Anatomic or imperfect reduction of certain acetabular fractures involving displacement of both the anterior and posterior columns, even with significant (greater than 5 mm) displacement of the posterior column, can be obtained through the modified Stoppa window and the lateral window of the ilioinguinal approach. The method for evaluating preoperative displacement had excellent reliability.

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.

Type III open tibia fractures from combat unite in 80.3% of cases at an average of 9.2 months. We recorded a 27% deep infection rate and a 22% amputation rate. The G/A type is associated with development of deep infection, need for amputation, and time to union. Positive surveillance cultures are associated with development of deep infection, osteomyelitis, and ultimate need for amputation. Surveillance cultures were not predictive of the infecting organism if a deep infection subsequently develops.

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.

No abstract

We describe fixation of transcondylar distal humeral fractures with column screws in geriatric patients and review our initial results. We conducted a retrospective review of a prospectively collected database at a Level I trauma center. Six patients met inclusion criteria of age older than 65 years and treatment of minimally or nondisplaced transcondylar distal humeral fracture with column screws only. All were closed fractures with no associated nerve injuries. One patient was lost to follow-up. The mechanism of injury was low-energy fall for the 5 remaining patients (average age, 74 y; age range, 70 to 83 y; average follow-up duration, 10.6 wk). One patient had a traumatic brain injury and a contralateral metacarpal fracture that was treated with internal fixation. The remaining 4 patients sustained isolated distal humeral fractures. No complications were noted, and all fractures healed at an average radiographic union time of 7.2 weeks. Average range of motion was 22 degrees extension [95% CI (-1.47, 45.47)], 114 degrees flexion [95% CI (89.4, 138.6)], and 92 degrees arc of motion [95% CI (58.68, 125.38)]. Treatment of select transcondylar distal humeral fractures with column screws in geriatric patients provides an option for stable fixation that allows early range of motion with minimal surgical morbidity.

No abstract

Objectives: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. Design: A retrospective cohort study. Setting: Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. Patients/Participants: Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. Intervention: Not applicable. Main Outcome Measurements: Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. Results: Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. Conclusions: Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.