'Modern' distal femoral locking plates allow safe, early weight-bearing with a high rate of union and low rate of failure: five-year experience from a United Kingdom major trauma centre.

AIMS: Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient's ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function. PATIENTS AND METHODS: All patients treated at our centre with lateral distal femoral locking plates (LDFLP) between 2009 and 2014 were identified. Fracture classification and operative information including weight-bearing status, rates of union, re-operation, failure of implants and mortality rate, were recorded. RESULTS: A total of 127 fractures were identified in 122 patients. The mean age was 72.8 years (16 to 101) and 92 of the patients (75%) were female. A consultant performed the operation in 85 of the cases, (67%) with the remainder performed under direct consultant supervision. In total 107 patients (84%) were allowed to bear full weight immediately. The rate of clinical and radiological union was 81/85 (95%) and only four fractures of 127 (3%) fractures required re-operation for failure of surgery. The 30-day, three- and 12-month mortality rates were 6 (5%), 17 (15%) and 25 (22%), respectively. CONCLUSION: Our study suggests an exponential increase in the incidence of a fracture of the distal femur with age, analogous to the population suffering from a proximal femoral fracture. Allowing immediate unrestricted weight-bearing after LDFLP fixation in these elderly patients was not associated with failure of fixation. There was a high rate of union and low rate of re-operation. Cite this article: Bone Joint J 2017;99-B:951-7.

Trauma-related amputations in war and at a civilian major trauma centre-comparison of care, outcome and the challenges ahead.

The Afghanistan conflict has resulted in a large number of service personnel sustaining amputations. Whilst obvious differences exist between military and civilian trauma-related amputations both settings result in life changing injuries. Comparisons offer the potential of advancement and protection of the knowledge gained during the last 12 years. This paper compares the military and civilian trauma-related amputee cohorts' demographics, management and rehabilitation outcomes measures. The UK military Joint Theatre Trauma Registry and a civilian major trauma centre database of trauma-related amputees were analysed. 255 military and 24 civilian amputees were identified. A significant difference (p>0.05) was seen in median age (24, range 18-43, vs. 48, range 24-87 years), mean number of amputations per casualty (1.6±SD 0.678 vs. 1±SD 0.0), mean ISS (22±SD 12.8 vs. 14.7±SD 15.7) and gender (99% males vs. 78%). Rehabilitation outcome measures recorded included the Special Interest Group in Amputee Medicine score where the military group demonstrated significantly better scores (91% Grade E+ compared to 19%). Differences in patients underlying physiology and psychology, the military trauma system and a huge sustained investment in rehabilitation are all contributing factors for these differing outcomes. However the authors also believe that the use of a consultant-led MDT and central rehabilitation have benefited the military cohort in the acute rehabilitation stage and is reflected in the good short-term outcomes.

From model to molecules: the development and experimental manipulation of an in vivo contaminated extremity war wound.

Wound infection is a key determinant of outcome in survivors of armed conflict. One factor having potential for promoting healing, decreasing bacterial burden and influencing prognosis is the dressing that covers the ballistic-injured extremity. Although antiseptic and silver dressings are applied to acute wounds, evidence to support their use is scarce with no controlled studies reported of antimicrobial wound dressings in extremity trauma. Given the recent burden of ballistic extremity injury, the requirement to investigate the role of antimicrobial dressings in contaminated wounds is transparent. This paper details a programme of work undertaken at the Defence Science and Technology Laboratory of developing and trialling a recovery model to investigate the early management of contaminated war wounds. A New Zealand White rabbit flexor carpi ulnaris muscle belly, isolated and then injured by a drop rig mechanism, was contaminated with Staphylococcus aureus to provide a reproducible contaminated muscle wound. This model was developed to support a series of randomised controlled trials to determine the impact of antimicrobial dressings on decreasing the bacterial burden of combat related extremity wounds. The results of the initial trial indicated that over a 48-h period, dressings augmented with antiseptic or silver offer no advantage over saline-soaked gauze in reducing the bacterial burden of a contaminated soft tissue injury. The model has subsequently been used to investigate the efficacy of dressings over a 7-day study period and impact of antibiotics and to evaluate biofilm formation and wound cytokines.

Modern military surgery: lessons from Iraq and Afghanistan.

The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma. The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research. In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East.

Historical origins and current concepts of wound debridement.

In the late 18th Century wound debridement consisted of incision of skin and deep fascia to release the swelling associated with ballistic injury, however extremity war wounds were more usually managed non-operatively or by amputation. During the First World War debridement was redefined to include excision of all non-viable and foreign material. In the modern era it has been proposed that wounds contain a zone of injured tissue which is not obviously non-viable at the initial debridement. Debridement which preserves this tissue has been described as marginal debridement. Wounds sustained in close proximity to explosions have an extensive zone of injury. Preservation of traumatised tissue may be beneficial in terms of limb salvage and limb reconstruction. Equally the complexity and contamination of these wounds, as well as the physiological frailty of the casualty, may make complete debridement in one sitting an unachievable goal. Where traumatised tissue has been left during debridement it must be reassessed at around 48 hours in order to reduce the risk of infection. Evacuation timelines and logistic infrastructure currently support serial marginal debridement but in future conflicts this may not be the case.

Initial extremity war wound debridement: a multidisciplinary consensus.

A joint meeting of the Limb Trauma and Wounds Working Groups resulted in the establishment of 29 consensus recommendations for the conduct of initial extremity war wound debridement. Pre-operative, operative and post-operative phases of debridement were considered along with wound irrigation and dressings. Wounds where a different surgical approach is required, such as superficial soft tissue wounds at one end of the spectrum and complex wounds sustained in close proximity to explosions at the other, were also discussed. The recommendations represent the consensus opinion of orthopaedic, vascular and plastic surgeons, as well as nursing officers, from across the Defence Medical Services and are intended to provide useful guidance to the deploying surgeon, regardless of their own personal experience.

Fractures of the pelvis.

High energy fractures of the pelvis are a challenging problem both in the immediate post-injury phase and later when definitive fixation is undertaken. No single management algorithm can be applied because of associated injuries and the wide variety of trauma systems that have evolved around the world. Initial management is aimed at saving life and this is most likely to be achieved with an approach that seeks to identify and treat life-threatening injuries in order of priority. Early mortality after a pelvic fracture is most commonly due to major haemorrhage or catastrophic brain injury. In this article we review the role of pelvic binders, angiographic embolisation, pelvic packing, early internal fixation and blood transfusion with regard to controlling haemorrhage. Definitive fixation seeks to prevent deformity and reduce complications. We believe this should be undertaken by specialist surgeons in a hospital resourced, equipped and staffed to manage the whole spectrum of major trauma. We describe the most common modes of internal fixation by injury type and review the factors that influence delayed mortality, adverse functional outcome, sexual dysfunction and venous thromboembolism.

Traumatic variation of popliteal artery entrapment syndrome.

Popliteal artery entrapment syndrome is a well recognised sequelae of anatomical variation in the origin of the medial head of gastrocnemius. It classically presents with distal ischaemia from progressive intimal fibrosis and eventual thrombosis. We present a unique case of acute lower limb ischaemia precipitated by trauma in a young man with undiagnosed popliteal artery entrapment. In this case sudden stress of the lower limb resulted in tearing of the tunica intima of the entrapped artery and exposure of the subendothelium with subsequent thrombus, distal embolisation and acute ischaemia. Successful limb salvage was achieved through endovascular thrombolysis and arterial reconstruction.