Up to 61 percent of all patients wounded during Operation Iraqi Freedom have had a head and neck injury, according to background information in the article. "Prior to May 2005, most American military personnel with facial fractures were air evacuated from the Iraqi theater for definitive treatment of their facial fractures," the authors write.

"Concerns about sterility, infection with Acinetobacter baumannii (a bacteria that has infected wounds and prostheses and caused catheter-related sepsis in many troops returning home) and delaying evacuation out of theater were all reasons cited for not definitively repairing facial fractures in theater."

Beginning in May 2005, American soldiers meeting strict guidelines underwent repair of their facial fractures by a procedure known as open reduction and internal fixation, which involves using mesh implants or plates to mend broken bones. Candidates for having the operation in Iraq met the following criteria:

- Their fracture was exposed either by a wound or by another procedure already being performed.
- Treating them in Iraq would not delay their evacuation from the theater of war.
- Treatment would allow them to remain in Iraq.

Manuel A. Lopez, M.D., and Jonathan L. Arnholt, M.D., of the Wilford Hall Medical Center, San Antonio, reviewed the records of 207 patients taken to the operating room by the otolaryngologist-facial plastic surgeon at the 322nd Expeditionary Medical Group at the Air Force Theater Hospital, Balad Air Base, Iraq from May to September 2005. The hospital is located in the Sunni Triangle, approximately 40 miles north of Baghdad.

A total of 175 patients (85 percent) were operated on for traumatic injury and 52 patients required open reduction and internal fixation of a facial fracture. Of these 52 patients, 17 were American military personnel who underwent an open reduction and internal fixation. An average of 8.3 months later, 16 of them were contacted or followed up on the global military medical database.

"None of these patients developed an Acinetobacter baumannii infection or had a complication caused by the definitive in-theater open reduction and internal fixation," the authors write. Only one patient required revision surgical repair due to high pressure in the skull.

"The practice of definitively treating facial fractures in a war zone using the criteria discussed in this article can lead to improved patient outcomes," the authors write. "It has been shown that a delay in fracture fixation can lead to both increased technical difficulties and infectious complications." An untreated fracture can become more difficult to repair because the surrounding facial muscles are fibrous and frequently contract. Complications such as nerve weakness and misaligned teeth are more prevalent in jaw fractures with delayed treatment, they note.

"Primary closure of soft tissue defects by open reduction and internal fixation of facial fractures on initial presentation to a well-equipped, in-theater hospital decreases the need for further facial surgery for patients when they return to the United States," they conclude.

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