Introduction Bone tumours of the foot are rare, representing 3–6% of all bone tumours. Of these 1... more Introduction Bone tumours of the foot are rare, representing 3–6% of all bone tumours. Of these 15–25% are thought to be malignant. Obtaining clear surgical margins remains an important factor in improving outcome from tumours. However, the anatomical complexity of the foot can lead to an inadequate resection, particularly if the operating surgeon is attempting to preserve function. The aim of this paper is to identify the clinical course of patients suffering from malignant bone tumours of the foot. Method A prospective tumour registry over a 30 yr period was used to identify patients with a malignant bone tumour of the foot. Patient demographics along with the site of primary malignancy, region of the foot involved and clinical management were recorded. Results 70 patients with a malignant foot tumour were identified. 25(35%) were chondrosarcomas, 20 Ewings Sarcoma, 10 Osteosarcoma and 15 were metastatic lesions. Of those diagnosed with a primary bone tumour, 8(14.5%) were referred following a “whoops” procedure. The median length of symptoms prior to diagnosis was 52 weeks. The most common regions affected were the 1 st Ray (31%) and Calcaneus (22%). The mainstay of treatment involved either Ray or Below Knee Amputation in 70% of cases. 11 patients developed either local recurrence or metastatic disease. Conclusion We present the largest single centre review of malignant bone tumours affecting the foot. Our series confirms that patients often have to suffer with protracted symptoms prior to the establishment of the correct diagnosis. The variety of differential diagnoses may explain the long delay in diagnosis. Worryingly, 14.5% of the primary bone malignancies in our series underwent a “whoops” procedure. This highlights further that physicians need to maintain a high index of suspicion when treating a patient with foot symptoms, even when the symptoms may be protracted.
It was a great privilege to experience the American-British-Canadian (ABC) Fellowship during the ... more It was a great privilege to experience the American-British-Canadian (ABC) Fellowship during the 2018 tour through North America. The following passages will introduce the fellowship and its history, and provide feedback relevant to orthopaedic practice in South Africa.
Journal of Bone and Joint Surgery - Series B, 2012
We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and wom... more We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed between the upper and the lower limbs. Explosions accounted for 164 (63%): 213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was needed in 18. A total of 36 patients continued in severe neuropathic pain. This paper outlines the methods used in the assessment of these injuries and provides information about the depth and distribution of the nerve lesions, their associated injuries and neuropathic pain syndromes.
Journal of Bone and Joint Surgery - Series B, 2012
The types of explosive devices used in warfare and the pattern of war wounds have changed in rece... more The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma. The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research. In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East. War wounds range from simple low-energy fragmentation wounds to highly complex injuries. The latter have been more recently encountered in Afghanistan and are well-described by Crabtree. 1 In Iraq and Afghanistan, improvised explosive devices (IEDs) have become the insurgents' preferred weapon and were the most common cause of coalition deaths in 2009 and 2010. 2 There has also been a notable increase in very high, lower extremity amputations or unsalvageable leg injuries with pelvic trauma. 3-5 The conflicts in the Middle East prompted the Academic Department of Military Surgery and Trauma to establish working groups to promote the development of best practice and to act as a focus for research. In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East. Speedier evacuation from the point of wounding can deliver patients to the Emergency Department at the very edge of survival, and the trauma care delivered by the Defence Medical Services on operations equals that available in the NHS in the United Kingdom. 6,7 A recent report by the Healthcare Commission described the military trauma system as 'exemplary'. 8 Between April 2006 and July 2008, 1474 patients were recorded on the United Kingdom's Joint Theatre Trauma Registry. Of these, 530 had an Injury Severity Score 9 > 16 and 296 survived, including unexpected survivors. 10 The Joint Theatre Trauma Registry is the United Kingdom database of all the prospectively collected data for service personnel injured on operational tour. It was started in December 2003.
Results During this period 12 patients were identified that fitted the criteria for local steroid... more Results During this period 12 patients were identified that fitted the criteria for local steroid injection. This represented 7% (12/179) of patients who were seen by the physiotherapy department in either an in or out-patient setting. All patients were injected with local anaesthetic and steroid injection with a single dose of intravenous antibiotic as antimicrobial cover. 10/12 (83.3%) were able to return to their unit within this theatre of operation. The only complication was one case of post injection flare of pain, which settled after 48 hours. ... Conclusion The use of local ...
Journal of Bone & Joint Surgery, British Volume, Sep 1, 2009
Following the invasion of Iraq in April 2003, Coalition forces have been conducting counter-insur... more 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.
All in-text references underlined in blue are linked to publications on ResearchGate, letting you... more All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately.
Frontiers in Bioengineering and Biotechnology, 2020
Penetrating injuries are commonly inflicted in attacks with explosive devices. The extremities, a... more Penetrating injuries are commonly inflicted in attacks with explosive devices. The extremities, and especially the leg, are the most commonly affected body areas, presenting high risk of infection, slow recovery, and threat of amputation. The aim of this study was to quantify the risk of fracture to the anteromedial, posterior, and lateral aspects of the tibia from a metal fragment-simulating projectile (FSP). A gas gun system and a 0.78-g cylindrical FSP were employed to perform tests on an ovine tibia model. The results from the animal study were subsequently scaled to obtain fracturerisk curves for the human tibia using the cortical thickness ratio. The thickness of the surrounding soft tissue was also taken into account when assessing fracture risk. The lateral cortex of the tibia was found to be most susceptible to fracture, whose impact velocity at 50% risk of EF1+, EF2+, EF3+, and EF4+ fracture types-according to the modified Winquist-Hansen classification-were 174, 190, 212, and 282 m/s, respectively. The findings of this study will be used to increase the fidelity of predictive models of projectile penetration.
Bone is one of the most highly adaptive tissues in the body, possessing the capability to alter i... more Bone is one of the most highly adaptive tissues in the body, possessing the capability to alter its morphology and function in response to stimuli in its surrounding environment. The ability of bone to sense and convert external mechanical stimuli into a biochemical response, which ultimately alters the phenotype and function of the cell, is described as mechanotransduction. This review aims to describe the fundamental physiology and biomechanisms that occur to induce osteogenic adaptation of a cell following application of a physical stimulus. Considerable developments have been made in recent years in our understanding of how cells orchestrate this complex interplay of processes, and have become the focus of research in osteogenesis. We will discuss current areas of preclinical and clinical research exploring the harnessing of mechanotransductive properties of cells and applying them therapeutically, both in the context of fracture healing and de novo bone formation in situations ...
The Improvised Explosive Device (IED), in all its forms, has become the most significant threat t... more The Improvised Explosive Device (IED), in all its forms, has become the most significant threat to troops operating in Afghanistan and Iraq. These devices range from rudimentary home made explosives to sophisticated weapon systems containing high-grade explosives. Within this broad definition they may be classified as Roadside explosives and blast mines, Explosive Formed Pojectile (EFP) devices and Suicide bombings. Each of these groups cause injury through a number of different mechanisms and can result in vastly different injury profiles. The "Global War on Terror" has meant that incidents which were previously exclusively seen in conflict areas, can occur anywhere, and clinicians who are involved in emergency trauma care may be required to manage casualties from similar terrorist attacks. An understanding of the types of devices and their pathophysiological effects is necessary to allow proper planning of mass casualty events and to allow appropriate management of the complex poly-trauma casualties they invariably cause. The aim of this review article is to firstly describe the physics and injury profile from these different devices and secondly to present the current clinical evidence that underpins their medical management.
Improved protective measures and medical care has increased the survivability from battlefield in... more Improved protective measures and medical care has increased the survivability from battlefield injuries. In an attempt to reduce the debilitating consequences of blast injury, understanding and mitigating the effects of explosion on the extremities is key. In this study, forensic biomechanical analyses have been applied to determine mechanisms of injury after the traumatic event. The aims of this study were (i) to determine which effects of the explosion are responsible for combat casualty extremity bone injury in two distinct environments, namely open, free-field (open group), and in vehicle or in cover (enclosed group), and (ii) to determine whether patterns of combat casualty bone injury differed between environments. Medical records of casualties admitted to a military hospital in Afghanistan were reviewed over a six-month period. Explosive injuries have been sub-divided traditionally into primary, secondary and tertiary effects. All radiographs were independently reviewed by a ...
Proceedings of the International Research Council on the Biomechanics of Injury conference, 2012
Lower extremities are particularly susceptible to injury in an under-vehicle explosion. Operation... more Lower extremities are particularly susceptible to injury in an under-vehicle explosion. Operational fitness of military vehicles is assessed through anthropometric test devices (ATDs) in full-scale blast tests. The aim of this study was to compare the response between the Hybrid-III ATD, the MiL-Lx ATD and cadavers in our traumatic injury simulator, which is able to replicate the response of the vehicle floor in an under-vehicle explosion. All specimens were fitted with a combat boot and tested on our traumatic injury simulator in a ...
Proceedings of the International Research Council on the Biomechanics of Injury conference, 2012
The lower limb of military vehicle occupants has been the most injured body part due to undervehi... more The lower limb of military vehicle occupants has been the most injured body part due to undervehicle explosions in recent conflicts. Understanding the injury mechanism and causality of injury severity could aid in developing better protection. Therefore, we tested 4 different occupant postures (seated, brace, standing, standing with knee locked in hyper-extension) in a simulated under-vehicle explosion (solid blast) using our traumatic injury simulator in the laboratory; we hypothesised that occupant posture would affect injury ...
Introduction Bone tumours of the foot are rare, representing 3–6% of all bone tumours. Of these 1... more Introduction Bone tumours of the foot are rare, representing 3–6% of all bone tumours. Of these 15–25% are thought to be malignant. Obtaining clear surgical margins remains an important factor in improving outcome from tumours. However, the anatomical complexity of the foot can lead to an inadequate resection, particularly if the operating surgeon is attempting to preserve function. The aim of this paper is to identify the clinical course of patients suffering from malignant bone tumours of the foot. Method A prospective tumour registry over a 30 yr period was used to identify patients with a malignant bone tumour of the foot. Patient demographics along with the site of primary malignancy, region of the foot involved and clinical management were recorded. Results 70 patients with a malignant foot tumour were identified. 25(35%) were chondrosarcomas, 20 Ewings Sarcoma, 10 Osteosarcoma and 15 were metastatic lesions. Of those diagnosed with a primary bone tumour, 8(14.5%) were referred following a “whoops” procedure. The median length of symptoms prior to diagnosis was 52 weeks. The most common regions affected were the 1 st Ray (31%) and Calcaneus (22%). The mainstay of treatment involved either Ray or Below Knee Amputation in 70% of cases. 11 patients developed either local recurrence or metastatic disease. Conclusion We present the largest single centre review of malignant bone tumours affecting the foot. Our series confirms that patients often have to suffer with protracted symptoms prior to the establishment of the correct diagnosis. The variety of differential diagnoses may explain the long delay in diagnosis. Worryingly, 14.5% of the primary bone malignancies in our series underwent a “whoops” procedure. This highlights further that physicians need to maintain a high index of suspicion when treating a patient with foot symptoms, even when the symptoms may be protracted.
It was a great privilege to experience the American-British-Canadian (ABC) Fellowship during the ... more It was a great privilege to experience the American-British-Canadian (ABC) Fellowship during the 2018 tour through North America. The following passages will introduce the fellowship and its history, and provide feedback relevant to orthopaedic practice in South Africa.
Journal of Bone and Joint Surgery - Series B, 2012
We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and wom... more We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed between the upper and the lower limbs. Explosions accounted for 164 (63%): 213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was needed in 18. A total of 36 patients continued in severe neuropathic pain. This paper outlines the methods used in the assessment of these injuries and provides information about the depth and distribution of the nerve lesions, their associated injuries and neuropathic pain syndromes.
Journal of Bone and Joint Surgery - Series B, 2012
The types of explosive devices used in warfare and the pattern of war wounds have changed in rece... more The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma. The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research. In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East. War wounds range from simple low-energy fragmentation wounds to highly complex injuries. The latter have been more recently encountered in Afghanistan and are well-described by Crabtree. 1 In Iraq and Afghanistan, improvised explosive devices (IEDs) have become the insurgents' preferred weapon and were the most common cause of coalition deaths in 2009 and 2010. 2 There has also been a notable increase in very high, lower extremity amputations or unsalvageable leg injuries with pelvic trauma. 3-5 The conflicts in the Middle East prompted the Academic Department of Military Surgery and Trauma to establish working groups to promote the development of best practice and to act as a focus for research. In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East. Speedier evacuation from the point of wounding can deliver patients to the Emergency Department at the very edge of survival, and the trauma care delivered by the Defence Medical Services on operations equals that available in the NHS in the United Kingdom. 6,7 A recent report by the Healthcare Commission described the military trauma system as 'exemplary'. 8 Between April 2006 and July 2008, 1474 patients were recorded on the United Kingdom's Joint Theatre Trauma Registry. Of these, 530 had an Injury Severity Score 9 > 16 and 296 survived, including unexpected survivors. 10 The Joint Theatre Trauma Registry is the United Kingdom database of all the prospectively collected data for service personnel injured on operational tour. It was started in December 2003.
Results During this period 12 patients were identified that fitted the criteria for local steroid... more Results During this period 12 patients were identified that fitted the criteria for local steroid injection. This represented 7% (12/179) of patients who were seen by the physiotherapy department in either an in or out-patient setting. All patients were injected with local anaesthetic and steroid injection with a single dose of intravenous antibiotic as antimicrobial cover. 10/12 (83.3%) were able to return to their unit within this theatre of operation. The only complication was one case of post injection flare of pain, which settled after 48 hours. ... Conclusion The use of local ...
Journal of Bone & Joint Surgery, British Volume, Sep 1, 2009
Following the invasion of Iraq in April 2003, Coalition forces have been conducting counter-insur... more 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.
All in-text references underlined in blue are linked to publications on ResearchGate, letting you... more All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately.
Frontiers in Bioengineering and Biotechnology, 2020
Penetrating injuries are commonly inflicted in attacks with explosive devices. The extremities, a... more Penetrating injuries are commonly inflicted in attacks with explosive devices. The extremities, and especially the leg, are the most commonly affected body areas, presenting high risk of infection, slow recovery, and threat of amputation. The aim of this study was to quantify the risk of fracture to the anteromedial, posterior, and lateral aspects of the tibia from a metal fragment-simulating projectile (FSP). A gas gun system and a 0.78-g cylindrical FSP were employed to perform tests on an ovine tibia model. The results from the animal study were subsequently scaled to obtain fracturerisk curves for the human tibia using the cortical thickness ratio. The thickness of the surrounding soft tissue was also taken into account when assessing fracture risk. The lateral cortex of the tibia was found to be most susceptible to fracture, whose impact velocity at 50% risk of EF1+, EF2+, EF3+, and EF4+ fracture types-according to the modified Winquist-Hansen classification-were 174, 190, 212, and 282 m/s, respectively. The findings of this study will be used to increase the fidelity of predictive models of projectile penetration.
Bone is one of the most highly adaptive tissues in the body, possessing the capability to alter i... more Bone is one of the most highly adaptive tissues in the body, possessing the capability to alter its morphology and function in response to stimuli in its surrounding environment. The ability of bone to sense and convert external mechanical stimuli into a biochemical response, which ultimately alters the phenotype and function of the cell, is described as mechanotransduction. This review aims to describe the fundamental physiology and biomechanisms that occur to induce osteogenic adaptation of a cell following application of a physical stimulus. Considerable developments have been made in recent years in our understanding of how cells orchestrate this complex interplay of processes, and have become the focus of research in osteogenesis. We will discuss current areas of preclinical and clinical research exploring the harnessing of mechanotransductive properties of cells and applying them therapeutically, both in the context of fracture healing and de novo bone formation in situations ...
The Improvised Explosive Device (IED), in all its forms, has become the most significant threat t... more The Improvised Explosive Device (IED), in all its forms, has become the most significant threat to troops operating in Afghanistan and Iraq. These devices range from rudimentary home made explosives to sophisticated weapon systems containing high-grade explosives. Within this broad definition they may be classified as Roadside explosives and blast mines, Explosive Formed Pojectile (EFP) devices and Suicide bombings. Each of these groups cause injury through a number of different mechanisms and can result in vastly different injury profiles. The "Global War on Terror" has meant that incidents which were previously exclusively seen in conflict areas, can occur anywhere, and clinicians who are involved in emergency trauma care may be required to manage casualties from similar terrorist attacks. An understanding of the types of devices and their pathophysiological effects is necessary to allow proper planning of mass casualty events and to allow appropriate management of the complex poly-trauma casualties they invariably cause. The aim of this review article is to firstly describe the physics and injury profile from these different devices and secondly to present the current clinical evidence that underpins their medical management.
Improved protective measures and medical care has increased the survivability from battlefield in... more Improved protective measures and medical care has increased the survivability from battlefield injuries. In an attempt to reduce the debilitating consequences of blast injury, understanding and mitigating the effects of explosion on the extremities is key. In this study, forensic biomechanical analyses have been applied to determine mechanisms of injury after the traumatic event. The aims of this study were (i) to determine which effects of the explosion are responsible for combat casualty extremity bone injury in two distinct environments, namely open, free-field (open group), and in vehicle or in cover (enclosed group), and (ii) to determine whether patterns of combat casualty bone injury differed between environments. Medical records of casualties admitted to a military hospital in Afghanistan were reviewed over a six-month period. Explosive injuries have been sub-divided traditionally into primary, secondary and tertiary effects. All radiographs were independently reviewed by a ...
Proceedings of the International Research Council on the Biomechanics of Injury conference, 2012
Lower extremities are particularly susceptible to injury in an under-vehicle explosion. Operation... more Lower extremities are particularly susceptible to injury in an under-vehicle explosion. Operational fitness of military vehicles is assessed through anthropometric test devices (ATDs) in full-scale blast tests. The aim of this study was to compare the response between the Hybrid-III ATD, the MiL-Lx ATD and cadavers in our traumatic injury simulator, which is able to replicate the response of the vehicle floor in an under-vehicle explosion. All specimens were fitted with a combat boot and tested on our traumatic injury simulator in a ...
Proceedings of the International Research Council on the Biomechanics of Injury conference, 2012
The lower limb of military vehicle occupants has been the most injured body part due to undervehi... more The lower limb of military vehicle occupants has been the most injured body part due to undervehicle explosions in recent conflicts. Understanding the injury mechanism and causality of injury severity could aid in developing better protection. Therefore, we tested 4 different occupant postures (seated, brace, standing, standing with knee locked in hyper-extension) in a simulated under-vehicle explosion (solid blast) using our traumatic injury simulator in the laboratory; we hypothesised that occupant posture would affect injury ...
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