Background

Serious traumatic injury is a leading cause of death and disability globally, with the majority of survivors developing chronic pain.

Purpose

Back pain is the primary cause of disability worldwide yet surprisingly little is known of the underlying pathobiology. We conducted a genome-wide association study (GWAS) meta-analysis of chronic back pain (CBP). Adults of European ancestry from 15 cohorts in the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) consortium, and UK Biobank were studied.

Introduction

Pain is an expected and appropriate experience following traumatic musculoskeletal injury. By contrast, chronic pain and disability are unhelpful yet common sequelae of trauma-related injuries. Presently, the mechanisms that underlie the transition from acute to chronic disabling post-traumatic pain are not fully understood. The aim of this study is to identify prognostic factors for risk of developing chronic pain and disability following acute musculoskeletal trauma.

Background: The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy are involved in the management of 15–20% of all people with low back pain (LBP) in the UK. Exploratory and descriptive research suggests that the management of non-specific LBP by some members of these groups does not follow best available evidence.

Purpose: To test the short-term effectiveness of a directly-posted, contextualised, printed educational package about the evidence-based management of acute LBP on changing UK chiropractors’, osteopaths’ and musculoskeletal physiotherapists’:

reported practice (based on a vignette of a patient with non-specific LBP)

Methods: A prospective, pragmatic randomised trial was designed to test the effectiveness of the printed educational package versus a no-intervention control. Questionnaires were posted to simple random samples of UK registered chiropractors (n=611), osteopaths (n=1368) and physiotherapists (n=1625). Intervention packages were sent to consenting practitioners in March 2004, and follow-up questionnaires were sent 6 months later.

Results: Good response rates to the baseline questionnaire were obtained, and most respondents were willing to participate in the RCT. Following exclusions based on criteria determined a priori, 1758/3380 (52.0%) consenting practitioners were recruited for the RCT: chiropractors 335/601 (55.7%), osteopaths 600/1335 (44.9%) and physiotherapists 823/1444 (57.0%). Overall response to the 6 month follow-up was 1557/1758 (88.6%): chiropractors 280/335 (83.6%), osteopaths 520/600 (86.7%) and physiotherapists 757/823 (92.0%).

Conclusions: Data analysis is now being carried out. The main trial results will be presented at the meeting.

Cerebral micro emboli have been noted to occur during both total hip and knee arthroplasty. These micro emboli have been implicated in the causation of postoperative cognitive impairment. The aim of this study was to determine whether cerebral micro emboli occur during hip fracture surgery.

28 patients undergoing hip fracture surgery had transcranial doppler assessment of the middle cerebral artery to detect cerebral micro emboli. Micro embolic signals (MESs) were recorded during the operative procedure.

Successful monitoring was carried out in 26 patients. MES were recorded in 16 out of 26 patients. 12 out of 16 patients who had MESs had undergone a cemented hemiarthroplasty; the remainder had a sliding hip screw for an extracapsular hip fracture. 75% (9/12) of patients who had a cemented hemiarthroplasty had the majority of MESs after reaming and cementing. MESs in the patients who had a sliding hip screw occurred throughout the operative procedure.

Conclusion: Cerebral micro emboli do occur during hip fracture surgery. These emboli may be responsible for the cognitive dysfunction that occurs in this susceptible group of patients.

Introduction and Aims: Cerebral micro emboli have been noted to occur during both total hip and knee arthroplasty. These micro emboli have been implicated in the causation of post-operative cognitive impairment. The aim of this study was to determine whether cerebral micro emboli occur during hip fracture surgery.

Method: Twenty-eight patients undergoing hip fracture surgery had transcranial doppler assessment of the middle cerebral artery to detect cerebral micro emboli. Micro embolic signals (MESs) were recorded during the operative procedure.

Results: Successful monitoring was carried out in 26 patients. MES were recorded in 16 out of 26 patients. Twelve out of 16 patients who had MESs had undergone a cemented hemiarthroplasty, the remainder had a sliding hip screw for an extracapsular hip fracture. Seventy-five percent (9/12) of patients that had a cemented hemiarthroplasty, had the majority of MESs after reaming and cementing. MESs in the patients that had a sliding hip screw occurred throughout the operative procedure.

Conclusion: Cerebral micro emboli do occur during hip fracture surgery. These emboli may be responsible for the cognitive dysfunction that occurs in this susceptible group of patients.

Introduction Foot surgery has an increased risk of postoperative infection when compared with surgery of other anatomical regions. A pre-surgical foot bath in a bactericidal solution is thought to reduce the incidence of postoperative wound infection. We compared the incidence of post-operative wound infection in two groups, one undergoing a pre-surgical footbath and one group that did not.

Method We prospectively assessed 83 patients undergoing forefoot surgery under the care of two surgical teams. Forty-one patients underwent a pre-surgical foot bath in povidone iodine solution. Forty-two patients did not have a pre-surgical foot bath. All patients had microbiological swabs taken on admission and following surgical preparation and draping. These were cultured for bacterial growth. All patients were reviewed at 2 and 6 weeks after surgery and were monitored for signs of infection. The results for each group were analysed and compared.

Results There were seven post-operative infections in the pre-surgical foot bath group. This compared with only two infections for the group who did not undergo pre-surgical bathing. Correlation of infection with complexity of surgery, medical co-morbidities, operative time, method of closure and use of metalwork was examined.

Conclusions These results suggest that pre-surgical bathing in a bactericidal solution is not effective in preventing post-operative infection.

Background The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy are involved in the management of 15–20% of people with low back pain (LBP) in the UK (CSAG 1994). Exploratory and descriptive research suggests that the management of non-specific low back pain (LBP) by some members of these groups does not follow best available evidence (RCGP 1999).

Purpose To test the short-term effectiveness (at 6 months) of a directly-posted, contextualised, printed educational package about the evidence-based management of acute back pain on changing UK chiropractors’, osteopaths’ and musculoskeletal physiotherapists’:

1) beliefs and attitudes about LBP

2) reported practice (using a clinical vignette)

Methods A prospective, pragmatic randomised trial was designed to test the effectiveness of the printed educational package versus a no-intervention control. MREC approval was gained and a questionnaire was developed and piloted (n=150). Information was gathered on practitioners’ demographics, their beliefs about LBP (using the HC-PAIRS, Rainville et al 1995) and reported practice based on a vignette of a patient with non-specific LBP (adapted from Bombardier et al 1995, Buchbinder 2001).

A total of 3602 questionnaires were posted to simple random samples of UK registered chiropractors (n=611), osteopaths (n=1367) and physiotherapists (n=1624). Intervention packages were sent to consenting practitioners in March 2004, and the follow-up is planned for September 2004.

Results Good response rates to the baseline questionnaire were obtained, and most respondents were willing to participate in the RCT. Following exclusions based on a priori criteria, 1773/3402 (52.1%) participants were recruited for the RCT: chiropractors 335/604 (55.4%), osteopaths 600/1338 (44.8%) and physiotherapists 838/1460 (57.4%). The RCT methodology and some baseline data will be presented.

Conclusions It is possible to recruit large numbers of healthcare practitioners, within and outside the NHS, to RCTs conducted by post. Whilst the results will be specific to these three professional groups in the UK, this study is believed to be the largest RCT of printed, evidence-based educational material in healthcare, to incorporate a no-intervention control group.

Background & Objectives: The physical therapy professions (musculoskeletal physiotherapy, osteopathy and chiropractic) are involved in the management of low back pain (LBP) in approximately 15–20% of all cases in the UK. LBP accounts for between 50% and 67% of the workload of this group. Initiatives to implement evidence-based practice (EBP) in the UK have included the development of national multidisciplinary guidelines for acute LBP, the target audience of which include all three physical therapy professions.

The objective of this study was to explore and identify perceptions, attitudes and beliefs held by practitioners from these three professional groups about their approaches to the care of LBP patients.

Methods & Results: An exploratory study was used to investigate beliefs and attitudes of practitioners, concerning factors that potentially influence practice. Particular attention was given to practitioners’ thoughts on the opportunities and threats of taking an EBP approach to LBP management, and identifying other factors that influence their clinical behaviour with LBP patients. Following ethical approval and informed consent, five focus groups were conducted with members of the physical therapy professions. Audio recordings of each focus group were made, and subsequently transcribed verbatim. Transcript data were analysed in line with a grounded theory approach to produce relevant themes.

Preliminary categories of themes that emerged were: Evidence; Perceived Knowledge; Personality Characteristics; Professional Identity; The Patient; and Motivation. Of particular interest, practitioners seem to have mixed opinions with regard to basing their practice on evidence from external research.

Conclusions: Practitioners’ views of EBP in LBP management are diverse and it cannot be presumed that all practitioners view EBP as desirable. They seem to have mixed opinions with regard to basing their practice on evidence from external research. Practitioner behaviour, and thus the implementation of EBP may relate to practitioners’ beliefs and attitudes.

Aims: Cell enlargement or hypertrophy is an intermediate transitional process in the transformation of Òsoft callusÒ into bone. The purpose of this study was to determine whether it is caused by an osmotic phenomenon. Following bone fracture, there is a local increase in tissue ßuid due to inßammation and neovascularisation. According to the osmosis principle, cells bathed in excess tissue ßuid swell. Methods: The specimens examined were 1 and 2-week old closed fractures of the right tibia of 12 NZW rabbits created by a drop tower technique. The specimens were prepared for routine histology. Thin sections were stained for haematoxylin and eosin and examined with the light microscope. Results: Cell enlargement and cell rupture were observed principally in the vicinity of the blood vessels. There was a hierarchy of cell sizes with the larger cells close to the blood vessels and the smaller ones further away from the vessels. Conclusions: According to these þndings, the fracture callus exhibits features which raise the possibility that an osmotic phenomenon is responsible for cell enlargement. The resulting increase in cell turgidity makes the fracture callus progressively stiffer and increases tissue strain. Cell enlargement also causes the tissue to expand. This may be the mechanism by which fracture callus migrates and bridges the fracture cleft.

Restoration of hand function following division of a flexor tendon remains a significant challenge.

We describe a new method of tendon repair. The first suture is placed in the standard fashion, the second suture is inserted with a round bodied needle to avoid damage to the first repair. This is placed at right angles to the first repair and enters the tendon at the furthest point from the cut tendon end. This suture is then tied with the knot on the surface of the tendon, using 4/0 Ti.cron. The repair is completed with a circumferential continuous epitenon suture, using 6/0 Prolene. This method produces a repair with a four-strand core suture and is referred to throughout this paper as the Evans repair.

Flexor digitorum profundus tendons harvested from pigs were used as the experimental model. They were divided at the mid-point and then repaired using either a ‘modified Kessler’ 4/0 Ethibond core suture, a ‘modified Kessler’ 4/0 Ti.cron core suture or the Evans double core suture. The specimens were then tested to failure on an Instron materials testing machine. This produced a figure for the ultimate tensile strength of each repair.

The average tensile strength for the Ethibond Kessler repair was 33 (range, 27–36) Newtons and that of the Ti.cron Kessler repair was 31 (range 21–43) Newtons. The average tensile strength for the Evans repair was 52 (range 43–60) Newtons, and it is significantly stronger than the two standard Kessler repairs (p< 0.001, Student’s t-test). Even the weakest of the Evans repairs was as strong as the strongest of the standard Kessler repairs.

We reviewed 188 patients at one to 20 years (mean 9.5) after surgery for anterior shoulder instability. Twenty-one had shown bilateral instability at the time of surgery, and 26 of the remaining 167 subsequently developed instability of the contralateral shoulder, giving an overall incidence of 24% bilateral involvement. Fourteen of these patients ultimately required bilateral surgery. The onset of contralateral instability was at one month to 15 years (mean 5.7 years) after anterior repair of the operated shoulder, the cumulative incidence increasing with time (p less than 0.01). The incidence was significantly higher in those under 15 years at the time of initial dislocation or under 18 at the time of surgery. One-half of the patients with contralateral instability had signs of posterior instability at follow-up. Other predisposing factors included having sustained the initial injury to the operated shoulder as a result of minimal trauma, and persistence of a sensation of instability in the operated shoulder. Factors which were not statistically significant included sex, dominant side, athletic activity, work history, and whether the initial surgery was for recurrent subluxations or dislocations. The high prevalence of bilateral shoulder instability suggests an intrinsic abnormality such as capsular and ligamentous laxity or muscle imbalance and warrants further investigations.

Haemophilia is a rare cause of avascular necrosis of the femoral head. We report three cases from one centre, an incidence of 2.8%. All three cases presented "silently", and this makes the early diagnosis difficult. Awareness of the condition should lead to examination of the hips of haemophiliac patients at every outpatient visit and admission in the hope that hip disease can be diagnosed at an early stage. This may allow earlier treatment, less femoral head deformity, and an improvement in the long-term prognosis.

One hundred and seven patients with intertrochanteric fractures of the femur treated with a Richards screw-plate were compared retrospectively with 103 patients treated with a Jewett nail-plate. The mortality and morbidity were similar in the two groups. In patients with comparable fractures, those treated with a Richards device mobilised more quickly and left hospital sooner, and more of them returned to their homes. Failures of stabilisation, both clinically and radiographically, were fewer in this group. The reliability of fixation with a correctly positioned Richards screw-plate could justify the omission of outpatient follow-up in all but a small group of patients with severe unstable fractures or grossly defective bone stock. The higher cost of a Richards implant and the slightly longer operative procedure were outweighed by savings in occupancy of acute and long-stay hospital beds.

Dislocations of the cervicothoracic junction are frequently missed. Experience of this rare injury over 27 years at the Spinal Injuries Unit in Sheffield confirms that nearly two-thirds were not properly diagnosed on admission. Only two of the 14 dislocations studied were reduced by conservative methods and these were both associated with fractures of the posterior bony elements. Open reduction is necessary to replace pure dislocations at the C7-T1 level. It seems likely that the spinal cord lesion is not influenced by reduction of the displacement. The three patients who had an incomplete lesion of the spinal cord made excellent neurological recoveries although none of the dislocations was reduced. It is concluded that on theoretical grounds it is justified to embark on operative reduction of displacements at this spinal level only if the cord lesion is incomplete, nerve root recovery therefore possible, and if the operation can be brought about soon after the injury.

Thirty-four patients wtih fibrodysplasia (syn., myositis) ossificans progressiva are described. Marked delay in diagnosis was usual, but all had characteristic skeletal malformations and ectopic ossification. The clinical features included: four types of malformation of the big toe, reduction defects of all digits, deafness, baldness of the scalp, and mental retardation. Progression of disability was erratic in all, but severe restriction of movement of the shoulder and spine was usual by the age of 10 years; the hips were usually involved by the age of 20 years; and most patients were confined to a chair by the age of 30 years. Exacerbating factors included trauma to the muscles, biopsy of the lumps, operations to excise ectopic bone, intramuscular injections, careless venepuncture and dental therapy. Progression of disability did not appear to be influenced by any form of medical treatment and therefore management of the patients must concentrate on the avoidance of exacerbating factors.