Background

Whereas arthroscopic arthrodesis of the ankle is commonplace and of the subtalar joint is established, reports of arthroscopic talo-navicular fusion are a rarity.

Background

Disability and slow return to sport and work after tendon rupture are major challenges. Platelet Rich Plasma (PRP) is an autologous supraphysiological concentration of platelets from whole blood that has demonstrated positive cellular and physiological effects on healing in laboratory conditions but evidence from adequately powered robust clinical trials is lacking. We aimed to determine the clinical efficacy of PRP for treatment of acute Achilles tendon rupture.

Abstract

Traditional open approaches for subtalar arthrodesis have reported nonunion rates of 5–16% and significant incidence of infection and nerve injury. The rationale for arthroscopic arthrodesis is to limit dissection of the soft tissues in order to preserve blood supply for successful fusion, whilst minimising the risk of soft tissue complications. The aim of this study was to determine the outcomes of sinus tarsi portal subtalar arthrodesis.

Case records of all patients undergoing isolated arthroscopic subtalar arthrodesis by two senior surgeons between 2004 and 2014 were examined. All patients were followed up until successful union or revision surgery. The primary outcome measure was successful clinical and radiographic union. Secondary outcome measures included occurrence of infection and nerve injury.

Seventy-seven procedures were performed in 74 patients, with successful fusion in 75 (97.4%). One (1.3%) superficial wound infection and one (1.3%) transient sural nerve paraesthesia occurred. Fixation with a single screw provided sufficient stability for successful arthrodesis.

To our knowledge this is the largest reported series of isolated arthroscopic subtalar arthrodeses to date, and the first series reporting results of the two portal sinus tarsi approach. This approach allows access for decortication of all three articular facets, and obviates the need for a posterolateral portal, features which may explain the high union rate and low incidence of sural nerve injury in our series.

Introduction:

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe a purely arthroscopic technique for excising talocalcaneal coalitions. We present a retrospective two-surgeon case series of the first eight patients (nine feet).

Introduction:

In a consecutive series of 71 arthroscopic subtalar arthrodeses performed between 2004 and 2011, 14 also involved arthroscopic decortication of the talonavicular joint (double arthrodesis) and 4 the subtalar, talonavicular and calcaneocuboid joints (triple arthrodeses).

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe an entirely arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet).

Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 year to 5.5 years.

Subtalar movements were improved in all feet. Deformity was not always fully corrected but pain and SAFAS scores improved in all patients bar one. They all had a rapid return to good function apart from this same patient who required subsequent fusions. The posterior tibial nerve was damaged in one patient.

Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from any operative technique. Patient selection and preoperative planning are crucial. This series from two independent surgeons supports the feasibility and effectiveness of this technique.

We report a single surgeon series of 33 arthroscopic subtalar fusions performed through a 2-portal sinus tarsi approach on 32 patients between March 2004 and February 2009. Background pathologies included primary arthrosis, post-traumatic arthritis, planovalgus foot, rheumatoid disease, sinus tarsi syndrome and CTEV.

97% [32/33] of fusions as assessed by both clinical and radiological means were achieved within 16 weeks [76% [25/33] within 12 weeks] with only a single outlier which had fused by 22 weeks. There were no deep infections, thrombotic events or neuromas. Five patients suffered complications of which four were successfully treated with a satisfactory outcome. One patient developed persistent pain and was eventually referred to another centre for further management.

In our experience arthroscopic subtalar fusion surgery has been demonstrated to give excellent outcomes with minimal complications. Furthermore, it is a technique allowing surgery even in patients with significant hindfoot deformity. It is a suitable operation even for patients with a compromised soft tissue envelope which would normally preclude an open procedure.

We present the clinical and radiological outcome of a prospective series of 22 Buechel-Pappas Total Ankle Replacements (TAR) implanted in 19 patients with a mean follow-up of 9 years (range 6 to 13). The only published long term results of this prosthesis in the literature are from the originators' unit.

Patients have been prospectively reviewed yearly since 1991. None was lost to follow-up. The primary diagnosis was rheumatoid arthritis in 11 and osteoarthritis in 8 patients. 12 patients were female. Mean patient age was 64 (range 39 to 81). At the time of review 4 patients (6 ankles) had died between 12 and 69 months post-operatively of unrelated causes with their prostheses in situ. One patient had a below knee amputation for chronic venous ulceration 11 years after a TAR which until that point had continued to function well. One patient with severe rheumatoid arthritis had the implant removed at 8 weeks for deep infection. Another patient with rheumatoid arthritis had the TAR revised to a tibio-talar-calcaneal fusion 59 months post-operatively for talar avascular necrosis. One patient has pain from impingement and another patient with rheumatoid arthritis has intermittent pain at 8 years following her TAR. Every other implant continues to function well. The New Jersey LCS ankle assessment scores increased from a mean of 35 pre-operatively to 82 post-operatively. The increases were largely due to pain relief and improved function with the pre-operative range of motion being preserved. These scores have been maintained in the long term. No surviving implant is radiologically loose.

Our results suggest that the Buechel-Pappas TAR offers good clinical and radiological long-term results to patients with often disabling ankle arthritis

Design: Retrospective chart and radiographic review.

Background: Stress fractures of the fifth metatarsal are increasingly common among elite professional footballers (soccer players). This reflects the use of lighter, less protective and more flexible sports footwear combined with the increasingly physical demands of the professional game at the highest level. Stress fractures of the fifth metatarsal can be satisfactorily treated non-operatively by cast immobilisation and a graduated return to activity. The demands placed on the modern elite professional footballer are such that a different treatment approach is required for the same injury in this subgroup of patients.

Methods: Stress fractures of the fifth metatarsal in elite professional footballers are treated by the senior author (JPH) by operative surgical fixation. We reviewed the charts and radiographs of all fifth metatarsal stress fractures that were treated operatively in elite professional footballers over a five year period. Details recorded included fracture location, method of fixation, complications, time to radiological union and time to return to independent weightbearing and competitive sporting activity.

Results: There were 32 fifth metatarsal stress fractures in 30 elite professional footballers. All fractures were clinically united at a mean 5.5 weeks and radiologically united at a mean of 10.3 weeks. The patients could weightbear immediately and could independently weightbear from 4 weeks. The mean time to return to full competitive activity was 10.3 weeks. There were no complications.

Conclusions: Operative treatment of fifth metatarsal stress fractures is an effective treatment in elite professional footballers that produces consistently good results and allows an early return to full activity.

Background: Open Tibiotalocalcaneal fusion has been shown to be an effective treatment for arthritis and complex foot deformities, but with a high complication rate. We are reporting the results of the first 14 feet undergoing arthroscopic tibiotalocalcaneal arthrodesis.

Methods: Retrospective review identified 13 patients who had 14 combined ankle and subtalar arthrodeses performed arthroscopically, with no bone grafting. The procedure was performed for the treatment of combined ankle and subtalar arthritis or hindfoot deformity. The majority had fixation using 6.5mm ASNIS screws (Stryker (Kalamazoo, Michigan, USA)) introduced percutaneously, although in one case a hindfoot nail was used. Outcome was assessed by a combination of chart review, clinical examination and questionnaire. Follow up averaged 16 (6 to 33) months.

Results: At follow up average patient satisfaction was 9.7/10. Average time to fusion was 12 (10–20) weeks. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 67 (41–83). Nine patients had no complications. Postoperative complications were pulmonary embolus, non-union, late stress fracture and infection.

Conclusion: Arthroscopic hindfoot arthrodesis is an effective technique, and allows treatment in patients whose soft tissues would not tolerate an open procedure, where often the only alternative is amputation. Patient satisfaction is high, with a short inpatient stay, but the procedure itself is demanding.

DDH incidence falls from 5–20 per 1000 at birth to 1–2 per 1000 by 3 weeks. Some patients present late and frequently require surgical intervention. If the hip cannot be contained without tension, these children undergo open reduction +/− a femoral shortening, varus and derotation osteotomy. Salter’s osteotomy, may be performed either at index surgery or later in the presence of persisting acetabular dysplasia. Our aim was to see if we could predict which cases of persistent DDH would require both femoral and pelvic surgery to contain the affected hip, using a single plain AP radiograph of the pelvis in the outpatient setting.

We performed a retrospective study of all children older than 18 months with persistent DDH of one or both hips, over the last 5 years, who had undergone femoral and/or pelvic surgery to contain the hip. Plain AP pelvic radiographs were standardised according to the method described by Tonnis. From these radiographs the acetabular indices and child’s age in months, were recorded. Syndromic and children with non-standard x-rays were excluded.

Thirty nine hips (34 female, 5 male), age range of 18–102 months, formed our study group. 53% of hips having femoral surgery later required pelvic surgery for persisting acetabular dysplasia. Examining the data in these cases, the difference between the acetabular index of the normal and affected hip was always greater than 20 degrees and the child’s age in months.

Using this method we conclude that it is possible to predict which cases of persistent DDH will require pelvic surgery to fully contain the affected hip and that this can be done with one AP pelvic radiograph in the outpatient clinic. The benefit is avoidance of unnecessary pelvic osteotomies, and being able to determine the cases which should have a pelvic osteotomy at index procedure.

Open Tibiotalocalcaneal fusion has been shown to be an effective treatment for arthritis and complex foot deformities, but with a high complication rate. We are reporting the results of the first 14 feet undergoing arthroscopic tibiotalocalcaneal arthrodesis.

Methods: Retrospective review identified 13 patients who had 14 combined ankle and subtalar arthrodeses performed arthroscopically, with no bone grafting. The procedure was performed for the treatment of combined ankle and subtalar arthritis or hindfoot deformity. The majority had fixation using 6.5 mm ASNIS screws (Stryker (Kalamazoo, Michigan, USA)) introduced percutaneously, although in one case a hindfoot nail was used. Outcome was assessed by a combination of chart review, clinical examination and questionnaire. Follow up averaged 16 (6 to 33) months.

Results: At follow up average patient satisfaction was 9.7/10. Average time to fusion was 12 (10–20) weeks. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 67 (41–83). 9 patients had no complications. Postoperative complications were pulmonary embolus, non-union, late stress fracture and infection.

Conclusion: Arthroscopic hindfoot arthrodesis is an effective technique, and allows treatment in patients whose soft tissues would not tolerate an open procedure, where often the only alternative is amputation. Patient satisfaction is high, with a short inpatient stay, but the procedure itself is demanding.

Introduction: The national comparative audit in 2007 of blood use in primary elective hip replacement, showed a 25% transfusion rate. Of those 93% received two or more units. Orthopaedic surgeons are large users of blood, so reducing blood use, should save costs and reduce risk from unnecessary donor exposure.

Methods: Over two years 221 consecutive primary total hip replacements were performed, on 84 male and 137 female patients, average age 70 years (42–91yrs). For each the Haematinics cell salvage system was used. Throughout the surgery the cell salvage system was used. At the end of the operation all swabs were washed, the washings were salvaged. Iodine/peroxide contaminated washing and swabs were discarded.

Results: Were we using blood at the level suggested by the comparative audit, 55 patients would have received an average of 2.4 units (132 units total). The actual number of patients transfused was 12, receiving an average of two units (24 units total). This is 108 units less with 43 fewer patients receiving allogenic blood. Using a test of proportions using the Normal distribution then the significance probability is extremely small (SP< 0.001) indicating that this group of patients had a significantly smaller number of transfusions than would be expected compared with the National Average. The transfused patients were older (78.9 vs. 69.8, p< 0.01), had a greater Hb drop (45 g/l vs. 31.2 g/l, p< 0.01), had a lower pre-op Hb (121.3 g/l vs. 138 g/l, p< 0.001), and a greater length of stay (12.8 days vs. 5.8 days, p< 0.05). Gender was not significant.

Discussion: Using the cell salvage system leads to a significant reduction in allogenic blood use. It may not be cost neutral once the use of disposables is factored in, but may represent a useful tool to cost effectively reduce allogenic blood use.

Introduction: Adult acquired flat foot deformity is recognised as a spectrum of pathology related to tibialis posterior dysfunction (TPD) and plantar ligament insufficiency. Cobb has described a method of reconstruction in pure Johnson and Strom type II TPD using a split Tibialis Anterior musculo-tendinous graft.

Methods: We describe a prospective study of 32 patients treated by the Cobb technique and a medial displacement translational os calcis osteotomy for Johnson and Strom type II TPD. There were 28 females and four males (age range 44–66, average 54) each with unilateral disease. The average follow up was 5.1 years, range 3 to 7.2 years. Each patient had failed conservative management and the staging was confirmed clinically and radiologically (ultrasound scanning and MRI). The surgery was performed as described by Cobb but with a bone tunnel in the navicular rather than the medial cuneiform. Postoperative immobilisation in plaster was for eight weeks followed by orthotics and physiotherapy.

Results: All the os calcis osteotomies healed uneventfully. 29 of the 32 patients were able to perform a single heel rise test (none prior to surgery) at twelve months follow-up. These patients had grade 5 power of the tibialis posterior tendon. The others had grade 4 power and were also happy with the result. The mean American orthopaedic foot and ankle society (AOFAS) hindfoot score was 82. There was one superficial wound infection successfully treated by antibiotics and a temporary dysaesthesia in the medial plantar nerve in another.

Discussion: This prospective study confirms that the Cobb technique is an excellent method of treating pure Johnson and Strom type II TPD after failed conservative management. The procedure is performed with a medial displacement os calcis osteotomy but in selected cases may be combined with spring ligament repair and lateral column lengthening. An updated classification will be presented designed to facilitate the decision making process in this difficult condition.

Arthroscopy of the ankle and subtalar joints are established techniques in foot and ankle surgery. Arthroscopic ankle arthrodesis is well described and is useful in patients with a poor soft tissue envelope. Subtalar fusion is traditionally an open procedure with potentially significant complications but there is little published on arthroscopic subtalar arthrodesis.

22 patients, made up of 9 males and13 females were operated on from March 2004 to present day with 12 to 36 months follow up. Indications for surgery included primary osteoarthritis and degeneration secondary to previous calcaneal fracture, tibialis posterior insufficiency, neurological conditions and previous ankle fusion. 8 Patients had a concurrent arthroscopic ankle fusion and 4 patients also had a talonavicular fusion.

All patients had surgery by the senior author and followed the same postoperative course. Patients were protected in plaster for 12 weeks with gradual increase to fully weightbearing at 6 weeks and x-rays taken at 6 and 12 weeks. Successful outcome was taken as clinical and radiological evidence of fusion.

21 patients (95.5%) achieved fusion by 12 weeks. There has been 1 nonunion but there have been no wound breakdowns, deep infections or other serious complications.

Previous authors have reported variable complication rates and significant rates of delayed and non-unions following open subtalar fusion. These early results suggest that arthroscopic subtalar fusion is a safe and reliable method with a high success rate and a low complication rate.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

Background: Chronic musculoskeletal pain is a major and costly health problem which is difficult to treat from both patients’ and practitioners’ perspectives. Gaining a greater understanding of patients’ and practitioners’ decision making may be one way of achieving more successful chronic pain consultations.

Aim: To explore the influences on patients’ decision making regarding care seeking, and practitioners’ decision making regarding care delivery for chronic musculoskeletal pain.

Method: In-depth qualitative interview study of chronic musculoskeletal pain patients and of NHS and private, mainstream and CAM practitioners who treat patients. Topic guides were developed which explored, patients’ and practitioners’ beliefs about the causes of pain and expectations of treatment, and the factors influencing decision making within the consultation. All interviews were audio taped and transcribed for analysis, and data was analysed using Framework.

Results: Fifteen patients and 21 practitioners (two GPs, five chiropractors, five osteopaths and 10 physiotherapists) were interviewed. Themes identified as influencing the process of care and decision making, were the level of trust within the patient-practitioner relationship, beliefs about whom should be responsible for patients’ health, the role of patients’ self identity on the management of pain, and beliefs about whom should hold the expertise within the consultation.

Conclusions: To improve primary care for chronic musculoskeletal pain, the level of trust within the patient-practitioner relationship may need to be increased. This may help practitioners to recognise and accept patients’ growing expertise within the consultation, which in turn may facilitate patients in taking more responsibility for their pain.

Background – Patients with chronic musculoskeletal pain seek care from a wide range of practitioners, both mainstream and complementary and alternative (CAM). Previous research suggests that patients’ social class and educational level may strongly influence their consulting behaviour. The role of health outcomes in influencing patients’ consulting behaviour has been less frequently studied.

Aims – To explore the relationship between health outcomes and consulting behaviour of chronic musculoskeletal pain patients.

Method – Secondary analysis of data collected as part of a population questionnaire survey of chronic pain. Univariate and multi variate analyses were undertaken to explore the relationship between health outcomes (e.g. health related quality of life) and consulting behaviour.

Results – The survey response rate was 62% and the prevalence of chronic pain was 38% (987/2504). 53% of patients had consulted mainstream practitioners only, 4% CAM practitioners only, 18% mainstream and CAM practitioners and 25% no one.

Patients’ who had consulted both mainstream and CAM practitioners reported the poorest health outcomes (EQ 5D = 0.55), followed by those who consulted just mainstream practitioners (EQ 5D = 0.61), and those who had consulted no one (EQ 5D = 0.72). The best health outcomes were reported amongst those who had just consulted CAM practitioners (EQ 5D =0.78). In multivariate analyses, the most powerful predictors of consulting both mainstream and CAM practitioners were working and having high levels of pain related disability.

Conclusions – This analysis suggests that poorer health outcomes may be powerful predictors of consulting CAM practitioners, in some cases, amongst those who do not have access to the financial resources to pay for such treatment.

Introduction: Hypermobility is a common finding, however, it lacks diagnostic parameters and is poorly understood, especially in the foot.

Aim: To quantify medial column/first ray mobility in patients with midfoot arthritis and planovalgus feet.

Methods: We compared first ray mobility in patients with radiologically defined midfoot tarsometatarsal osteoarthritis, a radiologically normal first ray and planovalgus feet, with control subjects who had normal feet and first rays. An all female group of 20 patients (mean age of 70) and 20 controls (mean age of 53) met the criteria. Analysis of patients’ x-rays identified the site of their arthritis and allowed angular measurements of their flat foot deformity. Patient and control subjects underwent identical examinations, recording hindfoot correctability, medial longitudinal arch appearance, hindfoot prontion and supination, forefoot supination and degrees of flexion/extension and abduction/adduction with an electronic goniometer. Each subject was graded by the AOFAS and SF-36 outcome scores.

Results: There was a significant difference in first ray mobility between the patient and control subjects for all positions adopted (P=< 0.001), except when dorsiflexed and weight bearing (P=0.052). Patients with a neutral non-weight bearing ankle exhibited greatest mobility of 16.8 +/− 4.7 degrees compared to 9.4 +/− 2.6 degrees in controls. This was a significant difference, P=< 0.001, as was the difference between patients adopting the NWB plantarflexed, dorsiflexed and WB neutral positions. P=0.002, P=0.014, P=0.001 respectively. Patients’ median score for 5 out of 8 SF36 domains were considerably less than controls, as were patients’ AOFAS. Reduced physical and social functioning were shown to be linked to poor foot scores.

Conclusion: Patients with planovalgus feet and tarsometatarsal OA have greater first ray mobility than controls with normal feet. Recognising this may help plan orthotic or surgical treatment.

Background: Low back pain is a common symptom in the general population. There is considerable evidence for the effectiveness of exercise for chronic low back pain but long-term adherence rates can be poor. It may be important to gain a greater understanding of patients’ beliefs about exercise for low back pain and their adherence to it.

Objectives: To systematically review studies exploring low back pain patients’ beliefs about exercise as a treatment for their pain.

Method: We searched Medline, Web of Science, National Research Register, PEDro, PsycINFO, AMED, CINAHL and EMBASE. Retrieved titles and abstracts were combined and screened for inclusion in the review. We quality appraised the included papers and did a thematic analysis of the data extracted from them.

Results: Three studies were eligible for inclusion in the review. The main themes identified were barriers and motivators to exercise. Time was the main barrier patients perceived. Fear of pain acted both as a barrier and a motivator to exercise. Health professionals motivated patients to exercise when the patient had regular contact and felt they understood their situation. Exercise had both physical and mental benefits, with responders feeling enabled to self manage their pain.

Conclusions: The impact of the health professional on beliefs about exercise and adherence is already acknowledged in the recommendations for supervised exercises. There is a lack of exploratory research in the area of exercise beliefs, especially in primary care. Further research is needed to understand how people with low back pain view physical activity more generally especially prior to receiving exercise as a treatment.

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.

Purpose: Methods: Evaluation of the results of arthroscopic ankle arthrodesis, performed in 49 consecutive patients (52 ankles), with disabling ankle arthritis, between 08/1998 and 12/2004. Thirty ankles had no significant deformity (group A), whereas 22 ankles had a varus or valgus deformity greater than 10° (mean 21.7°, max 45°) (group B). Mean age in groups A and B was 49.7 and 57.5 years respectively (p=0.15). The primary diagnosis in groups A and B was post-traumatic arthritis in 66% and 27% and idiopathic osteoarthritis in 17% and 59%, respectively. Average hospital stay was 3.63 and 3.68 days in groups A and B respectively (p=0.96). Postoperative treatment included ankle immobilization for 3 months. Progressive weight-bearing was initiated at two weeks. Mean follow-up was 14.9 months (range 6–60).

Results: No infections or neurovascular problems occurred. Fusion occurred in 29/30 cases in group A at an average time of 11.52±5.2 weeks and in 21/22 patients at 11.67±2.3 weeks in group B (p=0.89). Not planned surgical procedures were required in eight cases (15.4%). Symptomatic arthritis from the adjacent joints developed in three cases during the follow-up period. The arthrodesis position angle measured in the sagittal plane from the lateral post-operative plane film averaged 105°±3° and 103°±6° in groups A and B respectively (p=0.27). The outcome in groups A and B was graded as very good in 73% and 72.7%, fair in 23% and 22.7% and poor in one case in each group, respectively (p=0.26).

Conclusions: The arthroscopic technique offers a high fusion rate, decreased time to fusion, short hospital stay and absence of limb-threatening complications. Deformity correction can be attempted with equally good results.

Introduction We report the experience of a district general hospital foot and ankle service, in performing a modified excision arthroplasty and tendon transfer to the metatarsophalangeal (MTP) joints of the lesser toes in both rheumatoid and non-rheumatoid patients. The procedure was carried out on 114 toes, in 58 feet of 55 patients over a 5-year period.

Background Historically, partial proximal phalangectomy was complicated by recurrence of the extension deformity. Stainsby (1990) described a technique of 7/8ths phalangectomy, repositioning of the plantar plate, extensor to flexor attachment and K-wire stabilisation to treat dislocated MTP joints of the lesser toes. However, it is recognised that the use of K-wires can be complicated by infection or premature removal. Angel reported the re-routing of the extensor tendon through a drill hole in the metatarsal head for MTP joint instability; this technique was attributed to Nigel Cobb. We have utilised the Stainsby technique and combined it with a Cobb tendon transfer to impart immediate stability to the toe, allowing K-wire fixation to be discarded.

Technique Following a percutaneous proximal extensor tenotomy, a radical partial proximal phalangectomy (via a dorsal incision) reduces a dislocated MTP joint and the plantar plate is repositioned beneath a mobilised metatarsal head. A drill hole is then placed in the metatarsal head and the extensor tendon is re-routed from a plantar to dorsal direction. This maintains the reduction of the toe and provides interposition between the cut end of the proximal phalanx and the metatarsal head.

Conclusion We believe that this modified combined technique is a reproducible alternative to the Stainsby procedure but, in addition, provides immediate stability of the MTP joint without the need for K-wire fixation.

Introduction The Buechel-Pappas Total Ankle Replacement (BP TAR) has been used in Cornwall since 1991. The early results were presented to the Foot Society in 1997. The only published long term results of this pros-thesis are from the designer’s unit.

Method We present the clinical and radiological outcome of a prospective series of 22 BP TARs implanted in 19 patients with a mean follow-up of 9 years (range 6–13). The primary diagnosis was rheumatoid arthritis (RA) in 11 and osteoarthritis in eight patients. Twelve patients were female. Mean patient age was 64 years (range 39–81). Patients were reviewed at yearly intervals. None were lost to follow-up.

Results At the time of review, four patients (six ankles) had died between 12 and 69 months post-operatively of unrelated causes with their prostheses in situ. One patient had a below knee amputation for chronic venous ulceration, 11 years after a BP TAR which was functioning well. One patient with severe RA had the implant removed at 8 weeks for deep infection. A second patient with RA had the TAR revised to a tibiotalocalcaneal fusion 59 months post-operatively for talar avascular necrosis. One patient has pain from impingement and another patient with RA has intermittent pain at 8 years following TAR. Every other implant remains asymptomatic. The New Jersey LCS ankle assessment scores increased from a mean of 35 pre-operatively to 82 post-operatively. The increases were largely due to pain relief and improved function with the pre-operative range of motion being preserved. These scores have been maintained in the long term. No surviving implant is radiologically loose.

Conclusion Our results suggest that the BP TAR offers good clinical and radiological long-term results to patients with often disabling ankle arthritis.

Background – Chronic musculoskeletal pain (CMP) is a major health problem, for which patients consult a wide range of practitioners often with little success. This may be due to the sometimes different explanatory models for pain held by patients and practitioners. Gaining an understanding of these models may improve care. An area of conflict may be the identification and management of the psychological aspects of pain.

Purpose – To explore patients’ and practitioners’ beliefs and expectations of treatment for CMP, in relation to the identification and management of the psychological aspects to pain.

Method – In-depth qualitative interview study of 24 practitioners (osteopaths, chiropractors, physiotherapists and GPs) and 24 patients with CMP which explored their beliefs about causation and treatment of CMP. Maximum variety purposive samples of both groups were selected. All interviews were audio-taped and transcribed for analysis. Data was analysed using FRAMEWORK.

Results – Patients and practitioners believed that stress influenced pain perception, however some patients believed that stress could also cause pain. In terms of the consultation, practitioners felt pressure from patients to provide them with emotional / psychological support which on the whole they felt ill-equipped to provide. Patients operated with a physical model of illness and felt dismissed if practitioners focused too much attention on the psychological aspects of their pain.

Conclusion– Practitioners expressed confusion over what they were expected to provide patients in terms of psychological support. They also expressed a need for training in the management of behavioural / psychological aspects to pain. Patients may also require education to increase their awareness of the psychological aspects to their pain.

Background – Patients with unexplained chronic musculoskeletal pain (CMP) can be difficult to help, consulting a range of services before consulting specialist pain services. Conflicts between the explanatory models for illness used by patients and health professionals might contribute to this complex ‘career path’, increasing the likelihood of unsatisfactory outcomes for both practitioners and patients.

Purpose – To explore the understanding of the experiences of diagnosis and management amongst patients who attended a specialist musculoskeletal pain clinic.

Method – Potential participants were sent a postal questionnaire 6–20 months after their first clinic attendance. Data was collected on pain presence, severity and location, health related quality of life and care seeking behaviour. Questionnaire data was used to inform combined purposive and theoretical sampling. In-depth interviews were conducted which probed participants’ understanding of their CMP and its management. Data was analysed using FRAMEWORK.

Results – 15 patients were interviewed. Four main themes were identified; a) spoiled identity – were pain limited patients activities so much that this affected their sense of self; b)Diminishing faith in medicine – Patients were disappointed with aspects of their care seeking experience; c) Making sense of pain – Patients made sense of their pain by locating their pain within the context of their lives; d) Learning to live with the pain – An issue for all patients was whether or not their pain would go.

Conclusion – Developing, implementing and evaluating approaches to address patients’ spoiled identity might allow us to improve patient centred outcomes in CMP.

Background – Chronic musculoskeletal pain (CMP) is a major health problem treated by a wide range of health professionals. Complementary therapies are likely to become more readily available on the NHS. Therefore a greater understanding of current service use may be helpful in ensuring appropriate targeting of services in the future.

Purpose – To describe current service use for CMP in a UK representative population. To examine predictors of CMP use.

Methods – Population questionnaire survey to 4100 patients registered with 17 Medical Research Council General Practice Research Framework general practices. The questionnaire collected data on demographics, presence of pain, pain location and severity, health related quality of life (HRQOL), care seeking and beliefs about pain. Univariate and multivariate analyses was undertaken to examine predictors of care seeking.

Results – Response rate of 61% of whom 47% reported CMP use. 77% consulted for their CMP; 60% mainstream medicine only, 17% mainstream and / or complementary and 22% no-one.

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)

Conclusion – Complementary therapies are currently only available to those patients who can afford them. If such therapies become available on the NHS it may be important to provide patients and health professionals with appropriate information to inform their choices about these care options.

Background: Chronic musculoskeletal pain (CMP) is a major health problem for the individual and the NHS. It is important to examine the prevalence of and factors associated with it, to identify unmet need and inform the development of interventions.

Purpose: To describe the prevalence of CMP in a community based sample, overall and by location; To describe the factors associated with presence of CMP.

Methods: Population questionnaire survey to 4100 patients registered with 17 Medical Research Council General Practice Research Framework practices. We collected questionnaire data on demographics, presence and location of pain, pain severity, health related quality of life, care seeking and beliefs about pain. We then did univariate and multivariate analyses to identify factors associated with CMP.

Results: Survey response rate was 61% (2509/4100); mean age 52 years (range 18–101); 56% female. CMP prevalence was 47%. One month period prevalence by area was; Lower back 23%; Knee 19%%; Shoulder 16%; Hip/thigh 14% and Upper back 6%. The majority of sufferers consulted their GP (61%), but a large minority (21%) consulted no-one. Factors associated with presence of CMP were being older, leaving school aged 16 or less, not working, having poorer quality of life and experiencing psychological distress (P< 0.05). In a multivariate analysis no factors were independently associated with presence of CMP.

Conclusion: Results demonstrate the significant burden CMP presents in the community and the need to focus interventions on those individuals who may be more likely to suffer. It may be particularly important to consider the needs of those who have not consulted anyone.

Background: A wide variety of practitioners with different belief systems and approaches treat chronic musculoskeletal pain. In trials of treatments for musculoskeletal pain the focus has tended to be on outcome rather than on understanding the process of care of these treatments. Gaining greater understanding of the process of care in consultations for chronic musculoskeletal pain may shed light on ways to improve patient care, as despite the range of options available many patients are still dissatisfied with their treatment.

Aim: To undertake a systematic review to explore how the beliefs and expectations of patients with chronic musculoskeletal pain and their treating primary and community care practitioners / therapists influence the process of care

Method: A comprehensive search strategy was developed. Databases including MEDLINE, PSYCHINFO, AMED, and MANTIS were searched by two members of the review group working independently. Two members of the group again working independently screened the title and abstract of each reference retrieved for inclusion. Studies were included if they Reported original research

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.

Results: 12, 667 articles were identified from the searches of bibliographic databases. At the present time 10 papers have been identified for potential inclusion in the review. The number of full papers to be considered for the review will be reported in this presentation along with the methods for data abstraction and synthesis. This study is ongoing.

Background: Chronic low back pain (CLBP) is a complex health problem often resulting in difficult consultations for both patients and practitioners. Triggers for consultation may include pain severity, impact of pain on health-related quality of life and troublesomeness of pain. Troublesomeness of CLBP may be influenced by patients’ beliefs about their health, such as beliefs about what is acceptable for their age or lifestyle and their perceptions of risk. Therefore, troublesomeness may be a powerful trigger for consultation for CLBP.

Aim: To explore whether troublesomeness of CLBP is associated with consultation.

To determine the most powerful predictors of consultation for CLBP from pain severity, troublesomeness, health related quality of life and psychological distress

Method: Postal questionnaire survey to randomly sampled patients registered with 18 MRC General Practice Research Framework general practices (5400 patients) with two reminders. Questionnaire measures persistent pain (presence and location), pain severity (using the Chronic Pain Grade questionnaire), health related quality of life (EQ5D), psychological distress (GHQ12), troublesomeness of pain on a simple five point Likert scale and patient demographics.

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.

Results: The survey is ongoing. A full data-set will be available for the presentation. So far 354 questionnaires have been returned, 48% (167/347) of participants report persistent pain of these 62% (104/167) reported at least moderately troublesome CLBP. Of those reporting troublesome CLBP, 74% (76/103) had consulted their GP, 87% (90/103) had consulted other practitioners including physiotherapists, osteopaths and chiropractors, 27% (28/103) had seen a hospital consultant and 17% (18/103) had consulted no one.

Conclusions: These data suggest that troublesomeness is a simple way to improve the ability of epidemiological studies of back pain to contribute to health needs assessment.

Background: Chronic back pain is a complex and costly health problem, treated by a wide range of practitioners, with different belief systems and approaches. Despite the range of options available, many patients appear to be dissatisfied with the treatment that they receive. This may be due to a mismatch between patients’ and practitioners’ beliefs about the cause of the pain and their expectations for treatment.

Objectives: To explore patients’ beliefs about the causes of their chronic back pain and their expectations regarding treatment.

Methods: Group interviews were held with two sample groups of individuals (experiencing moderate and severe chronic pain) to inform a series of qualitative individual interviews with patients and practitioners, exploring beliefs about the causation of chronic pain and expectations for treatment.

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.

Results: Participants presented sophisticated accounts of their pain and their care seeking. General practitioners were seen as the most appropriate first ‘port of call’, as chronic back pain was viewed as a medical problem requiring a medical solution such as X-rays, referral to hospital specialist and eventually operations. Participants presented to their GP in hope of a medical solution, which was seldom realised. Participants appeared to be resolved to this situation, yet sustained the belief that a different way of communicating their problem to their GP may lead to appropriate action.

Conclusion: There was a marked contrast between the groups on some issues, which will be explored further within this presentation.

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.