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Internal Fixation in a Combat Theater Hospital

MAJ Thomas M. Large, MD, USAFR, MC; MAJ Cale Bonds, MD, USAF, MC; MAJ Michael Howard, MD, USAF, MC

War Course.4-11 Initial structed from temporary struc- Abstract: Limited data are available on the use of internal treatments are damage con- tures with operating rooms in fixation in combat zone hospitals. The authors performed a trol interventions, including storage containers. The Craig retrospective review of 713 surgical cases during 2 Operation hemorrhage control, wound Theater Hospital facility Enduring Freedom deployments to a Level III theater hospital debridement and irrigation, is a permanent facility similar in 2007 and 2009 to 2010. The epidemiology and short- to placement of external fixators in size to a small community intermediate-term outcomes of patients treated with internal and negative-pressure wound hospital in the United States fixation devices were studied. The authors found that, with ju- therapy devices, and amputa- but designed for and primar- dicious use, internal fixation under a damage control protocol tions or fasciotomies when ily dedicated to trauma care in a combat theater hospital can be performed with acceptable indicated. Implanting internal (Figure 1). Sterility of oper- complication rates. fixation devices in American ating conditions was more personnel is generally contra- of a concern at the Combat indicated in the war zone.5,6 Surgical Hospital. Digital ra- usculoskeletal extrem- guided by the Joint Theater However, host nation military diography, computerized to- Mity injuries are present Trauma System Clinical and civilians often receive de- mography scanning, fluoros- in 49% to 71% of Operation Practice Guidelines, the finitive treatment of their inju- copy, and a wide complement Iraqi Freedom and Operation Emergency War Surgery hand- ries at these combat hospitals. of orthopedic implants are Enduring Freedom casual- book, International Committee Treatment may include inter- available. Cases performed in ties.1-3 American military in- of the Red Cross manuals, and nal fixation devices as wounds both facilities are included in jury treatment in theater is courses such as the Extremity and fracture personalities this study. dictate. Limited data exist on The authors deployed mul- internal fixation performed in tiple times to the Level III The authors are from the Department of Orthopaedic Trauma Services the war zone.12-21 hospital in Bagram and selec- (TML), Mission Hospital, Asheville, North Carolina; and the Department The Level III hospital facil- tively used internal fixation of Orthopaedic Surgery (CB, MH), David Grant Medical Center, Travis Air Force Base, Solano, California. ity in Bagram, Afghanistan, devices for definitive fracture Dr Large is a stockholder in The Orthopaedic Company. Drs receives many Afghan casu- treatment. The cost of these Bonds and Howard have no relevant financial relationships to disclose. alties for definitive treatment implants is substantial, and The views expressed in this manuscript are those of the authors and do of their injuries. At the end of the ability to remove infected not reflect the official policy of the Department of the Army, Department of Defense, or US government. All authors are employees of the United States February 2007, the hospital implants after the withdrawal government. This work was prepared as part of their official duties, and as moved from the 14th Combat of American military medi- such, there is no copyright to be transferred. Surgical Hospital to the Craig cal personnel may be limited. Correspondence should be addressed to: MAJ Thomas M. Large, Joint Theater Hospital. The Many factors affect Afghan pa- MD, Department of Orthopaedic Trauma Services, Mission Hospital, 509 Biltmore Ave, Asheville, NC 28801 ([email protected]). Combat Surgical Hospital was tients’ ability to follow up, in- doi: 10.3928/01477447-20130724-06 a traditional field hospital, con- cluding finances, distance, and

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security concerns. However, many patients attend 1 or more follow-up appointments. The authors studied the epidemiology of deployed or- thopedic surgical cases and the short- to intermediate- term follow-up on the use of internal fixation in a combat zone military hospital. They hypothesized that the use of 1A 1B a consistent, defined protocol for the treatment of battlefield fractures would contribute to acceptable rates of and union after the use of in- ternal fixation in a Level III combat theater hospital.

Materials and Methods This study was approved by the institutional review board at David Grant USAF Medical Center Clinical 1C 1D Investigation Facility (protocol Figure 1: Photographs of the 14th Combat Surgical Hospital (A) and the operating room (B), Bagram, Afghanistan. Photo- graphs of the Craig Joint Theater Hospital (C) and the operating room (D), Bagram, Afghanistan, which opened February 2007. number FDG20120011E). A retrospective review was per- formed of all patients treated Kihei, Hawaii) databases and graphically as bridging of the Red Cross publica- surgically during 2 deploy- the locally held digital radiolo- on 3 cortices or clinically as tions, relevant Extremity War ments to Bagram in support of gy system. Fractures were clas- full weight bearing without Injuries Symposia publica- Operation Enduring Freedom: sified according to the Gustilo- pain. Statistical analysis was tions, and personal conversa- January 2007 to May 2007 and Anderson performed using Student’s t tions with other military or- November 2009 to May 2010. classification22,23 and the AO/ test and chi-square analysis thopedic surgeons.4-11 These cases were logged in the OTA classification system.24 with Bonferonni correction. Patients underwent early, surgeon’s (T.M.L.) personal Outpatient follow-up All patients admitted and aggressive wound debride- case log. Patients designated occurred at the Combat definitively treated in theater ment, removing devitalized as detainee status were exclud- Surgical Hospital, Craig Joint for battlefield injuries from tissue and foreign debris, gen- ed from the study. Inpatient Theater Hospital, or other improvised explosive devices erally within hours of their and outpatient care were military facilities throughout (IEDs), gunshot wounds, and injury depending on the num- documented in an electronic Afghanistan. Due to variable indirect fire mechanisms un- ber of casualties received. All medical record (Composite documentation, follow-up derwent the same treatment wounds were irrigated with a Health Care System; Science analysis gathered no data on protocol during both deploy- minimum of 9 L of normal sa- Applications International range of motion or functional ments. This protocol was de- line without additives. Patients Corporation, Tysons Corner, outcomes, but rather focused vised by the author (T.M.L.) returned to the operating room Virginia). The review of pa- on infection and fracture heal- through a combination of in 24 to 72 hours for repeat de- tients treated with internal ing. If the presence or absence recommendations from the bridements as dictated by the fixation was performed using of infection was not docu- Joint Theater Trauma System extent of the soft tissue injury the Composite Health Care mented by the provider, the Clinical Practice Guidelines, and contamination. Seventy- System and Theater Medical patient was excluded. Fracture Emergency War Surgery hand- two hours was preferred for Data Store (Akimeka LLC, healing was defined radio- book, International Committee most cases. All wounds under-

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went a minimum of 2 irrigation Wounds and surgical in- the night before surgery and cases again shows that a major- and debridement procedures cisions were closed in lay- not given the morning of sur- ity were Afghan patients: 126 prior to fixation, at which time ers using monofilament su- gery. Exceptions to the above (31.0%) were performed on US wounds were closed or cov- tures and sometimes staples. protocols occurred as dictated military personnel, 21 (5.2%) ered with grafts or flaps. Any Wounds were not cultured by the clinical situation, such on NATO military personnel, debridements that occurred at on presentation or repeat de- as altered antibiotic regimens 134 (33.0%) on Afghan civil- a forward operating base were bridement procedures. Skin due to abdominal injuries. ians, 120 (29.6%) on Afghan not counted toward these 2 de- grafts were dressed with non- National Army or Afghan bridements. Internal fixation adherent gauze (Adaptic; Results National Police personnel, and was postponed if wounds re- Johnson & Johnson Services During the January to May 5 (1.2%) on third-country na- quired additional debridement Inc, New Brunswick, New 2007 deployment, 307 sur- tionals or contractors. of devitalized tissue at the Jersey) and negative-pressure gical cases were performed, During the 2007 deploy- third operation. wound therapy at 125 mm Hg frequently requiring multiple ment, 66 internal fixation pro- All wounds associated with continuous suction for procedures on single or multi- cedures were performed on 50 open fractures were treated 5 days. Occasionally, nega- ple limbs (Figures 2-4). Many patients. During the 2009 to with a negative-pressure tive-pressure wound therapy patients returned for multiple 2010 deployment, 87 fixation wound therapy device (VAC; was used as a dressing over operations, so 118 unique procedures were performed on Kinetic Concepts, Inc, San closed surgical wounds, such patients were treated. These 77 patients, for a total of 153 Antonio, Texas) at 125 mm Hg as fasciotomies or those under patients sustained injuries to fixation cases in 127 patients. continuous suction. Internal any tension, at 125 mm Hg an average of 1.46 limbs. The Patients definitively treated fixation devices were used if continuous suction for 3 days. mechanisms of injury and pa- with or casts the fracture was thought to be The authors estimate that this tient demographics are sum- are not included in these num- reconstructible and, most im- was done for 20% of patients. marized in Tables 1 and 2. bers. These numbers include portantly, the soft tissue injury No allograft or autograft An analysis of the 307 proce- percutaneous and open pin- and wounds were clean and bone graft was placed acutely dures shows a preponderance ning fracture cases, mostly in could be closed or covered. in war-injured open fracture of Afghan patients: 21 (6.8%) the hands, feet, or pediatric External fixator pin sites sites. Large segmental defects were performed on US military elbows. These were excluded, were curetted and irrigated were treated with antibiotic- personnel, 3 (1.0%) on North leaving 117 internal fixation prior to intramedullary nail- impregnated polymethyl- Atlantic Treaty Organization cases in 92 patients. ing and were left open to heal methacrylate (PMMA) bead (NATO) military personnel, Follow-up was available by secondary intention. Pins spacers and staged iliac crest 194 (63.2%) on Afghan civil- on 64 (55%) internal fixa- were wrapped with bolstered autografting in 6 to 8 weeks, ians, 85 (27.7%) on Afghan tion cases in 47 patients. Nine gauze bandages; no cleaning occasionally augmented with National Army or Afghan (14%) of these cases were per- regimen was used. During the allograft chips or demineral- National Police personnel, and formed in the Combat Surgical 2007 deployment, patients re- ized bone matrix. Bead pouch- 4 (1.3%) on third-country na- Hospital and 55 (86%) in the ceived cefazolin and gentamy- es were not used as initial pro- tionals or contractors. Craig Joint Theater Hospital cin, with penicillin G added phylactic treatment. No bone During the November 2009 (Tables 3, 4). The 38 open frac- for wounds contaminated with morphogenic protein products to May 2010 deployment, 406 tures were classified using the vegetative debris. Gentamycin were used. Small nonsegmen- surgical cases were performed, Gustilo-Anderson classifica- and penicillin G were contin- tal defects were treated with again with many patients hav- tion,22,23 and all fractures were ued for 72 hours and cefazolin antibiotic-impregnated cal- ing multiple operations; 266 classified with the AO/OTA was continued for 48 hours af- cium sulfate beads (Osteoset; unique patients were treated classification.24 Two fractures ter wound closure or coverage. Wright Medical Technology, (Figures 5-10). These patients were above amputations. One During the 2010 deployment, Inc, Arlington, Tennessee) sustained injuries to an aver- elective case was patients received cefazolin and at the time of internal fixa- age of 1.74 limbs, a significant not classified. Average follow- levofloxacin; penicillin G was tion and closure/coverage. increase from 2007 (P5.019). up was 122 days (range, 14- not used. Cefazolin and levo- Patients without contraindica- The mechanisms of injury and 447 days). Patients included floxacin were continued for tions were started on 30 mg of patient demographics are sum- 3 US military personnel, 39 48 hours after wound closure enoxaparin twice daily after marized in Tables 1 and 2. An Afghan National Army or or coverage. surgery. Enoxaparin was given analysis of the 406 surgical Afghan National Police per-

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sonnel, and 22 Afghan civil- ians. Four cases were pediat- ric and 60 were adult. Three cases were referral cases with preexisting . Four cases were referral or pending malunion cases. Six patients received antibiotic-impregnated cal- cium sulfate grafting of a nonsegmental defect. Two patients received antibiotic- 2A 2B 2C 2D impregnated PMMA beads or Figure 2: 2007 deployment. Clinical photograph of a left open tibia fracture with a closed medial malleolus fracture and closed calcaneal fracture with a right closed talar neck fracture and open right leg wounds sustained when a rocket- spacers for segmental defects; propelled grenade hit a pickup truck (A). Lateral (B), anteroposterior (C), and mortise (D) radiographs at 292-day follow-up. 1 patient received an antibiot- All wounds healed and the patient was fully weight bearing without pain bilaterally. ic-impregnated PMMA tibial nail for treatment of an in- fected tibial nonunion. Eight patients required split-thick- ness skin grafts, and 3 had rotational muscle flaps for soft tissue coverage; the remainder with open wounds underwent delayed primary closure. Six 3A 3B 3C patients with tibial fractures Figure 3: 2007 deployment. Anteroposterior radiograph in a temporizing external fixator of an improvised explosive device had injury with an open tibial fracture (A). Clinical photograph of the wound at 2-week follow-up; it healed uneventfully (B). treated with medial and lateral Anteroposterior radiograph at 159-day follow-up showing a healed fracture (C). fasciotomies. Two (3%) infections oc- with tibial nail dynamization curred: 1 in a patient referred and iliac crest autograft, and with a preexisting infection the other was treated with dy- and the other in a referral case namization and a fibular oste- revised from a lag screw and otomy. The nonunion patient external fixation construct to was the same with an ongo- a femoral intramedullary nail. ing infected tibial nonunion The former patient had an on- mentioned above. In addition, going infected nonunion, and 2 patients with large segmen- the treatment plan moving tal defects underwent planned 4A 4B 4C forward was not clearly docu- exchange of their antibiotic- Figure 4: 2007 deployment. Anteroposterior radiographs 233 days after suicide mented. The latter patient was impregnated PMMA bead bomber injuries caused right open femur (A), left open femur (B), and left open treated with hardware removal spacers with iliac crest auto- tibia (C) fracture showing well-healed fractures. The patient was ambulating and intravenous antibiotics, graft. Thus, a total of 5 (8%) without pain or assistive devices. but documentation of infection cases required additional pro- eradication was not available. cedures. Owens et al2 in their review of tively, in the study of Owens Of the 37 patients with ad- 3575 extremity injuries: 59.8% et al.2 Notably, the percent- equate follow-up to determine Discussion were from explosions (IED or age of IED injuries increased fracture healing, 2 delayed The epidemiology of the indirect fire) and 23.3% from from 8.5% to 36.5% between unions and 1 nonunion oc- 713 deployed orthopedic surgi- gunshot wounds in the current deployments (P,.0001), re- curred, a rate of 8%. Of the 2 cal cases presented in this arti- study’s most recent deployment flecting an increased use of this delayed unions, 1 was treated cle is similar to that reported by data vs 75% and 16%, respec- technology. Also, the number

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Table 1 Table 2 Mechanisms of Injury Epidemiology of 713 Deployed Surgical Cases

No. (%) of Unique Patients No. (%) 2007 2009-2010 2007 2009-2010 Injury Mechanism Deployment Deployment P Characteristic Deployment Deployment IED 10 (8.5) 97 (36.5) ,.0001 Cases 307 406 Gunshot wounds 15 (12.7) 55 (20.7) — Unique patients 118 266 Indirect firea 41 (34.7) 62 (23.3) .0196 Average injured limbs 1.46 1.74 per patienta Otherb 52 (44.1) 52 (19.5) ,.0001 US military personnel 18 (5.2) 120 (45.1) Abbreviation: IED, improvised explosive device. aRocket-propelled grenades, mortars, landmines, suicide bombs, NATO military personnel 3 (2.5) 19 (7.1) grenades. Local nationals 69 (58.5) 68 (25.6) bFalls, motor vehicle and other accidents, knife injuries, elective conditions (osteomyelitis, , tumors, congenital deformities). ANA or ANP personnel 26 (22) 55 (20.7) Other 2 (1.7) 4 (1.5) Abbreviations: ANA, Afghan National Army; ANP, Afghan National Police; NAT0, North Atlantic Treaty Organization. aStatistically significant P( 5.019).

5A 5B 6A Figure 5: 2009-2010 deployment. Clinical photograph of an open supracondy- lar femur fracture, patellar tendon laceration, and missing substantial patella due to an AK-47 gunshot wound (A). Anteroposterior radiograph at 8-week follow-up (B). The patient’s wounds healed and he began weight bearing 81 days after discharge from hospital. of injured limbs per patient sensitive stabilizing proce- significantly increased from dures as patients move through 4-6 1.46 to 1.74 (P5.019), also re- the evacuation chain. In rare 6B flecting an increasing severity injuries, such as a displaced of energy mechanisms during femoral neck fracture, inter- Operation Enduring Freedom. nal fixation may be consid- Of the 713 cases, 79% were not ered in coalition patients. With American casualties, provid- minimal data available, it is ing a large number of patients difficult to conclude whether 6C requiring definitive treatment the benefits of operative fixa- Figure 6: 2009-2010 deployment. Clinical photographs of wound healing (A) of their injuries in a combat en- tion would outweigh infection and knee motion (B) 3 weeks after open tibia and closed medial malleolus vironment. risk. In addition, many Level fractures with compartment syndrome from an improvised explosive device. Clinical photograph of wound healing at 6 weeks (C). The patient was fully Internal fixation in US and III and some Level II facili- weight bearing without pain at 131-day follow-up. NATO forces is generally not ties provide care to host nation indicated in the combat zone personnel, which includes de- due to concerns over infection finitive treatment of their in- available, it is difficult to treat casts or external fixators, and rates and the need for time- juries. With limited follow-up these patients definitively in hospital capacities would not

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7A 7B Figure 7: 2009-2010 deployment. Anteroposterior radiograph 10 weeks after open tibia and bimalleolar ankle fractures due to an improvised explosive device 8A 8B 8C (A). Clinical photograph of wound healing at 10 weeks (B). The patient underwent tibial nail dynamization and fibular osteotomy for a delayed union at 160 days. Figure 8: 2009-2010 deployment. Anteroposterior (A) and mortise (B) radio- graphs of open pilon, talus, and calcaneal fractures with compartment syndrome after an improvised explosive device injury. Anteroposterior radiograph 2 weeks after treatment with tibiotalocalcaneal fusion nailing using a short femoral nail (C).

9A 9B

10A 10B Figure 10: 2009-2010 deployment. Anteroposterior radiographs of a closed 9C 9D 9E anterior column acetabulum fracture at 5 weeks (A) and closed supracondylar humerus and olecranon fractures with 75% triceps laceration at 3 weeks (B) Figure 9: 2009-2010 deployment. Clinical photograph of a tibia fracture caused after suicide bomber injuries. by a high-energy gunshot wound (A). Clinical photograph of wound healing at 11 weeks (B). Anteroposterior radiographs after external fixation (C), after intra- medullary nailing and placement of an antibiotic bead spacer (D), and 3 weeks III facility during Operation jury cases. A higher proportion after posterolateral bone autografting into the bead pouch, performed 8 weeks Iraqi Freedom. They reported of ballistic injuries and open after intramedullary nailing (E). no known infections, but no fractures are presented in the patient with a high-grade soft current study (Table 1), and accommodate keeping these outline many important as- tissue injury underwent intra- 82% of their patients had fixa- patients until fracture healing pects of damage control treat- medullary nailing, whereas the tion on the day of injury. They has occurred, so when soft ment of combat orthopedic in- current study included many reported 1 infection, presenting tissue injuries will reasonably juries, but few conclusions can patients with high-grade soft 4 weeks out, and concluded allow the use of internal fixa- be drawn about the safety or tissue injuries. that the judicious use of inter- tion for reconstructible bony usefulness of internal fixation Stinner et al14 presented 50 nal fixation in an established, injuries, clear advantages ex- in combat injuries.15-21,25 More internal fixation procedures in well-equipped facility within ist. Some data exist on the use recently, Keeney et al13 report- American military personnel a combat environment may be of internal fixation in combat ed 2-month follow-up on 12 performed in a combat envi- safely performed.14 zone facilities. fractures and 6-month follow- ronment. Thirty-two percent Mody et al12 reported 58 US Historical articles from up on 5 fractures treated with of fractures were open from a military patients receiving in- World War II through the femoral intramedullary nails in blast or gunshot wound, where- tramedullary fixation at Walter Bosnian-Croatian-Serbian War host nation patients at a Level as 68% were closed, blunt in- Reed Army Medical Center

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iologic ideal time for definitive Table 3 Table 4 surgery in Pape’s27 description Internal Fixation Case Characteristics Internal Fixation Procedures of the immunologic response to polytrauma. Despite the poor Characteristic No. (%) Procedure No. access to health care for most Injury mechanism Tibia IMN 15 Afghan people, multi-drug re- IED 14 (22) Femur IMN 10 sistant organisms are frequent- ly present in Afghan patients IDF 21 (33) Ankle ORIF 8 in Bagram.28 Environmental GSW 14 (22) Humerus ORIF 6 or genetic factors may help ex- Other 15 (23) Tibia pilon ORIF 3 plain the current study’s lack Open/closed Proximal tibia ORIF 3 of surgical infections from Open 38 (59) Forearm ORIF 3 antibiotic-resistant organisms Closed 26 (41) Pelvis ORIF 2 reported by others on combat AO/OTA classificationa Calcaneal ORIF 2 casualties.29-31 A 16 (25) Talus ORIF 2 The current authors aggres- B 23 (37) Supracondylar humerus 2 sively used negative-pressure and olecranon ORIF wound therapy and antibiotic- C 24 (38) Humerus IMN 1 impregnated calcium sulfate Gustilo/Anderson classificationb Supracondylar humerus ORIF 1 or PMMA beads, which have II 5 (13) Hand proximal phalanx ORIF 1 been shown to decrease infec- tion rates.32-37 Intravenous ce- IIIA 22 (58) Acetabulum ORIF 1 fazolin was continued for 48 IIIB 3 (8) Femoral neck ORIF 1 hours after the wounds were IIIC 2 (5) Distal femur ORIF 1 closed or covered. Others have Abbreviations: GSW, gunshot wound; IDF, Tibiotalocalcaneal IMN 1 recommended discontinuing indirect fire; IED, improvised explosive device. Pelvis/femur osteotomy ORIF 1 aOne osteotomy case was not classified. antibiotics 24 hours after the bSix (16%) had inadequate documentation to be Abbreviations: IMN, intramedullary nailing; wound is clean, even if it is not classified. ORIF, open reduction and internal fixation. closed.38 A recent review pro- vides recommendations on an- tibiotic use for combat extrem- for battlefield femur and tibia and the timing of infections other series had more exten- ity injuries, which also covers fractures. Eighty-eight percent was not reported. Patients with sive wounds. different antibiotic selections of their fractures were open vs positive surveillance cultures Two infections occurred in between deployments.38 59% in the current study. They were more likely to develop an the current series, 1 in a pa- The 5 (8%) patients in the had a 40% infection rate, with infection or undergo an ampu- tient being treated for a pre- current series requiring ad- a median time to infection of tation, but these cultures were existing tibial infection that ditional procedures compares 15 days. Fifty-seven percent not predictive of the infecting recurred. Two other patients favorably with the 21% report- of infections occurred within organism.28 The current au- treated for preexisting infec- ed by Stinner et al.14 Longer 1 month, and 75% presented thors did not perform surveil- tions were cured of ongoing follow-up would likely result by day 113.12 Thus, the current lance cultures in this series. infection at most recent follow- in a higher number. Although study’s follow-up of 14 to 447 Although it is likely that some up. The low rate of infection the follow-up rate of 55% is a days should have captured the patients from the current se- experienced here may be due limitation of the current study, majority of infections. ries presented elsewhere with to many factors. A consistent given the challenges related More recently, Burns et late infections, it is unlikely damage control protocol with to following patients and col- al28 reported a 27% infection that these missed infections a minimum of 2 debridements lecting data in deployed loca- rate in 213 Gustilo-Anderson would increase the infection was used prior to any fixation tions, this is the largest series type III combat open tibial rate from 3% to the 27% to procedures, so all open fracture reported on the use of inter- fractures. Patients received an 40% rates reported above12,28; internal fixation procedures oc- nal fixation in a combat hos- average of 6 debridements, however, the patients in these curred on day 5 to 10, the phys- pital. A major contribution

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from this study is an evalu- face loss. Many patients treat- Committee of the Red Cross; B. Osteosynthesis revision in 1996. war fractures. Unfallchirurg. ation of the possible burden ed during this time period had 8. Gray R. War Wounds: Basic 1998; 101(6):476-481. left from Operation Enduring casts, definitive external fix- Surgical Management: The 20. Zeljko B, Lovrć Z, Amć E, Freedom after the withdrawal ators, or percutaneous pinning. Principles and Practice of Busić V, Lovrć L, Markovć I. of American medical assets. However, in other cases, inter- the Surgical Management of War injuries of the extremities: Wounds Produced by Missiles or twelve-year follow-up data. Mil Advanced implant use could nal fixation devices were the Explosions. Geneva, Switzerland: Med. 2006; 171(1):55-57. leave thousands of Afghan treatment of choice. This International Committee of the 21. Pukljak D. External fixation- patients with implants that lo- study’s results support that in- Red Cross; 1994. minimal osteosynthesis: in- cal surgeons cannot remove if ternal fixation, when used se- 9. Giannou C, Baldan M. War dications, role, and place in Surgery: Working With Limited war surgery. J Trauma. 1997; they become infected. This is lectively under a reproducible Resources in Armed Conflict 43(2):275-282. and Other Situations of an ongoing concern, but based damage control protocol, can 22. Gustilo RB, Anderson JT. Violence. Geneva, Switzerland: on the experience presented be safely used in a combat en- Prevention of infection in the International Committee of the treatment of one thousand and here, does not seem likely to vironment with a low compli- Red Cross; 2009. twenty-five open fractures be a widespread burden. cation rate. Further study and 10. Pollak AN, Calhoun JH. of long : retrospective longer-term follow-up on this Extremity war injuries: state of and prospective analyses. J the art and future directions. J Bone Joint Surg Am. 1976; Conclusion issue will be critical. Am Acad Orthop Surg. 2006; 58(4):453-458. The authors’ purpose is 14(10 spec no.):S1-S214. 23. Gustilo RB, Mendoza RM, not to advocate for aggressive References 11. Andersen RC, Ursua VA, Williams DN. Problems in Valosen M, et al. Damage con- the management of type III internal fixation use in com- 1. Belmont PJ, Goodman GP, trol orthopaedics: an in-theater (severe) open fractures: a new Zacchilli M, Posner M, Evans bat hospitals. The majority of perspective. J Surg Orthop Adv. classification of type III open C, Owens BD. Incidence and 2010; 19(1):13-17. fractures. J Trauma. 1984; these procedures were per- epidemiology of combat in- 24(8):742-746. formed in Craig Joint Theater juries sustained during “The 12. Mody RM, Zapor M, Hartzell JD, et al. 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