Background. The conflict in Afghanistan has been epitomised by the emergence of the Improvised Explosive Device (IEDs). Improvements in protection and medical treatments have resulted in increasing numbers of casualties surviving with complex lower extremity injuries. To date, there has been no analysis of foot and ankle blast injuries as a result of IEDs. Therefore the aims of this study are to report the pattern of injury and determine which factors were associated with a poor clinical outcome. Methods. Using a prospective trauma registry, UK Service Personnel who sustained lower leg injuries following an under-vehicle explosion between Jan 2006 and Dec 2008 were identified. Patient demographics, injury severity, the nature of lower limb injury and clinical management was recorded. Clinical endpoints were determined by . (i). need for amputation and. (ii). need for ongoing clinical output at mean 33.0 months follow-up. Results. 63 UK Service Personnel (89 injured limbs) were identified with lower leg injuries from explosion. 50% of casualties sustained multi-segmental injuries to the foot and ankle complex. 26(29%) limbs required amputation, with six amputated for chronic pain 18 months following injury. Regression analysis revealed that hindfoot injuries, open fractures and vascular injuries were independent predictors of amputation. Of the 69 limbs initially salvaged, the overall infection rate was 42%, osteomyelitis 11.6% and non-union rates was 21.7%. Symptomatic traumatic osteoarthritis was noted in 33.3% salvaged limbs. At final follow-up, 66(74%) of injured limbs had persisting symptoms related to their injury, with only 9(14%) fit to return to their pre-injury duties. Conclusions. This study demonstrates that foot and ankle injuries from IEDs are frequently associated with a high amputation rate and poor clinical outcome. Although, not life-threatening, they remain a source of long-term morbidity in an active population. Primary prevention of these injuries remain key in reducing the injury burden

Introduction. Fusion represents an effective treatment option in patients affected by end-stage arthritis. To minimise the risk of non-union following fusion, biological preparations such as bone marrow aspirate concentrate (BMAC) are commonly used intra-operatively. Mechanotransduction represents an emerging field of research whereby physical stimuli can be used to modulate the behaviour and differentiation of cells. Blast waves (a subtype of shock waves) are one such physical stimulus. The aim of this study was to investigate whether the osteogenic potential of BMAC can be enhanced using a blast wave, and thus improve its efficacy in fusion surgery. Methods. Human BMAC samples were obtained from three healthy patients and exposed to a single blast wave (peak overpressure= 50psi), before being placed in a suspension of mesenchymal stem cells, to represent the biological environment of the fusion site. Three test groups were used: MSC (the experimental control); MSC + BMAC; MSC + BMAC + blast wave. Calcium mineralisation assays were performed on the MSCs on Day 7 and 14 to assess for osteoblastic transformation. Results. Calcium mineralisation on Day 7 was significantly increased in the MSC + BMAC group compared to the MSC group (mean percentage change 42.12 vs 0.0, p=0.012). The MSC + BMAC + blast wave group also demonstrated significantly increased levels compared to the MSC + BMAC group (84.56 vs. 42.14, p = 0.039). The difference in calcium mineralisation between the MSC and MSC + BMAC + blast wave groups was strongly significant (0.00 vs. 84.56, p = 0.003). Conclusion. Exposure of BMAC to a single blast wave enhances its osteogenic potential. This represents a potential novel way to improve healing following fusion surgery and reduce the rates of non-union

Objectives

The surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function.