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Antibiotic prophylaxis following low-velocity gunshot fractures: an updated review

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Abstract

Purpose

Low-velocity gunshot fractures (LVGFs) are a common type of gunshot-induced trauma with the potential for complications such as infection and osteomyelitis. The effectiveness of antibiotic therapy in LVGFs remains uncertain, leading to ongoing debate about the appropriate treatment. In this review, we evaluate recent updates on the current understanding of antibiotic therapy in LVGFs, how previous studies have investigated the use of antibiotics in LVGFs, and the current state of institutional policies and protocols for treating LVGFs with antibiotics.

Methods

We conducted a review of PubMed, Embase, and Web of Science databases to identify studies that investigated the use of antibiotics in LVGFs after the last review in 2013. Due to the lack of quantitative clinical trial studies, we employed a narrative synthesis approach to analyze and present the findings from the included primary studies. We categorized the outcomes based on the anatomical location of the LVGFs.

Results

After evaluating 67 publications with the necessary qualifications out of 578 abstracts, 17 articles were included. The sample size of the studies ranged from 22 to 252 patients. The antibiotics used in the studies varied, and the follow-up period ranged from three months to ten years. The included studies investigated the use of antibiotics in treating LVGFs at various anatomic locations, including the humerus, forearm, hand and wrist, hip, femur, tibia, and foot and ankle.

Conclusion

Our study provides updated evidence for the use of antibiotics in LVGFs and highlights the need for further research to establish evidence-based guidelines. We also highlight the lack of institutional policies for treating LVGFs and the heterogeneity in treatments among institutions with established protocols. A single-dose antibiotic approach could be cost-effective for patients with non-operatively treated LVGFs. We suggest that a national or international registry for gunshot injuries, antibiotics, and infections could serve as a valuable resource for collecting and analyzing data related to these important healthcare issues.

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Data availability

Data provided in supplementary files.

References

  1. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL (2015) Firearm injuries in the United States. Prev Med 79:5–14

    Article  PubMed  PubMed Central  Google Scholar 

  2. Lee J, Quraishi SA, Bhatnagar S, Zafonte RD, Masiakos PT (2014) The economic cost of firearm-related injuries in the United States from 2006 to 2010. Surgery 155(5):894–898

    Article  PubMed  Google Scholar 

  3. Hinsley D, Phillips SL, Clasper JC (2006) Ballistic fractures during the 2003 Gulf conflict—early prognosis and high complication rate. BMJ Mil Health 152(2):96–101

    CAS  Google Scholar 

  4. Gustilo RB (1979) Use of antimicrobials in the management of open fractures. Arch Surg 114(7):805–808

    Article  CAS  PubMed  Google Scholar 

  5. Gustilo RB, Anderson JT (2002) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. JBJS 84(4):682

    Article  Google Scholar 

  6. Patzakis MJ, Harvey JP Jr, Ivler D (1974) The role of antibiotics in the management of open fractures. JBJS 56(3):532–541

    Article  CAS  Google Scholar 

  7. Hampton OP Jr (1961) The indications for debridement of gun shot (bullet) wounds of the extremities in civilian practice. J Trauma Acute Care Surg 1(4):368–372

    Article  Google Scholar 

  8. Howland WS Jr, Ritchey SJ (1971) Gunshot fractures in civilian practice: an evaluation of the results of limited surgical treatment. JBJS 53(1):47–55

    Article  Google Scholar 

  9. DeMUTH WE (1966) Bullet velocity and design as determinants of wounding capability: an experimental study. J Trauma Acute Care Surg 6(2):222–232

    Article  Google Scholar 

  10. Papasoulis E, Patzakis MJ, Zalavras CG (2013) Antibiotics in the treatment of low-velocity gunshot-induced fractures: a systematic literature review. Clin Orthop Relat Res 471:3937–3944

    Article  PubMed  PubMed Central  Google Scholar 

  11. Vaidya R, Sethi A, Oliphant BW, Gibson V, Sethi S, Meehan R (2014) Civilian gunshot injuries of the humerus. Orthopedics 37(3):e307–e312

    Article  PubMed  Google Scholar 

  12. Mehta SK, Dale WW, Dedwylder MD, Bergin PF, Spitler CA (2018) Rates of neurovascular injury, compartment syndrome, and early infection in operatively treated civilian ballistic forearm fractures. Injury 49(12):2244–2247

    Article  PubMed  Google Scholar 

  13. Veltre DR, Tornetta P III, Krause P, George MP, Vallier H, Nguyen MP et al (2021) Gunshot fractures of the forearm: a multicenter evaluation. J Orthop Trauma 35(10):e364–e370

    Article  PubMed  Google Scholar 

  14. Nguyen MP, Reich MS, O’donnell JA, Savakus JC, Prayson NF, Golob JF Jr et al (2017a) Infection and complications after low-velocity intra-articular gunshot injuries. J Orthop Trauma 31(6):330–333

    Article  PubMed  Google Scholar 

  15. Nguyen MP, Savakus JC, O'Donnell JA, Prayson NF, Reich MS, Golob JF Jr et al (2017b) Infection rates and treatment of low-velocity extremity gunshot injuries. J Orthop Trauma 31(6):326–329

    Article  PubMed  Google Scholar 

  16. Donahue J, Heimke I, Cho E, Furdock R, Vallier HA (2022) Early results of low-velocity ballistic femoral shaft fractures. Injury 53(11):3810–3813

    Article  PubMed  Google Scholar 

  17. Patch DA, Levitt EB, Andrews NA, Heatherly AR, Bonner HV, Halstrom JR et al (2022) Civilian ballistic femoral shaft fractures compared with blunt femur shaft fractures. J Orthop Trauma 36(7):355–360

    Article  PubMed  Google Scholar 

  18. Shultz CL, Schrader SN, Garbrecht EL, DeCoster TA, Veitch AJ (2019) Operative versus nonoperative management of traumatic arthrotomies from civilian gunshot wounds. Iowa Orthop J 39(1):173

    PubMed  PubMed Central  Google Scholar 

  19. Lee, C., Brodke, D. J., Engel, J., Schloss, M. G., Zaidi, S. M. R., O’Toole, R. V., . . . Bergin, P. F. (2021). Low-energy gunshot-induced tibia fractures: what proportion develop complications? Clin Orthop Relat Res, 479(8), 1793.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Nguyen MP, Como JJ, Golob JF Jr, Reich MS, Vallier HA (2018) Variation in treatment of low energy gunshot injuries—a survey of OTA members. Injury 49(3):570–574

    Article  PubMed  Google Scholar 

  21. Donnally CJ III, Lawrie CM, Sheu JI, Gunder MA, Quinnan SM (2018) Primary intra-medullary nailing of open tibia fractures caused by low-velocity gunshots: does operative debridement increase infection rates? Surg Infect 19(3):273–277

    Article  Google Scholar 

  22. Husain ZS, Schmid S, Lombardo N (2016) Functional outcomes after gunshot wounds to the foot and ankle. J Foot Ankle Surg 55(6):1234–1240

    Article  PubMed  Google Scholar 

  23. Shelton WL, Krause PC, Fox R, Lowe M, DeLatin L, Leonardi C et al (2023) Risk of infection following gunshot wound fractures to the foot and ankle: a multicenter retrospective study. J Foot Ankle Surg 62(1):50–54

    Article  PubMed  Google Scholar 

  24. Bauhahn G, Veen H, Hoencamp R, Olim N, Tan EC (2017) Malunion of long-bone fractures in a conflict zone in the Democratic Republic of Congo. World J Surg 41:2200–2206

    Article  PubMed  Google Scholar 

  25. Woolum JA, Bailey AM, Dugan A, Agrawal R, Baum RA (2020) Evaluation of infection rates with narrow versus broad-spectrum antibiotic regimens in civilian gunshot open-fracture injury. Am J Emerg Med 38(5):934–939

    Article  PubMed  Google Scholar 

  26. Naranje, S. M., Gilbert, S. R., Stewart, M. G., Rush, J. K., Bleakney, C. A., McKay, J. E., . . . Sawyer, J. R. (2016). Gunshot-associated fractures in children and adolescents treated at two level 1 pediatric trauma centers. J Pediatr Orthop, 36(1), 1-5.

    Article  PubMed  Google Scholar 

  27. Perkins C, Scannell B, Brighton B, Seymour R, Vanderhave K (2016) Orthopaedic firearm injuries in children and adolescents: an eight-year experience at a major urban trauma center. Injury 47(1):173–177

    Article  PubMed  Google Scholar 

  28. Chang Y, Bhandari M, Zhu KL, Mirza RD, Ren M, Kennedy SA et al (2019) Antibiotic prophylaxis in the management of open fractures: a systematic survey of current practice and recommendations. JBJS Rev 7(2):e1

    Article  PubMed  Google Scholar 

  29. Su CA, Nguyen MP, O’Donnell JA, Vallier HA (2018) Outcomes of tibia shaft fractures caused by low energy gunshot wounds. Injury 49(7):1348–1352

    Article  PubMed  Google Scholar 

  30. Watters WC III, Baisden J, Bono CM, Heggeness MH, Resnick DK, Shaffer WO, Toton JF (2009) Antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery. Spine J 9(2):142–146

    Article  PubMed  Google Scholar 

  31. Mellinghoff SC, Otto C, Cornely OA (2019) Surgical site infections: current management and role of new antibiotics. Curr Opin Infect Dis 32(5):517–522

    Article  PubMed  Google Scholar 

  32. Nguyen MP, Savakus JC, Reich MS, Golob JF Jr, McDonald AA, Como JJ, Vallier HA (2021) Costs of care for low-energy extremity gunshot injuries are reduced with standardized treatment. J Orthop Trauma 35(2):e61–e63

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, RN123A, Boston, MA, 02215, USA

    Mohammad Khak, Mohammad Javad Shariyate, Juan Bernardo Villarreal-Espinosa, Nadim Kheir, Kaveh Momenzadeh & Ara Nazarian

  2. Knowledge Services, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Megan McNichol

  3. J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA

    Paul Appleton, John J. Wixted & Edward K. Rodriguez

  4. Department of Orthopaedic Surgery, Yerevan State University, Yerevan, Armenia

    Ara Nazarian

Authors
  1. Mohammad Khak
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  2. Mohammad Javad Shariyate
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  3. Juan Bernardo Villarreal-Espinosa
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  4. Nadim Kheir
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  6. Megan McNichol
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  7. Paul Appleton
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  10. Ara Nazarian
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Contributions

All authors contributed to the study’s conception and design. Material preparation, data collection, and analysis were performed by Mohammad Khak, Mohammad Javad Shariyate, Juan Bernardo Villarreal-Espinoza, Nadim Kheir, Kaveh Momenzadeh, and Megan McNichol. The first draft of the manuscript was written by Mohammad Khak. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Ara Nazarian.

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Khak, M., Shariyate, M.J., Villarreal-Espinosa, J.B. et al. Antibiotic prophylaxis following low-velocity gunshot fractures: an updated review. International Orthopaedics (SICOT) 48, 37–47 (2024). https://doi.org/10.1007/s00264-023-06052-w

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  • DOI: https://doi.org/10.1007/s00264-023-06052-w

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