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).

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.

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 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.

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).