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BMJ Open Is Committed to Open Peer Review. As Part of This Commitment We Make the Peer Review History of Every Article We Publish Publicly Available BMJ Open: first published as 10.1136/bmjopen-2019-033557 on 25 November 2019. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on September 29, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2019-033557 on 25 November 2019. Downloaded from A comparison of facial injury management undertaken at US and UK Medical Treatment Facilities during the Iraq and Afghanistan conflicts ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2019-033557 Article Type: Original research Date Submitted by the 13-Aug-2019 Author: Complete List of Authors: Breeze, John; Royal Centre for Defence Medicine, Royal Centre for Defence Medicine Bowley, Douglas; University Hospitals Birmingham NHS Foundation Trust Combes, James; Royal Surrey County Hospital NHS Foundation Trust Baden, James; University Hospitals Birmingham NHS Foundation Trust Rickard, Rory; Royal Centre for Defence Medicine DuBose, Joseph; R Adams Cowley Shock Trauma Center Powers, David; Duke University Medical Center Military, Face, Trauma management < ORTHOPAEDIC & TRAUMA Keywords: SURGERY http://bmjopen.bmj.com/ on September 29, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 30 BMJ Open 1 2 A comparison of facial injury management undertaken at US and UK 3 BMJ Open: first published as 10.1136/bmjopen-2019-033557 on 25 November 2019. Downloaded from 4 Medical Treatment Facilities during the Iraq and Afghanistan conflicts 5 6 7 8 Breeze J 1, Bowley DM 2, Combes JG 3, Baden J 4, Rickard RF 5, DuBose J 6, 9 10 Powers DB 7 11 12 13 14 1 Duke University Medical Center, Durham, North Carolina, USA. 15 16 [email protected] 17 2 University Hospitals Birmingham, Birmingham, UK. [email protected] 18 For peer review only 19 3 Royal Surrey County Hospital, Guildford, UK. [email protected] 20 4 21 University Hospitals Birmingham, Birmingham, UK. [email protected] 22 5 Academic Department of Military Surgery and Trauma, Royal Centre for Defence 23 24 Medicine, Birmingham, UK. [email protected] 25 26 6 Center for the Sustainment of Trauma and Readiness Skills, R Adams Cowley Shock 27 28 Trauma Center, Baltimore, Maryland, US. [email protected] 29 7 Duke University Medical Center, Durham, North Carolina, US. [email protected] 30 31 32 33 Keywords 34 35 Face; trauma; military; fracture; tracheostomy 36 37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44 45 on September 29, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 30 1 2 Abstract 3 BMJ Open: first published as 10.1136/bmjopen-2019-033557 on 25 November 2019. Downloaded from 4 Objectives: To perform the first direct comparison of the facial injuries sustained and 5 6 treatment performed at United States (US) and United Kingdom (UK) deployed Medical 7 Treatment Facilities (MTF) in support of the military campaigns in Iraq and Afghanistan. 8 9 Setting: The US and UK Joint Theatre Trauma Registries were scrutinized for all patients 10 11 with facial injuries presenting alive to a UK or US deployed MTF between 01 March 2003 12 13 and 31 October 2011. 14 Participants: US and UK military personnel, local police, local military and civilians. 15 16 Primary and secondary outcome measures: An adjusted multiple logistic regression 17 18 model was performedFor using tracheostomypeer review as the primary only dependent outcome variable and 19 20 treatment in a US MTF, US or UK military, mandible fracture, and treatment of mandible 21 fracture as independent secondary variables. 22 23 Results: Facial injuries were identified in 16944 casualties, with the most common being 24 25 those to skin/muscle (64%), bone fractures (36%), inner/middle ear (28%) and intra-oral 26 damage (11%). Facial injuries were equally likely to undergo surgery in US MTF as UK 27 28 MTF (OR: 1.06, 95% CI: 0.4603 to 1.142, p= 0.6656), however, variations were seen in 29 30 injury type treated. In US MTF, 692/1452 (48%) of mandible fractures were treated by 31 2 32 either open or closed reduction compared to 0/167 (0%) in UK MTF (χ : 113.6; 33 p=<0.0001). US military casualties who had treatment of their mandible fracture (ORIF or 34 35 MMF) were less likely to have had a tracheostomy than those who did not undergo 36 37 stabilization of the fractured mandible (OR: 0.61, 95% CI: 0.44 to 0.86; p= 0.0066). http://bmjopen.bmj.com/ 38 39 Conclusions: The capability to surgically treat mandible fractures by open or closed 40 reduction should be considered as an integral component of deployed coalition surgical 41 42 care in the future. 43 44 Trial registration: not applicable. 45 on September 29, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 30 BMJ Open 1 2 Strengths and limitations 3 BMJ Open: first published as 10.1136/bmjopen-2019-033557 on 25 November 2019. Downloaded from 4 US MTF treated almost half of all mandible fractures prior to aeromedical 5 6 evacuation, whereas the UK MTF treated none. 7 8 US military casualties who had treatment of their mandible fracture were statistically 9 less likely to require a tracheostomy than those who did not. 10 11 This paper support accepted US military doctrine that mandible fractures should be 12 13 treated by open reduction in deployed MTF whenever agreed indications exist. 14 15 The lack of standardization between the two trauma registries limits further outcome 16 analyses between nations. 17 18 It is not possibleFor to collate peer long-term review outcome data only in the US system due to the lack 19 20 of uniformity of reporting methods. 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44 45 on September 29, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 30 1 2 Introduction 3 BMJ Open: first published as 10.1136/bmjopen-2019-033557 on 25 November 2019. Downloaded from 4 In support of military operations in the Iraq and Afghanistan, the United States (US) and 5 6 United Kingdom (UK) deployed numerous military Medical Treatment Facilities (MTF). 7 Their primary role was to treat coalition military forces, but as the mission evolved, 8 9 treatment was offered to host nation police and military members, as well as the civilian 10 11 population according to the prevailing 'Rules of Eligibility’ (1). Coalition MTF deployed to 12 13 Iraq and Afghanistan are broadly classified by the North Atlantic Treaty Organization 14 (NATO) into Roles (or echelons). Role 1 provides primary health care with specialized first 15 16 aid, triage, resuscitation and stabilization (1,2). Role 2 MTF provide enhanced 17 18 resuscitation with capabilityFor forpeer life-saving review surgery, in addition only to further triage and 19 20 treatment of casualties. Role 2 facilities are divided into ‘Basic (R2B)’, where damage 21 control surgery (DCS) procedures can be undertaken, and ‘Enhanced’ (R2E) with 22 23 additional capabilities and greater resources, including the capability to prepare casualties 24 25 for strategic aeromedical evacuation (STRATEVAC) (1). Role 3 MTF provide all the 26 capabilities of the R2E MTF as well as the capability for specialized imaging and surgery, 27 28 blood banking and laboratory support. 29 30 31 32 The US military deployed surgeons formally trained in the management of facial skeletal 33 trauma to their Role 3 MTF at Balad (Iraq), Baghdad (Iraq) and Bagram (Afghanistan) 34 35 (3,4). Further management of facial trauma in US military personnel occurred following 36 37 STRATEVAC to Landstuhl Regional Medical Centre in Germany (Role 4), with a http://bmjopen.bmj.com/ 38 39 proportion further evacuated to homeland US facilities (Role 5) (4,5). The UK deployed 40 surgeons formally trained in the management of facial trauma to the R3 MTF in Camp 41 42 Bastion and, for a shorter period to the Canadian-led R3 MTF in Kandahar (6–9). Taught 43 44 British practice was to repatriate patients with facial injury without stabilization or fixation of 45 the facial skeleton to the Royal Centre for Defence Medicine (RCDM) in Birmingham UK on September 29, 2021 by guest.
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