Following the invasion of Iraq in April 2003, Coalition forces have been conducting counter-insurgency operations in a bid to maintain security within the country. The improvised explosive device (IED) has become the weapon of choice of the terrorist and is the leading cause of death and injury amongst Coalition troops in the region. From Jan 2006, data was collected on 100 consecutive casualties who were either injured or killed during hostile action. Mechanism of injury, new Injury Severity Score (NISS), ICD-9 diagnosis and anatomical pattern of wounding was recorded in a trauma registry. During the study period, 53 casualties were injured by IEDs in 23 incidents (mean 2.3 casualties per incident). Twelve (22.6%) were killed or died of wounds. Mean NISS score of survivors was 5.4 (Range 1–50). There was no significant difference in NISS scores of survivors from fatal and non-fatal incidents. A mean 2.61 body regions were injured per casualty. Limb injuries were present in 45 (84.9%) of casualties, but primary blast injuries were seen in only 9 (14%). Twenty (48.7%) of survivors underwent surgery by British surgeons in the field hospital. Sixteen (39%) were deemed fit to return to duty after injury. IEDs used in Iraq do not follow the traditional pattern of injuries seen with conventional high explosives. Primary blast injuries were uncommon despite all casualties being in close proximity to the explosion. When the IED is detonated, an Explosive Formed Projectile (EFP) is formed which results in catastrophic injuries to casualties caught in its path, but causes relatively minor injuries to personnel sited adjacent to its trajectory. Enhanced vehicle protection may prevent the EFP from entering the passenger compartments and thereby reduce fatalities.
Resurfacing arthroplasty is advantageous over conventional total hip arthroplasty in that femoral bone stock is preserved. However, there has been controversy over the preservation of acetabular bone stock in resurfacing arthroplasty, with the concern that it may result in excess reaming compared with total hip replacement. This is of concern as the prosthesis is primarily advocated in the young patient, who is likely to face future revision surgery. We prospectively identified a cohort of 68 patients with primary hip osteoarthritis undergoing conventional total hip arthroplasty. During surgery, the excised femoral head and neck diameter was measured, along with the diameter of the final acetabular reamer used to achieve a bed of bleeding cancellous bone. The measured neck diameter was then used to calculate the minimum possible resurfacing head and cup sizes, with corresponding final reamer sizes that could have been used in each patient without neck notching for both Birmingham Hip Resurfacing (BHR, Smith &
Nephew, 3rd Generation) and Articular Surface replacement (ASR, De Puy, 4th Generation). Reaming diameter and volume was compared for all 3 groups. Mean reaming diameters for the THR, ASR and BHR groups were 51, 52 and 56mm respectively. Mean reaming volumes were 39, 40 and 47cc. There was a statistically significant difference between the THR and BHR groups for both reamed diameter and volume (p<
0.001). There was also a significant difference between the ASR and BHR groups for both reamed diameter and volume (p<
0.001). This difference was more pronounced with larger neck diameters. Our data shows that the BHR results in more ace-tabular bone loss compared to total hip replacement. An implant with a lower profile acetabular cup and a larger variety of sizes such as the ASR may allow better preservation of acetabular bone stock.
British military forces remain heavily committed in both Iraq and Afghanistan. A recent workload analysis from Op HERRICK identified a high surgical workload, particularly orthopaedic, under the care of a sole consultant orthopaedic surgeon. There are no orthopaedic training posts in UK that consistently provide training in ballistic trauma. In order to prepare Military orthopaedic trainees for future deployment, a new orthopaedic registrar post, on Op HERRICK, was created. Prospective analysis of trainee and trainer operative logbooks, between Jan 27th and March 24th 2008, was performed. Records were kept of orthopaedic and postgraduate teaching schedules, audit and research projects and all OCAP training assessments. One hundred and fifty-seven cases and 272 procedures were performed during the study period. Sixty-two per cent of cases were orthopaedic. Fourteen major amputations were performed and 7 external fixators applied. Five fasciotomies, 9 skeletal traction pins were inserted and 7 skin grafting procedures were performed. Limb debridement was the most common procedure (n=59). Eleven per cent of cases were children and 50 per cent of cases were emergencies. Thirty-eight per cent of cases were performed out of hours (18.00–08.00 hrs). Mean operating hours per week was 35 hrs. Four Procedure Based Assessments were performed and 16 hours of postgraduate education was conducted during the deployment. Two major audits were initiated and five publications were prepared, one has already been accepted for publication. Trainee exposure to high-energy transfer trauma is high when compared to that seen in the NHS. The numbers of certain index procedures, such as external fixation, is similar to those achieved by an average orthopaedic trainee in six years of higher surgical training. The opportunity for one-on-one training exceeds that available in the NHS and learning and academic opportunities are maximised due to the close working environment.
The conflict in Iraq has evolved from a conventional war in April 2003 to a guerrilla-based insurgency. We investigated whether this change altered the pattern of wounding and types of injuries seen in casualties presenting to a military field hospital. From January 2006 – October 2006, data was collected on all casualties who presented to the sole British field hospital in the region following injury from hostile action (HA). 86 casualties presented with injuries from hostile action (HA). 3 subsequently died of wounds (DOW – 3.5%). 46 (53.5%) casualties had their initial surgery performed by British military surgeons. 20 casualties (23.2%) sustained gunshot wounds, 63 (73.3%) suffered injuries from fragmentation weapons and 3 (3.5%) casualties sustained injury from blunt trauma. These casualties sustained a total 232 wounds (mean 2.38) affecting an average 2.4 anatomical locations per patient. The current insurgency illustrates the likely evolution of modern urban conflict. Discrete attacks from improvised explosive devices (IED’s) have become the predominant cause of injury. These tactics have been employed against both military and civilian targets. With the current threat from terrorism, both military and civilian surgeons should be aware of the spectrum and management of the injuries caused. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.
