‘Primum non nocere’ is one of the most well known moral principles associated with the medical profession. Often, in our bid to maintain and improve quality of life, we neglect to recognise those patients who are in fact nearing the end of theirs. Thus, our aim was to ascertain if we are recognising the ‘dying’ orthopaedic patient and whether key elements of management in accordance with SIGN are being addressed.

All hip-fracture deaths occurring at a District General Hospital over a 4-year period (2012–2015) were included. Paper and electronic notes were used to record patient demographics, days from admission to death, diagnosis of ‘dying’ and discussions regarding DNACPR and ceiling of care. Total numbers of investigations undertaken during the week prior to death were noted.

89 hip-fracture deaths occurred between 2012–2015, of which 57 were female with a mean age at death of 84 years. The number of days post-admission to death was 17.5 (range 0–109). 45 patients had a new DNACPR recorded and 13 were longstanding. 43 patients (48.3%) were diagnosed as dying at a mean of 7.2 days following admission, 31 of whom (72.1%) had ceiling of care discussed. Of this cohort, 32 had futile investigations during their last week of life and astoundingly 10 on the day of death.

Although some effort is being made to recognise the ‘dying’ orthopaedic patient, further work is needed to establish a clear ceiling of care pathway, which maintains and respects patient comfort and dignity during their last days of life.

Purposes and background of study: We compared the effects of lumbar muscle-strengthening programmes with and without pelvic stabilisation on low back pain (LBP). A dynamometer employing a stabilisation procedure (lumbar extension machine, MedX, Ocala, FL) is effective in improving strength and reducing LBP symptoms (Nelson et al., Orthopedics, 1995, 18,971–981), and researchers have hypothesised that this effectiveness is due to the pelvic stabilisation (Graves et al., Arch Phys Med Rehabil, 1994, 75,210–215). However, effects of the dynamometer with and without pelvic stabilisation on LBP have not been compared, so we examined this issue.

Methods and Results: Fifty-seven chronic LBP patients were randomly assigned to a lumbar extension training with pelvic stabilisation group (STAB; n=20), a lumbar extension without pelvic stabilisation group (NO-STAB; n=17) and a control group (n=20). STAB and NO-STAB participants completed one weekly session of dynamic variable resistance exercise (one set of 8–12 repetitions to fatigue) on the lumbar extension machine (with or without pelvic stabilisation) for 12 weeks. Pre- and post-test measures of self-reported LBP (101-point visual analogue scale; pre-test mean of 25), related disability (Oswestry disability index; pre-test mean of 34) and lumbar strength were taken. After the exercise programme, the STAB group increased significantly in lumbar strength at all joint angles, and decreased significantly in visual analogue and Oswestry scores. However, there were no significant changes in these variables in the NO-STAB and control groups.

Conclusion: Isolated lumbar extension exercise is very effective in reducing LBP in chronic patients. However, when the pelvis is not stabilised, otherwise identical exercises appear ineffective in reducing LBP.

Purpose: The cruciate four-strand flexor tendon repair technique has been advocated for its ease of use and biomechanical strength. However, the in vivo efficacy of the cruciate 4-strand repair has not been reported; no has this method of repair been assessed for its ability to allow for an early active motion rehabilitation protocol. The purpose of this study was to report early clinical results using the cruciate 4-strand repair for proximal zone I and zone II flexor tendon lacerations.

Method: Thirty-five digits in thirty-one patients had proximal zone I (3 digits) or zone II (32 digits) flexor tendon lacerations which were repaired using the cruciate 4-strand technique and an epitendinous state. Average patient age was 30.8 years (range 9.7–63.7). An early active motion rehabilitation protocol was initiated an average of 1.5 days following tendon repair. The supervised therapy program was continued for 12 weeks post-operatively. Assessment of total active motion (TAM), as well as PIP and DIP TAM, grip strength, and joint contractures were recorded at 3 months and at 6 months or greater post-operatively. Functional assessments (using the Strickland and American Society of Surgery for the Hand criteria) were performed for each patient at 3 and 6 month intervals.

Results: All patients were followed for a minimum three-month period. At 3 months postoperatively, there were 16 excellent, 7 good, 6 fair, and 6 poor results by the Strickland criteria, and 12 excellent, 15 good, 7 fair, and 1 poor by the ASSH criteria. Total active motion averaged 225° (±44°), PIP and DIP motion averaged 136° (±40°). Grip strength was available for 17 patients and averaged 60% of the contralateral, uninvolved hand. By 6 months or greater postoperatively there were 18 digits available for follow-up. There were 15 excellent results and 3 good results by the Strickland criteria, and 11 excellent and 7 good results by the ASSH criteria. Six patients had PIP contractures averaging 11° (range 3–15°), and two patients had DIP contractures averaging 13° (range 5–20°). Total active motion averaged 257° (±22°), and PIP and DIP motion averaged 166° (±22°). Grip strength was available on 14 patients and averaged 91% of the contralateral hand. To date, of the patients followed up to 6 months or longer, there have been no ruptures, no re-operations for tenolysis, and no loss of motion.

Conclusion: Early clinical results using the cruciate 4-strand suture technique for flexor tendon repair have demonstrated outcomes equivalent or superior to other methods. The relative simplicity of the technique, with biomechanical strength properties facilitating a modified early active motion rehabilitation protocol, may make this method of repair attractive. Further clinical studies will need to be performed to determine the long-term efficacy of this method of tendon repair.

Background: It is universally acknowledged that psychological distress in chronic low back pain (LBP) is commonplace and the early identification of such distress is increasingly being advocated as an important aspect of LBP assessment. The Distress and Risk Assessment Method (DRAM) is a screening tool, using the Modified Zung (MZ) and Modified Somatic Perception Questionnaires (MSPQ), developed to provide a simple classification of patients with LBP. Patients are classified as normal, at risk of developing distress, and those who are distressed (Distressed Depressive {DD} and Distressed-Somatic {DS}). The DRAM was used to screen LBP patients for entrance to an RCT examining different physiotherapy regimes for recurrent LBP.

Methods: Patients referred for physiotherapy, at three hospitals within South Birmingham, with a diagnosis of recurrent LBP were screened using the DRAM and Roland Morris Disability Questionnaire (RMDQ). Distressed patients were excluded from the trial as psychological distress has been shown to be associated with an increased risk of poor treatment outcome.

Results: 214 patients were screened for entrance to the trial with 69 (31%) excluded on the basis of their DRAM scores (DD=39, DS=30). Excluded (distressed) patients (n=69) had a mean MZ score of 33.30 (SD: 9.28, range= 7 to 56), with patients entered into the trial (non-distressed, n=95) having a mean of 18.12 (SD: 7.83, range=3 to 36). The mean MSPQ score for the distressed patients was 12.70 (SD: 5.69, range=0 to 26), and for the non-distressed patients was 4.37 (SD: 3.67, range= 0 to 22). RMDQ scores (functional disability) were higher for the distressed group (mean 14.09 [SD: 4.80], range=3 to 23) than the non-distressed group (mean 10.52 [SD: 4.22], range= 5 to 21).

Conclusions: The results indicate that approximately one third of patients referred for physiotherapy at the units studied exhibited a level of distress that increased their relative risk of poor outcome by 3 to 4 times. The impact of these results has been to slow the recruitment to the ongoing RCT. The clinical implications are that screening this group of patients may indicate when liaison with clinical psychologists is appropriate and possibly identify patients who are too distressed to respond to physiotherapy.