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BACKGROUND: Patient-reported outcome measures are an important metric in evaluating treatment efficacy of reconstructive surgery. Toe-to-hand transfer can restore vital prehensile function; however, this surgery is complex, extensive rehabilitation is required, and there are concerns about donor-site morbidity. This study longitudinally explores the benefits of this procedure, from the patient's perspective, using patient-reported outcome measures. METHODS: Twenty-three patients who underwent free toe-to-hand transfers from 2012 to 2015 were evaluated preoperatively and postoperatively using the following validated questionnaires: the Michigan Hand Outcomes Questionnaire, the 36-Item Short-Form Health Survey, and the Lower Limb Outcomes Questionnaire. Subgroup analysis was performed between dominant and nondominant reconstructed hands. RESULTS: Mechanism of injury was crush in 83 percent; the remainder sustained cutting, avulsion, and burn injuries. Thirty-four toes were transferred: nine great toes, 20 second toes, and five third toes. Michigan Hand Outcomes Questionnaire results showed significant improvement in overall activities of daily living, work, aesthetics, and patient satisfaction (p < 0.05). The results of the 36-Item Short-Form Health Survey showed significant improvements in physical and emotional roles (p < 0.05). The Lower Limb Outcomes Questionnaire showed no deterioration of foot function (p = 0.55). Subgroup analysis showed significant improvement in patient-reported outcome measures for patients undergoing dominant hand reconstruction but no difference between thumb reconstruction and finger-only reconstruction. CONCLUSIONS: Patient-reported outcome measures demonstrate the significant utility of toe-to-hand transfer procedures in both functional and psychosocial domains in that there are relatively greater benefits in reconstructing the dominant hand, and that donor-site morbidity is well tolerated. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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BACKGROUND: Currently, patients receiving vascularized composite allotransplantation (VCA) grafts must take long-term systemic immunosuppressive therapy to prevent immunologic rejection. The morbidity and mortality associated with these medications is the single greatest barrier to more patients being able to receive these life-enhancing transplants. In contrast to solid organs, VCA, exemplified by hand or face transplants, allow visual diagnosis of clinical acute rejection (AR), directed biopsy and targeted graft therapies. Local immunosuppression in VCA could reduce systemic drug exposure and limit adverse effects. This proof of concept study evaluated, in a large animal forelimb VCA model, the efficacy and tolerability of a novel graft-implanted enzyme-responsive, tacrolimus (TAC)-eluting hydrogel platform, in achieving long-term graft survival. METHODS: Orthotopic forelimb VCA were performed in single haplotype mismatched mini-swine. Controls (n = 2) received no treatment. Two groups received TAC hydrogel: high dose (n = 4, 91 mg TAC) and low dose (n = 4, 49 mg TAC). The goal was to find a dose that was tolerable and resulted in long-term graft survival. Limbs were evaluated for clinical and histopathological signs of AR. TAC levels were measured in serial blood and skin tissue samples. Tolerability of the dose was evaluated by monitoring animal feeding behavior and weight. RESULTS: Control limbs underwent Banff Grade IV AR by post-operative day six. Low dose TAC hydrogel treatment resulted in long-term graft survival time to onset of Grade IV AR ranging from 56 days to 93 days. High dose TAC hydrogel also resulted in long-term graft survival (24 to 42 days), but was not well tolerated. CONCLUSION: Graft-implanted TAC-loaded hydrogel delays the onset of Grade IV AR of mismatched porcine forelimb VCA grafts, resulting in long term graft survival and demonstrates dose-dependent tolerability.

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INTRODUCTION: Vascularized composite allotransplantation can reconstruct devastating tissue loss by replacing like-with-like tissues, most commonly in the form of hand or face transplantation. Unresolved technical and ethical challenges have meant that such transplants remain experimental treatments. The most significant barrier to expansion of this field is the requirement for systemic immunosuppression, its toxicity and effect on longevity.Hydrogen sulfide (H2S) has been shown experimentally to ameliorate the ischemia reperfusion injury associated with composite tissue autotransplantation, which has been linked to acute rejection in solid organ transplantation. In this protocol, a large-animal model was used to evaluate the effect of H2S on acute rejection after composite tissue allotransplantation. MATERIALS AND METHODS: A musculocutaneous flap model in SLA-mismatched swine was used to evaluate acute rejection of allotransplants in 2 groups: control animals (n = 8) and a treatment group in which the allografts were pretreated with hydrogen sulfide (n = 8). Neither group was treated with systemic immunosuppression. Acute rejection was graded clinically and histopathologically by an independent, blinded pathologist. Data were analyzed by t tests with correction for multiple comparisons by the Holm-Sídák method. RESULTS: Clinically, H2S-treated tissue composites showed a delay in the onset of rejection that was statistically significant from postoperative day 6. Histopathologically, this difference between groups was also apparent, although evidence of a difference in groups disappeared beyond day 10. CONCLUSIONS: Targeted hydrogen sulfide treatment of vascularized composite allografts immediately before transplantation can delay acute rejection. This may, in turn, reduce or obviate the requirement for systemic immunosuppression.

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PURPOSE: Free tissue transfer is a powerful reconstructive surgical technique. The ischemia reperfusion injury (IRI) at revascularization affects the flap and the patient; reducing this insult could improve outcomes. This study evaluated the effect of C1 esterase inhibitor (C1-inh) on IRI in a porcine musculocutaneous flap model. MATERIALS AND METHODS: A musculocutaneous flap was transferred from the limb to the neck of 12 swine. Flaps underwent a 3-hour ischemic interval prior to revascularization. Intervention group flaps (n = 6) were perfused intra-arterially with 100U C1-inh at the commencement of the ischemic period; controls (n = 6) received heparinized saline solution. Protocol duration was 14 days; markers of reperfusion injury (creatine kinase [CK], aspartate transaminase [AST], tumor necrosis factor-alpha) were evaluated. RESULTS: All flaps from the intervention group were viable at 14 days; five of six control flaps were viable at 14 days (P = 1). Systemic levels of biomarkers of tissue necrosis and inflammation were reduced in the intervention group. On post-operative day one, statistically significant reductions in mean levels of AST and CK were demonstrated (2,293 ± 1 × 103 U/L vs. 1,586 ± 767 U/L [P = 0.04] and 429 × 103 ± 214 × 103 U/L vs. 213 × 103 ± 156 × 103 U/L [P = 0.002], respectively). Flaps of both groups healed in their recipient locations, no adverse reactions were observed. CONCLUSIONS: C1-inh is protective of IRI and may have utility in free tissue transfer, vascularized composite allotransplantation, and spare parts surgery. © 2016 Crown copyright. Microsurgery © 2016 Wiley Periodicals, Inc. Microsurgery 37:142-147, 2017.

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We present a case series of patients with patellofemoral joint (PFJ) chondral injuries presenting as anterior knee pain secondary to participation in high-intensity functional training programmes. We aim to highlight PFJ chondral injuries as a potential complication of military servicemen engaging in high-intensity functional training programmes. This may allow medical staff to identify the injuries early, and highlight this possible injury mechanism to Physical Training staff to help educate participants and mitigate the risk of injury.

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BACKGROUND: The restoration of complex tissue deficits with vascularized composite allotransplantation is a paradigm shift in reconstructive surgery. Clinical adoption of vascularized composite allotransplantation is limited by the need for systemic immunosuppression, with associated morbidity and mortality. Small-animal models lack the biological fidelity and preclinical relevance to enable translation of immunologic insights to humans. Large-animal models have been described; however, limitations persist, including the inability of heterotopic models to evaluate functional nerve regeneration, and the sensitivity of primates to toxicity of immunosuppressive drugs. The authors' novel orthotopic porcine limb transplant model has broad applicability and translational relevance to both immunologic and functional outcomes after vascularized composite allotransplantation. METHODS: Recipients underwent amputation at a level corresponding to the mid forearm. Replantation or transplantation of grafts was performed by plate fixation of the radio-ulna, microsurgical repair of brachial artery and median nerve, and extensor and flexor tendon repairs. Viability of replants was monitored clinically and radiologically. Transplants were monitored for clinicopathologic signs of rejection. Animals mobilized freely postoperatively. RESULTS: Replantations remained viable until the endpoint of 14 days. Transplants developed Banff grade 4 acute rejection by postoperative day 7. Doppler sonography and angiography confirmed vascular patency. Serial biopsy specimens of skin and histopathology of replants at endpoint confirmed tissue viability and bone healing. CONCLUSIONS: An orthotopic load-bearing porcine forelimb vascularized composite allotransplantation model was successfully established. Technical, procedural, and logistic considerations were optimized to allow model use for immunologic, bone healing, functional nerve regeneration, and other translational studies.

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The aim of this study was to characterise severe open tibial shaft fractures sustained by the UK military personnel over 10 years of combat in Iraq and Afghanistan. The UK military Joint Theatre Trauma Registry was searched for all such injuries, and clinical records were reviewed for all patients. One hundred Gustilo-Anderson III tibia fractures in 89 patients were identified in the 10 year study period; the majority sustained injuries through explosive weapons (63, 68 %) with the remainder being injured from gunshot wounds. Three fractures were not followed up for 12 months and were therefore excluded. Twenty-two (23 %) of the remaining 97 tibial fractures were complicated by infection, with S. aureus being the causative agent in 13/22 infected fractures (59 %). Neither injury severity, mechanism, the use of an external fixator, the need for vascularised tissue transfer nor smoking status was associated with subsequent infection. Bone loss was significantly associated with subsequent infection (p < 0.0001, Fisher's exact test). This study presents 10 years of open tibial fractures sustained in Iraq and Afghanistan. Most infection in combat open tibia fractures is caused by familiar organisms, i.e. S. aureus. While the overall severity of a casualty's injuries was not associated with infection, the degree of bone loss from the fracture was.

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The gunshot wounds sustained on the battlefield caused by military ammunition can be different in nature to those usually encountered in the civilian setting. The main difference is that military ammunition has typically higher velocity with therefore greater kinetic energy and consequently potential to destroy tissue. The surgical priorities in the management of gunshot wounds are hemorrhage control, preventing infection, and reconstruction. The extent to which a gunshot wound needs to be surgically explored can be difficult to determine and depends on the likely amount of tissue destruction and the delay between wounding and initial surgical treatment. Factors associated with greater energy transfer, e.g., bullet fragmentation and bony fractures, are predictors of increased wound severity and therefore a requirement for more surgical exploration and likely debridement. Gunshot wounds should never be closed primarily; the full range of reconstruction from secondary intention to free tissue transfer may be required.

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We present eleven years of prospectively-gathered data defining the full spectrum of the United Kingdom's (UK) Naval Service (Royal Navy and Royal Marines) casualties, and characterise the injury patterns, recovery and residual functional burden from the conflicts of the last decade. The UK Military Trauma Registry was searched for all Naval Service personnel injured between March 2003 and April 2013. These records were then cross-referenced with the records of the Naval Service Medical Board of Survey (NSMBOS), which evaluates injured Naval Service personnel for medical discharge, continued service in a reduced capacity or Return to Full Duty (RTD). Population at risk data was calculated from service records. There were 277 casualties in the study period: 63 (23%) of these were fatalities. Of the 214 survivors, 63 or 29% (23% of total) were medically discharged; 24 or 11% (9% of total) were placed in a reduced fitness category with medical restrictions placed on their continued military service. A total of 127 individuals (46% of the total and 59% of survivors) RTD without any restriction. The greatest number of casualties was sustained in 2007. There was a 3% casualty risk per year of operational service for Naval Service personnel. The most common reason cited by Naval Service Medical Board of Survey (NSMBOS) for medical downgrading or discharge was injury to the lower limb, with upper limb trauma the next most frequent. This study characterises the spectrum of injuries sustained by the Naval Service during recent conflicts with a very high rate of follow-up. Extremity injuries pose the biggest challenge to reconstructive and rehabilitative services striving to maximise the functional outcomes of injured service personnel.

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INTRODUCTION: Recent conflicts have been characterised by the use of improvised explosive devices causing devastating injuries, including heavily contaminated wounds requiring meticulous surgical debridement. After being rendered surgical clean, these wounds are dressed and the patient transferred back to the UK for on-going treatment. A dressing that would prevent wounds from becoming colonised during transit would be desirable. The aim of this study was to establish whether using nanocrystalline silver dressings, as an adjunct to the initial debridement, would positively affect wound microbiology and wound healing compared to standard plain gauze dressings. METHODS: Patients were prospectively randomised to receive either silver dressings, in a nanocrystalline preparation (Acticoat™), or standard of care dressings (plain gauze) following their initial debridement in the field hospital. On repatriation to the UK microbiological swabs were taken from the dressing and the wound, and an odour score recorded. Wounds were followed prospectively and time to wound healing was recorded. Additionally, patient demographic data were recorded, as well as the mechanism of injury and Injury Severity Score. RESULTS: 76 patients were recruited to the trial between February 2010 and February 2012. 39 received current dressings and 37 received the trial dressings. Eleven patients were not swabbed. There was no difference (p=0.1384, Fishers) in the primary outcome measure of wound colonisation between the treatment arm (14/33) and the control arm (20/32). Similarly time to wound healing was not statistically different (p=0.5009, Mann-Whitney). Wounds in the control group were scored as being significantly more malodorous (p=0.002, Mann-Whitney) than those in the treatment arm. CONCLUSIONS: This is the first randomised controlled trial to report results from an active theatre of war. Performing research under these conditions poses additional challenges to military clinicians. Meticulous debridement of wounds remains the critical determinant in wound healing and infection and this study did not demonstrate a benefit of nanocrystaline silver dressing in respect to preventing wound colonisation or promoting healing, these dressings do however seem to significantly reduce the unpleasant odour commonly associated with battlefield wounds.

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BACKGROUND: Devastating extremity injuries are prevalent but often survivable on the modern battlefield. These complex injuries require advanced methods of reconstruction, involving prolonged ischemic periods and reperfusion injury. Using our group's validated porcine model of gracilis myocutaneous flap transplantation, this study demonstrates that an interim perfusion of hydrogen sulfide (H2S) mitigates the effects of reperfusion injury in the setting of delayed restoration of blood flow. METHODS: A gracilis myocutaneous flap (200-400 g; surface area, 250 cm²) was procured from the hind limb of a Yorkshire swine (70-90 kg, n=16). The right external carotid artery and the internal jugular vein are the recipient axis. Group 1 (control, n = 6) underwent delayed anastomosis with a 3-hour ischemic period. Group 2 (n=10) underwent a similar delayed anastomosis with an interim perfusion of H2S during the ischemic period. The animals survived for 14 days. Systemic biomarker assays for skeletal muscle tissue injury (creatine kinase, lactate dehydrogenase, and aspartate transaminase) and proinflammatory markers (tumor necrosis factor α and interleukin 6) provide assessment of reperfusion injury at the cellular level. RESULTS: The control animals (3 hours of ischemia with an interim perfusion of heparinized saline) demonstrated increased levels of injury biomarkers and proinflammatory cytokines compared with the animals receiving H2S infusion and identical ischemic interval. The control flaps had a mean creatine kinase level of 280³×10 U/L (±80×10³), compared with the H2S group, which had a mean of 99×10³ U/L (±14×10³; P=0.0007 at postoperative day 2). lactate dehydrogenase levels (mean) were 26×10³ U/L (±8×10³) versus 9×10³ U/L (±3×10³; P=0.0004) and aspartate transaminase levels (mean) were 1651 U/L (±324) versus (873 U/L [±279]; P=0.0013) for the control and treatment groups, respectively. Similarly, an intergroup difference in IL-6 was found, although not statistically significant. Tumor necrosis factor α levels (mean) were 93 pg/mL (±14) versus 39 pg/mL (±4; P=0.0013) for the control and treatment groups, respectively. CONCLUSIONS: This study demonstrated the mitigating properties of H2S on reperfusion injury. Interim perfusion with H2S resulted in diminution of ischemia-dependent biomarkers after 3 hours of ischemia. Follow-up studies will translate these findings as an evolving method for reconstructing previously unreconstructable injuries.

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AIM: There is little documented advice on the management of scrotal trauma sustained in combat. This paper reviews this injury, its present surgical management and makes recommendations for the future. METHOD: All UK forces sustaining scrotal injuries between 2003 and 2009, in Iraq and Afghanistan, initially treated at a Role 2 (enhanced) or Role 3 deployed military surgical facility were identified from the Joint Theatre Trauma Registry. The cause and extent of the injury, in addition to the surgical management, are reported. RESULTS: Twenty-seven patients sustained trauma to their scrotum; improvised explosive device (IED) (n=21), mine (n=3), rocket propeller grenade (RPG) (n=2), mortar round (n=1). Of those injured by an IED, eleven had traumatic orchidectomies, of which 4 were bilateral, one received fragmentation wounds to the scrotum with a testicular injury that was salvaged and there were six scrotal fragmentation wounds not associated with a testicular injury. Scrotal exploration was performed with testicular salvage in all cases involving mortar, RPG or mines. For all aetiologies the scrotum was debrided with primary closure over a drain (n=7), debridement and subsequent delayed primary closure (DPC) (n=4) or healing by secondary intension (n=6). Skin grafts were applied in two cases of traumatic bilateral orchidectomy. To date there have been two cases of delayed orchidectomy; chronic pain and delayed presentation of a disrupted testis. All reported patients survived. CONCLUSION: The established principles of debridement should be the mainstay of treatment. Testicular ischaemia, a consequence of cord transaction, necessitates orchidectomy. Salvage of the disrupted testis, with debridement and closure of the tunica rather than orchidectomy, should be performed whenever possible, particularly when there is significant bilateral testicular injury. Scrotal wounds can be treated by closure over a drain, DPC or healing by secondary intention.

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The aim of this study was to report the pattern of severe open diaphyseal tibial fractures sustained by military personnel, and their orthopaedic-plastic surgical management.The United Kingdom Military Trauma Registry was searched for all such fractures sustained between 2006 and 2010. Data were gathered on demographics, injury, management and preliminary outcome, with 49 patients with 57 severe open tibial fractures identified for in-depth study. The median total number of orthopaedic and plastic surgical procedures per limb was three (2 to 8). Follow-up for 12 months was complete in 52 tibiae (91%), and half the fractures (n = 26) either had united or in the opinion of the treating surgeon were progressing towards union. The relationship between healing without further intervention was examined for multiple variables. Neither the New Injury Severity Score, the method of internal fixation, the requirement for vascularised soft-tissue cover nor the degree of bone loss was associated with poor bony healing. Infection occurred in 12 of 52 tibiae (23%) and was associated with poor bony healing (p = 0.008). This series characterises the complex orthopaedic-plastic surgical management of severe open tibial fractures sustained in combat and defines the importance of aggressive prevention of infection.

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Due to the nature of IED injuries, during the conflicts in Iraq and Afghanistan The traditional, two-stage amputation for unsalvageable combat lower limb injuries has evolved into a strategy of serial debridement and greater use of plastic surgical techniques in order to preserve residual limb length. This study aimed to characterise the current treatment of lower limb loss with particular focus on the impact of specific wound infections. The UK military trauma registry and clinical notes were reviewed for details of all lower limb amputation identifying: 51 patients with 70 lower limb amputations. The mean number of debridements per stump prior to closure was 4.1 (95% CI 3.5-4.7). A final more proximal amputation level was required in 21 stumps (30%). Recovery of A. hydrophillia from wounds was significantly associated with a requirement for a more proximal amputation level (p=0.0038) and greater number of debridements (p=0.0474) when compared to residual limb wounds withoutA. hydrophillia.

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INTRODUCTION: Surgical trauma care on operations is delivered by consultants. The DMS presently delivers training to surgeons to enable them to deliver this care as newly-qualified consultants. Deploying as a trainee is one of many training evolutions available to achieve this competency. This paper describes the process involved in trainees deploying, and the training received by the first author (CAF) during a recent deployment. METHODS: Pre-deployment training and the process for gaining recognition of training time by the GMC are described. All surgical procedures performed by the first author were recorded prospectively, together with the level of supervision. RESULTS: The first author performed 210 procedures in 124 operations on 87 patients in a seven week deployment. This was prospectively recognised for training by the GMC. All procedures were supervised by consultant trainers. Procedures included trauma surgical procedures and those under the specialties of Plastic Surgery, Orthopaedic Surgery and General Surgery. CONCLUSIONS: Deploying on operations as a trainee is invaluable in preparing DMS juniors for their future roles as consultants in the DMS. Training is received not only in a breadth of surgical and resuscitative procedures, beyond a trainee's "base specialty", but also in other critical aspects of deployments including Crew Resource Management.

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OBJECTIVE: The objective of this study was to characterize the use of topical negative pressure therapy in combat wounds. METHODS: This study was a retrospective review of the records of patients whose wounds were managed with topical negative pressure between April 2007 and March 2008. The main outcome measure was episodes of antibiotic prescription, which was used as a surrogate marker of clinically relevant infection. RESULTS: Of the 62 cases identified, 25 clinical notes were unavailable and were excluded from the study leaving 37 included cases. All but one of the cases was male with an average age of 29 (19-39) and New Injury Severity Score (NISS) of 21.3 (14.4-28.1). In 20 cases, topical negative pressure was changed less than once per 4.9 days on average, and in the remaining 17 cases, this was done more frequently. Comparison of the rate of antibiotic prescription between these groups reveals a significantly higher rate in the cohort managed with more frequent topical negative pressure changes. However this relationship was not borne out in a multiple variable analysis. CONCLUSION: This study describes the use of topical negative pressure in the management of a uniquely challenging group of patients. Statistical analysis of relatively small numbers is challenging but these results support the current complex wound management strategies where wounds are temporized with topical negative pressure for several days following thorough wound debridement. This period allows patients to be physiologically stabilized, other injuries to be addressed and appears not to be associated with increased infections.

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INTRODUCTION: Definitive laparotomy (DL), with completion of all surgical tasks at first laparotomy has traditionally been the basis of surgical care of severe abdominal trauma. Damage control surgery (DCS) with a goal of physiological normalisation achieved with termination of operation before completion of anatomical reconstruction, has recently found favour in management of civilian trauma. This study aims to characterise the contemporary UK military surgeon's approach to abdominal injury. PATIENTS AND METHODS: A retrospective analysis was performed on British service personnel who underwent a laparotomy for intestinal injury at UK forward hospitals from November 2003 to March 2008 as identified from the Joint Theatre Trauma Registry. Patient demographics, mechanism and pattern of injury and clinical outcomes were recorded. Surgical procedures at first and subsequent laparotomy were evaluated by an expert panel. RESULTS: 22 patients with intestinal injury underwent laparotomy and survived to be repatriated; all patients subsequently survived to hospital discharge. Mechanism of injury was GSW in seven and blast in 13. At primary laparotomy, as defined by the operating surgeon, 15/22 underwent DL and 7/22 underwent DCS. Mean Injury Severity Score (ISS) was 19 for DL patients compared to 29 for DCS patients (p = 0.021). Of the 15 patients undergoing DL nine had primary repair (suture or resection/ anastomosis), one of which subsequently leaked. Unplanned re-look was required in 4/15 of the DL cases. CONCLUSION: This review examines the activity of British military surgeons over a time period where damage control laparotomy has been introduced into regular practice. It is performed at a ratio of approximately 1:2 to DL and appears to be reserved, in accordance with military surgical doctrine, for the more severely injured patients. There is a high rate of unplanned relook procedures for DL suggesting DCS may still be underused by military surgeons. Optimal methods of selection and implementation of DCS after battle injury to the abdomen remain unclear.

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