The Whole Hospital Information System (WHIS) was introduced to Camp Bastion on 01 Feb 2012. It is a custom-built software solution for electronic patient records. A one-day training package is mandatory as part of current pre-deployment training

The aim of this study was to identify how well the data recorded on WHIS correlates with the information recorded within the paper-based theatre logbook.

A bespoke search was created by the Hospital J6 team, which identified the procedure, the surgeons involved, the date and time of the procedures and the demographic of the patient. The search was completed to include all operations performed from 01 Feb 2012 to 31 Mar 2013. This corresponds to the first 14 months of WHIS usage.

The results at first looked promising, showing that 2672 surgical episodes had been performed, with an average 1.68 (0–11) procedures per episode, and 2.1 (0–9) surgeons per case. The mean operative duration was 98 minutes. However on closer scrutiny, the records showed that 447 cases (16.7%) had no procedure and 138 (5.2%) cases had no surgeon. 29 (1.1%) cases had no procedure and no surgeon recorded.

The data recorded on WHIS during the study period is not currently complete enough to discontinue usage of paper records.

Ballistic fractures are devastating injuries often necessitating reconstructive surgery or amputation. Complications following surgery are common, particularly in the austere environment of war. Workload from the recent conflict was documented in order to guide future medical need. All data on ballistic fractures was collected prospectively. Fractures were scored using the Red Cross Fracture Classification.

During the first two weeks of the conflict, 202 Field Hospital was the sole British hospital in the region. Thereafter, until the end of the conflict, it became the tertiary referral hospital for cases requiring orthopaedic and plastic surgery opinions. Thirty-nine patients, with 50 ballistic fractures were treated by British military surgeons. Patients were predominantly Iraqi (20 enemy prisoners of war and 15 civilians); 4 children sustained five fractures.

Fifty percent were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. A total of 30 per cent of wounds became infected, 12 per cent were deep infection necessitating surgical drainage. Thirteen limbs were amputated; seven were traumatic amputations.

Ballistic fractures remain a challenge for surgeons in times of war. There is a continued need to relearn the principles of war surgery in order to minimise complications and restore function. Military medical skills training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts.

UK military forces have been deployed in Afghanistan since 2006 as part of the International Stabilisation Assistance Force. The Operation is supported by a 50-bedded hospital. In 2007 the Defence Medical Services introduced a massive haemorrhage policy. In asymmetric warfare gunshot wounds (GSW), improvised explosive devices (IED) and mine injuries are prevalent and we hypothesized that they would require significant blood products.

We prospectively collected data from consecutive trauma resuscitations over 3 months (January to March 2008). Pre-hospital time points, mechanism of injury, injury distribution, injury severity score (ISS), new injury severity score (NISS), surgical procedures, blood product utilisation and outcome were recorded.

115 trauma resuscitations were performed over the study period. Median pre-hospital time was 95 minutes (range 30–325), with median 64 minutes to the arrival of the Medical Emergency Response Team helicopter. The cause of injury was landmine (20), IED (31) and GSW (40); mean number of involved body systems was 1.4, 1.8 and 1.5 respectively and injured structures 2.8, 3.5 and 2.3 respectively (IED> GSW p< 0.05). Mean ISS was 16, 16.8, 14.9 and NISS 18.7, 20.9, and 17.9 respectively. Blood transfusion was required in 3 mine, 14 IED and 17 GSW casualties (mine< IED & GSW, p< 0.05) with 10.6, 11.4, and 13.9 units of blood transfused per casualty.

Injury severity for casualties is high with multiple injuries to body systems irrespective of mechanism. Anti-personnel mine injuries were significantly less likely to require transfusion. Large quantities of blood products were still required when necessary in all mechanisms of trauma. It is therefore recommended that during the pre-hospital time the major transfusion protocol should be placed on stand-by.

Introduction: Young active patients with malignant tumours arising in the distal fibula, requiring bone and soft tissue excision, present a challenge to the treating surgeon. Wide local excision is advocated, to achieve clearance, however, disruption of the ankle mortise results and fusion is often required to restore stability. The loss of movement is poorly tolerated in the younger patient and leads to progressive degenerative changes in surrounding joints.

Method: Excision of the distal fibula lesion followed by rotation of the proximal fibula on its vascular pedicle recreates the ankle mortise with consequent restoration of ankle stability and retaining ankle movement.

Results: Between 2000 and 2008, we have performed this technique on four patients, (2F, 2M) mean age 21 (13–33). Diagnoses were that of chondrosarcoma, parosteal osteosarcoma, Ewings sarcoma and osteofibrodysplasia. Follow up at 5 years (18m-8 year) with no evidence of local or distant recurrence. One case was complicated by deep infection requiring surgical debridement and antibiotic therapy. In all cases the fibula grafts survived. Good to excellent functional results were achieved (Toronto Extremity Salvage Scores, mean 88 range 82–94).

Discussion: We will present the technical aspects of this procedure with particular reference to the most recent case, performed on a young female patient with parosteal osteosarcoma.

We believe this technique provides good oncological and functional results and recommend this treatment option is considered in young active patients required distal fibula excisions for sarcoma.

Background: Total ankle replacement (TAR) has become an established surgical procedure for the management of end-stage ankle arthropathy offering an alternative to ankle fusion. Controversy exists over whether to correct concomitant hindfoot arthropathy or malalignment as a separate procedure or simultaneously with TAR. Simultaneous surgery confers the advantage of one operation and recovery period, however, many authors believe complication rates may be higher and long-term function compromised.

Method: A retrospective review of all patients, between January 2003 and January 2007, who had undergone simultaneous bony hindfoot or midfoot corrective surgery and TAR, at our institution was performed. A matched group of primary TAR patients were included as controls. Mean follow-up was 38 and 39 months respectively. Data collected included demographics and indications, details of operative procedure, and complications with outcomes assessed by patient satisfaction, range of movement, walking distance and Visual Analogue Score (VAS) for pain.

Results: The two groups were matched for age, sex, follow-up, prostheses and diagnosis. The underlying pathology was predominantly osteoarthritis. Mean VAS improved by 7.66 points in the TAR alone group and 8 points in the TAR and adjuvant surgical procedure group. There was no statistical difference in infection, delayed wound healing, malleolar fracture or re-operation rates between the two groups.

Conclusion: We believe that an experienced Foot and Ankle surgeon can perform corrective hindfoot or mid-foot surgery simultaneously with TAR without significantly compromising outcome.

British military forces remain heavily committed in both Iraq and Afghanistan. A recent workload analysis from Op HERRICK identified a high surgical workload, particularly orthopaedic, under the care of a sole consultant orthopaedic surgeon. There are no orthopaedic training posts in UK that consistently provide training in ballistic trauma. In order to prepare Military orthopaedic trainees for future deployment, a new orthopaedic registrar post, on Op HERRICK, was created.

Prospective analysis of trainee and trainer operative logbooks, between Jan 27th and March 24th 2008, was performed. Records were kept of orthopaedic and postgraduate teaching schedules, audit and research projects and all OCAP training assessments.

One hundred and fifty-seven cases and 272 procedures were performed during the study period. Sixty-two per cent of cases were orthopaedic. Fourteen major amputations were performed and 7 external fixators applied. Five fasciotomies, 9 skeletal traction pins were inserted and 7 skin grafting procedures were performed. Limb debridement was the most common procedure (n=59). Eleven per cent of cases were children and 50 per cent of cases were emergencies. Thirty-eight per cent of cases were performed out of hours (18.00–08.00 hrs). Mean operating hours per week was 35 hrs. Four Procedure Based Assessments were performed and 16 hours of postgraduate education was conducted during the deployment. Two major audits were initiated and five publications were prepared, one has already been accepted for publication.

Trainee exposure to high-energy transfer trauma is high when compared to that seen in the NHS. The numbers of certain index procedures, such as external fixation, is similar to those achieved by an average orthopaedic trainee in six years of higher surgical training. The opportunity for one-on-one training exceeds that available in the NHS and learning and academic opportunities are maximised due to the close working environment.

Young active patients with malignant tumours arising in the distal fibula, requiring excision, present a challenge to the treating surgeon. Wide local excision is advocated, to achieve clearance, however, disruption of the ankle mortise results and fusion is often required to restore stability. The loss of movement is poorly tolerated in the younger patient and leads to progressive degenerative changes in surrounding joints.

Excision of the distal fibula lesion followed by harvesting of the proximal fibula and using this graft to recreate the ankle mortise restores ankle stability and retains ankle movement.

Between 1998 and 2007, we have performed this technique on 4 patients. Diagnoses were Ewing’s sarcoma, chondrosarcoma, parosteal osteosarcoma and osteofibrous dysplasia. To date there has been no evidence of distant or local recurrence. One case was complicated by infection, which resolved with radical debridement and antibiotics; the other three fibula grafts survived. Good to excellent results were achieved.

We will present the technical aspects of this procedure, with particular reference to the most recent case, performed on a young female patient with parosteal osteosarcoma.

We believe this technique provides good oncological and functional results and recommend this treatment option is considered in young active patients requiring distal fibula excisions for sarcoma.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

Objectives: Behind armour blunt trauma (BABT) to the thorax results from motion of the body wall arising from the defeat of high-energy projectiles by body armour. NATO predicts that BABT will increase in future conflicts. This study aims to define biomechanical tolerance levels for BABT to the lateral thorax.

Methods: Terminally anaesthetised pigs (n=19) were subjected to 4 levels of severity of BABT (Table). Two types of armour plates were used. Group 1 were subjected to a 7.62 mm round (INIBA armour) whilst group 2 was subjected to a 12.7 mm round (EBA armour) the latter group being further subdivided by the presence or absence of two thicknesses of trauma attenuating backing (TAB). Accelerometers were attached to the pleural aspect of ribs 7, 8 and 9 mid-way between the spine and the sternum.

Results: Outcome was assessed by classifying severity of injury, in terms of mortality, into 3 groups – survivors (animals surviving to 6 h post-impact), early (0–30 min) and late deaths (> 30 min–6 h). The peak acceleration values were obtained from the accelerometer closest to the point of impact. Mean peak acceleration was significantly higher in the early death group (1070 km/s²) compared to survivors (591 km/s²) (p< 0.05).

There were 6 early deaths, 5 late deaths and 8 survivors. In terms of outcome Group 1 represented the lowest threat with 5 survivors and 1 late death. The animals in Group 2 with no TAB fared worst with 2 early deaths, one late death and no survivors. Deaths were due to respiratory failure/apnoea (n=4), pneumothorax (n=2), haemothorax (n=1), respiratory failure/pulmonary contusion (n=3) and ventricular fibrillation (n=1).

Conclusions: Peak acceleration of the body wall may be used to rank the outcome following BABT. There is a significant difference in peak acceleration at the extremes of the injury scale.

Background: Ballistic fractures produce a significant burden on medical facilities in war. Workload from the recent conflict was documented in order to guide future medical needs.

Method: All data on ballistic fractures was collected prospectively. Wounds were scored using the Red Cross Wound Classification and the Red Cross Fracture Classification.

Results: During the first two weeks of the conflict, 202 Field Hospital was the sole British hospital in the region. Thereafter, until the end of the conflict, it became the tertiary referral hospital for cases requiring orthopaedic and plastic surgery opinions. Thirty-nine patients, with 50 ballistic fractures, had their initial surgery performed by British military surgeons. Fifty-two percent (26/50) were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. Four children sustained five fractures. Thirty per cent of wounds became infected. Thirteen limbs were amputated; seven were traumatic amputations. The relationship between those fractures with adverse outcomes and their fracture and wound scores will be discussed.

Conclusion: War is changing; modern conflicts appear likely to be fought in urban or remote environments, producing different wounding patterns and placing civilians in the line of fire. Military medical skills training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts.

Anti-personnel (AP) mines pose a serious threat to mine clearance personnel and developing effective foot/ leg protection is of benefit. In order to evaluate the effectiveness of a protective system it is necessary to have a physical model of the human leg and foot that replicates bony injury from AP mines.

The purpose of this study was to develop and assess a lower limb model (LLM) that reflects human bony injury from AP mines.

The LLM comprised a red deer tibia, calcaneum, talus, tarsus and metatarsal encased in 20% gelatine. A British Army combat boot was fitted onto the LLM. Two types of simulated AP mine were used comprising 29g and 50g of plastic explosive (PE). Mines were surface laid and the heel of the boot was placed directly over the top of the mine. Firings with both mine types were performed with the heel in contact with the mine. Further firings with the 50g PE mine included a variable stand-off (e.g. distance of the sole of the boot from the mine) of 25–100mm.

The LLM was assessed for bony injury using the International Committee for the Red Cross (ICRC) mine injury system and a mine fracture score (MFS). The pattern of injury resulting from the two mine types, with no stand-off, was different. The 50g mine produced traumatic amputations in four out of five firings, fractures occuring at 3–11 cm from the ankle joint line (pattern 1 injury – ICRC classification). The 29g mine produced hindfoot injuries with comminuted fractures of the calcaneum and talus in all five firings. These are similar to the bony injuries seen in AP mine casualties in Croatia. Use of the MFS allowed comparison with previous cadaver experiments and demonstrated a graded response to increasing stand-off.

The LLM replicated the pattern of some bony injuries seen in landmine casualties and could be used to assess the effectiveness of mine protective foot/leg wear.

Phosgene has been deployed as a CW and is also widely used in the chemical industry. Following exposure, acute lung injury (ALI) occurs after a latency period of 6 – 12 h, with pulmonary oedema ensuing. Death may occur 6–24 h after exposure. There is no specific therapy.

Conventional ventilation strategies (VS) for the treatment of ALI and ARDS utilise tidal volumes of 10 – 12 ml.Kg⁻¹ with variable PEEP. A recent multinational clinical trial advocates a protective VS (PVS) combining reduced tidal volume and increased PEEP, which resulted in a significant reduction in mortality.

The purpose of this study is to determine if a similar strategy is beneficial in the treatment of PIALI.

Twenty female pigs were anaesthetised and instrumented for the collection of physiological and biochemical data. Following surgery the animals equilibrated for 1 hour, and exposed to air (Control) or Phosgene (10 min). At 30 minutes post exposure, ventilation was initiated and the animals further divided into treatment groups prior to monitoring for up to 24 hours.

Preliminary results show that, utilising a PVS, there is an increase in oxygenation together with reduced mortality at 24 hour post exposure. Post mortem showed a decrease in severity of pathology and lung wet weight/ body weight ratio.

These results would indicate that in a clinical situation this strategy would be of benefit in the treatment of PIALI.