Statement of purpose

To determine the outcome of the use of Bone Morphogenetic Protein 7 (BMP7) as a replacement for bone graft in a limb reconstruction unit

UK personnel have been deployed in Afghanistan since 2001 and over this time a wealth of experience in contemporary war surgery has been developed. Of particular note in the latter Herrick operations the injury pattern suffered by personnel is largely blast wounds, primarily from improvised explosive devices. With the development of improved body armour, previously unsurvivable blasts now result in a large number of traumatic amputations, predominantly affecting the lower limb. Faced with this, deployed medical personnel in the Role 3 facility, Camp Bastion, have developed, by a process of evolution, a standard process for timely management of these injuries.

We present a documented schema and photographic record of the ‘Bastion’ process of management of traumatic amputation through the resuscitation department, radiology, theatres and post-operatively. In resuscitation the priority is control of catastrophic haemorrhage with exchange of CAT tourniquets to Pneumatic tourniquets. While undergoing a CT, time can be used to complete documentation. In theatre a process of social debridement & wash then sterile prep followed by formal debridement allows rapid management of the amputated limbs.

This work provides a record of current best practice that generates maximum efficiency of personnel and time developed over a large number of procedures. This allows reflection both now in relation to continuing Herrick operations and when military medical services are faced with a future conflict and an inevitable change in injury patterns.

The Rotaglide+ knee arthroplasty was introduced in 2000 as a successor to the Nuffield and Rotaglide knees. Both prosthesis were used in our unit and data was collected prospectively on sex, diagnosis, range of motion, pain score and American knee association score (AKSS). All operations were done under the care of one Surgical team (BBM) using the same instrumentation and the same pathway. Between 1987 and 2000 444 primary Nuffield were performed. 278 primary Rotaglide+ knees between 2000 and 2006.

65% of Nuffields implanted were in female candidates and 55% in the Rotaglide+. 75% of Nuffields were performed for Osteoarthritis, 69% in the Rotaglide+, this reflects the authors growing interest in inflammatory arthritis. Pre-operative functional range of motion and pain scores were similar. Both series showed a significant and sustained improvement in pain score, and walking time. Similar improvement was seen in range of motion. Comparison of the two series showed the Nuffield knee scored better on AKSS at year’s one and two and on pain score at year one but other than this outcomes were similar for both series. Revision rate in the Nuffield series is 9% at 25 years and in the Rotaglide+ series 4% at 8 years. This compares favourably with other published knee series’.

Despite being introduced as an improved design the Rotaglide+ fails to demonstrate any improvement in function and pain compared to its predecessor the Nuffield knee. Knee surgeons need to maintain a healthy cynicism of manufacturers ‘improved’ implants.

Introduction: The management atlanto-axial fractures, particularly those of the odontoid peg, remains controversial. We managed patients with C1/C2 fractures non-operatively in rigid immobilization until CT-scanning confirmed bony union, rather than for the standard 3-month period. We examined whether this improved outcomes and reduced the need for surgery.

Method: All patients admitted to our unit with atlanto-axial fractures between 2001–2007 were retrospectively analyzed. All fractures had the ‘intention-to-treat’ conservatively in either halothoracic vest (85%) or Aspen collar (15%). Rigid immobilization was maintained until CT-scanning demonstrated bony fusion. Functional stability was subsequently assessed with flexion-extension radiographs after removal of rigid immobilization.

Results: Twenty-seven patients were studied. Nineteen had odontoid peg fractures (10 type II; 9 type III). The remainder consisted of 3 Hangman’s, 3 lateral mass and 2 atlas ring fractures. 83% of patients progressed to union at an average of 13.2 weeks (range 5–22). Six complications related to halo immobilization were observed (three skull perforations/pin-site infections). All of these patients progressed to union non-operatively.

Failure of non-operative management was deemed as non-union or poor patient tolerance of halo, and occurred in 4 patients (17%). All four had type II odontoid peg fractures, and had transarticular screw fixation. One postoperative complication of screw fracture was recorded.

Conclusion: Non-union rates of conservatively managed atlanto-axial fractures with standard 3-month rigid immobilization have been reported as high as 35%. In our series, CT-imaging to confirm bony union prior to removal of the rigid immobilization (prolonging immobilization where necessary) significantly lowered the rate of non-union and therefore the need for subsequent surgery.

Ethics approval: None Audit

Interest Statement: None

Introduction: Avascular necrosis of the femoral head after resurfacing hip replacement is an important complication which may lead to fracture or failure. The surgical approach may affect the blood supply to the femoral head. We compared the changes in femoral head oxygenation resulting from the extended posterior approach to those resulting from the anterolateral approach, the trochanteric flip approach and a modified, soft tissue preserving posterior approach.

Methods: We recruited 48 patients who underwent hip resurfacing arthroplasty (HRA) to measure bone oxygen levels. A calibrated gas-sensitive electrode was inserted in the femoral head following division of the fascia lata. Intra-operative X-ray confirmed correct electrode placement. Base-line oxygen concentration levels were recorded immediately after electrode insertion and continuous measurements were then performed throughout surgery. All results were expressed relative to the baseline, which was considered as 100% relative oxygen concentration and changes during surgery through the posterior approach (n=10), the antero-lateral approach (n=12), the trochanteric flip approach (n=15) and the modified posterior approach (n=11) were compared.

Results: The relative oxygen concentration at the end of the procedure was significantly reduced when hip resurfacing was performed through the posterior (22%, SD 31%, p< 0.005) or a modified posterior (35%, SD 31%, p< 0.005) approach, but recovered in the anterolateral (123%, SD 99%, p=0.6) and trochanteric flip group (89%, SD 62%, p=0.5). Sub-group analysis of these two relatively blood preserving approaches showed that intra-operative oxygen concentration was significantly more consistent during surgery through the trochanteric flip approach (p< 0.02).

Discusssion and conclusion: This study has demonstrated that disruption of blood flow to the femoral head during HRA is dependent on the surgical approach. We therefore believe that blood supply preserving approaches (i.e. anterolateral, trochanteric flip) may be associated with a lower risk of avascular necrosis and femoral neck fracture.

Study Purpose: To investigate whether the use of reinfusion drains and post-operative autogenous blood transfusion reduces the rate of allogeneic blood transfusion after primary total knee replacement in our unit.

Methods: A prospective audit was carried out over a 14-week period. Patients received either a reinfusion drain, a suction drain or no drain according to surgeon preference. Post-operative allogeneic blood transfusion criteria were based on clinical indication rather than an absolute haemoglobin level.

Results:127 consecutive patients underwent total knee replacement during the study period. Patients were matched between the three groups for age, medical co-morbidity, DVT prophylaxis, and implant used.

Conclusion: The use of reinfusion drains did not significantly reduce the requirement for post-operative allogeneic blood transfusion. This directly contrasts much of the published literature.