Introduction: Prosthetic joint infections (PJIs) are difficult to treat and represent a significant burden to the healthcare system. Two-stage revision surgery with placement of an antibiotic-loaded cement spacer is currently the gold standard for treatment in the United States for late-onset infections. We evaluate the efficacy of varying doses of vancomycin added to antibiotic-containing acrylic cement spacers and discuss the biomechanical and antimicrobial properties of using high versus low doses of vancomycin in cement spacers in the hip and knee. Materials and Methods: Commercially available Copal cement containing either gentamicin and clindamycin (G + C) or gentamicin and vancomycin (G + V) was prepared with the manual addition of low (2 g) and high (6 g) doses of vancomycin. In vitro mechanical testing was then carried out according to ISO 5833 and DIN 53435, as well as inhibition zone assays against common PJI pathogens. Additionally, inhibition zone assays were conducted on two commercially available prefabricated spacers containing gentamicin: Copal Exchange G and Cemex Spacer-K. Results: In biomechanical testing, Copal G + V with the addition of 6 g of vancomycin failed to meet the ISO standard. Copal G + C and Copal G + V with low and high dosages of vancomycin were all effective against the tested pathogens and displayed constant efficacy for a duration of 42 days. High doses of vancomycin showed significantly lower mechanical stability. Moreover, Copal Exchange G showed significantly larger inhibition zones across 42 days. Discussion: While higher concentrations of vancomycin appear to improve the antimicrobial efficacy of cement, they also reduce its mechanical stability. Despite its smoother surface, the Copal Exchange G spacer exhibits large inhibition zones after 1 day and maintains consistently large inhibition zones over 6 weeks. Thus, it may be preferred for use in two-stage revision surgery. Conclusion: Copal Exchange G is more effective than Cemex Spacer K against S. aureus and E. coli. The manual addition of vancomycin to cement containing double antibiotics is very effective. The influence on ISO compression is low, the ISO bending modulus is increased, and ISO bending, DIN bending, and DIN impact, are reduced.

Introduction: Insurance type can result in disparities in access to specialist orthopaedic care. Here, we sought to quantify how insurance type affects time to surgery in patients with a distal radius fracture that needs surgical treatment. Methods: A retrospective cohort study of patients ≥18 years with surgically managed, closed distal radius fractures was conducted. We measured the time from injury to surgery, the time from injury to clinic visit, and the time from clinic visit to surgery. Data were analyzed using linear regression models. Results: We included 131 patients (69.0%) with private insurance and 56 patients (29.5%) with public insurance. The mean time from injury to surgery for the entire cohort was 12.4 ± 0.6 days. Private insurance patients had an average time from injury to surgery of 11.0 ± 0.5 days; public insurance patients had an average of 16.2 ± 1.3 days (P < 0.001). The increased time from injury to surgery for publicly insured patients was due to a 4.3-day longer (P < 0.001) time from injury to clinic visit; the time from clinic visit to surgery was similar (0.9 days, P = 0.216). In a stratified analysis, age was an effect modifier of the relationship between insurance type and time to surgery, with greater delays for younger patients. Preferred language other than English was associated with a 5.4 day longer time to surgery (P = 0.022) in a multivariate model. Discussion: In patients with surgically treated distal radius fractures, public insurance was associated with a longer time to surgery, with such effect more pronounced for younger patients. Patients who spoke a language other than English also experienced greater delays. These findings warrant system-level efforts to address inequitable delays in care.

Periprosthetic femur fractures most often occur in elderly, frail patients and represent a devastating injury with high rates of morbidity and mortality even with appropriate surgical management. Hip arthroplasties with cemented femoral fixation have a decreased risk of periprosthetic fracture relative to cementless designs, especially when composite beam stems are used compared to polished, taper-slip stems. Early mobilization is the primary goal of treatment for periprosthetic femur fractures, which can be achieved either through open reduction internal fixation or through revision arthroplasty. Where the pattern is reconstructable, such as in most B1 patterns and some B2 fractures around polished, taper-slip stems, open reduction internal fixation of fractures around cemented stems has been associated with decreased perioperative complications compared to revision arthroplasty. In the setting of a compromised bone–cement interface, inadequate metaphyseal bone stock, or implant breakage, revision arthroplasty is the preferred treatment strategy.