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The aim of this presentation is to discuss the military conflict situation. The management dilemma with regards to amputation versus Lynn, the salvage primary amputation considerations whether or not limb salvage is useful. Using the present discussion within the literature. Of course, the absolute indications for amputation, the relative indications for amputation and the UK military consensus on amputation in the conflict situation. And finally, a brief discussion on through knee amputation. So military conflict brings out the best in people based into unusual situations. Rapport between personnel rapidly produces a high functioning team. All with one aim with high functioning teams comes advances. We are all aware that severe injuries to the extremities present the surgical team with the management dilemma. The choice being to proceed directly to primary amputation of the extremity or to attempt limb salvage advances in surgical technology and instrumentation, fracture fixation, micro vascular tissue transfer permit limb salvage in a large percentage of trauma cases. However, prolonged hospitalization, multiple procedures, pain, psychological trauma, economic hardship, unsuccessful rehabilitation and potentially lead to late amputation are all areas that should be considered. What do we consider as successful in salvage in the early 19 nineties, giardiasis and coworkers from Cleveland Ohio studied the long term outcomes and quality of life in patient's with open tibial sharp structures, sustaining severe top soft tissue loss in their study, which was relatively small in number. It was noted that limb salvage patient's took longer to achieve full weightbearing status, were less willing or able to work. Had a significant decrease in range of motion at the ankle, the limb salvage patient's thought they had a significant disability and had problems with performing occupational and recreational activities. This was supported further from another study from New Zealand by Fairhurst published a year later, they compared 12 below knee amputees with 12 salvaged limbs. This group concurred with the findings that early amputees had higher functional scores, fewer operations returned to work and sporting activities within six months and supported early amputation when confronted with borderline salvage tibial injury. However, dug Derschau and coworkers looked at the mangled extremity and in particular, when it should be amputated and published in 1996 that transtibial amputation outcome was relatively good, but transfemoral or trans radial was poor and salvage of some useful function should be attempted at all costs. So more recently, the lower extremity assessment project study group or leep, which is an ongoing multi center collaboration aimed at looking in detail at many of the aspects of a severe limb trauma have found no difference in functional outcomes between patient's who either underwent limb salvage surgery or early amputation at two and seven year follow up points, outcomes were found to be poor in both groups. Level of amputation was a further predictor of outcome. However, they stated that comparison between military and civilian populations could only roughly be made from their findings as there were central differences in the two populations and these included age, pre injury, fitness and economic status, etcetera. The latest literature looks at the economic effects of amputations versus salvage and both mckenzie and coworkers and Chung a towel from different institutions. But American papers conclude the efforts to undertake limb salvage should be undertaken at all costs. This ongoing debate has led to the UK setting up a long term advanced study. This is a 20 year cohort study comparing amputees with age match, non amputee patient's. This is looking more broadly at cardiovascular challenge is over this period, as well as over all bone health, mental well being and working activities, et cetera. The first participants are now being reviewed at the five year point and we await any difference in thinking overall. So as we are all aware, wounding patterns in the military conflict are very different from those observed in the more civilian setting. With blast injury, gunshot wound and crush injury being prevalent, injury patterns may not be that complex. However, the number of casualties, the limited resources available, medical expertise and other events occurring at the same time often make these situations much more complex as you all well, no immediate assessment is of paramount importance. However, delay in transferred to medical stations may completely change the outcome and decision making process. So, factors affecting decision making in the management of Seeley. A trauma are very difficult to define a UK military qualitative study into this decision making process associated purely with lim extremity trauma interviewed consultants with a significant experience in both the military and civilian extremity trauma settings. A semi structured in depth interview technique was undertaken with an opening question of what predictors of limb salvage do you utilize at times of difficult decisions. This slide shows the responses from all the consultants interviewed to date and the biggest factor was experience in this field of medicine. Although others included not a single consultant or senior doctor decision, a physiological condition of the patient, a sketch emmick time and neurovascular status. Of course, soft tissue injury, contamination, bony injury and local considerations. Of course, there are times when the decision has been made for you. As demonstrated here. In the left hand picture, the limb is clearly grossly contaminated has multiple levels of bony and soft tissue damage and injury distally. The foot is disrupted to an unsalvageable point. By comparison, the right sided picture presents a different situation. This injury appears to be predominantly below the level of the trifurcation of the tibial artery. There is considerable soft tissue damage and a bony deficit. However, it had initially had distal pulses which were lost during the time the patient was waiting to go to theater following a multiple casualty situation. But debridement wash out an external fixator and reassessment clearly the way to proceed. At least initially in this circumstance, the decisions should not be undertaken by a single surgeon or even a single specialty, but included orthopedic general surgery and the anesthetic specialties. At the very least, this particular patient who was a civilian was treated under the rules of medical engagement. Undertaken at that time of the conflict, he did have additional injuries requiring a general surgical input and he arrived with multiple casualties, several of whom were in a significantly worse condition than he was. He ended up with a prolonged ischemic time. And whilst in a civilian setting, with more resources, locally, we would have considered external fixator, vascular bypass and late reconstruction. Our situation did not allow for this at this time. Hence, a dis joint decision was taken to primarily amputate this leg. These three pictures demonstrate the stepwise closure of the stump over a period of five days, we looked at 48 to 72 hours and then closed over a drain and with final closure at five days as shown on the right. So the absolute indications for amputation are relatively obvious. The adv allst extremity, the un reconstruct a bulb only damage very severe soft tissue envelope and destruction and a warm ischemic time of greater than six hours. Although in the upper limb it might be worth pushing this time out a little more. This picture demonstrates the avulsed lower extremity. As you can see, it is not through the joint but actually results as a combination of primary and tertiary blast injury. There's nothing to reconstruct. This slide demonstrates unreconstructed bulb only damage. This patient actually had intact overlying soft tissues but the combined physiological insult was enormous. And despite resuscitation and early use of blood products, we could not stabilize the patient. He stabilized with an immediate true knee and bologna amputation via debridement, debridement, debridement and leaving open the tissues. This patient is now a successful paralympian. Little else apart from amputation can be done with this patient. However, thorough debridement and physiological stabilization is absolutely key in this situation. So, relative indications for amputation remain relatively again, straight forward. A age, multiple associated injuries, severe damage to the it's a lateral foot, femoral or tibial nerve transection, major soft tissue loss, uncontrollable hemorrhage, poor injury, poor pre injury function and comorbidities and of course late it is soft tissue infection and osteomyelitis a wrote working group from the academic department of UK. Military Surgery provided consensus opinion paper following our Middle Eastern experiences over several years, which we are still utilizing today and I will just summarize its findings. These include examination findings on initial arrival and the indications for amputation should be documented carefully. We don't use existing limb salvage scores as they lack sensitivity and specificity with regard to the military casualty limb. Salvage scores were designed for the use of the ischemic limb rather than the contaminated limb in the military casualty. And this particular area was a focus of a specific study by the UK military. In an attempt to see if we could assist our deploying surgeons with their decision making, it remains discarded. We do not use a limb salvage score continuing on in this vein whenever possible, the decision to amputate immediately should be made by two senior doctors. All wounds should be photographed and x rays should be obtained prior to amputation. Unless the resultant delay will compromise the care of the casualty. Neurological dysfunction should not be part of the initial immediate decision to amputate as literature reports in 50%. A return, particularly with regards to sensation, all significant wounds should be derided, aiming to exercise as much foreign material and nonviable tissue as possible. Thus, reducing the infestation risk or viable tissue should be maintained even if the bone length looks excessive as it may be used as spare parts surgery at a later time and also allows the maintenance of the stump as much as possible. It may also be possible to utilize any additional soft tissue that remains for reconstruction of other areas. No flax should be created at the initial debride mint. If the foot remains variable, the bribe mint of the wounds surrounding rather than amputation should be undertaken as salvage may still be possible. There is no place for a guillotine amputation. This is a procedure that should now be historical and offers no benefit to the patient except to lose at length in their remaining stump. In the longer term amputations do not need to be through fractures. The fracture can be fixed at a later date. After debridement, no part of the rooms should be closed at the initial surgery. This may result in soft tissue, swelling and potential ski mia and therefore the loss of this vital tissue. Later, bone does not need to be covered immediately. Sutures should not be placed in the skin to prevent skin retraction. Definitive closure should be delayed and further assessment should be performed at 48 to 72 hours as a minimum. Then further closure undertaken at five days. If the tissues look clean in certain circumstances, that wounds can be left for five days after a thorough initial debridement in accordance with the Red Cross principles. So some general comments regarding amputation in this setting, there are of course multiple levels of amputation possible in both extremities and these are certainly outside the remit of this discussion. However, may I that maintaining length as much as possible is important in both limbs. The longer the lever arm, particularly in the lower limb, the less the metabolic cost for walking and the greater the likelihood to return to good function below knee amputees expend about 25% more energy in normal walking and above knee amputees, approximately 63%. This makes the through knee amputation much more relevant if it is appropriate in the correct situation. So let's briefly consider the through knee amputation, it's still in frequently considered. However, with more advances that have been made recently, with regards to lower limb prosthetics, means that they are much more successful than previously considered. May I remind everyone that the minimal length that a bologna amputation stump should be around 6.35 centimeters, four, successful prosthetic fisting and soft tissue coverage may preclude this in certain circumstances. The above knee amputation will shorten the lever arm and make stable sitting and walking, hugely more difficult soft tissue coverage may often discard the consideration of a through knee amputation but flat surgery may be possible uh to maintain the overall length. In addition, you can always shorten the fen was shaft itself at a later date. The initial advantages over the through knee amputation include a significantly less blood loss. You have no bone or muscle sectioning required with the reduction of the post operative hemorrhage and potentially reducing a heterotopic ossification formation. The procedure is relatively straightforward. So the longer term positive considerations do include it providing an end bearing stump which makes prosthetic, fitting easier and a much more stabilized, fit, the enhanced fit and stability, improves proprioception in and which is associated with preservation of the adductor magnus muscle. And thus the area over which is available for weight bearing is much greater increasing overall stability. The hip is free from any prosthetic fitting, providing a normal range of motion for symmetrical sitting and again, appropriate sets of function. This allows overall much more improved prosthetic control. The energy demand for walking is less than the above knee amputation, although more than the bologna amputation. So there are of course disadvantages if there is inadequate blood supply to the surrounding soft tissue envelope, this will diminish the skin quality and may result in tissue breakdown. A split skin graft is not sufficient to full weight, bear and lacks sensation. The location of the prosthetic knee is more distal than the normal leg. And therefore, this leads to some stride length discrepancies. This has however much improved recently with new prosthetic design, the prosthetic knee is prominent when the patient is sitting down. So just a brief discussion on the technique through knee amputation. A posteriorly based flat is most commonly used but a fish mouth flat or a skew flat. Each equally useful. Of course, dependent upon the soft tissue remaining postdebridement. Maintenance of the insertion of the abductor magnus muscle is absolutely required. This amputation is not good without this a cruciate ligaments and the posterior capsule are preserved and the patellar is preserved unless it's not structurally viable. The quadriceps tendon is sown to the preserved posterior cruciate ligament and the posterior capsule and brings down the patella into direct contact contact with the distal end of the femur. This results in the patella almost forming an anatomical lock around the distal end of the femur. They're hamstrings are my adi's to the quadriceps tendon and the posterior Paxil of the femur. And thus the whole distal femur is completely enclosed within a soft tissue envelope. Of course, the main skin closure is over a drain which is removed when the extra date is minimal. So this is an example of a through knee amputation I performed over 15 years ago. This patient is also a successful carry Olympian and continues to run marathon distances on a regular basis. Just to comment on the proximal migration of the patella anteriorly, which may occur over time but does not seem to limit this patient as a final comment. As I bring this presentation to a close, no one who's not present at the moment of arrival and initial management of the operation with the severe extremity injury can criticize your management plan, especially if your reasoning is included in your medical notes. The situations are fluid and difficult and there will never be a correct or a wrong answer. At the outset of our most recent conflicts in the early two thousands. Every limb extremity injury was reviewed by a panel. This felt challenging to the younger surgeons who were experiencing war injury patterns for the first time. But it led us to identify areas where we could improve and thus provide more appropriate training for surgeons deploying into such environments.