Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts: A comparison of treatment at US and United Kingdom medical treatment facilities.

INTRODUCTION: The United States and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed medical treatment facilities (MTFs) 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 the independent variables were ISS on arrival, nationality, MTF nationality, and presence of head and neck surgeon. RESULTS: A total of 3,357 (4.9%) of 67,586 patients who arrived alive at deployed military MTF were recorded to have sustained neck injuries; of which 2,186 (83%) were PNIs and the remainder were blunt injuries. When service members killed in action were included, the incidence of neck injury rose from 4.9% to 10%. Seven hundred nine (32%) of 2,186 patients with PNI underwent neck exploration; 555 patients were recorded to have sustained cervical vascular injury, 230 (41%) of 555 underwent vascular ligation or repair. Where it was recorded, PNI directly contributed to death in 64 (28%) of 228 of patients. Fatality status was positively associated with ISS on arrival (odds ratio, 1.05; 95% confidence interval, 1.04-1.06; p < 0.001) and the casualty being a local national (odds ratio, 1.74; 95% confidence interval, 1.28-2.38; p < 0.001). CONCLUSION: 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: Retrospective cohort study, level III.

Facial injury management undertaken at US and UK medical treatment facilities during the Iraq and Afghanistan conflicts: a retrospective cohort study.

OBJECTIVES: To perform the first direct comparison of the facial injuries sustained and treatment performed at USA and UK deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan. SETTING: The US and UK Joint Theatre Trauma Registries were scrutinised for all patients with facial injuries presenting alive to a UK or US deployed MTF between 1 March 2003 and 31 October 2011. PARTICIPANTS: US and UK military personnel, local police, local military and civilians. PRIMARY AND SECONDARY OUTCOME MEASURES: An adjusted multiple logistic regression model was performed using tracheostomy as the primary dependent outcome variable and treatment in a US MTF, US or UK military, mandible fracture and treatment of mandible fracture as independent secondary variables. RESULTS: Facial injuries were identified in 16 944 casualties, with the most common being those to skin/muscle (64%), bone fractures (36%), inner/middle ear (28%) and intraoral damage (11%). Facial injuries were equally likely to undergo surgery in US MTF as UK MTF (OR: 1.06, 95% CI 0.4603 to 1.142, p=0.6656); however, variations were seen in injury type treated. In US MTF, 692/1452 (48%) of mandible fractures were treated by either open or closed reduction compared with 0/167 (0%) in UK MTF (χ2: 113.6; p≤0.0001). US military casualties who had treatment of their mandible fracture (open reduction and internal fixation or mandibulo-maxillary fixation) were less likely to have had a tracheostomy than those who did not undergo stabilisation of the fractured mandible (OR: 0.61, 95% CI 0.44 to 0.86; p=0.0066). CONCLUSIONS: The capability to surgically treat mandible fractures by open or closed reduction should be considered as an integral component of deployed coalition surgical care in the future.

Treatment of mandibular third molars and pericoronitis in British military personnel: influence of guidelines from the National Institute for Health and Clinical Excellence.

We studied the dental records of British military personnel who were less than 20 years old on enlistment, and had at least five years' service with at least five recorded dental inspections, at three military dental centres in the UK. The median (IQR) period from first to last inspection in 720 subjects was 15 (10-19) years, and the median frequency of inspection was every 14 (13-16) months. A total of 288/1250 mandibular third molars were extracted (23%). There were significant increases in the proportion of extractions stating caries in the mandibular third molar or multi-episode pericoronitis as indications (n=13, 14%, p <0.001) (n=15, 19%, p <0.001) post-introduction of NICE guidance. The number of extractions with no documented indication was reduced by 50 (26%, p<0.001) and that for a single episode of pericoronitis by 20 (9%, p =0.02). Extractions of mandibular third molars because of caries in the adjacent second molar increased by 4 (4%, p=0.045). The median age at the time of extraction before introduction of the guidelines was 23 years compared with 25 years afterwards (p<0.001). Twenty-five of 114 (22%) extractions of mandibular third molars were in patients over the age of 30 after the introduction of guidelines compared with 1/174 (<1%) before. The introduction of the NICE guidelines on the management of third molars has significantly changed our practice. Whether or not these changes have resulted in a net benefit to patients is still a matter for debate.

Facial reconstruction in the developing world: a complicated matter.

Around the world there is a small industry of non-governmental organisations that provide health care in niche areas that cannot be met by national health care provision. One topic is facial deformity that can have a dramatic effect on quality of life. In this study we investigate the morbidity and outcome of a British surgical team working for a 2-week period in Ethiopia. Thirty-five patients who presented with facial deformities had 47 operations during a 2-week period. Data were recorded for a minimum of 3 weeks postoperatively. Operative techniques were classified as simple or complex. Postoperative complications were assessed and classified as major, intermediate, and minor. In addition, the character of each complication was recorded and the cause elucidated. After 3 weeks the clinical objectives had been achieved in 14/17 who had simple procedures but in only 5/18 who had complex operations (p=0.004). We conclude that complex procedures are technically possible within an under-privileged health care system but successful outcome depends on paying attention to multiple factors in patients' care and wound management. Early outcome studies may be a useful way to measure the quality of humanitarian surgical missions.

Treatment of chronic lip fissures with carbon dioxide laser.

Resurfacing of cutaneous tissue with carbon dioxide laser increases the amount and quality of collagen and elastin subepithelially. We used this technique to ablate 12 chronic lip fissures in one woman and 10 men. Five patients' fissures had persisted for durations ranging from several months to seven years; the other six had fissures that split between one and five times annually, and took weeks or months to heal. Ten fissures had re-epithelialised completely six weeks postoperatively, while in two cases the treatment was repeated. At mean long-term follow-up of 70 months (range 44-93) of 11 cases, eight had had no recurrence. One patient, whose fissure had healed at three months was lost to follow-up; one fissure had not improved; one had recurred less severely; and one had split only once, then healed quickly and not recur. Only one patient had postoperative discomfort that required analgesia, and one had a mildly raised scar. This small series shows that this is a successful, safe technique with low morbidity, however, the technology is not always readily available.