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).

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).

Objectives

The surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function.

Since 2008 the improvised explosive device has been responsible for a significant proportion of injuries sustained whilst on operational duty in Afghanistan. Vehicles have been developed and adapted to offer maximal protection to service personnel. As a result of the decrease in mortality, there has been an increase in the severity of injuries to the lower limb.

Hind-foot injuries are a difficult cohort of injuries to treat successfully. Those that are amenable to reconstruction carry a significant morbidity, which may result in either early or delayed amputation.

There has been a new injury pattern to the lower limb, not previously described in the medical literature. This pattern consists of a displaced intra-articular calcaneal fracture, distal third tibial fracture and midfoot injury within the same limb.

We believe the combination of the three injuries form the “unhappy triad of the ankle”. Each of the injuries is individually reconstructable, but the combination of all three primary amputation should be considered as part of the surgical options.

AIM: To investigate the relationship between patient variables and surgeons’ grade and experience on one hand and re-operation and mortality rates at six months on the other hand.

Method: Seven hundred and sixty-one patients with proximal femoral fractures (PFF) (463 intracapsular fractures, 286 extracapsular fractures, and 12 subtrochanteric fractures) were treated surgically between April 2005 to October 2007. The level of experience among trainees was quantified as the number of PFF they had fixed or replaced as the first surgeon, from the start of their training at Senior House Officer level to the beginning of the study period.

Logistic regression model was used to investigate the relationship between mortality and re-operation at six months and case mix variables (age, ASA grade, fracture types, pre-fracture residence, and mobility and activity level), and management variables (days to operation, the grade of the surgeon and supervision level). Mann-Whitney test was used to compare the level of experience among trainees in the group of patients who died or required re-operation at six months.

Results: At six months, the mortality rate was 24.2% (184) and the re-operation rate was 3.8% (29).

The logistic regression model used to predict six months mortality was highly significant (X2=166.6 [24df], p< 0.0001). It showed that age, ASA grade and pre-fracture activity level were strongly associated with mortality at six months. Patients operated on by a trainee without the consultant being scrubbed were 1.8 times (p< 0.05) more likely to die at 6 months. (Odds ratio of 1.8 with 95% confidence interval of 1.15 to 2.75). Re-operation at six months could not be predicted by these factors.

Regarding patients operated on by trainees, there was no significant difference in the level of experience among trainees who operated on patients who died or who required re-operation at six months compared to those who did not.

The biomechanics of civilian fractures have been extensively studied with a view to defining the forces responsible e.g. bending, torsion, compression and crushing. Little equivalent work has been carried out on military fractures, although fractures from gunshot can be divided into direct and indirect. Given that the effects of blast can be sub-divided into primary, secondary, tertiary and quaternary, the aim of this study was to try to determine which effects of the blast are responsible for the bony injury. This may have implications for management and prognosis as well as prevention.

We reviewed emergency department records, case notes, and all radiographs of patients admitted to the British military hospital in Afghanistan over a 6 month period (Apr 08–Sept 08) to identify any fracture caused by an explosive mechanism. In addition we reviewed all relevant radiographs from the same period at the Royal Hospital Haslar, who report all radiographs taken, and keep a copy of the images. Early in the study it became clear that due to the complexity of some of the injuries it was inappropriate to consider bones separately and we used the term ‘fracture zone’ to identify separate areas of injury, which could involve from 1 – 28 bones. It also became clear that the pattern of injury differed considerably between patients in open ground, and those in houses or vehicles. These 2 groups were considered separately and compared.

We identified 86 patients with fractures. The 86 patients had 153 separate fracture zones (range 1–6). 56 casualties in the open sustained 87 fracture zones (mean 1.55 fracture zones per casualty). 30 casualties in a vehicle or other cover sustained 66 fracture zones (2.2 per casualty). Of the casualties in the open, 17 fracture zones were due the primary effects of blast, 10 a combination of primary and secondary effects, 30 due to secondary effects and 30 from the tertiary effects of blast. Of the casualties in vehicles we could not identify anyone with a fracture due to either the primary or secondary effects of blast, all 66 fracture zones appeared to be due to the tertiary effects.

In both groups there appeared to be a significant number of fractures, often with no break in the skin, caused by severe axial loading of the limb. This was possibly due to the casualty impacting against the ground, building or the inside of a vehicle, and this is a group of injuries we are now studying in greater detail.

The role of Evidence Based Medicine in modern surgical practice is to provide a framework for the integration of expertise, evidence and the biology of the individual patient. The research presented at the Combined Services Orthopaedic Society (CSOS) annual meeting is an important source of evidence which is used to support clinical decisions made about patients on military operations and in the NHS. The purpose of this study is to review the levels of evidence presented at this meeting since 2001.

We reviewed all of the abstracts presented at the annual meetings of the CSOS between 2001 and 2008, and a single meeting of both the Society of Military Orthopaedic Surgeons (SOMOS) and the British Trauma Society (BTS). Basic science studies, animal studies, cadaveric studies, surveys and guest lectures were excluded. The research abstracts were coded by the lead author (TJB), according to the Oxford Centre for Evidence-based Medicine Levels of Evidence. A second author (AM) reviewed the coding of all abstracts to provide inter-observer reliability. Statistical analysis included a chi-squared test to compare the percentages of each level of evidence between the meetings and between each year of the CSOS meeting.

We identified 140, 51 and 96 abstracts in the CSOS, SOMOS and BTS group respectively, which met the inclusion criteria. Level 1 evidence accounted for 73.8%, 64.7% and 68.8% in the CSOS, SOMOS and BTS groups respectively. Level 1 evidence was uncommon at all three meetings representing 4.1%, 5.9% and 8.3% in the CSOS, SOMOS and BTS groups respectively. The chi-squared test did not demonstrate any statistical difference in the evidence levels between the three groups (X2=11.63 (8df), p=0.17). There was no significant difference in the levels of evidence between years during the study period at the CSOS meeting.

The average level of evidence presented at the CSOS annual meeting compares favourably with other trauma meetings. The high proportion of level 4 evidence presented at these meetings reflects the challenging task of performing research in trauma surgery. This challenge is further exacerbated in the military environment where operational commitments must be the priority. However, simple methods to strengthen research may involve the inclusion of control groups, prospective patient enrolment, standard treatment protocols, well-defined outcome measures, logistical support for good follow-up and use of patient-focused assessment tools. Co-ordination and focus of military orthopaedic research effort may advance the quality of research produced.

Introduction: Previous studies have demonstrated the value of the tip-apex distance (TAD) and the location of the screw in the femoral head in predicting cut-out. Similarly surgeons’ volume has been shown to affect mortality and morbidity in various surgical specialties, including in trauma and orthopaedics.

Aim: To determine whether re-operation due to cut out at six month can be predicted using TAD, location of the screw and fracture type; and whether the experience of the surgeon is important.

Methods: Logistic regression was used to analyse data collected retrospectively from 241 patients with extracapsular fractures (Jensen’s modification of Evans’ classification: Class I – 90, Class II – 93 and Class III – 58), treated with a dynamic hip screw, classic hip screw or intramedullary hip screw from April 2005 to October 2007.

Results: There were 7 cut outs (2.5%) requiring re-operation within 6 months – 1 in the consultant group and 6 in the trainee group,. The model used was statistically significant (X2=23.6 [13df], p< 0.05). The tip-apex distance was a strong predictor (p< 0.05) of cut-out requiring re-operation at six months. The odds of the patient requiring re-operation due to cut out increases by a factor of 1.2 for each millimetre increase in the TAD. Location of the hip screw and fracture type were however not significant predictors. The first surgeon was a consultant in 54 cases and trainee in 187 cases. There was no statistically significant difference in re-operation rate due to cut out between patients operated on by consultants compared to trainees.

Conclusion: The TAD is a strong predictor of cut out requiring re-operation at 6 months. No difference was found in our series in re-operation rate due to cut out among cases performed by consultants compared to trainees.

Presentation and subsequent publication has become ‘the holy grail’ of surgical trainees. This perceived importance of presenting work is further reinforced by the fact that over sixty percent of information contained in standard orthopaedic texts is quoted from published abstracts and not full papers. There is concern that increasing reliance is placed on such work and there are calls to restrict the routine use of abstracts in this manner.

This concern is born out of evidence that conversion of presented work into peer-reviewed publication is globally poor throughout the medical specialities.

The purpose of this study is to determine the conversion rate of work presented at the Combined Services Orthopaedic Society into peer review publication.

A Medline search of 81 consecutive published abstracts over six years was carried out. Further cross-referencing was established using Dialog Datastar with a search strategy. The rate of publication of papers presented at these meetings was then compared against other medical specialities across national and international forums.

26 full paper publications were identified. This yields a conversion rate of 32%. This figure is on a par with meetings such as the BOA (35%), the AAOS (34%) and EFORT (40%). It is also a similar level to that seen with work presented at other speciality meetings.

The conversion rate of papers presented at the Combined Services Orthopaedic Society is competitive with other orthopaedic and medical meetings. Overall conversion of presented works to robust literature is poor. Reasons for low publication rates include pressures of time, insufficient planning and disputes amongst colleagues.

In light of increasing pressure on selection of trainees and the perceived need to present work at meetings, this paper reinforces the need for thorough planning when undertaking research & audit and strict acceptance criteria from organising bodies.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

To evaluate a peri-operative protocol developed to facilitate day case open shoulder procedures that historically have required overnight hospital admission. 75 consecutive day-case open shoulder procedures were performed in 75 patients (aged 18 – 65) followed up prospectively for a minimum of 6 months. The procedures included Open Primary Anterior Capsulo-Labral Reconstruction (ACLR) (24), open Revision ACLR (4), open Posterior Capsulo-Labral Reconstruction (2), mini-arthrotomy and rotator cuff repair (6), mini-arthrotomy and sub-acromial decompression (28), modified Weaver Dunn Reconstruction of Acromio-clavicular joint (ACJ) (2), decompression of ACJ (7), open release for frozen shoulder (2). Exclusion criteria included concomitant medical problems, and patients who would have no assistance in their care for the first 24 post operative hours. All patients received general anaesthesia, peri-operative analgesia using intravenous Fentanyl, and Diclofenac (PR), and local Bupivicaine 0.5% to incisions and intra-articular spaces; patients were discharged with oral analgesics. Patient satisfaction with overall experience, pain control, the incidence of nausea that was difficult to manage, the incidence of unplanned admission, attendance or delayed admission to hospital and postoperative complications were measured. 98% of patients were satisfied with their pain management. None of the patients suffered intractable post operative pain, nausea or vomiting; none required unplanned hospital admission or unexpected re-admission. All the patients were satisfied with their overall experience. There were no short or long term post operative complications. In conclusion, the anaesthetic protocol and surgical techniques used in this study permitted same day discharge for a wide variety of open shoulder procedures. For selected patients, open shoulder surgery as a day case appears to be safe effective and acceptable to the patient.

Background: The usefulness of the Nottingham Health Profile as a generic quality of health outcome measure has been described in a number of Orthopaedic conditions. This study was done to compare two quality of life questionnaires, the Nottingham Health Profile (NHP) and the Oswestry Disability Index (ODI) regarding the internal consistency, validity and responsiveness as outcome measures in patients undergoing surgery for lumbar nerve root decompression. We also assessed the effects of smoking, type of lesion, clinical presentation, number of levels involved, operating surgeon and duration of symptoms.

Methods: 37 patients with clinical nerve root entrapment, confirmed radiologically were treated with decompression surgery by two surgeons. We used the NHP and the ODI to assess the severity of symptoms prior to and at 3 and 8 months following surgery

Results: We were unable to detect factors predictive of better healthcare outcome scores after surgery for sciatica. There was a statistically significant improvement in the total ODI score and all NHP domain scores within the whole cohort, after treatment. NHP had a greater responsiveness in detecting improvement for pain and physical ability as measured by the effect size. Cronbach’s alpha for reliability of scores was consistently above the acceptable threshold of 0.90 for NHP scores and consistently below 0.90 for ODI scores. A “floor and ceiling” analysis revealed that the NHP consistently skewed scores at 3 months post op towards a better outcome compared to the ODI.

Conclusion: The generic Nottingham Health Profile appears to be a more sensitive health questionnaire than the Oswestry Disability Index in assessing the outcome of nerve root decompression surgery. We were unable to identify factors predictive of better outcomes using these scores as outcome measures.

Elderly patients with a high mortality risk for revision surgery are severely handicapped by a loosened hip prosthesis. Loosening is mainly caused by particle-induced osteolysis leading to the formation of a synovium-like interface tissue. As an alternative to revision surgery we have investigated the possibility of removing the tissue using a gene therapy approach and thereafter stabilizing the prosthesis with percutaneous cement injection.

First we demonstrated that transduction of interface cells with a gene coding for E.coli nitroreductase (NTR) resulted in a 60-fold increase in sensitivity to the prodrug CB1954 that is converted to a toxic metabolite by NTR. Given these in-vitro data, we explored if intra-articular administration of this adenoviral vector encoding NTR followed by the prodrug was able to kill sufficient tissue in-vivo to allow refixation of the prosthesis by cement.

We report the first three patients from a phase 1 study of 12 patients with a loosened hip who are experiencing debilitating pain and have significant comorbidity. On day 1 the vector is injected into the hip joint and on day 3 the prodrug is injected. On day 10 three holes are drilled in the femur and one in the acetabulum. Biopsies are taken from the periprosthetic space and low viscosity cement (Osteopal, Biomet Merck, Sjöbo, Sweden) is injected under fluoroscopic guidance.

The first three patients have been included in the study and five more are planned for treatment before June 2005. The patients are females of 86, 72, and 79 years old. There were no adverse effects from vector injection (3x10 exp 9 particles). Six hours after prodrug injection the patients experienced nausea, (WHO grade 1) a commonly reported reaction to this prodrug. There was vomiting in two patients. Hip pain increased, but this was anticipated as this therapy will increase prosthesis loosening. 16 ml of cement was subsequently injected into the periprosthetic space in the first patient and 18 ml in the second. The patients were ambulated the day after surgery.

The first two patients have a follow-up of twelve and six weeks. There was no pain in the hip. The maximum walking distance had increased from 5 to 30 meters in the first patient.

The current study is the first to use in vivo intra-articular adenoviral mediated gene transfer in a clinical setting. Our preliminary results suggest that gene therapy and cement injection for hip prosthesis refixation is clinically feasible.

There have been no studies looking at the long-term follow-up of service personnel following spinal fusion. The activities demanded by service life exert significant strain on the axial spine and there are no figures documenting the return to full service post-surgery.

A retrospective review of theatre records and case notes was made of 65 service personnel who had undergone spinal fusion at the Royal Hospital Haslar between 1990 and 2000 and the following recorded: mechanisms of injury, Service, sex of patient and age of patient at operation, the type of operation performed (instrumented v in situ fusion) and final medical category upon discharge from follow-up or from the Service.

A comparison of previously published indications for spinal fusion was made.

65 patients were identified as Service personnel undergoing spinal fusion, of which 53 were entered into the study. 48 males, 5 females average age 33.16 yrs. 35/53 (66%) spondylolisthesis, 8/53 multi-level degenerative disc disease, 4/53 (7.5%) post-discectomy instability. 33/53 (62.2%) in-situ fusion, 20/53 (37.7%) instrumented fusion.

18/53 (33.9%) are still serving of whom 5/53 (9.43%) are back to full fitness. 23/53 (43.4%) were given a medical discharge.

Spinal fusion in service personnel has similar results to those that have been published previously. A full occupational assessment at initial OPD with preoperative rehabilitation as well as post-operative rehabilitation is required to maximise the potential of return to full fitness. In military patients, even apparent successful surgery is not indicative of return to full fitness. For a service perspective, successful surgery is that which returns a service person back to their operational role.

Common pre- and post-operative details were obtained.

For a service environment, successful surgery would result in the return of a service person back to their operational role.

INTRODUCTION: Chronic back ache is a common disorder which rarely indicates surgery. There are accepted indications for surgical intervention; namely that of neurogenic leg pain in the presence of spondylolisthesis or gross instability of the lower lumbar segments. There have been no studies looking at the long term follow-up of service personnel following spinal fusion. The activities demanded by service life exert significant strain on the axial spine and there are no figures documenting the return to full service post-surgery.

METHOD: A retrospective review of case notes of service personnel undergoing spinal fusion at the Royal Hospital Haslar was performed from 1990 onwards. 65 patients were identified and their case notes analysed. The following information was obtained:

Age, sex, pre-operative diagnosis, medical category pre-op, non-operative treatment, surgical procedure, post-operative rehabilitation, medical category post-surgery and whether still serving.

ANALYSIS: Outcome parameters: medical category post surgery, and ability to continue serving in the armed services.

DISCUSSION: Successful results from spinal surgery depends on good patient selection and the development of a treatment protocol. From a service perspective, a successful surgical outcome would result in the return of a service person back to their operational role. We discuss a potential treatment algorithm for the surgical management of low back pain.