We conducted a community survey of the prevalence, health impact and location of chronic pain. We explored the relationship and patterns of chronic pain that commonly occur, with a view to understanding why some treatment approaches may be more appropriate than others for particular patterns of pain. In 2002, 2504 randomly sampled patients from 16 General Practices in the South East of England responded to a postal questionnaire about chronic pain. Those with chronic pain completed a pain drawing. We calculated descriptive statistics, relative risk and correlations to identify the associations and risks of having linked pain. The highest prevalences were low back (23%), shoulder (20%) and knee (18%) pain. The number of pain sites experienced was age related in men but less so in women. Lower body pain was more age related than upper body and non musculoskeletal pain. Multi site pain was more common than single site pain. Of those with low back, knee and shoulder pain, 14%, 4.5 % and 1.9% had only low back, knee and shoulder pain respectively. Correlations and minimum spanning trees showed that chronic upper and lower body pain are distinct and axial pain link the two. Chronic pain is more likely to be multi site, especially at middle age. Research, physical treatments and approaches to managing chronic pain are often site specific, therefore specialising treatment to one area eg low back pain often negates the bigger issue. This may help explain the self perpetuating problem of persistent chronic pain.
A prospective audit was conducted at an associate teaching hospital in the south west to assess the outcome of operative treatment of ankle fractures of all patients over the age of 50 years in the last 2 years. The aim of the study was to assess whether change in timing of surgery for ankle factures in accordance with the CEPOD guidelines has affected the outcome in terms of early complications. This is a follow up paper to the one published from this institution in 1994 (data 1988 to 1989). Since then the CEPOD rules have led to changes in theatre protocols, so very few ankles are fixed out of hours. Over this period there has been the emergence of MRSA which was not a problem in the 1990s. We retrospectively reviewed the notes and x-rays for 107 consecutive patients older than 50 years who had their ankles fixed over a period of 2 years spanning 2003 to 2004. Our series had 12.1% incidence of clinical infections, 15.9% delayed wound healing as compared to 1.8% and 5.2% in previous publication from this institution. In our study 17.7% of ankles were fixed within 24 hours as opposed to 84.2 % in the previous paper. All of the infected wounds (100%) occurred in patients who had their operations 48hrs or more post injury. We also came across 2 cases of MRSA infection in our series. We are concerned that changes in CEPOD rules as well as new hospital practice has resulted in delays in time to fixation. This seems to be the only variable to result in increased infection rates and delays in wound healing leading to increase in hospital stay and reoperations.
Patients who consulted complementary practitioners were more likely to be female, to be psychologically distressed, to work, to have left school aged over 16 and to have severe pain (p<
0.05 in all cases). Working was independently associated with consulting a complementary practitioner (Exp (B) = 2.0, p=0.00)
Explored patient’s or practitioners; beliefs and expectations, or both. Studied patients with chronic musculoskeletal pain, which does not have a known systemic, inflammatory or malignant origin treated in primary or community care. The full review group resolved disagreements. Full text articles meeting the inclusion criteria will be obtained and coded further into non-randomised studies, randomised studies and qualitative studies. Data abstraction forms will be developed for each type of study. Data abstraction will be undertaken by two members of the group working independently.
To determine the most powerful predictors of consultation for CLBP from pain severity, troublesomeness, health related quality of life and psychological distress
Chi square tests will be undertaken to explore the relationship between troublesomeness of CLBP and consultations for pain in general and with whether consulted mainstream or complementary practitioners. Multiple logistic regression will be undertaken to explore the most powerful predictors of consultation for CLBP.
Participants were identified from respondents reporting chronic pain in a postal questionnaire survey administered through a local general practice. Participants were allocated to groups according to the severity of their pain, as measured by the Chronic Pain Grade. Those with grades II and I were allocated to group one and those with grades III and IV to group two.
We wish to report a technique for the reconstruction of the late presenting Tendo Achilles rupture. A proximal intra muscular Z lengthening through a separate incision facilitates distal translation of the proximal tendon stump, allowing direct repair distally with minimum tension. Post operatively, a below knee cast is applied for six weeks, with progressive dorsiflexion at two weekly intervals. A dorsiflexion restriction splint accompanies early physiotherapy for a further six weeks, with unprotected weight bearing commencing at three months. There were eleven patients in the study group with an average follow up of 24 months. All tendons united. There were no re-ruptures. Two distal wound breakdowns occurred and one of these healed by secondary intention. Good single stance power returned in patients with smaller separations but greater calf wasting and weakness was observed in those patients with large separations. We conclude that this technique can be employed for the reconstruction of late presenting Achilles tendon ruptures, but great care is required with soft tissue dissection distally.
The operative and non-operative treatment options for acute tendo achilles rupture are well documented in the literature. The management of late presenting tendon rupture is usually operative, and can be complicated by acute shortening of the muscle-tendon unit and leave repairs under tension, which may lead to re-rupture. We report the use of the sliding graft technique for reconstruction of late presenting rupture. A proximal intra muscular Z lengthening through a separate incision facilitates distal translation of the proximal tendon stump, allowing direct repair distally with minimum tension. Post operatively a below knee cast is applied for six weeks with progressive dorsiflexion at two weekly intervals. A dorsiflexion restriction splint accompanies early physiotherapy for a further six weeks with unprotected weight bearing commencing at three months. There were eleven patients in the study group with an average follow up of 13 months. All tendons united. There were no re-ruptures. Two distal wound breakdowns occurred and one of these healed by secondary intention. Good single stance power returned in patients with smaller separations but greater calf wasting and weakness was observed in those patients with large separations. We conclude that this technique can be employed for the reconstruction of late presenting tendo achilles ruptures but great care is required with soft tissue dissection distally. Consideration could be given to deep flexor transfers in the widely separated case.
The aim of our study was to demonstrate the safety of the use of a maximal allowable blood loss formula to reduce the transfusion requirements of elective primary arthroplasty patients. In the UK, many arthroplasties are performed each year. Many patients will receive blood transfusion post operatively. Often these patients don’t predonate blood, and most units don’t use re-infusion drains. Blood is both costly, and potentially hazardous product to use; we felt it may be beneficial to patients to reduce the unnecessary use of allogenic blood. We began with a prospective six-month audit, of transfusion requirements of our elective primary arthroplasty patients, establishing our blood use. Our results showed that 66% (58% knees, 73% hips) had at least one unit of blood post operatively, averaging 1.3 units per patient (1.1 knees, 1.5 hips). Following this, we instituted a new protocol for postoperative blood transfusion. The protocol involved calculation of a maximum allowable blood loss (MABL) the patient could safely lose prior to the need for blood transfusion. This value is based on the patients weight and preoperative haematocrit. Blood loses up to this value would be made up with colloid replacement. When this MABL value is reached the patient has a bedside measurement of their haematocrit. If it has fallen below 0.3 for males and 0.27 for female patients then they are transfused blood, one unit at a time until it is at or above these reference values. As a ‘safety net’ all patients have a formal full blood count on days 1,2, and 3, and are transfused if their Hb is less than 8.5 g/dl. This protocol was in place for one year (Feb. 2001-Feb. 2002). Our results show, on average a reduction of blood use from 1.3 units to 0.56 units per patient. The percentage transfused was reduced from 66% to 24% (11% knees, 34% hips). Overall we had a significant reduction of 59% in units of blood transfused to patients following the new protocol. And feel that this method demonstrates a safe system to reduce transfusion requirements.
We describe the histology of a specimen taken from an amputated leg seven months after a 15 cm bone gap in the tibia had been closed by bone transport. Lengthening appeared to have occurred by repeated minor trauma to the bone, with the fractured trabeculae in sufficiently close contact for the repair process to proceed. Osteogenesis did not occur through a cartilage phase, but the fracture gaps were bridged by collagen fibres, around which new bone formed. Microfractures had repaired by primary healing with woven bone and with no microcallus. Small regions of bone were necrotic. Resorption of the necrotic bone and remodelling of the immature bundle and woven bone were still at an early stage, suggesting that complete remodelling in man may take years rather than months.