Discussion
Ballistic fractures have been increased in the last two decades and made splash in order to establish new therapeutic algorithms and reduce the morbidity rate . Unfortunately, there is a lack of high-level evidence guiding management. According to previous studies gunshot injuries to the hip joint accounts for two percent of all limb gunshot injuries and open reduction and internal fixation is suggested as preferred treatment in acute phase .
Remarkable, hip arthroplasty is preserved for failed fixations.The ration of this algorithm may refer to the high complication rate after hip joint gunshot injuries since poor functional results reported in cases of acetabulum fracture and contamination with bowel contents . However, the severity of injury and contamination varies from case to case . Although vascular injuries condemned as risk factor for infection after low velocity intra-articular gunshot injury, in a recent study there were no risk factor for infection in such injuries.
The major consideration in hip joint GSI is decision making about delayed vs. immediate hip arthroplasty with regard to high contamination possibility since Weinstein et al. showed all bullet tracks are grossly contaminated with foreign materials.
Naziri et al. evaluated the outcome and complications of THA in nine patients with secondary arthritis due to prior GSI. Although THA in these patients was technically demanding, the outcome was surprising and comparable to primary THA due to degenerative joint disease. Georgidiasis et al. reported a 22-year-old male with hip GSI and femoral neck fracture treated with internal fixation and valgus osteotomy. Pazraci et al. showed that THA after debridement is a feasible treatment in young patients with a history of hip GSI; although the poor post-operative harris hip score (65.5%) after THA in hip joint gunshot injuries. They included 10 patients and operated them four to eight months after injury. Intestinal injury was associated with high infection rate. Ozden et al. demonstrated that THA is an effective option to improve patients with secondary hip arthritis due to previous hip GSI. Martin et al. reported a 70-year-old female with hip GSI resulted in femoral head and acetabulum fracture. She was treated with open reduction and internal fixation of acetabulum, as well as bipolar hemiarthroplasty. Bell et al. reported a 39-year-old with hip GSI and comminuted fracture of femoral head and neck who undergone staged arthroplasty after initial placement of an antibiotic spacer.
Here, in our study, we describe a two sequential management for THA in a young male after hip GSI. Since, there was a severe comminution in acetabulum and femoral head and the post-trauma arthritis was amenable, we just reconstruct the posterior column and avoid more soft tissue manipulation. After achieving bone union THA was done to improve his function.
In conclusion, hip GSI deserves multidisciplinary approach and managing the soft tissue as well as decreasing infection rate in secondary THA. Delayed THA with a two-step sequential approach is a feasible management in this situation.
Acknowledgment: none
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