Case of Gunshot Wound Resulting in Femoral Neck Fracture Treated With Staged THA - report

New Jersey, USA: Bell et al reported a case of a patient who sustained comminuted femoral head and neck fractures and significant soft-tissue injury secondary to a gunshot wound who was successfully treated with staged THA.

A 39-year-old healthy male, with no significant medical or surgical history, presented with a trauma with multiple gunshot wounds. He reported abdominal, left thigh, and flank pain.

On physical examination, he had 7 gunshot wounds involving his abdomen, left flank, buttock, lateral distal thigh, posterior medial thigh, and right medial and lateral thigh. He was neurovascularly intact in bilateral lower extremities.

Radiographs of his left hip demonstrated comminuted femoral head and neck fractures with multiple bullet fragments.

The patient was hemodynamically unstable with an abdominal gunshot wound, so he was taken from the emergency department directly to the operating room for an emergent abdominal exploratory laparotomy and started on intravenous ertapenem. At that time, 2 gunshot wounds were identified within the small bowel, which resulted in a small bowel resection and primary anastomosis. An additional gunshot wound and serosal tear were found in the sigmoid colon, and the tear was repaired without complications.

A computed tomography scan was subsequently obtained, which demonstrated left comminuted femoral head and neck fractures with comminution of the greater trochanter and intraarticular bullet fragments.

Owing to the fracture pattern and retained intraarticular bullet fragments, 2 days after the initial injury, the patient was taken for irrigation and debridement of the hip through a posterior approach to the joint with staged reconstruction including an antibiotic cement spacer, treatment with intravenous antibiotics, and a delayed THA. At the time of surgery, the degree of soft-tissue injury was significant with no identifiable tissue planes and edema. Staging allowed for resolution of the acute local trauma to more optimized conditions for arthroplasty and prophylaxis against infection. Initial surgical management included irrigation and debridement with 12 liters of irrigation and placement of an antibiotic cement spacer. Simplex P with tobramycin bone cement plus an additional 2 grams of vancomycin and 1 gram of tobramycin per bag of cement was used.

The fracture of the greater trochanter was repaired with heavy nonabsorbable sutures as the fracture was not displaced, and this avoided the use of implants within a contaminated field.

Postoperatively, he was toe-touch weight bearing on the left lower extremity and received 48 hours of intravenous piperacillin-tazobactam. He was discharged home on 6 weeks of oral-amoxicillin-clavulanate, 500 milligrams, 3 times a day. His intraoperative tissue and fluid cultures resulted in no growth.

The patient was lost to follow-up after 12 weeks postoperatively because of difficult social circumstances. He presented to the clinic at 12 weeks after antibiotic spacer placement and was ambulating with a cane.

He was then admitted for medical evaluation before second-stage reconstruction, and erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were obtained, which were normal for our laboratory references at 14 and 8 mg/L, respectively.

An aspiration of the hip before the second-stage surgery was recommended; however, the patient declined. At 13 weeks postoperatively, the articulating spacer was removed, and THA was performed. Intraoperative cultures remained negative. Postoperatively, the patient was weight bearing as tolerated. Overall, the procedure and postoperative recovery were uneventful. The patient was discharged home without further antibiotics.

The patient presented for follow-up at 6 weeks postoperatively. At that time, the incision was completely healed without signs of complication. The patient was able to bear full weight without the need for an assistive device. Radiographs appeared stable. At 2 years postoperatively, the patient was walking with a normal gait pattern with no limp or pain. He returned to normal activities with no local hip discomfort and remained free of signs of infection.

This case report discusses the uncommon clinical presentation where THA was indicated in the acute setting after a bullet injury involving the hip joint. Owing to the severity of soft tissue insult and the concern for periprosthetic joint infection secondary to the bullet fragment involving the hip joint, reconstruction was staged with an initial emphasis on irrigation and debridement, removal of intraarticular bullet fragments, and prophylactic antibiotics to avoid infection.

Further reading :

Gunshot Wound Resulting in Femoral Neck Fracture Treated With Staged Total Hip Arthroplasty

Courney Bell, Hope E. Skibicki, Zachary D. Post, Alvin C. Ong, Danielle Y. Ponzio,

https://doi.org/10.1016/j.artd.2021.12.010