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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