Elevated Risk of Infection and Reoperation in Low-Energy Gunshot Tibial Fractures: A Comparative Analysis

To investigate the deep infection and reoperation rates associated with low-energy gunshot wound (LE-GSW) tibial shaft fractures and compare outcomes to fractures caused by blunt-force mechanisms and to analyze the microbial profile of infections in these cases.

Design : Retrospective cohort study.

Three Level 1 trauma centers in a large urban health system from 2014 to 2024.

Included were patients aged 16-65 years with tibial shaft fractures (OTA/AO 41A2-3, 42A-C, and 43A) treated with intramedullary nails (IMN) following LE-GSW or blunt-force mechanisms. Exclusions were pre-existing infections, high-velocity gunshot wounds, less than 6 weeks of follow-up, or delayed presentation (greater than 24 hours).

Primary outcomes included deep infection and unplanned reoperations. Patients were categorized into closed fractures, LE-GSWs, Type I/II, and Type III open fractures. Data between these categories were compared using chi-square, Fisher's exact, and ANOVA with multivariable logistic regression.

Included were 195 patients (mean age 37.6 years, range 17-65; M:F ratio 136:59). Fractures were closed (n=68), Type I/II (n=55), Type III (n=37), and LE-GSWs (n=35). LE-GSWs had significantly higher deep infection (34.3%) and reoperation rates (57.1%) compared to closed fractures (1.5% and 13.2%, respectively, p<0.001). Type III infection rates were 16.2%. Multivariable analysis confirmed LE-GSWs as a significant risk factor for both infection (OR 4.26, p=0.003) and reoperations (OR 3.51, p=0.002). Infections in LE-GSW fractures were predominantly polymicrobial and Gram-positive.

LE-GSW tibial fractures were associated with high rates of deep infection and reoperation with infection rates comparable to those of Type III open fractures. Treatment options such as broader prophylaxis or local antibiotic treatments should be considered in their initial management.

Level III - Retrospective Cohort Study.