Donnally Chester J, Lawrie Charles M, Sheu Jonathan I, Gunder Meredith A, Quinnan Stephen M
Department of Orthopedics, University of Miami Hospital , Miami, Florida.
Surg Infect (Larchmt). 2018 Apr;19(3):273-277. doi: 10.1089/sur.2017.211. Epub 2018 Jan 17.
Although gunshot-induced extremity fractures are typically not considered open fractures, there is controversy regarding wound management in the setting of operative fixation to limit infection complications. Previous studies have evaluated the need for a formal irrigation and debridement (I&D) prior to intra-medullary nailing (IMN) of gunshot-induced femur fractures but none have specifically evaluated tibias. By comparing primary IMN for tibial shaft fractures caused by low-velocity firearms additionally treated with a formal operative I&D (group 1) with those without an I&D (group 2), we sought to identify whether there are: differences in treatment group infection rates; particular fracture patterns more prone to infection; and patient characteristics more prone to infections.
Retrospective cohort study at a single level I trauma center of gunshot-induced tibial shaft fractures managed primarily with IMN in 39 patients from October 1, 2008 to October 30, 2016. The following were studied: demographics, follow-up, fracture characteristics, injury management, and patient outcome. Fractures were categorized based on the Orthopaedic Trauma Association (OTA) classification system for diaphyseal tibia/fibula fractures. All patients had intravenous antibiotic agents at presentation and received three days of post-operative intravenous antibiotic agents per institutional protocol.
In group 1, 6 of 23 patients (26.1%) developed superficial infections and 4 of 23 patients (17.4%) developed deep infections. In group 2, none of 16 patients (0%) developed superficial infections and 1 patient (6.25%) developed a deep infection, making the total cohort infection rate 28.2% (11/39). Superficial infections were associated with a formal I&D whereas deep infections were not. Tobacco smokers and type 42-A fractures had higher infection rates when treated with a formal I&D.
A formal debridement, followed by primary IMN in tibia fractures caused by low-velocity firearms is associated with an increased risk of superficial infection that is well managed with antibiotic agents, but the incorporation of a debridement does not affect rate of deep infection. A formal I&D during IMN fixation should be avoided in patients that are smokers and have type 42-A tibia fractures as these are factors associated with increased infection rates.
尽管枪伤所致的四肢骨折通常不被视为开放性骨折，但在手术固定以限制感染并发症的情况下，伤口处理仍存在争议。先前的研究评估了枪伤所致股骨骨折行髓内钉固定（IMN）前进行正规冲洗和清创（I&D）的必要性，但尚无研究专门评估胫骨骨折。通过比较低速火器所致胫骨干骨折行一期IMN并额外接受正规手术I&D治疗的患者（第1组）和未接受I&D治疗的患者（第2组），我们试图确定是否存在：治疗组感染率的差异；更易发生感染的特定骨折类型；以及更易发生感染的患者特征。
在一家一级创伤中心进行回顾性队列研究，研究对象为2008年10月1日至2016年10月30日期间39例主要采用IMN治疗的枪伤所致胫骨干骨折患者。研究内容包括：人口统计学资料、随访情况、骨折特征、损伤处理及患者预后。骨折根据骨科创伤协会（OTA）胫骨干/腓骨干骨折分类系统进行分类。所有患者入院时均接受静脉抗生素治疗，并根据机构方案术后接受三天静脉抗生素治疗。
第1组23例患者中有6例（26.1%）发生浅表感染，23例患者中有4例（17.4%）发生深部感染。第2组16例患者中无一例（0%）发生浅表感染，1例患者（6.25%）发生深部感染，使整个队列的感染率为28.2%（11/39）。浅表感染与正规I&D相关，而深部感染则不然。接受正规I&D治疗时，吸烟者和42 - A型骨折患者的感染率较高。
低速火器所致胫骨骨折先行正规清创，再行一期IMN，与浅表感染风险增加相关，抗生素可有效控制，但清创并不影响深部感染率。对于吸烟者和42 - A型胫骨骨折患者，IMN固定期间应避免正规I&D，因为这些是与感染率增加相关的因素。
