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.

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.

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.

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 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.