Retained Missile to the Foot and Ankle: When Should They Come Out?

CATEGORY: Trauma INTRODUCTION/PURPOSE: Gunshot wounds are common injuries encountered by orthopaedists in urban settings. Retained missiles can lead to significant morbidity and functional impairment. Despite the potential for adverse sequelae, controversy remains regarding the role of routine bullet removal. Suggested indications for bullet removal include those leading to infection and lead toxicity. Bullets located in the palm of the hand, sole of the foot, or intraarticularly are commonly removed as well. Given the unlikeliness of a retained missile sparing the many joints or sole of the foot, we question the indications for conservative management. The purpose of this case series of is to further develop indications for bullet removal from the foot. METHODS: A medical record search was performed at a single one trauma institution, with high volume of patients with ballistic injury, for patients who underwent bulletectomy from 2008 until 2018. Of the 169 patients originally obtained, 17 patients underwent bulletectomy, with associated irrigation and debridement, of the foot and ankle. The record of each patient in this retrospective case series was individually reviewed for location of retained missile, indications for removal, whether the procedure was performed at the bedside or in the operating room, concomitant injuries or surgeries, and follow up. RESULTS: Of the 17 patients with retained bullets removed from the foot and ankle, four (23.5%) were removed at the bedside versus the operating room. Indications for removal were painful palpable subcutaneous position of the bullet (11 or 64.7%), periarticular or intraarticular bullet (five or 29.4%), and infected wound with removal of foreign body to optimize healing (one or 5.9%). The location of the palpable missiles included three on the plantar foot, four on the dorsal foot, and four located in subcutaneous tissues adjacent to the ankle joint. Nine out of seventeen (52.9%) had fractures associated with the retained missile. Of the patients with OR procedure (13), the majority of them (nine or 69.2%) were in the operating room for another procedure as well. CONCLUSION: The indications for bulletectomy of the foot and ankle are not definite, however, it is recommended that bullets located in the weightbearing plantar foot or intraarticularly be removed. After analysis of a seventeen patient retrospective case series, we support these indications but also advocate for the removal of any painful subcutaneous or periarticular bullet, whether under local anesthesia or in the operating room. In our experience, the prominent foot and ankle bullet is often removed during a procedure for another anatomic site. Bulletectomy of the foot and ankle in a stable polytrauma patient should be considered.