Implant-related sepsis in lower limb fractures following gunshot injuries in the civilian population: A systematic review

Low energy gunshot injuries: Does removal of retained bullet fragmentation at the time of internal fixation reduce the risk of fracture related infection?

OBJECTIVE

To examine the effects of RBF (Retained Bullet Fragment) removal at the time of long bone fixation on FRI (fracture related infection) rates in low energy GSI (Gunshot Injury) related fractures.

DESIGN

Retrospective Cohort Study SETTING: Level 1 Academic Trauma Center INTERVENTION: Retrospective review of the impact of RBFs on the risk of FRI when employing internal fixation in low energy GSI (Gunshot Injury) related fractures. In situations where the injury pattern requires surgical fixation, the question arises as to whether or not the RBFs need to be removed to prevent FRI.

MAIN OUTCOME MEASURES

Whether or not the RBFs removed in our patient population prevented short- and long-term fracture related infection after low-energy gunshot injury (FRI-LGI).

RESULTS

Of the 2,136 GSI related fractures, 131 patients met inclusion criteria, 81 patients underwent removal (R) of RBFs at the time of internal fixation while 50 patients did not undergo any removal (NR) at time of internal fixation. Among the patients who underwent surgical intervention, (Open Reduction Internal Fixation) ORIF was performed in 55 cases (R: 39; NR: 16), and (Intramedullary Nail) IMN was performed in 76 cases (R: 42; NR: 34). The overall rate of deep FRI-LGI was 6.9 % of the 131-patient cohort. We found that removal of RBFs had a statistically significant impact on the rate of deep FRI-LGI when compared to the NR group (p = 0.031). In the RBF removal group, only two patients (2.4 %) developed deep FRI-LGIs, whereas in the NR group, seven patients (14.0 %) developed deep FRI-LGIs. The incidence of early FRI-LGI was higher in the NR group (median 0.6 months) compared to the R group, which was associated with late FRI-LGIs (median 10.1 months) when they occurred.

DISCUSSION

In our study population, we found a statistically significantly increased incidence of deep and early FRI-LGI when RBFs are not removed at the time of extra-articular long bone internal fixation. The presence of retained bullet fragments following internal fixation may pose a risk factor for future development of deep FRI-LGI. We believe a surgeon should use their best judgment as to whether a RBF can safely be removed at the time of long bone fixation. Based on our findings, if safely permitted, RBF removal should be considered at the time of GSI long bone fixation resulting from low energy hand gun injuries.

Functional and Radiographic Outcomes of Open Proximal Femoral Fractures Caused by Gunshot Wounds in Yemen: A Prospective Cohort Study

Background

Open proximal femoral fractures caused by gunshot wounds are rare but devastating injuries that pose considerable challenges for prognosis and management. The aim of this study was to evaluate the functional and radiographic outcomes of patients with open proximal femoral fractures caused by gunshot wounds treated at 3 Level-I trauma centers in Yemen and to identify the factors that influence them.

Methods

We prospectively enrolled 174 patients with open proximal femoral fractures caused by gunshot wounds. The fractures were classified according to the Gustilo-Anderson and OTA/AO systems. The primary outcome measures were fracture union, infection, and functional outcomes. The secondary outcome measures were the Harris hip score (HHS) and the Short Form-36 (SF-36) health survey score. We performed multivariable logistic regression modeling to identify the predictors of complications and poor functional outcomes.

Results

The overall rate of fracture union was 87%. The complication rates were 18% for infection, 13% for nonunion, 23% for reoperation, 12% for delayed union, 4% for osteonecrosis, 6% for heterotopic ossification, and 2% for amputation. The mean HHS at the final follow-up was 78.4, and the mean SF-36 score was 67.3.

Conclusions

Open proximal femoral fractures caused by gunshot wounds are associated with high rates of complications and poor functional outcomes in Yemen. Early debridement, appropriate fixation, infection control, and adequate soft-tissue coverage are essential for achieving satisfactory results. The type of wound, the type of fracture, and the type of definitive fixation are significant predictors of the outcomes. Future studies should compare different fixation methods and evaluate the long-term outcomes and complications of these injuries.

Level of Evidence

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Current concepts review: Management of civilian transpelvic gunshot fractures

INTRODUCTION

Civilian gunshot fractures of the pelvic ring represent a unique challenge for orthopaedic surgeons due to a high incidence of complicating associated injuries. Internationally accepted guidelines for these injuries are not available. The aim of this review is to summarize the available literature and to provide concise management recommendations.

METHODS

Literature search was performed using PubMed. The review focuses on civilian gunshot fractures of the pelvic ring and includes the acetabulum and hip joint only where it was deemed necessary for the understanding of the management of these patients.

RESULTS

The management of civilian transpelvic gunshot fractures is complicated by potentially life-threatening associated injuries, the risk of contamination with bowel content and retained bullets in joints. The infection risk is higher compared to extremity gunshot fractures. There is no clear evidence for the use of antibiotics available. The studies focusing on civilian pelvic ring gunshot fractures reported no case of orthopaedic fracture fixation in their series. Routine wash-out and debridement of fractures is not warranted based on the literature but conflicting recommendations for surgical interventions exist.

CONCLUSION

There is limited evidence available for civilian transpelvic gunshot fractures. The high frequency of associated injuries requires a thorough clinical examination and multidisciplinary management. We recommend routine antibiotic prophylaxis for all transpelvic gunshots. For fractures with a high risk of infection, a minimum of 24 h broad-spectrum antibiotics is recommended. The indication for orthopaedic fixation of civilian transpelvic gunshot fractures is based on the assessment of the stability of the fracture and is rarely necessary. Although conflicting recommendations exist, routine wash-out and debridement is not recommended based on the literature. Bullets buried in bone without contact to synovial fluid do not warrant removal, unless they have traversed large bowel and are accessible without undue morbidity. Furthermore, bullets should be routinely removed if they are retained in the hip joint, if mechanical irritation of soft tissues by projectiles is expected or if the bullet traversed large bowel before entering the hip joint.

Epidemiology of ballistic fractures in the United States: A 20-year analysis of the Firearm Injury Surveillance Study

INTRODUCTION

Ballistic (i.e., gunshot-induced) fractures present unique treatment challenges and can be associated with high rates of complications and considerable morbidity. Large-scale epidemiologic data on these types of fractures are scarce. There is concern that gun-related violence may be on the rise, potentially increasing the burden of ballistic orthopaedic trauma, but there are few contemporary studies on the topic. The aim of this study, therefore, was to investigate the incidence and demographics of patients with ballistic fractures in the United States (US) over the last 20 years.

MATERIALS AND METHODS

This descriptive epidemiology study retrospectively analyzed the Firearm Injury Surveillance Study to identify cases of ballistic fractures in the US from 2000 to 2019. Overall and annual numbers of fractures and fracture incidence rates (IRs), patient demographics, incident characteristics, and temporal trends were analyzed. Patients of all ages were included. Ballistic fractures were grouped by anatomic location for comparisons (non-spine axial, spine, upper extremity, lower extremity).

RESULTS

An estimated N = 240,555 patients (n = 8,322 unweighted cases) sustained ballistic fractures over the 20-year study period for an overall IR of 39.2 per 1,000,000 person-years at-risk (PYR). Overall, lower extremity fractures accounted for the largest percentage of cases (45.9%; IR=18.8 PYR), followed by upper extremity fractures (32.8%; IR=13.4 PYR), non-spine axial fractures (16.1%; IR=6.6 PYR), and spine fractures (5.2%; IR=2.1 PYR). Diaphyseal femur fractures were the most common ballistic fractures overall. Nearly three-fourths (71.2%) of all cases occurred in males in the second through fourth decades. The most common injury intent was assault (71.8%) and a majority of patients (71.2%) required hospital admission. Accounting for population growth yielded a significantly increasing incidence of all ballistic fractures over the study period from 15.7 PYR in 2000 to 96.8 PYR in 2019 (average annual percent change=10.3, p < 0.00001).

CONCLUSION

These data suggest that the nationwide burden of ballistic fractures in the US has increased significantly in the last two decades. Ballistic fractures are associated with significant morbidity and societal cost, and increasing injury rates highlight the need for future research aimed at better understanding the ideal treatment of these types of fractures and their outcomes.

Civilian gunshot injuries in orthopaedics: a narrative review of ballistics, current concepts, and the South African experience

The incidence of civilian gunshot injuries is on the rise worldwide.Unfortunately, there is a lack of high-level evidence guiding management. The treatment of orthopaedic injuries from gunshots is complex and requires consideration of multiple aspects, including energy transfer to the tissue, severity of the wound, possible contamination, presence of fractures and associated injuries. With this narrative review we aim to discuss some of the relevant ballistics, current concepts, and controversies in the general management of civilian gunshot-related orthopaedic injuries based on the available evidence and personal experience. Important points which will be highlighted are the initial management in the emergency room, the assessment and management of soft tissue injuries, associated injuries, use of antibiotics, indication and techniques for fracture fixation, and gunshot injuries to joints.

Comparison of Clinical Outcomes After Intramedullary Fixation of Tibia Fractures Caused by Blunt Trauma and Civilian Gunshot Wounds: A Retrospective Review

OBJECTIVE

To assess the outcomes of patients who sustained blunt trauma tibia fractures compared with tibia fractures from civilian gunshot injuries when treated with intramedullary fixation.

DESIGN

Retrospective chart review.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Two hundred and seven patients underwent intramedullary nailing for 211 tibia fractures.

METHODS

A retrospective review of tibia fracture(s) treated with intramedullary fixation with comparison of closed, open, and gunshot wound (GSW) fracture outcomes.

MAIN OUTCOME MEASUREMENTS

Outcomes included infection and nonunion.

RESULTS

The infection rate in closed and GSW tibia fractures was significantly lower compared with the infection rate of open fractures (1% vs. 9% vs. 20%; P = 0.00005). Significantly lower rates of nonunion in closed fractures compared with open fractures and GSW fractures were appreciated (8% vs. 20% vs. 30%; P = 0.003). There was no difference in infection or nonunion between GSW fractures with small wounds, no exposed bone, and minimal comminution and closed injuries (P = 0.24, P = 0.60). Conversely, there was a significantly higher nonunion rate in GSW fractures with large wounds, exposed tibia, and comminution compared with blunt injuries (P = 0.0014).

CONCLUSIONS

This study suggests that tibia fractures from civilian GSWs are heterogeneous injuries, and outcomes are dependent on the extent of soft-tissue injury, bone exposure, and bone loss. There are comparable infection rates in all fractures due to civilian GSWs and closed fractures, which are lower than high-grade open fractures. Tibia GSW fractures with exposed bone and comminution have higher complication rates and should be treated accordingly.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of histopathology and preoperative 18F-FDG-PET/CT of osteomyelitis aiming for image guided surgery: A preliminary trial

OBJECTIVE

There are currently no robust methods for accurately localizing the infection focus of osteomyelitis. Accumulation of fluorodeoxyglucose (FDG) is nonspecific, and it is well-known that it can indicate inflammatory cells and sites of inflammation, and its effectiveness in detecting osteomyelitis has been reported recently. However, the optimal cut-off value for the Standardized Uptake Value (SUV) in detecting the focus of osteomyelitis through 18F-FDG-PET/CT is not known. We investigated the optimal SUV cut-off values using 18F-FDG positron emission tomography (PET)computed tomography (CT) to visualize the infection focus of osteomyelitis accurately.

PATIENTS AND METHODS

Initially, we investigated a case where osteomyelitis was bacteriologically detected after orthopedic surgery on lower limb. Based on the surgical pathology, we explored the optimal SUV cut-off value of the 18F-FDG PET/CT image taken before surgery. The SUV cut-off value was varied, using the GE Rainbow Color Scale on a dedicated workstation. We searched for the most accurate visualization of the extent of the infectious lesion. Subsequently, using the SUV cut-off value decided on the basis of the first case studied, we investigated the accuracy for diagnosing osteomyelitis. A total of sixteen patients underwent 18F-FDG PET/CT for suspected osteomyelitis (one case involved the upper extremity and 15 cases the lower one). All patients underwent surgery. The final diagnosis was made by means of bacteriologic culture of surgical specimens and histopathologic analysis. We compared surgical pathology and preoperative 18F-FDG PET/CT.

RESULTS

In the first case studied, the infection was most accurately localized with a SUV with a lower level of 2.00 and an upper of 8.00. Upon comparing the pathological findings and the 18F-FDG PET/CT, we set a SUV with a lower level of 2.00 and an upper level of 8.00. In thirteen cases, infection was detected with positive pathological findings. Preoperative 18F-FDG PET/CT showed high accumulation in these cases. In the remaining three cases, no infection was detected on either pathological findings nor 18F-FDG PET/CT findings.

CONCLUSIONS

The infection focus of osteomyelitis was accurately visualized by setting the SUV cut-off lower level to 2.00 and upper level to 8.00. We believe that this 18F-FDG PET/CT technique is helpful for image guided surgery of osteomyelitis.