Current military conflicts are characterised by the use of the Improvised Explosive Device (IED). Improvements in personal protection, medical care and evacuation logistics have resulted in increasing numbers of casualties surviving with complex musculoskeletal injuries, often leading to life-long disability. Thus, there exists an urgent requirement to investigate the mechanism of extremity injury caused by these devices in order to develop mitigation strategies. In addition, the wounds of war are no longer restricted to the battlefield; similar injuries can be witnessed in civilian centres following a terrorist attack.

Key to mitigating such injuries is the ability to deconstruct the complexities of an explosive event into a controlled, laboratory-based environment. In this study, an anti-vehicle underbelly injury simulator, capable of recreating in the laboratory the impulse from an anti-vehicle (AV) explosion, is presented and characterised. Tests were then conducted to assess the simulator's ability to interact with human cadaveric legs. Two mounting conditions were assessed, simulating a typical seated and standing vehicle passenger using instrumented cadaveric lower limbs.

This experimental device, will now allow us (a) to gain comprehensive understanding of the load-transfer mechanisms through the lower limb, (b) to characterise the dissipating capacity of mitigation technologies, and (c) to assess the biofidelity of surrogates.

Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings.

In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications.

The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO.

A total of 11 patients with combined traumatic injuries of the brachial plexus and spinal cord were reviewed retrospectively. Brachial plexus paralysis in such dual injuries tends to be diagnosed and treated late and the prognosis is usually poor. The associated injuries, which were all on the same side as the plexus lesion, were to the head (nine cases), shoulder girdle (five), thorax (nine) and upper limb (seven). These other injuries were responsible for the delayed diagnosis of brachial plexus paralysis and the poor prognosis was probably because of the delay in starting treatment and the severity of the associated injuries. When such injuries are detected in patients with spinal cord trauma, it is important to consider the possibility of involvement of the brachial plexus

Background. With an ageing population, the incidence of traumatic injuries in those aged over 65 years is increasing. As a result, strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures is described by the BOAST4 guidelines. We describe our experience of managing elderly patients presenting with open tibial fractures to our Major Trauma Centre. Methods. Patients were identified via prospectively collected national and departmental databases. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long term outcomes. Results. Between April 2013 and January 2016, 97 patients aged over 65 were admitted with open fractures, 38 of these were open tibial fractures. 10 patients required soft tissue reconstruction for Gustillo and Anderson IIIB tibial fractures (age range 67–95). In this group there were 4 midshaft (AO 42), 1 proximal (AO 41) and 5 distal (AO 43) fractures. Five patients were treated with internal fixation and 5 with circular frames. The median length of hospital stay was 33 days (range 16–113 days), 50% longer than comparable patients under 65. Four patients received pedicled local flaps and six underwent free tissue transfer. Of the 6 patients treated with free tissue transfer, one required pre-operative femoral angioplasty. There were no flap losses. Two patients had fasciocutaneous flaps, one an EDB flap and one gastrocnemius flap. All patients went on to unite and return to their pre-morbid weight-bearing status (2 using frames, 3 using sticks, 5 independent). Discussion. Although the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and post-operatively. These challenges are reflected in the significantly longer length of stay in comparably injured patients under the age of 65

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Patient decision aids have previously demonstrated an improvement in the quality of the informed consent process. This study assessed the effectiveness of detailed written patient information, compared to standard verbal consent, in improving postoperative recall in adult orthopaedic trauma patients.

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Current levels of hip fracture morbidity contribute greatly to the overall burden on health and social care services. Given the anticipated ageing of the population over the coming decade, there is potential for this burden to increase further, although the exact scale of impact has not been identified in contemporary literature. We therefore set out to predict the future incidence of hip fracture and help inform appropriate service provision to maintain an adequate standard of care.

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Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data.

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Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines.

Traumatic injuries to the sternoclavicular joint (SCJ) are uncommon representing only 3% of all injuries to the shoulder girdle. Acutely, the majority are managed non-operatively with physiotherapy rehabilitation. However, if there is evidence of neurovascular compromise emergency reduction is indicated. There is no consensus on treatment of SCJ dislocations and subluxations that remain symptomatic after conservative treatment. Multiple surgical techniques have been described to alleviate this problem. These include resection of the medial end of the clavicle and various stabilization techniques using Kirschner wires, muscle tendon (subclavius, sternocleidomastoid, semi-tendinosus and palmaris longus) and synthetic materials (Dacron). However, all techniques have reported problems in terms of pain, decreased range of movement and a relatively high complication rate. We report a new technique using a LARS® ligament (Ligament Augmentation and Reconstruction System) with good early post-operative results. 5 symptomatic SCJ dislocations were repaired over a 3 year period. The operations were conducted by the same surgeon and at the same unit. The patients were on average 20 years old (17–22). Mean follow up time was 21 months (9–41). Functional assessment was made using the DASH (Disabilities of the Arm, Shoulder and Hand) and the OSS (Oxford Shoulder Score) outcome measures. An improvement between pre- and post-operative scoring was observed in both DASH median 51.7 (24.2–75.0) v 13.7 (8.3–20.8) (p=0.024) and OSS 20.6 (15–32) v 41.8 (39–47) (p<0.001). One patient had a pneumothorax intra-operatively but this resolved with conservative treatment. There were no long term complications experienced during follow up

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The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs.

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To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury.

We reviewed 173 patients undergoing distraction osteogenesis to determine the incidence, location and timing of fractures occurring as a complication of the procedure. There were 17 fractures in 180 lengthened segments giving an overall rate of fracture of 9.4%. Unexpectedly, the pattern and location of the fractures were very variable; six were within the regenerate itself, six at the junction between the regenerate and the original bone and five at distant sites in the limb. Of those occurring in the regenerate, five were noted to be associated with compression and partial collapse of the regenerate. In three patients collapse and deformity developed gradually in the distracted segment over the six months after removal of the frame. The method of treatment of these fractures should be chosen to take into account multiple factors, which are additional and often different from those to be considered during management of acute traumatic injuries. Internal fixation appears to be most appropriate for displaced fractures, although in small children, or in those in whom there has been, or is, infection of the screw tracks, a new period of treatment using external fixation may be needed. Fixation by intramedullary nailing was associated with a risk of infection, even if screw tracks were assessed as healthy at the time of insertion of the nail. Internal fixation with the use of plates is safe for displaced, unstable fractures in children

Background. The decision to attempt limb salvage vs to amputate in a significant traumatic limb injury is based on patient´s best predicted outcome. When amputation cannot be avoided the aim is to provide a pain free limb whilst preserving the soft tissue and limb length. Methods. Retrospective study covering 5 years (2011–2016), all the trauma patients requiring lower limb amputation (LLA) included. Demographics, mechanism, type of injury, amputation type, cause and level, theatre trips for stump management were analysed. Results. 19 patients aged 27–93 included. RTC was the leading cause (47%) of LLA. Amputation type: traumatic, caused by the injury itself (31.5%) acute surgical, amputation performed in a limb threatening injury (37%); 72% of them had vascular compromise delayed amputations after failure of limb salvage surgery (31.5%); failed soft tissue coverage and poorly functioning limb were the lead cause (33% each) Type of injury: open fractures (89%), isolated to a limb segment (53%). One level/extended level=9/10 patients. More than 50% of initial amputations were extended with multiple subsequent theatre trips (33/10 patients) for stump management. Conclusions. It was difficult to predict the patients needing an extended amputation. Early MDT and prosthetic rehab service involvement is crucial in LLA decision. When consenting patients for LLA consider a 50% change to extend the initial level of amputation with subsequent theatre trips

Introduction. Patients suffering from finger joint pain or dysfunction due to arthritis and traumatic injury may require arthroplasty and joint replacement. Single-part silicone-based implants remain the material of choice and most widely used option, although reports on their long-term clinical performance are variable. For trauma indications, patients have a high expectation of functionality necessitating the use of materials with high wear resistance and mechanical performance. A new proximal inter phalangeal (PIP) joint designed by Zrinski AG (Wurmlingen, Germany), comprising a self-mating carbon fibre reinforced polyetheretherketone (CFR-PEEK) coupling, may provide a suitable alternative. Here we describe the wear performance of the CFR-PEEK components in a PIP joint wear simulator and subsequent characterisation of the wear particles. Methods. Four proximal and distal PIP components were milled (Zrinski AG) from CFR-PEEK (Invibio Ltd, UK) and subjected to wear testing (Endo Lab ® GmbH, Germany). The test was conducted at 37°C over 5 million cycles in 25% bovine serum (refreshed every 0.5 million cycles). The load was a static force of 63N applied at a frequency of 1Hz with a flexion/extension angle of ±40°. Wear rate was determined by mass loss from each component. Pooled serum samples from the wear simulator were subjected to protein digest and the remaining particulate debris isolated by serial filtration through 10μm, 1μm and 0.1μm filters. Particle size and morphology was subsequently determined by scanning electron microscopy (SEM) (Continuum Blue, UK). Results. Both components exhibited high resistance to wear, with the proximal component resulting in a wear rate of 0.09mg/million cycles, whilst that of the distal component was 0.07mg/million cycles. Particle analysis revealed that the majority of debris generated during the wearing in phase (0.5 million cycles) was <0.5μm in diameter. During the steady state phase (0.5–3 million cycles) a large peak in particle size was observed in the 2μm diameter range, whilst in the latter stage (3–5 million cycles) peaks in particle size were seen at 0.4μm and 2μm. During each stage, both the particle count and aspect ratio remained relatively unchanged. Conclusion. Under these test conditions the CFR-PEEK coupling demonstrated a linear and consistently low wear rate over the 5 million cycle test period, with the majority of particles generated being <2μm in diameter. The low wear rate and biocompatibility demonstrated by CFR-PEEK suggests it is a suitable alternative to silicone in PIP joint prostheses. Acknowledgements. The authors would like to thank Zrinski AG, Christian Kaddick at EndoLab GmbH for the wear simulator work and Mark Yeoman at Continuum Blue Ltd. for particle analysis

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Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture.

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It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site.

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Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare surgical wait times, mortality, length of stay (LOS), and healthcare costs for similar hip fracture patients evaluated with and without preoperative echocardiograms.

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To describe a new objective classification for open fractures of the lower limb and to correlate the classification with patient-centred outcomes.

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The aim of this study was to explore the patients’ experience of recovery from open fracture of the lower limb in acute care.

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