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There is currently no consensus on the appropriate sports and occupational restrictions for military service members with a joint replacement. Data from the United States show that 14% of military patients complete an operational deployment after the index surgery. No published data are available on arthroplasty in the militaries of other North Atlantic Treaty Organization countries. Research is needed to determine the appropriate medical employment limitations for Canadian Armed Forces members with a knee or hip replacement. Service members wanting to continue military service should be carefully screened to ensure that their duties do not compromise the longevity of the implant and that the risk of mission-threatening complications is minimal.

Medical support to deployed field forces is increasingly becoming a shared responsibility among allied nations. National military medical planners face several key challenges, including fiscal restraints, raised expectations of standards of care in the field and a shortage of appropriately trained specialists. Even so, medical services are now in high demand, and the availability of medical support may become the limiting factor that determines how and where combat units can deploy. The influence of medical factors on operational decisions is therefore leading to an increasing requirement for multinational medical solutions. Nations must agree on the common standards that govern the care of the wounded. These standards will always need to take into account increased public expectations regarding the quality of care. The purpose of this article is to both review North Atlantic Treaty Organization (NATO) policies that govern multinational medical missions and to discuss how recent scientific advances in prehospital battlefield care, damage control resuscitation and damage control surgery may inform how countries within NATO choose to organize and deploy their field forces in the future.

The Canadian Forces’ (CF) deployable hospital, 1 Canadian Field Hospital, was deployed to Haiti after an earthquake that caused massive devastation. Two surgical teams performed 167 operations over a 39-day period starting 17 days after the index event. Most operations were unrelated to the earthquake. Replacing or supplementing the destroyed local surgical capacity for a brief period after a disaster can be a valuable contribution to relief efforts. For future humanitarian operations/disaster response missions, the CF will study the feasibility of accelerating the deployment of surgical capabilities.

Background: Prolonged field care is required when casualty evacuation to a surgical facility is delayed by distance or tactical constraints. This can occur in both civilian and military environments, including remote locations in Canada. In these circumstances, there are no established treatment options for extremity compartment syndrome. One solution is to remotely mentor the tactical clinician to perform surgical compartment release. Methods: Six military clinicians were recruited to perform a 2-incision leg fasciotomy on a synthetic model under the remote guidance of an orthopedic surgeon. The operators wore smartglasses that allowed synchronous communication and the display of anatomic holograms in their field of view. Three control legs were created: 1 complete fasciotomy and 2 with major errors. The experimental and control legs were evaluated by 2 blinded surgeons according to criteria described by Kucera and colleagues. Results: All 6 study participants were Canadian Armed Forces physician assistants. They had extensive experience as military clinicians but minimal experience performing surgical procedures. None had performed a fasciotomy previously. The study was conducted over 3 days, during which bandwidth varied widely at the study site: ping ranged from 12 to 338 ms, download speed from 0.93 to 3.48 Mbps and upload speed from 0.44 to 0.64 Mbps. The mentor, located 300 km away from the study site, had a stable Internet connection with sufficient bandwidth. The average duration of the procedure was 53 minutes (standard deviation 12 min). All 6 procedures were completed without major errors: release of all 4 compartments was achieved through fulllength incisions in the skin and fascia. The only minor error was a laceration of the saphenous vein (n = 1). All 3 control specimens were correctly assessed by the evaluators. None of the participants experienced adverse effects from wearing the AR headset. Four dropped calls occurred. In all cases, the connection was reestablished, and the procedure was completed successfully. Conclusion: Despite limited bandwidth, we were able to successfully perform 2-incision leg fasciotomy in all cases. We attribute the dropped calls to a mismatch between the size of the graphic files and the available bandwidth. A better technical understanding of the software by the mentor would have avoided this problem. Important considerations for future research and practice include protocols for dropped communications, communications training for mentoring surgeons and surgical skills training for the operators.

Damage-control and emergency surgical procedures in trauma have the potential to save lives. They may occasionally not be performed due to clinician inexperience or lack of comfort and knowledge. Canadian Armed Forces (CAF) non-surgeon Medical Officers (MOs) participated in a live tissue training exercise. They received tele-mentoring assistance using a secure video-conferencing application on a smartphone/tablet platform. Feasibility of tele-mentored surgery was studied by measuring their effectiveness at completing a set series of tasks in this pilot study. Additionally, their comfort and willingness to perform studied procedures was gauged using pre- and post-study surveys. With no pre-procedural teaching, participants were able to complete surgical airway, chest tube insertion and resuscitative thoracotomy with 100% effectiveness with no noted complications. Comfort level and willingness to perform these procedures were improved with tele-mentoring. Participants felt that tele-mentored surgery would benefit their performance of resuscitative thoracotomy most. The use of tele-mentored surgery to assist non-surgeon clinicians in the performance of damage-control and emergency surgical procedures is feasible. More study is required to validate its effectiveness. •Feasibility study that examined tele-mentoring of trauma surgical skills to non-surgeons using a live-tissue model.•Mentored operators found tele-mentoring most helpful for more rarely performed and difficult procedures such as thoracotomy.•Operators effectively completed surgical airway, chest tube insertion and thoracotomy with tablet-based mentoring.

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture. We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304. Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI –1·4 to 3·4). For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds. US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Although currently out of favour, a cross leg flap was chosen in this case. A sural neurocutaneous flap was harvested from the contralateral leg. An external fixator was then applied to hold the legs crossed (Fig. 2). The periphery of the traumatic wound and the sural flap donor site were skin grafted immediately. Although awkward, the leg position was tolerated well by the patient. Twenty-one days after the index surgery the pedicle was divided. Vigorous retrograde bleeding was noted from the severed pedicle.

[...]recently, their incidence was difficult to predict but nomograms now allow individualised forecasts for the first 5 years after the index procedure.3 4 The projected injury rates can be combined with aviation risk matrices to evaluate individual aircrew.5 Synthetic cases will illustrate our approach and highlight that superficially similar aircrew can have widely different levels of operational risk. [...]patients need extended rehabilitation to meet military operational fitness standards. [...]the rate of injury after the first postoperative year is the most appropriate measure of operational risk. [...]they could occur during pre-flight activities and compromise the mission.Table 1 The Canadian Armed Forces aeromedical risk matrix risk applied to Pilot A Medical event class Incidence 1 2 3 4 Likely (>2%/y) Possible (>1–2%/y) Unlikely (>0.5–1%/y) Highly unlikely (<0.5%/y) Aseptic loosening Deep infection Acute injury We consider periprosthetic fractures and dislocations to be class 4 medical events as they would be ‘likely to result in a flight safety critical event’ if they occurred during flight.

IntroductionCanadian Armed Forces (CAF) members must complete an annual fitness evaluation. Members with a total hip arthroplasty (THA) may be at risk of injury during these strenuous tests. To inform CAF policy, we sought expert consensus on the safety of fitness testing for members with a THA.MethodsWe conducted a three-round Delphi study with a panel of hip arthroplasty experts to determine the safety of CAF operational fitness evaluations for members with a THA. The experts evaluated videos of the 10 individual tasks included in the evaluations.ResultsAll individual tasks were judged to be safe by consensus. One task, which involves digging with a shovel, was considered safe provided that participants avoid deep hip flexion. The nine other tasks were judged to be safe without modifications or interventions. The experts also supported a policy recommendation that would allow members to perform military fitness evaluations if they (1) have a primary THA, (2) had no episodes of instability, (3) are at least 12 months postoperatively and (4) have been cleared by an orthopaedic surgeon and a physiatrist/physiotherapist.ConclusionA panel of arthroplasty experts concluded, based on video analysis, that CAF fitness evaluations are generally safe for members with a THA.

IntroductionAcute extremity compartment syndrome requires rapid decompression. In remote locations, distance, weather and logistics may delay the evacuation of patients with extremity trauma beyond the desired timeline for compartment release. The aim of this study was to establish the feasibility of performing telementored surgery for leg compartment release and to identify methodological issues relevant for future research.MethodsThree anaethetists and one critical care physician were recruited as operators. They were directed to perform a two-incision leg fasciotomy on a Thiel-embalmed cadaver under the guidance of a remotely located orthopaedic surgeon. The operating physician and the surgeon (mentor) were connected through software that allows for real-time supervision and the use of a virtual pointer overlaid onto the surgical field. Two experienced orthopaedic traumatologists independently assessed the adequacy of compartment decompression and the presence of iatrogenic complications.Results14 of 16 compartments (in four leg specimens) were felt to have been completely released. The first evaluator considered that the deep posterior compartment was incompletely released in two specimens. The second evaluator considered that the superficial posterior compartment was incompletely released in two specimens. The only complication was a large laceration of the soleus muscle that occurred during a period of blurred video signal attributed to a drop in bandwidth.ConclusionsThis study suggests that surgical telementoring may enable physicians to safely perform two-incision leg fasciotomy in remote environments. This could improve the chances of limb salvage when compartment syndrome occurs far from surgical care. We found interobserver variation in the assessment of compartment release, which should be considered in the design of future research protocols.