Classifying the causes of morbidity and error following treatment of facial fractures.

Analysing morbidity and using this to improve the quality of patient care is an important component of clinical governance. Several methods of data collection and clinical analysis have been suggested, but to date none have been widely adopted. All adult patients sustaining facial fractures were prospectively identified between 01 March 2019 and 28 February 2020, and matched to those who required a return to theatre for surgical complications. Morbidity resulting in a return to theatre was determined using the Clavien-Dindo classification and the Northwestern University error ascribing method. During this period, return to theatre occurred for 33/285 (11.6%) procedures and 23/173 (13.3%) of patients being treated for facial fractures. According to the 27 procedures discussed, Clavien-Dindo Grade IIIb was most commonly found (20/27). Error in judgement (13/35) and nature of disease (12/35) were ascribed as the most common causes of error. Presence of a consultant was associated with increased odds of a return to theatre (p = 0.014). Standardised national data collection of morbidity and error is required for comparisons of outcomes within a single institution or between institutions. To the best of our knowledge, this is the first paper to utilise these widely used methods of morbidity analysis for facial fracture surgery. We would recommend further development of an error analysis method that is more specific to complications from facial fracture surgery

Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts; a comparison of treatment at US and UK Medical Treatment Facilities.

INTRODUCTION The United States (US) and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed Medical Treatment Facilities (MTF) in support of the military campaigns in Iraq and Afghanistan. METHODS The US and UK combat trauma registries were scrutinized for patients with penetrating neck injury (PNI) at deployed coalition MTF between March 2003 and October 2011. A multivariate mixed effects logistic regression model (threshold p< 0.05) was used stratified by MTF location and year of injury. The dependent variable was fatality on leaving Role 3, and independent variables ISS on arrival, nationality, MTF nationality, and presence of head and neck surgeon. RESULTS 3357/67586 (4.9%) of patients who arrived alive at deployed military MTF were recorded to have sustained neck injuries; of which 2186 (83%) were PNI and the remainder were blunt injuries. When service members KIA were included, the incidence of neck injury rose from 4.9 to 10%. 709/2186 (32%) patients with PNI underwent neck exploration; 555 patients were recorded to have sustained cervical vascular injury, 230/555 (41%) underwent vascular ligation or repair. Where it was recorded, PNI directly contributed to death in 64/228 (28%) of patients. Fatality status was positively associated with ISS on arrival (OR 1.05, 95% CI 1.04 -1.06, p<0.001) and the casualty being a local national (OR 1.74, 95% CI: 1.28-2.38, p<0.001). CONCLUSIONS Significant differences in the treatment and survival of casualties with PNI were identified between nations in this study, this may reflect differing cervical protection, management protocols and surgical capability and is worthy of further study. In an era of increasing specialization within surgery, neck exploration remains a skill that must be retained by military surgeons deploying to Role 2 and Role 3 MTF. LEVEL OF EVIDENCE Level 3: retrospective study with up to two negative criteria

Mapping the Risk of Fracture of the Tibia From Penetrating Fragments.

Penetrating injuries are commonly inflicted in attacks with explosive devices. The extremities, and especially the leg, are the most commonly affected body areas, presenting high risk of infection, slow recovery, and threat of amputation. The aim of this study was to quantify the risk of fracture to the anteromedial, posterior, and lateral aspects of the tibia from a metal fragment-simulating projectile (FSP). A gas gun system and a 0.78-g cylindrical FSP were employed to perform tests on an ovine tibia model. The results from the animal study were subsequently scaled to obtain fracture-risk curves for the human tibia using the cortical thickness ratio. The thickness of the surrounding soft tissue was also taken into account when assessing fracture risk. The lateral cortex of the tibia was found to be most susceptible to fracture, whose impact velocity at 50% risk of EF1+, EF2+, EF3+, and EF4+ fracture types - according to the modified Winquist-Hansen classification - were 174, 190, 212, and 282 m/s, respectively. The findings of this study will be used to increase the fidelity of predictive models of projectile penetration