Prevention and Management of Infections Associated With Combat-Related Extremity Injuries

Murray, Clinton K.; Hsu, Joseph R.; Solomkin, Joseph S.; Keeling, John J.; Andersen, Romney C.; Ficke, James R.; Calhoun, Jason H.

doi:10.1097/ta.0b013e318163cd14

Cited by 117 publications

(88 citation statements)

References 118 publications

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“…The injuries to US service members were evenly distributed between upper and lower extremities, and 75% were the result of explosive munitions [15,16]. To further explore the phenomenon of ectopic bone formation occurring after blast amputation, we developed an animal model to replicate the process without addition of exogenous osteogenic agents.…”

Section: Discussionmentioning

confidence: 99%

“…Consequently, the prevalence of wounded service members surviving major battlefield injury has increased substantially, with more than 88% of reported events in the Iraq conflict being survivable [9]. In the Middle East, nearly 70% of injuries are isolated to the extremities, and 80% of injuries are caused by explosive devices, resulting in high rates of survivable combat-related amputations [5,6,15]. Having survived initial trauma and resulting limb amputation, service members face complications that can compromise return to productive civilian life, including the development of heterotopic ossification (HO) in the residual limb.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Does Blast Medium Affect Heterotopic Ossification in a Blast-amputation Model?

Yoo

Blevins

Gasbarro

et al. 2015

Clinical Orthopaedics &Amp; Related Research

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Background Heterotopic ossification (HO) develops after nearly 2 .3 of traumatic blast amputations in the contemporary battlefield. This phenomenon has potentially devastating consequences for servicemen and women and its pathophysiology warrants further investigation using a previously developed animal blast model. Questions/purposesWe asked, what is the (1) severity (quantity) and (2) type (location) of HO bone formation after a hindlimb blast amputation with two distinct blast media. We hypothesized that a more ''war-relevant'' blast medium could be a more accurate model and potentially intensify the development of HO. Methods Using a Sprague-Dawley rat model, the pathophysiology of ectopic bone formation in a traumatic hindlimb blast amputation was evaluated. Twenty-four animals underwent blast amputations and closure based on a previously established experimental model. Half the amputations were subjected to blasted sand and the other 1/2 to blasted water. Serial orthogonal radiography was performed on each animal until euthanasia at 24 weeks to track the development of HO. Heterotopic bone severity and type were assessed by three independent graders at each time using a novel grading scale to assess quantity and quality of HO. Results All animals had radiographic evidence of HO develop. No differences were observed in ectopic bone development between sand and water blasting regarding severity or type at any time. Animals that received water and sand blasting had moderate HO develop at 24 weeks (median, 2.0 and 2.5 weeks, respectively; range, 1-3 weeks; difference of medians, 0.5; p = 0.67). At the time of euthanasia, 10 animals that were water blasted had Type 3 HO compared with 11 in the sand-blasted group (p = 1.00).The institution of one or more of the authors (DEJ, VDP) has received, during the study period, funding from the United States Department of Defense Congressionally Directed Medical Research Program (Washington, DC, USA). One of the authors certifies that he (VDP), or a member of his immediate family, has or may receive payments or benefits, during the study period, an amount of USD 100,000-USD 1,000,000, from the United States Department of Defense Congressionally Directed Medical Research Program (Washington, DC, USA), an amount of USD 100,000-USD 1,000,000 from DePuy Orthopaedics (Warsaw, IN, USA), and USD 100,000-USD 1,000,000 from the Agency for Healthcare Research and Quality (Rockville, MD, USA). Conclusions Our study showed a clear development of HO after hindlimb blast amputation in a Sprague-Dawley rat model; however, no difference was observed in HO development based on the type of blast media. This suggests it is the blast mechanism that induces ectopic bone development, regardless of the blasted medium. The grading scale we developed for our animal-model study provided a reliable means of assessing HO severity and type. Clinical Relevance We anticipate that future investigations will elucidate similarities between service members' wartime extremity injuries and the animal...

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Does Blast Medium Affect Heterotopic Ossification in a Blast-amputation Model?

Yoo

Blevins

Gasbarro

et al. 2015

Clinical Orthopaedics &Amp; Related Research

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“…This conflict was also notable for the resurgence of debridement as a military surgical practice. While benefits of early surgical intervention were evident from the Russo-Turkish war [17], it fell to Antoine Depage to resurrect and define the art of debridement. Key to his practice was the recognition that debridement was a two-stage process: exploration (or incision) and excision.…”

Section: Infection In Conflict Wounded-historical Backgroundmentioning

confidence: 99%

“…In addition, in the absence of clinical evidence of infection, routine collection of peri-debridement culture samples is inappropriate in combat-related extremity injuries [17].…”

Section: Infection In Conflict Wounded-evidence From Recent Conflictsmentioning

confidence: 99%

Infection in conflict wounded

Eardley

Brown

Bonner

et al. 2011

Phil. Trans. R. Soc. B

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Although mechanisms of modern military wounding may be distinct from those of ancient conflicts, the infectious sequelae of ballistic trauma and the evolving microbial flora of war wounds remain a considerable burden on both the injured combatant and their deployed medical systems. Battlefield surgeons of ancient times favoured suppuration in war wounding and as such Galenic encouragement of pus formation would hinder progress in wound care for centuries. Napoleonic surgeons eventually abandoned this mantra, embracing radical surgical intervention, primarily by amputation, to prevent infection. Later, microscopy enabled identification of microorganisms and characterization of wound flora. Concurrent advances in sanitation and evacuation enabled improved outcomes and establishment of modern military medical systems. Advances in medical doctrine and technology afford those injured in current conflicts with increasing survivability through rapid evacuation, sophisticated resuscitation and timely surgical intervention. Infectious complications in those that do survive, however, are a major concern. Addressing antibiotic use, nosocomial transmission and infectious sequelae are a current clinical management and research priority and will remain so in an era characterized by a massive burden of combat extremity injury. This paper provides a review of infection in combat wounding from a historical setting through to the modern evidence base.

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“…If placed correctly the risks associated with these devices are low and therefore this method is also frequently applied for combat and disaster related casualties [5,9,12,16,18,20].…”

Section: Introductionmentioning

confidence: 99%