Surgical advances during the First World War: the birth of modern orthopaedics.

The First World War (1914-1918) was the first truly industrial conflict in human history. Never before had rifle fire and artillery barrage been employed on a global scale. It was a conflict that over 4 years would leave over 750,000 British troops dead with a further 1.6 million injured, the majority with orthopaedic injuries. Against this backdrop, the skills of the orthopaedic surgeon were brought to the fore. Many of those techniques and systems form the foundation of modern orthopaedic trauma management. On the centenary of 'the War to end all Wars', we review the significant advances in wound management, fracture treatment, nerve injury and rehabilitation that were developed during that conflict.

Risk stratification for the recurrence of trigger thumb after surgical release in the paediatric patient.

Trigger thumb, or stenosing tenovaginitis, is a relatively uncommon condition affecting the flexor pollicis longus tendon of children. The condition is characterized by the formation of a nodule within the tendon and thickening of the tendon sheath as it passes through the flexor pulley of the thumb at the level of the metacarpo-phalangeal joint. The optimum age for surgical intervention continues to be discussed. The aim of this study is to establish the temporal relationship and surgical variables to determine factors that may contribute to recurrence of the condition. A retrospective analysis of the entire surgical logbook and patient notes of a stand-alone consultant paediatric orthopaedic practice was scrutinized. 94 patients, 107 thumbs, over a 13-year period were operated on for trigger thumb. The recurrence rate was found to be 5.61 %. The average age of patients at primary release who went on to recurrence was 2.8 years, which is significantly younger than those that did not recur (p = 0.044). Sensitivity analysis revealed that the primary procedure at an age of less than 2.5 years confers a higher risk of recurrence. The data presented here advocate surgical release of trigger thumb after 2½ years of age, a senior surgeon as lead operator and a transverse skin incision at the level of the nodule or a more extensive "zig-zag" one to clearly see the structures to be released. We recommend that the surgeon ensures the stenosing pulley and sheath are released in their entirety.

What Is the Magnitude and Long-term Economic Cost of Care of the British Military Afghanistan Amputee Cohort?

BACKGROUND: Personal protection equipment, improved early medical care, and rapid extraction of the casualty have resulted in more injured service members who served in Afghanistan surviving after severe military trauma. Many of those who survive the initial trauma are faced with complex wounds such as multiple amputations. Although costs of care can be high, they have not been well quantified before. This is required to budget for the needs of the injured beyond their service in the armed forces. QUESTION/PURPOSES: The purposes of this study were (1) to quantify and describe the extent and nature of traumatic amputations of British service personnel from Afghanistan; and (2) to calculate an estimate of the projected long-term cost of this cohort. METHODS: A four-stage methodology was used: (1) systematic literature search of previous studies of amputee care cost; (2) retrospective analysis of the UK Joint Theatre Trauma and prosthetic database; (3) Markov economic algorithm for healthcare cost and sensitivity analysis of results; and (4) statistical cost comparison between our cohort and the identified literature. RESULTS: From 2003 to 2014, 265 casualties sustained 416 amputations. The average number of limbs lost per casualty was 1.6. The most common type of amputation was a transfemoral amputation (153 patients); the next most common amputation type was unilateral transtibial (143 patients). Using a Markov model of healthcare economics, it is estimated that the total 40-year cost of the UK Afghanistan lower limb amputee cohort is £288 million (USD 444 million); this figure estimates cost of trauma care, rehabilitation, and prosthetic costs. A sensitivity analysis on our model demonstrated a potential ± 6.19% variation in costs. CONCLUSIONS: The conflict in Afghanistan resulted in high numbers of complex injuries. Our findings suggest that a long-term facility to budget for veterans' health care is necessary. CLINICAL RELEVANCE: Estimates here should be taken as the start of a challenge to develop sustained rehabilitation and recovery funding and provision.

Heterotopic ossification in victims of the London 7/7 bombings.

Heterotopic ossification (HO) is the formation of bone at extraskeletal sites. Over 60% of amputees injured by improvised explosive devices in the recent conflict in Afghanistan have developed HO, resulting in functional impairment. It is hypothesised that a key aetiological factor is the blast wave; however, other environmental and medical risk factors, which the casualties have been exposed to, have also been postulated. The suicide terrorist bombings in London in 2005 resulted in many blast-related casualties, many of whom were managed by the Royal London Hospital. This cohort of severely injured patients whose injuries also included trauma-related amputations shared some, but not all, of the risk factors identified in the military population. We reviewed these patients, in particular to assess the presence or absence of military-established risk factors for the formation of HO in these casualties.

Posterior mini-incision total hip arthroplasty controls the extent of post-operative formation of heterotopic ossification.

Heterotopic ossification (HO) is the formation of bone at extra-skeletal sites. Reported rates of HO after hip arthroplasty range from 8 to 90 %; however, it is only severe cases that cause problems clinically, such as joint stiffness. The effects of surgical-related controllable intra-operative risk factors for the formation of HO were investigated. Data examined included gender, age of patient, fat depth, length of operation, incision length, prosthetic fixation method, the use of pulsed lavage and canal brush, and component size and material. All cases were performed by the same surgeon using the posterior approach. A total of 510 cases of hip arthroplasty were included, with an overall rate of HO of 10.2 %. Longer-lasting operations resulted in higher grades of HO (p = 0.047). Incisions >10 cm resulted in more widespread HO formation (p = 0.021). No further correlations were seen between HO formation and fat depth, blood loss, instrumentation, fixation methods or prosthesis material. The mini-incision approach is comparable to the standard approach in the aetiology of HO formation, and whilst the rate of HO may not be controllable, a posterior mini-incision approach can limit its extent.

Campylobacteriosis outbreak associated with consumption of undercooked chicken liver pâté in the East of England, September 2011: identification of a dose-response risk.

A foodborne outbreak with 49 cases (22 culture positive for Campylobacter sp.) following a wedding party in the East of England was investigated. A retrospective cohort study identified an association between consumption of chicken liver pâté and infection with Campylobacter jejuni/coli. There was a statistically significant association between dose (amount of chicken liver pâté eaten) and the risk of disease ['tasted': odds ratio (OR) 1·5, 95% confidence interval (CI) 0·04-∞; 'partly eaten': OR 8·4, 95% CI 1·4-87·5; 'most or all eaten': OR 36·1, 95% CI 3·3-2119). The local authority found evidence that the preparation of chicken livers breached Food Standards Agency's guidelines. This epidemiological investigation established a clear dose-response relationship between consumption of chicken liver pâté and the risk of infection with Campylobacter. The continuing need to raise public awareness of the risk to human health posed by undercooked chicken liver is evident.

Persistence of 2,4-D and its effects on benthic macroinvertebrates following spring treatment of Eurasian Watermilfoil, Myriophyllum spicatum L. in two lakes in southeastern Wisconsin, USA.

The purpose of this study was to determine the persistence of 2,4-dichlorophenoxyacetic acid (2,4-D) applied to two lakes (one mesotrophic and one eutrophic) for the control of Eurasian watermilfoil (EWM), and to determine the impacts of 2,4-D on benthic macroinvertebrates in one of the lakes. One lake was treated with a liquid formulation, and the other with a slow release granular formulation of 2,4-D. Concentrations of 2,4-D in the water column were highest 1 and 2 days post-treatment and declined to below detection limits by 7 and 10 days post-treatment. We observed negative correlations between days post-treatment and taxa richness, and between days post-treatment and abundance of three of 12 taxonomic groups of macroinvertebrates. Lake managers need to balance control of EWM with possible impacts of 2,4-D to nontarget organisms.

Risk factors for time to diagnosis of feline upper respiratory tract disease in UK animal adoption shelters.

Feline upper respiratory tract disease (URTD), mainly caused by feline calicivirus (FCV) and feline herpesvirus, is a major cause of disease outbreaks in feline accommodation such as animal shelters, catteries and multi-cat households. We conducted a longitudinal, yearlong study in five UK feline animal shelters to identify risk factors for the time to diagnosis of URTD. We were especially interested in risk factors that could be identified at the time the cat entered the shelter. Shelter staff recorded data for 1,434 cats during 2002-2003. Most of the cats were domestic shorthair cats and were from private households, or were stray or abandoned. Sixty cats without clinical signs of URTD at entry had URTD diagnosed (typically within the first month at the centre). We used two multivariable models: one was a Cox proportional-hazards model, and the other a regression analyses with complementary log-log model. The hazard varied substantially between shelters and was considerably lower for the shelter that had a purpose-built admissions unit with its own isolation facilities. The hazard was greater for purebred cats (HR 4.3-5.0) and for neutered cats (HR 2.0). The hazard was also typically greater if the centre had a greater proportion of cats present with URTD. The analyses suggested that the centre-level risk factors were more important in determining hazard than cat-level risk factors.

Burn injuries from the london suicide bombings: a new classification of blast-related thermal injuries.

In July 2005, four suicide bombers detonated explosive improvised high explosive devices (IEDs) in three separate underground carriages and a double decker bus in London, resulting in 56 deaths and 775 injured. This study aims to understand the mechanisms and patterns of burn injuries from high explosives, and the related factors that determine mortality. The types and patterns of burn injuries in survivors and fatalities in the confined underground train carriages and the bus were analysed, evaluating injury severity score and the victims' relative position from the detonation point. The data were sourced from collated police witness statements, hospital records, forensic post mortem examinations and forensic examinations at the scene. The detonation of an explosive device in a confined space causes complex injuries to the human body, resulting in blast-related direct thermal and radiant burns. Injury patterns and mortality were related to crowd density, enclosure design, position of the victims and proximity to the device. Suicide bombings using IEDs will result in direct thermal burns and radiant burns currently categorised in the quaternary (miscellaneous) blast injury group. We propose a classification of these burns following an analysis of the London bombing data with respect to burns in both the fatalities and survivors. Distance from the device, crowd density and environment influences these burns.

En juillet 2005, 4 kamikazes faisaient exploser leur engin artisanal dans 3 rames de métro et 1 autobus à impériale de Londres, faisant 56 morts et 775 blessés. Cette étude a pour but d'étudier les mécanismes et la physiopathologie des brûlures liées à une explosion ainsi que d'évaluer les facteurs associés de mortalité. Nous avons analysé le type et la localisation des brûlures, l'ISS selon la position des victimes par rapport à l'épicentre. Les données provenaient des témoignages recueillis par les forces de police, des dossiers médicaux, des autopsies et des analyses de site. Une explosion en milieu clos entraînent des lésions complexes parmi lesquelles des brûlures thermiques directes et par radiation. La topographie des lésions et la mortalité étaient en relation avec la densité humaine, la topographie du volume clos, la position des victimes et leur situation par rapport à l'épicentre. Les brûlures directes et par radiation sont actuellement catégorisées dans les blasts quaternaires. A la suite des attentats londoniens, nous proposons une classification de ces brûlures, influencées par la distance à l'épicentre, la densité humaine et l'environnement.

40 years of terrorist bombings - A meta-analysis of the casualty and injury profile.

INTRODUCTION: Terrorists have used the explosive device successfully globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of high lethality and target accuracy. The aim of this study was to identify trends and analyse the demographics and casualty figures of terrorist bombings worldwide. METHODS: Analysis of the Global Terrorism Database (GTD) and a PubMed/Embase literature search (keywords "terrorist", and/or "suicide", and/or "bombing") from 1970 to 2014 was performed. RESULTS: 58,095 terrorist explosions worldwide were identified in the GTD. 5.08% were suicide bombings. Incidents per year are increasing (P<0.01). Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The kill:wounded ratio was statistically higher in suicide attacks than non-suicide attacks, 1:1.3 and 1:1.24 respectively (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe (13.2%) ranked 4th. The literature search identified 41 publications reporting 167 incidents of which 3.9% detailed building collapse (BC), 60.8% confined space (CS), 23.5% open space (OS) and 11.8% semi-confined space (SC) attacks. 60.4% reported on suicide terrorist attacks. Overall 32 deaths and 180 injuries per incident were seen, however significantly more deaths occurred in explosions associated with a BC. Comparing OS and CS no difference in the deaths per incident was seen, 14.2(SD±17.828) and 15.63 (SD±10.071) respectively. However OS explosions resulted in significantly more injuries, 192.7 (SD±141.147), compared to CS, 79.20 (SD±59.8). Extremity related wounds were the commonest injuries seen (32%). DISCUSSION/CONCLUSION: Terrorist bombings continue to be a threat and are increasing particularly in the Middle East. Initial reports, generated immediately at the scene by experienced coordination, on the type of detonation (suicide versus non-suicide), the environment of detonation (confined, open, building collapse) and the number of fatalities, and utilising the Kill:Wounded ratios found in this meta-analysis, can be used to predict the number of casualties and their likely injury profile of survivors to guide the immediate response by the medical services and the workload in the coming days.

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.

Early scintigraphic detection of experimental myocardial infarction in dogs with technetium-99m-glucaric acid.

Recent data have generated some interest in technetium-99m-(99mTc) glucaric acid as an in vivo viability marker. We studied 99mTc-glucaric acid retention in canine models of myocardial ischemia (20-min occlusion of the LAD/40-min reperfusion), acute myocardial infarction (MI) (90-min LAD occlusion/3-hr reperfusion), and chronic MI (90-min occlusion and either 48-hr or 10-day reperfusion). Regional myocardial blood flow was measured by radiolabeled microspheres. No preferential uptake of glucaric acid was observed in ischemic but viable myocardium. The compound showed high affinity for necrotic myocardial tissue for several days following injury. The preferential uptake in infarcted tissue disappeared by 10 days following injury. This study shows that 99mTc-glucaric acid acts exclusively as a marker of necrosis in canine models of MI. Technetium-99m-glucaric acid may have clinical utility in early cardiac imaging of myocardial infarction and in differentiating recent from old injuries.

Technetium-99m-labeled chemotactic peptides in acute infection and sterile inflammation.

UNLABELLED: Chemotactic peptides have been proposed as vehicles to image infection and inflammation. Previous studies have shown high uptake at the site of infection soon after injection, most likely because of specific binding to receptors on locally present leukocytes. To investigate this hypothesis, the in vivo behavior of a synthetic chemotactic peptide was compared to a control peptide of similar molecular weight with low receptor binding affinity. In addition, the potential to target to different infections and sterile inflammation was tested. METHODS: Twenty-four hours after induction of Escherichia coli, Staphylococcus aureus and zymosan abscesses, rabbits were i.v. injected with either 1 mCi of 99mTc-labeled formyl-methionyl-leucyl-phenylalanyl-lysine-hydrazinonicotinamid e (99mTc-fMLFK-HYNIC) or 99mTc-labeled hydrazinonicotinamide-methionyl-leucyl-phenylalanyl-OMe (99mTc-HYNIC-MLFOMe, control peptide). Gamma camera images were obtained at 5 min and 1, 4, 8 and 20 hr postinjection. Biodistribution was determined at 20 hr postinjection. RESULTS: The blood clearances of 99mTc-fMLFK-HYNIC and 99mTc-HYNIC-MLFOMe were similar. With time, 99mTc-fMLFK-HYNIC was retained in the abscess (E. coli), whereas the control agent 99mTc-HYNIC-MLFOMe was cleared from the abscess (0.049 +/- 0.011 versus 0.005 +/- 0.0003% 1D/g at 20 hr postinjection; p < 0.0005). Abscess-to-contralateral muscle ratios of 99mTc-fMLFK-HYNIC rose to 36.8 +/- 4.3 at 20 hr postinjection. E. coli, S. aureus and zymosan abscesses were clearly visualized from 4 hr postinjection onward. Abscess-to-background ratios increased to values varying from 4.4 +/- 0.2 (zymosan) to 7.1 +/- 0.6 (S. aureus) at 20 hr postinjection. The uptake in S. aureus and zymosan abscesses did not differ significantly from the uptake in E. coli abscesses. CONCLUSIONS: fMLFK-HYNIC is retained in both acute infection and sterile inflammation by means of specific receptor binding if sufficient cellular infiltration is present.

Potential 99mTc radiopharmaceuticals for renal imaging: tris(N-substituted-3-hydroxy-2-methyl-4-pyridinonato)technetium(IV) cations.

A series of monocationic complexes of N-substituted-3-hydroxy-2-methyl-4-pyridinones labeled with technetium(IV)-99m have been evaluated in vivo as potential radiopharmaceuticals. The pyridinones have different substituents at the ring nitrogen atom: ethyl, i-propyl, i-butyl, benzyl, phenyl, p-methoxyphenyl, 3-butoxypropyl and cyclohexyl. Biodistribution studies of the 99mTc complexes have been carried out in rabbits and mice. High kidney uptake and retention of the radionuclide has been shown in rabbits and mice with the cationic complexes of 3-hydroxy-1-(p-methoxyphenyl)-2-methyl-4-pyridinone and 1-(cyclohexyl)-3-hydroxy-2-methyl-4-pyridinone. These 99mTcL3+ compounds appear to be morphologic renal agents.

Towards developing a non-SnCl2 formulation for RP444, a new radiopharmaceutical for thrombus imaging.

There are many factors influencing the yield and radiochemical purity (RCP) of the radiopharmaceutical RP444. These include heating temperature, heating time, pH, the use of a buffering agent and a bulking agent, as well as the component (XV066, tricine, TPPTS, and Na99mTcO4) concentration. Through a series of radiolabeling experiments, we found that a formulation comprised of 20 microg of XV066, 6.5 mg of tricine, 40 mg of mannitol, 5 mg of TPPTS, and 0.1 mg of Pluronic acid dissolved in 1.0 mL of 250 mM succinate buffer (pH 5.0) gives the best RCP for RP444. The formulation can be lyophilized to form a stable crystal "cake". The radiolabeling is achieved by adding 1.5 mL generator eluant (33-133 mCi of Na99mTcO4) to a lyophilized vial and heating the reaction mixture at 100 degrees C for 10 min. Using this formulation, RP444 is prepared consistently in high yield with RCP > or = 90%. Formation of [99mTc]colloid is minimal (< 0.5%).

A 99Tcm-labelled leukotriene B4 receptor antagonist for scintigraphic detection of infection in rabbits.

In a search for a rapid and accurate imaging agent for scintigraphic detection of infection and inflammation, an LTB4 receptor antagonist, 99Tcm-RP517, which contains the hydrazino nicotinamide moiety, has been developed recently. To study the in vivo behaviour of 99Tcm-RP517, rabbits with Escherichia coli infection were injected intravenously with 99Tcm-RP517. Gamma camera images were obtained and ex vivo bio-distribution was determined at several hours post-injection (p.i.). In a separate set of rabbits the choledochal duct was cannulated to quantitatively monitor the hepatobiliary clearance of the radiopharmaceutical. The receptor binding fraction of the radiolabelled RP517 exceeded 70%. Accumulation of 99Tcm-RP517 in the abscess was visualized as early as 1 h p.i. Due to rapid blood clearance (t1/2 alpha=18+/-0.6 min, t1/2 beta=6.5+/-0.4 h) and high abscess uptake, the abscess-to-muscle ratios increased with time from 7.0+/-2.3 at 1 h p.i. to 44.3+/-4.6 at 20 h p.i. The agent mainly cleared via the hepatobiliary route: 50% of the radiolabel was recovered in the small bowel at 1 h p.i., whereas 85% was found in cecum and sigmoid at 20 h p.i. In conclusion, 99Tcm-RP517 rapidly visualized E. coli abscesses in rabbits. The agent rapidly cleared from the blood, mainly via the hepatobiliary route. High abscess-to-background ratios were achieved. The accumulation in the intestines could limit the applicability of this agent for detecting infectious processes in the abdominal area. The development of a more hydrophilic analogue of 99Tcm-RP517 could improve the clinical applicability of this agent.

Meat inspection: an overview of present practices and future trends.

This is a review of meat inspection literature, its history, current concerns and needs for the future. The value and limitations of meat inspection are discussed, along with the possible modifications or changes that are being developed to modernize an increasingly outdated method of safeguarding public health. The potential of on-farm risk assessment of slaughter animals and the practical considerations that need to be overcome are outlined. The needs of the consumer and subsequent challenges to the meat and farming industry are proposed as the driving force behind the changes occurring in veterinary public health. The current risk to consumers, from such microbial pathogens as Salmonella, Escherichia coli O157:H7 and Campylobacter infection, are highlighted.

High voltage electrical stimulation: its effect on microbial contamination of lamb carcases in a commercial abattoir.

This study was designed to establish the effect of an abattoir's commercial high voltage electrical stimulator on lamb carcase microbial contamination, including TVC, coliform and Campylobacter colony counts. Over eight visits, batches of six lamb carcases were sampled using the wet and dry swab technique both before and after passage through a high voltage electrical stimulator. On each visit three of the carcases were sent through the electrical stimulator while it was operational (the treatment group) and three carcases were sent through when the electrical stimulator had its power turned off (the control group). The swabs were placed into maximum recovery diluent, transported 'on-ice' and held at 0°C overnight before dilutions and plating out the following day. Too few coliform colonies were recovered for a meaningful analysis and no campylobacters were recovered. The total viable counts of the electrically stimulated and the control carcases were found not to be significantly different.

Welfare implications of identification of cattle by ear tags.

The damage caused by ear tags used for identification was studied by examining the ears of normal beef cattle and cull cows after slaughter, and by comparing the effects of metal and polyurethane ear tags in calves which had been double-tagged in the same ear. Metal tags were associated with more damage to the ears than polyurethane tags, the difference being most marked in the young calves, in which slight changes were found in 36.6 per cent and severe changes in 9.8 per cent of ears. There was a high incidence of blood around the point of insertion of the metal tags at three weeks old, but with the polyurethane tags only one calf showed slight evidence of blood around the point of insertion. In the beef cattle fitted with metal tags, a slight reaction was recorded in 40 per cent, a moderate reaction in 17 per cent and significant changes were found in 12 per cent of ears. By comparison, 16 per cent of ears with polyurethane tags showed only a slight reaction, and 80 per cent of the polyurethane tags were considered to be a good fit, compared with 37 per cent of metal tags. More changes were observed in the ears of the cull cows, with 23.5 per cent of ears with polyurethane tags being free from damage, compared with only 2.9 per cent of ears with metal tags.

Welfare implications of sheep ear tags.

The damaging effects of ear tags used to identify sheep were studied by examining the ears of sheep after slaughter in three different abattoirs and the ears of sheep on a farm. In total, 1040 ears with tags were examined. There were six types of ear tag: metal 'Ketchum' style loop tags; two-piece rigid plastic tags; 'Allflex' style flexible plastic tags with a male and female part; golf tee-shaped plastic ear tags; one-piece rigid plastic loop tags; and one-piece flexible plastic tags with a flap. The metal loop tags and plastic loop tags caused the most lesions, and the majority of the severe lesions. Ear tags placed near to the tip of the ear appeared to cause more damage. Some of the Ketchum style metal tags and two-piece rigid plastic tags appeared to be relatively new, as if recently fitted. These tags were more often associated with ear lesions, particularly moderate or severe lesions. The Allflex style flexible plastic tags caused the fewest problems, and the golf tee-shaped plastic tags also caused significantly fewer problems than the other tags.