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Are is that we will discuss the importance of the personality of the faction looking at current care pathways that have been described by various different groups and I CRC has use. Um and the British military surgery pocketbook, we'll look to see if there's any current evidence in the literature and we'll show some illiterate tive cases and look at the long term challenges and management strategies. We will not be focusing on the world of plastics or vascular surgery as this is not our area of expertise, but obviously is an important consideration. When dealing with a number of these injuries, we will discuss the personality of the fracture. This was first described in the 19 sixties by Nickel and it's looking at the patient as a whole and also looking at the capacity of the team. So it's not just the fracture, it's about the whole of the luminous of tissues, the patient themselves, but also just as important, the capacity of the team, their clinical skills and experience and the access to theaters and equipment and in the context of a war, the number of patient's that are injured and need treatment at the same time So first of all, we look at the British Military surgery pocketbook. This is a little book that all UK medical officers are given and it deals with the management of all injuries from the point of injury to the evacuation. And obviously the first thing is resuscitation and assessment. But what they deal with and talk about is mainly the primary treatment, the excision of the wound, whether that requires an arthrotomy set to the wound debridement, that brain will go into a bit later. The main thing that would point out is you need to try and preserve the Sino Veum and don't be too aggressive with getting rid of osteo condor fragments unless they're absolutely completely lose. And principle is to try and close Sino be um and capsule to cover the joint of possible but not necessarily closing the whole wound. At that stage, we talk about the use of a suction drain and then stabilization of a joint, whether that's with a plaster with traction or with an external fixator. They discover use of antibiotics being about, which is military is that they will be able in certain certain circumstances to give the antibiotics very early on. And they talked about trying to give it within the first hour of wounding and then the use of perhaps into articular antibiotics at the time of the deprive mint and then delayed primary closure or the use of plastic surgery at 45 days or 48 hours is the significant contamination in debris, etcetera. And then the outline delayed definitive treatment. The wall surgery filled manu by use. Um Sweet Yang and Eric fosse published in 2011. Similar guidelines. Again, resuscitation and assessment debridement and wash out. They talk about only close closing the side, no view. Um If the injury is less than eight hours old by the time you get to it, they again talk about use of intraarticular antibiotics as well as systemic perhaps slightly differently. They also discuss the use of continuous joint irrigation in high risk injuries. Those are highly contaminated, a lot of debris and the use of antibiotics in that irrigation fluid. So, Pencillin five mega units per lead to a saline and then they mentioned but don't really describe delayed definitive procedures. And then finally, the updated I CRC guidelines which have been done in the W H O and A and these were published in 2016. Former would guide mint as per the usual for long bones navarre 3 to 12 liters closing the sign over move possible again, resisting the temptation to remove large osteochondral fragments. And they only really talk about systemic antibiotics. Careful iss forums less than 72 hours unless there's definite infection. So not blanket cover with antibiotics, joint stabilisation by whatever means and then delay definitive procedures. So I think conclusion all summery, all these guidelines are concerned with primary treatment. What they agree on is antibiotics as soon as possible. Uh systemic short term, the management of this is not for the infection debridement but be conservative. Remove the bullet fragments from a joint close society. Vaccum delayed primary closure and then definitive management will be dependent on how much of the joint it's left. It's stability and the soft tissues. Reviewing the literature. One of the more recent papers from March this year, which is an interesting paper from South Africa, but it's a systematic review of 100 and 50 years of management. Gunshot was literature search. They're identified over 1500 papers but only 68 papers were included, mess were excluded for various reasons. But in total, it's over 540 for patient's. By far, the majority of patient's were lower limb injuries and it looked at the infection rate looking at and dividing it between those where antibiotics were not around to the pre antibiotic era and those when antibiotics were available. So the pre antibiotic area, when antibiotics not available, you can see that the infection rate is high over 50%. But with the use of antibiotics, um infection came down to 6%. The incidence of late infection was very born dependent on the joint and also other injuries. Um in the hip with no abdominal injury, 11% the knee, 28% of no antibiotics available. And down to two if antibiotics were used. And you can see that the infection rates if joint replacements were used was quite fine. It didn't have very many recommendations and I'll go into that and the next slide, but those that it did come up with was to be aware that gunshot wounds, the hit with associated bowel injury. The infection rates were high. 37%. So huge, there was a significant incidence of lead arthropathy. 12% of all the patient's and even need toxicity. So the guys was that all into articular bullets and fragments should be removed. They recommended that they needed to be further research but actually needed individual eyes care pathways for each joint because each joint would behave differently. The difficulties with this paper, it was all level four evidence. Two thirds of the papers were simple case studies and because of the quality of the papers, small numbers in certain cases know meta analysis could be undertaken. The other thing that struck me about this paper is that one in some respects follow what was short a mean of only four months. And I would suggest from our experience that that's not really long enough to understand these very difficult injuries. The other thing is there's only 65% of the injuries are associated with a fracture. And certainly in our experience, that's fairly unusual. There's no mention of the soft tissue injuries or the need for soft tissue reconstruction. And what struck me perhaps about this paper was this, these papers were mainly um regarding no energy transfer injuries rather than the high energy transfer injuries that you see in time of war, I am going to talk more about the clinical side and the specific cases, the injuries that I don't show are almost all from the Middle East. But this one is very similar to the punishment shootings from northern Ireland. There is the wound which is right through the patella. The immediate management is the deprived mint. In order to deprive this wound, we extend it and remove devitalized fragments, debris and contamination. And this will be familiar to you because this is very straightforward primary divide mint. But the the bullet, the track of the bullet went through the through the center of the patella and then through the center of the of the distal femur and the forceps are following the track through the femur. The devitalized fragments of the contamination is removed and washed out for reasons that are not certain but their reasons to which we subscribe. We remove the bullet if we can. I was not familiar with lead toxicity or lead based arthros iss as a consequence of of intraortic shin of bullets. But in preparing this talk, I have been quite pleased to see that the theory supports our practice and then we return to the closure. I should say that because the bullet went right through the knee. We explored the Popliteal fossa and remove the fragments from there because that's where they may be doing the most damage. And I repeat that we only close the extensions of the ballistic wounds and then we stabilize in this case because the fractures were relatively stable. We stabilized it rather than with a bridging external fixator, which is a possibility we've put on a simple back slab and that is a satisfactory in these circumstances. As an external fixator would be, I would just like to draw attention to this paper from Northern Ireland, which put where for many years there has been a tendency for punishment shootings. They used to be called kneecap ing's because most of the wounds were in the knee. Uh And the significant part of the injury was the vascular injury. In this case that I have shown there was no vascular injury. But as with everything else, punishment shootings have evolved and now can affect up to four limbs and the joints in four limbs. An interesting paper for more severe injuries and where it's very unstable, obviously, a cast is insufficient and a electrical fixator is more appropriate. But the outcome following simple principles will be the same. And was in this case, the bribe mint stabilisation, delayed closure. And in this case, a strategy to which we can return uh for reconstructing where the the ankle is completely destroyed. There is a key point association with the choice of the method of stabilisation and that is that for any level of contamination, increased stability reduces the risk of infection. It was a very clever and careful experimental confirmation of that key point. Now, if that is the case that for any level of contamination, increased stability reduces the risk of infection, should there be a place for very good civility? That open reduction and internal fixation would confer this is a a shotgun wound from 2013 and the cartridge was atomized steal powder. This weapon, the atomized steal powder cartridges used for blowing out locks of locked doors. Now, if you were, if we were in a lecture theater, I would ask for a show of hands for all those who would consider an operation to fix this internally. And before we ask that question, we'll let you consider it. I just show you one more thing that what you see within the red ellipse is an arthrogram caused by atomized steal powder. And of course, if we are considering whether or not there is a place for open reduction, internal fixation that brings us immediately back to the personality of the fracture because that is the context in which the decision will be made. This was in sergeant patient in 2013 and he opted to fix it to put the jigsaw back together and fix it with a plate. The metal, most of the metal has subsequently been removed. But this is where we are in 2021. You see the picture in 2013 and in 2021 he has a little bit of various and 100 and 15 degrees of flexion. But we have to emphasise that we should only proceed with extreme caution if if all the circumstances, all right, and the patient understands there is a significant risk of ineradicable infection. This patient has um done really very well. He's continued to work. But because of the minor various well announcement, he has progressive medial compartment articular cartilage of municipally gentle change, more pain which has been temporarily, I believe relieved by arthroscopy in May last year. So this case brings us to think about strategies for later reconstruction and whether or not we should restore his mechanical axis with a an osteotomy. And if so, where should we do it in the tibia or in the femur at present? His symptoms are not bad enough for him to want any intervention moving on from alignment in the context of our strategies for later reconstruction. The first, the next issue is are thrill icis equinus ankles and stiff means are a prominent cause of pain and disability in articular ballistic injuries of the low limb. The the aim is for a plenty grade foot and reflection more than 90 degrees uh in the leg that you see where my cursor is pointing, that is the maximum flexion after multiple operations for a super Kanda femoral fracture and an external fixator for many months. This operation we're doing your quadriceps, plasty. And uh there is an an important there are variations of the technique of quadriceps, plasty. But there is any one that I have seen successful in this context, the surgical technique that we use that has been effective. This is the same lake during the operation. It requires a, a freeing of the concepts from the distal femur to the trick conta and rectus femoris and reflected head of rectus femoris is also divided. In addition to the uh in addition to the incision, which you see, we usually do a medial, a short medial para patellar incision. Uh That is the interpretive result. Four months later, he still has about 100 and 20 degrees of flexion. The third strategy for later reconstruction is of course, arthrodesis. It's extremely effective in the hind foot in the ankle. Uh And it's also surprisingly effective in the knee. Uh No person in the video clip which I'll show in a minute, this was his knee after a a gunshot wound directly through the joint, his knee was painful, it was stiff and it was disabling this video. We took two weeks ago during our latest visit and this is how he walks. He walks obviously with a stiff need and he has a short leg because of his previous operations. Uh It's quite difficult to judge exactly how much of a shoe rays he would need. So he's been given a shoe raise one centimeter at a time until he finds the correct level for him. The surgical technique for knee, arthritis is's very straightforward and although a stiff knee is um is inconvenient. All our young men who have had it done have been like this one. They have no pain. This fellow is back to work as a labourer. He can carry weights, he can use stairs, ladders and scaffolding. The next strategy perhaps is the question of arthroplasty. Uh The literature for arthroplasty year after gunshot wound is almost nonexistent. Uh I looked for it for another purpose and searched as much as I could and found one report of two cases. The authors of this paper uh believe that success is almost inevitable and that serious complications were found in both patient's. So once again, we would advise extreme caution before considering arthroplasty after gunshot wound. Our problem in the Middle East is that everyone knows about joint replacements, but they don't know about infection and the risks following this sort of um this sort of injury, they go elsewhere, they have drug replacement, so they come back again with them infected. So we have a very negative view of joint replacement after gunshot wound of the knee. The opposite side of that particular according is that perhaps you can find a way of making it work of successful after plastic. But I would strongly suggest that that is not widely employed. A final strategy which we just came to mention is the question of agitation. These patient's both have uh critical vascular injuries and the it's perfectly obvious from the slide that the right leg in this patient of the left idea of this one as a vascular injury, owned a dead or dying foot. There are two phases for amputation. In the vascular phase, amputation will be early and uh is really dictated by the injury. If vascular repair is unsuccessful, excusing, the second phase is if liberation instruction is unsuccessful and the limb is permanently painful and relatively useless. The acceptability of late amputation will depend very largely on the reputation of the Auth Arctic service. A provision of prosthetics. If the artificial legs are known to be good, there will be much less resistance to a uh to an amputation where it is clearly necessary to provide an effective lokomotiva organ, which is how we like to look at an amputation, stump that is all I proposed to say on strategies for later reconstruction in the leg. We are not really going to discuss uh the same problems in the arm except to say that exactly the same principle supply but perhaps the the neurological injury, the nerve in tree is more um is often more pronounced and more disabling in the arm than in the leg. The radio injuries which are quite common in upper limb wounds are divided approximately half and half between the iniquity, Torri and the early treatment. We've seen a distressingly large number of radial nerve injuries from uh expert application of an external fixator the, the shoulder injuries that we have. Uh this one, the bullet had passed through the shoulder joint beneath the, the scapula and lodged just at the, it was outside the chest just at the medial aspect of the scapula. And we fished it out. I think it was, it was this one, the, if the joint, as in this case is not destroyed, we just deal with it in exactly the same way that we deal with other joints with, with uh debridement with lavage with removing the devitalized tissue. We've not had to stabilize the shoulder. But with patient's from the former Yugoslavia War. More than 20 years ago, there was no effort to replace a shoulder joint that was destroyed and provided the plexus was intact and the elbow and the were reasonably normal, relatively good function was preserved. There is obviously the option of arthrodesis of the shoulder joint which I've seen in other circumstances of which has been very effective, but we haven't found it necessary in our experience of uh articular gunshot rules. I thought we would end by going back to the title slide and emphasizing the value of simple principles. This wound was caused by a grenade and this patient is a Gurkha soldier adopting the principles of debridement stabilization. And in this case, wrist arthrodesis produced a result. A very happy soldier for those of you, for whom risked arthrodesis is who are familiar with wrist arthrodesis or perhaps those who are not, I could tell you that it is a first division operation. If it goes well, it is very well tolerated and leaves an effective functional hand exactly a year after this injury. But his treatment was complete. He was still in the army and he had a functional dominant wrist, the shoulder injuries that we have. Uh this one, the bullet had passed through the shoulder joint beneath the, the scapula and lodged just at the, it was outside the chest, just at the medial aspect of the scapula. And we fished it out. I think it was, it was this one the, if the joint as in this case, is not destroyed, we just deal with it in exactly the same way that we deal with other joints with, with uh debridement with lavage with removing the devitalized tissue. We've not had to stabilize the shoulder. Um But you in other circumstances, in other circumstances, with patient's from Ukraine, not from Ukraine, from the former Yugoslavia. During that ghastly war more than 20 years ago, uh there was no effort to replace a shoulder joint that was destroyed and provided the plexus was intact and the elbow and the were reasonably normal. Um mhm Relatively good function was preserved. There is obviously the option of arthrodesis of the shoulder joint, but which I've seen in other circumstances of which has been very effective, but we haven't found it necessary in our experience of uh articular gunshot rules.