Advances in military surgery have led to significant numbers of soldiers surviving with bilateral above knee amputations. Despite advances in prosthetic design and high quality rehabilitation not all amputees succesfully ambulate. Five patients (10 stumps) with persisting socket fit issues were selected for osseointegration (OI) using a transcutaneous prosthesis with press-fit fixation in the residual femur. Prior to surgery all five were primarily/exclusively wheelchair users.

Follow up was from 7 to 25 months (mean 12.2). There were no deaths, episodes of sepsis or osteomyelitis. There was one proximal femoral fracture secondary to a fall. One stump required soft tissue refashioning. Cellulitis needing oral antibiotics occurred in four cases.

Functional improvement occurred in all cases with all currently primarily prosthetic users, the majority all day users. Three patients are still completing rehabilitation. Six minute walk tests (SMWT) improved by a mean of 20%. Three are now graded mobility SIGAM F (normal gait) and two SIGAM D-b (limited terrain; with one stick).

This cohort suggests that OI may have a role in the treatment of military blast amputees. A larger scale clinical evaluation is planned in the UK blast related amputee population to further establish the benefits and risks of this technique

The UK Military Trauma Registry was searched for all cases of primary bilateral lower limb amputation sustained over 6-years between March 2004 and March 2010. There were 1694 UK military patients injured or killed during this six-year study period.

Forty-three of these (2.8%) were casualties with bilateral lower limb amputations. All were men injured in Afghanistan by Improvised Explosive Devices. Six casualties were in vehicles when they were injured with the remaining 37 (80%) patrolling on foot. The mean New Injury Severity Score was 48.2 (SD 13.2). Nine patients also lost an upper limb (triple amputation); no patients survived loss of all four limbs. Six patients (14%) sustained an open pelvic fracture. Perineal/genital injury was a feature in 19 (44%) patients, ranging from unilateral orchidectomy to loss of genitalia and permanent requirement for colostomy and urostomy. The mean requirement for blood products was 66 units (SD=41.7). The minimum transfusion requirement was 8 units and the greatest was a patient requiring a total of 193 units of blood products.

Our findings detail the severe nature of these injuries together with the massive surgical and resuscitative efforts required to firstly keep patients alive and secondly reconstruct and prepare them for rehabilitation.

Background: Severe and chronic back pain often originates from degenerated intervertebral discs, probably from lesions in the outer posterior anulus. Unlike the nucleus, the outer anulus has a high cell density and adequate metabolite transport. The outer annulus can heal after injury in small and young experimental animals, but little is known about the healing potential of adult human discs.

Purpose: We seek evidence that healing of the human outer anulus follows the three stages of tendon healing: inflammation, repair, remodelling. If so, then manual therapy and self-treatment techniques known to facilitate tendon healing could be adapted to treat discogenic back pain.

Methods: Anulus tissue was removed at surgery (usually posteriorly) from 14 patients with discogenic back pain. Tissue was paraffin embedded and sectioned at 5 μm for histology and immunohistochemistry. Apoptosis was detected using an antibody for caspase-3.

Results: Fissures in the peripheral posterior annulus, and herniated tissue fragments, were associated with blood vessels, inflammatory cells, and with focal loss of proteoglycans. Cell density decreased with distance from fissures from the disc periphery. Overall cell density decreased with age. Apoptosis was greater in the nucleus than in the annulus, and was particularly associated with cell clusters, and with anulus fissures.

Conclusion: These preliminary results suggest an inflammatory healing response in the outer anulus, strongly associated with radial fissures. Loss of proteoglycan from fissure margins may facilitate the ingrowth of capillaries and nerves, which then stimulate local healing in the vicinity of the fissures.

Conflicts of Interest: None

Source of Funding: BackCare

1. The technique and results of arthroplasty of the metatarso-phalangeal joints for the grossly deformed forefoot are described.

2. The early results are very encouraging.

3. Attention is drawn to some of the complicating problems in rheumatoid arthritis, particularly the hazard of arteritis.