Objectives:To assess the operative results of femoral neck fractures (FNFs) in young adults in a large multicenter series, specifically focusing on risk factors for treatment failure.Design:Large multicenter retrospective cohort series.Setting:Twenty-six North American Level 1 trauma centers.Patients:Skeletally mature patients younger than 50 years with displaced and nondisplaced FNFs treated between 2005 and 2017.Intervention:Operative repair of FNF.Main outcome measurements:The main outcome measure is treatment failure: nonunion and/or failed fixation, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). Logistic regression models were conducted to examine factors associated with treatment failure.Results:Of 492 patients with FNFs studied, a major complication and/or subsequent major reconstructive surgery occurred in 45% (52% of 377 displaced fractures and 21% of 115 nondisplaced fractures). Overall, 23% of patients had nonunion/failure of fixation, 12% osteonecrosis type 2b or worse, 15% malunion (>10 mm), and 32% required major reconstructive surgery. Odds of failure were increased with fair-to-poor reduction [odds ratio (OR) = 5.29, 95% confidence interval (CI) = 2.41–13.31], chronic alcohol misuse (OR = 3.08, 95% CI = 1.59–6.38), comminution (OR = 2.63, 95% CI = 1.69–4.13), multiple screw constructs (vs. fixed-angle devices, OR = 1.95, 95% CI = 1.30–2.95), metabolic bone disease (OR = 1.77, 95% CI = 1.17–2.67), and increasing age (OR = 1.03, 95% CI = 1.01–1.06). Women (OR = 0.57, 95% CI = 0.37–0.88), Pauwels angle ≤50 degrees (type 1 or 2; OR = 0.64, 95% CI = 0.41–0.98), or associated femoral shaft fracture (OR = 0.19, 95% CI = 0.10–0.33) had lower odds of failure.Conclusions:FNFs in adults <50 years old remain a difficult clinical and surgical problem, with 45% of patients experiencing major complications and 32% undergoing subsequent major reconstructive surgery. Risk factors for complications after treatment of displaced FNFs were numerous.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patients with prior exposure are more likely to be prescribed more opiates after femoral shaft fracture treatment. We recommend a protocol of prescribing half the mean of MMEs currently prescribed by orthopedists equating to 47 (711 MMEs) pills of oxycodone 10 mg in up to 3 prescriptions.

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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 PARTICIPANTSThis 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 MEASURESThe 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. RESULTSThe 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.

Objective: This retrospective study aimed at identifying opiate prescribing practices, the number of morphine milligram equivalents (MMEs) prescribed by orthopaedic and nonorthopaedic providers in patients with operatively treated isolated lower extremity fractures, and provide opiate prescribing recommendations. Methods: Patients older than 18 years with isolated lower extremity (unicondylar, bicondylar, tibial shaft, pilon, and ankle) fractures between 2005 and 2016 were identified. Prescribing information was obtained from the State Controlled Substance Monitoring Database. Descriptive statistics were calculated for each injury and plotted for MME use. Mann–Whitney and Wilcoxon tests were used for data analysis. To aid in clinical relevance, MMEs were converted to number of pills of oxycodone 10 mg (OC 10 mg). Results: Three hundred forty-one patients met our inclusion criteria. Mean age was 45 years; 56% (192/341) were men. Forty-seven percent (159/341) were prescribed opiates before their injury. Orthopaedic providers prescribed more opiates to patients with pilon fractures compared with unicondylar (P = 0.010), tibial shaft (P < 0.001), and ankle (P < 0.001) fractures. Bicondylar plateau fracture patients also received more opiates when compared with unicondylar (P = 0.001), tibial shaft (P < 0.001), and ankle (P < 0.001) fractures. Nonorthopaedic providers prescribed more opiates to patients with pilon fractures when compared with unicondylar (P = 0.006), bicondylar (P < 0.001), tibial shaft (P < 0.001), and ankle fractures (P = 0.006). Differences between orthopaedic and nonorthopaedic MMEs prescribed are significantly different for each injury type (<0.05). Conclusions: Patients with pilon or bicondylar tibial plateau fractures are currently being prescribed more opiates when compared with other isolated fractures. We have developed an opiate prescription guideline based on what is being prescribed by orthopaedic providers.