It is unclear whether combat casualties with complex hindfeet fractures would have an improved outcome with reconstruction or amputation. This study aimed to determine the outcomes of British military casualties sustaining calcaneal fractures. In the 12 years of conflict in Iraq and Afghanistan there were 116 calcaneal fractures in 98 patients. Seventy-four patients (74/98 76%) were contactable, providing follow up data for 85 fractures (85/116 73%). Median follow up was 5-years (64 months, IQR 52–79). Thirty limbs (30/85 35%) had undergone trans-tibial amputation at time of follow-up: there was no association between open fractures and requirement for amputation (p=0.06). Definitive treatment choice had a significant association with later requirement for amputation (p=0.0479). Fifty-two patients (52/74 70%) had been discharged from the military due to their injuries: there was a significant association between amputation and military discharge (p=0.001). Only 17 patients (17/74 23%) had been able to complete a military fitness test since their injury. The median physical component score of the SF-12 quality of life outcome tool for those undergoing amputation was 51.9 (IQR 48.1–54.3). The median for those retaining their limb was 44.1 (IQR 38.6–53.8). The difference between the two cohorts was not statistically significant (p=0.989).

We present the first systematic review conducted by the UK Defence Medical Services in conjunction with the Cochrane Collaboration. Irrigation fluids are used to remove contamination during the surgical treatment of traumatic wounds in order to prevent infection. This review aims to determine whether there is evidence that one wound irrigation fluid is superior to another at reducing infection. A pre-published methodology was used and two reviewers independently assessed the search results. The search produced 917 studies, of which three met the inclusion criteria. All were studies in open fractures, incorporating a total of 2,903 patients. Each RCT involved a distinct comparison, precluding meta-analysis: i) sterile saline vs. distilled/boiled water; ii) antibiotic solution vs. soap solution; iii) saline vs. soap solution. The odds ratios of infection following irrigation with various fluids was as follows: i) saline vs. distilled or boiled water 0.25 (95%CI 0.08–0.73); ii) antibiotic solution vs. soap 1.42 (95%CI 0.82–2.46); iii) saline vs. soap solution 1.00 (95%CI 0.80–1.26). These results suggest that neither soap nor antibiotic solution is superior to saline and that saline is inferior to distilled or boiled water.

Anterior Cruciate Ligament injuries are a common cause of downgrade in Service personnel. The Multidisciplinary Injury Assessment Clinic (MIAC) is a service which patients can be referred to for expert musculoskeletal injury management. MIAC has a Fast Track (FT) referral system in place for imaging, and can subsequently refer isolated ACL injuries to a private provider for reconstruction. We examined this pathway in the South West region which has an overall population at risk of 19775. Over 4 years 173 knee injuries were referred to MIAC, of which 32 were ACL injuries. Of the 29 patients referred for MRI, the median time to imaging was 8 days with FT (n=13, range 2–14) and

15 days via the NHS (n=16, range 5–64). The majority of injuries were found to involve multiple pathologies (n=19), excluding them from FT surgery. Time to NHS clinic from point of referral took a median time of 54 days, and onward delay to surgery was 47 days. None of the referrals to the private provider for reconstruction were accepted (n=3). We have identified aspects of current referral and treatment pathways that are inefficient and discuss a current solution utilising Military surgeons.

This is a retrospective study examining the injury pattern, management and short-term outcomes of British Military casualties sustaining hindfoot fractures from the conflicts in Iraq and Afghanistan. In the 12-years of war, 114 patients sustained 134 hindfoot injuries. The calcaneus was fractured in 116 cases (87%): 54 (47%) were managed conservatively, with 30 (26%) undergoing internal fixation.

Eighteen-month follow-up was available for 92 patients (81%) and 114 hindfeet (85%). Nineteen patients (17%) required trans-tibial amputation in this time, with a further 17 (15%) requiring other revision surgery. Deep infection requiring surgical treatment occurred in 13 cases (11%) with S. aureus the commonest infective organism (46%). Deep infection was strongly associated with operative fracture management (p=0.0022). When controlling for multiple variables, the presence of deep infection was significantly associated with a requirement for amputation at 18 months (p=0.001). There was no association between open fractures and requirement for amputation at 18 months (p=0.926), nor was conservative management associated with amputation requirement (p=0.749).

Bone non-union following fracture is a major cause of morbidity in combat casualties.

The various clinical treatments used to prevent or treat non-union remain of limited efficacy. Research therefore continues in pre-clinical animal models in an attempt to identify an effective clinical treatment. The aim of this study was to systematically evaluate emerging pre-clinical therapies in order to rationalise priorities for translational research.

The methodological protocol of this study was registered with the Collaborative Approach to Meta Analysis and Review of Animal Data from Experimental Studies (CAMARADES) and published.

The review identified 3251 animal studies, 851 of which fulfilled the criteria for inclusion as detailed in the protocol. Of these, 702 of the studies described therapies that had progressed to clinical trials and were therefore excluded. The remaining 149 papers described eighteen categories of therapy that represent novel therapies yet to translate to clinical trials. These studies used a range of animal models, with heterogeneity that precluded formal synthesis and meta-analysis.

This study provides a systematic evaluation of novel therapies with potential to prevent or treat non-union. It also represents a novel application of an emerging epidemiological technique to address a key priority in Combat Casualty Care research.

High-energy firearms do not necessarily produce ‘high-energy’ Gun Shot Wounds (GSWs). The aim of this study was to characterise the gun shot injuries sustained by UK forces, and secondly test the hypothesis that the likely severity of GSWs can be predicted by features of the wound. The UK Military trauma registry was searched for cases injured by GSW in the five years between 01 Jan 2009 and 31 Dec 2013: only UK personnel were included. There were 450 cases who met the inclusion criteria. 96 (21%) were fatally injured, with 354 (79%) surviving their injuries. Of the 325 survivors with full records, 236 had GSWs to the limbs and pelvis. ‘Through and through’ wounds were strongly associated with less requirement for debridement (p<0.0001). Fractures were associated with a requirement for a greater number of wound debridements (p=0.00022) GSW with intact, retained bullets and those involving bullet fragmentation, required similar numbers of wound debridements (p=0.53744). This study characterises the GSWs sustained by UK Military personnel over 5-years of warfare. More complex wounds as indicated by the requirement for repeated debridements are associated with injuries where the bullet does not pass straight through the body, or where a bone is fractured.

In June 2012 the Orthopaedic Speciality Advisory of the Joint Committee on Surgical Training defined ‘minimum indicative numbers’ that trainees would have to meet before completion of specialist training. It has been speculated that regions have varied in their ability to provide operative opportunities to their trainees. This study aims to test the hypothesis that there are regional differences in operative training experience. The eLogbook database was interrogated for cases over a 12 month period from 7 August 2013 to 5 August 2015. Within each region, the mean of the cases registered by orthopaedic trainees in each year of training during the study period was calculated and summed to give a representative surgical experience for the years ST3-8. First surgeon only cases were analysed for 11 index procedures in 30 T&O rotations. Considerable variation in training existed across rotations. In three index procedures, including DHS, no rotation achieved the minimum indicative number required. All rotations achieved the minimum indicative number of external fixator applications. This study proves the extent of the significant regional variation in surgical training in Trauma and Orthopaedics in the UK and raises concerns regarding the volume of operative training currently achieved.

The TRISS methodology is used in by both the UK and US military trauma registries and relies on dividing casualties according to mechanism: penetrating or blunt. The UK and US military trauma registries use the original coefficients devised in 1987 and it is not clear how either registry analyses explosive casualties according to the TRISS methodology. This study aims to use the UK military trauma registry (JTTR) to calculate new TRISS coefficients for contemporary battlefield casualties injured by either gunshot or explosive mechanisms. The JTTR was searched for all UK Casualties injured or killed between 2003 and 2014. A logistic regression analysis was performed to devise new TRISS coefficients, these were then used to re-examine survival over the 12 years of the study. Comparing the predictions from the GSW TRISS model to the observed outcomes, it demonstrates a sensitivity of 98.1% and a specificity of 96.8% and an overall accuracy 97.8%. With respect to the explosive TRISS model, there is a sensitivity of 98.6%, a specificity of 97.4% and an overall accuracy of 98.4%. When this improved TRISS methodology was used to measure changes in survival, there was a sustained improvement over the 12-year study period.

The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 – 2010 were contacted and interviewed. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation in the same period. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria, of which 30 patients (61%) were followed-up. Ten of the 30 patients required revision surgery, 3 of which involved conversion to a circular frame. Twenty-two of the 30 patients (73%) recovered sufficiently to complete a basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma.

The aim of this study was to characterise severe open tibial shaft fractures sustained by UK military personnel over 10-years of combat and to determine the infection rate and factors that influence it. The UK military Joint Theatre Trauma Registry was searched and X-rays, clinical notes and microbiological records were reviewed for all patients. One hundred GA III open tibia fractures in 89 patients were identified. Three fractures were not followed up for 12-months and were therefore excluded. Twenty-two (23%) of the remaining 97 tibial fractures were complicated by infection requiring surgical treatment, with S. aureus being the causative agent in 13/22 infected fractures (59%). Neither injury severity, mechanism, the use of an external fixator, the need for vascularised tissue transfer or smoking status were significantly associated with infection. Bone loss was significantly associated with subsequent infection (p<0.0001). Most infection in combat open tibia fractures is caused by familiar organisms i.e. S. aureus. The use of external fixators to temporarily stabilise fractures is not associated with an increased risk of subsequent infection. While the overall severity of a casualty's injuries was not associated with infection, the degree of bone loss from the fracture was.

The aim of this study was to establish medium term outcomes in military casualties following severe open tibia fractures.

Cases from a previously published series were contacted and assessed with the SF-36 outcome tool. Their results were then compared to a similar study of military trans-tibial amputees.

Of the original data set of 49 patients, 30 patients were followed up and completed an SF-36 (61%) with a median follow-up of 4 years (49 months, IQR 397–63). Ten of the 30 required revision surgery, 3 of which involved conversion from initial fixation to a circular frame. Twenty-two of the 30 patients recovered sufficiently to complete a military basic fitness test. The median physical component of SF-36 in the tibia fracture group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in the amputation or fracture group reporting pain (p= 0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney).

We present the patient reported outcomes following combat open tibia fracture and show that they are similar to those achieved after trans-tibial amputation.

The UK Military Trauma Registry was searched for all RN/RM personnel injured between March 2003 and April 2013. These records were then cross-referenced with the records of the Naval Service Medical Board of Survey which evaluates injured RN/RM personnel for medically discharge, continued service in a reduced capacity or return to full duty (RTD). Population at risk data was calculated from service records.

There were 277 casualties in the study period: 61 (22%) of these were fatalities; of the 216 survivors, 63 or 29% were medically discharged; 24 or 11% were placed in a reduced fitness category. A total of 129 individuals (46% of the total and 60% of survivors) returned to full duty. The greatest number of casualties was sustained in 2007; there was a 3% casualty risk per year of operational service between 2007–2013. The most common reason cited by the Naval Service medical board of survey for medical downgrading or discharge was injuries to the lower limb with upper limb trauma being the next most frequent injury.

This study characterises the injuries sustained by RN and RM personnel during recent conflicts and demonstrates significant challenge of predominantly orthopaedic injuries for reconstructive and rehabilitation services.

The UK Military Trauma Registry was searched for all cases of primary bilateral lower limb amputation sustained over 6-years between March 2004 and March 2010. There were 1694 UK military patients injured or killed during this six-year study period.

Forty-three of these (2.8%) were casualties with bilateral lower limb amputations. All were men injured in Afghanistan by Improvised Explosive Devices. Six casualties were in vehicles when they were injured with the remaining 37 (80%) patrolling on foot. The mean New Injury Severity Score was 48.2 (SD 13.2). Nine patients also lost an upper limb (triple amputation); no patients survived loss of all four limbs. Six patients (14%) sustained an open pelvic fracture. Perineal/genital injury was a feature in 19 (44%) patients, ranging from unilateral orchidectomy to loss of genitalia and permanent requirement for colostomy and urostomy. The mean requirement for blood products was 66 units (SD=41.7). The minimum transfusion requirement was 8 units and the greatest was a patient requiring a total of 193 units of blood products.

Our findings detail the severe nature of these injuries together with the massive surgical and resuscitative efforts required to firstly keep patients alive and secondly reconstruct and prepare them for rehabilitation.

The aim of this study was to characterise injury patterns and examine whether survival had improved over the last decade of conflict in Iraq and Afghanistan. A logistical regression model was applied to all UK casualty data from the Joint Theatre Trauma Registry.

There were 2785 casualties over the 10-years. 72% of casualties from hostile action were injured by blast weapons. The extremities were the post commonly injured body region, being involved in 43% of all injuries sustained. The New Injury Severity Score that was observed to be associated with a 50% chance of survival rose every year from 38 in 2003 to 62 in 2012. The odds ratio of surviving with a Trauma and Injury Severity Score (TRISS) of 50% rose by 1.349 (95% CI = 1.265–1.442) per year. The actual TRISS value associated with a 50% chance of survival dropped every year from 35.3% in 2003 to 0.9 in 2010 and was un-calculable in 2011–12.

This study confirms that the last decade of conflict has been characterised by blast wounds and injuries involving the extremities. A consistent improvement in survival over the 10 years has been demonstrated, to the point that traditional metrics for measuring improvement in trauma care have been exhausted.

Some military personnel are having Femoral Acetabular Impingement (FAI) surgery. The use of the alpha angle (AA) to help assess the diagnosis is common. Currently there are no standardised values available across a asymptomatic pre-arthritic population.

Retrospective analysis of 200 consecutive individuals (400 hip joints) with ages 20 to 50, who had a CT performed between 1 Apr 2011 and 29 Nov 2011 due to abdominal pathology. The AA of Notzli was measured on the axial view.

The mean AA value was 53.5 (95%CI 1.30) for Right hips and 53.4 (95% CI 1.31) for the left. In age 20–30 Right 52.6 (95%CI 3.5) the Left 52.0 (95%CI 2.9), 31–40 Right 53.9 (95%CI 2.5) Left 53.4 (95%CI 3.1), 41–50 Right 53.8 (95% CI 1.9) Left 53.2 (95% CI 1.8). Mean male Right 52.9 (95% CI 1.5) Left 53.2 (95%CI 1.9) Female Right 52.5 (95% CI 1.5) Left 49.9 (95% CI 1.6). 144/400 (37%) of patients had angle >55 degrees.

Previous literature suggests an AA >55 degrees is diagnostic of FAI, we suggest that the AA is highly variable across age and sex and that >1/3rd of asymptomatic patients will have an AA that was previously regarded as abnormal.

This study aimed to characterise severe open femoral fractures sustained by military personnel and to describe their orthopaedic management and preliminary outcomes. The UK Military Trauma Registry was searched for open femoral fractures sustained between 2006–2010. Clinical records and radiographs were reviewed and data gathered on demographics, injury, management and preliminary outcomes.

Thirty-four patients with 34 open femoral fractures were eligible for inclusion. The mean NISS was 22.4 (SD 12.28). Nineteen fractures were caused by gunshot wounds (56%), with the remainder due to blasts. Three patients (9%) suffered Grade 4 segmental bone loss. Intramedullary nailing was used in 22 patients (69%). A minimum of 12 month follow up was available for 33 patients (97%). Twenty-three patients (70%) had achieved fracture union within the first twelve months. One patient suffered deep infection requiring surgical debridement. Ten patients (30%) underwent a revision procedure due to femoral shortening or malunion: two required a transfemoral amputation. There was a significant association between bone loss and a poor outcome (revision surgery) at 12 months (p=0.00016). Infection rates were significantly lower in open femoral fractures when compared to similar published work on open tibial fractures (p=0.0257).

Introduction

Open fractures are common, and infection a frequent complication. There is still uncertainty regarding the urgency of initial treatment. The majority of animal studies indicate that early irrigation and debridement reduces infection; unfortunately, these studies often do not involve antibiotics. Clinical studies indicate that the timing of initial debridement does not affect the infection rate. These studies are observational and fraught with confounding variables. The purpose of this study was to control for these variables using an animal model incorporating both systemic antibiotics and surgical treatment.

Open fractures are common, and infection a frequent complication. There is still uncertainty regarding the urgency of initial treatment. The majority of animal studies indicate that early irrigation and debridement reduces infection; unfortunately, these studies often do not involve antibiotics. Clinical studies indicate that the timing of initial debridement does not affect the infection rate. These studies are observational and fraught with confounding variables. The purpose of this study was to control for these variables using an animal model incorporating both systemic antibiotics and surgical treatment.

This study used a segmental defect rat femur model contaminated with Staphylococcus aureus and treated with a 3 day course of systemic cefazolin (5 mg/Kg 12 hourly) and surgical treatments, both of which were initiated independently at 2, 6 and 24 hour time points. After 14 days bone and hardware was harvested for separate microbiological analysis.

These results show that the earlier systemic antibiotic treatment or surgery is initiated. When antibiotics are started at 2 hours, delaying surgical treatment from 2 to 6 hours significantly increases infection (p=0.047). However, delaying surgery to 24 hours increases infection, but not significantly (p=0.054). The timing of antibiotics had a more significant effect on the proportion of positive samples than earlier surgery. At the 2 and 6 hour treatments, the p value was 0.004 and for the 6 and 24 timings it was 0.003.

Surgery and antibiotics at 2 hours completely eradicates the bacteria, but surgical delay for 6 hours appears to allow the bacteria to form non-susceptible colonies. Delaying antibiotics to 6 or 24 hours had a profound detrimental effect on the infection rate regardless of timing of surgery. These findings are consistent with the concept that bacteria progress from a vulnerable planktonic form to a treatment-resistant biofilm.

We present the British Military's experience of treating devastating lower limb injuries in personnel returning from Iraq and Afghanistan. We evaluate current surgical practice of attempting to maximise stump length through sequential debridement, rather that early amputation outside the zone of injury. Following an observation that the frequency of sequential amputation had appeared to increase during spring 2009, it was speculated that there may be factors which would predict which patients would require a more aggressive early amputation.

The Joint Theatre Trauma Registry was interrogated for all cases of amputation between Apr 06 and Sep 09. The following data were collected: demographics, mechanism of injury, requirement for massive transfusion, use of combat applied tourniquet, number of stump debridements and echelon of care performed at, all microbiology and final level of amputation. A regression analysis was performed to establish correlation between each data-set and final level of amputation. 95 cases were identified; 21 were either digits or upper limbs and excluded. Clinical notes of the remaining 74 cases were requested, of which 48 were available representing a total of 66 lower limb stumps.

No significant relationships were established between sequential amputation and any of the variables we examined. It was not possible to identify factors with predictive value with respect to which patients would benefit from a more aggressive early amputation approach. These results support current practice by demonstrating that attempts to balance maximal stump length with sufficient debridement to eradicate infected tissue, does not expose patients to unnecessary operative “hits”.

Topical Negative Pressure Therapy (TNPT) has gained increasing acceptance as a useful tool in wound management. Since 2002, the Royal Centre for Defence Medicine (RCDM) in South Birmingham has gained considerable experience with managing complex combat trauma with TNPT. The mainstay of managing high-energy combat wounds has changed little over the last century of conflict and remains early debridement, wound lavage, fracture stabilisation and delayed closure. Over the last 10 years the use of TNPT has proved to be a useful adjunct in promoting delayed primary and secondary closure, and is now common practise in the US and UK military medical services. There is however, little level 1 evidence to support the use of TNPT in military trauma.

All military patients admitted to Selly Oak Hospital between April 2007 and March 2008 that were treated with TNPT were identified, those whose notes were available were included.

37 cases were included. There was a strong correlation between ISS, NISS, and antibiotic use during TNPT use and the total duration of secondary care. However, we found no correlation between delay to first TNPT application, the frequency or location of TNPT dressing changes and any of our surrogate markers of outcome.

TNPT is just one of a number of techniques for managing military high-energy injuries and should not be seen as an alternative to the established principles. The high frequency of TNPT dressing changes is not supported by this research and this should be reflected in the clinical management of patients requiring prolonged TNPT.