69 results found
Hurley ET, Stewart SK, Kennedy JG, et al., 2021, Current management strategies for osteochondral lesions of the talus, BONE & JOINT JOURNAL, Vol: 103B, Pages: 207-212, ISSN: 2049-4394
Breeze J, Bowley DM, Naumann DN, et al., 2020, Torso body armour coverage defined according to feasibility of haemorrhage control within the prehospital environment: a new paradigm for combat trauma protection., BMJ Mil Health
Developments in military personal armour have aimed to achieve a balance between anatomical coverage, protection and mobility. When death is likely to occur within 60 min of injury to anatomical structures without damage control surgery, then these anatomical structures are defined as 'essential'. However, the medical terminology used to describe coverage is challenging to convey in a Systems Requirements Document (SRD) for acquisition of new armour and to ultimately translate to the correct sizing and fitting of personal armour. Many of those with Ministry of Defence responsible for the procurement of personal armour and thereby using SRDs will likely have limited medical knowledge; therefore, the potentially complex medical terminology used to describe the anatomical boundaries must be translated into easily recognisable and measurable external landmarks. We now propose a complementary classification for ballistic protection coverage, termed threshold and objective, based on the feasibility of haemorrhage control within the prehospital environment.
Nguyen A, Ramasamy A, Calder J, 2020, Autologous Osteochondral Transplantation for Large Osteochondral Lesions of the Talus Is a Viable Option in an Athletic Population: Response, AMERICAN JOURNAL OF SPORTS MEDICINE, Vol: 48, Pages: NP48-NP48, ISSN: 0363-5465
Nguyen TT, Carpanen D, Rankin I, et al., 2020, Mapping the risk of fracture of the tibia from penetrating fragments, Frontiers in Bioengineering and Biotechnology, Vol: 8, Pages: 1-11, ISSN: 2296-4185
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 fracture-risk 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 tofracture,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.
Stewart S, Tenenbaum O, Masouros S, et al., 2020, Fracture non-union rates across a century of war: a systematic review of the literature, BMJ Military Health, Vol: 166, Pages: 271-276, ISSN: 2633-3767
IntroductionFractures have been a common denominator of the injury patterns observed over the past century of warfare. The fractures typified by the blast and ballistic injuries of war lead to high rates of bone loss, soft tissue injury and infection, greatly increasing the likelihood of non-union. Despite this, no reliable treatment strategy for non-union exists. This literature review aims to explore the rates of non-union across a century of conflict and war, in order to determine whether our ability to heal the fractures of war has improved.MethodsA systematic review of the literature was conducted, evaluating the rates of union in fractures sustained in a combat environment over a one hundred year period. Only those fractures sustained through a ballistic or blast mechanism were included. The review was in accordance with the Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA). Quality and bias assessment was also undertaken. ResultsThirty studies met the inclusion criteria, with a total of 3232 fractures described across fifteen different conflicts from the period 1919-2019. Male subjects made up 96% of cases, and tibial fractures predominated (39%). The lowest fracture union rate observed in a series was 50%. Linear regression analysis demonstrated that increasing years had no statistically significant impact on union rate.ConclusionFailure to improve fracture union rates is likely a result of numerous factors, including greater use of blast weaponry and better survivability of casualties. Finding novel strategies to promote fracture healing is a key defence research priority, in order to improve the rates of fractures sustained in a combat environment.
McMenemy L, Ramasamy A, Sherman K, et al., 2020, Direct Skeletal Fixation in bilateral above knee amputees following blast: 2 year follow up results from the initial cohort of UK service personnel, INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED, Vol: 51, Pages: 735-743, ISSN: 0020-1383
Nguyen TT, Carpanen D, Stinner D, et al., 2020, The risk of fracture to the tibia from a fragment simulating projectile, Journal of The Mechanical Behavior of Biomedical Materials, Vol: 102, ISSN: 1751-6161
Penetrating injuries due to fragments energised by an explosive event are life threatening and are associated with poor clinical and functional outcomes. The tibia is the long bone most affected in survivors of explosive events, yet the risk of penetrating injury to it has not been quantified. In this study, an injury-risk assessment of penetrating injury to the tibia was conducted using a gas-gun system with a 0.78-g cylindrical fragment simulating projectile. An ovine tibia model was used to generate the injury-risk curves and human cadaveric tests were conducted to validate and scale the results of the ovine model. The impact velocity at 50% risk (±95% confidence intervals) for EF1+, EF2+, EF3+, and EF4+ fractures to the human tibia – using the modified Winquist-Hansen classification – was 271 ± 30, 363 ± 46, 459 ± 102, and 936 ± 182 m/s, respectively. The scaling factor for the impact velocity from cadaveric ovine to human was 2.5. These findings define the protection thresholds to improve the injury outcomes for fragment penetrating injury to the tibia.
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 such as nonunion.
Ramasamy A, Humphrey J, Robinson AHN, 2019, The Ankle Injury Management (AIM) trial: the way forward or off target?, Bone and Joint Journal, Vol: 101-B, Pages: 1466-1468, ISSN: 2049-4394
Nguyen A, Ramasamy A, Walsh M, et al., 2019, Autologous osteochondral transplantation for large osteochondral lesions of the talus Is a viable option in an athletic population., American Journal of Sports Medicine, Pages: 1-7, ISSN: 0363-5465
BACKGROUND: Autologous osteochondral transplantation (AOT) has been shown to be a viable treatment option for large osteochondral lesions of the talus. However, there are limited data regarding the management of large lesions in an athletic population, notably with regard to return to sport. Our investigation focused on assessing both qualitative and quantitative outcomes in the high-demand athlete with large (>150 mm2) lesions. HYPOTHESIS: AOT is a viable option in athletes with large osteochondral lesions and can allow them to return to sport at their preinjury level. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The study population was limited to professional and amateur athletes (Tegner score, >6) with a talar osteochondral lesion size of 150 mm2 or greater. The surgical intervention was AOT with a donor site from the lateral femoral condyle. Clinical outcomes at a minimum of 24 months included return to sport, visual analog scale (VAS) for pain score, and Foot and Ankle Outcome Score (FAOS). In addition, graft incorporation was evaluated by magnetic resonance imaging (MRI) using MOCART (magnetic resonance observation of cartilage repair tissue) scores at 12 months after surgery. RESULTS: A total of 38 athletes, including 11 professional athletes, were assessed. The mean follow-up was 45 months. The mean lesion size was 249 mm2. Thirty-three patients returned to sport at their previous level, 4 returned at a lower level compared with preinjury, and 1 did not return to sport (mean return to play, 8.2 months). The VAS improved from 4.53 preoperatively to 0.63 postoperatively (P = .002). FAOSs improved significantly in all domains (P < .001). Two patients developed knee donor site pain, and both had 3 osteochondral plugs harvested. Univariant analysis demonstrated no association between preoperative patient or lesion characteristics and ability to return to sport. However, there was a strong correlation between MOCART scores and ability to ret
Franklin N, Hsu JR, Wilken J, et al., 2019, Advanced Functional Bracing in Lower Extremity Trauma: Bracing to Improve Function, SPORTS MEDICINE AND ARTHROSCOPY REVIEW, Vol: 27, Pages: 107-111, ISSN: 1062-8592
Grigoriadis G, Carpanen D, Webster CE, et al., 2019, Lower limb posture affects the mechanism of injury in under-body blast, Annals of Biomedical Engineering, Vol: 47, Pages: 306-316, ISSN: 0090-6964
Over 80% of wounded Service Members sustain at least one extremity injury. The 'deck-slap' foot, a product of the vehicle's floor rising rapidly when attacked by a mine to injure the limb, has been a signature injury in recent conflicts. Given the frequency and severity of these combat-related extremity injuries, they require the greatest utilisation of resources for treatment, and have caused the greatest number of disabled soldiers during recent conflicts. Most research efforts focus on occupants seated with both tibia-to-femur and tibia-to-foot angles set at 90°; it is unknown whether results obtained from these tests are applicable when alternative seated postures are adopted. To investigate this, lower limbs from anthropometric testing devices (ATDs) and post mortem human subjects (PMHSs) were loaded in three different seated postures using an under-body blast injury simulator. Using metrics that are commonly used for assessing injury, such as the axial force and the revised tibia index, the lower limb of ATDs were found to be insensitive to posture variations while the injuries sustained by the PMHS lower limbs differed in type and severity between postures. This suggests that the mechanism of injury depends on the posture and that this cannot be captured by the current injury criteria. Therefore, great care should be taken when interpreting and extrapolating results, especially in vehicle qualification tests, when postures other than the 90°-90° are of interest.
Bali N, Aktselis I, Ramasamy A, et al., 2017, An evolution in the management of fractures of the ankle: Safety and efficacy of posteromedial approach for Haraguchi type 2 posterior malleolar fractures, Journal of Bone and Joint Surgery, British Volume, Vol: 99-B, Pages: 1496-1501, ISSN: 0301-620X
AimsThere has been an evolution recently in the management of unstable fractures of the anklewith a trend towards direct fixation of a posterior malleolar fragment. Within thesefractures, Haraguchi type 2 fractures extend medially and often cannot be fixed using astandard posterolateral approach. Our aim was to describe the posteromedial approach toaddress these fractures and to assess its efficacy and safety.Patients and MethodsWe performed a review of 15 patients with a Haraguchi type 2 posterior malleolar fracturewhich was fixed using a posteromedial approach. Five patients underwent initial temporaryspanning external fixation. The outcome was assessed at a median follow-up of 29 months(interquartile range (IQR) 17 to 36) using the Olerud and Molander score and radiographswere assessed for the quality of the reduction.ResultsThe median Olerud and Molander score was 72 (IQR 70 to 75), representing a goodfunctional outcome. The reduction was anatomical in ten, with a median step of 1.2 mm(IQR 0.9 to 1.85) in the remaining five patients. One patient had parasthaesiae affecting themedial forefoot, which resolved within three months.ConclusionWe found that the posteromedial approach to the ankle for the surgical treatment ofHaraguchi type 2 posterior malleolar fractures is a safe technique that enables goodvisualisation and reduction of the individual fracture fragments with promising earlyoutcomes
Introduction Malignant osseous foot tumours are uncommon. Their oncological outcomes have been poorly documented in the literature so far. The aim of this study was to establish the incidence and to evaluate the oncological outcomes of such patients. Methods Our large orthopaedic oncology database was used to review 70 malignant osseous foot tumour patients. Results The age at diagnosis of malignant osseous foot tumours demonstrated a bimodal distribution peaking in the second and eighth decades of life. Overall, 55 primary malignant bone tumours of the foot (79%) were identified. The median duration from onset of symptoms to diagnosis was 52 weeks (interquartile range [IQR]: 17-104). Eight primary tumours (15%) underwent an accidental excision (ie intralesional excision of a malignant bone tumour where some of the tumour has been left behind, also known as a 'whoops procedure') prior to referral to our unit. Forty-six patients (84%) underwent surgery overall and thirteen of these developed recurrence or metastases. Seven of eight patients with a previous accidental excision underwent amputation. Fifteen osseous metastatic foot lesions were identified. The median length of foot symptoms to diagnosis was 24 weeks (IQR: 20-36 weeks). The median time to death following diagnosis of osseous foot metastases was 20.1 months (IQR: 11.3-27.8 months). Conclusions A high index of suspicion and awareness of clinical features of malignant osseous foot tumours are both essential to avoid diagnostic delays. Amputation is associated with a respectable outcome for patients who have undergone previous accidental excisions.
Ramasamy A, 2017, The Medical Management of Military Injuries, Military Injury Biomechanics The Cause and Prevention of Impact Injuries, Publisher: CRC Press, ISBN: 9781498742825
An international team of experts have been brought together to examine and review the topics. The book is intended for researchers, postgraduate students and others working or studying defence and impact injuries.
Ramasamy A, masouros S, grigoriadis, 2017, The lower extremities: Computational Modelling Attempts to Predict Injury, Military Injury Biomechanics The Cause and Prevention of Impact Injuries, Publisher: CRC Press, ISBN: 9781498742825
An international team of experts have been brought together to examine and review the topics. The book is intended for researchers, postgraduate students and others working or studying defence and impact injuries.
Evans S, Laugharne E, Kotecha A, et al., 2016, Megaprostheses in the management of trauma of the knee, JOURNAL OF ORTHOPAEDICS, Vol: 13, Pages: 467-471, ISSN: 0972-978X
Ramasamy A, Eardley WGP, Edwards DS, et al., 2016, Surgical advances during the First World War: the birth of modern orthopaedics, JOURNAL OF THE ROYAL ARMY MEDICAL CORPS, Vol: 162, Pages: 12-17, ISSN: 0035-8665
Evans S, Ramasamy A, Jeys L, et al., 2014, Delayed diagnosis in metastatic lesions of the foot, ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, Vol: 96, Pages: 536-538, ISSN: 0035-8843
Hoencamp R, Huizinga EP, van Dongen TTCF, et al., 2014, Impact of Explosive Devices in Modern Armed Conflicts: In-Depth Analysis of Dutch Battle Casualties in Southern Afghanistan, WORLD JOURNAL OF SURGERY, Vol: 38, Pages: 2551-2557, ISSN: 0364-2313
Hoencamp R, Tan ECTH, Idenburg F, et al., 2014, Challenges in the training of military surgeons: experiences from Dutch combat operations in southern Afghanistan, EUROPEAN JOURNAL OF TRAUMA AND EMERGENCY SURGERY, Vol: 40, Pages: 421-428, ISSN: 1863-9933
Ramasamy A, Newell N, Masouros S, 2014, From the battlefield to the laboratory: the use of clinical data analysis in developing models of lower limb blast injury, JOURNAL OF THE ROYAL ARMY MEDICAL CORPS, Vol: 160, Pages: 117-120, ISSN: 0035-8665
Evans S, Ramasamy A, Deshmukh SC, 2014, Distal volar radial plates: How anatomical are they?, ORTHOPAEDICS & TRAUMATOLOGY-SURGERY & RESEARCH, Vol: 100, Pages: 293-295, ISSN: 1877-0568
Evans S, Ramasamy A, Deshmukh SC, 2014, Distal volar radial plates: How anatomical are they?, Revue de Chirurgie Orthopedique et Traumatologique, Vol: 100, Pages: 225-225, ISSN: 1877-0517
Background: Fractures of the distal radius are common, with volar locking plates being increasingly used in their treatment. They aim to provide stable internal fixation and are designed to mirror the natural anatomy. Current volar plate designs incorporate a volar cortical angle (VCA) of 25 degrees. Hypothesis: The aim of this study is to determine whether the VCA in uninjured distal radii corresponds accurately with modern volar plate designs. Materials and methods: A retrospective radiological analysis utilizing computed tomography scans to assess the VCA of 100 distal radii. Each distal radius was subjected to 3 measurements of the VCA in the sagittal plane. Results: One hundred patients were identified (67 males, 33 females; mean age 37.4. years). The mean VCA was 32.9 degrees (SD ± 5.14 degrees). The VCA in male patients was significantly greater than in females (33.6 vs. 31.5 degrees; P= 0.04). There was a statistically significant difference between the lateral VCA and medial VCA (32.2 vs. 34.3 degrees, P= 0.02). Discussion: Our study clearly demonstrates that the VCA measured in the distal radius is significantly greater than the volar angulation incorporated within modern plate design. Given that the aim of ORIF is to anatomically reconstruct the distal radius, our study highlights that this may not be possible with current plates. Levels of evidence: Level IV. Retrospective case series. © 2014 Elsevier Masson SAS.
Evans S, Ramasamy A, Marks DS, et al., 2014, The surgical management of spinal deformity in children with a Fontan circulation THE DEVELOPMENT OF AN ALGORITHM FOR TREATMENT, BONE & JOINT JOURNAL, Vol: 96B, Pages: 94-99, ISSN: 2049-4394
Masouros SD, Newell N, Ramasamy A, et al., 2013, Design of a Traumatic Injury Simulator for Assessing Lower Limb Response to High Loading Rates, ANNALS OF BIOMEDICAL ENGINEERING, Vol: 41, Pages: 1957-1967, ISSN: 0090-6964
Clasper J, Ramasamy A, 2013, Traumatic amputations., Br J Pain, Vol: 7, Pages: 67-73, ISSN: 2049-4637
Traumatic amputations remain one of the most emotionally disturbing wounds of conflict, as demonstrated by their frequent use in films to illustrate the horrors of war. Unfortunately, they remain common injuries, particularly following explosions, and, in addition, many survivors require primary amputation for unsalvageable injuries or to save their life. A third group, late amputations, is being increasingly recognised, often as a result of the sequelae of complex foot injuries. This article will look at the epidemiology of these injuries and their acute management, complications and outcome.
BACKGROUND: Improvements in protection and medical treatments have resulted in increasing numbers of modern-warfare casualties surviving with complex lower-extremity injuries. To our knowledge, there has been no prior analysis of foot and ankle blast injuries as a result of improvised explosive devices (IEDs). The aims of this study were to report the pattern of injury and determine which factors are associated with a poor clinical outcome. METHODS: U.K. service personnel who had sustained lower leg injuries following an under-vehicle explosion from January 2006 to December 2008 were identified with the use of a prospective trauma registry. Patient demographics, injury severity, the nature of the lower leg injury, and the type of clinical management were recorded. Clinical end points were determined by (1) the need for amputation and (2) ongoing clinical symptoms. RESULTS: Sixty-three U.K. service personnel (eighty-nine injured limbs) with lower leg injuries from an explosion were identified. Fifty-one percent of the casualties sustained multisegmental injuries to the foot and ankle. Twenty-six legs (29%) required amputation, with six of them amputated because of chronic pain eighteen months following injury. Regression analysis revealed that hindfoot injuries, open fractures, and vascular injuries were independent predictors of amputation. At the time of final follow-up, sixty-six (74%) of the injured limbs had persisting symptoms related to the injury, and only nine (14%) of the service members were fit to return to their preinjury duties. CONCLUSIONS: This study demonstrates that foot and ankle injuries from IEDs are associated with a high amputation rate and frequently with a poor clinical outcome. Although not life-threatening, they remain a source of long-term morbidity in an active population.
Durrant JJ, Ramasamy A, Salmon MS, et al., 2013, Pelvic fracture-related urethral and bladder injury, JOURNAL OF THE ROYAL ARMY MEDICAL CORPS, Vol: 159, Pages: 32-39, ISSN: 0035-8665
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