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.

The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma.

The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research.

In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East.

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.

The biomechanics of civilian fractures have been extensively studied with a view to defining the forces responsible e.g. bending, torsion, compression and crushing. Little equivalent work has been carried out on military fractures, although fractures from gunshot can be divided into direct and indirect. Given that the effects of blast can be sub-divided into primary, secondary, tertiary and quaternary, the aim of this study was to try to determine which effects of the blast are responsible for the bony injury. This may have implications for management and prognosis as well as prevention.

We reviewed emergency department records, case notes, and all radiographs of patients admitted to the British military hospital in Afghanistan over a 6 month period (Apr 08–Sept 08) to identify any fracture caused by an explosive mechanism. In addition we reviewed all relevant radiographs from the same period at the Royal Hospital Haslar, who report all radiographs taken, and keep a copy of the images. Early in the study it became clear that due to the complexity of some of the injuries it was inappropriate to consider bones separately and we used the term ‘fracture zone’ to identify separate areas of injury, which could involve from 1 – 28 bones. It also became clear that the pattern of injury differed considerably between patients in open ground, and those in houses or vehicles. These 2 groups were considered separately and compared.

We identified 86 patients with fractures. The 86 patients had 153 separate fracture zones (range 1–6). 56 casualties in the open sustained 87 fracture zones (mean 1.55 fracture zones per casualty). 30 casualties in a vehicle or other cover sustained 66 fracture zones (2.2 per casualty). Of the casualties in the open, 17 fracture zones were due the primary effects of blast, 10 a combination of primary and secondary effects, 30 due to secondary effects and 30 from the tertiary effects of blast. Of the casualties in vehicles we could not identify anyone with a fracture due to either the primary or secondary effects of blast, all 66 fracture zones appeared to be due to the tertiary effects.

In both groups there appeared to be a significant number of fractures, often with no break in the skin, caused by severe axial loading of the limb. This was possibly due to the casualty impacting against the ground, building or the inside of a vehicle, and this is a group of injuries we are now studying in greater detail.

UK military forces have been deployed in Afghanistan since 2006 as part of the International Stabilisation Assistance Force. The Operation is supported by a 50-bedded hospital. In 2007 the Defence Medical Services introduced a massive haemorrhage policy. In asymmetric warfare gunshot wounds (GSW), improvised explosive devices (IED) and mine injuries are prevalent and we hypothesized that they would require significant blood products.

We prospectively collected data from consecutive trauma resuscitations over 3 months (January to March 2008). Pre-hospital time points, mechanism of injury, injury distribution, injury severity score (ISS), new injury severity score (NISS), surgical procedures, blood product utilisation and outcome were recorded.

115 trauma resuscitations were performed over the study period. Median pre-hospital time was 95 minutes (range 30–325), with median 64 minutes to the arrival of the Medical Emergency Response Team helicopter. The cause of injury was landmine (20), IED (31) and GSW (40); mean number of involved body systems was 1.4, 1.8 and 1.5 respectively and injured structures 2.8, 3.5 and 2.3 respectively (IED> GSW p< 0.05). Mean ISS was 16, 16.8, 14.9 and NISS 18.7, 20.9, and 17.9 respectively. Blood transfusion was required in 3 mine, 14 IED and 17 GSW casualties (mine< IED & GSW, p< 0.05) with 10.6, 11.4, and 13.9 units of blood transfused per casualty.

Injury severity for casualties is high with multiple injuries to body systems irrespective of mechanism. Anti-personnel mine injuries were significantly less likely to require transfusion. Large quantities of blood products were still required when necessary in all mechanisms of trauma. It is therefore recommended that during the pre-hospital time the major transfusion protocol should be placed on stand-by.

Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today’s global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties.

We retrospectively reviewed hospital charts and autopsy reports of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention and cause of death was recorded.

During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 (7%) actually survived to reach hospital. Four subsequently died from injuries within 72 hours. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation, however this patient died as result of a co-existing head injury.

Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life threatening conditions.

Over 75% of combat casualties from Iraq and Afghanistan sustain injuries to the extremities, with 70% resulting from the effects of explosions. Damage to peripheral nerves may influence the surgical decision on limb viability in the short-term, as well as result in significant long-term disability. To date, there have been no reports of the incidence and severity of nerve injury in the current conflicts.

A prospective assessment of United Kingdom (UK) Service Personnel attending a specialist nerve injury clinic was performed. For each patient the mechanism, level and severity of injury to the nerve was assessed and associated injuries were recorded.

Fifty-six patients with 117 nerve injuries (median 2, range 1–5) were eligible for inclusion. This represents 12.9% of casualties sustaining an extremity injury. The most commonly injured nerves were the tibial (19%), common peroneal (16%) and ulnar nerves (16%). 25% (29) of nerve injuries were conduction block, 41% (48) axonotmesis and 34% (40) neurotmesis. The mechanism of injury did not affect the severity of injury sustained (explosion vs gunshot wound (GSW), p=0.53). An associated fracture was found in only 48% of nerve injuries and a vascular injury in 35%. The presence of an associated vascular injury resulted in more severe injuries (conduction vs axonotmesis and neurotmesis, p< 0.05). Nerves injured in association with a fracture, were more likely to develop axonotmesis (p< 0.05).

The incidence of peripheral nerve injury from combat wounds is higher than previously reported. This may be related to increasing numbers of casualties surviving with complex extremity wounds. In a polytrauma situation, it may be difficult to assess a discrete peripheral neurological lesion. As only 35% of nerves injured are likely to have anatomical disruption, the presence of an intact nerve at initial surgery should not preclude the possibility of an injury. Therefore, serial examinations combined with appropriate neurophysiologic examination in the post-injury period are necessary to aid diagnosis and to allow timely surgical intervention. In addition, conduction block nerve injuries can be expected to make a full recovery. As this accounts for 25% of all nerve injuries, we recommend that the presence of an insensate extremity should not be used as an indicator for assessing limb viability.

Following the invasion of Iraq in April 2003, Coalition forces have been conducting counter-insurgency operations in a bid to maintain security within the country. The improvised explosive device (IED) has become the weapon of choice of the terrorist and is the leading cause of death and injury amongst Coalition troops in the region.

From Jan 2006, data was collected on 100 consecutive casualties who were either injured or killed during hostile action. Mechanism of injury, new Injury Severity Score (NISS), ICD-9 diagnosis and anatomical pattern of wounding was recorded in a trauma registry.

During the study period, 53 casualties were injured by IEDs in 23 incidents (mean 2.3 casualties per incident). Twelve (22.6%) were killed or died of wounds. Mean NISS score of survivors was 5.4 (Range 1–50). There was no significant difference in NISS scores of survivors from fatal and non-fatal incidents. A mean 2.61 body regions were injured per casualty. Limb injuries were present in 45 (84.9%) of casualties, but primary blast injuries were seen in only 9 (14%). Twenty (48.7%) of survivors underwent surgery by British surgeons in the field hospital. Sixteen (39%) were deemed fit to return to duty after injury.

IEDs used in Iraq do not follow the traditional pattern of injuries seen with conventional high explosives. Primary blast injuries were uncommon despite all casualties being in close proximity to the explosion. When the IED is detonated, an Explosive Formed Projectile (EFP) is formed which results in catastrophic injuries to casualties caught in its path, but causes relatively minor injuries to personnel sited adjacent to its trajectory. Enhanced vehicle protection may prevent the EFP from entering the passenger compartments and thereby reduce fatalities.

British military forces are heavily committed in Iraq and Afghanistan. Operation HERRICK, currently supported by a Role 2(Enhanced) medical facility at Camp Bastion, is predicted to continue for the next 10 years.

There has been no large published series on surgical workload on Operation HERRICK. The aim of this study is to determine and plan future medical needs.

A retrospective analysis of operating theatre records between 10th October 2006 and 31st Oct 2007 was performed. Data was collated on a monthly basis, to assess seasonal variation, and included patient demographics, operation type and time of operation.

During the study period 968 cases required 1262 procedures. Thirty-four per cent were ISAF, 27% were Afghan soldiers, police or enemy forces and 39% were civilians, of which, 43% were children. Ninety-one per cent were secondary to battle injury and 50% were emergencies. The breakdown of procedures, by specialty, was 67% (841) were orthopaedic, 16% (199) general surgery, 8% (96) head and neck, 5% (55) burns surgery and a further 4% (50) were non-battle, non-emergency procedures. During the second half of the study period 655 cases were operated on compared to 313 in the preceding half (p< 0.05). Twenty-eight per cent of cases were performed between 6pm and 8am.

Surgical workload remains consistently high throughout the study period, however there was significant seasonal variation with casualty rates being greater in the summer months, this may have bearing on the decision to deploy additional surgeons and trainees in the future.

Resurfacing arthroplasty is advantageous over conventional total hip arthroplasty in that femoral bone stock is preserved. However, there has been controversy over the preservation of acetabular bone stock in resurfacing arthroplasty, with the concern that it may result in excess reaming compared with total hip replacement. This is of concern as the prosthesis is primarily advocated in the young patient, who is likely to face future revision surgery.

We prospectively identified a cohort of 68 patients with primary hip osteoarthritis undergoing conventional total hip arthroplasty. During surgery, the excised femoral head and neck diameter was measured, along with the diameter of the final acetabular reamer used to achieve a bed of bleeding cancellous bone. The measured neck diameter was then used to calculate the minimum possible resurfacing head and cup sizes, with corresponding final reamer sizes that could have been used in each patient without neck notching for both Birmingham Hip Resurfacing (BHR, Smith & Nephew, 3rd Generation) and Articular Surface replacement (ASR, De Puy, 4th Generation). Reaming diameter and volume was compared for all 3 groups.

Mean reaming diameters for the THR, ASR and BHR groups were 51, 52 and 56mm respectively. Mean reaming volumes were 39, 40 and 47cc. There was a statistically significant difference between the THR and BHR groups for both reamed diameter and volume (p< 0.001). There was also a significant difference between the ASR and BHR groups for both reamed diameter and volume (p< 0.001). This difference was more pronounced with larger neck diameters.

Our data shows that the BHR results in more ace-tabular bone loss compared to total hip replacement. An implant with a lower profile acetabular cup and a larger variety of sizes such as the ASR may allow better preservation of acetabular bone stock.

British military forces remain heavily committed in both Iraq and Afghanistan. A recent workload analysis from Op HERRICK identified a high surgical workload, particularly orthopaedic, under the care of a sole consultant orthopaedic surgeon. There are no orthopaedic training posts in UK that consistently provide training in ballistic trauma. In order to prepare Military orthopaedic trainees for future deployment, a new orthopaedic registrar post, on Op HERRICK, was created.

Prospective analysis of trainee and trainer operative logbooks, between Jan 27th and March 24th 2008, was performed. Records were kept of orthopaedic and postgraduate teaching schedules, audit and research projects and all OCAP training assessments.

One hundred and fifty-seven cases and 272 procedures were performed during the study period. Sixty-two per cent of cases were orthopaedic. Fourteen major amputations were performed and 7 external fixators applied. Five fasciotomies, 9 skeletal traction pins were inserted and 7 skin grafting procedures were performed. Limb debridement was the most common procedure (n=59). Eleven per cent of cases were children and 50 per cent of cases were emergencies. Thirty-eight per cent of cases were performed out of hours (18.00–08.00 hrs). Mean operating hours per week was 35 hrs. Four Procedure Based Assessments were performed and 16 hours of postgraduate education was conducted during the deployment. Two major audits were initiated and five publications were prepared, one has already been accepted for publication.

Trainee exposure to high-energy transfer trauma is high when compared to that seen in the NHS. The numbers of certain index procedures, such as external fixation, is similar to those achieved by an average orthopaedic trainee in six years of higher surgical training. The opportunity for one-on-one training exceeds that available in the NHS and learning and academic opportunities are maximised due to the close working environment.

Introduction: Hip resurfacing is a successful pain-relieving procedure which restores function in young patients. However, some patients have persisting pain. We suggest that load characteristics in relation to position of the cup may influence these symptoms. We aimed to determine the effect of acetabular cup inclination angle on pain following hip resurfacing.

Methods: 92 consecutive hips in 81 patients were resurfaced with the ASR prosthesis. The average age was 56.5 years (35–72). 33 were female hips. Harris Hip Scores (HHS) and UCLA activity scores were recorded pre-operatively and at last follow-up. Patient satisfaction was recorded. Acetabular cup inclination angle was measured. An acceptable angle for hip replacement is 45 degrees +/− 5 degrees. We therefore grouped cups into those above 50 degrees and those below. Average follow-up was 17.9 months (8–31). There were 39 hips with an angle less than 50 degrees (A), and 53 greater than 50 (B). Patients in each group were comparable for age, sex, follow-up and BMI.

Results: In group A HHS improved from 53.4 to 98.7 and UCLA activity score improved from 4.2 to 7.5. All patients were extremely or very pleased. In group B HHS improved from 49.0 to 94.0 and UCLA activity score improved from 3.9 to 7.1. 48 of 53 patients were extremely or very pleased. At follow up 37 of 39 (95%) of patients in group A had no pain. In group B 35 of 53 had no pain (66%). This is a statistically significant difference when analysed with Fisher’s exact test (p< 0.05).

Discussion: This study shows that an excessively open acetabular cup may contribute to persisting pain and patient dissatisfaction. This may be a result of excessive eccentric wear and metal ion deposition, and may lead to early failure of the prosthesis.

The conflict in Iraq has evolved from a conventional war in April 2003 to a guerrilla-based insurgency. We investigated whether this change altered the pattern of wounding and types of injuries seen in casualties presenting to a military field hospital.

From January 2006 – October 2006, data was collected on all casualties who presented to the sole British field hospital in the region following injury from hostile action (HA).

86 casualties presented with injuries from hostile action (HA). 3 subsequently died of wounds (DOW – 3.5%). 46 (53.5%) casualties had their initial surgery performed by British military surgeons. 20 casualties (23.2%) sustained gunshot wounds, 63 (73.3%) suffered injuries from fragmentation weapons and 3 (3.5%) casualties sustained injury from blunt trauma. These casualties sustained a total 232 wounds (mean 2.38) affecting an average 2.4 anatomical locations per patient.

The current insurgency illustrates the likely evolution of modern urban conflict. Discrete attacks from improvised explosive devices (IED’s) have become the predominant cause of injury. These tactics have been employed against both military and civilian targets. With the current threat from terrorism, both military and civilian surgeons should be aware of the spectrum and management of the injuries caused.

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