Background. Medical grade Calcium Sulphate can be used as a delivery vehicle for antibiotics. We use these for treating patients with established osteomyelitis, but also use it prophylactic for contaminated war injuries, to fill voids in bone with osteo conductve filler that delivers local antibiotics, and can integrate with bone. Although antibiotic loaded calcium sulphate is increasingly used, there is little data to demonstrate that systemic levels generated by local release of antibiotics are safe. For this reason, we routinely assay systemic levels of antibiotics. Objectives. To determine if systemic toxicity occurs after the use of antibiotic loaded calcium sulphate in the treatment of bone and soft tissue infection. Material and Method. Bone cavities and soft tissue dead spaces were aggressively debrided, lavaged and packed with Calcium Sulphate (10–40 cc) loaded with Vancomycin (1–4 g) and Gentamicin (240–960 mg). Post-operatively serial assays of Vancomycin and Gentamicin levels 1 hour after surgery then daily for three days. Renal function was also measured. Results. In patients with normal renal function. : The systemic levels were either un-measurable at the first assay, or below the acceptable trough level (Mean 2.4 and 1.8 for Vancomycin and Gentamycin respectively). They had measurable systemic levels at the third assay . In patients with renal dysfunction. : Systemic levels were in the therapeutic range determined for systemically administered antibiotics, but these levels remained high and did not decrease until patients had undergone their routine dialysis. Conclusions. In patients treated with antibiotic loaded Calcium Sulphate: Antibiotic assays are not necessary in patients who have normal renal function. Patients with impaired renal function should have:. Use lower doses of antibiotics. Should undergo assays routinely. Ensure dialysis after surgery. If they remain high, the antibiotic loaded calcium sulphate could be removed

Summary. For injuries to the lower leg or forearm, supplemental support from soft tissue compression (STC) with a splint or brace-like system and combined with external fixation could be done effectively and quickly with a minimal of facilities in the field. Introduction. Soft tissue compression (STC) in functional braces has been shown to provide rigidity and stability for most closed fractures, selected open fractures and can supplement some other forms of fracture fixation. However, soft tissue injuries are compromised in war injuries. This study was designed to evaluate if STC can provide adequate rigidity and stability either with, or without other forms of fixation techniques of simple fractures or bone defects after standardised soft tissue defects. The load was applied either axially or in bending as the bending configuration is more like conditions when positioned on a stretcher in the field. Methods. A simple, oblique fracture was created in 23 cadaveric femurs, 23 tibiae and fibulae, 22 humeri and 22 radii and ulnae of intact limb segments. The weight of each intact limb segment was measured. Cyclic axial loads (12 – 120N) were applied for each progressive condition: intact limb, mid shaft osteotomy, a lateral 1/4 circumferential soft tissue defect, 1/3 circumferential defect and finally, 3 cm bone defect. Limbs were randomly assigned to be stabilised be either plate and screw (PS), intramedullary rod (IR) or external fixation (EF). Testing with and without STC in a brace was performed after each condition. In an additional 36 forearms, bending rigidity was measured using a modular fracture brace with external fixation. The bone and the soft tissue weighed separately and the ratio of soft tissue to bone was calculated. ANOVA multi-variant analysis corrected for multiple comparisons was used to compare the axial rigidity between the different conditions tested. Results. There was no significant difference in axial rigidity for humerus or femoral shaft fractures treated by any of the methods related to the degree of soft tissue damage. Femurs, tibias and humeri with a 3 cm bone defect were best stabilised with IR. Forearms with a 3 cm bone defect were best stabilised with PS. Progressive increase in soft tissue defects did create progressive loss in rigidity in forearms and legs, but the most dramatic loss occurred with the bone defect and ST defect. The rigidity of IR and EF in legs decreased over 50% with bone defect, and about 20% of that was restored with STC. The rigidity of IR and EF in forearms decreased almost 79%, and about 21% of that was restored with STC. The increase in resistance to bending in the forearm was most significantly improved by STC. Discussion/Conclusions. Invasive types of surgical intervention provide the best rigidity to fractures, regardless of the presence of or size of a soft tissue defect. In general, use of PS and IR and application of conventional types of braces to achieve STC is not practical in the field. EF, however, can be applied quickly and easily with a minimal of facilities in the field and can be applied in such a way that no foreign bodies end up in the contaminated wound. For injuries to the leg or forearm, supplemental support from STC with a splint or brace-like system could be effective

We welcome letters to the Editor concerning articles that have recently been published. Such letters will be subject to the usual stages of selection and editing; where appropriate the authors of the original article will be offered the opportunity to reply.

The June 2012 Trauma Roundup³⁶⁰ looks at: nerve injuries of warfare; the medical complications of earthquakes; the measuring of tissue pressures in compartment syndrome; the risk of plunging through the bone when drilling; bony nonunion and negative pressure therapy; surgery for the posteriorly dislocated hip; whether to use the sliding screw or intramedullary nail for the trochanteric fracture; antegrade interlocking nailing for the distal femoral fracture; and gunshot wounds to the pancreas.

Introduction and aims. We present a series of patients who have had secondary reconstruction of war injuries to the upper and lower limbs, sustained during the Iraq and Afghanistan conflicts. Material and Methods. All patients were seen at the combined Peripheral Nerve Injuries Clinic at the Defence Medical Centre for Rehabilitation, Headley Court. All surgery was performed at Odstock Hospital. Procedures include scar excision and neurolysis (all patients), release of scar contractures, tenolysis, tendon transfers, revision nerve grafts, excision of neuroma, and soft tissue reconstruction using pedicled or free flaps. Results. 24 patients have been treated at the time of submission. We have used 13 free flaps (1 free groin flap, 9 anterolateral thigh, 3 parascapular, with 4 as through-flow flaps) and 1 pedicled groin flap, with no flap losses. There were 6 amputation stump revisions (1 above elbow, 5 below knee). The majority (n=23) have had nerve recovery distal to the level of injury following revision surgery. Conclusions. Nerve repairs recover following neurolysis (and revision nerve graft if necessary) with provision of good soft tissue cover. Release of scar contractures with flap cover allows healing of chronic wounds and permits mobilisation of joints. Thin fascio-cutaneous flaps provide good contour and can be elevated more easily than skin grafted muscle flaps for secondary surgery. Free or regional flaps are preferable to local flaps in high energy-transfer military wounds. Immediate complex reconstruction is not always appropriate in multiply-injured patients

Introduction. We present a series of patients who have had secondary reconstruction of war injuries to the upper and lower limbs, sustained during the Iraq and Afghanistan conflicts. Material and Methods. All patients were seen at the combined Peripheral Nerve Injuries Clinic at the Defence Medical Centre for Rehabilitation, Headley Court. All surgery was performed at Odstock Hospital. Procedures include scar excision and neurolysis (all patients), release of scar contractures, tenolysis, tendon transfers, revision nerve grafts, excision of neuroma, and soft tissue reconstruction using pedicled or free flaps. Results. 24 patients have been treated at the time of submission. We have using 13 free flaps (1 free groin flap, 9 anterolateral thigh, 3 parascapular, with 4 as through-flow flaps) and 1 pedicled groin flap, with no flap losses. There were 6 amputation stump revisions (1 above elbow, 5 below knee). The majority (n=23) have had nerve recovery distal to the level of injury following revision surgery. Conclusions. Nerve repairs recover following neurolysis (and revision nerve graft if necessary) with provision of good soft tissue cover. Release of scar contractures with flap cover allows healing of chronic wounds and permits mobilisation of joints. Thin fasciocutaneous flaps provide good contour and can be elevated more easily than skin grafted muscle flaps for secondary surgery. Free or regional flaps are preferable to local flaps in high energy-transfer military wounds. Immediate complex reconstruction is not always appropriate in multiply-injured patients

The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.

We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed between the upper and the lower limbs. Explosions accounted for 164 (63%): 213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was needed in 18. A total of 36 patients continued in severe neuropathic pain. This paper outlines the methods used in the assessment of these injuries and provides information about the depth and distribution of the nerve lesions, their associated injuries and neuropathic pain syndromes

During the second Lebanon war, between 12/07/06 to 14/08/06, 241 war injuries were admitted to Rambam Medical Center emergency room: 202 soldiers and 39 citizens. (Post traumatic stress disorders victims were not included). Majority of the injured soldiers (98%) were mobilized by the Israeli Air Force helicopters. More then 40 helicopters had landed in the hospital heliport during the war. Distribution of injuries according to the injury type:. 110 patients (44% of all injured) had Orthopedic injuries (including hand injuries). 76 patients (31% of all injured) had Orthopedic injuries combined with other injuries. Not orthopedic injury – 63 patients (25%) Majority of all wounded (75%) had suffered from an orthopedic injury. Distributions of soldier’s injuries among soldiers were similar to the above :. 81 soldiers (41%) Orthopedic injuries (including hand injuries). 64 soldiers (33%) Orthopedic injuries combined with other injuries. 50 soldiers (26 %) Not orthopedic injury. About 75 % of the injured soldiers suffered from orthopedic injuries. Vast majority of the injuries were shrapnel injuries, which were divided to 3 levels:. Mild soft tissue damage due to few or superficial shrapnel injury – 107 (49%) soldiers. Moderate soft tissue injuries due to multiple shrapnel injuries – 54 (25%) soldiers. Severe soft tissue injuries had muscular and neurovascular damage. Organs injury distribution:. 24 Patients total of 54 fractures, 24 of those had been long bone fractures. 17 Patients had sustained a Major vascular injury. 20 Patients had sustained a nerves injury. Amputation – 5 soldiers were underwent completion of traumatic lower limb amputation. One soldiers had bilateral below knee amputation, 1 above knee amputation and 3 unilateral below knee amputation. Two hundred and three orthopedic surgery interventions were done by Orthopedics’ B’ department in Rambam Medical Hospital, during the Second Lebanon War

There have been few reports in the literature of total elbow arthroplasty extending beyond 10 to 15 years. We reviewed 40 patients (41 elbows) with a mean age of 56 years (19 to 83) who had undergone a Coonrad/Coonrad-Morrey elbow arthroplasty by one surgeon for various diagnoses between 1974 and 1994. Surgical selection excluded patients with previous elbow infection or who refused to accept a sedentary level of elbow activity postoperatively. Objective data were collected from charts, radiographs, clinical photographs and supplemented by the referring orthopaedic surgeons’ records and radiographs if health or distance prevented a patient from returning for final review. Subjective outcome was defined by patient satisfaction.

Of the 41 elbows, 21 were functional between 10 and 14 years after operation, ten between 15 and 19 years and ten between 20 and 31 years. There were 14 complications and 13 revisions, but no cases of acute infection, or permanent removal of any implant.

Objective The aim of this study was to prospectively study the effectiveness of external fixation for war injuries during the recent Gulf conflict. Patients and Methods We studied all patients seen at 202 Field Hospital, which received the majority of patients who had external fixators applied by the British Armed Forces. Results Fifteen patients had external fixators applied with follow-up available for 14 (15 external fixators). Of the 15, 13 (87%) required early revision or removal due to complications of the injury or the fixator. Seven required early removal at a mean of 9.1 days (range 1–19). Six required early revision at a mean of 5.9 days (range 1–22). Instability was a problem with 10 fixators (67%). Seven fixators were revised and 3 were removed. Pin loosening was noted with 5 fixators (33%) involving twelve pins. The cause was multifactorial, but was related to injury severity and frame design. A significant pin track infection developed at 14 pin sites (3 fixators – 20%). All 3 fixators were removed after a mean of 15.5 days (range 14–19). Only 2 fixators did not require early removal or revision. Conclusion We have demonstrated a high early failure rate with the use of external fixation and would caution against its universal acceptance. For many fractures plaster or skeletal traction provide an alternative option. When external fixation is required, stability must be achieved. Even with this there is likely to be a high complication rate due to pin track infection and loosening, and amputation must still be considered as a possible outcome for military injuries

Background War wounds produce a significant burden on medical facilities in war. Workload from the recent conflict was documented in order to guide medical needs in future conflicts. Method Data on war injuries was collected prospectively. In addition, all patients sustaining penetrating injuries that received their treatment at our hospital had their wounds scored using the Red Cross wound classification. This information was supplemented with a review of all patients admitted during the study period. Results During the first two weeks of the conflict, the sole British field hospital in the region received 482 casualties. One hundred and four were battle injuries of which nine were burns. Seventy-nine casualties had their initial surgery performed by British military surgeons and form the study group. Twenty-nine casualties (37%) sustained gunshot wounds, 49 casualties (62%) suffered wounds due to fragmentation weapons and one casualty detonated an anti personnel mine. Sixty-four casualties (81%) sustained limb injuries. These 79 patients had a total of 123 wounds that were scored using the Red Cross wound classification. Twenty-seven of the wounded (34%) were non-combatants; of these, eight were children. Median delay from point of wounding to definitive care for coalition forces was 6 hours (range 1 to 11.5 hours) compared to 12 hours (range 1 hour to 7 days) for Iraqi casualties. Four patients (5%) died; all had sustained gunshot wounds. Conclusion War continues to demand that a full spectrum of hospital specialists be available to treat our own personnel and the Defence Medical Services are increasingly likely to be called to provide humanitarian assistance to wounded non-combatants. Military medical skills, training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts

Aims: To evaluate the clinical outcome of the treatment of severe high-energy war injuries to limbs using circular external þxation frames. Metods: 43 patients after war injuries with 57 high-energy fractures were treated. According to Gustilo and Anderson all fractures were open grade 3B and 3C. There was other major organ trauma in 52,8% of patients. On admission, the fractured bones were stabilized with an AO tubular external þxation frame followed by thorough extensive soft tissue debridement, vascular reconstruction if needed. After 5 to 7 days the tubular þxator is exchanged for a circular frame that allows receiving stability, sufþcient for full weight bearing by minimal invasive þxation and freeing the previously bridged joints, in order to preserve their range of movement. Closed reduction of fractures was performed in most patients by successful implementation of ligamentotaxis and use thin wires with olives. In patients with high-energy Ç ßoating joint È injuries the circular devices were connected by hinges to permit early initiation of joint motions and functional treatment. In patients with upper limb injuries a separate bone þxation was used to allow early ßexion/ extension and pronation/supination motions. Results: In all patients the circular external þxation was the deþnitive treatment. Bone grafting was not necessary in any patient because of compression-distraction possibility. Fracture union was achieved at median time of 8 months (range 3 60). Throughout the period of fracture healing the patients were ambulatory, living at home. Conclusion: The circular þxation frame allows perform successful skeletal stabilization and functional restoration of limbs in patients with extensive bone and soft tissue loss, even in limbs of the risk