Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications?

Abstract

Background Gunshot injuries of the extremities are common in the United States, especially among people with nonfatal gunshot wounds. Controversy persists regarding the proper management for low-energy gunshot-induced fractures, likely stemming from varying reports on the likelihood of complications. There has yet to be published a study on a large cohort of patients with gunshot-induced tibia fractures on which to base our understanding of complications after this injury. Questions/purposes (1) What percentage of patients with low-energy gunshot-induced tibia fractures developed complications? (2) Was there an association between deep infection and fracture location, injury characteristics, debridement practices, or antibiotic use? Methods This was a multicenter retrospective study. Between January 2009 and December 2018, we saw 201 patients aged 16 years or older with a gunshot-induced fracture who underwent operative treatment; 2% (4 of 201) of those screened had inadequate clinical records, and 38% (76 of 201) of those screened had inadequate follow-up for inclusion. In all, 121 patients with more than 90 days of follow-up were included in the study. Nonunion was defined as a painful fracture with inadequate healing (fewer than three cortices of bridging bone) at 6 months after injury, resulting in revision surgery to achieve union. Deep infection was defined according to the confirmatory criteria of the Fracture-Related Infection Consensus Group. These results were assessed by a fellowship-trained orthopaedic trauma surgeon involved with the study. Complication proportions were tabulated. A Kaplan-Meier chart demonstrated presentations of deep infection by fracture location (proximal, shaft, or distal). Univariate statistics and multivariate Cox regression were used to examine the association between deep infection and fracture location, entry wound size, vascular injury, intravenous (IV) antibiotics in the emergency department (ED), deep and superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics, while adjusting for age, race/ethnicity, smoking status, and BMI. A power analysis for the result of deep infection demonstrated that we would have had to observe a hazard ratio of 4.28 or greater for shaft versus proximal locations to detect statistically significant results at 80% power and alpha = 0.05. Results The overall complication proportion was 49% (59 of 121), with proportions of 14% (17 of 121) for infection, 27% (33 of 121) for wound complications, 20% (24 of 121) for nonunion, 9% (11 of 121) for hardware breakage, and 26% (31 of 121) for revision surgery. A positive association was present between deep infection and deep debridement (HR 5.51 [95% confidence interval 1.12 to 27.9]; p = 0.04). With the numbers available, we found no association between deep infection and fracture location, entry wound size, vascular injury, IV antibiotics in the ED, superficial debridement, the duration of postoperative IV antibiotics, and the use of topical antibiotics. Conclusion In this multicenter study, we found a higher risk of complications in operative gunshot-induced tibia fractures than prior studies have reported. Infection, in particular, was much more common than expected based on prior studies. Consequently, surgeons might consider adopting the general management principles for nongunshot-induced open tibia fractures with gunshot-induced fractures, such as the use of IV antibiotics both initially and after surgery. Further research is needed to test and validate these approaches. Level of Evidence Level IV, therapeutic study.

The integration of ortho-plastic limb salvage teams in the humanitarian response to violence-related open tibial fractures: evaluating outcomes in the Gaza Strip

“…Additionally, the prolonged duration until complete soft tissue closure, the extended hospital stays, and the need for multiple surgeries and admissions, further emphasize the enduring impact and heightened burden of those injuries on the patients and on the already under-resourced and overburdened Gaza healthcare system [ 24 ]. We also identified a noteworthy non-union rate among patients (53.0%), which is notably higher than the estimated global range of 10–30% for non-union in open tibial fractures [ 25 – 28 ]. This can be attributed to the challenging healthcare environment in the Gaza Strip, where limited resources, including medical supplies, personnel, and infrastructure, often hinder the delivery of adequate care, especially in emergency situations [ 24 ].…”

CORR Insights®: Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications?

“…Lee and colleagues [4] support this concept, particularly in patients who underwent a deep debridement as defined by the authors. Indeed, Lee et al found loss of soft tissue was associated with a higher risk of deep infection [4].…”

“…For example, researchers could limit the study population to those who potentially have a higher risk of complications. Lee and colleagues [4] found that patients with gunshot wounds who had deep debridement after tibia fracture have a higher risk for infection; this high-risk population may be suitable for randomization in studies looking to mitigate a deep infection in view of higher complication rates, which should allow smaller numbers to be analyzed based on power calculations.…”

“…In this issue of Clinical Orthopaedics and Related Research ® , Lee and colleagues [4] present results from a multicenter retrospective study that evaluated more than 200 skeletally mature patients (age 16 years or older) who sustained gunshot-induced tibia fractures and underwent operative treatment. Variables included the use of systemic antibiotic, its duration, extent of debridement, and type of definitive fixation.…”

“…However, a recent study noted that: "… tibia fractures from civilian GSWs are heterogenous injuries, and outcomes are dependent on the extent of soft tissue injury, bone exposure, and bone loss … Tibia GSW fractures with exposed bone and comminution have higher complication rates and should be treated accordingly" [6]. Lee and colleagues [4] support this concept, particularly in patients who underwent a deep debridement as defined by the authors. Indeed, Lee et al found loss of soft tissue was associated with a higher risk of deep infection [4].…”