title: Infectious complications of damage control orthopedics in war trauma.
abstract: BACKGROUND
  War-trauma, especially due to blast injury, can be associated with long bone fracture. Immediate external fixation of fractures, followed by internal fixation when the patient is medically stabilized (damage control orthopedics [DCO]), is the U.S. Army policy for war-related fractures. Data on infectious outcomes when DCO is used for war-trauma fractures are scant.
  
  
  METHODS
  A retrospective review of U.S. war-trauma patients from 2003 to 2007 with femoral or tibial fractures treated by DCO was conducted. Fisher's Exact and Mann-Whitney tests were used for comparisons.
  
  
  RESULTS
  Fifty-eight soldiers were identified. Fifty-five were males with a median age of 26 years (19-54 years) and a median time to internal fixation by intramedually nailing of 9 days (4-414 days). Eighty-eight percent of fractures were open, and 57% were femoral fractures. The median duration of follow-up was 447 days (20-1,340 days). Fracture site infection occurred in 40% (23 of 58), with suspected osteomyelitis in 17% (10 of 58). Of infected nails, fracture union occurred in 70% and nail retention in 57%. Median time to infection after nail placement was 15 days (0-717 days) with 75% of infections occurring by day 113. Multiple bacterial pathogens including Acinetobacter baumannii and Staphylococcus spp. were causative organisms. Blast injuries occurred in 91% of infected versus 47% of uninfected (p = 0.005). There was no difference between infections occurring in femoral (61%) versus tibial (39%) (p = 0.620) location.
  
  
  CONCLUSIONS
  Infection was associated with 40% of DCO-associated intramedullary nails. Blast injury was a predictor of infection. Despite infection, fracture union and nail retention rates were high, suggesting a good outcome.
authors.affiliation: Infectious Disease Service, Walter Reed Army Medical Center, Washington, DC 20307, USA.
authors.forename: Rupal M
authors.initials: RM
authors.lastname: Mody
authors.forename: Michael
authors.initials: M
authors.lastname: Zapor
authors.forename: Joshua D
authors.initials: JD
authors.lastname: Hartzell
authors.forename: Paul M
authors.initials: PM
authors.lastname: Robben
authors.forename: Paige
authors.initials: P
authors.lastname: Waterman
authors.forename: Robert
authors.initials: R
authors.lastname: Wood-Morris
authors.forename: Richard
authors.initials: R
authors.lastname: Trotta
authors.forename: Romney C
authors.initials: RC
authors.lastname: Andersen
authors.forename: Glenn
authors.initials: G
authors.lastname: Wortmann
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D001753:Blast Injuries / Q000150:complications*; D005260:Female; D005264:Femoral Fractures / Q000601:surgery; D005592:Fracture Fixation / Q000379:methods*; D050723:Fractures, Bone / Q000209:etiology / Q000601:surgery*; D005597:Fractures, Open / Q000601:surgery; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D008875:Middle Aged; D008889:Military Personnel; D010019:Osteomyelitis / Q000453:epidemiology*; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology*; D014481:United States; D055815:Young Adult