Spinal fractures in current military deployments.

OBJECTIVE: To describe spinal fracture patterns presenting to deployed medical facilities during recent military operations. METHODS: Retrospective analysis of the United Kingdom Centre for Defence Imaging Computed Tomography database, 2005-2009. Fractures are classified, mechanism noted and associated injuries recorded. Statistical analysis is by Fisher's Exact test. RESULTS: 128 fractures in 57 casualties are analysed. Ballistic (79%) and non-ballistic mechanisms contribute to vertebral fracture at all regions of the spinal column in patients treated at deployed medical facilities. There is a high incidence of lumbar spine fractures, which are more likely to be due to explosion than gunshot wounding (p < 0.05). Two thirds of thoracolumbar spine fractures caused by explosive devices are unstable and are mainly burst-fractures in configuration. 60% of spinal fracture patients had concomitant injuries. There is a strong relationship between spinal fractures caused by explosions and lower limb fractures. CONCLUSION: Injuries to the spine caused by explosive devices account for greater numbers, greater associated morbidity and increasing complexity than other means of spinal injury managed in contemporary warfare. With the predominance of explosive injury in current conflict, this work provides the first detail of an evolving injury mechanism with implications for injury mitigation research.

Accurate placement of a pelvic binder improves reduction of unstable fractures of the pelvic ring.

The aim of this study was to assess the accuracy of placement of pelvic binders and to determine whether circumferential compression at the level of the greater trochanters is the best method of reducing a symphyseal diastasis. Patients were identified by a retrospective review of all pelvic radiographs performed at a military hospital over a period of 30 months. We analysed any pelvic radiograph on which the buckle of the pelvic binder was clearly visible. The patients were divided into groups according to the position of the buckle in relation to the greater trochanters: high, trochanteric or low. Reduction of the symphyseal diastasis was measured in a subgroup of patients with an open-book fracture, which consisted of an injury to the symphysis and disruption of the posterior pelvic arch (AO/OTA 61-B/C). We identified 172 radiographs with a visible pelvic binder. Five cases were excluded due to inadequate radiographs. In 83 (50%) the binder was positioned at the level of the greater trochanters. A high position was the most common site of inaccurate placement, occurring in 65 (39%). Seventeen patients were identified as a subgroup to assess the effect of the position of the binder on reduction of the diastasis. The mean gap was 2.8 times greater (mean difference 22 mm) in the high group compared with the trochanteric group (p < 0.01). Application of a pelvic binder above the level of the greater trochanters is common and is an inadequate method of reducing pelvic fractures and is likely to delay cardiovascular recovery in these seriously injured patients.

A retrospective study into the levels of evidence presented at the Combined Services Orthopaedic Society annual meeting.

OBJECTIVES: The role of Evidence Based Medicine in clinical care is to provide a framework for the integration of expertise, current evidence and the needs of the individual patient. Research presented at scientific meetings is an important source of such evidence, informing clinical decision making both on military operations and in home nation health care systems. The aim of this study is to review the levels of evidence presented at the Combined Services Orthopaedic Society (CSOS) and two other related scientific meetings. METHODS: Retrospective review of abstracts presented at the annual scientific meetings of the CSOS, Society of Military Orthopaedic Surgeons (SOMOS) and the British Trauma Society (BTS). Basic science studies, animal studies, cadaveric studies, surveys and guest lectures were excluded. Research abstracts were categorised according to the Centre for Evidence-Based Medicine's (CEBM) hierarchy of evidence. Statistical comparison was performed to investigate differences in evidence levels presented at each scientific meeting and between each year of the CSOS meeting. RESULTS: 596 abstracts met the inclusion criteria for this study (179 CSOS, 173 SOMOS, 244 BTS). Level IV evidence accounted for the majority of presented abstracts at each meeting (72.6% CSOS, 69.4% SOMOS, 68.9% BTS). Level I evidence was uncommon at each meeting (6.1% CSOS, 5.2% SOMOS, 2.9% BTS). There was no statistical difference in the evidence levels presented at the three scientific meetings. CONCLUSIONS: The proportion of comparative clinical studies (Levels I-III) presented at military or trauma societies' scientific meetings reflects the difficulty of performing research in emergency surgery. This is further exacerbated in the military environment where operational commitments and delivery of care take priority. However, the future value of comparative clinical research in battlefield healthcare could have an enduring legacy that shapes trauma care for many decades.

The effect of post-operative mechanical axis alignment on the survival of primary total knee replacements after a follow-up of 15 years.

Correct positioning and alignment of components during primary total knee replacement (TKR) is widely accepted to be an important predictor of patient satisfaction and implant durability. This retrospective study reports the effect of the post-operative mechanical axis of the lower limb in the coronal plane on implant survival following primary TKR. A total of 501 TKRs in 396 patients were divided into an aligned group with a neutral mechanical axis (± 3°) and a malaligned group where the mechanical axis deviated from neutral by > 3°. At 15 years' follow-up, 33 of 458 (7.2%) TKRs were revised for aseptic loosening. Kaplan-Meier survival analysis showed a weak tendency towards improved survival with restoration of a neutral mechanical axis, but this did not reach statistical significance (p = 0.47). We found that the relationship between survival of a primary TKR and mechanical axis alignment is weaker than that described in a number of previous reports.

Infection in conflict wounded.

Although mechanisms of modern military wounding may be distinct from those of ancient conflicts, the infectious sequelae of ballistic trauma and the evolving microbial flora of war wounds remain a considerable burden on both the injured combatant and their deployed medical systems. Battlefield surgeons of ancient times favoured suppuration in war wounding and as such Galenic encouragement of pus formation would hinder progress in wound care for centuries. Napoleonic surgeons eventually abandoned this mantra, embracing radical surgical intervention, primarily by amputation, to prevent infection. Later, microscopy enabled identification of microorganisms and characterization of wound flora. Concurrent advances in sanitation and evacuation enabled improved outcomes and establishment of modern military medical systems. Advances in medical doctrine and technology afford those injured in current conflicts with increasing survivability through rapid evacuation, sophisticated resuscitation and timely surgical intervention. Infectious complications in those that do survive, however, are a major concern. Addressing antibiotic use, nosocomial transmission and infectious sequelae are a current clinical management and research priority and will remain so in an era characterized by a massive burden of combat extremity injury. This paper provides a review of infection in combat wounding from a historical setting through to the modern evidence base.

Variation in bone mineral density by anatomical site in patients with proximal humeral fractures.

Low-energy fractures of the proximal humerus indicate osteoporosis and it is important to direct treatment to this group of patients who are at high risk of further fracture. Data were prospectively collected from 79 patients (11 men, 68 women) with a mean age of 69 years (55 to 86) with fractures of the proximal humerus in order to determine if current guidelines on the measurement of the bone mineral density at the hip and lumbar spine were adequate to stratify the risk and to guide the treatment of osteoporosis. Bone mineral density measurements were made by dual-energy x-ray absorptiometry at the proximal femur, lumbar spine (L2-4) and contralateral distal radius, and the T-scores were generated for comparison. Data were also collected on the use of steroids, smoking, the use of alcohol, hand dominance and comorbidity. The mean T-score for the distal radius was -2.97 (SD 1.56) compared with -1.61 (SD 1.62) for the lumbar spine and -1.78 (SD 1.33) for the femur. There was a significant difference between the mean lumbar and radial T scores (1.36 (1.03 to 1.68); p < 0.001) and between the mean femoral and radial T-scores (1.18 (0.92 to 1.44); p < 0.001). The inclusion of all three sites in the determination of the T-score increased the sensitivity to 66% compared with that of 46% when only the proximal femur and lumbar spine were used. This difference between measurements in the upper limb compared with the axial skeleton and lower limb suggests that basing risk assessment and treatment on only the bone mineral density taken at the hip or lumbar spine may misrepresent the extent of osteoporosis in the upper limb and the subsequent risk of fracture at this site. The assessment of osteoporosis must include measurement of the bone mineral density at the distal radius to avoid underestimation of osteoporosis in the upper limb.

Glomus tumour following a total knee replacement: a case report.

Pain following total knee replacement (TKR) is a common problem and cause of poor satisfaction amongst patients. We report on a glomus tumour causing pain on the anterolateral aspect of the knee, 2 years after an otherwise successful total knee replacement for osteoarthritis. The tumour was treated by excision biopsy under general anaesthesia and the diagnosis confirmed by histopathological examination. The removal of the tumour relieved the pain and the patient regained good function. We conclude that a thorough clinical assessment of a patient with a painful knee following TKR is essential to detect and treat coincidental painful pathology.

Management of a complex hind foot war injury with negative pressure wound therapy: a case study.

We report the use of Negative Pressure Wound Therapy (NPWT) in a 39 year old patient with a complex open hind foot injury. The patient sustained an open calcaneal fracture with extensive soft tissue damage following the detonation of an explosively formed penetrating round in a confined space. A remarkable recovery was made following surgical debridement, internal fixation of the fracture and use of NPWT over the soft tissue injury. The patient returned to his normal level of function, without complications within a few months.