Background Nonunion of the distal femur after lateral plating is associated with axial malalignment, chronic pain, loss of ambulatory function, and decreased knee ROM.

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.

Contrary to our hypothesis, almost all children aged 2-16 had a radiographically safe screw pathway for an iliosacral screw at S1, and most of the children had an available pathway for a TSTI screw at S2. However, only 51% had a pathway for a TSTI screw at S1.

Bipolar clavicular dislocation rarely occurs. Although referred to by several different names (panclavicular dislocation, bifocal clavicle dislocation, traumatic floating clavicle, and periarticular clavicle dislocation), knowledge regarding appropriate treatment of this condition is limited. Conservative therapy remains the gold standard in asymptomatic individuals. In younger individuals with higher functional demands, or individuals with persistent pain or instability, open reduction with internal fixation of the acromioclavicular joint has also proven successful. In situations with continued medial instability, internal fixation can be used at both the acromioclavicular joint and sternoclavicular joint.Chronic bipolar dislocation may require total claviculectomy, especially when chronic dislocation has led to nonviable acromioclavicular and sternoclavicular joint viability. This article presents a chronic case of bipolar dislocation treated by complete claviculectomy.

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