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.

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The shoulder is the most frequently dislocated joint in the body due to a larger range of motion and a small area of articulation between the humeral and glenoid surfaces. Traumatic shoulder dislocations, especially those associated with injury to the labroligamentous or bony stabilizers of the joint, lead to further reduction of articular surface contact with resultant glenohumeral instability and recurrent shoulder dislocations. Imaging plays an increasingly important role in the preoperative evaluation of patients with traumatic shoulder instability by evaluating glenohumeral bone loss (uni- or bipolar), assessing soft tissue injuries and identifying patients at risk of postoperative recurrence. Quantification of bone loss is key to differentiate engaging vs. non-engaging Hill-Sachs lesions, while newer concepts of "on-track" vs. "off-track" lesions are being discussed that can determine the required surgical approaches. In this article, we review the preoperative imaging approaches, traditional treatments, outline the bone loss measurement strategies and review these new tracking concepts with relevant case examples.

Objectives: To evaluate the need for reoperation of geriatric intertrochanteric hip fractures treated with 10-mm cephalomedullary nails versus those treated with nails larger than 10 mm. Design:Retrospective review at a single institution.Setting: Level I trauma center.Patients/Participants: All patients age 60 and over treated with cephalomedullary fixation for an intertrochanteric femur fracture at a single institution.Intervention: Cephalomedullary fixation with variable nail diameters.Main Outcome Measurements: Reoperation rates of geriatric intertrochanteric fractures treated with a size 10-mm diameter cephalomedullary nail compared with patients treated with nails larger than 10 mm.Results: There were no significant differences in reoperation rates when the 10-mm cohort was compared with an aggregate cohort of all nails larger than 10 mm (P = 0.99). This result was true for both allcause reoperation and noninfectious reoperation. There was no difference between cohorts in regards to age, gender, or fracture pattern.Conclusions: A 10-mm cephalomedullary nail can be used in lieu of a larger diameter fixation in patients age 60 and older with intertrochanteric femur fractures while still maintaining a comparable rate of reoperation.

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.