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

Published infection rates following wounds sustained in combat vary dramatically. We reviewed UK military extremity trauma, sustained in Afghanistan over a two year period, to evaluate early infection rates and causative organisms. Data on wound site, time to onset of infection, organisms detected and method of presentation were collected.

351 patients had full datasets for clinical wound surveillance and microbiological data. 58 (16.5%) patients were diagnosed with wound infections. Median time to diagnosis was 17 days (range = 749, Interquartile range =31.75 days). Limb infection was detected in 53 (15.1%) patients. Infection was statistically significantly more likely to be incurred in the lower extremity (p=0.0220). Multiple organisms were identified in 34 (64.2%) of the 53 patients with a limb infection. Fungi were significantly more common in early presenters (<30 days after injury) (p=0.0024). Staphylococcus aureus was significantly more likely in late presentation (p=0.002). Infection was more likely in those injured by an improvised explosive device (p=0.0019).

The overall infection rates recorded are low when compared to historical data. Organisms isolated from infected wounds are frequently multiple. The microbial spectrum and the number of organisms present on diagnosis change with time from wounding.

Aim/Purpose

Review our unique experience in the management of 29 consecutive casualties who survived open pelvic fractures following a blast mechanism.

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.