Extremity injuries on the battlefield are commonly secondary to high energy mechanisms. These cause significant injury to soft tissue and bone and are contaminated. Evacuation to medical care can be difficult in the operational environment and may delay the time to initial surgery. There is already substantial literature on the complications of such injuries but this is the first report from UK forces. Our aim was to assess the complications, but specifically infections, in relation to delay in surgery and also the method of fracture stabilisation.

Military patients who had ballistic mangled extremity injuries were identified from the database (courtesy of ADMEM). Using both the trauma audit and the hospital notes, demographics were assessed. The injuries sustained (including the fractured bones), time to theatre, associated injuries, method of stabilisation at Role 3, definitive fixation and complications were noted.

81 patients were identified with 95 limbs injured (68 lower limb, 27 upper limb). The most commonly fractured bones were the tibia, radius/ulna, femur and humerus. Primary stabilisation was either ExFix (53%) or plaster (44%). Of those stabilised by ExFix, the definitive stabilisation was mainly by either a nail (44%) or plate (17%). Those stabilised by plaster mainly stayed in plaster. 72% of patients developed at least one complication, the most common of which was superficial infections. Other complications were deep infections, delayed union, haematomas, neuropathic pain and flap failures. The main organisms involved were Acinetobacter, Bacillus and Pseudomonas. There was no association between delay to theatre and decision to amputate. There was an association between the use of plaster for definitive stabilisation and superficial infection and plates for definitive stabilisation and deep infections. There was no association between time delay to theatre and infections.

This provides the first report of complications from extremity injuries secondary to ballistic missile devices in UK forces. It allows for comparison with reports from other sources on similar injuries and helps to guide further management of patients. In particular it agrees with recent civilian data that initial surgery does not have to be carried out as soon as possible, which has implications for military planning.

There are well-established guidelines for musculoskeletal and connective tissue disorders in the assessment of potential recruits. There have been no critical appraisals of the application of these guidelines since their recent revision. The aim of this study was to examine whether common presenting conditions are covered by the guidelines and whether there was adherence by the assessor to the recommended outcome. We reviewed 110 potential recruits presenting to an Orthopaedic Consultant. There were a number of conditions not covered and a few occasions when the decision seemed contrary to the guidelines. In particular we think more consideration is needed of congenital deformities.

Introduction and Aims: Rotationplasty is a functional alternative to above knee amputation in very young patients with a lot of growth remaining and patients with large tumors necessitating excision of the thigh musculature. The development of gait following rotationplasty surgery was studied with serial gait and clinical analysis.

Method: Five patients have been reviewed using three dimensional gait analysis incorporating temporal and spatial measures. A gait analysis was performed after the initial prosthetic fitting, six and 12 months postoperatively. The gait analysis included velocity, temporal/spatial measurements (velocity, cadence, step/stride length, pedobarographs), optical tracking and electromyography.

Results: The kinematic and kinetic data revealed the rapid incorporation of knee flexion/extension (ankle dorsi/plantar flexion) into the gait cycle. Electromyography also showed the gastrocnemius to be simulating the quadriceps and the tibialis anterior to mimic the hamstrings in terms of firing time in the stance and swing phase of the rotated limb. Propulsive forces on the kinetic analysis suggest further gait maturation can occur for several years following this procedure.

Conclusion: Children adapt very well to the altered anatomy following rotationplasty and using gait analysis confirms the new role of the altered muscles. Weakness about the hip remains a major concern that needs to be addressed with physiotherapy for several years postoperatively.

Introduction: The majority of patients with extremity osteo-sarcoma undergo limb salvage surgery. The most common location is about the knee, where at least one half of the knee joint is usually removed. A select group of patients with proximal tibial osteosarcomas had preservation of the entire articular surface following reconstruction.

Method: Since 1993, 67 patients with osteosarcoma have been treated. Sixteen patients had tibial tumors. The original MRI of five patients showed part of the condyle appeared uninvolved. These five underwent joint sparing surgery. A portion of the proximal tibial condyle was resected, leaving the articular surface intact. The tibial defect was reconstructed with autograft bone from the iliac crest and a vascularised fibula. A gastrocnemius muscle flap was rotated to cover the grafts. Four patients had continuation of high dose chemotherapy following surgery and one patient had acute liver failure in the post-operative period requiring the cessation of further chemotherapy.

Results: There are three males and two females aged 10 to 18 years. The length of resection was 6.5cm to 12cm and the distance from the articular surface of the tibia to the proximal resection margin ranged from 3mm to 8mm. One patient had reattachment of the tibial tendon because the tibial tubercle had to be resected with the tumor. Pathologic examination showed greater than 90% necrosis in all patients. One patient required two additional procedures because of fracture of the vascularised fibular graft. Her leg is solidly united at 70 months follow-up. Another patient had delayed wound healing with spontaneous resolution. Two patients had contralateral epiphyseodesis to prevent a progressive limb length discrepancy. Follow-up is 13, 46, 55, 70 and 81 months since surgery. The patients are continuously disease-free. The knees in four patients are stable to medial and lateral stress; one patient has slight medial opening, and no patients exhibit anteroposterior laxity. The range of motion of all knees is complete and there is no joint narrowing. Four patients have resumed sports and two wear a brace for these activities.

Conclusion: This surgical approach resulted in excellent outcomes in a selected group of patients. Since this is a biologic reconstruction, the patient is allowed unrestricted athletic activities. There is no sign of joint deterioration after short follow-up. Further investigations are required to determine the safety of the procedure and define surgical indications.

Introduction and Aims: The treatment of bone defects secondary to congenital pseudoarthrosis of the tibia, infections and tumors is problematic. The vascularised fibular graft has been used for many years as a way to improve blood supply and successfully achieve union. Lengthening the limb prior to grafting can improve outcomes.

Method: Forty-one patients with major bone defects secondary to tumor resections, infections and congenital pseudoarthroses had reconstruction with a vascularised fibular graft. Of these, 10 patients had limb length discrepancies, which were treated by application of an external fixater for lengthening through the bone gap. Following restoration of length with an external fixater, a vascularised fibular graft was inserted to bridge the bone defect. The external fixater was not removed until union of the graft to the host bone and initial hypertrophy occurred.

Results: The 10 patients (five males and five females) were aged 2.5 to 14.5 years (mean 7.6 years). The affected bones included eight tibias, one humerus and one ulna. The limb length discrepancies ranged from three to 20cm (mean 6.44cm). The duration of lengthening prior to definitive vascularised fibular graft ranged between one to 15 weeks (mean seven weeks) in nine patients. In the patient with a discrepancy of 20cm, lengthening spanned 52 weeks. At the time of the definitive vascularised fibular graft procedure, the fixater was partially disassembled to facilitate surgery and microvascular anastomosis. The frame was then reassembled and used as the fixation device to protect the graft. The fixater was removed from seven to 24 weeks (mean 16 weeks) after definitive surgery. There were no complications during the lengthening process. However, two patients experienced non-unions, which were successfully treated by autologous bone grafts. One patient had a fracture of the vascularosed fibular graft, which healed uneventfully.

Conclusion: A staged approach to reconstruction of major long bone deficiencies leads to a better outcome than insertion of vascularised fibular grafts without addressing the limb length discrepancy. In this type of procedure, the patients not only bridged their bone defect, but achieved limb length equality as well.

The proximal fibular epiphysis was transferred in young puppies using microvascular techniques. The study demonstrated, as have previous investigators, that free epiphysial transfer without vascular anastomosis results in death of the chondrocytes of the growth plate. Histologically, the chondrocytes do not take up labelled proline, indicating diminished metabolic activity; do not take up radioactive thymidine, indicating that they are not dividing; and there is eventual disruption of the normal histological picture. In contrast, where the microvascular anastomoses re-established the blood supply to the growth plate, the epiphyses demonstrated normal histological appearance, uptake of radioactive proline and thymidine and continued to grow but at a slightly diminished rate. It is concluded that continued growth can occur after free vascularised epiphysial transfer in the dog.