Osteoprogenitors on the inner layer of periosteum are the major cellular contributors to appositional bone growth and bone repair by callus formation. Previous work showed that periosteal-derived cells have little or no osteogenic activity under standard in vitro osteogenic culture conditions. This study was conducted to determine what growth factor(s) can activate periosteal osteogenic capacity.

This study was conducted with IACUC approval. Periosteum from five equine donors was digested in collagenase for 3-4 hours at 37C. Isolated periosteal cells were maintained in DMEM/10% FBS medium and exposed to PDGF, Prostaglandin E2, BMP-2 and TGF-b3 at a range of concentrations for 72 hours. Changes in osteogenic gene expression (Runx2, OSX and ALP) were measured by qPCR. Periosteal cells were pre-treated with TGF-b3 or maintained in control medium were transferred into basal or osteogenic medium. Osteogenic status was assessed by Alizarin Red staining for mineralized matrix, ALP enzymatic activity and induction of osteogenic genes.

PDGF, PgE2 and BMP-2 had little impact on expression of osteogenic markers by periosteal cells. In contrast, TGF-b3 stimulated significant increases in Osterix (over 100-fold) ALP expression (over 70-fold). Pre-treating periosteal cells with TGF-b3 for 72 hours stimulated rapid cell aggregation and aggregate mineralization once cells were transferred to osteogenic medium, while cells not exposed to TGF-b3 exhibited minimal evidence of osteogenic activity.

This study indicate that TGF-b signaling is vital for periosteal osteogenic activity. Transient ‘priming’ of periosteal cells through TGF-b exposure was sufficient to activate subsequent osteogenesis without requiring ongoing growth factor stimulation. TGF beta ligands are secreted by many cell types, including periosteal progenitors and osteocytes, providing opportunities for both autocrine and paracrine pathways to regulate periosteal bone formation under homeostatic and reparative conditions.

Introduction

Decreases in trainees' working hours, coupled with evidence of worse outcomes when hip arthroscopies are performed by inexperienced surgeons, mandate the development of additional means of arthroscopic training. Though virtual reality simulation training has been adopted by other surgical specialities, its slow uptake in arthroscopic training is due to a lack of evidence as to its benefits. These benefits can be demonstrated through learning curves associated with simulator training – with practice reflecting measurable increases in validated performance metrics.

Summary

Objective assessment of tendon histomorphology, particularly in the context of tissue repair, requires comprehensive analyses of both cellular distribution and matrix architecture. Fourier Transform analyses of histological images collected with second harmonic generation (SHG-FT) technique provide objective, quantitative assessment of collagen fiber organization with high specificity. Concurrent nuclear staining allows simultaneous analyses of cell morphology and distribution.

Summary

Corticosteroids (CS) are commonly administered by intra-articular injection to control the symptoms of osteoarthritis; however, CSs also suppress articular chondrocyte matrix synthesis. Both triamcinolone and methylprednisolone acetate significantly suppressed BMPs −2 and −7, and TGF-b1 expression, suggesting a mechanism by which CSs suppress articular chondrocyte matrix synthesis and cartilage homeostasis.

Introduction

Implant-cement debonding at the knee has been reported previously [1]. The strength of the mechanical interlock of bone cement on to an implant surface can be associated with both bone cement and implant related factors. In addition to implant surface profile, sub-optimal mixing temperatures and waiting times prior to cement application may weaken the strength of the interlock.

Introduction

Fatigue and wear at the head/stem modular junction of large diameter total hip replacements can be exacerbated as a result of the increase in frictional torque. In vivo, a “toggling,” anterior-posterior (A-P) movement of the head taper on the trunnion may facilitate corrosion in the presence of physiological fluids, leading to increased metal ion release. Clinically, metal ion release has been linked to the formation of pseudo tumours and tissue necrosis [1].

Peripheral nerve injuries (PNI) occur in 10% of combat casualties. In the immediate field-hospital setting, an insensate limb can affect the surgeon's assessment of limb viability and in the long-term PNI remain a source of considerable morbidity. Therefore the aims of this study are to document the recovery of combat PNI, as well as report on the effect of current medical management in improving functional outcome. In this study, we present the largest series of combat related PNI in Coalition troops since World War II.

From May 2007 – May 2010, 100 consecutive patients (261 nerve injuries) were prospectively reviewed in a specialist PNI clinic. The functional recovery of each PNI was determined using the MRC grading classification (good, fair and poor). In addition, the incidence of neuropathic pain, the results of nerve grafting procedures, the return of plantar sensation, and the patients' current military occupational grading was recorded.

At mean follow up 26.7 months, 175(65%) of nerve injuries had a good recovery, 57(21%) had a fair recovery and 39(14%) had a poor functional recovery. Neuropathic pain was noted in 33 patients, with Causalgia present in 5 cases. In 27(83%) patients, pain was resolved by medication, neurolysis or nerve grafting. In 35 cases, nerve repair was attempted at median 6 days from injury. Of these 62%(22) gained a good or fair recovery with 37%(13) having a poor functional result. Forty-two patients (47 limbs) initially presented with an insensate foot. At final follow up (mean 25.4 months), 89%(42 limbs) had a return of protective plantar sensation. Overall, 9 patients were able to return to full military duty (P2), with 45 deemed unfit for military service (P0 or P8).

This study demonstrates that the majority of combat PNI will show some functional recovery. Adherence to the principles of war surgery to ensure that the wound is clear of infection and associated vascular and skeletal injuries are promptly treated will provide the optimal environment for nerve recovery. Although neuropathic pain affects a significant proportion of casualties, pharmacological and surgical intervention can alleviate the majority of symptoms. Finally, the presence of an insensate limb at initial surgery, should not be used as a marker of limb viability. The key to recovery of the PNI patient lies in a multi-disciplinary approach. Essential to this is regular surgical review to assess progress and to initiate prompt surgical intervention when needed. This approach allows early determination of prognosis, which is of huge value to the rehabilitating patient psychologically, and to the whole rehabilitation team.

The biomechanics of civilian fractures have been extensively studied with a view to defining the forces responsible e.g. bending, torsion, compression and crushing. Little equivalent work has been carried out on military fractures, although fractures from gunshot can be divided into direct and indirect. Given that the effects of blast can be sub-divided into primary, secondary, tertiary and quaternary, the aim of this study was to try to determine which effects of the blast are responsible for the bony injury. This may have implications for management and prognosis as well as prevention.

We reviewed emergency department records, case notes, and all radiographs of patients admitted to the British military hospital in Afghanistan over a 6 month period (Apr 08–Sept 08) to identify any fracture caused by an explosive mechanism. In addition we reviewed all relevant radiographs from the same period at the Royal Hospital Haslar, who report all radiographs taken, and keep a copy of the images. Early in the study it became clear that due to the complexity of some of the injuries it was inappropriate to consider bones separately and we used the term ‘fracture zone’ to identify separate areas of injury, which could involve from 1 – 28 bones. It also became clear that the pattern of injury differed considerably between patients in open ground, and those in houses or vehicles. These 2 groups were considered separately and compared.

We identified 86 patients with fractures. The 86 patients had 153 separate fracture zones (range 1–6). 56 casualties in the open sustained 87 fracture zones (mean 1.55 fracture zones per casualty). 30 casualties in a vehicle or other cover sustained 66 fracture zones (2.2 per casualty). Of the casualties in the open, 17 fracture zones were due the primary effects of blast, 10 a combination of primary and secondary effects, 30 due to secondary effects and 30 from the tertiary effects of blast. Of the casualties in vehicles we could not identify anyone with a fracture due to either the primary or secondary effects of blast, all 66 fracture zones appeared to be due to the tertiary effects.

In both groups there appeared to be a significant number of fractures, often with no break in the skin, caused by severe axial loading of the limb. This was possibly due to the casualty impacting against the ground, building or the inside of a vehicle, and this is a group of injuries we are now studying in greater detail.

Over 75% of combat casualties from Iraq and Afghanistan sustain injuries to the extremities, with 70% resulting from the effects of explosions. Damage to peripheral nerves may influence the surgical decision on limb viability in the short-term, as well as result in significant long-term disability. To date, there have been no reports of the incidence and severity of nerve injury in the current conflicts.

A prospective assessment of United Kingdom (UK) Service Personnel attending a specialist nerve injury clinic was performed. For each patient the mechanism, level and severity of injury to the nerve was assessed and associated injuries were recorded.

Fifty-six patients with 117 nerve injuries (median 2, range 1–5) were eligible for inclusion. This represents 12.9% of casualties sustaining an extremity injury. The most commonly injured nerves were the tibial (19%), common peroneal (16%) and ulnar nerves (16%). 25% (29) of nerve injuries were conduction block, 41% (48) axonotmesis and 34% (40) neurotmesis. The mechanism of injury did not affect the severity of injury sustained (explosion vs gunshot wound (GSW), p=0.53). An associated fracture was found in only 48% of nerve injuries and a vascular injury in 35%. The presence of an associated vascular injury resulted in more severe injuries (conduction vs axonotmesis and neurotmesis, p< 0.05). Nerves injured in association with a fracture, were more likely to develop axonotmesis (p< 0.05).

The incidence of peripheral nerve injury from combat wounds is higher than previously reported. This may be related to increasing numbers of casualties surviving with complex extremity wounds. In a polytrauma situation, it may be difficult to assess a discrete peripheral neurological lesion. As only 35% of nerves injured are likely to have anatomical disruption, the presence of an intact nerve at initial surgery should not preclude the possibility of an injury. Therefore, serial examinations combined with appropriate neurophysiologic examination in the post-injury period are necessary to aid diagnosis and to allow timely surgical intervention. In addition, conduction block nerve injuries can be expected to make a full recovery. As this accounts for 25% of all nerve injuries, we recommend that the presence of an insensate extremity should not be used as an indicator for assessing limb viability.

Shoulder Instability impacts on the ability of military personnel to fulfil their operational role and maintain sporting competence. Magnetic Resonance Imaging (MRI) and Arthrogram (MRA) are increasingly available as diagnostic adjuncts. We analysed MR reports from personnel undergoing stabilisation, correlating clinical diagnosis with operative findings and reviewed the literature in order to recommend improvements. We report a retrospective, consecutive case note analysis of 106 personnel undergoing open anterior capsulolabral reconstruction (ACLR) by a single surgeon.

Seventy patients had MR (48 MRA, 22 MRI). Commonly reported pathology included Hill Sachs Lesions (41%), Soft tissue (59%) and bony Bankart lesions (16%), capsular laxity (20 %), supraspinatus lesion (20%), ACJ disease (13%) and SLAP tear (12%). The sensitivity of MR for identification of labral lesions was 82% with a specificity of 86%. For bony glenoid lesions, sensitivity was 63% and specificity 94%. Disparity between report and operative findings occurred mainly in standard MRI. Patients with lesions unrelated to instability achieved a pain free functioning shoulder following stabilisation. 100% of patients referred for ACLR with clinical evidence of instability without MR had positive pre-operative and operative correlation with instability. In 5 cases, the original equivocal MRI was repeated by MRA due to clinical suspicion of instability. In all cases the repeat MRA correlated with pre-operative and operative findings of instability. In 5 cases with equivocal clinical findings, MRA provided confirmation of instability. Delay in referral due to scanning and follow up ranged from 0 – 15 weeks.

The diagnosis of those instigating referral is accurate. Reporting of MR is open to variation and has cost implications. MRA performed by a radiologist with a musculoskeletal specialist interest is recommended on an individual basis only and routine use of non-arthrographic studies should be discontinued. This will improve the efficiency of the fast track pathway.

Objectives: To review the changing pattern of orthopaedic injury encountered by deployed troops with regard to the importance of hand trauma.

Methods: A literature review of orthopaedic practice in recent conflict. The search period extended from 1990–2007. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded according to Levels of Evidence.

Results: 210 published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. The evidence is overall level 5 with the majority of papers comprising reviews, individual sub-unit experiences, historical perspectives and individual database analyses.

The evolving importance of extremity trauma is clear from the quantity of its reporting. The paucity of life threatening cavity trauma is highlighted. Casualty survival off the battlefield is increasing perhaps due to the impact of personal protective equipment. The combination of changing ballistics and increasing survivability leads to an apparent increase in limb threatening and complex hand trauma being encountered by military surgeons.

Despite being rarely reported in isolation, the proportion of complex hand trauma is broadening with an increase in open fractures and mutilated soft tissue injuries resultant from high and low energy transfer ballistics.

Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Sporting activities and inappropriate use of equipment are responsible for soft tissue and bony injury with considerable morbidity.

The literature was analysed with regard to the classification of hand trauma. Articles relating to recent conflicts were notable for their lack of classification of these injuries.

The bulk of papers retrieved concerning military hand trauma management were published prior to the conflicts of the last decade. It is within these papers that classification and treatment priorities including the nature of debridement and fracture stabilisation are discussed and highlighted as core knowledge.

Conclusion: The nature of injuries sustained by troops in conflict is evolving. Changing survivability is resulting in increasingly complex hand trauma presenting to military surgeons.

Despite a culture of ensuring that today’s trauma surgeons learn from mistakes made by their predecessors, in the field of hand trauma this is not the case.

A comprehensive review of changing orthopaedic conflict related injury patterns with special regard to hand trauma and the key learning points from historical literature are highlighted. Proposals for improving management are discussed with regard to improved training opportunities and dialogue between military trauma surgeons.

Following the invasion of Iraq in April 2003, Coalition forces have been conducting counter-insurgency operations in a bid to maintain security within the country. The improvised explosive device (IED) has become the weapon of choice of the terrorist and is the leading cause of death and injury amongst Coalition troops in the region.

From Jan 2006, data was collected on 100 consecutive casualties who were either injured or killed during hostile action. Mechanism of injury, new Injury Severity Score (NISS), ICD-9 diagnosis and anatomical pattern of wounding was recorded in a trauma registry.

During the study period, 53 casualties were injured by IEDs in 23 incidents (mean 2.3 casualties per incident). Twelve (22.6%) were killed or died of wounds. Mean NISS score of survivors was 5.4 (Range 1–50). There was no significant difference in NISS scores of survivors from fatal and non-fatal incidents. A mean 2.61 body regions were injured per casualty. Limb injuries were present in 45 (84.9%) of casualties, but primary blast injuries were seen in only 9 (14%). Twenty (48.7%) of survivors underwent surgery by British surgeons in the field hospital. Sixteen (39%) were deemed fit to return to duty after injury.

IEDs used in Iraq do not follow the traditional pattern of injuries seen with conventional high explosives. Primary blast injuries were uncommon despite all casualties being in close proximity to the explosion. When the IED is detonated, an Explosive Formed Projectile (EFP) is formed which results in catastrophic injuries to casualties caught in its path, but causes relatively minor injuries to personnel sited adjacent to its trajectory. Enhanced vehicle protection may prevent the EFP from entering the passenger compartments and thereby reduce fatalities.

British military forces are heavily committed in Iraq and Afghanistan. Operation HERRICK, currently supported by a Role 2(Enhanced) medical facility at Camp Bastion, is predicted to continue for the next 10 years.

There has been no large published series on surgical workload on Operation HERRICK. The aim of this study is to determine and plan future medical needs.

A retrospective analysis of operating theatre records between 10th October 2006 and 31st Oct 2007 was performed. Data was collated on a monthly basis, to assess seasonal variation, and included patient demographics, operation type and time of operation.

During the study period 968 cases required 1262 procedures. Thirty-four per cent were ISAF, 27% were Afghan soldiers, police or enemy forces and 39% were civilians, of which, 43% were children. Ninety-one per cent were secondary to battle injury and 50% were emergencies. The breakdown of procedures, by specialty, was 67% (841) were orthopaedic, 16% (199) general surgery, 8% (96) head and neck, 5% (55) burns surgery and a further 4% (50) were non-battle, non-emergency procedures. During the second half of the study period 655 cases were operated on compared to 313 in the preceding half (p< 0.05). Twenty-eight per cent of cases were performed between 6pm and 8am.

Surgical workload remains consistently high throughout the study period, however there was significant seasonal variation with casualty rates being greater in the summer months, this may have bearing on the decision to deploy additional surgeons and trainees in the future.

Shoulder Instability impacts on the ability of military personnel to fulfil their operational role and maintain sporting competence. Magnetic Resonance Imaging (MRI) and Arthrogram (MRA) are increasingly available as diagnostic adjuncts. We analysed MR reports from personnel undergoing stabilisation, correlating clinical diagnosis with operative findings and reviewed the literature in order to recommend improvements.

This was a retrospective, consecutive case note analysis of 106 personnel undergoing open anterior capsulolabral reconstruction (ACLR) by a single surgeon.

70 patients had MR (48 MRA, 22 MRI). Commonly reported pathology included Hill Sachs Lesions (41%), Soft tissue (59%) and bony Bankart lesions (16%), capsular laxity (20 %), supraspinatus lesion (20%), ACJ disease (13%) and SLAP tear (12%). The sensitivity of MR for identification of labral lesions was 82% with a specificity of 86%. For bony glenoid lesions, sensitivity was 63% and specificity 94%. Disparity between report and operative findings occurred mainly in standard MRI. Patients with lesions unrelated to instability achieved a pain free functioning shoulder following stabilisation. 100% of patients referred for ACLR with clinical evidence of instability without MR had positive pre-operative and operative correlation with instability. In 5 cases, the original equivocal MRI was repeated by MRA due to clinical suspicion of instability. In all cases the repeat MRA correlated with pre-operative and operative findings of instability. In 5 cases with equivocal clinical findings, MRA provided confirmation of instability. Delay in referral due to scanning and follow up ranged from 0–15 weeks.

The diagnosis of those instigating referral is accurate. Reporting of MR is open to variation and has cost implications. MRA performed by a radiologist with a musculoskeletal specialist interest is recommended on an individual basis only and routine use of non-arthrographic studies should be discontinued. This will improve the efficiency of the fast track pathway.

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.

To review the changing pattern of orthopaedic injury encountered by deployed troops with special regard to the importance of hand trauma sustained in conflict and non- war fighting activities.

Literature review relating to recent military operations (1990–2007) encompassing 100 conflicts worldwide. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded by Oxford Centre for Evidence-based Medicine Levels of Evidence.

Two hundred and ten published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. These works were primarily level five evidence comprising reviews, correspondence, sub-unit experiences and individual nation database analyses.

The importance of extremity trauma is clear. The combination of changing ballistics and increasing survivability off the battlefield leads to a previously under emphasised increase in complex hand trauma.

Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Articles concerning military hand trauma management were mainly published prior to the conflicts of the last decade. Within these papers injury classification and treatment priorities are highlighted as core knowledge for trauma surgeons.

This paper provides a review of conflict related injury patterns with special regard to hand trauma. The key learning points from historical literature are highlighted. Proposals for improving management of these injuries from battlefield to home nation are discussed with regard to training opportunities and dialogue to ensure past lessons are not forgotten.

The conflict in Iraq has evolved from a conventional war in April 2003 to a guerrilla-based insurgency. We investigated whether this change altered the pattern of wounding and types of injuries seen in casualties presenting to a military field hospital.

From January 2006 – October 2006, data was collected on all casualties who presented to the sole British field hospital in the region following injury from hostile action (HA).

86 casualties presented with injuries from hostile action (HA). 3 subsequently died of wounds (DOW – 3.5%). 46 (53.5%) casualties had their initial surgery performed by British military surgeons. 20 casualties (23.2%) sustained gunshot wounds, 63 (73.3%) suffered injuries from fragmentation weapons and 3 (3.5%) casualties sustained injury from blunt trauma. These casualties sustained a total 232 wounds (mean 2.38) affecting an average 2.4 anatomical locations per patient.

The current insurgency illustrates the likely evolution of modern urban conflict. Discrete attacks from improvised explosive devices (IED’s) have become the predominant cause of injury. These tactics have been employed against both military and civilian targets. With the current threat from terrorism, both military and civilian surgeons should be aware of the spectrum and management of the injuries caused.

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

Introduction A prospective study of consecutive hand injuries treated at a British Field Hospital revealed a distinctive pattern of injury. This is a unique review of hand injuries in a recent military deployment.

Method Patients presenting to the field hospital with hand injuries over a two-month period were entered into a database.

The parameters studied included mechanism of injury, timing and nature of treatment and ultimate disposal. An anatomical comparison of pattern of injury with six months retrospective data and a literature search was performed.

Results Of nine hundred and thirty one patients attending the hospital in this period, fifty-three had injuries to the hand.

Only seven cases resulted from battle injuries. Of the remainder, thirty-three were work related and the 13 were due to sport.

Twenty-eight of the patients required a surgical procedure; the mean time to surgery was 1.7 hours.

Twelve patients were subsequently aero medically evacuated.

Conclusion Wounds of conflict account for a small proportion of hand injuries seen in the operational environment. The injury pattern seen reflects Daily Non-Battle Injury (DNBI) – the hazards encountered by deployed troops on a daily basis

To compare the effectiveness of immediate open anterior capsulolabral reconstruction (ACLR) with conventional treatment in young military personnel who had sustained a first-time traumatic shoulder dislocation, we carried out a prospective non-randomised study of 34 recruit and active-duty servicemen (average, 20 years).

All patients met the following criteria: 1) an acute first- time traumatic anterior dislocation, 2) no history of impingement or occult subluxation, 3) the dislocation required a manual reduction, and 4) no concomitant fracture or neurological injury. Group 1 (16 patients) were immobilised in a sling for 6 weeks followed by an intensive rehabilitation programme. Group 2 (18 patients) underwent open ACLR within 10 days of dislocation followed by the same rehabilitation protocol as Group 1.

The average follow-up was 36 months; all patients were available for review. Twelve (75%) non-operatively treated patients developed recurrent instability all of whom required subsequent open repair. In the surgical repair group, there were no cases of recurrent instability.

Early open repair (ACLR) significantly reduces the incidence of recurrent instability in young military personnel who sustain an acute initial anterior shoulder dislocation.