Context Trauma centers benefit thousands of injured individuals every day and play a critical role in responding to disasters. The last full accounting of the number and distribution of trauma centers identified 471 trauma centers in the United States in 1991. Objective To determine the number and configuration of trauma centers and identify gaps in coverage.

Major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias.

Background-Barriers to trauma care for rural populations are well documented, but little is known about the magnitude of urban-rural disparities in injury mortality. This study sought to quantify differences in injury mortality comparing rural and non-rural residents with traumatic injuries.

A number of clinical studies in the spine literature suggest that the use of local vancomycin powder may substantially reduce surgical site infections (SSIs). These studies are primarily retrospective and observational and few focus on orthopaedic trauma patients. This study is a phase III, prospective, randomized, clinical trial to assess the efficacy of locally administered vancomycin powder in the prevention of SSI after fracture surgery. The primary goal of the VANCO Study is to compare the proportion of deep SSI 6 months after fracture fixation surgery. A secondary objective is to compare species and antibacterial susceptibilities among study patients who develop SSI. An additional objective is to build and validate a risk prediction model for the development of SSI. The study population consists of patients aged 18-80 years with tibial plateau or pilon (tibial plafond) fractures, at higher risk of infection, and definitively treated with plate and screw fixation. Participants are block randomized (within center) in a 1:1 ratio to either treatment group (local vancomycin powder up to a maximum dose of 1000 mg, placed immediately before wound closure) or control group (standard of care) for each study injury location, and return to the clinic for evaluations at 2 weeks, 3 months, and 6 months after fixation. The targeted sample size for the study is 500 fractures per study arm. This study should provide important information regarding the use of local vancomycin powder during the definitive treatment of lower extremity fractures and has the potential to significantly reduce the incidence of infection after orthopaedic trauma.

Objectives: To determine if the use of intrawound vancomycin powder reduces surgical-site infection after open reduction and internal fixation of bicondylar tibial plateau, tibial pilon, and calcaneus fractures. Design: Retrospective analysis. Setting: Level I trauma center. Patients: All fractures operatively treated from January 2011 to February 2015 were reviewed; 583 high-risk fractures were included, of which 35 received topical vancomycin powder. A previously published prospectively collected cohort of 235 similar high-risk fractures treated at our center from 2007 through 2010 served as a second comparison group. Intervention: Topical vancomycin powder at wound closure. Main Outcome Measurements: Deep surgical-site infection. Analyses used both univariate comparison of all patients and 1:2 matching analysis using both nearest neighbor and propensity-based matching. Results: Compared with a control group of fractures treated during the same time period without vancomycin powder, the infection rate with vancomycin powder was significantly lower [0% (0/35) vs. 10.6% (58/548), P = 0.04]. Compared with our previously published historical infection rate of 13% for these injuries, vancomycin powder was also associated with significantly decreased deep surgical-site infection (0% vs. 13%, P = 0.02). These results agreed with the matched analyses, which also showed lower infection in the vancomycin powder group (0% vs. 11%–16%, P ≤ 0.05). Conclusions: Vancomycin powder may play a role in lowering surgical-site infection rates after fracture fixation. A larger randomized controlled trial is needed to validate our findings. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

The Trauma Survivors Network provides a critical component of trauma care that can be adapted for local needs throughout the country. Implementation of these services is a necessary step in the development of comprehensive trauma systems that not only save lives but also reduce long-term disability among survivors.