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Introduction: Femoral neck fractures in the young patient present a unique challenge. Most surgeons managing these injuries prefer a fixed angle implant, however these devices are fraught with problems. A dynamic hip screw (DHS) is one such fixed angle device that risks malreduction through rotational torque during screw insertion. To avoid this risk some surgeons utilize a dynamic helical hip system (DHHS), however little is known about the complication profile of this device. We hypothesized that the complication rate between these two devices would be similar., Patients and Methods: All patients presenting to a single tertiary referral center with a femoral neck fracture were identified from a prospectively collected trauma database over an 11-year period. Patients were included if they were less than 60 years of age, treated with a DHS or DHHS, and had at least 6 months of follow-up. Demographic data, injury characteristics, and post-operative complications were obtained through chart review. Standard statistical comparisons were made between groups. A total of 77 patients met inclusion criteria., Results: Average age of patients was 38 years (range: 18-59) and 56 (73%) were male. The DHS was used in 37 (48%) patients and the DHHS was used in 40 (52%) patients. Demographic data including average age, gender, body mass index, and smoking status did not differ between the groups. There were 29 (39%) total complications of interest (femoral neck shortening >5 mm, non-union requiring osteotomy, conversion to THA, and osteonecrosis. There were 19 (51%) complications in the DHS group and 10 (25%) in the DHHS group (p = 0.01, risk difference 25%, 95% CI 7-43). Comparisons of the individual complications about the DHS and DHHS cohort did not reach statistical significance for non-union (8% vs 3%) or THA (16% vs 13%) (p = 0.33, p = 0.64, respectively) but a difference was detected in the rate of shortening (27% vs 10%; p = 0.05)., Conclusion: This study demonstrates a high risk of complication when managing young femoral neck fractures in line with prior literature. The major complication rate of non-union requiring osteotomy or fixation failure resulting in THA was no different between the two groups, but the rate of shortening was greater the DHS group. This data suggests the DHHS may be a suitable device to manage the young femoral neck fracture and without increased risk of complication., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest specifically relevant to this study. Individual conflicts of interest are listed below. Dr. Lucas Marchand reports no disclosures. Dr. Bennett Butler reports no disclosures. Phillip McKegg reports no disclosures. Genaro DeLeon reports no disclosures. Nathan O'Hara receives research funding from the Agency of Healthcare Research and Quality and stock options with Arbutus Medical Inc; all unrelated to this work. Christopher LeBrun reports no disclosures. Dr. Marcus Sciadini is a paid consultant for Globus Medical and Stryker, receives royalties from Globus Medical, and receives stock or stock options from Stryker, all unrelated to this work. Dr. Jason Nascone is a paid consultant for Smith & Nephew, Zimmer and DePuy Synthes; receives stock options from Imagen; and receives royalties from Coorstek and DePuy Synthes; all unrelated to this work. Dr. Robert O'Toole is a paid consultant for Lincotek and Smith & Nephew, receives stock options from Imagen, and receives royalities from Lincotek, all unrelated to this work. Dr. Slobogean reported receiving research funding from the Patient-Centered Outcomes Research Institute, the US Department of Defense, and the National Institutes of Health unrelated to this research; serving as a paid consultant with Smith & Nephew and Zimmer Biomet unrelated to this research; and receiving personal fees from Nuvasive Orthopedics unrelated to this research., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: The optimal treatment of elderly patients with an acetabular fracture is unknown. We conducted a prospective clinical trial to compare functional outcomes and reoperation rates in patients older than 60 years with acetabular fracture treated with open reduction and internal fixation (ORIF) alone versus ORIF plus concomitant total hip arthroplasty (ORIF + THA). Our hypothesis was that patients who had ORIF + THA would have better patient reported outcomes and lower reoperation rates postoperatively., Methods: Inclusion criteria were patients older than 60 years with acetabular fracture plus at least one of three fracture characteristics: dome impaction, femoral head fracture, or posterior wall component. Eligible patients were operative candidates based on fracture displacement, ambulatory status, and physiological appropriateness. Patients received either ORIF alone or ORIF + THA (accomplished at same surgery through same incision). Outcome measurements included Western Ontario and McMaster Universities Osteoarthritis Index hip score, Short Form 36, Harris Hip Score, and Patient Satisfaction Questionnaire Short Form scores. Additionally, patients were monitored for any unplanned reoperation within 2 years., Results: Forty-seven of 165 eligible patients with an average age of 70.7 years were included. The mean Harris Hip Score difference favored ORIF + THA (mean difference, 12.3, [95% confidence interval (CI), -0.3 to 24.9, p = 0.07]). No clinically important differences were detected in any other validated outcome score or patient satisfaction score 1 year after surgery. ORIF + THA decreased the absolute risk of reoperation by 28% (95% CI, 13% to 44%, p < 0.01). No postoperative hip dislocation occurred in either group., Conclusions: In patients older than 60 years with an operative displaced acetabular fracture with specific fracture features (dome impaction, femoral head fracture, or posterior wall component), treatment with ORIF + THA resulted in fewer reoperations than treatment with ORIF alone. No differences in patient satisfaction and other validated outcome measures were detected., Competing Interests: Declaration of Competing Interest T. T. Manson is a paid consultant for DePuy and Stryker; receives royalties from Globus Medical; receives research support from DePuy Synthes; serves as a board or committee member for the American Academy of Orthopaedic Surgeons and the American Association of Hip and Knee Surgeons; serves on the editorial or governing board of Clinical Orthopaedics and Related Research, Journal of Arthroplasty, and Journal of Orthopaedics and Traumatology; all unrelated to this study. G. P. Slobogean reported receiving research funding from the Patient-Centered Outcomes Research Institute, the US Department of Defense, and the National Institutes of Health unrelated to this research; serving as a paid consultant with Smith & Nephew and Zimmer Biomet unrelated to this research; and receiving personal fees from Nuvasive Orthopaedics unrelated to this research. J. W. Nascone is a paid consultant for DePuy Synthes, Smith & Nephew, and Zimmer; receives stock or stock options from Imagen; receives royalties from CoorsTek and DePuy Synthes; all unrelated to this study. M. F. Sciadini is a paid consultant for Globus Medical and Stryker, receives stock or stock options from Stryker, and receives royalties from Globus Medical, all unrelated to this study. C. T. LeBrun serves on the editorial or governing board of the Journal of Bone and Joint Surgery and Journal of Orthopaedic Trauma, and serves as a board or committee member for the Orthopaedic Trauma Association and Society of Military Orthopaedic Surgeons. C. L. Boulton reports no declarations. N. N. O'Hara receives stock or stock options from Arbutus Medical, Inc., unrelated to this study. A. N. Pollak receives royalties from Globus Medical, Smith & Nephew, and Zimmer; receives publishing royalties from AAOS-JBL; serves on the editorial or governing board of NAEMT/JB Learning; and serves as a board or committee member of the Orthopaedic Research and Education Foundation; all unrelated to this study. R. V. O'Toole is a paid consultant for Lincotek and Smith & Nephew, receives stock options from Imagen, and receives royalties from Lincotek, all unrelated to this study. This study was supported by a grant from the Orthopaedic Research and Education Foundation., (Copyright © 2021. Published by Elsevier Ltd.)

Objectives: To determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol., Design: Prospective cohort study., Setting: Academic trauma center., Patients: Eight pilon fracture patients and 19 tibial plateau fracture patients who underwent open reduction internal fixation., Main Outcome Measures: Skin perfusion (fluorescence units) as measured by LA-ICGA., Results: Six patients were classified as Tscherne grade 0, 9 as grade 1, 10 as grade 2, and 2 as grade 3. Perfusion decreased by 14 fluorescence units (95% confidence interval, -21 to -6; P < 0.01) with each increase in Tscherne grade. Sixteen patients underwent staged fixation with an external fixator (mean time to definitive fixation 14.1 days). The mean perfusion increased significantly at the time of definitive fixation by a mean of 13.9 fluorescence units (95% confidence interval 4.8-22.9; P = 0.01)., Conclusions: LA-ICGA perfusion measures are associated with severity of soft tissue injury surrounding orthopaedic trauma fractures and appear to improve over time when fractures are stabilized in an external fixator. Further research is warranted to investigate whether objective perfusion measures are predictive of postoperative wound healing complications and whether this tool can be used to effectively guide timing of safe surgical fixation., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The indocyanine green dye used in the study was donated by Stryker. The remaining authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist., Objective: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections., Design, Setting, and Participants: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers., Interventions: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder., Main Outcomes and Measures: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence., Results: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections., Conclusions and Relevance: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin., Trial Registration: ClinicalTrials.gov Identifier: NCT02227446.

This study sought to determine (1) whether surgeons can accurately predict functional outcomes of operative fixation of pilon fractures based on injury and initial postoperative radiographs, (2) whether the surgeon's level of experience is associated with the ability to successfully predict outcome, and (3) the association between patients' demographic and clinical characteristics and surgeons' prediction scores. A blinded, randomized provider survey was conducted at a level I trauma center. Seven fellowship-trained orthopedic traumatologists and 4 orthopedic trauma fellows who were blinded to outcome reviewed data regarding 95 pilon fractures in random order. Injury ankle radiographs, initial postoperative fixation radiographs, and brief patient histories were assessed. Midterm follow-up functional outcome scores obtained a mean 4.9 years after surgery were available for all patients. Main outcome measures were Pearson correlation coefficient-assessed functional outcomes and surgeon-predicted outcomes. A mixed-effect model determined the association between patients' characteristics and surgeons' prediction scores. Minimal positive correlation was observed between functional outcomes and prediction scores. No difference was noted between the attending and fellow groups in prediction ability. When surgeons' prediction confidence level was greater than 1 SD above the mean confidence level, correlation between functional outcome and prediction improved, although poor correlation was still observed. AO/OTA type 43C fractures, high-energy mechanisms, and older patient age were characteristics associated with lower prediction scores. Surgeons had poor ability to predict functional outcomes of patients with pilon fractures based on injury and initial postoperative radiographs, and level of experience was not associated with ability to predict outcome. [Orthopedics. 2020; 43(1): e43-e46.]., (Copyright 2019, SLACK Incorporated.)

Objectives: As hospitals seek to control variable expenses, orthopaedic surgeons have come under scrutiny because of relatively high implant costs. We aimed to determine whether feedback to surgeons regarding implant costs results in changes in implant selection., Methods: This study was undertaken at a statewide trauma referral center and included 6 fellowship-trained orthopaedic trauma surgeons. A previously implemented implant stewardship program at our institution using a "red-yellow-green" (RYG) implant selection tool classifies 7 commonly used trauma implant constructs based on cost and categorizes each implant as red (used for patient-specific requirements, most expensive), yellow (midrange), and green (preferred vendor, least expensive). The constructs included were femoral intramedullary nail, tibial intramedullary nail, long and short cephalomedullary nails, distal femoral plate, proximal tibial plate, and lower-limb external fixator. Baseline implant usage from the previous year was obtained and provided to each surgeon. Each surgeon received a monthly feedback report containing individual implant utilization and overall ranking., Results: The overall RYG score increased from 68.7 to 79.1 of 100 (P < 0.001). Three of the 7 implants (tibial and femoral nails and lower-limb external fixation) had significant increases in their RYG scores; implant selections for the other 4 implants were not significantly altered. A decrease of 1.8% (95% confidence interval, 0.4-3.2, P = 0.01) was noted in overall implant costs over the study period., Conclusion: Our intervention resulted in changes in surgeons' implant selections and cost savings. However, surgeons were unwilling to change certain implants despite their being more expensive.

Objective: To compare the magnitude of knee pain between the suprapatellar (SP) and infrapatellar (IP) approach for tibial nailing in patients who are more than 1 year after injury., Design: Retrospective cohort study., Setting: Academic Level I trauma center., Patients/participants: All tibia fracture patients 18-80 years of age treated with an intramedullary tibial nail during a 5-year period were retrospectively reviewed for inclusion. The surgical approach was determined by surgeon preference, with 3 of the 9 surgeons routinely using the SP approach. The primary outcome was knee pain during kneeling, with secondary assessments comparing knee pain during resting, walking, and the past 24 hours., Intervention: Intramedullary nailing of a tibia fracture with either the SP or IP approach., Main Outcome Measurements: Knee pain assessed with the Numeric Rating Scale between 0 and 10. A difference of >1.0 was considered to be clinically meaningful., Results: The study group consisted of 262 patients (SP, n = 91; IP, n = 171) with a mean age of 41.4 years (SD = 16.6). The median follow-up was 3.8 years (range: 1.5-7.0). No difference in knee pain during kneeling was detected between the surgical approaches (IP: 3.9, SP 3.8; P = 0.90; mean difference: -0.06, 95% confidence interval, -1 to 0.9). Similarly, no differences were detected in average knee pain scores at rest (IP: 2.0, SP: 2.0; P = 1.00), walking (IP: 2.7, SP 3.0; P = 0.51), or the last 24 hours (IP: 2.6, SP 2.9; P = 0.45)., Conclusions: In contrast to a study conducted by Sun et al, in which there was a statistical difference in knee pain between the SP and IP surgical approaches, we did not detect any statistical or clinical differences in knee pain between the SP and IP surgical approaches among patients with greater than 12 months of follow-up., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Intramedullary (IM) nail fixation is a common operative treatment, yet concerns regarding the frequency of complications, such as nonunion, remain. Treatment of tibial shaft fractures remains a challenge, and little evidence of prognostic factors that increase risk of nonunion is available. The aim of this study was to develop a predictive model of tibial shaft fracture nonunion 6 weeks after reamed intramedullary (IM) nail fixation based on commonly collected clinical variables and the radiographic union score for tibial fractures (RUST)., Methods: A retrospective case-control study was conducted. All tibial shaft fractures treated at our level I trauma center from 2007 to 2014 were retrospectively reviewed. Only patients with follow-up until fracture healing or secondary operation for nonunion were included. Fracture gaps ≥3 mm were excluded. A total of 323 patients were included for study., Results: Infection within 6 weeks of operation, standard RUST, and the Nonunion Risk Determination (NURD) score had statistically significant associations with nonunion (odds ratio > or < 1.0; p < 0.01). The NURD score was increasingly predictive of nonunion with decreasing RUST. All patients in the high RUST group (RUST ≥ 10), achieved union regardless of NURD score. In the medium RUST group (RUST 6-9), 25% of patients with a NURD score ≥7 experienced nonunion. In the low RUST group (RUST <6 or infection within 6 weeks), 69% of patients with a NURD score ≥7 experienced nonunion., Conclusion: Three variables predicted nonunion. Based on these variables, we created a clinical prediction tool of nonunion that could aid in clinical decision making and discussing prognosis with patients., (Copyright © 2018. Published by Elsevier Ltd.)

Objectives: To report functional outcomes of displaced acetabular fractures treated nonoperatively in the geriatric patient population., Design: Retrospective case series., Setting: Two Level I trauma centers., Patients: Twenty-seven patients 60 years of age or older who sustained displaced acetabular fractures during an 11-year period., Intervention: Nonoperative treatment., Main Outcome Measurements: Primary outcome measurements were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and Short Form 8 (SF-8) scores. Secondary outcome measurements were conversion to open reduction and internal fixation or total hip arthroplasty and 1-year mortality., Results: Twenty-six patients completed the WOMAC and SF-8 surveys. The overall WOMAC score was 12.9 ± 15.6 (range, 0-59.4). The average physical SF-8 was 51.1 ± 8.7 (range, 30.4-58.6), and the average mental SF-8 was 55 ± 6.2 (range, 30.4-58.6). The 1-year mortality rate was 24%. Conversion of treatment occurred in 15% of patients., Conclusions: Elderly patients with fracture patterns that would qualify for operative treatment in younger healthy patients had surprisingly good outcome scores when treated nonoperatively., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To determine the incidence of vacuum phenomenon related intra-articular or subfascial gas found on computer-assisted tomography (CT) scans of closed lower extremity fractures., Design: Retrospective Review., Setting: Level I Trauma Center., Patients/participants: A total of 153 patients with closed lower extremity fractures., Intervention: CT scans of identified individuals were reviewed for the presence or absence of gaseous accumulations., Main Outcome Measurements: The presence or absence of gas on CT., Results: Twenty seven (17.6%) of the 153 fractures were found to have intra-articular or subfascial gas on CT despite clear documentation, indicating a closed injury with no significant skin compromise. Of the intra-articular fractures (OTA/AO 33B/C, 41B/C and 43B/C), 20% (23 of 113) were found to have gas on CT. All cases were associated with fracture of the tibia (P = 0.002)., Conclusions: Computed tomography demonstrated the presence of intra-articular or subfascial gas in 17.6% (27/153) of closed lower extremity fractures and in 20% (23/113) of closed intra-articular fractures. The possibility of vacuum phenomenon must be considered when using this imaging modality as the confirmatory test for open intra-articular fracture or traumatic arthrotomy., Level of Evidence: Level IV.

Orthopedic procedures represent a large expense to the Medicare program, and costs of implantable medical devices account for a large proportion of those procedures' costs. Physicians have been encouraged to consider cost in the selection of devices, but several factors make acquiring cost information difficult. To assess physicians' levels of knowledge about costs, we asked orthopedic attending physicians and residents at seven academic medical centers to estimate the costs of thirteen commonly used orthopedic devices between December 2012 and March 2013. The actual cost of each device was determined at each institution; estimates within 20 percent of the actual cost were considered correct. Among the 503 physicians who completed our survey, attending physicians correctly estimated the cost of the device 21 percent of the time, and residents did so 17 percent of the time. Thirty-six percent of physicians and 75 percent of residents rated their knowledge of device costs "below average" or "poor." However, more than 80 percent of all respondents indicated that cost should be "moderately," "very," or "extremely" important in the device selection process. Surgeons need increased access to information on the relative prices of devices and should be incentivized to participate in cost containment efforts.

Concerning the past decade of war, three special topics were examined at the Extremity War Injuries VII Symposium. These topics included the implementation of tourniquets and their effect on decreasing mortality and the possibility of transitioning the lessons gained to the civilian sector. In addition, the training of surgeons for war as well as residents in a wartime environment was reviewed.

Background: Variations in ankle mortise anatomy may be a predisposing factor to ankle instability., Hypothesis: A posteriorly positioned fibula associated with ankle instability may not be a true pathologic entity but rather the result of measuring off an internally rotated talus., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: The authors reviewed 60 ankle computed tomography scans performed on patients from their institution for reasons unrelated to ankle instability. They also reviewed ankle computed tomography scans on 21 patients surgically treated for clinical ankle instability. The position of the fibula in relation to the talar articular surface was calculated and expressed as the axial malleolar index, as described by Scranton et al. They also calculated the intermalleolar index, a new method that references the medial malleolus, not the talus., Results: Using the method of Scranton et al, the axial malleolar index in the control and instability patients was similar to values previously described, and there was a significant difference between control and instability patients (P < .01). However, using the intermalleolar index method referencing the medial malleolus, there was not a significant difference between control and instability patients (P = .43)., Conclusion: The new method of referencing the medial malleolus assesses fibular position independent of talar rotation. The data, when referencing the medial malleolus, do not show significant variation in fibular position in patients with and without ankle instability.