Heterotopic ossification is the formation of lamellar bone in soft tissues and is a common complication of high-energy combat injury. This disabling condition can cause pain, joint ankylosis, and skin ulceration in the residua of amputees. This project is aimed at developing a novel treatment to dissolve hydroxyapatite in heterotopic ossification and prevent the crystallisation of this this mineral at sites of ectopic bone formation. Previously reported results demonstrated that hexametaphosphate could dissolve hydroxyapatite at physiological pH. Further work has been undertaken to investigate the mechanism of this dissolution and establish a means of temporal control of action. In addition, physicochemical analyses of samples of human heterotopic ossification have yielded important insights into the nature of this pathological tissue. Techniques include mapped micro X-ray fluorescence, mapped Raman spectroscopy, scanning electron microscopy, and micro computed tomography. Formulation engineering work has begun in order to develop an appropriate delivery vehicle for this agent. This includes rheological testing and hexametaphosphate elution profiles. Finally, micro CT analysis has shown that hexametaphosphate is able to dissolve human heterotopic ossification tissue. In summary, this work has moved us closer towards our goal of a novel injectable agent for the treatment and prevention of heterotopic ossification.

Bone non-union following fracture is a major cause of morbidity in combat casualties.

The various clinical treatments used to prevent or treat non-union remain of limited efficacy. Research therefore continues in pre-clinical animal models in an attempt to identify an effective clinical treatment. The aim of this study was to systematically evaluate emerging pre-clinical therapies in order to rationalise priorities for translational research.

The methodological protocol of this study was registered with the Collaborative Approach to Meta Analysis and Review of Animal Data from Experimental Studies (CAMARADES) and published.

The review identified 3251 animal studies, 851 of which fulfilled the criteria for inclusion as detailed in the protocol. Of these, 702 of the studies described therapies that had progressed to clinical trials and were therefore excluded. The remaining 149 papers described eighteen categories of therapy that represent novel therapies yet to translate to clinical trials. These studies used a range of animal models, with heterogeneity that precluded formal synthesis and meta-analysis.

This study provides a systematic evaluation of novel therapies with potential to prevent or treat non-union. It also represents a novel application of an emerging epidemiological technique to address a key priority in Combat Casualty Care research.

Scapula fractures mostly occur following high energy trauma, however, the demographics are unknown in deployed soldiers. We analysed the incidence, aetiology, associated injuries, treatment and complications of these fractures in military personnel from Afghanistan and Iraq (2004–2014). Forty-four scapula fractures from 572 upper limb fractures (7.7%) were sustained. 85% were caused by blast or gunshot wounds and 54% were open blast fractures. Multiple injuries were noted including lung, head, vascular and nerve injuries. Injury Severity Scores were almost double compared to the average upper limb injury without a scapula fracture (21 vs. 11). Brachial plexus injuries (17%) have a favourable outcome following GSW compared to blast injuries. Glenoid fractures or floating shoulders were internally fixed (10%) and resulted from high velocity gunshot wounds or mounted blast ejections. There were no cases of deep soft tissue infection or osteomyelitis and all scapula fractures united. Scapula fractures have a 20 times higher incidence in military personnel compared to the civilian population. These fractures are often associated with multiple injuries, including brachial plexus injuries, where those sustained from blast have less favourable outcome. High rates of union following fixation and low rates of infection are expected despite significant contamination and soft tissue loss.

The explosive device has successfully been used by terrorists globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of, high lethality and target accuracy. This aim of this study was to analyse the demographics and casualty figures of terrorist bombings worldwide. Analysis of the Global Terrorism Database and a PubMed search (keywords “terrorist”, and/or “suicide”, and/or “bombing”) from 1970 to date was performed. Of 58,095 reported terrorist explosions worldwide, 5.08% were suicide bombings. Incidents per year is increasing (P<0.01). PubMed identified 41 publications reporting 167 incidents. Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe ranked 4^th in the number of terrorist related explosion (13.2%). Differing injury patterns were seen in open, confined and building collapse incidents. Terrorist bombings continue to be a threat and are increasing in the Middle East and Europe. Suicide bombings are becoming an increased threat with greater casualty figures per incident seen. This data assists in the planning of security, logistics, casualty evacuation and care.

Major upper limb arterial injuries sustained in combat are associated with significant trauma. We analysed the survival and complication rates following upper limb vascular injury in Iraq and Afghanistan (2004–2014). Fifty-two soldiers sustained 59 major arterial injuries in 54 limbs. Axillary artery injuries were more likely to be caused by gunshot wounds (86%), whilst brachial and ulnar artery injuries were primarily associated with blasts (72% and 87% respectively); no such correlation was identified with radial artery injuries. Apart from three temporary shunts, all vascular injuries were treated definitively in the local field hospital before repatriation. Proximal injuries were predominantly treated with long saphenous vein grafts and distal injuries with ligation. One soldier required an immediate amputation following failed LSV grafting, however no amputations followed repatriation. There were five identified graft failures (21%), although these were not associated with subsequent perfusion issues. There were no graft failures following temporary shunting. Associated nerve injuries often required operative intervention and have a guarded outcome. 100% of radial fractures went onto non-union if combined with a radial artery injury. Successful immediate re-perfusion of a vascular compromised upper limb correlates with excellent long-term limb survival, despite a significant number of grafts developing secondary failure.

Heterotopic ossification (HO) is the formation of bone in extraskeletal sites. It is a major problem for combat-related casualties with 64% of such patients showing radiological evidence of the disease. Of these, 19% require surgical excision. Current prophylaxis is problematic due to poor efficacy and unsuitability in a military setting. Our novel anti-HO strategy is to use an inorganic reagent to inhibit the deposition of HA and disperse any pre-formed mineral. Literature review identified several potentially effective agents. These were tested for their ability to disperse solid monoliths of HA. In addition, a standard HA synthetic reaction was performed in the presence of each agent to establish their inhibiting activity. One reagent (a condensed phosphate) dispersed a solid monolith of HA by 38% (mass loss) over 30 days. This reagent was also shown to inhibit HA crystal synthesis yield by 28%. Early work on a hydrogel delivery system has produced favourable results. These preliminary data demonstrate proof of concept that HA may be dispersed and its formation inhibited by a non-toxic polyphosphate. This work will form the justification for development into in vitro osteogenic cell culture models and animal HO models.

Military personnel operating on high speed marine craft are exposed to Whole-Body Vibration (WBV). Additionally planing craft operate at speeds with minimal contact of the hull with warer making the crew vulnerable to mechanical shock. An association between Low Back Pain (LBP) and exposure to WBV has been extensively reported in civilian literature. LBP is reported by military personnel operating on planing craft leading to downgrades and potential discharge. There is a clear need to understand the impact prolonged exposure has on our population operating these craft. We performed a bibliographical search of the PubMed database for records using a combination of keywords. Abstracts were screened for relevance and references cited in retrieved papers reviewed. There is no consensus in the literature on the potentially pivotal pathological process behind the association. Evidence from professional driving suggests current safe operating exposure levels require review to protect against long-term damage however with little evidence concerning the unique environment in which boats crews operate, the parity of these environments require investigation to allow direct comparison. Due to the prevalence of LBP in this population a need exists to establish the pathological process and add to the evidence base driving safe operating exposure levels.

The use of external fixation in the management of long bone fractures has long been recognised.

The aim of this study was to compare 3 differing constructs of Hoffman-2 and Hoffman-3 External Fixator systems to assess which potentially withstood the greatest load.

Three different constructs (2, 3 and 4-bar) of Hoffman 2 and 3 External Fixation systems were tested. A UHMWPE tube was utilised as a bone substitute to construct a biomechanically reproducible model which could be tested on an MTS testing jig. Each construct was loaded to 3, 5, 8, 12 and 15mm of displacement at the fracture gap. Each construct was cyclically loaded 200 times for each test and repeated 5 times.

The results demonstrate that the Hoffman-3 configurations withstood a load of at least twice that of the Hoffman 2 configurations across all displacements. Using a 2-way ANOVA test at all displacements the 2-bar configuration withstood greater load than the 3 bar (P<0.0001). With Hoffman 2 the 2-bar configuration withstood a greater load than the 4 bar diamond configuration.

These results demonstrate that Hoffman-3 External Fixation Device has a greater axial loading capacity than its Hoffman-2 predecessor.

A retrospective analysis of all paediatric patients admitted to Camp Bastion Role 3 between June 2006 and March 2013 was conducted from the UK trauma database. Patient demographics, mechanism of injury, anatomical distribution of injury and treatment are described.

Two hundred and ninety eight children were admitted, 225 males with a median age of 9 years old. The highest number of cases (78) was recorded in 2011. Overall there were 55 fatalities (85.6% male). Most injuries were by IED (68% of cases) with 74% requiring operative intervention. Seventy-four percent of casualties had three or more anatomical regional injuries. Whilst the most commonly injured region was the lower limb (78%), head injuries were seen in 41%, abdominal injuries in 48% and thorax injuries in 44%. Debridement (including amputations) (59.4%) and laparotomy (30.6%) were the commonest operations performed. Sixty percent of cases were in theatre within one hour of arrival. Amongst survivors the mean ISS score was 17 and amongst fatalities 43; NISS 22 and 51; RTS 5.45 and 2.91.

Paediatric blast injuries represent a significant burden to medical facilities in contemporary conflict. Whilst limb injuries predominate, the proportion of head and torso injuries is higher than seen in adult blast injuries.

With the drawdown from Afghanistan focus turns towards future operations, and their demands on the DMS. Training for surgeons deploying to military operations will have to take into account the decreased opportunities and experience gained by current conflicts. The aim is to focus on current UK surgical training for military operations specifically. A comparison is made with US surgical training.

A questionnaire was distributed to UK military surgical consultants in General Surgery, Trauma and Orthopaedics and Plastic Surgery. A similar questionnaire was sent to deployed US surgeons in SE Afghanistan. Response rates of 55% were achieved. Respondents were questioned on their confidence to perform several key procedures. Most UK consultants were satisfied with their overall training for deployment. Satisfaction rates were high for the MOST course and Danish Surgery. US satisfaction with pre-deployment training was poor. The majority of respondents felt confident to perform all haemorrhage and contamination control procedures in an emergency. However, most felt training for military personnel should be lengthened by a year or more to include greater exposure to other specialties.

Whilst satisfaction with surgical training is high, many UK surgeons appear to suggest an increase in specialty exposure in preparation for future deployments.

Coronal alignment is an important factor in long-term survival of TKA. Many implant systems are available and most aim to produce a posterior slope on the tibial component to reproduce the 7⁰ seen in the normal tibia. We hypothesized that resecting the tibial plateau with a posterior slope can introduce error in coronal plane alignment in TKA.

We used a standard saw-bones model in conjunction with a computer navigation system that is available for use in TKA (Stryker Orthopaedics). The normal protocol for preliminary referencing was followed; care was taken to identify tibial landmarks (tibial plateau reference point, true sagittal plane and transmalleolar axis). We then used a standard extramedullary alignment jig (Scorpio TKR System, Stryker Orthopaedics) with cutting blocks designed to give 0, 3, 5 and 7 degrees of posterior slope and varied the position of the alignment jig.

Variations included:

Medial rotation of the cutting block,

In all experiments, there was a greater deviation from ideal coronal alignment as the slope on the tibial cut was increased. The greatest influence was with external rotation of the distal part of the jig, which produced 3⁰ of varus at only 15⁰ of external rotation with a 7⁰ slope. Medialisation of the proximal reference point worsened this to 4.5⁰ of varus.

We have quantified the degree of coronal malalignment that can occur for different posterior slopes during tibial resection for TKA. We recommend either using a minimal slope or navigation to ensure correct implant positioning.

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

Background: Coronal alignment is important in long-term survival of TKA. Many systems are available; most aim to produce a posterior slope on the tibial component in order to reproduce the 7⁰ seen in the normal tibia. Some are designed to produce a bone cut with 7⁰ of slope whereas others combine the slope of the bone cut with an in-built slope on the polyethylene insert. We have investigated the theory that resecting the tibial plateau with a posterior slope can introduce error in coronal plane alignment in TKA.

Methods: We used a standard saw-bones model in conjunction with a computer navigation system that is available for use in TKA (Stryker Orthopaedics). The normal protocol for preliminary referencing was followed; care was taken to identify tibial landmarks (tibial plateau reference point, true sagittal plane and transmalleolar axis). We then used a standard extra-medullary alignment jig (Scorpio TKR System, Stryker Orthopaedics) with cutting blocks designed to give 0, 3, 5 and 7 degrees of posterior slope and varied the position of the alignment jig. Variations included:

Medial rotation of the cutting block

Results: In all experiments, there was a greater deviation from ideal coronal alignment as the slope on the tibial cut was increased. The greatest influence was from external rotation of the distal part of the jig which produced 3⁰ of varus at only 15⁰ of external rotation with a 7⁰ slope. Medialisation of the proximal reference point worsened this to 4.5⁰ of varus.

Conclusions: We have quantified the degree of coronal malalignment that can occur for different posterior slopes during tibial resection for TKA. We recommend either using a minimal slope or navigation to ensure correct implant positioning.

Introduction and Aims: The aim was to assess the efficacy of current arthroscopic knotting techniques with commonly used suture materials.

Method: A Hounsfield tensiometer with 1000N load cell, strain rate 25mm/min, bar separation of 7.5mm under standard temperature and pressure was used. Suture materials used, 2 Ethibond, 1 PDS and 1 Panacryl. The knotting techniques compared were the Tennessee slider, Tautline hitch, Duncan Loop, SMC knot and Surgeon’s knot. Two surgeons tied each 10 times using a suture passer and standardised knot technique. Each knot was tested to failure on 10 sequential experiments. Suture material strength was tested in isolation, tested to failure using the different knots then repeated after suture immersion in normal (0.9%) saline.

Results: Ultimate strength of the suture material and the knotting techniques were assessed. The mode of failure, slip or suture material fracture was also investigated. The 2 Ethibond had higher ultimate strength than either 1 PDS or 1 Panacryl. The Tautline hitch and Surgeon’s knot had significantly lower slip rates, with superior internal security than the other knotting techniques (P less than 0.002). The Tennessee slider, Duncan Loop and SMC knots had low security and slipped in more than 50 percent of experiments. There was no difference after saline soaking. The number of additional half hitches required for maximum knot holding capacity was consistently three, confirming previous findings.

Conclusion: The Tautline hitch is recommended due to internal security, tying characteristics and overall knot strength. Whichever knot is selected, three additional alternating half hitches to obtain consistent security is strongly supported.

Introduction The aim of this study was to assess the efficacy of current arthroscopic knotting techniques with commonly used suture materials.

Methods A Hounsfield tensiometer with a 1000N load cell, strain rate of 25 mm/min, bar separation of 7.5 mm was used under standard temperature and pressure. Suture materials were those in common use; 2 Ethibond, 1 PDS and 1 Panacryl. The knotting techniques compared were the Tennessee slider, Tautline hitch, Duncan Loop, SMC knot and the Surgeon’s knot. Two surgeons tied each knot 10 times using a suture passer and standardised knot technique. Each knot was tested to failure on 10 sequential experiments. Suture material strength was tested alone, tested to failure using the different knots and after suture immersion in normal saline. The ultimate strength of the suture material and of the various knotting techniques were assessed. The mode of failure, slip or suture material fractured was also investigated.

Results The 2 Ethibond had superior strength compared to 1 PDS or 1 Panacryl. The Tautline hitch and Surgeon’s knot had a significantly lower slip rate, with superior internal security than the other knotting techniques (p < 0.002). The Tennessee slider, Duncan Loop and SMC knots slipped in more than 50% of experiments. No difference was observed after soaking in normal saline. The number of additional half hitches required for maximum knot holding was consistently three, confirming previous findings.

Conclusions The Tautline hitch is recommended with its superior internal security, tying characteristics and overall knot strength. Whichever arthroscopic knot is selected, the addition of three alternating half hitches for consistent security and reliability is strongly supported.

Poor shoulder function may complicate the non-operative treatment of a humeral diaphyseal fracture. This has often been regarded as an unavoidable consequence of the relative immobility of the shoulder during brace treatment. Tears of the rotator cuff have not previously been recognised as an underlying cause of persistent shoulder pain and stiffness in this situation.

In this report, we identified six patients, from a consecutive series of 294 patients with humeral fractures treated in our Institution over a five-year period, who were found to have symptomatic rotator cuff tears following non-operative treatment of their humeral diaphyseal fracture. All had normal pre-injury upper limb function, but had persistent pain and loss of active shoulder movement after their fracture had united. Large, retracted cuff tears, affecting the cuff muscles attached to the greater tuberosity, were identified pre-operatively from imaging of the rotator cuff and intra-operatively at open surgery. Surgical reconstruction of the cuff was carried out in all cases and yielded satisfactory return of shoulder function, on assessment at least eighteen months after injury.

Congenital Dislocation of the Hip (CDH) has been routinely screened for at birth using clinical tests since the early 60’s. In Edinburgh Macnicol (1) assessed the screening programme between 1962 to 1986. It particularly focussed on the change in incidence of late diagnosis when screening was undertaken by experienced staff in comparison to junior staff. The treatment of Orthopaedic conditions in children within the Edinburgh area was combined at the Royal Hospital for Sick Children in 1995. Therefore this paper aims to reassess the screening programme for CDH between 1995–1999 and compare it with the previously achieved results in the same population.

From 1 Jan 1995 to 31 Dec 1999 there were 34,597 live births at Edinburgh’s Maternity hospitals. An orthopaedic clinical assistant examined all infants within the first 24 hours with considerable experience in this field. In addition to the Ortolani and Barlow tests, skeletal and skin fold asymmetry, limitation of abduction and loss of the physiological flexion deformity present in the normal neonate were observed. FH, delivery and circumstances of the pregnancy were noted. Hips found to be clinically unstable were referred on to the CDH clinic where further assessment and ultrasound were performed in order to decide upon the further management of each child.

In 1995 there were 7179 live births, 2.93 of which were harnessed (incidence per 1000 births), 1.11 late diagnosis, (incidence per 1000 births) and 1.39 were operated upon (incidence per 1000 births).

In 1996 there were 7144 live births, 3.64 of which were harnessed (incidence per 1000 births), 1.40 late diagnosis, (incidence per 1000 births) and 1.82 were operated upon (incidence per 1000 births).

In 1997 there were 7065 live births, 2.12 of which were harnessed (incidence per 1000 births), 0.57 late diagnosis, (incidence per 1000 births) and 0.71 were operated upon (incidence per 1000 births).

In 1998 there were 6763 live births, 4.14 of which were harnessed (incidence per 1000 births), 0.59 late diagnosis, (incidence per 1000 births) and 0.30 were operated upon (incidence per 1000 births).

In 1999 there were 6446 live births, 6.12 of which were harnessed (incidence per 1000 births), 0.78 late diagnosis, (incidence per 1000 births) and 0.62 were operated upon (incidence per 1000 births).

Overall there were 34597 live births, 3.76 of which were harnessed (incidence pre 1000 births), 0.89 late diagnosis, (incidence per 1000 births) and 0.98 were operated upon (incidence per 1000 births).

The incidence of late diagnosis of CDH in Midlothian has increased from 0.5 per 1000 as reported by Macnicol between 1962–1986 to 0.89 per 1000 over the last 5 years. These results are clearly disappointing. Although Catford et al (2) has proposed that the incidence of CDH has been increasing this does not explain the size of the increase in late diagnosis seen. Further investigation is required in order to reduce this late presentation rate to that previously achieved.