and coagulopathy and increasing the ratio of plasma to red cells during early shock resuscitation has improved survival.