n the cutting edge Section Editor: Bennie G.P. Lindeque, MD 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 Surgery 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 Joint 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 Implant 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 610 ORTHOPEDICS | Healio.com/Orthopedics n the cutting edge 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 infection 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 bone 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 open fracture 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- AUGUST 2013 | Volume 36 • Number 8 611 n the cutting edge 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