Open fracture infection following combat trauma : defining the problem and evaluating novel treatments

PhD ThesisThe British military was engaged in combat operations in Iraq and Afghanistan over a 12-year period from 2003 to 2014. It has been asserted that over this time survival after combat injury improved generating a cohort of patients with complex limb injuries, including open fractures, which are prone to infection and challenging to reconstruct. Using an anatomic measure of injury severity I demonstrate an improvement in survival after combat injury. I further tested this finding by devising a military specific version of an anatomic-physiological injury scoring system, which confirmed the survival improvement. The UK military trauma registry was used to determine that the most frequently fractured bone was the Tibia and 65% of these fractures were open. Of these, 23% were surgically treated for infection in the first year and S. aureus bacteria was the causative organism in 60%. Infection was significantly associated with amputation or unplanned revision surgery. To further investigate open fracture infections in a controlled setting, an established rodent model of a stabilised, S. aureus contaminated, femoral defect was refined. This model was used to investigate the relationship between timing of treatment and infection. The results of this study indicate that delaying antibiotics administration has a greater effect on infection rates than delaying surgery and that early antibiotics can reduce the greater infection seen with surgical delay but not negate its effect entirely. Novel treatments with potential to reduce infection in open fractures were then evaluated. Chlorhexidine was found to be similar to saline for wound irrigation with respect to preventing infection. A novel biodegradable antibiotic gel proved to be superior at preventing infection in the model than the existing clinical standard local antibiotic delivery vehicle: bone cement (Polymethylmethacrylate) beads. Finally Bismuth Thiols were demonstrated to potentiate the effect of antibiotics in preventing infection

Intraoperative fluid irrigation for traumatic wounds (Protocol)

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of intraoperative fluid irrigation in preventing wound infection in traumatic wounds

Refining the Trauma and Injury Severity Score (TRISS) to Measure the Performance of the UK Combat Casualty Care System

The Trauma and Injury Severity Score (TRISS) methodology is used in both the UK and US Military trauma registries. The method relies on dividing casualties according to mechanism, penetrating or blunt, and uses different weighting coefficients accordingly. The UK Military Joint Theatre Trauma Registry uses the original coefficients devised in 1987, whereas the US military registry uses updated civilian coefficients, but it is not clear how either registry analyzes explosive casualties according to the TRISS methodology. This study aims to use the UK Military Joint Theatre Trauma Registry to calculate new TRISS coefficients for contemporary battlefield casualties injured by either gunshot or explosive mechanisms. The secondary aim of this study is to apply the revised TRISS coefficients to examine the survival trends of UK casualties from recent military conflicts. Materials and Methods: The Joint Theatre Trauma Registry was searched for all UK casualties injured or killed in Iraq and Afghanistan by explosive or gunshot mechanisms between January 1, 2003 and December 31, 2014. Details of these casualties including injuries and vital signs were reviewed. Logistic regression analysis was performed to devise new TRISS coefficients; these were then used to examine survival over the 12 yr of the study.Comparing the predictions from the gunshot TRISS model to the observed outcomes, it demonstrates a sensitivity of 98.1% and a specificity of 96.8% and an overall accuracy of 97.8%. With respect to the explosive TRISS model, there is a sensitivity of 98.6%, a specificity of 97.4%, and an overall accuracy of 98.4%. When this updated and mechanism-specific TRISS methodology was used to measure changes in survival over the study period, survival following these injuries improved until 2012 when performance was maintained for the last 2 yr of the study. Conclusion: This study for the first time refines the TRISS methodology with coefficients appropriate for use within combat casualty care systems. This improved methodology reveals that UK combat casualty care performance appears to have improved until 2012 when this standard was maintained

The injury burden of recent combat operations: mortality, morbidity, and return to service of U.K. naval service personnel following combat trauma

Objectives: The study establishes the functional outcomes of service personnel injured in current conflicts by correlating data on initial injury to the findings of medical boards after trauma and reconstructive treatment. Data comprehensively include all casualties of the Royal Navy and Royal Marines and all functional outcomes. Methods: Details of all casualties from 2003 to 2010 taken from the Joint Theatre Trauma Registry and records of all medical boards relating to these personnel were analysed. Population at risk and probability of survival data were calculated. Results: There were 221 casualties: 54 (24%) were fatalities; of 167 survivors, 21 (9% of total) were medically discharged; 26 (12%) were placed in reduced fitness category and 120 (55%) returned to full duty. Casualty risk per year of operational service for Naval Service personnel was 4.6%. New injury severity score and functional outcome were closely correlated, with specific exceptions. There were 3 unexpected survivors and no unexpected fatalities. Extremity injuries predominate in survivors. Conclusions: The Defence Medical Service (DMS) provides excellent trauma and rehabilitative care. The authors contend that this is a valid proxy for other larger coalition formations. Specific injury patterns have higher impact on functional outcomes; future research efforts should focus on these areas

Pre-clinical evaluation of therapies to prevent or treat bone non-union:a systematic review protocol

BACKGROUND: Non-union of fractured bone is a major cause of morbidity in the orthopaedic population. Despite this, optimal management of non-union is still unclear and remains a significant clinical challenge. Research continues in animal models in an attempt to identify an effective clinical treatment. The proposed systematic review will evaluate current therapies of bone non-union in animal models, in order to identify those that may translate successfully to clinical therapies. METHODS/DESIGN: The methodology for the systematic review will be in accordance with standard guidelines. All potential sources for pre-clinical studies will be interrogated and the search strategy written in conjunction with a specialist in this field. Data extraction will be conducted by two reviewers to minimise bias. Analysis will be predominantly qualitative because of the heterogeneity that is likely to exist between the studies. However, quantitative synthesis will be performed where homogeneity in a sub-group of studies exists. Quality assessment will be undertaken utilising a risk of bias tool. DISCUSSION: To date, there has not been a systematic review addressing bone non-union therapies in animal models despite the plethora of pre-clinical research currently being undertaken. This protocol details and outlines the methodology and justification for such a review. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s13643-015-0148-6) contains supplementary material, which is available to authorized users

Preclinical therapies to prevent or treat fracture non-union: A systematic review

<div><p>Background</p><p>Non-union affects up to 10% of fractures and is associated with substantial morbidity. There is currently no single effective therapy for the treatment or prevention of non-union. Potential treatments are currently selected for clinical trials based on results from limited animal studies, with no attempt to compare results between therapies to determine which have the greatest potential to treat non-union.</p><p>Aim</p><p>The aim of this systematic review was to define the range of therapies under investigation at the preclinical stage for the prevention or treatment of fracture non-union. Additionally, through meta-analysis, it aimed to identify the most promising therapies for progression to clinical investigation.</p><p>Methods</p><p>MEDLINE and Embase were searched from 1^St January 2004 to 10^th April 2017 for controlled trials evaluating an intervention to prevent or treat fracture non-union. Data regarding the model used, study intervention and outcome measures were extracted, and risk of bias assessed.</p><p>Results</p><p>Of 5,171 records identified, 197 papers describing 204 therapies were included. Of these, the majority were only evaluated once (179/204, 88%), with chitosan tested most commonly (6/204, 3%). Substantial variation existed in model design, length of survival and duration of treatment, with results poorly reported. These factors, as well as a lack of consistently used objective outcome measures, precluded meta-analysis.</p><p>Conclusion</p><p>This review highlights the variability and poor methodological reporting of current non-union research. The authors call for a consensus on the standardisation of animal models investigating non-union, and suggest journals apply stringent criteria when considering animal work for publication.</p></div

Summary of study inclusion and exclusion criteria.

<p>Summary of study inclusion and exclusion criteria.</p