The conflict in Afghanistan has been epitomised by the emergence of the Improvised Explosive Device(IEDs). Improvements in 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 firstly report the pattern of injury and secondly determine which factors were associated with a poor clinical outcome in order to focus future research. 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. 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. 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

Conflict in Afghanistan demonstrated predominantly lower extremity and pelvi-perineal trauma secondary to Improvised Explosive Devices (IEDs). Mortality due to pelvic fracture (PF) is usually due to exsanguination. This study group comprised 169 military patients who sustained a PF and lower limb injury. There were 102 survivors and 67 fatalities (39% mortality). Frequent fracture patterns were a widened symphysis (61%) and widening of the sacroiliac joints (SIJ) (60%). Fatality was 20.7% for undisplaced SIJs, 24% for unilateral SIJ widening and 64% fatality where both SIJs were disrupted, demonstrating an increase in fatality rate with pelvic trauma severity. A closed pubic symphysis was associated with a 19.7% mortality rate versus 46% when widened. Vascular injury was present in 67% of fatalities, versus 45% of survivors. Of PFs, 84% were associated with traumatic amputation (TA) of the lower limb. Pelvic fracture with traumatic lower limb amputation presents a high mortality. It is likely that the mechanism of TA and PF are related, and flail of the lower limb(s) is the current hypothesis. This study prompts further work on the biomechanics of the pelvic-lower limb complex, to ascertain the mechanism of fracture. This could lead to evidence-based preventative techniques to decrease fatalities.

Introduction

A common injury pattern in current military experience is traumatic lower limb amputation from improvised explosive devices. This injury can co-exist with pelvic girdle fractures.

Spinal fractures are common following underbody blast. Most injuries occur at the thoracolumbar junction, and fracture patterns suggest the spine is flexed at the moment of injury. However, current mechanistic descriptions of vertebral fractures are based on low energy injuries, and there is no evidence to correlate fracture pattern with posture at the loading rates seen in blast injury. The T12-L1 segment of 4 human spines was dissected to preserve the paraspinal ligaments and potted in polymethylmecrylate. The specimens were impacted with a 14 kg mass at 3.5m/s in a drop tower; two specimens were impacted in neutral posture, one in flexion, and one in extension. A load cell measured the load history. CT scans and dissection identified the injury patterns. Each specimen sustained a burst fracture. The neutral specimens demonstrated superior burst fractures, the flexed specimen demonstrated a superior burst fracture with significant anterior involvement, and the extended specimen showed a posterior vertebral body burst fracture. At high loading rates, the posture of the spine at the moment of injury appears to affect the resulting fracture. This supports understanding the behaviour of the spine in blast injury and will allow improved mitigation system design in the future

The lower limbs of vehicle occupants are vulnerable to severe injuries during under vehicle explosions. Understanding the injury mechanism and causality of injury severity could aid in developing better protection. Therefore, we tested three different knee positions in standing occupants (standing, knee in hyper-extension, knee flexed at 20˚) of a simulated under‐vehicle explosion using cadaveric limbs in a traumatic blast injury simulator; the hypothesis was that occupant posture would affect injury severity. Skeletal injuries were minimal in the cadaveric limbs with the knees flexed at 20˚. Severe, impairing injuries were observed in the foot of standing and hyper‐extended specimens. Strain gauge measurements taken from the lateral calcaneus in the standing and hyper-extended positions were more than double the strain found in specimens with the knee flexed position. The results in this study demonstrate that a vehicle occupant whose posture incorporates knee flexion at the time of an under‐vehicle explosion is likely to reduce the severity of lower limb injuries, when compared to a knee extended position

Improve the quality of care mine-explosive wounds and preventing infection in mine blast injury. We have treated 19 patients affected by MEI during Anti-Terrorist Operation (ATO) in Ukraine. The patients had been received by our department within 5–28 days after the injury. All patients were comprehensively examined (general surgeon, neurosurgeon, thoracic surgeon, CT, X-ray, ultrasound, lab tests). 14/19 patients had an open fractures (10 of those 14 had a soft tissue defects). All patients with open fractures underwent secondary surgical treatment (radical debridement, irrigation, ultrasonic cavitation, fracture stabilization by external fixation). The patients with soft tissue defects underwent variety of plastic surgery. After soft tissues healing a plate or IM nail was installed. Evaluation of results was based on X-ray monitoring and the lower limb function assessment. 16 patients had full fracture consolidation and good function, 3 patients had slow consolidation and limitation of movement. Analysis of treatment showed that adherence to radical debridement and thorough soft tissue management led to significant reducing of the incidence of infectious complications in combat related fractures

Previous reports of the prevalence of Heterotopic Ossification (HO) in limbs from UK blast-related amputees from Afghanistan, is demonstrated to be 57.1%. With the end of UK military operations in Afghanistan in 2014 the aim of this study is establish the rate of HO, assess causality demographics and ascertain risk factors for the formation of HO during the entire period of operations in Afghanistan. Military databases, case notes and radiographs were scrutinised to quantify and qualify the prevalence and risk factors for the formation of HO. 256 servicemen sustained 398 military trauma related amputations. The overall prevalence of HO was 65.9%. Significant (p<0.05) risks identified for the formation of HO included a blast mechanism of injury, a zone of injury the same as the subsequent amputation, and an increased number of debridements prior to closure. Positive correlation existed between the number of amputations and the presence and grade of HO (p=0.04). HO presents clinical problems to military blast injury patient populations. This study demonstrates that both a blast mechanism of injury and an increased injury load are key factors in the increased prevalence of HO seen in military trauma

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

Conflict in the Middle East has seen a change in warfare tactics from the use of ballistic missiles to blast weapons. This has resulted in a change in wounding patterns. Due to the severity of the injuries, there have been large numbers of amputations, as life and limb saving procedures. The purpose of this paper was to retrospectively review all the amputated limbs over the past 8 years of conflict and compare those from the early years to the more recent ones. In particular, the aim was to examine differences in the mechanisms of injury, number of limbs injured, associated injuries, method of amputation, microbiology of contaminating organisms and outcome. There were significantly more amputations, injured limbs and soft tissue perineal wounds as well as a significantly higher ISS in the later group. There were also significant differences in the surgical techniques, with more guillotine amputations in the early group, and mechanism of injury, with more blast injuries in the late group. This confirms the clinical impression that there has been a significant change in limb trauma from Iraq to Afghanistan. These injury patterns have significantly different logistical implications, which must be considered when planning the required medical assets in future conflicts

Traumatic amputations (TAs) are amongst the most significant orthopaedic sequelae following IED strikes. Biomechanically, longer residual limb length confers better function. However, post-trauma definitive through knee amputation (TKA) remains controversial. UK military casualties sustaining ≥1 major TA, 01/08/2008–01/08/2010 were identified using the UK JTTR and post mortem CT databases. All through- and below-knee TAs were termed ‘potential TKAs’ (p-TKAs); hypothetical candidates for definitive TKA. We hypothesised that traumatic TKAs were more common than previously reported (4.5% of lower limb TAs) and a significant cohort of blast injuries exist suitable for definitive TKA. 146 cases (75 survivors, 71 fatalities) sustained 271 TAs (235 lower limb). TKA rate was 34/235 (14.2%). 63/130 survivor TAs and 66/140 fatality TAs merited analysis as p-TKAs. Detailed pathoanatomy was only available for fatality p-TKAs, for whom definitive TKA would have been proximal to the zone of injury (ZOI) in only 3/66 cases. Blast-mediated traumatic TKAs are significantly more common than previously reported (p=0.0118). Most lower limb TAs are skeletally amenable to definitive TKA. Maximising stump length for function incurs the risks of definitive amputation within the original ZOI (including infection and heterotopic ossification) but proximal extent of blast soft tissue injury commonly makes this unavoidable

Characterising material properties of ligaments is essential in the analysis of human morbidity and mortality of low-speed sporting accidents, high-speed road traffic accidents, and very high-speed battlefield injuries. At lower strain rates the elastic modulus and ultimate stress increase relative to strain rate, although very high strain rate testing has not been performed to date. A porcine stifle joint lateral collateral ligament experiment was conducted that simulated the strain rates that occur during across a full range of different human knee ligament injuries. Tensile testing was performed at five strain rates, each an order of magnitude apart, in the range 10. 0. –10. 4. %/s. Seven specimens were tested at each rate. Three loading techniques were used: 1) screw-driven, 2) servo-hydraulic, 3) drop weight rig with tensile impact adaptor. Cross sectional area was measured by counting pixels on a standardized digital photograph of an alginate-paste cast of the mid-substance of each sample. Strain was measured directly from the mid-substance of each ligament by high-speed video extensometry. Stress-strain curves were produced and used to quantify the elastic modulus, failure strain and ultimate stress at each strain rate. Across the range of strain rates, elastic modulus increased from 288 to 905 MPa (p< 0.05), and ultimate stress increased from 39.9 to 77.3 MPa (p< 0.05). A relationship between strain rate and both, elastic modulus and ultimate stress was identified. Strain rate sensitivity was not observed at very fast strain rates. Ligament strength increases when strain rates are high. These data provide an explanation for very high strain rate failure of ligaments under extreme loading conditions, that can be considered protective of bone fracture, such as can be seen in traumatic through knee amputations in blast injuries

Treatment of large segmental defects in the extremities is challenging. A segmental tibial defect model in a large animal can provide a basis through which in vivo testing of materials and techniques for use in non-unions and severe trauma cases can be examined. This study reports such a model. Six aged ewes (> 5 years) were used following ethical approval. A 5cm piece of the mid diaphysis of the left tibia was removed including its associated periosteum. The tibia was stabilized with an 8mm stainless steel cross locked intramedullary nail and all tissues closed in their respective layers. Animals were euthanised at 12 weeks following surgery and evaluated using radiographic, micro-computed tomography (CT), soft tissue and hard tissue histology techniques. Three weeks post operatively one of the intramedullary nails failed through the first of the distal two cross locking screw holes, the sheep was euthanised and the tibia was harvested. Early signs of callus formation were evident at the osteotomy edges originating from the periosteal surface; the defect space was bridged by fibrous scar tissue. The remaining 5 sheep were taken out to the 12 week time point then all relevant tissues were harvested. Gross dissection revealed a lack of bony union in the defect site and no evidence of infection. X-rays and CT showed a lack of hard tissue callus bridging in the defect region at 12 weeks. Histological sections of the bridging tissues revealed, callus originating from both the periosteal and endosteal surfaces, with fibrous tissue completing the bridging in all instances. One case had cartilaginous tissue developing; however this was incomplete at 12 weeks. As none of the 12 week time point sheep achieved clinical union; this model may be effective as a basis for the investigation of healing adjuncts to be used in non-union cases, where severe traumatic injury has lead to significant bone loss such as blast injuries or following large tumour removal

Aims

Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach.

On 7 July 2005, four bombs were detonated on the London transport system. Three of these bombs exploded almost simultaneously at 08:50h affecting the underground tube network at Aldgate, King's Cross and Edgware Road stations. The fourth bomb exploded at 09:47h on a double-decker bus in Tavistock Square. There were 54 deaths in total at the scenes and over 700 injured. 194 patients were brought to the Royal London Hospital. 167 were assessed in a designated minor injuries unit and discharged on the same day. 27 patients were admitted of whom 7 required ITU care, 1 died in theatre and 1 died post-operatively. The median Injurity Severity Score (ISS) in this group of patients was 6 (range 0-48) and the mean ISS was 12. The general pattern of injury in the critically ill patients was of mangled lower limbs and multiple, severely contaminated fragment wounds. Hepatitis B prophylaxis was administered to those patients with wounds contaminated by foreign biological material. 11 primary limb amputations were performed in 7 patients. 9 limb fasciotomies, 5 laparotomies and 1 sternotomy were carried out. 3 patients had blast lung injury. All patients who underwent primary amputations and debridement received further regular inspections in theatre. These inspections formed the majority of our theatre work. Under no circumstance was initial reconstructive surgery attempted. Delayed primary closure and split skin grafting of all wounds was completed by the end of the second week. There have been no sepsis-related deaths. Our experience at The Royal London has allowed us to revisit the principles of blast wound management in a peacetime setting. A number of lessons were learned regarding communication and resource allocation. A multi-disciplinary approach with the successful execution of a major incident plan is the key to managing an event of this magnitude

Currently, there is no animal model in which to evaluate the underlying physiological processes leading to the heterotopic ossification (HO) which forms in most combat-related and blast wounds. We sought to reproduce the ossification that forms under these circumstances in a rat by emulating patterns of injury seen in patients with severe injuries resulting from blasts. We investigated whether exposure to blast overpressure increased the prevalence of HO after transfemoral amputation performed within the zone of injury. We exposed rats to a blast overpressure alone (BOP-CTL), crush injury and femoral fracture followed by amputation through the zone of injury (AMP-CTL) or a combination of these (BOP-AMP). The presence of HO was evaluated using radiographs, micro-CT and histology. HO developed in none of nine BOP-CTL, six of nine AMP-CTL, and in all 20 BOP-AMP rats. Exposure to blast overpressure increased the prevalence of HO.

This model may thus be used to elucidate cellular and molecular pathways of HO, the effect of varying intensities of blast overpressure, and to evaluate new means of prophylaxis and treatment of heterotopic ossification.

Cite this article: Bone Joint J 2015;97-B:572–6