Journal article
Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications?
Clinical orthopaedics and related research, Vol.479(8), pp.1793-1801
08/01/2021
DOI: 10.1097/CORR.0000000000001736
PMCID: PMC8277282
PMID: 33760776
Abstract
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.
(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?
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.
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.
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 IV, therapeutic study.
Details
- Title: Subtitle
- Low-energy Gunshot-induced Tibia Fractures: What Proportion Develop Complications?
- Creators
- Christopher Lee - University of California, Los AngelesDane J Brodke - University of California, Los AngelesJamie Engel - University of California, Los AngelesMichael G Schloss - University of California, Los AngelesSyed Muhammad R Zaidi - University of California, Los AngelesRobert V O'Toole - University of California, Los AngelesTrevor Gulbrandsen - University of California, Los AngelesMatthew Hogue - University of California, Los AngelesJustin Badon - University of California, Los AngelesPatrick F Bergin - University of California, Los AngelesSeth T Lirette - University of California, Los AngelesJohn Morellato - University of California, Los Angeles
- Resource Type
- Journal article
- Publication Details
- Clinical orthopaedics and related research, Vol.479(8), pp.1793-1801
- DOI
- 10.1097/CORR.0000000000001736
- PMID
- 33760776
- PMCID
- PMC8277282
- ISSN
- 0009-921X
- eISSN
- 1528-1132
- Grant note
- U54 GM115428 / NIGMS NIH HHS
- Language
- English
- Date published
- 08/01/2021
- Academic Unit
- Orthopedics and Rehabilitation
- Record Identifier
- 9984304706002771
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