Conflict in the Middle East has seen a change in warfare tactics from the use of ballistic missiles to blast weapons. This has resulted in a change in wounding patterns. Due to the severity of the injuries, there have been large numbers of amputations, as life and limb saving procedures.

The purpose of this paper was to retrospectively review all the amputated limbs over the past 8 years of conflict and compare those from the early years to the more recent ones. In particular, the aim was to examine differences in the mechanisms of injury, number of limbs injured, associated injuries, method of amputation, microbiology of contaminating organisms and outcome.

There were significantly more amputations, injured limbs and soft tissue perineal wounds as well as a significantly higher ISS in the later group. There were also significant differences in the surgical techniques, with more guillotine amputations in the early group, and mechanism of injury, with more blast injuries in the late group.

This confirms the clinical impression that there has been a significant change in limb trauma from Iraq to Afghanistan. These injury patterns have significantly different logistical implications, which must be considered when planning the required medical assets in future conflicts.

Infection is a common complication of severe open fractures and compromises bone healing. The present standard of care is a two-stage approach comprising of initial placement of antibiotic-impregnated PMMA beads to control infection followed later by bone grafting. Although the systemic antibiotics and PMMA/antibiotic beads control the infection initially, there are often residual bacteria within the wound. After grafting and definitive closure, the implanted graft is placed in an avascular defect and could function as a nidus for infection. Bioactive porous polyurethane (PUR) scaffolds have been shown to improve bone healing by delivering recombinant human bone morphogenetic protein-2 (BMP-2) and reduce infection by delivering antibiotics. The release kinetics of the BMP-2 were an initial burst to recruit cells and sustained release to induce the migrating cells. The Vancomycin (Vanc) release kinetics were designed to protect the graft from contamination until vascularisation by having an initial burst and then remaining over the MIC for Staph. aueus for two months. In this study, PUR+BMP-2+Vanc scaffolds were first tested in a non-infected critical size rat femoral segmental defect and was found to perform comparably to PUR+BMP-2, thus indicating that Vanc did not hinder bone healing. PUR+BMP-2+Vanc scaffolds were subsequently evaluated in an infected critical size rat femoral segmental defect. The dual delivery approach resulted in significantly more new bone formation and infection control than both PUR+BMP-2 and the collagen+BMP-2 treatments. These data indicate that the dual-delivery strategy effectively protects the graft from infection during wound healing and regenerates more bone in contaminated defects. This moderately osteoconductive bone graft is capable of being injected, provides a more sustained release of BMP-2 than the collagen sponge, and can release antibiotics for over 8 weeks. The dual-delivery approach may improve patient outcomes of open fractures by protecting the osteoinductive graft from colonization until vascularization occurs.

Peripheral nerve injuries (PNI) occur in 10% of combat casualties. In the immediate field-hospital setting, an insensate limb can affect the surgeon's assessment of limb viability and in the long-term PNI remain a source of considerable morbidity. Therefore the aims of this study are to document the recovery of combat PNI, as well as report on the effect of current medical management in improving functional outcome. In this study, we present the largest series of combat related PNI in Coalition troops since World War II.

From May 2007 – May 2010, 100 consecutive patients (261 nerve injuries) were prospectively reviewed in a specialist PNI clinic. The functional recovery of each PNI was determined using the MRC grading classification (good, fair and poor). In addition, the incidence of neuropathic pain, the results of nerve grafting procedures, the return of plantar sensation, and the patients' current military occupational grading was recorded.

At mean follow up 26.7 months, 175(65%) of nerve injuries had a good recovery, 57(21%) had a fair recovery and 39(14%) had a poor functional recovery. Neuropathic pain was noted in 33 patients, with Causalgia present in 5 cases. In 27(83%) patients, pain was resolved by medication, neurolysis or nerve grafting. In 35 cases, nerve repair was attempted at median 6 days from injury. Of these 62%(22) gained a good or fair recovery with 37%(13) having a poor functional result. Forty-two patients (47 limbs) initially presented with an insensate foot. At final follow up (mean 25.4 months), 89%(42 limbs) had a return of protective plantar sensation. Overall, 9 patients were able to return to full military duty (P2), with 45 deemed unfit for military service (P0 or P8).

This study demonstrates that the majority of combat PNI will show some functional recovery. Adherence to the principles of war surgery to ensure that the wound is clear of infection and associated vascular and skeletal injuries are promptly treated will provide the optimal environment for nerve recovery. Although neuropathic pain affects a significant proportion of casualties, pharmacological and surgical intervention can alleviate the majority of symptoms. Finally, the presence of an insensate limb at initial surgery, should not be used as a marker of limb viability. The key to recovery of the PNI patient lies in a multi-disciplinary approach. Essential to this is regular surgical review to assess progress and to initiate prompt surgical intervention when needed. This approach allows early determination of prognosis, which is of huge value to the rehabilitating patient psychologically, and to the whole rehabilitation team.

The aim of this prospective study was to determine the prevalence of bone marrow oedema (BME) in asymptomatic knees of athletes and to investigate the factors associated with appearance of BME in this group.

A total of 25 asymptomatic athletes who competed at an international, national or county level during their most recent sport season were recruited in this study and had MRI scan of both knees (n=50). MRI scans were reported independently by two experienced musculoskeletal radiologists. Statistical analysis included Cohen's kappa test to identify inter-observer agreement for MRI diagnosis of bone marrow oedema and multiple logistic regression model to identify the factors associated with BME on MRI scan.

There was very good agreement between radiologists for diagnosis of BME (Kappa = 0.896). Seven participants (28%) were found to have BME. Six of the participants had BME in unilateral knees and one participant had BME in bilateral knees. The commonest location of BME was medial femoral condyle (62.5%) The amount of time spent in preseason training (34-38 weeks) was significantly associated with appearance of BME (P=0.048)

BME seems to be common in asymptomatic athletes and one should realize that this finding might not be related to the clinical complaints of the patients. The results of the present study show that there is a training effect associated with BME. Knowing what is a ‘normal’ or ‘abnormal’ scan is important for a competitive athlete, as erroneously diagnosing BME as the underlying cause of athletes' symptoms could lead to decreased playing time or inappropriate therapy.