Tibiotalar nailing using an antegrade intramedullary tibial nail: a salvage procedure for unstable distal tibia and ankle fractures in the frail elderly patient.

AIM: This article describes the technique of tibiotalar nailing performed using an antegrade tibial nail for salvage of distal tibia and ankle fractures in elderly patients. MATERIALS AND METHODS: We report indications, surgical technique, and the clinical outcomes and complication rate in our series to date. A retrospective review was performed at our level 1 major trauma centre. Patient demographics, comorbidities, and 12-month post-operative course were collected. Fractures were classified using the OTA/AO and modified Gustilo-Anderson classification. Fifteen patients underwent the procedure. We present data with a minimum 12-month follow-up. The median age of the patients in this cohort was 83 years (range, 51-102). Five patients were diabetic. Six patients (6/15; 40%) presented with an open fracture. RESULTS: At final follow-up, fourteen patients reported painless walking and had returned to baseline activity. CONCLUSION: This technique may serve as a salvage procedure, with indications similar to those for tibio-talar-calcaneal arthrodesis. Indications would include non-constructible pilon fractures, comminuted intra-articular fractures in low-demand patients, or patients at high risk of wound complications. LEVEL OF CLINICAL EVIDENCE: 3.

Orthoplastic Treatment of Open Lower-Limb Fractures Improves Outcomes: A 12-Year Review.

BACKGROUND: The British Orthopaedic Association Standards for Orthopaedics and Trauma 4 (BOAST 4) inform the management of open lower-limb fractures. The authors conducted repeated reviews of performance against these standards over a 12-year period. This latest iteration has shown further improvements in outcomes concomitant with changes in service delivery. METHODS: Data on Gustilo-Anderson grade IIIB or IIIC open lower-limb fractures were collected from a prospectively constructed departmental database and analyzed using Excel. Outcomes assessed included time to stabilization, time to definitive soft-tissue coverage, and deep infection rates. RESULTS: A total of 69% of patients in our cohort received care that aligned with BOAST 4 guidelines. Median time to stabilization was 14.2 hours and to soft-tissue coverage was 47 hours, with 71% of cases compliant with BOAST 4 guidelines. The overall deep infection rate was 6.5% in our cohort. There was a significantly lower deep infection rate in BOAST 4-compliant cases (2%) versus noncompliant cases (16%), respectively (P = 0.05). A total of 41 of 61 patients had fixation and soft-tissue coverage in a single operation (fix and flap), eight had staged operations, and 12 required local flap closure. There was no significant difference in deep infection rates among these approaches. CONCLUSIONS: Compliance with the BOAST 4 guidelines and time to definitive soft-tissue coverage have improved at our center since the last review. Deep infection rates were significantly lower in BOAST 4-compliant cases, further validating this approach. The fix and flap technique was introduced during the study period and reduces operative burden for patients. These results support a joint orthoplastic approach as the optimal management for these complex injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Preclinical therapies to prevent or treat fracture non-union: A systematic review.

BACKGROUND: Non-union affects up to 10% of fractures and is associated with substantial morbidity. There is currently no single effective therapy for the treatment or prevention of non-union. Potential treatments are currently selected for clinical trials based on results from limited animal studies, with no attempt to compare results between therapies to determine which have the greatest potential to treat non-union. AIM: The aim of this systematic review was to define the range of therapies under investigation at the preclinical stage for the prevention or treatment of fracture non-union. Additionally, through meta-analysis, it aimed to identify the most promising therapies for progression to clinical investigation. METHODS: MEDLINE and Embase were searched from 1St January 2004 to 10th April 2017 for controlled trials evaluating an intervention to prevent or treat fracture non-union. Data regarding the model used, study intervention and outcome measures were extracted, and risk of bias assessed. RESULTS: Of 5,171 records identified, 197 papers describing 204 therapies were included. Of these, the majority were only evaluated once (179/204, 88%), with chitosan tested most commonly (6/204, 3%). Substantial variation existed in model design, length of survival and duration of treatment, with results poorly reported. These factors, as well as a lack of consistently used objective outcome measures, precluded meta-analysis. CONCLUSION: This review highlights the variability and poor methodological reporting of current non-union research. The authors call for a consensus on the standardisation of animal models investigating non-union, and suggest journals apply stringent criteria when considering animal work for publication.

Outcomes following trauma laparotomy for hypotensive trauma patients: A UK military and civilian perspective.

BACKGROUND: The management of trauma patients has changed radically in the last decade, and studies have shown overall improvements in survival. However, reduction in mortality for the many may obscure a lack of progress in some high-risk patients. We sought to examine the outcomes for hypotensive patients requiring laparotomy in UK military and civilian cohorts. METHODS: We undertook a review of two prospectively maintained trauma databases: the UK Joint Theatre Trauma Registry for the military cohort (February 4, 2003, to September 21, 2014) and the trauma registry of the Royal London Hospital major trauma center (January 1, 2012, to January 1, 2017) for civilian patients. Adults undergoing trauma laparotomy within 90 minutes of arrival at the emergency department (ED) were included. RESULTS: Hypotension was present on arrival at the ED in 155 (20.4%) of 761 military patients. Mortality was higher in hypotensive casualties (25.8% vs. 9.7% in normotensive casualties; p < 0.001). Hypotension was present on arrival at the ED in 63 (35.7%) of 176 civilian patients. Mortality was higher in hypotensive patients (47.6% vs. 12.4% in normotensive patients; p < 0.001). In both cohorts of hypotensive patients, neither the average injury severity, the prehospital time, the ED arrival systolic blood pressure, nor mortality rate changed significantly during the study period. CONCLUSIONS: Despite improvements in survival after trauma for patients overall, the mortality for patients undergoing laparotomy who arrive at the ED with hypotension has not changed and appears stubbornly resistant to all efforts. Specific enquiry and research should continue to be directed at this high-risk group of patients. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, level IV.

Refining the Trauma and Injury Severity Score (TRISS) to Measure the Performance of the UK Combat Casualty Care System.

INTRODUCTION: The Trauma and Injury Severity Score (TRISS) methodology is used in both the UK and US Military trauma registries. The method relies on dividing casualties according to mechanism, penetrating or blunt, and uses different weighting coefficients accordingly. The UK Military Joint Theatre Trauma Registry uses the original coefficients devised in 1987, whereas the US military registry uses updated civilian coefficients, but it is not clear how either registry analyzes explosive casualties according to the TRISS methodology. This study aims to use the UK Military Joint Theatre Trauma Registry to calculate new TRISS coefficients for contemporary battlefield casualties injured by either gunshot or explosive mechanisms. The secondary aim of this study is to apply the revised TRISS coefficients to examine the survival trends of UK casualties from recent military conflicts. MATERIALS AND METHODS: The Joint Theatre Trauma Registry was searched for all UK casualties injured or killed in Iraq and Afghanistan by explosive or gunshot mechanisms between January 1, 2003 and December 31, 2014. Details of these casualties including injuries and vital signs were reviewed. Logistic regression analysis was performed to devise new TRISS coefficients; these were then used to examine survival over the 12 yr of the study. RESULTS: Comparing the predictions from the gunshot TRISS model to the observed outcomes, it demonstrates a sensitivity of 98.1% and a specificity of 96.8% and an overall accuracy of 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 updated and mechanism-specific TRISS methodology was used to measure changes in survival over the study period, survival following these injuries improved until 2012 when performance was maintained for the last 2 yr of the study. CONCLUSION: This study for the first time refines the TRISS methodology with coefficients appropriate for use within combat casualty care systems. This improved methodology reveals that UK combat casualty care performance appears to have improved until 2012 when this standard was maintained.

Extremity injuries sustained by the UK military in the Iraq and Afghanistan conflicts: 2003-2014.

INTRODUCTION: Extremity injuries predominate in warfare, however their nature, and overall burden to the individual and the health service is yet to be characterised for the UK military in the recent conflicts of Iraq and Afghanistan. METHODS: We reviewed the all extremity injuries in survivors from the Joint Theatre Trauma Registry (JTTR) between 2003 and 2014. All cases recorded in the JTTR between the invasion of Iraq on the 19th March 2003 and cessation of combat operations in Afghanistan on the 27th October 2014, were examined. Casualties who were killed in action or died from their wounds were excluded. All extremity injury codes were included, capturing patients with soft tissue injuries but no fracture or amputation. RESULTS: Of 2348 UK combatants surviving injury in Iraq and Afghanistan, 1813 (77%) had extremity injuries; of these 205 (11%) had at least one amputation at the wrist/ankle or more proximal. Trans-tibial was the most common level of limb loss. Eighty five casualties lost 2 limbs, 83 of these (98%) lost both lower limbs and 17 lost 3 limbs. Aside from amputations, there were 1530 fractures, 501 (33%) involving the upper limb and 1029 (67%) in the lower limb and pelvis. The tibia was the most frequently fractured bone. Of the lower limb fractures, 597 (58%) were open compared with 344 (69%) in the upper limb. Total Length of Stay (LOS) following extremity injury was 24,486days or 69 years and 1 month; there were a total 2817 surgical episodes performed on extremities. Median length of stay Length of Stay (LOS) for major amputations (i.e. those at the wrist/ankle or more proximal) was 51days (IQR 30-65) with a median of 7 surgical procedures on their limbs (IQR 5-9). In casualties with fractures but no amputation, median LOS was 13days (IQR 6-25) with a median of 2 surgical procedures (IQR 1-4). CONCLUSION: Utilising a dedicated injury database, this study illustrates for the first time in the United Kingdom military population, that the extremities are involved in the vast majority of combat injuries and the large surgical workload required for their treatment.

Salvage of Combat Hindfoot Fractures in 2003-2014 UK Military.

BACKGROUND: Hindfoot fractures pose a considerable challenge to military orthopaedic surgeons, as combat injuries are typically the result of energy transfers not seen in civilian practice. This study aimed to characterize the pattern of hindfoot injuries sustained by UK military casualties in recent conflicts, define the early amputation and infection rate, and identify factors associated with poor early outcomes. METHODS: The UK Joint Theatre Trauma Registry was searched for British military casualties sustaining a hindfoot fracture from Iraq and Afghanistan between 2003 and 2014. Data on the injury pattern and management were obtained along with 18-month follow-up data. Statistical analysis was performed with the chi-square test and binomial logistic regression analysis. The threshold for significance was set at P < .05. One hundred fourteen patients sustained 134 hindfoot injuries. Eighteen-month follow-up was available for 92 patients (81%) and 114 hindfeet (85%). RESULTS: The calcaneus was fractured in 116 cases (87%): 54 (47%) were managed conservatively, 32 (28%) underwent K-wire fixation, and 30 (26%) underwent internal fixation. Nineteen patients (17%) required transtibial amputation during this time. A deep infection requiring operative treatment occurred in 13 cases (11%) with Staphylococcus aureus, the most common infectious organism (46%). A deep infection was strongly associated with operative fracture management ( P = .0016). When controlling for multiple variables, the presence of a deep infection was significantly associated with a requirement for amputation at 18 months ( P = .023). There was no association between open fractures and a requirement for amputation at 18 months ( P = .640), nor was conservative management associated with a requirement for amputation ( P = .999). Thirty-six fractures (32%) required unplanned revision surgery within the first 18 months following salvage, of which 19 (53%) involved amputation. CONCLUSION: A deep infection was the sole variable significantly associated with a requirement for amputation by 18 months. These results suggest that attempts at salvaging these injuries are at the limits of orthopaedic technical feasibility. LEVEL OF EVIDENCE: Level III, comparative series.

Gun-shot injuries in UK military casualties - Features associated with wound severity.

INTRODUCTION: Surgical treatment of high-energy gun-shot wounds (GSWs) to the extremities is challenging. Recent surgical doctrine states that wound tracts from high-energy GSWs should be laid open, however the experience from previous conflicts suggests that some of these injuries can be managed more conservatively. The aim of this study is to firstly characterise the GSW injuries sustained by UK forces, and secondly test the hypothesis that the likely severity of GSWs can be predicted by features of the wound. METHODS: The UK Military trauma registry was searched for cases injured by GSW in the five years between 01 January 2009 and 31 December 2013: only UK personnel were included. Clinical notes and radiographs were then reviewed. Features associated with energy transfer in extremity wounds in survivors were further examined with number of wound debridements used as a surrogate marker of wound severity. RESULTS: There were 450 cases who met the inclusion criteria. 96 (21%) were fatally injured, with 354 (79%) surviving their injuries. Casualties in the fatality group had a median New Injury Severity Score (NISS) of 75 (IQR 75-75), while the median NISS of the survivors was 12 (IQR 4-48) with 10 survivors having a NISS of 75. In survivors the limbs were most commonly injured (56%). 'Through and through' wounds, where the bullet passes intact through the body, were strongly associated with less requirement for debridement (p<0.0001). When a bullet fragmented there was a significant association with a requirement for a greater number of wound debridements (p=0.0002), as there was if a bullet fractured a bone (p=0.0006). CONCLUSIONS: 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. Gunshot wounds should be assessed according to the likely energy transferred, extremity wounds without features of high energy transfer do not require extensive exploration.

Pre-clinical evaluation of therapies to prevent or treat bone non-union: a systematic review protocol.

BACKGROUND: Non-union of fractured bone is a major cause of morbidity in the orthopaedic population. Despite this, optimal management of non-union is still unclear and remains a significant clinical challenge. Research continues in animal models in an attempt to identify an effective clinical treatment. The proposed systematic review will evaluate current therapies of bone non-union in animal models, in order to identify those that may translate successfully to clinical therapies. METHODS/DESIGN: The methodology for the systematic review will be in accordance with standard guidelines. All potential sources for pre-clinical studies will be interrogated and the search strategy written in conjunction with a specialist in this field. Data extraction will be conducted by two reviewers to minimise bias. Analysis will be predominantly qualitative because of the heterogeneity that is likely to exist between the studies. However, quantitative synthesis will be performed where homogeneity in a sub-group of studies exists. Quality assessment will be undertaken utilising a risk of bias tool. DISCUSSION: To date, there has not been a systematic review addressing bone non-union therapies in animal models despite the plethora of pre-clinical research currently being undertaken. This protocol details and outlines the methodology and justification for such a review.

High velocity gunshot injuries to the extremities: management on and off the battlefield.

The gunshot wounds sustained on the battlefield caused by military ammunition can be different in nature to those usually encountered in the civilian setting. The main difference is that military ammunition has typically higher velocity with therefore greater kinetic energy and consequently potential to destroy tissue. The surgical priorities in the management of gunshot wounds are hemorrhage control, preventing infection, and reconstruction. The extent to which a gunshot wound needs to be surgically explored can be difficult to determine and depends on the likely amount of tissue destruction and the delay between wounding and initial surgical treatment. Factors associated with greater energy transfer, e.g., bullet fragmentation and bony fractures, are predictors of increased wound severity and therefore a requirement for more surgical exploration and likely debridement. Gunshot wounds should never be closed primarily; the full range of reconstruction from secondary intention to free tissue transfer may be required.

Improved survival in UK combat casualties from Iraq and Afghanistan: 2003-2012.

BACKGROUND: The United Kingdom was at war in Iraq and Afghanistan for more than a decade. Despite assertions regarding advances in military trauma care during these wars, thus far, no studies have examined survival in UK troops during this sustained period of combat. The aims of this study were to examine temporal changes of injury patterns defined by body region and survival in a population of UK Military casualties between 2003 and 2012 in Iraq and Afghanistan. METHODS: The UK Military Joint Theatre Trauma Registry was searched for all UK Military casualties (survivors and fatalities) sustained on operations between January 1, 2003, and December 31, 2012. The New Injury Severity Score (NISS) was used to stratify injury severity. RESULTS: There were 2,792 UK Military casualties sustaining 14,252 separate injuries during the study period. There were 608 fatalities (22% of all casualties). Approximately 70% of casualties injured in hostile action resulted from explosive munitions. The extremities were the most commonly injured body region, involved in 43% of all injuries. The NISS associated with a 50% chance of survival rose each year from 32 in 2003 to 60 in 2012. CONCLUSION: An improvement in survival during the 10-year period is demonstrated. A majority of wounds are a result of explosive munitions, and the extremities are the most commonly affected body region. The authors recommend the development of more sophisticated techniques for the measuring of the performance of combat casualty care systems to include measures of morbidity and functional recovery as well as survival. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Local bismuth thiols potentiate antibiotics and reduce infection in a contaminated open fracture model.

OBJECTIVE: This proof-of-concept study tested the hypothesis that combining bismuth thiols (BTs) with systemic antibiotics will more effectively reduce infection in an animal model of contaminated open fracture than systemic antibiotics alone. METHODS: An implant-stabilized segmental defect rat model was contaminated with Staphylococcus aureus and then treated with surgical debridement 6 hours after injury and 3 days of systemic cefazolin. A single dose of BTs suspended in a hydrogel was administered to the wound immediately after debridement. After 14 days, the bone and implant were harvested for microbiological analysis. RESULTS: A single local dose of 0.05 mg of BT (MB-8-2), when combined with systemically administered cefazolin, decreased infection, without any noticeable local or systemic toxicity, from 60% to 10% (P = 0.002), with only 0.02% of the recovered bacteria quantity of the cefazolin-only group (P < 0.001). Higher doses were less effective and caused side-effects. CONCLUSIONS: BTs administered locally to infected open fracture wounds at an appropriate dose potentiate the effect of systemically administered antibiotics and reduce infection rate and bacteria quantity associated with bone and orthopaedic implants. Local delivery of BTs is a promising strategy for increasing the efficacy of systemically administered antibiotics in preventing and treating infections of open fractures.

Local antibiotic delivery by a bioabsorbable gel is superior to PMMA bead depot in reducing infection in an open fracture model.

OBJECTIVES: Local delivery allows a high concentration of antibiotics to be achieved in the wound while avoiding the side effects and cost of systemic administration. Beads molded from polymethylmethacrylate cement are commonly used for local antibiotic delivery but are not ideal. The purpose of this study was to determine whether a bioabsorbable gel delivering vancomycin and gentamicin is more effective in reducing infection than beads delivering vancomycin and tobramycin. METHODS: This study used a segmental defect rat model contaminated with Staphylococcus aureus and treated with clinically relevant local antibiotic doses, delivered by gel or beads. In the gel group, 1 mL of gel containing gentamicin and vancomycin was spread throughout the wound. In the bead group, four 3-mm beads containing tobramycin and vancomycin were placed in the wound, 2 in the defect and 2 in the adjacent tissue envelope, there was also a control group that received no antibiotic treatment. After 14 days, bone and hardware was harvested for separate microbiological analysis. RESULTS: There was a significantly lower infection rate in groups treated with antibiotics delivered by gel compared with those treated with either antibiotic beads or no antibiotics at all (P < 0.001). Quantitative cultures also demonstrate significantly less bacteria in the wounds treated with the gel than in the control or bead groups (P ≤ 0.004). CONCLUSIONS: These results suggest that antibiotic delivery by a gel is superior to beads. The authors propose that antibiotic depot by polymethylmethacrylate antibiotic beads is less effective because this method has to rely on diffusion of the antibiotic from the high concentration close to the beads to all regions of the wound.

The injury burden of recent combat operations: mortality, morbidity, and return to service of U.K. naval service personnel following combat trauma.

OBJECTIVES: The study establishes the functional outcomes of service personnel injured in current conflicts by correlating data on initial injury to the findings of medical boards after trauma and reconstructive treatment. Data comprehensively include all casualties of the Royal Navy and Royal Marines and all functional outcomes. METHODS: Details of all casualties from 2003 to 2010 taken from the Joint Theatre Trauma Registry and records of all medical boards relating to these personnel were analysed. Population at risk and probability of survival data were calculated. RESULTS: There were 221 casualties: 54 (24%) were fatalities; of 167 survivors, 21 (9% of total) were medically discharged; 26 (12%) were placed in reduced fitness category and 120 (55%) returned to full duty. Casualty risk per year of operational service for Naval Service personnel was 4.6%. New injury severity score and functional outcome were closely correlated, with specific exceptions. There were 3 unexpected survivors and no unexpected fatalities. Extremity injuries predominate in survivors. CONCLUSIONS: The Defence Medical Service (DMS) provides excellent trauma and rehabilitative care. The authors contend that this is a valid proxy for other larger coalition formations. Specific injury patterns have higher impact on functional outcomes; future research efforts should focus on these areas.

Comparison of the antimicrobial effect of chlorhexidine and saline for irrigating a contaminated open fracture model.

OBJECTIVES: The objective of this study is to compare antimicrobial effect of irrigation with chlorhexidine gluconate (CHG) to saline in an animal model. METHODS: This study used a segmental defect rat femur model contaminated with Staphylococcus aureus and treated 6 hours after injury with debridement and irrigation with 60 mL of fluid delivered at low pressure. In study groups of 10 animals each, 3 concentrations of CHG (0.5%, 0.05%, and 0.005%) were used and a group irrigated with 0.05% CHG and then saline and a control group treated with saline only. After irrigation the wounds were closed, and the rats were recovered. Fourteen days later, bone and implants were harvested for separate microbiological analysis. RESULTS: There was no statistical difference detected between the subsequent presence or quantity of bacteria after irrigation, with aqueous CHG at a range of concentrations comparing irrigation with saline alone. CONCLUSIONS: This study does not support the use of CHG as an irrigant. This may be due to the antibacterial effect of CHG being offset by the associated host tissue toxicity. Host tissue damage from high irrigation pressures and cytotoxic solutions has been shown to allow bacteria to thrive. We believe this is due to a "rebound" of bacteria growth in a wound bed containing small quantities of necrotic tissue damaged by CHG exposure.

Use of topical negative pressure in british servicemen with combat wounds.

OBJECTIVE: The objective of this study was to characterize the use of topical negative pressure therapy in combat wounds. METHODS: This study was a retrospective review of the records of patients whose wounds were managed with topical negative pressure between April 2007 and March 2008. The main outcome measure was episodes of antibiotic prescription, which was used as a surrogate marker of clinically relevant infection. RESULTS: Of the 62 cases identified, 25 clinical notes were unavailable and were excluded from the study leaving 37 included cases. All but one of the cases was male with an average age of 29 (19-39) and New Injury Severity Score (NISS) of 21.3 (14.4-28.1). In 20 cases, topical negative pressure was changed less than once per 4.9 days on average, and in the remaining 17 cases, this was done more frequently. Comparison of the rate of antibiotic prescription between these groups reveals a significantly higher rate in the cohort managed with more frequent topical negative pressure changes. However this relationship was not borne out in a multiple variable analysis. CONCLUSION: This study describes the use of topical negative pressure in the management of a uniquely challenging group of patients. Statistical analysis of relatively small numbers is challenging but these results support the current complex wound management strategies where wounds are temporized with topical negative pressure for several days following thorough wound debridement. This period allows patients to be physiologically stabilized, other injuries to be addressed and appears not to be associated with increased infections.

Outcomes in lower limb amputation following trauma: a systematic review and meta-analysis.

INTRODUCTION: Lower limb amputation (LLA) is life-changing surgery. Shorter residual limbs are known to place greater physiological strain on patients than longer residual limbs; however, there is ongoing debate as to whether through-knee amputations are preferable to above-knee amputations. This analysis aims to resolve this question by systematically collecting and pooling published and unpublished data on this subject. METHODS: An exhaustive search of Medline, Embase and Recal databases was made for outcome studies of patients with lower limb amputations following trauma. Studies concerned with amputations of the upper limb or foot and ankle were excluded as were papers reporting outcomes in a population of mixed trauma and non-trauma patients. Authors of studies published in the last 10 years were contacted for unpublished details. Patients were then divided, according to amputation height, into four groups: below-knee amputation (BKA), through-knee amputation (TKA), above-knee amputation (AKA) and bilateral amputation. The primary outcome measure was Physical Component Score (PCS) of the short-form-36 measure of quality of life and secondary outcomes were pain, employment, ability to walk 500m and proportion of time that prosthesis is worn. RESULTS: As many as 27 studies were included, representing a total of 3105 patients, 1855 with a BKA, 104 with a TKA, 888 with an AKA and 258 bilateral amputees. There was progressive and significant lowering of PCS (worsening outcomes) as unilateral amputation height became more proximal from BKA to TKA and AKA. A significantly greater proportion of patients with a BKA or a TKA were able to walk 500m than those with an AKA or bilateral amputation (p=0.0035). However, patients with a TKA wore their prosthesis significantly less, and had significantly more pain than those with an AKA. CONCLUSION: This study describes the impact of LLA of different levels on patients' lives. The results indicate that patients with a TKA have a better physical quality of life than those with an AKA and, therefore, support the surgical strategy of maintaining maximum length and performing TKA in preference to AKA, where possible.

Isolated hand injuries on operational deployment: an examination of epidemiology and treatment strategy.

This study presents an analysis of 6 years of isolated hand injuries repatriated from Afghanistan or Iraq. Of a total of 6,337 medical cases evacuated back to the United Kingdom, 414 (6.5%) cases were identified as hand injuries; from these exclusions were: 207 who did not return to Royal Centre for Defence Medicine, 12 who were incorrectly coded, 1 was an old injury, and 41 whose notes were unavailable. The notes of the remaining 153 patients were reviewed: only 9% had battle injuries; nearly half involved fractures; overall, 73% required surgery, a total of 171 surgical episodes, a third of these operations occurred in deployed facilities. Patients with primary nerve or tendon repairs in deployed medical facilities had a trend toward significantly worse outcomes than those whose primary repair was delayed until repatriation. This study supports the current recommendation of delaying tendon and nerve repair until repatriation.