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.