Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA, USA.
Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA.
Clin Orthop Relat Res. 2021 Aug 1;479(8):1793-1801. doi: 10.1097/CORR.0000000000001736.
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?
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.
在美国，四肢的枪伤很常见，尤其是在那些有非致命性枪伤的人群中。对于低能量枪击引起的骨折的适当治疗方法仍存在争议，这可能源于对并发症发生可能性的不同报告。目前还没有发表过关于大量枪击引起的胫骨骨折患者的研究，因此我们对这种损伤后的并发症的理解还不够。
问题/目的：（1）低能量枪击引起的胫骨骨折患者中有多少人出现并发症？（2）深部感染是否与骨折部位、损伤特征、清创术实践或抗生素使用有关？
这是一项多中心回顾性研究。2009 年 1 月至 2018 年 12 月，我们共治疗了 201 名年龄在 16 岁及以上的枪击引起的骨折患者，其中 2%（201 名中 4 名）患者的临床记录不充分，38%（201 名中 76 名）患者的随访时间不足，无法纳入研究。共有 121 名患者的随访时间超过 90 天被纳入研究。骨不连定义为受伤后 6 个月时疼痛性骨折，愈合不良（少于 3 个皮质桥接骨），需要进行翻修手术以达到愈合。深部感染根据骨折相关感染共识小组的确认标准定义。研究中的一名 fellowship-trained orthopaedic trauma surgeon 对这些结果进行了评估。并发症的比例进行了制表。Kaplan-Meier 图表显示了深部感染的发生部位（近端、骨干或远端）。单变量统计和多变量 Cox 回归用于研究深部感染与骨折部位、入口伤口大小、血管损伤、急诊室（ED）静脉（IV）抗生素、深部和浅层清创、术后 IV 抗生素的持续时间以及局部抗生素的使用之间的关系，同时调整了年龄、种族/民族、吸烟状况和 BMI。对深部感染结果的功效分析表明，我们必须观察到骨干与近端部位的比值比为 4.28 或更高，才能在 80%的功效和α=0.05 的水平上检测到统计学显著结果。
总的并发症发生率为 49%（59/121），感染率为 14%（17/121），伤口并发症率为 27%（33/121），骨不连率为 20%（24/121），内固定断裂率为 9%（11/121），翻修手术率为 26%（31/121）。深部感染与深部清创术呈正相关（HR 5.51[95%置信区间 1.12 至 27.9]；p=0.04）。在可用的数字中，我们没有发现深部感染与骨折部位、入口伤口大小、血管损伤、ED 静脉抗生素、浅层清创术、术后 IV 抗生素的持续时间和局部抗生素的使用之间的关联。
在这项多中心研究中，我们发现手术治疗的枪击引起的胫骨骨折的并发症风险高于之前的研究报告。特别是感染比之前的研究报告更为常见。因此，外科医生可能会考虑采用一般的非枪击引起的开放性胫骨骨折的治疗原则来治疗枪击引起的骨折，例如在初始和手术后都使用静脉抗生素。需要进一步的研究来测试和验证这些方法。
IV 级，治疗性研究。
