title: Salvage of Combat Hindfoot Fractures in 2003-2014 UK Military.
abstract: 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.
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Level III, comparative series.
authors.affiliation: 1 Institute of Naval Medicine, Alverstoke, UK.
authors.forename: Philippa M
authors.initials: PM
authors.lastname: Bennett
authors.affiliation: 1 Institute of Naval Medicine, Alverstoke, UK.
authors.forename: Thomas
authors.initials: T
authors.lastname: Stevenson
authors.affiliation: 2 Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Edgbaston, UK.
authors.forename: Ian D
authors.initials: ID
authors.lastname: Sargeant
authors.affiliation: 2 Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Edgbaston, UK.
authors.forename: Alistair
authors.initials: A
authors.lastname: Mountain
authors.affiliation: 1 Institute of Naval Medicine, Alverstoke, UK.|3 Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Birmingham, UK.
authors.forename: Jowan G
authors.initials: JG
authors.lastname: Penn-Barwell
mesh_terms: D000671:Amputation, Surgical / Q000379:methods*; D002111:Calcaneus / Q000601:surgery*; D005528:Foot / Q000601:surgery*; D005593:Fracture Fixation, Internal / Q000379:methods*; D005597:Fractures, Open / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D023821:Limb Salvage / Q000379:methods*; D008889:Military Personnel; D012189:Retrospective Studies; D013211:Staphylococcus aureus / Q000378:metabolism / Q000472:pathogenicity*; D006113:United Kingdom
keywords: calcaneus; combat; hindfoot; injuries and wounds; limb salvage; outcomes; talus; war