The purpose of this study is to provide a systematic review of the literature and assess outcome of our experience of Ilizarov Bone Transport in reconstruction for primary malignant tumours of bone (PMTB).

A systematic review of the literature for reported cases of primary reconstruction of PMTB using distraction osteogenesis was performed. All cases of distraction osteogenesis for primary reconstruction of PMTB in our institution were reviewed. Outcome was determined from retrospective review of case notes and radiology. Patients were contacted to define final status.

There are few cases of primary reconstruction of PMTB using Ilizarov method in the literature. Most reports relate to benign tumours or reconstruction of secondary deformities or non-union after tumour resection. At our institution we have treated 7 patients with bone defects resulting from excision of a PMTB. Mean age was 42.1 years (23–48). Tumours occurred in the tibia in 4 cases and the femur in 3 cases. Histologic diagnosis was chondrosarcoma in 3, malignant fibrous histiocytoma in 2, adamantinoma in 1 and malignant intraosseous nerve sheath tumour in 1.

All patients were assessed through the hospital sarcoma board and shown to have isolated bone lesions without metastases. Mean bone defect after resection was 13.1 cm (10–17). Mean frame time was 13.6 months (5–23). Mean follow-up was 46 months (15–137). Complications included pin infection, docking site non-union, premature fusion of corticotomy, soft tissue infection and minor varus deformity. There was one local recurrence of tumour at five months after resection, resulting in a through hip disarticulation. The other cases remain tumour-free with united, well-aligned bones and acceptable long-term function.

PMTB is rare and poses a major reconstructive dilemma. Distraction osteogenesis provides an effective method of biologic reconstruction in selected cases, and good outcomes can be achieved.

A systematic literature review of distraction osteogenesis (DO) for the primary reconstruction of bone defects following resection of primary malignant tumours of long bones (PMTLB) is presented. Fewer than 50 cases were identified. Most reports relate to benign tumours or secondary reconstructive procedures. The outcomes of our own series of 7 patients is also presented (4 tibiae, 3 femora). All patients had isolated bone lesions without metastases and were assessed through the hospital sarcoma board. Mean follow-up was 59 months (17–144). Mean age was 42 years. Final histologic diagnoses were 3 chondrosarcoma, 2 malignant fibrous histiocytoma, 1 adamantinoma and 1 malignant intraosseous nerve sheath tumour. Mean bone defect after resection was 13.1cm (10–17) and bone transport was the reconstruction method in all. There was one local recurrence of tumour six months post-resection, necessitating amputation. Mean frame index for remaining cases was 30.9 days/cm (15.7–41.6). Complications included pin infection, docking site non-union, premature corticotomy union, soft-tissue infection and minor varus deformity. Six cases remain tumour-free with united, well-aligned bones and good long-term function. We conclude DO provides an effective biologic reconstruction option in select cases of PMTLB.

During two sequential deployments to Afghanistan, it was noticed that an inordinately high number of patients with bilateral lower limb injuries that resulted in amputations at Camp Bastion itself, had associated upper limb injuries. It was decided to study the incidence and distribution of the same. Permission was granted to conduct this study as it would throw a light on the pattern of injuries and allow a further study of the impact of this on rehabilitation.

This was both a retrospective as well as a prospective study. Of the 221 cases, 68 were recorded and data collected prospectively whereas the data for the rest was gathered using the patients' scanned records from Camp Bastion, their radiology reports and clinical photographs (from the Joint Theatre Trauma Registry).

A total of 221 patients were studied as described above. They included UK, NATO, US, ANA, ANP, EF and Afghan civilians (June 2009 - January 2011). There were 59 fatalities from these 221 cases. That data pertaining to these cases was discarded. Of the surviving 162 cases, 31 cases had no upper limb involvement. A number of these individuals were subjected to an IED attack when mounted, although dismounted injuries still accounted for the vast majority. 131 individuals had upper limb involvement of some sort or the other. The injuries were classified into anatomical distribution as well and the type of trauma (amputations, composite soft tissue, fractures, vascular, nerves etc). The predominance of the injuries was on the distal portion of the upper limb (i.e involving the digits, hands and forearm (digits and hands – 66 patients, wrist and forearm in 69 patients, elbow and arm in 42 patients). The most common form of involvement was a composite tissue injury (involving skin, muscle and vessels/nerves) in 85 patients. 27 patients ended up as triple amputees by the time they left the Camp Bastion Role 3 Hospital.

From the pattern and severity of injuries it is obvious that dismounted individuals presented with a very severe spectrum of injuries. The predominance of the left upper limb being involved is in keeping with a dismounted right-handed soldier out on patrol with the left upper limb extended along the barrel of the rifle or his weapon. Using various cases (clinical photographs as well as radiographs) the spectrum of injuries is explained and a case is made for truly differentiating the debridement and radical treatment of upper limb versus lower limb trauma during initial surgery.

The operative workload at the surgical facility in Camp Bastion, Afghanistan, has previously been reported for the two-year period 1 May 2006 to 1 May 2008. The nature of the Afghanistan conflict has changed considerably since 2007, and wounds from improvised explosive devices (IEDs) have replaced those of small arms fire as the signature injury of the insurgency. The severity of injury from IEDs has increased such that casualties routinely present with high bilateral traumatic lower limb amputations and associated pelvic, perineal, upper limb and facial wounds. These complex injuries affecting multiple anatomical zones necessitate a multi-surgeon team approach in their management. We present recent data for the surgical activity at the JF Med Gp Role 3 Hospital, Camp Bastion, for the two-year period 1 November 2008 to 1 November 2010.

During the study period, a total of 4276 cases required 5737 surgical procedures, representing a 2.6-fold increase in activity compared with the previously reported 2-year period. Of these cases, 42% were coalition troops (ISAF) and 6% children. Wound debridement (44%) and relook/delayed primary closure of wounds (10%) remain the most commonly performed procedures. There has been a marked increase in the rates of amputation (8% of procedures, 48% being above-knee), laparotomy (9%), application of external fixation (4.5%), and fasciotomies (3%). Scrotal exploration accounted for 1.9% of procedures, resulting in 17 orchidectomies. During the 2-year study period, we have also observed a considerable increase in the incidence of cases requiring 5 or more surgeons operating simultaneously.

The beneficial effects of therapeutic hypothermia have been capitalised upon in fields such as cardiac surgery for several decades. Hypothermia not only slows metabolism and consumption of metabolic substrates, but also confers cellular protection against ischaemia and reperfusion. Hypothermia has historically been considered as something to avoid in trauma casualties, with coagulopathy being the main concern. There is now increasing evidence for the role of controlled therapeutic hypothermia in trauma, particularly improved functional outcomes following brain injury and the utility of ‘suspended animation’ or ‘emergency preservation’ in the resuscitation of severe haemorrhagic shock. With the ongoing ‘Eurotherm’ trial of hypothermia in the treatment of traumatic brain injury, and the imminent launch of the ‘Emergency Preservation and Resuscitation (EPR) for Cardiac Arrest From Trauma’ clinical trial in the USA, this presentation will provide a timely overview of the developments of therapeutic hypothermia in trauma management.

Aim: To investigate the magnitude of revenue lost by the Department of Trauma and Orthopaedics at Ports-mouth Hospitals NHS Trust in 2007 as a result of providing outpatient viscosupplementation joint injections.

Methods: Data was collated on all outpatient intra-articular hyaluronic acid viscosupplementation performed by our department in 2007. Information on existing HRG tariffs for orthopaedic outpatient attendances as well as clinical coding of joint injections by our department was also gathered.

Results: The 2007/2008 tariffs for orthopaedic outpatient first and follow-up appointments were £147 and £73 respectively for adults, and £157 and £85 respectively for children (under 17 years of age). No additional mandatory tariff currently exists for joint injections performed in the outpatient setting. During our study period, the cost of a dose of viscosuplementation (Hyaluronic acid 60mg/ 3 ml) varied between £213 and £248. A total of 812 doses of viscosupplementation were administered to outpatients by our department resulting in pharmaceutical costs of £175,126. Only 751 cases of outpatient appointment with joint injection (all types) were recorded and coded by the department.

Conclusions:

As long as no mandatory DoH tariff exists for out-patient joint injections, outpatient viscosupplementation remains an expensive service for trusts to provide and may warrant rationalisation.