Comparison of Outcome in Immediate Vs Delayed Management in Patients with Gunshot Injuries to Face, A Prospective Study

Methods: A descriptive cross-sectional study consisting of 60 patients getting their treatment in Department of Oral and Maxillofacial Surgery, Mayo hospital, Lahore. Data were analyzed by SPSS version 20.0. Chi-square test was used to compare the results with p-value ≤ 0.05 as signi�cant. Results: Age group on average was 21 to 60 years. Out of these 60 gunshot facial injury patients, 52 (86.7%) were males and 8 (13.3%) were females. Among these, patients managed with immediate closure after gunshot injuries were 44 (73.3%) and 16 (26.7%) were managed with delayed closure. Wound infection and wound dehiscence were compared in both groups. The mean wound defect size was found among patients 3.98 ± 1.30cm. Statistically signi�cant difference was observed for wound infection and wound dehiscence among both immediate versus delayed groups (p-value < 0.05). Conclusions: In this study, we found that early management is better in terms of lower percentage of wound infection and dehiscence.

to face and placed in group A or delayed management were placed in group B. In group A, all patients having gunshot injuries to the face were reconstructed immediately within one week after injury with miniplates and skin grafts to close the facial skin defects if needed as the decision will be totally clinical and taken per operative.In group B, all patients having gunshot injuries to the face were managed after rst week of injury.There was delay in management due to unavoidable circumstances such as patients presenting late after sustaining rearm injury, patients with poor general health until improved and those with severe concomitant.Follow up of patients done after two weeks and after one month for the assessment of complications i.e. wound.All this information was recorded on a predesigned proforma attached.

PJHS VOL. 4 Issue. 2 February 2023
Copyright © 2023.PJHS, Published by Crosslinks International Publishers undergone necrosis to prevent infection and minimization of wound tension.Con icting opinion was observed among researches as to whether immediate or delayed treatments should be done [5].In some researches, early management of gunshot wounds results in better psychosocial pro le, aesthetics, reduced hospital stay and early return to function.While in others, late repair followed by clean incisions of wounds in the past delayed management was advocated [6].However, delayed reconstruction may lead towards permanent deformity in facial expressions and delayed wound healing [7].Similarly, there are challenges carrying out early intervention such as concomitant injuries to other parts of body, swelling, edema of soft tissues, loosened teeth, mobile bony fragments which may make treatment complex [8].In high-velocity or blast injuries, primary or single stage surgery is not su cient to clear the debridements; however, primary management is signi cant in soft tissue contracture and reassure coverage for osseous reconstruction [9].There are con icting data regarding early and late closure of gunshot wounds.In a study conducted by Clark et al. shows insigni cant difference between two treatment modalities [10].The data shows 45.8% patients show complication (in terms of wound dehiscence or infection) with early intervention while 50% shows complications with delayed management with p-2 value > 0.05.However, another study shows that 58.8% patients presenting for immediate closure after gunshot injuries and only 20% of patients with early management came with complications of wound discharge and infection [11].
Descriptive Cross-sectional study was carried out in the Department of Oral and Maxillofacial Surgery, Mayo Hospital, allied with King Edward Medical University Lahore, a tertiary care Sample size of 60 cases was calculated with 95% con dence level after gunshot injury.Non-probability Consecutive sampling technique was used.The diagnosis was on clinical basis selected from Emergency Department of Oral Maxillofacial Surgery, Mayo Hospital.An informed consent was obtained from them or their parents for using their data for research and procedure was explained to them.No ethical issues or risk involved to patient.Computed tomography had performed to assess bony defects and fractures of mid face, defect size or nature of injury was assessed clinically and radio graphically.Correction of fractures had done with proper reduction and xation.Fixation of the fractured bones had done with miniplates according to the standard guidelines.Patients presenting in hospital emergency were sorted to receive either immediate management for gunshot injuries

R E S U L T S
Data were entered and analyzed in SPSS version 20.0.Mean and standard deviation was calculated for quantitative variables like age of patient and defect size of wound and number of infections.There were total 60 patients with gunshot injuries to the face who were enrolled in this study after taking an informed consent.The mean age of the patients was 34.9 ± 11.04 years of which the minimum age was 21 year and maximum of 60 years.Out of these 60 patients 52 (86.7%) were males and 8 (13.3%) were females (Table 1).Wound infection was observed in 11 (18.3%) of total patients; among these 5 (11.4%) were examined in immediate closure group and 6 (37.5%) were came acrossed at delayed closure group.It was revealed that highest percentage of wound infection was noticed in delayed group and the difference between both groups was found statistically signi cant with the p-value = 0.021(Table 3).
closures and wound infections were 37.5% which was signi cantly high than immediate closure.Ideally, closure should occur within the rst 8 hours after injury [16].A meta-analysis done by Bhattacharya concluded that the management of facial injuries should be followed by immediate closure.The complex injuries can later be managed by secondary closure of complex tissues r e a r r a n g e m e n t [ 1 7 ] .S o c i o d e m o g r a p h i c , c o s t effectiveness and cost analysis are important factors that are associated with a surgical intervention.The primary and immediate closure are found to be cost effective that the delayed closures due to cosmetology surgery involvement.Cost analysis was nor a parameter included in our study as the study setting was in government funded tertiary care hospital of Lahore [18].Mitchener and Canham-Chervak proved de nitive repair of bony and soft tissue injuries must be done in single operation.It improves the functional quality and outcomes of the wounds and in high-velocity or blast injuries, primary or single stage surgery is not su cient to clear the debridement's; however, primary management is signi cant in soft tissue contracture and reassure coverage for osseous reconstruction [19].Free ap reconstruction is done in patients who had complex facial injuries.De nitive primary closure must be done.And it decreases the number of multiple stage surgeries and reduce the morbidities and incidence of wound infections.In our study total of 4 (6.7%)face gunshot injury patients were observed with wound dehiscence post-operatively at one month follow-up out of which 1 (2.3%) vs 3 (18.8%)were treated for wound dehiscence in immediate versus delayed closure group respectively.It seems that risk is high in the delayed closure group and differ signi cantly with the immediate group i.e., p-value= 0.024 [20].Contaminations and wound infections are not considered among surgical procedure managements, immediate or delayed, by the postoperative care proven to be the leading factors by certain researchers [21].Tomotography and angiography, the two surgeries that have been found very bene cial for the cranio facial reconstruction of free ap for non-traumatic cases and for traumatic cases that have rather lowerextremity of the injuries, both the surgeries have not been found very bene cial or useful for other traumatic wounds [22] Aveta and Caseati have concluded that the general principles of the surgical procedure are very useful for less complex facial injuries of the soft tissues but for other patients with special cases have to deal with different proximities of the trauma of facial injuries, these special patients were evacuated to a level I trauma center, that enabled the gunshot and battle eld facial wounds to be managed with much discipline and with greater e ciency, just like other types of facial wounds The goal of this study was to assess the outcome of early surgical intervention versus delayed intervention in patients suffering from facial gunshot injuries in terms of complications associated with either treatment option.No local study has compared both early and delayed intervention.While the international data by Suominen and Tukiainen showed difference in results [12].In one study there was insigni cant difference between outcomes of two types of intervention while other study favors early intervention [13].These con icting results provide a rationale for our study so that we can assess which treatment option is better than other [14].The soft tissue injuries need to be operated on time, Vitkus studied the immediate closure effects.The early repair of soft tissues also had proven signi cant ndings in concomitant injuries.Also, the immediate closure corresponds with aesthetic improved results of surgical interventions.In our study 73% of patients undergone immediate surgeries and wound infections were 18.3% in them.Which is signi cantly less than delayed closure [15].With the passage of time wounds of soft tissues get swelling, that make a split wound di cult to operate in primary closure.Also, the delayed wound closure harbors more infections.Also proven by our study 26.7% of patients were managed with delayed A total of 4 (6.7%)face gunshot injury patients were observed with wound dehiscence post-operatively at one month follow-up out of which 1 (2.3%) vs 3 (18.8%)were treated for wound dehiscence in immediate versus delayed closure group respectively.It seems that risk is high in the delayed closure group and differ signi cantly with the immediate group i.e., p-value= 0.024 (Table 4) descriptive analysis was done to quantify the variables.
[23].Choosing D I S C U S S I O N PJHS VOL. 4 Issue. 2 February 2023 Copyright © 2023.PJHS, Published by Crosslinks International Publishers

Table 1 :
Frequency Distribution according to GenderPatients who were present within rst week of their gunshot injuries and managed with immediate closure were 44 (73.3%) and 16 (26.7%)patientsweremanaged with delayed closure (Table2).

Table 2 :
Distribution according to no. of patients with Immediate closure

Table 3 :
Comparison of Wound Infection between Immediate vs Delayed Closure p-value = 0.021 (Statistically Signi cant)

Ahmed HW et al.,
Management in Patients with Gunshot Injuries to Face