Introduction and aims. We present a series of patients who have had secondary reconstruction of war injuries to the upper and lower limbs, sustained during the Iraq and Afghanistan conflicts. Material and Methods. All patients were seen at the combined Peripheral Nerve Injuries Clinic at the Defence Medical Centre for Rehabilitation, Headley Court. All surgery was performed at Odstock Hospital. Procedures include scar excision and neurolysis (all patients), release of scar contractures, tenolysis, tendon transfers, revision nerve grafts, excision of neuroma, and soft tissue reconstruction using pedicled or free flaps. Results. 24 patients have been treated at the time of submission. We have used 13 free flaps (1 free groin flap, 9 anterolateral thigh, 3 parascapular, with 4 as through-flow flaps) and 1 pedicled groin flap, with no flap losses. There were 6 amputation stump revisions (1 above elbow, 5 below knee). The majority (n=23) have had nerve recovery distal to the level of injury following revision surgery. Conclusions. Nerve repairs recover following neurolysis (and revision nerve graft if necessary) with provision of good soft tissue cover. Release of scar contractures with flap cover allows healing of chronic wounds and permits mobilisation of joints. Thin fascio-cutaneous flaps provide good contour and can be elevated more easily than skin grafted muscle flaps for secondary surgery. Free or regional flaps are preferable to local flaps in high energy-transfer military wounds. Immediate complex reconstruction is not always appropriate in multiply-injured patients

A randomised controlled trial was conducted using a rabbit model of a complex contaminated extremity war wound. Compared to saline soaked gauze dressings Inadine (iodine) and Acticoat (nanocrystalline silver) had significantly lower levels of Staphylococcus aureus after 7 days while Activon Tulle (Manuka honey) had significantly higher levels. Molecular level analysis of the wound was conducted. Plasma cytokines of interest were assayed using ELISA and levels of expression of relevant tissue genes measured using PCR following RNA extraction. Appreciable levels of Interleukins 4 and 6 and Tumour Necrosis Factor-α were identified in plasma with significantly higher levels of IL-4 and TNFα detected in the Activon Tulle group. In tissue TNFα, Matrix metalloproteinase-3 and the ratio of Matrix metalloproteinase-9 to Tissue Inhibitor of Matrix metalloproteinase-1 were significantly higher in tissue injured limbs than the uninjured limbs with no significant differences between groups. Interpretation of these results is challenging. IL-4 has been associated with transition from pathological inflammation to repair and TNFα with impaired healing. However, Activon Tulle had significantly higher levels of S. aureus and we found no differences in observational, histology, haematology or tissue gene expression outcomes over 7 days which would correlate with these molecular biology results

A randomised controlled pre-clinical trial utilising an existing extremity war wound model compared the efficacy of saline soaked gauze to commercial dressings. The Flexor Carpi Ulnaris of anaesthetised New Zealand rabbits was exposed to high-energy trauma using computer-controlled jig and inoculated with 10. 6. Staphylococcus aureus 3 hours prior to application of dressing. After 7 days the animals were culled. Quantitative microbiological assessment of post-mortem specimens demonstrated statistically significantly reduced S aureus counts in groups treated with iodine or silver based dressings (2-way ANOVA p< 0.05). Clinical observations and haematology were performed during the study. Histopathological assessment of post-mortem muscle specimens included image analysis of digitally scanned haematoxylin and eosin stained tissue sections and subjective semi-quantitative assessment of pathology severity using light microscopy to grade muscle injury and lymph node activation. Tissue samples were also examined using scanning electron microscopy to determine the presence of bacteria and biofilm formation within the injured muscle. Non-parametric data were compared using Kruskal-Wallis. There were no bacteraemias, significantly raised white cell counts, abscesses, purulent discharge or evidence of contralateral axillary lymph node activation. All injured muscle specimens showed evidence of haemorrhage, inflammatory cell infiltration and fibrosis. All ipsilateral axillary lymph nodes were activated. There were no significant differences in the amount of muscle loss, size of the activated lymph nodes or in subjective semi-quantitative scoring criteria for muscle injury or lymph node activation. There was no evidence of bacterial penetration or biofilm formation. This study demonstrated statistically significant reductions in Staphylococcus aureus counts associated with iodine and silver dressings, and no evidence that these dressings cause harm. This was a time-limited study which was primarily powered to detect reduction in bacterial counts; however, there was no significant variation in secondary outcome measures of local or systemic infection over 7 days

Ballistic fractures are devastating injuries often necessitating reconstructive surgery or amputation. Complications following surgery are common, particularly in the austere environment of war. Workload from the recent conflict was documented in order to guide future medical need. All data on ballistic fractures was collected prospectively. Fractures were scored using the Red Cross Fracture Classification. During the first two weeks of the conflict, 202 Field Hospital was the sole British hospital in the region. Thereafter, until the end of the conflict, it became the tertiary referral hospital for cases requiring orthopaedic and plastic surgery opinions. Thirty-nine patients, with 50 ballistic fractures were treated by British military surgeons. Patients were predominantly Iraqi (20 enemy prisoners of war and 15 civilians); 4 children sustained five fractures. Fifty percent were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. A total of 30 per cent of wounds became infected, 12 per cent were deep infection necessitating surgical drainage. Thirteen limbs were amputated; seven were traumatic amputations. Ballistic fractures remain a challenge for surgeons in times of war. There is a continued need to relearn the principles of war surgery in order to minimise complications and restore function. Military medical skills training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts

Peripheral nerve injuries (PNI) occur in 10% of combat casualties. In the immediate field-hospital setting, an insensate limb can affect the surgeon's assessment of limb viability and in the long-term PNI remain a source of considerable morbidity. Therefore the aims of this study are to document the recovery of combat PNI, as well as report on the effect of current medical management in improving functional outcome. In this study, we present the largest series of combat related PNI in Coalition troops since World War II. From May 2007 – May 2010, 100 consecutive patients (261 nerve injuries) were prospectively reviewed in a specialist PNI clinic. The functional recovery of each PNI was determined using the MRC grading classification (good, fair and poor). In addition, the incidence of neuropathic pain, the results of nerve grafting procedures, the return of plantar sensation, and the patients' current military occupational grading was recorded. At mean follow up 26.7 months, 175(65%) of nerve injuries had a good recovery, 57(21%) had a fair recovery and 39(14%) had a poor functional recovery. Neuropathic pain was noted in 33 patients, with Causalgia present in 5 cases. In 27(83%) patients, pain was resolved by medication, neurolysis or nerve grafting. In 35 cases, nerve repair was attempted at median 6 days from injury. Of these 62%(22) gained a good or fair recovery with 37%(13) having a poor functional result. Forty-two patients (47 limbs) initially presented with an insensate foot. At final follow up (mean 25.4 months), 89%(42 limbs) had a return of protective plantar sensation. Overall, 9 patients were able to return to full military duty (P2), with 45 deemed unfit for military service (P0 or P8). This study demonstrates that the majority of combat PNI will show some functional recovery. Adherence to the principles of war surgery to ensure that the wound is clear of infection and associated vascular and skeletal injuries are promptly treated will provide the optimal environment for nerve recovery. Although neuropathic pain affects a significant proportion of casualties, pharmacological and surgical intervention can alleviate the majority of symptoms. Finally, the presence of an insensate limb at initial surgery, should not be used as a marker of limb viability. The key to recovery of the PNI patient lies in a multi-disciplinary approach. Essential to this is regular surgical review to assess progress and to initiate prompt surgical intervention when needed. This approach allows early determination of prognosis, which is of huge value to the rehabilitating patient psychologically, and to the whole rehabilitation team

This is a retrospective study examining the injury pattern, management and short-term outcomes of British Military casualties sustaining hindfoot fractures from the conflicts in Iraq and Afghanistan. In the 12-years of war, 114 patients sustained 134 hindfoot injuries. The calcaneus was fractured in 116 cases (87%): 54 (47%) were managed conservatively, with 30 (26%) undergoing internal fixation. Eighteen-month follow-up was available for 92 patients (81%) and 114 hindfeet (85%). Nineteen patients (17%) required trans-tibial amputation in this time, with a further 17 (15%) requiring other revision surgery. Deep infection requiring surgical treatment occurred in 13 cases (11%) with S. aureus the commonest infective organism (46%). Deep infection was strongly associated with operative fracture management (p=0.0022). When controlling for multiple variables, the presence of deep infection was significantly associated with a requirement for amputation at 18 months (p=0.001). There was no association between open fractures and requirement for amputation at 18 months (p=0.926), nor was conservative management associated with amputation requirement (p=0.749)

Military personnel operating on high speed marine craft are exposed to Whole-Body Vibration (WBV). Additionally planing craft operate at speeds with minimal contact of the hull with warer making the crew vulnerable to mechanical shock. An association between Low Back Pain (LBP) and exposure to WBV has been extensively reported in civilian literature. LBP is reported by military personnel operating on planing craft leading to downgrades and potential discharge. There is a clear need to understand the impact prolonged exposure has on our population operating these craft. We performed a bibliographical search of the PubMed database for records using a combination of keywords. Abstracts were screened for relevance and references cited in retrieved papers reviewed. There is no consensus in the literature on the potentially pivotal pathological process behind the association. Evidence from professional driving suggests current safe operating exposure levels require review to protect against long-term damage however with little evidence concerning the unique environment in which boats crews operate, the parity of these environments require investigation to allow direct comparison. Due to the prevalence of LBP in this population a need exists to establish the pathological process and add to the evidence base driving safe operating exposure levels

UK personnel have been deployed in Afghanistan since 2001 and over this time a wealth of experience in contemporary war surgery has been developed. Of particular note in the latter Herrick operations the injury pattern suffered by personnel is largely blast wounds, primarily from improvised explosive devices. With the development of improved body armour, previously unsurvivable blasts now result in a large number of traumatic amputations, predominantly affecting the lower limb. Faced with this, deployed medical personnel in the Role 3 facility, Camp Bastion, have developed, by a process of evolution, a standard process for timely management of these injuries. We present a documented schema and photographic record of the ‘Bastion’ process of management of traumatic amputation through the resuscitation department, radiology, theatres and post-operatively. In resuscitation the priority is control of catastrophic haemorrhage with exchange of CAT tourniquets to Pneumatic tourniquets. While undergoing a CT, time can be used to complete documentation. In theatre a process of social debridement & wash then sterile prep followed by formal debridement allows rapid management of the amputated limbs. This work provides a record of current best practice that generates maximum efficiency of personnel and time developed over a large number of procedures. This allows reflection both now in relation to continuing Herrick operations and when military medical services are faced with a future conflict and an inevitable change in injury patterns

Aim/Purpose. Review our unique experience in the management of 29 consecutive casualties who survived open pelvic fractures following a blast mechanism. Methods and Results. Retrospective study utilising a prospectively collected combat trauma registry. Records of UK Service Personnel sustaining open pelvic fractures from an explosion from Aug 2008 – Aug 2010 identified. Casualties who survived to be repatriated to the Royal Centre for Defence Medicine, University Hospital Birmingham were selected for further study. The median New Injury Severity Score (NISS) was 41. Mean blood requirement in the first 24 hours was 60.3 units. In addition to their orthopaedic injury, 6 (21%) had an associated vascular injury, 7(24%) had a bowel injury, 11 (38%) had a genital injury and 7(24%) had a bladder injury. 8 (28%) fractures were managed definitively with external fixation, and 7 (24%) fractures required internal fixation. Of those patients who underwent internal fixation, 5 (57%) required removal of metalwork for infection. Faecal diversion was performed on 9 (31%) casualties. Median length of stay was 70.5 days, and mean total operative time was 29.6 hours. At a mean 20.3 months follow-up, 24 (83%) were able to ambulate, and 26 (90%) had clinical and radiological evidence of pelvic ring stability. Conclusion. As a result of the “Global War on Terror” injuries that were previously confined exclusively to conflict areas can now occur anywhere in the form of terrorist attacks. Given the nature of the soft tissue injury, we would advocate an approach of predominantly external fixation in the management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is mandated in all cases

The aim of this study is to review our unique experience in the management of 29 consecutive casualties who survived open pelvic fractures following a blast mechanism, in order to determine the injury pattern, clinical management and outcome of these devastating injuries. All patients were serving soldiers who were injured whilst on operations in Afghanistan. The median New Injury Severity Score (NISS) was 41. Mean blood requirement in the 1. st. 24 hours was 60.3 units. In addition to their orthopaedic injury, 6 (21%) had an associated vascular injury, 7(24%) had a bowel injury, 11 (38%) had a genital injury and 7(24%) had a bladder injury. 8 (28%) fractures were managed definitively with external fixation, and 7 (24%) fractures required ORIF. Of those patients who underwent ORIF, 4 (57%) required removal of metalwork for infection. Faecal diversion was performed on 9 (31%) casualties. Median length of stay was 70.2 days, and mean total operative time was 29.6 hours. At a mean 20.3 months follow-up, 24 (83%) were able to ambulate, and 26 (90%) had clinical and radiological evidence of pelvic ring stability. The “Global War on Terror” has resulted in incidents that were previously confined exclusively to conflict areas can now occur anywhere, and surgeons who are involved in trauma care may be required to manage similar injuries from terrorist attacks. Our study clearly demonstrates that the management of this injury pattern is extremely resource intensive with the need for significant multi-disciplinary input. Given the nature of the soft tissue injury, we would advocate an approach of minimal internal fixation in the management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is mandated in all cases

Surgical training in the UK since the Second World War has developed into a world class education programme. However, with the dramatic increase in the number of doctors and surgeons, combined with the improvement in access to health care, pathologies are now being treated earlier, and trainee exposure to advanced pathology has consequentially reduced. Not all countries are as privileged as the UK to have 3 doctors per 1000 head of population; South Africa has approximately 1/3rd of this number, Cambodia 1/10. th. , and Malawi 1/100. th. Many of these countries have difficulty filling posts for medical professionals within their own hospitals. The publication of the CRISP report and Lord Crisp's subsequent book ‘Turning the world upside down’ in 2010, highlighted, and tried to produce evidence of the mutual benefit of international health links to both the developed and the developing countries. It cited the bilateral transfer of skills and ideas, development of management skills, and improved workforce morale as beneficial effects of such links. The Department for International Development has prioritised the formation of these international partnerships. The Tropical Health Education Trust has been given the task of distributing grant funds. There are over 100 currently established and funded different health links across the UK. Some local links already exist such as the Gloucester NHS Trust Kambia, Sierra Leone link which focuses on maternal health, NHS South Centrals leadership programme which has a broader remit and works in conjunction with the ministries of health in certain areas of Tanzania and Cambodia and UHB/BRI link with Mbarara, Uganda in obstetrics, child health, ophthalmology. Over the last 4 years, a series of South West Trainees have spent 1 year working in hospitals in Malawi and South Africa. The positive feedback that they have given, the dramatic increase in the surgical exposure as documented in their log books, and the number of high quality research projects that they have published as a result, has led to the programme director looking favourably on future requests. We feel it would be mutually beneficial to formalise these links, with a regular stream of surgeons from this region spending time in these hospitals. Benefits for the recipient hospital would be a dependable and regular supply of staff, who could be incorporated into more long scale programmes, aimed at improving regional health care. Benefits to the donor institution and surgeon would be streamlined application process, simpler living logistics, car house etc, continuity of research projects, and the possibility to apply for funding for local research staff

Anti-vehicle mines (AV) and Improvised Explosive Devices (IEDs) remain the most prevalent threat to Coalition troops operating in Iraq and Afghanistan. Detonation of these devices results in rapid deflection of the vehicle floor resulting in severe injuries to calcaneus. Anecdotally referred to as a ‘deck-slap’ injury, there have been no studies evaluating the pattern of injury or the effect of these potentially devastating injuries since World War II. Therefore the aim of this study is to determine the pattern of injury, medical management and functional outcome of UK Service Personnel sustaining calcaneal injuries from under-vehicle explosions. From Jan 2006 – Dec 2008, utilising a prospectively collected trauma registry (Joint Theatre Trauma Registry, JTTR), the records of all UK Service Personnel sustaining a fractured calcaneus from a vehicle explosion were identified for in depth review. For each patient, demographic data, New Injury Severity Score (NISS), and associated injuries were recorded. In addition, the pattern of calcaneal fracture, the method of stabilisation, local complications and need for amputation was noted. Functional recovery was related to the ability of the casualty to return to military duties. Forty calcaneal fractures (30 patients) were identified in this study. Mean follow-up was 33.2 months. The median NISS was 17, with the lower extremity the most severely injured body region in 90% of cases. Nine (30%) had an associated spinal injury. The overall amputation rate was 45% (18/40); 11 limbs (28%) were amputated primarily, with a further 3 amputated on return to the UK. Four (10%) casualties required a delayed amputation for chronic pain (mean 19.5 months). Of the 29 calcaneal fractures salvaged at the field hospital, wound infection developed in 11 (38%). At final follow-up, only 2 (6%) were able to return to full military duty with 23 (76%) only fit for sedentary work or unfit any military duty. Calcaneal injuries following under-vehicle explosions are commonly associated with significant polytrauma, of which the lower limb injury is the most severe. Spinal injuries were frequently associated with this injury pattern and it is recommended that radiological evaluation of the spine be performed on all patients presenting with calcaneal injuries from this injury mechanism. The severity of the hindfoot injury witnessed is reflected by the high infection rate and amputation rate seen in this cohort of patients. Given the high physical demands of a young, active military population, only a small proportion of casualties were able to return to pre-injury duties. We believe that the key to the reduction in the injury burden to the soldier lies in the primary prevention of this injury. Work is currently on going to develop experimental and numerical models of this injury in order to drive future mitigation strategies