Short-term outcomes of severe open wartime tibial fractures treated with ring external fixation

Functional Outcomes After Modern External Ring Fixation or Internal Fixation for Severe Open Tibial Shaft Fractures

BACKGROUND

This study compared the functional outcomes of patients with open tibial shaft fractures who were randomized to either modern external ring fixation (EF) or internal fixation (IF). We hypothesized that there would be differences in patient-reported function between the treatment groups.

METHODS

This preplanned analysis of secondary outcomes from the FIXIT study, a multicenter randomized clinical trial, included patients 18 to 64 years of age with a Gustilo-Anderson Type-IIIB or severe-Type IIIA diaphyseal or metaphyseal tibial fracture who were randomly assigned to either IF (n = 132) or EF (n = 122). Follow-up visits occurred at 6 weeks and 3, 6, and 12 months after randomization. Outcomes included Short Musculoskeletal Function Assessment (SMFA) scores, the Veterans RAND 12-Item Health Survey (VR-12) physical component score (PCS), use of ambulatory assistive devices, and ability to ambulate.

RESULTS

The mean VR-12 PCS was slightly higher (better) for IF (24.8) than for EF (22.6) at 3 months (mean difference, 2.2 [95% confidence interval (CI): 0.2, 4.3]; p = 0.03) and trended higher for IF (27.0) compared with EF (25.3) at 6 months (mean difference, 1.8 [95% CI: -0.9, 4.4]; p = 0.19). However, there was no difference between the groups at 12 months. There were no clinically important or significant differences in SMFA Dysfunction and Bother scores between the treatment groups at any time point. EF was associated with a higher risk of using any ambulatory assistive device at 6 months (relative risk, 1.5 [95% CI: 1.21, 1.82]; p < 0.0001). The absolute percentage of patients using any ambulatory device was 37.6% for IF and 45.4% for EF at 1 year. There was no difference in ambulatory status between the treatment groups at any time point.

CONCLUSIONS

We found no difference in physical function between patients with severe tibial fractures treated with IF versus EF. There was a high rate of impairment overall. Assistive devices for walking were more often utilized in the EF group at 6 months, and both treatment groups demonstrated similar overall impairment.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

External fixators in austere environments under surge capacity conditions: A systematic review

BACKGROUND

High-energy trauma causing open fractures can take place in low-resource settings ("austere" environment) and mainly affects the lower limbs. In these environments, external fixators often provide definitive surgical treatment. This systematic review identifies those external fixators for use on lower limbs as a definitive treatment that are most clinically effective in the austere environment.

METHODS

Multiple databases were searched to identify studies investigating outcomes of external fixators used in austere environments. Case reports were excluded. Hand searching and expert input identified additional references.

FINDINGS

33 publications met the inclusion criteria. These were used worldwide. Commercially available fixators were used in 18 publications, and non-commercial ones including Balkan-designed devices in 6. The remaining non-commercial devices had 1 or 2 publications each. Union rates, where reported, varied from 47 to 100 % with no discernible difference between devices or location of use. Clinical complications varied from infection (0-79 %) through to nonunion and delayed union (0-22 %), loosening (0-36 %), osteomyelitis (0-19 %), construct stability (27-100 %), and amputation (0-50 %).

INTERPRETATION

The variability in union and complication rates highlights the variability in severity of injuries, type of austere environment, and variability in fixator device efficacy. The non-commercial or "one-off" devices show promise, with comparable or better outcomes to the commercial devices, whereas others did not work well, with poor outcomes. The need for surge capacity availability in these austere environments would enable locally manufactured devices to be quickly made which are fit for purpose, yet regulation and quality control of these remains a challenge in their rollout.

Evaluation of a Military Global Health Engagement Mission for Critical Wartime Surgical Specialty Readiness

INTRODUCTION

Surgical volume at Military Treatment Facilities (MTFs) has been gradually decreasing for roughly the past 2 decades. The Knowledge, Skills, and Abilities (KSA) Clinical Readiness Program linked surgical volume and readiness using a tool known as the KSA metric. However, the extent to which military medical missions contribute to the readiness of critical wartime specialties has not been evaluated using this metric.

METHODS

In this study, a retrospective analysis was conducted using the surgical case logs from the US Naval Ship (USNS) Comfort missions in 2018 and 2019. The comprehensive case log data were categorized by year, surgeon, procedure, and location. The analysis focused on providing detailed descriptive statistics, including percentages pertaining to the types of procedures performed during these missions. The 2018 mission was 11 weeks in duration, and supported activities in Ecuador, Peru, Colombia, and Honduras. The USNS Comfort mission in 2019 lasted 6 months (June-November 2019), and visited 12 countries in Central America, South America, and the Caribbean.

RESULTS

The 2019 mission case log, spanning 6 months, was evaluated using the KSA score in order to assess readiness and compare against 6 months of MTF KSA values within the same calendar year. In 2019, the orthopedic surgeon aboard the USNS Comfort had a total KSA score of 44,006, but the 6-month USNS Comfort mission only contributed 5,364 points (12% of the annual score). The general surgery practice aboard the USNS Comfort produced lower KSA scores compared to each surgeon's respective MTF practice (Table III). Analyzing the cases logged by general surgeons also highlights minimal surgical diversity during these missions, with more than 90% of cases being hernia repairs or laparoscopic cholecystectomies (Table I). In addition, 35% of total procedures performed in 2018 and 2019 were performed laparoscopically.

CONCLUSIONS

The analysis of operative data from the 2019 USNS Comfort mission, in comparison with the surgeons' work at their respective MTFs, reveals limited benefit in the ability of hospital-ship missions to bolster surgical readiness as measured by the KSA score. However, this is not a reflection on the value of Global Health Engagement (GHE) itself but a review of the way in which it is leveraged to support surgical readiness. Military surgeons participate in GHE as part of a larger strategy to strengthen relationships with partner nations, improve military medical force interoperability, and bolster partner nation medical capacity and capabilities. The KSA score offers an excellent tool to compare readiness metrics across significantly different GHE missions, and facilitates the opportunity for future prospective studies to improve case volume, diversity, and ultimately readiness.

Risk factors for infection in severe open tibial shaft fractures

OBJECTIVE

To evaluate risk factors for infection in severe open tibial shaft fractures.

METHODS

A secondary analysis of a multicenter prospective study investigated internal versus external fixation of severe open tibia fractures at 20 US Level I trauma centers. Adult patients, aged <65 years, with a Gustilo-Anderson Type IIIB or severe IIIA metaphyseal or diaphyseal tibia fracture were included. All fractures underwent definitive fixation with either a modern ring external fixator, intramedullary device, and/or plate. Fourteen variables previously identified as risk factors for infection were included in the analysis. Deep surgical site infection was defined as an infection treated with surgical debridement within 1 year of index surgery.

RESULTS

The study cohort included 430 patients. Deep surgical site infection requiring reoperation occurred in 108 (25 %) patients. The final model identified four risk factors for infection: age >40 years (OR, 2.00; 95 % CI, 1.3-3.1), Gustilo-Anderson Type IIIB (OR, 1.80; 95 % CI, 1.1-3.0), embedded wound contamination (OR, 1.69; 95 % CI, 1.1-2.7), and wound length (OR, 1.02/cm; 95 % CI, 1.0-1.05). The model performed poorly at distinguishing infected from uninfected patients (Area Under the Curve=0.57; 95 % CI, 0.51-0.63).

CONCLUSIONS

Surgeons can now counsel patients with these risk factors that they are at a markedly higher risk of infection. The identification of these risk factors may direct future research aimed at mitigating the risk of deep surgical site infection in this patient population.

Circular frame versus reamed intramedullary tibial nail in the treatment of grade III open tibial diaphyseal fractures

BACKGROUND

Grade III open tibial diaphyseal fractures are challenging to treat and controversy exists on whether to treat them with an intramedullary nail (IMN) or a circular frame (CF). This study aims to compare outcomes for intramedullary nail and circular frame in the treatment of open tibial diaphyseal fractures.

METHODOLOGY

Retrospective study at a major trauma center of all patients admitted with a grade III open tibial diaphyseal fracture between January 2016 and January 2022. The primary outcome measures were major complications: non-union, malunion, refracture, DBI and amputation. Secondary outcome measures were time to union and reoperation rates.

RESULTS

Fifty-five patients were included in the study, 32 patients in CF group and 23 patients in IMN group. There were no significant differences in the baseline demographics of patients in both groups. Major complications were recorded in 13 limbs (54%) in IMN group and in 18 limbs (56%) in CF group which were not statistically significant (p = 0.797). Deep bone infection rates were noted in 4 (12.5%) in the CF group, compared to 1 (4%) in IMN group; however, the result was not statistically significant (p = 0.240). Amputation rates as a result of infected non-unions were seen in 1 limb (4%) in IMN group and 2 limbs (6%) in CF group (p = 0.99). Median time to union was significantly shorter in IMN group at 30 weeks compared to 30 weeks for CF group (p = 0.04).

CONCLUSION

IMN should be the treatment of choice in the treatment of grade III open tibial diaphyseal fracture, but CF should be considered for delayed treatment and in patients with bone loss.

External fixation versus intramedullary nailing for the management of open tibial fracture: meta-analysis of randomized controlled trials

AIM

Tibial shaft fractures are the most common type of long-bone fractures. External fixation (EF) and intramedullary nailing (IMN) are widely used surgical techniques for the definitive fixation of open tibial shaft fractures. The aim of this systematic review and meta-analysis was to compare EF to IMN for the definitive fixation of open tibial fractures.

METHODS

Medline, Embase, and CENTRAL databases were searched for eligible studies. We included randomized controlled trials (RCTs) that compared EF to IMN for skeletally mature adults with open tibial fracture (Gustilo I, II, and III). We evaluated the following outcomes: superficial infection, pin-track infection, deep infection, malunion, nonunion, delayed union, and implant/hardware failure. The risk ratio (RR) was used to represent the desired outcomes. The statistical analysis was performed using the random-effects model.

RESULTS

A total of 12 RCTs that enrolled 1090 participants were deemed eligible for the analysis. EF showed a significantly higher rate of superficial infection, pin track infection, and malunion compared to IMN (RR = 2.30, 95% confidence interval (CI): 1.34 to 3.95; RR = 13.52, 95% CI: 6.16 to 29.66; RR = 2.29, 95% CI 1.41 to 3.73, respectively). No substantial difference was found between EF and IMN in terms of deep infection, nonunion, delayed union, or implant/hardware failure (RR = 1.15, 95% CI 0.67 to 1.98; RR = 0.92, 95% CI 0.77 to 1.10; RR = 1.50, 95% CI 0.98 to 3.33; RR = 0.96, 95% CI 0.36 to 2.60, respectively).

DISCUSSION

The findings of our meta-analysis are consistent with the previous systematic reviews excepts for the implant/hardware failure which was found to be significant in favour of IMN by one of the previous reviews.

CONCLUSION

This meta-analysis confirms that IMN is better than EF with respect to clinical outcomes and complication rate for the definitive fixation of open tibial fracture.

The Current Status, Prospects, and Challenges of Shape Memory Polymers Application in Bone Tissue Engineering

Bone defects can occur after severe trauma, infection, or bone tumor resection surgery, which requires grafting to repair the defect when it reaches a critical size, as the bone's self-healing ability is insufficient to complete the bone repair. Natural bone grafts or artificial bone grafts, such as bioceramics, are currently used in bone tissue engineering, but the low availability of bone and high cost limit these treatments. Therefore, shape memory polymers (SMPs), which combine biocompatibility, biodegradability, mechanical properties, shape tunability, ease of access, and minimally invasive implantation, have received attention in bone tissue engineering in recent years. Here, we reviewed the various excellent properties of SMPs and their contribution to bone formation in experiments at the cellular and animal levels, respectively, especially for the repair of defects in craniomaxillofacial (CMF) and limb bones, to provide new ideas for the application of these new SMPs in bone tissue engineering.

Modern External Ring Fixation Versus Internal Fixation for Treatment of Severe Open Tibial Fractures: A Randomized Clinical Trial (FIXIT Study)

BACKGROUND

Modern external ring fixation has been hypothesized to reduce complications requiring hospital readmission compared with internal fixation when treating patients with high-energy open tibial shaft fractures. In this study, the 1-year probability of a major limb complication was compared between external and internal fixation of severe open tibial fractures.

METHODS

This multicenter randomized clinical trial included patients 18 to 64 years of age with severe open tibial shaft fractures randomly assigned to either modern external ring fixation (n = 127) or internal fixation (n = 133). The primary outcome was a major limb complication within 365 days after randomization; these complications included amputation, infection, a soft-tissue problem, nonunion, malunion, and a loss of reduction/implant failure.

RESULTS

Of 260 randomized patients, 254 were included in the final analysis. Their mean age (standard deviation) was 39 (13) years; 214 (84%) were men. The probability of at least 1 major limb complication was higher for external fixation (62.1% [95% confidence interval (CI): 53.4% to 70.8%]) than internal fixation (43.7% [95% CI: 35.5% to 52.9%]), with a risk difference of 18.4% (95% CI: 5.8% to 30.4%); p = 0.005). The most notable difference was in loss of reduction/implant failure, the rate of which was higher for external fixation (risk difference: 14.4% [95% CI: 7.0% to 21.6%]; p = 0.002). There was no appreciable difference in the probability of deep infection between external fixation (26.1%) and internal fixation (29.7%) (risk difference: -3.5% [95% CI: -14.8% to 7.8%]; p = 0.54). There were also no appreciable differences in the probabilities of amputation, nonunion, soft-tissue problems, malunion, or fracture healing between the groups.

CONCLUSIONS

These results argue against routine use of modern external ring fixation for the treatment of these severe open tibial fractures.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Microbial Interspecies Associations in Fracture-Related Infection

OBJECTIVES

Describe co-occurrence or clustering of microbial taxa in fracture-related infections to inform further exploration of infection-related interactions among them.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Four hundred twenty-three patients requiring surgical intervention for deep surgical site infection between January 2006 and December 2015.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENT

Connection between microbial taxa.

RESULTS

Methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, and coagulase-negative Staphylococcus represented the majority of monomicrobial observations (71%). Gram-negative rods, gram-positive rods, and anaerobes presented more frequently in polymicrobial infections. Enterobacter, vancomycin-sensitive Enterococcus, and Pseudomonas are present in polymicrobial infections with the highest frequencies and represent the top 3 most important nodes within the microorganism framework, with the highest network centrality scores.

CONCLUSIONS

The present study indicates that there are common microbial taxa (Enterobacter, Enterococcus, and Pseudomonas) that tend to co-occur with other microbes greater than 75% of the time. These commonly co-occurring microbes have demonstrated interactive relationships in other disease pathologies, suggesting that there may be similar important interactions in fracture-related infections. It is possible that these microbial communities play a role in the persistently high failure rate associated with management of infection after trauma. Future studies are needed to study the intermicrobial interactions that explain the frequency at which taxa co-occur. Understanding and potentially disrupting these intermicrobial relationships could inform improvements in the treatment of established infections and in the prevention of infection in high-risk patients.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intentional Temporary Limb Deformation for Closure of Soft-Tissue Defects in Open Tibial Fractures

OBJECTIVES

(1) Evaluate intentional temporary limb deformation for closure of soft-tissue defects as a reconstruction strategy in open tibia fractures and (2) analyze the deformity parameters required for such reconstruction.

DESIGN

Multicenter retrospective cohort.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Nineteen patients 18 years of age and older at the time of initial trauma, with a Gustilo-Anderson type IIIB or IIIC open tibia fracture treated with hexapod external fixation and intentional bony deformity created to facilitate soft-tissue closure.

INTERVENTION

Intentional limb deformation for soft-tissue closure, followed by gradual correction with a hexapod external fixator.

OUTCOME MEASUREMENTS

Radiographic healing, radiographic assessment of limb alignment, and functional and bony Application of the Method of Ilizarov Group score.

RESULTS

The average age was 45.3 (20-70), and 79% of patients were men. The most common mechanism of injury was motor vehicle accidents. The distal 1 of 5 of the tibia was the most common fracture location, with 37% of these involving the articular surface at the plafond. After wound closure, deformity correction was initiated after 30 days on average. Varus and apex posterior were the most common initial deformity required for primary soft-tissue closure. Bony and functional Application of the Method of Ilizarov Group outcomes were good or excellent in 94% of patients.

CONCLUSION

Intentional deformation followed by a gradual correction can be an effective strategy to obtain bone union and soft-tissue coverage in certain open fractures. This technique, in essence, converts these injuries from type IIIB to IIIA. This strategy obviates the need for flap coverage and results in satisfactory outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acute limb shortening or creation of an intentional deformity to aid in soft tissue closure for IIIB/IIIC open tibia fractures

BACKGROUND

Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage.

METHODS

This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded.

RESULTS

Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10-20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation.

CONCLUSIONS

Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.

Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery

SIGNIFICANCE

Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues.

AIM

The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery.

APPROACH

The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative.

RESULTS

Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management.

CONCLUSION

While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.

Fracture union rates across a century of war: a systematic review of the literature

INTRODUCTION

Fractures have been a common denominator of the injury patterns observed over the past century of warfare. The fractures typified by the blast and ballistic injuries of war lead to high rates of bone loss, soft tissue injury and infection, greatly increasing the likelihood of non-union. Despite this, no reliable treatment strategy for non-union exists. This literature review aims to explore the rates of non-union across a century of conflict, in order to determine whether our ability to heal the fractures of war has improved.

METHODS

A systematic review of the literature was conducted, evaluating the rates of union in fractures sustained in a combat environment over a 100-year period. Only those fractures sustained through a ballistic or blast mechanism were included. The review was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Quality and bias assessment was also undertaken.

RESULTS

Thirty studies met the inclusion criteria, with a total of 3232 fractures described across 15 different conflicts from the period 1919-2019. Male subjects made up 96% of cases, and tibial fractures predominated (39%). The lowest fracture union rate observed in a series was 50%. Linear regression analysis demonstrated that increasing years had no statistically significant impact on union rate.

CONCLUSIONS

Failure to improve fracture union rates is likely a result of numerous factors, including greater use of blast weaponry and better survivability of casualties. Finding novel strategies to promote fracture healing is a key defence research priority in order to improve the rates of fractures sustained in a combat environment.

Knee Sepsis after Suprapatellar Nailing of an Open Tibia Fracture: Treatment with Acute Deformity and External Fixation

Case

A 31-year-old male was involved in a dirt bike accident and sustained an isolated type II open mid-distal tibia fracture. The patient underwent suprapatellar intramedullary nailing and subsequently developed knee sepsis.

Conclusion

This patient was managed with irrigation and debridements of the knee, fracture site, and intramedullary canal. A resultant soft-tissue defect over the fracture site obviated primary closure. Creation of an acute deformity stabilized by a Taylor spatial frame allowed primary wound closure. After soft tissue healing occurred, the frame was used to correct the intentional deformity and maintain reduction until full healing occurred.

Assessment of Mechanical Characteristics of Ankle-Foot Orthoses

Recent designs of ankle-foot orthoses (AFOs) have been influenced by the increasing demand for higher function from active individuals. The biomechanical function of the individual and device is dependent upon the underlying mechanical characteristics of the AFO. Prior mechanical testing of AFOs has primarily focused on rotational stiffness to provide insight into expected functional outcomes; mechanical characteristics pertaining to energy storage and release have not yet been investigated. A pseudostatic bench testing method is introduced to characterize compressive stiffness, device deflection, and motion of solid-ankle, anterior floor reaction, posterior leaf spring, and the intrepid dynamic exoskeletal orthosis (IDEO) AFOs. Each of these four AFOs, donned over a surrogate limb, were compressively loaded at different joint angles to simulate the foot-shank orientation during various subphases of stance. In addition to force–displacement measurements, deflection of each AFO strut and rotation of proximal and supramalleolar segments were analyzed. Although similar compressive stiffness values were observed for AFOs designed to reduce ankle motion, the corresponding strut deflection profile differed based on the respective fabrication material. For example, strut deflection of carbon-fiber AFOs resembled column buckling. Expanded clinical test protocols to include quantification of AFO deflection and rotation during subject use may provide additional insight into design and material effects on performance and functional outcomes, such as energy storage and release.

Local control of polymicrobial infections via a dual antibiotic delivery system

BACKGROUND

Contaminated traumatic open orthopedic wounds are frequently complicated by polymicrobial contamination and infection. In high-risk wounds, the standard of care comprises debridement and irrigation combined with antibiotics which can be applied directly or combined with systemic antibiotics. Recently, bioabsorbable chitosan sponges have been shown to be an effective single-agent delivery device for local antibiotics with and without negative pressure wound therapy (NPWT). Severely contaminated orthopedic wounds, however, are often complicated by polymicrobial infections, necessitating multiple antibiotic agents. As such, the purpose of this study was to determine if a chitosan sponge would provide a suitable delivery vehicle for multiple antibiotics for the treatment of a polymicrobial infection in a large animal polytraumatic extremity wound model.

METHODS

A complex polytraumatic extremity wound was created in 11 adult male Boer goats. Each wound was contaminated with a bioluminescent strain of S. aureus (1 ml of 10⁸ colony forming units/ml) and of P. aeruginosa (1 ml of 10⁸ CFU/ml) which are genetically engineered to allow quantification with a photon-counting camera. Six hours following initial wound creation and contamination, wounds were debrided and irrigated with low-pressure normal saline. The animals were randomized into one of two treatments: wet-to-dry dressings alone or a commercially available chitosan sponge loaded with 1 g vancomycin and 1.2 g of tobramycin. Each animal was then recovered and reimaged 48 h later for total bacteria content; tissue samples were taken from the wound bed to determine relative bacterial colonization.

RESULTS

All animals in the chitosan sponge group saw significant reductions in overall bacterial load of S. aureus and P. aeruginosa (p = 0.001). The bioluminescence was also significantly reduced compared to the wet-to-dry dressing group (p = 0.0001). Furthermore, whereas the antibiotic sponge group displayed near complete eradication of bacteria, the wounds treated with the wet-to-dry dressings alone displayed a significant 2-log increase in total bacteria at 48 h p = 0.0001). S. aureus was the predominant species found in the wounds, comprising 95 and 99% of all bacteria found in the chitosan sponge and wet-to-dry, respectively.

CONCLUSION

Dual antimicrobial therapy loaded in a chitosan sponge is an effective way to reduce polymicrobial infections traumatic extremity wound.

Virtual stress testing of fracture stability in soldiers with severely comminuted tibial fractures

Virtual stress testing (VST) provides a non-invasive estimate of the strength of a healing bone through a biomechanical analysis of a patient's computed tomography (CT) scan. We asked whether VST could improve management of patients who had a tibia fracture treated with external fixation. In a retrospective case-control study of 65 soldier-patients who had tibia fractures treated with an external fixator, we performed VST utilizing CT scans acquired prior to fixator removal. The strength of the healing bone and the amount of tissue damage after application of an overload were computed for various virtual loading cases. Logistic regression identified computed outcomes with the strongest association to clinical events related to nonunion within 2 months after fixator removal. Clinical events (n = 9) were associated with a low tibial strength for compression loading (p < 0.05, AUC = 0.74) or a low proportion of failed cortical bone tissue for torsional loading (p < 0.005, AUC = 0.84). Using post-hoc thresholds of a compressive strength of four times body-weight and a proportional of failed cortical bone tissue of 5%, the test identified all nine patients who failed clinically (100% sensitivity; 40.9% positive predictive value) and over three fourths of those (43 of 56) who progressed to successful healing (76.8% specificity; 100% negative predictive value). In this study, VST identified all patients who progressed to full, uneventful union after fixator removal; thus, we conclude that this new test has the potential to provide a quantitative, objective means of identifying tibia-fracture patients who can safely resume weight bearing. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:805-811, 2017.

A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators Versus Internal Fixation (FIXIT Study)

The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.

Time-Dependent Effectiveness of Locally Applied Vancomycin Powder in a Contaminated Traumatic Orthopaedic Wound Model

OBJECTIVES

To evaluate the effectiveness of locally applied vancomycin powder at different times postinfection in a contaminated traumatic animal model.

METHODS

This study used an established segmental defect rat femur model contaminated with Staphylococcus aureus UAMS-1 followed by treatment at 6 or 24 hours postinfection. Three treatments were evaluated: debridement and irrigation alone (control group) or in combination with either vancomycin powder or vancomycin-impregnated poly(methyl methacrylate) beads. Serum vancomycin levels were determined at scheduled time points over 14 days; bone, surrounding muscle, and implants were harvested for bacterial and inflammatory analyses.

RESULTS

Locally applied vancomycin powder and impregnated beads significantly reduced bacteria both within the bone and implant when treatment was performed at 6 hours. Delaying treatment to 24 hours significantly reduced the therapeutic efficacy of locally applied vancomycin of both groups. Serum vancomycin levels were detectable in all animals treated with vancomycin powder at 24 hours, but absorption was negligible from beads. At 14 days, vancomycin was detectable in the surrounding musculature of all animals and in serum of 20% of animals treated with vancomycin powder.

CONCLUSIONS

This study suggests that vancomycin powder is a promising adjunctive therapy for preventing infection in traumatic wounds when treatment is performed early. This time-dependent effectiveness of vancomycin powder is similar to that observed with systemic and other local delivery adjuncts, which is likely attributable to biofilm formation after contamination, conferring intrinsic recalcitrance to antimicrobials.

A Novel Nanosilver/Nanosilica Hydrogel for Bone Regeneration in Infected Bone Defects

Treating bone defects in the presence of infection is a formidable clinical challenge. The use of a biomaterial with the dual function of bone regeneration and infection control is a novel therapeutic approach to this problem. In this study, we fabricated an innovative, dual-function biocomposite hydrogel containing nanosilver and nanosilica (nAg/nSiO2) particles and evaluated its characteristics using FT-IR, SEM, swelling ratio, and stiffness assays. The in vitro antibacterial analysis showed that this nAg/nSiO2 hydrogel inhibited both Gram-positive and Gram-negative bacteria. In addition, this nontoxic material could promote osteogenic differentiation of rat bone marrow stromal cells (BMSCs). We then created infected bone defects in rat calvaria in order to evaluate the function of the hydrogel in vivo. The hydrogel demonstrated effective antibacterial ability while promoting bone regeneration in these defects. Our results indicate that this nAg/nSiO2 hydrogel has the potential to both control infection and to promote bone healing in contaminated defects.

Late Amputation Following Refracture After Removal of Multiplanar Circular External Fixator for Treatment of Severe Combat-Related Tibial Fracture: A Case Report

CASE

The multiplanar circular external fixator is commonly used in the treatment of severe combat-related tibial fractures. We present the case of a patient who sustained a refracture after removal of such a fixator. This complication contributed to failure of the limb salvage and ultimately resulted in the patient undergoing transtibial amputation.

CONCLUSION

The choice to pursue limb salvage or amputation must be a shared decision between the patient and provider. This discussion must now include the possibility of refracture if limb salvage is pursued using multiplanar circular external fixation. Further study is also required to define fracture stability after the removal of a multiplanar circular external fixator.

Early Conversion of External Fixation to Interlocked Nailing in Open Fractures of Both Bone Leg Assisted with Vacuum Closure (VAC) - Final Outcome

INTRODUCTION

Management of compound grade III fractures of both bone leg includes external stabilization for long period, followed by various soft tissue coverage procedures. Primary interlocking of tibia had been also done with variable results. External fixation for long time without any bone loss often leads to infected nonunion, loss of reduction, pin tract infection and failure of fixation, primary interlocking in compound grade III fractures had shown high medullary infection rate. We managed all cases of compound grade III A/B fractures with primary external fixation, simultaneous wound management using vacuum assisted closure (VAC) followed by early conversion to interlocking within 2 weeks of fixator application.

AIM

To determine the effectiveness of vacuum assisted closure (VAC) for the early conversion of external fixator to definitive interlocking in open fractures of the both bone leg.

MATERIALS AND METHODS

In current study we selected 84 cases of compound grade IIIA/B diaphyseal fractures of both bone leg during period of May 2010 to September 2013. We managed these cases by immediate debridement and application of external fixation followed by repeated debridement, application of vacuum assisted closure (VAC) and conversion to interlocking within two weeks.

RESULTS

Out of 84 cases union was achieved in 80(95%) of cases with definitive tibial interlocking. Excellent to good result were obtained in 77(91.8%) of cases and fair to poor result seen in rest of 7(8.2%) of cases according to modified Ketenjian's criteria. 5 out of these 7 poor result group cases were from Compound Grade III B group to start with. Deep infection rate in our series were 7% i.e. total 6 cases and 4 out of these were from compound Grade III B group to start with.

CONCLUSION

Vacuum assisted closure (VAC) give a good help for rapid closure of the wound and help in early conversion to definitive intramedullary nailing. Reamed nail could well be used in compound grade IIIA/B fractures without increasing the risk of infection. It gives better stability to fracture site and lessen the risk of implant failure.

Analysis of Orthopaedic Research Produced During the Wars in Iraq and Afghanistan

BACKGROUND

Military orthopaedic surgeons have published a substantial amount of original research based on our care of combat-wounded service members and related studies during the wars in Iraq and Afghanistan. However, to our knowledge, the influence of this body of work has not been evaluated bibliometrically, and doing so is important to determine the modern impact of combat casualty research in the wider medical community.

QUESTIONS/PURPOSES

We sought to identify the 20 most commonly cited works from military surgeons published during the Iraq and Afghanistan conflicts and analyze them to answer the following questions: (1) What were the subject areas of these 20 articles and what was the 2013 Impact Factor of each journal that published them? (2) How many citations did they receive and what were the characteristics of the journals that cited them? (3) Do the citation analysis results obtained from Google Scholar mirror the results obtained from Thompson-Reuters' Web of Science?

METHODS

We searched the Web of Science Citation Index Expanded for relevant original research performed by US military orthopaedic surgeons related to Operation Iraqi Freedom and Operation Enduring Freedom between 2001 and 2014. Articles citing these studies were reviewed using both Web of Science and Google Scholar data. The 20 most cited articles meeting inclusion criteria were identified and analyzed by content domain, frequency of citation, and sources in which they were cited.

RESULTS

Nine of these studies examined the epidemiology and outcome of combat injury. Six studies dealt with wound management, wound dehiscence, and formation of heterotopic ossification. Five studies examined infectious complications of combat trauma. The median number of citations garnered by these 20 articles was 41 (range, 28-264) in Web of Science. Other research citing these studies has appeared in 279 different journals, covering 26 different medical and surgical subspecialties, from authors in 31 different countries. Google Scholar contained 97% of the Web of Science citations, but also had 31 duplicate entries and 29 citations with defective links.

CONCLUSIONS

Modern combat casualty research by military orthopaedic surgeons is widely cited by researchers in a diverse range of subspecialties and geographic locales. This suggests that the military continues to be a source of innovation that is broadly applicable to civilian medical and surgical practice and should encourage expansion of military-civilian collaboration to maximize the utility of the knowledge gained in the treatment of war trauma.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Challenges in definitive fracture management of blast injuries

The United States military remains engaged in the longest armed conflict in this nation's history. The majority of casualties in the global war on terror come from blast-related injuries. Multiple centers have published their experience and outcomes with these complex patients. Findings from the study of injured military personnel have implications for mass casualty events resulting from industrial accidents or terrorism in the civilian sector. This article will review the pathophysiology of blast-related injury. The authors will summarize treatment considerations, priorities, and techniques that have proven successful. Finally, the authors will discuss the incidence and management of common complications after blast-related injuries.

Grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature

We report on the surgical and functional outcome of 22 patients with Grade 3 open tibial fractures treated with circular frame. All cases united and there were no re-fractures or amputations. All patients were assessed at a minimum of 1-year post frame removal. Assessment included clinical examination, IOWA ankle and knee scores, Olerud and Molander ankle score and EuroQol EQ-5D. Clinical scores were either good or excellent in over half of the patients in all knee and ankle scores. There was a significant positive correlation between functional outcomes and the EQ-5D score. The EQ-5D mean health state visual analogue score was comparable to the general UK population despite patients scoring less than the average UK population in three of the five domains. 36% reported some difficulties in walking and 41% had problems with pain. 14% had difficulties with self-care and 46% had difficulties with their usual activities. 14% had problems with anxiety or depression. Systematic review of the literature suggests, in the management of open tibial fractures, circular frames provide equivalent or superior surgical outcomes in comparison with other techniques. Our study finds the application of a circular frame also results in a good functional outcome in the majority of cases.

Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications?

OBJECTIVES

The importance of the timing of flap coverage of open tibial shaft fractures remains controversial. Many studies have shown increased complications and infection rates associated with delay in coverage but have not controlled for risk factors that might be associated with both delay in coverage and complications. We hypothesized that the timing of flap coverage of open tibial fractures is not predictive of complications after controlling for known risk factors.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS

Sixty-nine patients treated for acute tibial fractures (45 tibial shaft, 17 plateau, and 12 pilon fractures) at our center from 2004 through 2009 required 74 flaps. Patients requiring flaps later for wound breakdown or infection were excluded.

INTERVENTION

Electronic records and prospective trauma database were reviewed. All fractures were AO classified by a trauma fellowship-trained orthopaedic surgeon.

MAIN OUTCOME MEASUREMENTS

Primary outcome was flap complication, defined as infection or other flap-related adverse outcome requiring surgical treatment. Logistic regression analysis was conducted.

RESULTS

A logistic regression model that separated the first 7 days after injury from subsequent days found no increased risk for days 1 through 7. The odds of complications, and of infection in particular, increased by 11% and 16%, respectively, for each day beyond day 7 (P < 0.04).

CONCLUSIONS

Even after controlling for known risk factors for complications, including injury severity, time to flap coverage was a significant predictor of complications.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Circular external fixation for treatment of distal humerus fractures: case report

High-energy blasts can lead to complex intra-articular distal humerus fractures with extensive soft tissue loss, and treatment is fraught with complications. We describe 2 patients with such injuries treated successfully with the use of aggressive wound management followed by distal humerus fracture stabilization with a circular external fixator. We chose this circular external fixator over the Ilizarov frame because of our experience and success in the treatment of open tibia fractures with negligible malalignment and high union rate. This circular external fixator allows for indirect reduction of fracture fragments over time to improve final alignment with great control to fine-tune the reduction postoperatively. In our humerus cases, fracture union was achieved with good alignment and acceptable functional range of motion. Symptomatic heterotopic ossification did not develop despite the presence of multiple risk factors.

Negative pressure wound therapy reduces the effectiveness of traditional local antibiotic depot in a large complex musculoskeletal wound animal model

OBJECTIVES

Negative pressure wound therapy (NPWT) has been used to help manage open wounds. Surgeons also often use local antibiotic depot as adjunctive therapy in an effort to reduce infection rates. These 2 techniques have been reported to be used in conjunction, but there are little data to support this practice. We sought to compare the contamination levels of wounds treated with the commonly used antibiotic bead pouch technique to wounds that received both antibiotic beads and NWPT.

METHODS

The effectiveness of a bead pouch was compared with antibiotic beads with NPWT. The anterior compartment and proximal tibia of goats were injured and inoculated with Staphylococcus aureus. Six hours later, the wounds were debrided and the animals were assigned to a group; the bacteria level was quantified immediately before and after initial debridement and 2 days after treatment.

RESULTS

The wounds in the antibiotic bead pouch group had 6-fold less bacteria than the augmented NPWT group, 11 ± 2% versus 67 ± 11% of baseline values, respectively (P = 0.01). As expected, high levels of the antibiotic were consistently recovered from the augmented NPWT effluent samples at all time points.

CONCLUSIONS

NPWT reduces the effectiveness of local antibiotic depot. These results can provide surgeons with the information to personalize the adjunctive therapies to individual patients, with the degree of difficulty in managing the wound and concern for infection being the 2 variables dictating treatment.

Comparative effect of orthosis design on functional performance

BACKGROUND

High-energy extremity trauma is common in combat. Orthotic options for patients whose lower extremities have been salvaged are limited. A custom energy-storing ankle-foot orthosis, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), was created and used with high-intensity rehabilitation as part of the Return to Run clinical pathway. We hypothesized that the IDEO would improve functional performance compared with a non-custom carbon fiber orthosis (BlueRocker), a posterior leaf spring orthosis, and no brace.

METHODS

Eighteen subjects with unilateral dorsiflexion and/or plantar flexion weakness were evaluated with six functional tests while they were wearing the IDEO, BlueRocker, posterior leaf spring, or no brace. The brace order was randomized, and five trials were completed for each of the functional measures, which included a four-square step test, a sit-to-stand five times test, tests of self-selected walking velocity over level and rocky terrain, and a timed stair ascent. They also completed one trial of a forty-yard (37-m) dash, filled out a satisfaction questionnaire, and indicated whether they had ever considered an amputation and, if so, whether they still intended to proceed with it.

RESULTS

Performance was significantly better with the IDEO with respect to all functional measures compared with all other bracing conditions (p < 0.004), with the exception of the sit-to-stand five times test, in which there was a significant improvement only as compared with the BlueRocker (p = 0.014). The forty-yard dash improved by approximately 35% over the values for the posterior leaf spring and no-brace conditions, and by 28% over the BlueRocker. The BlueRocker demonstrated a significant improvement in the forty-yard dash compared with no brace (p = 0.033), and a significant improvement in self-selected walking velocity on level terrain compared with no brace and the posterior leaf spring orthosis (p < 0.028). However, no significant difference was found among the posterior leaf spring, BlueRocker, and no-brace conditions with respect to any other functional measure. Thirteen patients initially considered amputation, but after completion of the clinical pathway, eight desired limb salvage, two were undecided, and three still desired amputation.

CONCLUSIONS

Use of the IDEO significantly improves performance on validated tests of agility, power, and speed. The majority of subjects initially considering amputation favored limb salvage after this noninvasive intervention.

Challenges in severe lower limb injury rehabilitation

Restoration of lower limb function following severe injury is a challenge. Rehabilitation must take into account psychosocial factors and patient self-efficacy as well as functional goals. The Return to Run clinical pathway, an integrated orthotic and rehabilitation initiative, is an example of goal-oriented rehabilitation with periodic assessment aimed at restoring wounded warriors to high-level performance following severe lower extremity trauma. Objective assessment measures of surgical and rehabilitation interventions are lacking for persons with high-level performance demands, such as those required by service members. Thus, the Military Performance Laboratory at the Center for the Intrepid has established normative data for several physical performance measures, some of which are now routinely used to assess service members with severe lower extremity trauma. Patient expectations of treatment and rehabilitation are high and must be met to avoid poor outcomes attributed to nonanatomic factors.

Axioms altered with research

The medical community is actively engaged in research to provide the highest level of evidence to support clinical practice. The care of wounded warriors creates unique challenges, and conducting research that provides evidence for clinical practice is important to outcomes in this patient population. When the current wars began, much debate centered on the best way to care for wounded warriors. To address these concerns, we use a MythBusters format, based on the popular television show, to describe how recent research has dispelled some earlier misconceptions and clarify how clinical practice has been changed. In addition, we assess the progress that has been made on addressing the original prioritized research objectives of the first Extremity War Injuries symposium.

Prevention of infections associated with combat-related extremity injuries

During combat operations, extremities continue to be the most common sites of injury with associated high rates of infectious complications. Overall, ∼ 15% of patients with extremity injuries develop osteomyelitis, and ∼ 17% of those infections relapse or recur. The bacteria infecting these wounds have included multidrug-resistant bacteria such as Acinetobacter baumannii, Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Klebsiella species and Escherichia coli, and methicillin-resistant Staphylococcus aureus. The goals of extremity injury care are to prevent infection, promote fracture healing, and restore function. In this review, we use a systematic assessment of military and civilian extremity trauma data to provide evidence-based recommendations for the varying management strategies to care for combat-related extremity injuries to decrease infection rates. We emphasize postinjury antimicrobial therapy, debridement and irrigation, and surgical wound management including addressing ongoing areas of controversy and needed research. In addition, we address adjuvants that are increasingly being examined, including local antimicrobial therapy, flap closure, oxygen therapy, negative pressure wound therapy, and wound effluent characterization. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Silver dressings augment the ability of negative pressure wound therapy to reduce bacteria in a contaminated open fracture model

BACKGROUND

Despite a lack of evidence supporting their use, silver dressings are often used with negative pressure wound therapy (NPWT). This study investigates the effectiveness of silver dressings to reduce bacteria in contaminated wounds when used with NPWT.

METHODS

Complex orthopedic wounds were created on the proximal left legs of anesthetized goats. The wounds were inoculated with either a strain of bioluminescent Pseudomonas aeruginosa or Staphylococcus aureus. These bacteria are genetically modified to emit photons, thereby allowing quantification of bacterial concentration with a photon-counting camera system. The wounds were debrided 6 hours after inoculation and were treated with silver impregnated gauze combined with NPWT. Repeat debridements were performed every 48 hours for 6 days. Imaging was performed pre- and postdebridement. These results were compared with standard NPWT controls that used dressings without silver.

RESULTS

There were fewer bacteria in the silver groups than the standard NPWT groups at 6 days. In the groups that were inoculated with P. aeruginosa, wounds in the silver group contained 21% ± 5% of baseline bacterial load compared with 43% ± 14% in the standard NPWT group. The addition of the silver dressings has a more pronounced effect on Staphylococcus. Wounds in the silver group contained 25% ± 8% of baseline bacterial load compared with 115% ± 19% in the standard NPWT group.

CONCLUSIONS

The use of silver dressings with NPWT is a fairly common practice with limited literature to support its use in contaminated wounds. This study demonstrates that the addition of a silver dressing to NPWT effectively reduces bacteria in contaminated wounds and is more beneficial on the gram-positive bacteria. These data support the use of silver dressings in contaminated wounds, particularly ones contaminated by S. aureus.

Complex wounds and their management

Complex wounds present a challenge to both the surgeon and patient in operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedic blunt or penetrating injuries, particularly in the extremities, as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene, and Fournier gangrene. The principles of management of complex wounds involve assessing the patient's clinical status and the wound itself, appropriate timing of intervention, providing antibiotic therapy when necessary, and planning and executing surgical therapy, including the establishment of a clean wound bed and closure/reconstructive strategies.

Infectious complications of combat-related mangled extremity injuries in the British military

BACKGROUND

During the wars in Iraq and Afghanistan, extremity injuries have predominated; however, no systematic review of field and stabilization care with subsequent infectious complications exists. This study evaluates the infectious complications and possible risk factors of British military casualties with mangled extremities, highlighting initial care and infections.

METHODS

This is a retrospective cohort study of British military casualties in Iraq and Afghanistan between August 2003 and May 2008. Casualties with mangled extremities undergoing limb salvage were evaluated for management strategies at the time of injury through evacuation back to the United Kingdom and subsequent infections.

RESULTS

There were 84 casualties with 85 extremities (20 infected and 65 uninfected). Infected extremities had more Gustilo Classification IIIb. There were no differences by Injury Severity Score, age, durations from injury to evacuation, or surgery, or arrival in England, use of clotting materials, or method of extremity stabilization between infected and uninfected extremity injuries. Tourniquet use in the field and fasciotomy were associated with infections. Antimicrobial coverage was associated with infections. Staphylococcus aureus were recovered later in casualties' clinical course in contrast to early recovery of Acinetobacter. On multivariate analysis, tourniquet in the field, antibiotics during evacuation and in the operating room, and fasciotomy were associated with infection as were certain bacteria, notably, Pseudomonas aeruginosa.

CONCLUSION

Infections occurred in 24% of those with mangled extremities including 6% with osteomyelitis. Certain procedures, likely reflective of injury severity, were associated with infections along with certain bacteria, P. aeruginosa and possibly S. aureus. Continued clarification is required for antimicrobial coverage (penicillin-based regimens vs. additional anaerobic coverage) and certain surgical procedures to improve casualty care.

Soft tissue management of war wounds to the foot and ankle

This article details the experiences of United States military reconstructive surgeons in the soft tissue management of war wounds of the foot and ankle resulting from the conflicts in Iraq and Afghanistan. War wounds from this conflict are commonly caused by blast and fragmentation, and are characteristically extensive, heterogeneous, and severe. Multiple serial débridement episodes are routinely necessary because of deterioration of the wounds over time, which is in contrast to civilian trauma wherein fewer débridement episodes are generally required. Wound therapy adjuncts, such as subatmospheric wound dressing and synthetic dermal replacement, have been used extensively with favorable results. Pedicled flaps, such as the distally based sural neurofasciocutaneous flap, are reliable, and avoid the risks and technical demands associated with microsurgery. Free tissue transfer, such as the anterolateral thigh flap, the latissimus dorsi muscle flap, and the rectus abdominis muscle flap, are powerful reconstructive tools, and have been extensively used in the reconstruction of war wounds of the foot and ankle.

Physical therapy of the patient with foot and ankle injuries sustained in combat

The rehabilitation of soldiers returning from Operation Iraqi Freedom and Operation Enduring Freedom after combat-related trauma poses significant challenges. Polytrauma from high-energy blasts are common and frequently associated with mangled extremities, axial fractures, and traumatic brain injuries. Current evidence in the physical therapy literature is scant for this population and an empiric approach is often used. This article highlights the challenges encountered and techniques used in the rehabilitation of soldiers with foot and ankle injuries sustained in recent combat operations.

Strategies for managing massive defects of the foot in high-energy combat injuries of the lower extremity

Blast-related lower extremity trauma presents many challenges in its management that are not frequently experienced in high-energy civilian trauma. Because many of the blasts experienced in the current conflicts are ground based, the foot and ankle have sustained considerable severity and extent of injury because of the proximity of the blast. The high functional demands required of active service members create several reconstructive challenges. The authors' experience in the current conflicts has shown a similar trend, with the magnitude of soft tissue injury usually dictating whether or not salvage may be possible. Several reconstructive options for bone defect management are outlined and discussed.

Prevention and treatment of infected foot and ankle wounds sustained in the combat environment

Combat injuries to the foot and ankle are challenging to treat due to frequent high-energy mechanisms, environmental contamination, and soft tissue and bony damage. Prevention and treatment of infections in injuries to the foot and ankle are critical to achieving the goals of tissue healing and restoration of function. The guidelines for treatment of these foot and ankle injuries are similar to those in place for civilians; however, allowances must be made for the realities of combat including an often austere environment, the need for evacuation, and limitations on resources available for treatment.

The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma

BACKGROUND

Urgent débridement of open fractures has been considered to be of paramount importance for the prevention of infection. The purpose of the present study was to evaluate the relationship between the timing of the initial treatment of open fractures and the development of subsequent infection as well as to assess contributing factors.

METHODS

Three hundred and fifteen patients with severe high-energy lower extremity injuries were evaluated at eight level-I trauma centers. Treatment included aggressive débridement, antibiotic administration, fracture stabilization, and timely soft-tissue coverage. The times from injury to admission and operative débridement as well as a wide range of other patient, injury, and treatment-related characteristics that have been postulated to affect the risk of infection within the first three months after injury were studied, and differences between groups were calculated. In addition, multivariate logistic regression models were used to control for the effects of potentially confounding patient, injury, and treatment-related variables.

RESULTS

Eighty-four patients (27%) had development of an infection within the first three months after the injury. No significant differences were found between patients who had development of an infection and those who did not when the groups were compared with regard to the time from the injury to the first débridement, the time from admission to the first débridement, or the time from the first débridement to soft-tissue coverage. The time between the injury and admission to the definitive trauma treatment center was an independent predictor of the likelihood of infection.

CONCLUSIONS

The time from the injury to operative débridement is not a significant independent predictor of the risk of infection. Timely admission to a definitive trauma treatment center has a significant beneficial influence on the incidence of infection after open high-energy lower extremity trauma.

Open midfoot blast trauma treated with ring external fixation: case report

Level of Evidence: V, Case Report