Jason H. Calhoun

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.

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update endorsed by the infectious diseases society of America and the surgical infection society

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Treatment of War Wounds: A Historical Review

The treatment of war wounds is an ancient art, constantly refined to reflect improvements in weapons technology, transportation, antiseptic practices, and surgical techniques. Throughout most of the history of warfare, more soldiers died from disease than combat wounds, and misconceptions regarding the best timing and mode of treatment for injuries often resulted in more harm than good. Since the 19th century, mortality from war wounds steadily decreased as surgeons on all sides of conflicts developed systems for rapidly moving the wounded from the battlefield to frontline hospitals where surgical care is delivered. We review the most important trends in US and Western military trauma management over two centuries, including the shift from primary to delayed closure in wound management, refinement of amputation techniques, advances in evacuation philosophy and technology, the development of antiseptic practices, and the use of antibiotics. We also discuss how the lessons of history are reflected in contemporary US practices in Iraq and Afghanistan.

Preoperative Risk Stratification and Risk Reduction for Total Joint Reconstruction: AAOS Exhibit Selection.

Demand for primary total hip arthroplasty and demand for total knee arthroplasty in the United States are anticipated to grow by 174% and 673%, respectively, over the next twenty years1. Satisfaction rates are good to excellent in most patients2-4. Modern techniques and perioperative care have reduced systemic and local complications5-7. Nevertheless, the risks of major adverse outcomes (2.2% to 7.4%)8-10 and death (0.1% to 0.8%)5,7-9,11-19 remain real. Careful preoperative clearance and targeted therapeutic interventions are necessary to minimize complications. Studies have demonstrated total joint arthroplasty to be a highly cost-effective procedure. Nevertheless, many payers, especially the U.S. Centers for Medicare & Medicaid Services (CMS), have targeted total joint arthroplasty for cost control20. Adoption of a pay-for-performance program by CMS21 has created a zero-sum game to reward overachievers and penalize underachievers. The current literature lacks a detailed, comprehensive approach for risk-stratifying total joint arthroplasty patients and a systematic method for preoperatively allaying these risks. Popular tools such as the American Society of Anesthesiologists (ASA) classification system may be effective in predicting the overall outcome of surgery, but they cannot predict specific complications22 and they do not facilitate further preparatory action23-25. Although medical evaluation should be performed in collaboration with the internist, evidence-based guidelines provide standardization and comprehensiveness. Conditions necessitating postponement or cancellation of total joint arthroplasty are present in approximately 4% of patients26. Complications related to the cardiovascular system represent 42% to 75% of major systemic adverse events and deaths following total joint arthroplasty7,13,27,28, and cardiovascular comorbidities are a significant risk factor for these events14,29. Intramedullary instrumentation …

Infection prevention and control in deployed military medical treatment facilities.

Infections have complicated the care of combat casualties throughout history and were at one time considered part of the natural history of combat trauma. Personnel who survived to reach medical care were expected to develop and possibly succumb to infections during their care in military hospitals. Initial care of war wounds continues to focus on rapid surgical care with debridement and irrigation, aimed at preventing local infection and sepsis with bacteria from the environment (e.g., clostridial gangrene) or the casualtys own flora. Over the past 150 years, with the revelation that pathogens can be spread from patient to patient and from healthcare providers to patients (including via unwashed hands of healthcare workers, the hospital environment and fomites), a focus on infection prevention and control aimed at decreasing transmission of pathogens and prevention of these infections has developed. Infections associated with combat-related injuries in the recent operations in Iraq and Afghanistan have predominantly been secondary to multidrug-resistant pathogens, likely acquired within the military healthcare system. These healthcare-associated infections seem to originate throughout the system, from deployed medical treatment facilities through the chain of care outside of the combat zone. Emphasis on infection prevention and control, including hand hygiene, isolation, cohorting, and antibiotic control measures, in deployed medical treatment facilities is essential to reducing these healthcare-associated infections. This 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.

Prevention of Infections Associated with Combat-Related Burn Injuries

Burns are a very real component of combat-related injuries, and infections are the leading cause of mortality in burn casualties. The prevention of infection in the burn casualty transitioning from the battlefield to definitive care provided at the burn center is critical in reducing overall morbidity and mortality. This review highlights evidence-based medicine recommendations using military and civilian data to provide the most comprehensive, up-to-date management strategies for initial care of burned combat casualties. Areas of emphasis include antimicrobial prophylaxis, debridement of devitalized tissue, topical antimicrobial therapy, and optimal time to wound coverage. 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.

Joseph C. Risser Sr., 1892–1982

This biographical sketch of Joseph C. Risser Sr. corresponds to the historic text, The Classic: The Iliac Apophysis: An Invaluable Sign in the Management of Scoliosis, available at DOI 10.1007/s11999-009-1096-z.

Prevention of infections associated with combat-related eye, maxillofacial, and neck injuries

The percentage of combat wounds involving the eyes, maxillofacial, and neck regions reported in the literature is increasing, representing 36% of all combat-related injuries at the start of the Iraq War. Recent meta-analysis of 21st century eye, maxillofacial, and neck injuries described combat injury incidences of 8% to 20% for the face, 2% to 11% for the neck, and 0.5% to 13% for the eye and periocular structures. This article reviews recent data from military and civilian studies to support evidence-based recommendations for the prevention of infections associated with combat-related eye, maxillofacial, and neck injuries. The major emphasis of this review is on recent developments in surgical practice as new antimicrobial studies were not performed. Further studies of bacterial infection epidemiology and postinjury antimicrobial use in combat-related injuries to the eyes, maxillofacial, and neck region are needed to improve evidence-based medicine recommendations. 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.

Prevention of infections associated with combat-related thoracic and abdominal cavity injuries

Trauma-associated injuries of the thorax and abdomen account for the majority of combat trauma-associated deaths, and infectious complications are common in those who survive the initial injury. This review focuses on the initial surgical and medical management of torso injuries intended to diminish the occurrence of infection. The evidence for recommendations is drawn from published military and civilian data in case reports, clinical trials, meta-analyses, and previously published guidelines, in the interval since publication of the 2008 guidelines. The emphasis of these recommendations is on actions that can be taken in the forward-deployed setting within hours to days of injury. 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.

Optimal timing of operative debridement: a known unknown: commentary on an article by Mara L. Schenker, MD, et al.: “Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review”.

Descriptions of debridement for treatment of open fractures are at least as old as The Iliad 1, but the question of the timing of debridement is still unresolved after more than a century of study. The origins of the “six-hour rule” are in animal studies, and even today much of what we know (and think we know) about the timing of debridement and antibiotics and about the relation of such timing to the risk of infection is the result of investigations involving rabbits and rats. The most recent animal studies of the timing of antibiotics, timing of lavage, and timing of debridement still suggest that these are each important in reducing infection when considered separately2, but even these three relatively easy-to-control variables have not been studied in combination, nor have the added variables that would mimic the reality of our modern Emergency Medical Services system, emergency departments, trauma centers, and personnel trained in fracture assessment and stabilization, early use of antibiotics, wound lavage, dressing care, and triage. In 2010, a review of 315 patients by the Lower Extremity Assessment Project (LEAP) Study Group found that the time from injury to operative debridement was not a significant predictor of infection risk3. The authors of the current study …