Abstract
Background:
Although the rate of non-fatal gunshot wounds (GSW) has increased, few studies have compared the effectiveness of operative and nonoperative treatment with specific focus on infection. We compared the risk of septic arthritis in patients with traumatic arthrotomies caused by GSW treated operatively with irrigation and debridement versus nonoperatively with antibiotics and wound care.
Methods:
From 2009 to 2016, 46 patients at our institution sustained traumatic arthrotomies from low-velocity GSW with at least 90-day follow-up. Medical records were reviewed for demographic information, imaging, type and duration of antibiotics, details of operative and nonoperative interventions, and evidence of infection at follow-up visits. We measured the rate of septic arthritis using a 2-tailed t test.
Results:
The knee was the most commonly affected joint (34 patients; 73.9%). Eight patients (17.4%) were treated nonoperatively and 38 (82.6%) were treated operatively. In the nonoperative group, one patient (12.5%) developed a superficial wound infection that resolved with oral antibiotics. In the operative group, one patient (2.6%) developed a superficial wound infection requiring operative irrigation and debridement. There was no statistically significant difference in risk of infection between the two groups (P = 0.32). No patient developed septic arthritis.
Conclusions:
In select patients, nonoperative treatment with wound care and antibiotics may be sufficient for preventing infection after GSW-related traumatic arthrotomies. Findings of randomized studies and treatment algorithms are needed to further evaluate this relatively common injury.
Level of Evidence: IV
Keywords: septic arthritis, gunshot, arthrotomy, antibiotics
Introduction
The clinical importance of infections from ballistic injuries is as relevant today as it was in 1881 for United States President James Garfield, who died of sepsis 79 days after a gunshot wound to his right shoulder and back.1 Firearm-related injuries in the United States are common and accounted for an average of 67,197 emergency department visits between 2010 and 2012.2 Although the rate of fatal firearm injuries has remained grossly unchanged, the rate of non-fatal firearm injuries has continued to rise in the past decade.3 About 49% to 67% of these injuries occur in the extremities.2 Management of firearm injuries has been well described, particularly regarding fracture care.4–13 Fractures caused by gunshot wounds (GSW) are generally defined as open injuries, although they constitute a unique problem owing to infection risk, soft tissue injury, and fracture stabilization.14
Ballistic injuries have been classified as low velocity (< 609.6 m/sec) and high velocity (> 609.6 m/sec). However, physical characteristics of the projectile, kinetic energy, entrance profile, and biologic characteristics of the soft tissue all play considerable roles in the extent of injury.14,15 Studies have shown that low-velocity bullets should be considered nonsterile;16,17 but use of antibiotic prophylaxis has not significantly altered infection rates in patients undergoing nonoperative treatment of low-velocity gunshot-induced fractures.6 Furthermore, controversy remains as to the extent of superficial versus deep extensive debridement in low-velocity GSW with stable fracture patterns.5
Some studies have proposed algorithms for treating intraarticular GSW,7,10 yet few data exist comparing operative and nonoperative treatments of these injuries. The aim of this study was to compare the risk for developing septic arthritis between operative treatment with irrigation and debridement (I&D) and nonoperative treatment with antibiotics and wound care of patients with traumatic arthrotomies caused by GSW.
Methods
Institutional review board approval was obtained for this study. The authors reviewed consult logs of all patients seen by the orthopaedic service at a level I trauma center from August 2009 to August 2016. A total of 109 patients with GSW were identified. Inclusion criteria were a positive saline load test or GSW near the shoulder, elbow, wrist, hip, knee or ankle. Patients were considered to have traumatic arthrotomies on the basis of a positive saline load test18 or presence of gas within the joint on computed tomography scans.19 Exclusion criteria were no follow-up within 90 days of injury, high-velocity GSW, or shotgun-related injuries.
A total of 46 patients with 46 traumatic GSW-related arthrotomies met inclusion criteria (Table 1). The average age was 32.6+/-15.9 years. Thirty-seven patients (80.4%) were men and 9 (19.6%) were women. Thirteen patients (27.7%) were uninsured, 27 (57.4%) had some form of government-assisted insurance, and 7 (14.9%) had private insurance. Thirty-four patients (73.9%) had an associated fracture with their arthrotomy. Most injuries were to the knee joint (34 patients, 73.9%).
Table 1.
Characteristics of 46 Patients with Gunshot Wounds
| Variable | No. Patients (%)* |
|---|---|
| Mean age, y +/-SD | 32.6+/-15.9 |
| Sex | |
| Male | 37 (80.4) |
| Female | 9 (19.6) |
| Insurance | |
| Uninsured | 13 (27.7) |
| Government | 27 (57.4) |
| Private | 7 (14.9) |
| Joints affected | |
| Knee | 34 (73.9) |
| Elbow | 4 (8.7) |
| Wrist | 2 (4.3) |
| Hip | 2 (4.3) |
| Shoulder | 4 (8.7) |
Values in the column reflect number of patients (and percentage) unless noted in the variable.
The medical records of each patient (n=46) were reviewed for demographic information, imaging, type and duration of antibiotics, details of any operative and nonoperative interventions, and evidence of infection at follow-up visits. Superficial infection, deep infection, and joint infection were defined according to the 2008 Centers for Disease Control and Prevention’s National Healthcare Safety Network criteria.20 Data were evaluated with 2-tailed t test. Statistical significance was set at alpha = 0.05.
Results
All 46 patients underwent bedside wound care. Forty-five were treated with prophylactic antibiotics. One patient left against medical advice before receiving antibiotics. Cefazolin was the most commonly used antibiotic. Details of antibiotic administration are shown in Table 2.
Table 2.
Antibiotics Administered to 46 Patients with Gunshot Wounds Treated Operatively (n=38) and Nonoperatively (n=8)
| Antibiotics | Operative Group No. Patients (%) | Nonoperative Group No. Patients (%) | Total |
|---|---|---|---|
| None | 0 | 1 (12.5) | 1 |
| Cefazolin | 32 (84.2) | 2 (25) | 34 |
| Cephalexin | 0 | 1 (12.5) | 1 |
| Cefazolin + other | 5 (13.1) | 4 (50) | 9 |
| Clindamycin + doxycycline | 1 (2.6) | 0 | 1 |
Owing to wound appearance, associated injuries, and surgeon preference, eight patients (17.4%) were treated nonoperatively and 38 patients (82.6%) were treated operatively within 48 hours. Table 3 shows treatment methods of patients treated nonoperatively and operatively. Two of the 8 patients treated nonoperatively and 1 of the 38 patients treated with I&D underwent arthroscopic removal of bullet fragments at 6 weeks after the injury.
Table 3.
Treatment Methods of Patients with Gunshot Wounds Treated Operatively (n=38) and Nonoperatively (n=8)
| Treatment | Operative Group No. Patients (%) | Nonoperative Group No. Patients (%) |
|---|---|---|
| Cefazolin with home antibiotics | -- | 7 (87.5%)** |
| No antibiotics | -- | 1 (12.5%) |
| I&D without arthrotomy | 7 (18.4%) | -- |
| I&D with fracture fixation | 2 (5.3%) | -- |
| I&D with open arthrotomy | 12 (31.6%) | -- |
| I&D with arthroscopy | 5 (13.1%) | -- |
| I&D with arthrotomy and fracture fixation | 12 (31.6%)* | -- |
Abbreviations: --, not applicable; I&D, irrigation and debridement.
*Of the 12 patients, one developed a wound infection.
**Of the 7 patients, one developed a wound infection.
Outcomes
No patient developed septic arthritis. Patients in the nonoperative group received an average 2.4 doses of cefazolin at 8-hour intervals, followed by a 5-day course of cephalexin. Two patients developed superficial infections. In the nonoperatively treated group, one patient (12.5%) presented with an erythematous wound at 4 weeks after injury, which resolved after completing an extended oral course of cephalexin. In the operatively treated group, one patient (2.6%) presented with an associated metadiaphyseal femur fracture treated with I&D and retrograde femoral nail fixation. He returned to clinic at 12 days after injury with purulent drainage from his wound and underwent superficial I&D. The patient had no intraoperative evidence of deep-space infection in the joint. Intraoperative cultures revealed methicillin sensitive staphylococcus aureus. This patient was administered a 48-hour course of cefazolin followed by 2 weeks of cephalexin. His fracture and wounds went on to heal uneventfully.
Discussion
The aim of our study was to evaluate the occurrence of septic arthritis in patients with intraarticular, low-velocity GSW treated operatively versus nonoperatively. Notably, we found a low rate of infection regardless of the type of treatment. This suggests a low risk for infection after appropriate treatment of intraarticular GSW and success with nonoperative treatment.
In general, the strict indications for operative treatment with I&D of GSW include fractures requiring internal fixation, large intraarticular loose osteoarticular fragments, or large bullet fragments remaining in the joint.21 Multiple studies22,23 have shown a risk of lead absorption from intraarticular bullet fragments, and this remains an indication for I&D and bullet removal. However, I&D can result in anesthetic and postoperative risks to patients and substantial healthcare costs.24 Patients undergoing I&D typically spend at least one night in the hospital, whereas those treated nonoperatively could potentially be discharged from the emergency department. To justify the risks and expense of operative treatment, demonstrable improvement in outcomes are needed. The current study findings indicate that equal outcomes (ie, prevention of infection) can be achieved nonoperatively. Thus, the goal of preventing infection may not single-handedly justify operative treatment with I&D of intraarticular GSW.
In patients with minimal soft tissue injury and minimal wound contamination, I&D may only result in further damage to surrounding tissues. Regarding small clean traumatic arthrotomies from a low-velocity GSW, extending the arthrotomy for formal I&D may not always be necessary and can contribute to morbidity such as stiffness. In the current study, eight patients treated without formal I&D in the operating room developed no deep infections or septic arthritis. Our results are similar to that of Nguyen et al.7 in which 24 patients with intraarticular GSW were treated nonoperatively and did not develop deep infections. Low-velocity GSW violating a joint without considerable soft tissue injury or contamination may be treated safely nonoperatively with prophylactic antibiotics and bedside I&D. Although some studies have found a high incidence of intraarticular meniscal and ligamentous injuries after GSW,4,25,26 proceeding to the operating room should be undertaken based on intraarticular pathological features (foreign body removal) or fracture patterns rather than the basis alone that a traumatic arthrotomy occurred.
There were limitations to this study. This was a retrospective review subject to inherit selection bias. Furthermore, numerous patients were treated operatively for indications other than infection control such as fracture fixation. Additionally, the decision for operative or nonoperative treatment was made at the discretion of several different treating surgeons, with no pre-defined criteria. The study was also limited by fewer number of patients and infections. A post-hoc analysis revealed that 110 patients in each group would be necessary to reach 80% power. The study is underpowered to clearly prove an acceptable infection rate with nonoperative treatment. The results of the 8 patients treated nonoperatively with no joint infections suggests this treatment may be effective and worth investigating in a larger randomized study.
The current study found low rates of infection in intraarticular, low-velocity GSW treated with or without operative intervention. Indications for operative treatment of intraarticular GSW include the need for fracture fixation or removal of intraarticular osteochondral fragments and bullet fragments. If selected appropriately, patients with intraarticular GSW may be safely treated nonoperatively without an increased risk of infection compared to those treated operatively.
Acknowledgements
The authors thank Sahar Freedman, BA, and Dustin Richter, MD, for assistance with institutional review board submission and manuscript editing. The authors also thank Daniel Wascher, MD, for reviewing the manuscript.
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