Mark E. Fleming

Invasive mold infections following combat-related injuries.

BACKGROUND Major advances in combat casualty care have led to increased survival of patients with complex extremity trauma. Invasive fungal wound infections (IFIs) are an uncommon, but increasingly recognized, complication following trauma that require greater understanding of risk factors and clinical findings to reduce morbidity. METHODS The patient population includes US military personnel injured during combat from June 2009 through December 2010. Case definition required wound necrosis on successive debridements with IFI evidence by histopathology and/or microbiology (Candida spp excluded). Case finding and data collected through the Trauma Infectious Disease Outcomes Study utilized trauma registry, hospital records or operative reports, and pathologist review of histopathology specimens. RESULTS A total of 37 cases were identified: proven (angioinvasion, n=20), probable (nonvascular tissue invasion, n=4), and possible (positive fungal culture without histopathological evidence, n=13). In the last quarter surveyed, rates reached 3.5% of trauma admissions. Common findings include blast injury (100%) during foot patrol (92%) occurring in southern Afghanistan (94%) with lower extremity amputation (80%) and large volume blood transfusion (97.2%). Mold isolates were recovered in 83% of cases (order Mucorales, n=16; Aspergillus spp, n=16; Fusarium spp, n=9), commonly with multiple mold species among infected wounds (28%). Clinical outcomes included 3 related deaths (8.1%), frequent debridements (median, 11 cases), and amputation revisions (58%). CONCLUSIONS IFIs are an emerging trauma-related infection leading to significant morbidity. Early identification, using common characteristics of patient injury profile and tissue-based diagnosis, should be accompanied by aggressive surgical and antifungal therapy (liposomal amphotericin B and a broad-spectrum triazole pending mycology results) among patients with suspicious wounds.

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.

How much do locked screws add to the fixation of "hybrid" plate constructs in osteoporotic bone?

Background: Hybrid locked plating has become a commonly used technique for treating complex fractures and nonunions, but information is lacking to direct the specific application of this fixation method. The purpose of this study was to determine the effect of the number and location of locked screws on the mechanical properties of hybrid plate constructs in an osteoporotic bone model. Methods: A synthetic commercial composite model of osteoporotic bone with a 5-mm simulated fracture gap was fixed with a 12-hole plate. Seven different constructs (n = 5/construct) were tested including 2 unlocked and 5 hybrid configurations. All constructs used bicortical screws tightened to 4 N·m torque. Cyclic (sinusoidal) testing was performed with a peak torsional load of ±8 N·m for 100,000 cycles. Torsional stiffness of each construct was measured in 10,000 cycle increments, and the maximum removal torque of each screw was measured at the conclusion of torsional testing. Results: Stiffness of the constructs at each testing interval was most affected by the number of screws; stiffness increased at least 33% when 4 screws were used on each side of the fracture versus 3 per side. Among the constructs with 4 screws in each fragment, no difference was observed when 1 or 2 unlocked screws were replaced with locked screws on each side of the simulated fracture. In contrast, replacement of 3 unlocked screws with locked screws increased the torsional stiffness of the construct by another 24% (P < 0.001). Compared with baseline (pretesting) values, postcycling screw removal torque was similar for locked screws at all positions (average 50% of peak removal), but removal torque of unlocked screws furthest from the fracture was increased by 274% if they were placed immediately adjacent to a locked screw (P < 0.001). Conclusions: At least 3 bicortical locked screws on each side of a fracture are needed to increase the torsional stiffness in an osteoporotic bone model. Locked screws placed between the fracture and unlocked screws protect the unlocked screws from loosening and may have some clinical utility in improving fatigue life of the construct. Level of evidence: Biomechanical level 1.

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.

The Use of Dilute Dakin's Solution for the Treatment of Angioinvasive Fungal Infection in the Combat Wounded: A Case Series

Disseminated fungal infections are normally opportunistic infections in the immunocompromised population. Current literature has documented a high mortality rate with these infections in civilian trauma or as complications of severe burns. There is only one published case of fungal infection in a combat-injured individual to date, which resulted in mortality despite aggressive debridement and appropriate antifungal agents. We present here three patients in whom aggressive debridement, antifungals, and the addition of dilute Dakins solution with negative pressure wound therapy was used to treat angioinvasive mold. Angioinvasive fungal infection continue to be one of the most aggressive and devastating infections that our combat-injured patients face. With the addition of dilute Dakins solution, we successfully managed three critically ill patients. Previous literature had shown close to 30% mortality associated with cutaneous mucormycosis and the mortality rate approaches 100% with disseminated angioinvasive fungal infections. These results provide hope not only for the combat-injured patients being treated for both local and disseminated angioinvasive fungal infections, but also for the civilian trauma and immunocompromised patients.

Soft tissue injury management with a continuous external tissue expander

BackgroundBlast exposure is a common cause of soft tissue injury within the battlefield setting, with the extremities often critically involved. The resulting injury pattern presents with massive soft tissue defects that may be further complicated by varying degrees of accompanying orthopedic and peripheral nerve damage. To address the severe soft tissue defect, various combinations of advanced reconstructive methods are typically required to achieve definitive wound coverage. Continuous external tissue expansion has been used by our institution to significantly reduce wound burden and provide for definitive wound closure in certain blast-injured patients. MethodsThe authors present an early series of 14 patients who suffered massive extremity soft tissue injuries and were treated with an external tissue expansion system (DermaClose RC). Outcome measurements included time to definitive closure and method of definitive wound closure. A 5-patient subset of this group was prospectively analyzed to determine measurements including initial wound surface area (WSA), percentage reduction in WSA, and related complications. ResultsOverall time to wound coverage ranged from 1 to 6 days, with mean time to wound coverage being 4.4 days. Of the 14 patients included in the series, 12 (85.7%) were able to undergo delayed primary closure, whereas 2 required split thickness skin grafting. In the 5-patient subgroup, WSA initially ranged from 20.25 to 1031.25 cm2. Mean wound size was 262.7 cm2. Decrease in WSA ranged from 44% to 93% of the initial WSA, with mean decrease being 74.3% (95% confidence interval, 57.33–91.3). ConclusionsIn the management of large complex wounds, external tissue expansion has proven to be a valuable adjunct in achieving definitive wound closure. It can often aid in successful delayed primary closure of certain soft tissue wounds, has low associated morbidities, and can reduce the need for more complex or morbid procedures when used properly. The authors propose an algorithm for the use of continuous external tissue expansion system to achieve effective and successful wound closure, while potentially reducing the need for increased donor-site morbidities associated with more complex or larger reconstruction measures.

The use of urinary bladder matrix in the treatment of trauma and combat casualty wound care.

Treatment of combat injuries and resulting wounds can be difficult to treat due to compromised and evolving tissue necrosis, environmental contaminants, multidrug resistant microbacterial and/or fungal infections, coupled with microvascular damage and/or hypovascularized exposed vital structures. Our group has developed surgical care algorithms with identifiable salvage techniques to achieve stable, definitive wound coverage often with the aid of certain regenerative medicine biologic scaffold materials and advanced wound care to facilitate tissue coverage and healing. This case series reports on the role of urinary bladder matrix scaffolds in the wound care and reconstruction of traumatic and combat wounds. Urinary bladder matrix was found to facilitate definitive soft tissue reconstruction by establishing a neovascularized soft tissue base acceptable for second stage wound and skin coverage options within traumatic and combat-related wounds.

Application of the orthoplastic reconstructive ladder to preserve lower extremity amputation length.

BackgroundA primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation. MethodsA series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length. ResultsSoft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with split-thickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle flaps or adjacent tissue rearrangements and free tissue transfers. ConclusionsThe preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.