We present the British Military's experience of treating devastating lower limb injuries in personnel returning from Iraq and Afghanistan. We evaluate current surgical practice of attempting to maximise stump length through sequential debridement, rather that early amputation outside the zone of injury. Following an observation that the frequency of sequential amputation had appeared to increase during spring 2009, it was speculated that there may be factors which would predict which patients would require a more aggressive early amputation. The Joint Theatre Trauma Registry was interrogated for all cases of amputation between Apr 06 and Sep 09. The following data were collected: demographics, mechanism of injury, requirement for massive transfusion, use of combat applied tourniquet, number of stump debridements and echelon of care performed at, all microbiology and final level of amputation. A regression analysis was performed to establish correlation between each data-set and final level of amputation. 95 cases were identified; 21 were either digits or upper limbs and excluded. Clinical notes of the remaining 74 cases were requested, of which 48 were available representing a total of 66 lower limb stumps. No significant relationships were established between sequential amputation and any of the variables we examined. It was not possible to identify factors with predictive value with respect to which patients would benefit from a more aggressive early amputation approach. These results support current practice by demonstrating that attempts to balance maximal stump length with sufficient debridement to eradicate infected tissue, does not expose patients to unnecessary operative “hits”

The aim of this study was to report the pattern of severe open diaphyseal tibial fractures sustained by military personnel, and their orthopaedic–plastic surgical management.The United Kingdom Military Trauma Registry was searched for all such fractures sustained between 2006 and 2010. Data were gathered on demographics, injury, management and preliminary outcome, with 49 patients with 57 severe open tibial fractures identified for in-depth study. The median total number of orthopaedic and plastic surgical procedures per limb was three (2 to 8). Follow-up for 12 months was complete in 52 tibiae (91%), and half the fractures (n = 26) either had united or in the opinion of the treating surgeon were progressing towards union. The relationship between healing without further intervention was examined for multiple variables. Neither the New Injury Severity Score, the method of internal fixation, the requirement for vascularised soft-tissue cover nor the degree of bone loss was associated with poor bony healing. Infection occurred in 12 of 52 tibiae (23%) and was associated with poor bony healing (p = 0.008). This series characterises the complex orthopaedic–plastic surgical management of severe open tibial fractures sustained in combat and defines the importance of aggressive prevention of infection. Cite this article: Bone Joint J 2013;95-B:101–5

This is a case series of prospectively gathered data characterising the injuries, surgical treatment and outcomes of consecutive British service personnel who underwent a unilateral lower limb amputation following combat injury. Patients with primary, unilateral loss of the lower limb sustained between March 2004 and March 2010 were identified from the United Kingdom Military Trauma Registry. Patients were asked to complete a Short-Form (SF)-36 questionnaire. A total of 48 patients were identified: 21 had a trans-tibial amputation, nine had a knee disarticulation and 18 had an amputation at the trans-femoral level. The median New Injury Severity Score was 24 (mean 27.4 (9 to 75)) and the median number of procedures per residual limb was 4 (mean 5 (2 to 11)). Minimum two-year SF-36 scores were completed by 39 patients (81%) at a mean follow-up of 40 months (25 to 75). The physical component of the SF-36 varied significantly between different levels of amputation (p = 0.01). Mental component scores did not vary between amputation levels (p = 0.114). Pain (p = 0.332), use of prosthesis (p = 0.503), rate of re-admission (p = 0.228) and mobility (p = 0.087) did not vary between amputation levels. These findings illustrate the significant impact of these injuries and the considerable surgical burden associated with their treatment. Quality of life is improved with a longer residual limb, and these results support surgical attempts to maximise residual limb length. Cite this article: Bone Joint J 2013;95-B:224–9

The Winston Churchill Memorial Trust was established in 1965 on Sir Winston's death as a national memorial and living tribute to him, and funded by many thousands of people who contributed to a public subscription. This now funds Travelling Fellowships to allow Churchill Fellows to travel abroad and learn lessons that can be brought back to benefit the local community and ultimately the UK as a whole. Both authors were recipients of this prestigious 2009 Fellowship in the category of “Treatment & Rehabilitation of Traumatic Injuries”. Over fifteen weeks we visited hospitals in Germany, Canada, and the USA with expertise in the early care, reconstruction and rehabilitation of the combat casualties of our NATO Allies. We aimed to learn lessons from their experience, exchange ideas and to make contacts. We visited the US military hospital in Landstuhl Regional Medical Center, Germany, the University of Alberta Hospital and Glenrose Rehabilitation Hospital and the two major centres of US military care at the Walter Reed Army Medical Center/National Naval Medical Center in Washington DC, and the Brooke Army Medical Center in San Antonio Texas. We present our experience from this Fellowship, some of the lessons we have learnt and the problems that we face in common with our NATO allies

The UK Military Trauma Registry was searched for all RN/RM personnel injured between March 2003 and April 2013. These records were then cross-referenced with the records of the Naval Service Medical Board of Survey which evaluates injured RN/RM personnel for medically discharge, continued service in a reduced capacity or return to full duty (RTD). Population at risk data was calculated from service records.

There were 277 casualties in the study period: 61 (22%) of these were fatalities; of the 216 survivors, 63 or 29% were medically discharged; 24 or 11% were placed in a reduced fitness category. A total of 129 individuals (46% of the total and 60% of survivors) returned to full duty. The greatest number of casualties was sustained in 2007; there was a 3% casualty risk per year of operational service between 2007–2013. The most common reason cited by the Naval Service medical board of survey for medical downgrading or discharge was injuries to the lower limb with upper limb trauma being the next most frequent injury.

This study characterises the injuries sustained by RN and RM personnel during recent conflicts and demonstrates significant challenge of predominantly orthopaedic injuries for reconstructive and rehabilitation services.

Heterotopic ossification (HO) is perhaps the single most significant obstacle to independence, functional mobility, and return to duty for combat-injured veterans of Operation Enduring Freedom and Operation Iraqi Freedom. Recent research into the cause(s) of HO has been driven by a markedly higher prevalence seen in these wounded warriors than encountered in previous wars or following civilian trauma. To that end, research in both civilian and military laboratories continues to shed light onto the complex mechanisms behind HO formation, including systemic and wound specific factors, cell lineage, and neurogenic inflammation. Of particular interest, non-invasive in vivo testing using Raman spectroscopy may become a feasible modality for early detection, and a wound-specific model designed to detect the early gene transcript signatures associated with HO is being tested. Through a combined effort, the goals of early detection, risk stratification, and development of novel systemic and local prophylaxis may soon be attainable.

This is a retrospective study of survivors of recent conflicts with an open fracture of the femur. We analysed the records of 48 patients (48 fractures) and assessed the outcome. The median follow up for 47 patients (98%) was 37 months (interquartile range 19 to 53); 31 (66%) achieved union; 16 (34%) had a revision procedure, two of which were transfemoral amputation (4%).

The New Injury Severity Score, the method of fixation, infection and the requirement for soft-tissue cover were not associated with a poor outcome. The degree of bone loss was strongly associated with a poor outcome (p = 0.00204). A total of four patients developed an infection; two with S. aureus, one with E. coli and one with A. baumannii.

This study shows that, compared with historical experience, outcomes after open fractures of the femur sustained on the battlefield are good, with no mortality and low rates of infection and late amputation. The degree of bone loss is closely associated with a poor outcome.

Cite this article: Bone Joint J 2015;97-B:842–6.

Aims

The aim of this study was to evaluate near-infrared spectroscopy (NIRS) as a continuous, non-invasive monitor for acute compartment syndrome (ACS).

Recent advances in combat casualty care have enabled survival following battlefield injuries that would have been lethal in past conflicts. While some injuries remain beyond our current capability to treat, they have the potential to be future ‘unexpected’ survivors. The greatest threat to deployed coalition troops currently and for the foreseeable future is the improvised explosive device (IED) Therefore, the aim of this study was to conduct an analysis of causes of death and injury patterns in recent explosive blast fatalities in order to focus research and mitigation strategies, to further improve survival rates. Since November 2007, UK Armed Forces personnel killed whilst deployed on combat operations undergo both a post mortem computed tomography (PMCT) scan and an autopsy. With the permission of the coroners, we analysed casualties with PMCTs between November 2007 and July 2010. Injury data were analysed by a pathology-forensic radiology-orthopaedic multidisciplinary team. Cause of death was attributed to the injuries with the highest AIS scores contributing to the NISS score. Injuries with an AIS < 4 were excluded. During the study period 227 PMCT scans were performed; 211 were suitable for inclusion, containing 145 fatalities due to explosive blast from IEDs. These formed the study group. 24 cases had such severe injuries (disruptions) that further study was inappropriate. Of the remaining 121, 79 were dismounted, and 42 were mounted (in vehicles). Leading causes of death were head CNS injury (47.6%), followed by intra-cavity haemorrhage (21.7%) in the mounted group, and extremity haemorrhage (42.6%), junctional haemorrhage (22.2%) and head CNS injury (18.7%) in the dismounted group. The severity of head trauma in both mounted and dismounted IED fatalites would indicate that prevention and mitigation of these injuries is likely to be the most effective strategy to decrease their resultant mortality. Two thirds of dismounted fatalities have haemorrhage implicated as a cause of death that may have been amenable to prehospital treatment strategies. One fifth of mounted fatalites have haemorrhagic trauma which currently could only be addressed surgically. Maintaining the drive to improve all haemostatic techniques for combat casualties from point of wounding to definitive surgical proximal control alongside development and application of novel haemostatics could yield a significant survival benefit

Injuries to the limb are the most frequent cause of permanent disability following combat wounds. We reviewed the medical records of 450 soldiers to determine the type of upper limb nerve injuries sustained, the rate of remaining motor and sensory deficits at final follow-up, and the type of Army disability ratings granted. Of 189 soldiers with an injury of the upper limb, 70 had nerve-related trauma. There were 62 men and eight women with a mean age of 25 years (18 to 49). Disabilities due to nerve injuries were associated with loss of function, neuropathic pain or both. The mean nerve-related disability was 26% (0% to 70%), accounting for over one-half of this cohort’s cumulative disability. Patients injured in an explosion had higher disability ratings than those injured by gunshot. The ulnar nerve was most commonly injured, but most disability was associated with radial nerve trauma. In terms of the final outcome, at military discharge 59 subjects (84%) experienced persistent weakness, 48 (69%) had a persistent sensory deficit and 17 (24%) experienced chronic pain from scar-related or neuropathic pain. Nerve injury was the cause of frequent and substantial disability in our cohort of wounded soldiers. Cite this article: Bone Joint J 2014;96-B:254–8

The aim of this study was to characterise severe open tibial shaft fractures sustained by UK military personnel over 10-years of combat and to determine the infection rate and factors that influence it. The UK military Joint Theatre Trauma Registry was searched and X-rays, clinical notes and microbiological records were reviewed for all patients. One hundred GA III open tibia fractures in 89 patients were identified. Three fractures were not followed up for 12-months and were therefore excluded. Twenty-two (23%) of the remaining 97 tibial fractures were complicated by infection requiring surgical treatment, with S. aureus being the causative agent in 13/22 infected fractures (59%). Neither injury severity, mechanism, the use of an external fixator, the need for vascularised tissue transfer or smoking status were significantly associated with infection. Bone loss was significantly associated with subsequent infection (p<0.0001). Most infection in combat open tibia fractures is caused by familiar organisms i.e. S. aureus. The use of external fixators to temporarily stabilise fractures is not associated with an increased risk of subsequent infection. While the overall severity of a casualty's injuries was not associated with infection, the degree of bone loss from the fracture was

The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 – 2010 were contacted and interviewed. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation in the same period. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria, of which 30 patients (61%) were followed-up. Ten of the 30 patients required revision surgery, 3 of which involved conversion to a circular frame. Twenty-two of the 30 patients (73%) recovered sufficiently to complete a basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma

Surgical planning is the first step in operative fracture management. Complex situations are often faced which pose difficulties on both technical and logistic fronts. Surgical planning is the first step in operative fracture management. The degree of planning that is required is therefore determined by a number of factors including: the nature of the injury mechanism and its concomitant physiological insult, complexity of the fracture and region, expertise of the surgical team and equipment limitations. This paper explores a novel planning process in orthopaedic trauma surgery based upon British Military Doctrine. The seven questions of surgical planning represent a novel method that draws inspiration from the combat estimate process. It benefits from a global approach that encompasses logistic as well as surgical constraints. This, in turn, allows the surgical team to form an understanding of the nature of the fracture in order to develop, document and deliver a surgical plan. This has benefits for the operating surgeon, operating room practitioners and trainees alike and ultimately can result in improved patient care

The aim of this study was to establish medium term outcomes in military casualties following severe open tibia fractures. Cases from a previously published series were contacted and assessed with the SF-36 outcome tool. Their results were then compared to a similar study of military trans-tibial amputees. Of the original data set of 49 patients, 30 patients were followed up and completed an SF-36 (61%) with a median follow-up of 4 years (49 months, IQR 397–63). Ten of the 30 required revision surgery, 3 of which involved conversion from initial fixation to a circular frame. Twenty-two of the 30 patients recovered sufficiently to complete a military basic fitness test. The median physical component of SF-36 in the tibia fracture group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in the amputation or fracture group reporting pain (p= 0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). We present the patient reported outcomes following combat open tibia fracture and show that they are similar to those achieved after trans-tibial amputation

Aims

Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity).

The mechanism of traumatic amputation (TA) from explosive blast has traditionally been considered to be a combination of blast wave induced bone injury – primary blast - followed by limb avulsion from the blast wind – tertiary blast. This results in a transosseous TA, with through joint amputations considered to be extremely rare. Data from previous conflicts has also suggested that this injury is frequently associated with a non-survivable primary blast lung injury (PBLI), further linking the extremity injury to the primary blast wave. However, our current experience in the Middle East would suggest that both the mechanism of TA and the link with fatal primary blast exposure need to be reconsidered. The aim of this study was to analyse the injury profile of the current cohort of TA fatalities to further investigate the underlying blast injury mechanism and to allow hypotheses on injury mechanisms to be developed for further analysis. With the permission of the coroners, 121 post-mortem CT (PMCT) scans of UK Armed Forces personnel who died following an IED blast were analysed. All orthopaedic injuries were identified, classified and the anatomical level of any associated soft tissue injury noted. PMCT evidence of PBLI was used as a marker of significant primary blast exposure. 75/121 (62%) sustained at least 1 TA, with 138 TAs seen in total. 31/138 (22%) were through joints, with through knee amputations most common (23/31, 74%). Only 7/31(23%) through joint amputations had an associated fracture proximal to and contiguous with the amputation site. The soft tissue injury profile of through joint and transosseous TAs were not significantly different (p=0.569). When fatality location was considered (i.e. mounted or dismounted), no overall relationship between PBLI and TA was evident. The two pathologies were not seen to consistently occur concurrently, as has been previously reported. The accepted mechanism for traumatic amputation following explosive blast does not adequately explain the significant number of through joint TAs presented here. The previously reported link between TA and PBLI in fatalities was not supported by this analysis of modern combat blast fatalities. Lack of an associated fracture with the majority of through joint TAs in conjunction with a lesser contribution of primary blast may implicate flail and periarticular soft tissue failure as a potential injury mechanism. Analysis of through joint TA incidence and associated injuries in survivors is now indicated. Case studies within the fatality dataset may facilitate generation of injury mechanism hypotheses. To further investigate the injury mechanism, work is required to understand osseous, ligamentous and other soft tissue behaviour and failure at high strain rates. This should allow characterisation and modeling of these injuries and inform mitigation strategies

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 compared early post-operative rates of wound infection in HIV-positive and -negative patients presenting with open tibial fractures managed with surgical fixation.

The wounds of 84 patients (85 fractures), 28 of whom were HIV positive and 56 were HIV negative, were assessed for signs of infection using the ASEPIS wound score. There were 19 women and 65 men with a mean age of 34.8 years. A total of 57 fractures (17 HIV-positive, 40 HIV-negative) treated with external fixation were also assessed using the Checkett score for pin-site infection. The remaining 28 fractures were treated with internal fixation. No significant difference in early post-operative wound infection between the two groups of patients was found (10.7% (n = 3) vs 19.6% (n = 11); relative risk (RR) 0.55 (95% confidence interval (CI) 0.17 to 1.8); p = 0.32). There was also no significant difference in pin-site infection rates (17.6% (n = 3) vs 12.5% (n = 5); RR 1.62 (95% CI 0.44 to 6.07); p = 0.47).

The study does not support the hypothesis that HIV significantly increases the rate of early wound or pin-site infection in open tibial fractures. We would therefore suggest that a patient’s HIV status should not alter the management of open tibial fractures in patients who have a CD4 count > 350 cells/μl.

Cite this article: Bone Joint J 2013;95-B:1703–7.

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.