Various injury severity scores exist for trauma; it is known that they do not correlate accurately to military injuries. A promising anatomical scoring system for blast pelvic and perineal injury led to the development of an improved scoring system using machine-learning techniques. An unbiased genetic algorithm selected optimal anatomical and physiological parameters from 118 military cases. A Naïve Bayesian (NB) model was built using the proposed parameters to predict the probability of survival. Ten-fold cross validation was employed to evaluate its performance. Our model significantly out-performed Injury Severity Score (ISS), Trauma ISS, New ISS and the Revised Trauma Score in virtually all areas; Positive Predictive Value 0.8941, Specificity 0.9027, Accuracy 0.9056 and Area Under Curve 0.9059. A two-sample t-test showed that the predictive performance of the proposed scoring system was significantly better than the other systems (p<0.001). With limited resources and the simplest of Bayesian methodologies we have demonstrated that the Naïve Bayesian model performed significantly better in virtually all areas assessed by current scoring systems used for trauma. This is encouraging and highlights that more can be done to improve trauma systems not only for the military, but also in civilian trauma.

The Whole Hospital Information System (WHIS) was introduced to Camp Bastion on 01 Feb 2012. It is a custom-built software solution for electronic patient records. A one-day training package is mandatory as part of current pre-deployment training

The aim of this study was to identify how well the data recorded on WHIS correlates with the information recorded within the paper-based theatre logbook.

A bespoke search was created by the Hospital J6 team, which identified the procedure, the surgeons involved, the date and time of the procedures and the demographic of the patient. The search was completed to include all operations performed from 01 Feb 2012 to 31 Mar 2013. This corresponds to the first 14 months of WHIS usage.

The results at first looked promising, showing that 2672 surgical episodes had been performed, with an average 1.68 (0–11) procedures per episode, and 2.1 (0–9) surgeons per case. The mean operative duration was 98 minutes. However on closer scrutiny, the records showed that 447 cases (16.7%) had no procedure and 138 (5.2%) cases had no surgeon. 29 (1.1%) cases had no procedure and no surgeon recorded.

The data recorded on WHIS during the study period is not currently complete enough to discontinue usage of paper records.

Despite improved body armour haemorrhage remains the leading cause of preventable death on the battlefield. Trauma to the junctional areas such as pelvis, goin and axilla can be life threatening and difficult to manage. The Abdominal Aortic Tourniquet (AAT) is a pre-hospital device capable of preventing pelvic and proximal lower limb haemorrhage by means of external aortic compression.

The aim of the study was to evaluate the efficacy of the AAT. Serving soldiers under 25 years old were recruited. Basic demographic data, height, weight, blood pressure and abdominal girth were recorded. Doppler Ultrasound was used to identify blood flow in the Common Femoral Artery (CFA). The AAT was applied whilst the CFA flow was continuously monitored. The balloon was inflated until flow in the CFA ceased or the maximum pressure of the device was reached.

16 soldiers were recruited. All participants tolerated the device. No complications were reported. Blood flow in the CFA was eliminated in 15 out of 16 participants. The one unsuccessful subject was above average height, weight, BMI & abdominal girth.

This study shows the Abdominal Aortic Tourniquet to be effective in the control of blood flow in the pelvis and proximal lower limb and potentially lifesaving.

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.

This study defines the patterns of perineal injury due to blast currently seen on operations. It refines our team-based surgical strategies of surgical resuscitation provides an evidence base for a perineal debridement - colonic diversion didactic on the Military Operational Surgical Training (MOST) course.

The Joint Theatre Trauma Registry (JTTR) held at RCDM was examined from 1 January 2003 to 31 December 2010. Data abstracted included patient demographics, mechanism of injury, injury severity score (ISS), treatment, management, length of stay (LOS) and outcomes.

Of 4807 military trauma patients, 118 (2.5%) had a recorded perineal injury, 56 died (48% all IED). Pelvic fractures were identified in 63 (53%) of which 17 (27%) survived. Mortality rates were significantly different between the combined perineal & pelvic fracture group compared to pelvic fracture & perineal injuries alone (41% & 18% respectively, p = 0.0001). Mean ISS for all patients was 41.03. Those with a pelvic fracture had a significantly higher ISS than those with perineal injuries alone (29.53 vs. 51.06, p = 0.0001). Recorded early antibiotic use was significantly more frequent in survivors (p = 0.0119). A literature review demonstrated the benefits of early feeding, emergent diversion, antibiotics, daily washouts and radical early debridement.

Combined perineal injuries & pelvic fractures have the highest rate of mortality. Early aggressive management is essential to survival in this cohort. Our recommendations are immediate faecal diversion, aggressive initial debridement & early enteral feeding (in the deployed ITU after first surgery). These findings will enable the rapid provision of an evidence based training schedule to be incorporated into our pre-deployment surgical training program (MOST) to improve surgical team preparation and patient outcomes.

Haemorrhage is the main cause of preventable death on the modern battlefield. As IEDs in Afghanistan become increasingly powerful, more proximal limb injuries occur. Significant concerns now exist about the ability of the CAT tourniquet to control distal haemorrhage following mid thigh application.

Anecdotal concern exists over the ability of current UK trainees to manage complex orthopaedic trauma.

A 15 item web-based survey sent to a sample of orthopaedic trainees. Power calculations deemed 222 responses from 888 trainees necessary to achieve a 5% error rate with 90% confidence limits.

232 responses were received. For cases involving external fixation or intramedullary nailing, perceived confidence and training adequacy was high despite infrequent exposure. Perceived confidence and adequacy of training in complex trauma is significantly lower. Less than 20% of trainees have full confidence in their ability to debride and stabilize mutilating hand injuries. 35% of trainees lack confidence in their assessment of limb viability and 56% lack confidence in amputation for extremity trauma. 71% of trainees are not confident in the management of junctional trauma and 68% regard their training in this field as inadequate. With regard to advanced resuscitation using novel blood product combinations; 65% of trainees are lacking confidence and 44% perceive their training as inadequate. For simple fracture stabilisation, vacuum dressings, antibiotic pro-phylaxis and fasciotomy, trainee perceived confidence increased with time in training. This increase did not occur in more complex trauma cases.

Perceived confidence amongst orthopaedic trainees in the management of routine extremity trauma is high despite limited exposure and concerns over changes in surgical training. This is in marked contrast to that reported in complex trauma. For military trainees, the value of supervised training on military deployment to gain experience in such cases is now apparent.

Aim: To investigate the training of civilian Orthopaedic Trainee’s in complex trauma management.

Methods: A web-based survey of orthopaedic trainees utilising three scenarios for investigating complex trauma management. 225 responses obtained, achieving a < 0.05 error rate with 90% confidence.

Results:

Pelvic packing in exanguinating pelvic trauma:

2.2% fully confidentto manage such a case. A positive correlation exists between increasing training and confidence. 58.9% have never seen such a case. No correlation exists between time in training and exposure. 62.8% report training in this case inadequate. A positive correlation exists between time in training and perceived inadequacy of ability to manage such a case.

Junctional traum with non-compressible groin haemorrhage:

0.4% fully confident. A positive correlation exists between time in training and confidence. 73.0% have never seen such a case. 67.9% report training in this case inadequate. No correlation was found between time spent in training and perceived training adequacy.

Blood product resuscitation in trauma:

11.6% were fully confident. 18.8% have never seen such a case. No correlation exists between time in training and confidence or exposure. 45.0% report training as inadequate in this case. No correlation seen between time in training and perceived training adequacy.

Conclusion: Current training provides limited opportunities for exposure to significant trauma.

The quality of care afforded to service personnel and civilians in recent conflict is unsurpassed and it is essential that the lessons learnt by deployed surgeons form a continuum to their successors.

For military orthopaedic trainees this reinforces the need for closely supervised secondments on deployment; attendance at established military surgical training courses and appropriate fellowships to maximise exposure prior to first consultant deployment.

Aim: To establish confidence and perceived adequacy of training of UK Orthopaedic Specialist Trainees in assessment of limb viability and amputation.

Methods: A web based survey of orthopaedic trainees using scenarios centred around limb viability assessment and amputation resultant from trauma. 225 responses obtained, achieving a < 0.05 error rate with 90% confidence.

Results:

Limb viability:

27.8% were fully confident. A positive correlation exists between training year and fully confident reports. 68.6% encounter such injury either every six months or less frequently. 18.6% regard their training in these cases inadequate. No correlation seen between experience and perceived adequacy of training.

Amputation:

10.3% were fully confident. A positive correlation exists between time in training and perceived fully confident reports.

57.3% encounter such injury either every six months or less frequently. 36.3% regard their training in these cases inadequate. No correlation seen between experience and exposure to cases or perceived adequacy of training.

Conclusion: Current training provides limited opportunities for decision making in limb viability and amputation. Confidence in dealing with such cases is seen to increase with training. Perceived adequacy of training did not change over time.

Military orthopaedic surgeons are providing injured service personnel and civilians with the best possible chance of successful rehabilitation from these injuries. It is fundamental that the experience of these individuals is accessible to their successors.

For military trainees, this reinforces the need for participation in closely supervised secondments on deployment, attendance at established military surgical training courses and appropriate fellowships to maximise exposure prior to completion of training and first consultant deployment.

Introduction: Complex extremity injury remains a challenge to those involved in both its emergent and definitive care. Anecdotal concerns exist regarding exposure of orthopaedic trainees to such cases in the light of recent changes in surgical training. We aim to establish the perceived confidence, exposure to caseload and adequacy of training of United Kingdom (UK) Orthopaedic Specialist Trainees in the management of significant extremity trauma.

Method: A web-based survey was sent to a sample of orthopaedic trainees. 222 responses from 888 trainees were required to achieve a 5% error rate with 90% confidence. 232 responses were received.

Results: Perceived confidence and adequacy of training in wound debridement and fasciotomy is high despite infrequent exposure and training is perceived as adequate. With regards to assessment of limb viability and amputation for extremity injury, exposure is minimal, perceived confidence is lower, particularly in the case of amputation and for this scenario over a third of trainees report their training as inadequate. Perceived confidence in dealing with hand trauma is low and is associated with sparse exposure to cases resulting in a quarter of trainees reporting their training as inadequate. For all scenarios, confidence is seen to increase with time spent in training with the notable exception of post-CCT trainees whom report a lower confidence to their colleagues in the latter years of training.

Discussion: Despite infrequent exposure, it has been demonstrated that perceived confidence and adequacy of training in many aspects of extremity injury is high. Concerns are apparent with the management of hand trauma and amputation surgery. This study is the first of its kind to offer a valuable insight into the current training perceptions and requirements of junior orthopaedic surgeons at a national level.

Femoral neck stress fractures (FNSF) are uncommon, representing around 5% of all stress fractures. In military personnel, FNSF represents one of the severest complications of military training, which can result in medical discharge. Clinical examination findings are frequently non-specific and plain radiography may be inconclusive leading to missed or late diagnosis of FNSF. This paper highlights the significance of FNSF’s in military personnel and alerts physicians to the potential diagnosis. We identified all military recruits, aged 17 to 26, who attended the Infantry Training Centre (Catterick, UK), over a four-year period from the 1^st July 2002 to 30^th June 2006, who suffered a FNSF. The medical records, plain radiographs, bone scans and MRI’s of the recruits were retrospectively reviewed. Of 250 stress fractures, 20 were of the femoral neck; representing 8% of all stress fractures and an overall FNSF rate of 12 in 10,000 military recruits. FNSF’s were most prevalent amongst Parachute Regiment recruits (1 in 250, p< 0.05). Onset of symptoms was most commonly between 13–16 weeks from the start of training. The majority (17/20, 85%) of FNSF’s were undisplaced, these were all treated conservatively. Three FNSF’s were displaced on presentation and were treated surgically. Overall, the medical discharge rate was 40% (8/20). FNSF’s are uncommon and the diagnosis remains a challenge to clinicians and requires a high index of suspicion in young athletic individuals. In such individuals early referral for MRI is recommended, to aid prompt diagnosis and treatment, to prevent serious sequelae.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

Hip osteoarthritis is uncommon in active military personnel but can be extremely debilitating. Previously in such cases total hip replacement was usually delayed as long as possible. The two main reasons for such reluctance were that these persons would be graded P7 Permanent after total hip replacement and that the amount of physical activity an active military person does would lead to early loosening of implant and revision surgery. Resurfacing Arthroplasty has allowed us to take an earlier and more interventional approach in younger active patients.

We describe our early results of 18 hip resurfacing operations in active serving military personnel. Average age was 48 years. All 18 were done in MDHU Northallerton by one in-service orthopaedic consultant in 2004 and 2005. There were no serious complications; average length of stay was 5.5 days. Specifically there were no fractured necks of femur and there were no early signs of component loosening. Final grading after six months was P3.

Hence we now recommend that in selected active military personnel where anatomy permits early hip resurfacing should be considered rather than a conventional hip replacement.

Aim To review the evidence supporting the British military policy that potential army recruits should have upper or lower limb metalwork removed before training.

Background British military policy requires that potential recruits with either upper or lower limb internal fixation metalwork fall below acceptable entry criteria. Military training introduces considerable new stresses upon individuals and this is not without risk. 25% of applicants fall below basic medical entry standards whilst many areas remain undermanned. The MoD has a duty of care as an employer towards recruits and established personnel.

Method A Medline literature search was conducted together with multinational correspondence from interested agencies to review the evidence for this policy.

Results Studies suggest that in the asymptomatic patient, metalwork should not be routinely removed. Recent literature suggests a 4–40% complication rate following removal of metalwork. Infection and refracture are among the common complications. Evidence in top-level athletes suggests only minimal problems relating to retained metalwork when returning to pre-injury performance levels.

Summary No evidence has been demonstrated to support current MoD policy, which appears to be historically based. Other nations often adopt a more lenient approach. Translating the evidence specifically to the “military” scenario would require further prospective study.

Forward surgical teams have been employed in many recent conflicts. However, as in the Gulf War, they have not usually been sited further forward than the Field Ambulance level. During recent operations in Northwest Pakistan and Afghanistan, two Special Forces Field Surgical Teams were forward deployed to isolated and remote desert areas to provide a completely independent surgical facility, backed up only by a small guard force.

Advanced resuscitation and damage control surgery including major vessel ligation, wound debridement and skeletal stabilization was undertaken. These operations all took place within a two resuscitation bay, two table surgical complex set up within a C-130 Hercules aircraft. This allowed for an extremely mobile response to any perceived threats approaching the complex. A small laboratory with a ruggedised ‘Thermopol’ blood refrigeration unit was also carried. This allowed for the forward provision of 50 units of mixed blood type. This facility was found to be life saving.

Following surgical stabilization, these patients were then casevaced by a separate pre-positioned, aeromed pre-fitted C-130 aircraft to a Deployed Operating Base Hospital in Oman. Here, further stabilization surgery, skeletal fixation and wound care was carried out. Twenty-four hours later, all casualties were in a teaching hospital in the UK where final definitive surgery took place.

The management and care of these patients at all of the above stages is presented and discussed with some appropriate lessons for future operations

Forward surgical teams have been employed in many recent conflicts. However, as in the Gulf War, they have not usually been sited further forward than the Field Ambulance level. During recent operations in Northwest Pakistan and Afghanistan, two Special Forces Field Surgical Teams were forward deployed to isolated and remote desert areas to provide a completely independent surgical facility, backed up only by a small guard force.

Advanced resuscitation and damage control surgery including major vessel ligation, wound debridement and skeletal stabilisation was undertaken. These operations all took place within a two resuscitation bay, two table surgical complex set up within a C-130 Hercules aircraft. This allowed for an extremely mobile response to any perceived threats approaching the complex. A small laboratory with a ruggedised ‘Thermopol’ blood refrigeration unit was also carried. This allowed for the forward provision of 50 units of mixed blood type. This facility was found to be life saving.

Following surgical stabilisation, these patients were then casevaced by a separate pre-positioned, aeromed pre-fitted C-130 aircraft to a Deployed Operating Base Hospital in Oman. Here, further stabilisation surgery, skeletal fixation and wound care was carried out. Twenty-four hours later, all casualties were in a teaching hospital in the UK where final definitive surgery took place.

The management and care of these patients at all of the above stages is presented and discussed with some appropriate lessons for future operations.