Traumatic Arthrotomies: Do They All Need the Operating Room?

Femoral neck fractures: a cohort comparison of nonunion and complication rates after ballistic versus blunt mechanism fractures

PURPOSE

This study aims to review complications and union rates of ballistic femoral neck fractures when compared to their blunt counterparts. We hypothesize that gunshot injuries to the femoral neck may have higher rates of complications (nonunion, avascular necrosis [AVN], and implant failure) as a result of increasing comminution and disruption to the already tenuous blood supply through the femoral neck.

METHODS

Following the Institutional Review Board approval, a retrospective chart review was performed identifying femoral neck fractures at a single level 1 trauma center from 2018 to 2023. Inclusion criteria were age 16-45 years old with intracapsular femoral neck fractures. Exclusion criteria were absence of radiographic and clinical follow-up beyond 6 weeks, prior femur fractures, pathologic fractures, or primary surgery of total hip arthroplasty. Garden classification and Pauwels angle were reported. Clinical union was defined as the absence of pain with ambulation in the absence of radiographic changes. Radiographic union was defined using the validated Radiographic Union Score for Hip (RUSH) scoring system. Complication rates (deep and superficial infection, failure of fixation, and AVN) and subsequent surgery were recorded.

RESULTS

After exclusion, 12 ballistic and 16 blunt femoral neck fractures met inclusion criteria and were reviewed. The ballistic cohort had significant more Garden I fractures than the blunt cohort (4 [33%] vs. 0 [0%]), and significantly fewer Garden IV fractures than the blunt cohort (2 [17%] vs. 9 [56%]). Despite different Garden classification types of fracture patterns, the Pauwels angle between the two cohorts was similar (51° ballistic vs. 60° blunt, p = 0.16). The overall nonunion rate was 24.1%. Nonunion rates were similar between the two cohorts (3, 25% ballistic vs. 4, 25% blunt, p = 0.99). The mean final RUSH score between the two cohorts was similar (20.1 ballistic vs. 23.4 blunt [p = 0.05]). The total complication rate was 31% (9/28) consisting of 7 nonunions and 2 malunions across both cohorts.

CONCLUSION

The current study found no difference in the union rates between blunt and ballistic femoral neck fractures. Although comparing these fractures using traditional classification systems (Garden and Pauwels) are difficult due to the inherent differences in mechanism and the applicability of these tools, both groups presented with high rates of nonunion and complications. We believe the similar RUSH scores and complication rates in both cohorts show these fractures fundamentally behave similarly and remain challenging injuries to manage with ORIF.

Detection of Traumatic Ankle Arthrotomies: Computed Tomography Scan Versus Saline Load Test

OBJECTIVE

Periarticular wounds present a common diagnostic dilemma for emergency providers and orthopedic surgeons because traumatic arthrotomies (TA) often necessitate different management from superficial soft tissue wounds. Historically, TA have been diagnosed with the saline load test (SLT). Computed tomography (CT) scan has been studied as an alternative to SLT in diagnosing TA in several joints, but there are limited data specifically pertaining to the ankle. This study aimed to compare the ability of a CT scan to identify an ankle TA versus a traditional SLT. The hypothesis was that there would be no significant difference between a CT scan and SLT in diagnosing ankle TA in a cadaveric model.

METHODS

This cadaveric study used 10 thawed fresh-frozen cadaveric ankles. A baseline CT scan was performed to ensure no intra-articular air existed before simulated TA. After the baseline CT, a 1 cm TA was created in the anterolateral arthroscopy portal site location. The ankles then underwent a postarthrotomy CT scan to evaluate for the presence of intra-articular air. After the CT scan, a 30 mL SLT was performed using the anteromedial portal site location.

RESULTS

After arthrotomy, intra-articular air was visualized in 7 of 10 cadavers in the postarthrotomy CT scan. All the ankles had fluid extravasation during the SLT with <10 mL of saline. The sensitivity of the SLT for TA was 100% versus 70% for the CT scan.

CONCLUSIONS

The SLT was more sensitive in diagnosing 1-cm ankle TA than a CT scan in a cadaveric model.

Civilian Ballistic Arthrotomies: Infection Rates and Operative Versus Nonoperative Management

OBJECTIVES

The purpose of this study was to determine whether a significant difference existed in the rate of infection after ballistic traumatic arthrotomy managed operatively compared with those managed without surgery.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Academic Level I Trauma Center.

PATIENT SELECTION CRITERIA

Patients with ballistic traumatic arthrotomies of the shoulder, elbow, wrist, hip, knee, or ankle who received operative or nonoperative management.

OUTCOME MEASURES AND COMPARISONS

The rates of infection and septic arthritis in those who received operative or nonoperative management.

RESULTS

One hundred ninety-five patients were studied. Eighty patients were treated nonoperatively (Non-Op group), 16 patients were treated with formal irrigation and debridement in the operating room (I&D group), and 99 patients were treated with formal I&D and open reduction and internal fixation (ORIF) (I&D + ORIF group). Patients in all 3 groups received local wound care and systemic antibiotics. No patients in the Non-Op or I&D group developed an infection. Six patients in the I&D + ORIF group developed extra-articular postoperative infections requiring additional interventions.

CONCLUSIONS

The infection rate in the I&D + ORIF group was consistent with the infection rates reported in orthopaedic literature after fixation alone. In addition, none of the infections were cases of septic arthritis. This suggests that traumatic arthrotomy does not increase the risk for infection beyond what is expected after fixation alone. Importantly, the Non-Op group represented a series of 80 patients who were treated nonoperatively without developing an infection, indicating that I&D may not be necessary to prevent infection after ballistic arthrotomy. The results suggest that septic arthritis after civilian ballistic arthrotomy is a rare complication regardless of the choice of treatment.

LEVEL OF EVIDENCE

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