1Department of Orthopaedic Surgery, University of South Alabama, Mobile, AL, USA M. L. Webb, University of South Alabama, Department of Orthopaedic Surgery, 1601 Center Street, Suite 3A, Mobile, AL 36604, USA, Email: [email protected] This CORR Insights® is a commentary on the article “Do Cultures Obtained During Primary THA Predict the Likelihood of Revision?” by Vargas-Reverón and colleagues available at: DOI: 10.1097/CORR.0000000000002460. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

AbstractThe long-term survival of ceramic-on-ceramic bearings in young, active patients with osteonecrosis undergoing total hip arthroplasty (THA) is unknown. A previously published study demonstrated a high activity level in these young patients at 5-year follow-up, and this is a second follow-up report on this previously reported series. The purpose of this study is to determine whether high activity level is associated with ceramic-on-ceramic THA failure at long-term follow-up. This is a retrospective review of a single-surgeon consecutive series of index cases performed between 2003 and 2010. Inclusion criteria were ceramic-on-ceramic THA articulations in patients younger than 50 with a diagnosis of osteonecrosis. Mean follow-up was 12.5 years (range 9–17). Data were collected by survey via mail, telephone, e-mail, and social media. Preoperative and postoperative Western Ontario and McMaster University (WOMAC) Arthritis Index and University of California at Los Angeles (UCLA) activity scores were collected. Student t-tests were used as appropriate. There were 97 patients in this series. Mean age at THA was 36 (range 14–50). Since the prior report, four more patients have been confirmed deceased, and four more have been lost to follow-up. We confirmed that six patients were deceased and 42 were otherwise lost to follow-up. The response rate was 54%. The vast majority of patients were highly active at latest follow-up (73% with UCLA scores between 7 and 10). UCLA scores (1–10 scale) improved from a preoperative mean of 3.4 to postoperative 7.1 (p < 0.001). WOMAC scores (1–100 scale) increased from preoperative mean of 38.7 to postoperative 86.1 (p < 0.001). At latest follow-up, four patients had undergone revision surgery. There were no ceramic component failures. One patient underwent early revision for femoral component loosening, one was revised for chronic pain at another institution. Since the prior report there have been two additional revisions; one patient was revised for instability at 5-year postop, and one patient was revised for periprosthetic fracture at 10 years. Despite additional loss to follow-up and lack of clinical and radiographic measures, this survey study suggests that at long-term follow-up ceramic bearings accommodate high activity level with excellent component survivorship (93%) in young patients undergoing THA.

Introduction: Total joint arthroplasty (TJA) volume and the number of orthopaedic surgeons in the United States have increased in recent years, but local growth variation has not been studied. This study assesses recent changes in state-level distribution of orthopaedic surgeons in the United States and corresponding local trends in TJA volume. Methods: Data from the National Inpatient Sample database (2000 to 2014) were reviewed. Urban versus rural setting and teaching versus nonteaching hospitals were identified among TJA procedures for comparison. Data from the American Academy of Orthopaedic Surgeons (2002 to 2016) detailing orthopaedic surgeon practice location were evaluated, and linear regression analysis was used to correlate state population data with orthopaedic surgeon density. Results: From 2000 to 2014, there was a 0.1% to 0.3% (P < 0.01) annual decrease in the proportion of TJA procedures conducted in rural hospitals. No notable change was observed in the proportion of TJA procedures conducted at urban teaching versus nonteaching hospitals. Linear regression analysis demonstrated that decreased state population was associated with higher orthopaedic surgeon density (adjusted R2 = 0.114, P < 0.01). States with a higher percentage of population living in rural areas had a lower density of orthopaedic surgeons in the South region and a higher density of orthopaedic surgeons in the remainder of the county. Conclusions: Less populated, rural states have a higher density of orthopaedic surgeons than states with increased population and less rural areas. Although TJA volume has increased since 2000, the proportion of TJA procedures conducted at rural hospitals has decreased. No change was found in the proportion of TJA procedures conducted at urban teaching versus nonteaching hospitals. This may indicate that more patients living in rural areas are seeking TJA care in urban centers. Future studies are needed to confirm this and ensure that patients living in rural areas have appropriate access to TJA care.

Background: The prevalence of diabetes mellitus (DM) continues to increase among patients undergoing total hip arthroplasty (THA). It is unclear how insulin use is correlated with risk for adverse outcomes. Methods: A cohort of 146,526 patients undergoing primary THA were identified in the 2005-2017 National Surgical Quality Improvement Program database. Patients were classified as insulin-dependent diabetic (IDDM), non-insulin-dependent diabetic (NIDDM), or not diabetic. Multivariate analyses were used. Results: Compared to patients without diabetes, patients with NIDDM were at increased risk for 4 of 17 perioperative adverse outcomes studied. Patients with IDDM were at increased risk for those 4 and 8 additional adverse outcomes (12 of the 17 studied). Conclusion: These findings have important implications for preoperative risk stratification and quality improvement initiatives.

Abstract. Objectives:. The aim of this study was to determine the educational value of a national virtual fracture conference implemented during the COVID-19 disruption of resident education. Design:. Survey study. Setting:. National virtual conference administered by the Orthopaedic Trauma Association. Participants:. Attendees of virtual fracture conference. Intervention:. Participation at a national virtual fracture conference. Main outcome measure:. Surveys of perception of quality and value of virtual conferences relative to in-person conferences. Results:. Ninety-six percent of participants rated the virtual fracture conference as similar or improved educational quality relative to conventional in-person fracture conference. Participants also felt they learned as much (35%) or more (57%) at each virtual fracture conference compared to the amount learned in-person. The quality of interpersonal interactions at both the resident–faculty level and faculty–faculty level was also perceived to be overall superior to those at participants’ own institutions. Learners felt they were more likely to engage the primary literature as well. Overall, 100% of participants were likely to recommend virtual conference to their colleagues and 100% recommended continuing this conference even after COVID-19 issues resolve. Conclusions:. We found that learners find significant educational value in a national virtual fracture conference compared to in-person fracture conferences at their own institution. COVID-19 has proven to be a disruptor not only in health care but in medical education as well, accelerating our adoption of innovative and novel resident didactics. Level of Evidence:. Therapeutic Level III.

BACKGROUND:Total knee arthroplasty (TKA) is one of the most common elective surgical procedures in the United States, with more than 650,000 performed annually. Computer navigation technology has recently been introduced to assist surgeons with planning, performing, and assessing TKA bone cuts. The aim of this study is to assess postoperative complication rates after TKA performed using computer navigation assistance versus conventional methods.METHODS:The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for unilateral TKA cases from 2008 to 2016. The presence of the CPT modifier for use of computer navigation was used to separate cases of computer-navigated TKA from conventional TKA. Multivariate and propensity-matched logistic regression analyses were performed to control for demographics and comorbidities.RESULTS:There were 225,123 TKA cases included; 219,880 were conventional TKA (97.7%) and 5,243 were navigated (2.3%). Propensity matching identified 4,811 case pairs. Analysis demonstrated no significant differences in operative time, length of stay, reoperation, or readmission, and no differences in rates of post-op mortality at 30 days postoperatively. Compared to conventional cases, navigated cases were at lower risk of serious medical morbidity (18% lower, p = 0.009) within the first 30 days postoperatively.CONCLUSION:After controlling for multiple known risk factors, navigated TKA patients demonstrated lower risk for medical morbidity, predominantly driven by lower risk for blood transfusion. Given these findings, computer-navigation is a safe surgical technique in TKA.

CASE A 17-year-old boy with a history of chronic bilateral navicular osteonecrosis with fragmentation was treated with 6-month staged bilateral open reduction and internal fixation of tarsal navicular with debridement of the necrotic bone and ipsilateral medial femoral condyle vascularized bone grafting. CONCLUSION The patient progressed to full painless weight-bearing on each extremity by 4 months postoperatively with osseous union of both chronic fracture sites and incorporation of vascularized bone grafts. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were improved from preoperative levels at 6 months from each operation. This patient's atypical presentation of a rare disease was successfully treated with the utilization of vascularized bone grafting to salvage the tarsal navicular and preserve the talonavicular joint, enabling return of function and avoidance of early arthrodesis procedure.

PURPOSE:Distal radius fracture (DRF) open reduction and internal fixation (ORIF) is a common surgical procedure. This study assesses reasons and risk factors for readmission after DRF ORIF using the large sample size and follow-up of the American College of Surgeons National Surgical Quality Improvement Program database. METHODS:Adult patients who underwent DRF ORIF were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Patient demographics, comorbidity status, hospital metrics, and 30-day perioperative outcomes were tabulated. Readmission, time to readmission, and reason for readmission were assessed. Reasons for readmission were categorized. Risk factors for readmission were assessed with multivariate analyses. RESULTS:Of 11,124 patients who underwent DRF ORIF, 196 (1.76%) were readmitted within 30 days. Based on multivariate analysis, predictors of readmission (P < 0.05) were as follows: American Society of Anesthesiologist class > 3 (Odds ratio [OR] = 2.87), functionally dependent status (OR = 2.25), diabetes with insulin use (OR = 1.97), and staying in hospital after the index surgery (inpatient procedure, OR = 2.04). Readmissions occurred at approximately 14 days postoperatively. Of the recorded reasons for readmission after DRF ORIF, approximately one quarter were for surgical reasons, whereas over 75% of readmissions were for medical reasons unrelated to the surgery. CONCLUSION:This study found the rate of 30-day unplanned readmissions after DRF ORIF to be 1.76%. Demographic, comorbid, and perioperative factors predictive of readmission were defined. Most postoperative readmissions were for medical reasons unrelated to the surgical site and occurred at an average of approximately 2 weeks postoperatively. Multivariate analysis found that patients with increased American Society of Anesthesiologist class > 3, functional dependence, insulin-dependent diabetes, and those who underwent inpatient surgery for any reason were at a greater risk for readmission. Understanding these factors may aid in patient counseling and quality improvement initiatives, and this information should be used for risk stratification and risk adjustment of quality measures.

Where Are We Now? Periprosthetic joint infection (PJI) is a devastating complication that poses substantial risks to our patients. Patients who undergo revision TKA for PJI are at a considerably greater risk of perioperative complications, readmission, and mortality compared to patients who undergo revision for aseptic causes [9]. Unfortunately, infection is now the most common reason for early revision TKA and the second most common reason for revision TKA overall [21]. The costs associated with PJI continue to increase and are projected to exceed USD 1.6 billion by 2020 [16]. One intraoperative intervention for primary prevention that has been widely adopted is the routine use of iodine-impregnated adhesive surgical drapes. Many surgeons use these drapes to create a physical barrier between sterile and nonsterile regions and to prevent migration of drapes during the procedure. In their randomized trial, Hesselvig et al. [13] found that iodine-impregnated adhesive drapes reduced the rates of bacterial contamination of surgical wounds during TKA. However, their study did not investigate whether this difference in the contamination rate was correlated with differences in the rate of subsequent PJI. Guidelines for the prevention, diagnosis, and treatment of PJI are continuously challenged and refined by emerging evidence [20]. A consensus meeting that discussed skin preparation and surgical draping found no evidence that these iodine-impregnated drapes reduce the rate of subsequent PJI [4]. A comparative study [18] and systematic review [22] also could not find an effect of these drapes on the rate of surgical-site infection, and some authors have suggested that their use for prophylaxis against surgical-site infection is not necessary in modern total joint arthroplasty [17]. Although an effect on PJI has not been proven, some reports have found that iodine-impregnated drapes do reduce the rates of bacterial wound contamination [11, 19]. A recent randomized, single-surgeon clinical trial of 101 nonimplant hip preservation surgeries found a lower rate of bacterial contamination (12%) in a group with iodine-impregnated adhesive drapes compared to a control group that did not use adhesive drapes (27%) [19]. This study by Hesselvig et al. [13] included five centers, 24 surgeons, 1187 patients, and all common knee arthroplasty procedures (including TKA, unicompartmental arthroplasty, and patellofemoral arthroplasty). Despite regional differences in skin preparation, perioperative antibiotic administration, and inherent variations between surgical centers and surgeons, Hesselvig et al. [13] found that the bacterial contamination rate was lower (10%) in procedures that used these drapes compared to those that did not (15%). Where Do We Need To Go? There are few randomized controlled trials on this subject in orthopaedic surgery. Hesselvig et al. [13] have completed one, and they should be applauded for this, but their study has several limitations. A future multicenter study could use a centralized clinical laboratory instead of relying on multiple site-specific laboratories with heterogenous standards and protocols. Additionally, future studies could standardize agents for perioperative antibiotic prophylaxis, and rigorous implementation and data collection could reduce the exclusion rate of future studies. Although Hesselvig et al. [13] found a correlation between iodine-impregnated drapes and reduced contamination rates, this study does not address the clinically important question of whether these drapes actually prevent infections. Many PJI isolates are skin flora, and for this reason, it is likely that a decreased rate of procedural wound contamination is associated with a decreased rate of subsequent PJI. However, most PJIs are a multifactorial consequence [1] of host factors [8, 14], surgical factors [2, 5, 12], and environmental exposure [3, 7]. Wound contamination is an imperfect surrogate for PJI, and more evidence is needed to prove the efficacy and cost-effectiveness of iodine-impregnated adhesive drapes in orthopaedic surgery. How Do We Get There? Hesselvig et al. [13] stated that they will follow their cohort to determine whether observed contamination is correlated with later infection. I hope that Hesselvig et al. will follow their entire cohort to determine whether the use of iodine-impregnated drapes is correlated with later PJI, regardless of whether culture swabs confirmed contamination at the index procedure. Institutional data regarding the real cost of iodine-impregnated drapes and the costs of treating patients with PJI could then be used to determine whether this intervention was cost-effective. Other surgical subspecialties are leading the way in this regard. In cardiac surgery, a propensity-matched study using longitudinally maintained data evaluated iodine-impregnated drapes versus non-iodine-impregnated drapes and found a lower rate of surgical-site infection with iodine-impregnated drapes at an average cost savings of nearly 800 Euros per patient [6]. Perhaps Hesselvig et al. could replicate that analysis in a follow-up study of their cohort [13]. Alternatively, an analysis of institutional costs could be used to determine the absolute risk reduction necessary for routine use of iodine-impregnated drapes to be cost-effective [15], and this information could be useful for a power analysis in a de novo trial. At most centers, the cost of iodine-impregnated adhesive drapes is relatively low and the absolute risk reduction necessary to find their use cost-effective is similarly low. Given this theoretically small target, the number of patients needed to appropriately power a definitive trial might not be feasible [10]. If the effect is small, Hesselvig et al.’s follow-up study ultimately may not find any statistical difference, and recent proof that the routine use of these drapes reduces the rates of wound contamination may be the best evidence that surgeons will get.

Background: The goal of kinematically aligned (KA) total knee arthroplasty (TKA) is to restore native knee anatomy. However, there are concerns about patellofemoral tracking problems with this technique that lead to early revision. We measured the differences between preoperative anatomic alignment and postoperative component alignment in a consecutive series of KA TKA and evaluated the association between alignment changes and the likelihood of early revision. Methods: The charts of 219 patients who underwent 275 KA TKA procedures were reviewed. Preoperative anatomic alignment and postoperative tibial and femoral component alignment were measured radiographically. The difference in component alignment compared with preoperative anatomic alignment was compared between patients who underwent aseptic revision and those who did not at a minimum of 12 months of follow-up. Receiver operating characteristic curves were created for statistically significant variables, and the Youden index was used to determine optimal alignment thresholds with regard to likelihood of revision surgery. Results: Change in tibial component alignment compared with native alignment was greater (P = .005) in the revision group (5.0 degrees +/- 3.7 degrees of increased varus compared with preoperative anatomic tibial angle) than in the nonrevision group (1.3 degrees +/- 4.2 degrees of increased varus). The Youden index indicated that increasing tibial varus by >2.2 degrees or more is associated with increased likelihood of revision. Preoperative anatomic alignment and change in femoral alignment and overall joint alignment (ie, Q angle) were not associated with increased likelihood of revision. Conclusion: Small increases in tibial component varus compared with native alignment are associated with early aseptic revision in patients undergoing KA TKA. (C) 2020 Elsevier Inc. All rights reserved.

BACKGROUND:Surgical treatment for lumbar degenerative spondylolisthesis has been shown to provide better long-term outcomes than conservative treatment. However, there is variation in surgical approaches employed by surgeons. This study investigates current surgical practice patterns and compares perioperative outcomes of 3 common surgical treatments for this pathology.METHODS:A survey was administered to surgeons who attended the Lumbar Spine Research Society (LSRS) meeting in 2014. Data were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2005 to 2014 to characterize the same responses. The 2 data sets were compared. Perioperative outcomes of those in the ACS-NSQIP posterior fusion subcohorts were characterized and compared.RESULTS:Posterior surgical approaches utilized by surgeons who responded to the LSRS survey were similar to those captured by ACS-NSQIP where 72% of those with degenerative spondylolisthesis were fused. Of those that were fused, 8% had an uninstrumented posterior fusion, 33% had an instrumented posterior fusion, and 59% had an instrumented posterior fusion with interbody. On multivariate analysis, there was no difference in risk of postoperative adverse events, readmission, or length of stay between these 3 common types of fusion.CONCLUSIONS:Practice patterns for the posterior management of lumbar degenerative spondylolisthesis were similar between LSRS survey responses and ACS-NSQIP data. The ACS-NSQIP perioperative outcome measures assessed were similar regardless of surgical technique. These findings highlight that cost-benefit considerations and longer-term outcomes have to be the measures by which surgical technique is chosen for degenerative spondylolisthesis.

ABSTRACT Background: Although publication rates from multiple orthopedic research conferences have been published in the literature, the publication rates of abstracts presented at the Lumbar Spine Research Society (LSRS) meetings have never been reported. The purpose of this study is to evaluate the publication rates from the LSRS annual meeting years 2008–2012 and then to compare those rates with that of other spine research society meetings. Methods: Podium presentations from 2008 to 2012 and poster presentations from 2010 to 2012 were reviewed. For each presentation, a PubMed search was performed to determine if a full-text publication existed. χ2 tests were used to compare LSRS publication rates to those of other spine meetings. In addition, impact of published articles was evaluated by average citation count and average journal impact factor. Results: From 2008 to 2012, a total of 332 podium and poster presentations were identified. The overall publication rate was 55.1% (183/332). For podium presentations, this was greatest in 2012 (66.0%) and lowest in 2008 (51.5%). For poster presentations, this was greatest in 2012 (53.6%) and lowest in 2010 (25.0%). The publication rate of presentations is statistically greater than the publication rates of Eurospine (37.8%, P < .001), North American Spine Society (40.0%, P < .001), The International Society for the Study of the Lumbar Spine (45.0%, P = .012), and the Scoliosis Research Society (47.0%, P = .042) but not statistically different than that of Cervical Spine Research Society (65.7%, P = .059). In addition, the average citation count per published article categorized by year ranged from 13 to 31. The average journal impact factor of published articles categorized by year ranged from 2.31 to 2.55. Conclusions: While LSRS is a relatively young society, these findings point to the high quality of presentations at this scientific meeting. These findings speak to the scientific rigor of presentations at LSRS. Clinical Relevance: This study helps clinicians and scientists gauge the quality of a research meeting and make informed choices on which gatherings to attend.

We describe and evaluate an innovative immersive 15 week final year assistantship in general practice. Evaluation data was taken from five years of routinely collected School data and available national comparative data. The assistantship aims to enable students to consolidate knowledge and hone their skills through central participation in the care of large numbers of patients with acute and long term conditions. We estimate that most students consulted with over 450 patients during the assistantship. Students report that they became useful to their practice teams, had multiple episodes of feedback on their performance which they found useful and, in the school exit survey, reported that they were highly prepared for practice. 9.4 per cent of students reported that the assistantship was 'too long' and, especially those who completed the assistantship in the second semester, they were out of hospital for too long before F1. Some described a learning 'plateau' after the 10th week which was addressed by modifications to the assistantship. Nevertheless, in national surveys, our graduates' self-reported preparedness for practice is high, a perception shared by their F1 supervisors. General practice can make a valuable contribution to the education of senior medical students and contribute to their preparedness for practice.

Background: Postoperative complications and risks factors for adverse events play an important role in both decision making and patient expectation setting. The present study serves to contrast surgeons' perceived and reported rates of postoperative adverse events following posterior lumbar fusion (PLF) and to assess the accuracy of predicting the impact of patient factors on such outcomes. Methods: A survey investigating perceived rates of adverse events and the impact of patient risk factors on them following PLF for degenerative conditions was distributed to spine surgeons at the Lumbar Spine Research Society (LSRS) 2016 annual meeting. For comparison, the corresponding rates and patient risk factors were assessed in patients undergoing elective PLF from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data years 2011-2014. Results: From the survey, there were 53 responses (response rate of 79%) from attending physicians at LSRS. From NSQIP, there were 16,589 patients who met the inclusion criteria. Adverse event rates estimated by the surgeons at LSRS were close to those determined by NSQIP data (no greater than 2.81% different). The largest differences were for deep vein thrombosis (overestimation of 2.81%, P < .001), anemia requiring transfusion (overestimation of 2.47%, P= .018), and urinary tract infection (overestimation of 2.29%, P < .001). Similarly, the estimated impact of patient factors was similar to the data (within relative risk of 2.02). The largest differences were for current smoking (overestimation of 2.02 relative risk, P < .001), insulin dependent diabetes (overestimation of 1.36, P < .001), and obesity (overestimation of 1.35, P < .001). Conclusions: The current study noted that surgeon estimates were relatively close to national numbers for estimating the adverse events and impact of patient factors on such outcomes after PLF for degenerative conditions. The estimates are roughly appropriate with a bias toward overestimation for planning and expectation setting.

Study Design. Retrospective cohort study Objective. To determine the rate of venous thromboembolism event (VTE) and risk factors for their occurrence in patients with vertebral fractures. Summary of Background Data. Deep vein thrombosis or pulmonary embolism (VTE) events are a significant source of potentially preventable morbidity and mortality in trauma patients. In patients with traumatic vertebral fractures, a common high-energy injury sometimes resulting in spinal cord injury, there is debate about what factors may be associated with such VTEs. Methods. All patients with vertebral fractures in the American College of Surgeons National Trauma Data Bank Research Data Set (NTDB RDS) from years 2011 and 2012 were identified. Multivariate logistic regression was used to determine factors associated with the occurrence of VTE while considering patient factors, injury characteristics, and hospital course. Results. A total of 190,192 vertebral fractures patients were identified. The overall rate of VTE was 2.5%. In multivariate analysis, longer inpatient length of stay was most associated with increased VTEs with an odds ratio (OR) of up to 96.60 (95% CI: 77.67 – 129.13) for length of stay longer than 28 days (compared to 0 – 3 days). Additional risk factors in order of decreasing odds ratios were older age (OR of up to 1.65 [95% CI: 1.45 – 1.87] for patients age 70 – 79 years [compared to age 18 – 29 years]), complete spinal cord injuries (OR: 1.49 [95% CI: 1.31 – 1.68]), cancer (OR: 1.37 [95% CI: 1.25 – 1.50]), and obesity (OR: 1.32 [95% CI: 1.18 – 1.48]). Multiple associated non-spinal injuries were also associated with increased rates of VTE. Conclusion. While the overall rate of VTE is relatively low after vertebral fractures, longer LOS and other defined factors to lesser extents were predisposing factors. By determining patients at greatest risk, protocols to prevent such adverse outcomes can be developed and optimized. Level of Evidence: 3

Commentary The use of vancomycin powder prophylactically in spine surgery wounds began in earnest after Sweet et al. demonstrated in a 2011 study that the addition of 2 g of intrawound vancomycin powder to traditional intravenous antibiotic prophylaxis reduced the rate of deep wound infections following thoracolumbar fusions1. Since then, the use of topical vancomycin powder placed directly over the instrumentation and bone graft has gradually become accepted as a new standard of care in spine surgery that seems to be a reasonable approach to enable further reductions in surgical site infections (SSIs), a commonly accepted indicator of the quality of surgical care. Thompson et al. present their early experience with vancomycin powder use in “growing spine” surgery among pediatric patients, including those treated with growing-rod constructs and vertical expandable prosthetic titanium rib (VEPTR) devices, both of which require repetitive surgeries and are associated with relatively high rates of postoperative wound infections2. All 36 patients in the retrospective analysis from the authors’ institution underwent growing spine procedures between 2010 and 2016, and were followed for a minimum of 90 days after each procedure. At this institution, 1 provider coordinated the care of all patients according to a standardized growing spine surgery care pathway. Surgeons at this institution began adding the use of intrawound vancomycin powder to their SSI-prevention protocol for growing spine surgeries in 2011. Use was initially at the individual surgeon’s discretion, with some surgeons adopting it early and others, later. A 2013 report found that the use of vancomycin powder in the pediatric population was safe3. Growing spine patients undergo multiple surgical procedures throughout the course of their treatment and are at a greater risk of infection than the general pediatric orthopaedic population, with an increasing risk of infection at each subsequent surgery2. The 36 patients in this cohort underwent 191 surgical procedures during the study period. The authors created relatively balanced cohorts (104 cases in which vancomycin powder was used and 87 without vancomycin powder) and compared the proportions of cases that were complicated by infection. The authors found that 13.8% of the procedures in the control group (no vancomycin powder) were complicated by infection compared with 4.8% of the procedures in the vancomycin treatment group; this difference was significant (p = 0.038). As with any observational study, it is difficult to conclude whether vancomycin powder decreased the rate of SSI or if vancomycin powder was associated with a decrease due to some secular trend, confounding variable, or detection bias. However, the authors of this study limited many of the potential sources of bias by adding vancomycin powder to surgeon protocols over time; the decision was not based on perceived patient risk factors. Although a single-institution study will have a smaller sample size than will a multi-institution or database study, limiting the study to a single institution with a standardized protocol does further reduce the possibility of bias or confounding factors. Infection may not be the greatest surgical risk in these complex cases with early onset scoliosis, but infection is one of the more common complications and may be one of the costliest overall. Furthermore, many of these patients are poor surgical candidates, and any physiological insult could be life-threatening. Investigation of any means to decrease the infection rate in this population is therefore an important contribution to the care of these patients. The authors present a reasonable analysis of their data that represents the “real world” of heterogeneity and patient-specific treatments in growing spine surgery, and the authors’ analysis of their experience at their institution may be the best representation of what other surgeons may expect if they add vancomycin powder to their own protocols. The authors present the best evidence available regarding the association between perioperative infection rates and vancomycin powder administration in growing spine surgery, further bolstering the widespread acceptance of topical vancomycin powder prophylaxis in both adult and pediatric spine surgery.

Alpine skiing and snowboarding are both popular winter sports that can be associated with significant orthopaedic injuries. However, there is a lack of nationally representative injury data for the two sports.