Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years

Abstract

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.

Methods: Follow-up was attempted in all United Kingdom military casualties sustaining hindfoot fractures. All respondents underwent short-form (SF)-12 scoring; those retaining their limb also completed the American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) outcomes questionnaire. A multivariate regression analysis identified injury features associated with poor functional recovery.

Results: In 12 years of conflict, 114 patients sustained 134 fractures. Follow-up consisted of 90 fractures (90/134, 67%), at a median of five years (interquartile range (IQR) 52 to 80 months).The median Short-Form 12 physical component score (PCS) of 62 individuals retaining their limb was 45 (IQR 36 to 53), significantly lower than the median of 51 (IQR 46 to 54) in patients who underwent delayed amputation after attempted reconstruction (p = 0.0351).Regression analysis identified three variables associated with a poor F&A score: negative Bohler's angle on initial radiograph; coexisting talus and calcaneus fracture; and tibial plafond fracture in addition to a hindfoot fracture. The presence of two out of three variables was associated with a significantly lower PCS compared with amputees (medians 29, IQR 27 to 43 vs 51, IQR 46 to 54; p < 0.0001).

Conclusions: At five years, patients with reconstructed hindfoot fractures have inferior outcomes to those who have delayed amputation. It is possible to identify injuries which will go on to have particularly poor outcomes.Cite this article: P. M. Bennett, T. Stevenson, I. D. Sargeant, A. Mountain, J. G. Penn-Barwell. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res 2018;7:131-138. DOI: 10.1302/2046-3758.72.BJR-2017-0217.R2.

Keywords: Amputation; Amputation and salvage; Calcaneal fracture; Hindfoot; Limb salvage; Military; Outcome.

Fig. 1

Graph showing the variation in American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) score depending on presence of key variables in initial injury. Key variables: negative Böhler’s angle on initial radiograph; coexisting talar and calcaneal fracture; fracture of tibial plafond in addition to hindfoot fracture.

Fig. 2

Graph showing the correlation between American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) score and Short-Form 12 (SF-12) physical component score (PCS). (Spearman’s correlation coefficient test).

Fig. 3

Graph showing the comparison between Short-Form 12 physical component score (SF-12 PCS) outcome scores for patients with reconstructed hindfoot injuries, and those requiring amputation following attempted reconstruction.

Fig. 4

Graph showing the variation in Short-Form 12 physical component (SF-12 PCS) outcome scores for those with reconstructed hindfoot injuries depending on presence of key variables in initial injury, compared with those patients requiring delayed amputation following attempted reconstruction. Key variables: negative Böhler’s angle on initial radiograph; coexisting talar and calcaneal fracture; fracture of tibial plafond in addition to hindfoot fracture.