title: Case suitability for definitive through knee amputation following lower extremity blast trauma: analysis of 146 combat casualties, 2008-2010.
abstract: BACKGROUND
  Analysis of recent UK Armed Forces combat casualty data has highlighted a significant number of through joint traumatic amputations (TAs), most commonly through knee (through knee amputations (TKAs)). Previously, a consensus statement on lower limb amputation from the UK Defence Medical Services reported better outcomes in some patients with TKAs when compared with those with above knee amputations. This study sought to define the proportion of recent combat casualties sustaining severe lower extremity trauma with acute osseous and soft tissue injury anatomy amenable to definitive TKA.
  
  
  METHODS
  The UK Joint Theatre Trauma Registry and post mortem CT (PM-CT) databases were used to identify all UK Armed Forces personnel (survivors and fatalities) sustaining a major extremity TA (through/proximal to wrist or ankle joint) between August 2008 and August 2010. Through knee and all below knee TAs were grouped as 'potential TKAs' (pTKAs), that is, possible candidates for definitive TKA.
  
  
  RESULTS
  146 Cases (75 survivors and 71 fatalities) sustaining 271 TAs (130 in survivors, 141 in fatalities) were identified. The through-joint TA rate was 47/271 (17.3%); 34/47 through-joint injuries (72.3%) were TKAs. Overall, 63/130 TAs in survivors and 66/140 TAs in fatalities merited analysis as the pTKA group. Detailed anatomical data on pre-debridement osseous and soft tissue injury levels were only consistently available for fatalities through PM-CT findings. Further analysis of the soft tissue injury profile revealed that a definitive TKA in the pTKA group (all BKAs as well as TKAs) would have been proximal to the zone of injury (ZOI) in only 3/66 cases.
  
  
  CONCLUSIONS
  Traumatic TKAs following explosive blast are more common than previously reported. The majority of lower limb TAs are skeletally amenable to a definitive TKA. Maximising residual stump length carries the risks of definitive level amputation within the original ZOI but this study demonstrates that the proximal extent of the soft tissue injury may frequently make this unavoidable. Further work is required to determine the relative merits of definitive below, through and above knee amputations in the short, medium and long term to ensure survivors are subject to minimal complications while maintaining capacity to achieve optimal functional outcomes.
authors.affiliation: The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK.
authors.forename: James A G
authors.initials: JA
authors.lastname: Singleton
authors.affiliation: The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK.
authors.forename: N M
authors.initials: NM
authors.lastname: Walker
authors.affiliation: Defense Centre for Imaging, Fort Blockhouse, Gosport, Hampshire, UK.
authors.forename: I E
authors.initials: IE
authors.lastname: Gibb
authors.affiliation: The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK.
authors.forename: A M J
authors.initials: AM
authors.lastname: Bull
authors.affiliation: Defense Centre for Imaging, Fort Blockhouse, Gosport, Hampshire, UK Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK.
authors.forename: J C
authors.initials: JC
authors.lastname: Clasper
mesh_terms: D000328:Adult; D000671:Amputation, Surgical / Q000379:methods*; D000673:Amputation, Traumatic / Q000453:epidemiology / Q000601:surgery; D001753:Blast Injuries / Q000601:surgery*; D006801:Humans; D007717:Knee / Q000601:surgery*; D035002:Lower Extremity / Q000293:injuries / Q000601:surgery; D008889:Military Personnel / Q000706:statistics & numerical data*; D006113:United Kingdom; D014857:Warfare; D055815:Young Adult