The impact of emergency department patient-controlled analgesia (PCA) on the incidence of chronic pain following trauma and non-traumatic abdominal pain.

The effect of patient-controlled analgesia during the emergency phase of care on the prevalence of persistent pain is unkown. We studied individuals with traumatic injuries or abdominal pain 6 months after hospital admission via the emergency department using an opportunistic observational study design. This was conducted using postal questionnaires that were sent to participants recruited to the multi-centre pain solutions in the emergency setting study. Patients with prior chronic pain states or opioid use were not studied. Questionnaires included the EQ5D, the Brief Pain Inventory and the Hospital Anxiety and Depression scale. Overall, 141 out of 286 (49% 95%CI 44-56%) patients were included in this follow-up study. Participants presenting with trauma were more likely to develop persistent pain than those presenting with abdominal pain, 45 out of 64 (70%) vs. 24 out of 77 (31%); 95%CI 24-54%, p < 0.001. There were no statistically significant associations between persistent pain and analgesic modality during hospital admission, age or sex. Across both abdominal pain and traumatic injury groups, participants with persistent pain had lower EQ5D mobility scores, worse overall health and higher anxiety and depression scores (p < 0.05). In the abdominal pain group, 13 out of 50 (26%) patients using patient-controlled analgesia developed persistent pain vs. 11 out of 27 (41%) of those with usual treatment; 95%CI for difference (control - patient-controlled analgesia) -8 to 39%, p = 0.183. Acute pain scores at the time of hospital admission were higher in participants who developed persistent pain; 95%CI 0.7-23.6, p = 0.039. For traumatic pain, 25 out of 35 (71%) patients given patient-controlled analgesia developed persistent pain vs. 20 out of 29 (69%) patients with usual treatment; 95%CI -30 to 24%, p = 0.830. Persistent pain is common 6 months after hospital admission, particularly following trauma. The study findings suggest that it may be possible to reduce persistent pain (at least in patients with abdominal pain) by delivering better acute pain management. Further research is needed to confirm this hypothesis.

A survey of acute pain services in the UK.

The organisational state of inpatient pain management in UK hospitals is difficult to determine. We sent an electronic questionnaire to 209 acute pain service leads throughout the UK. Questions were about staffing and service provision. We received 141 responses (67%); 47% of all UK hospitals. Each service was responsible for a median (IQR [range]) of 566 (400-839 [120-2800]) beds. Each acute pain specialist nurse was responsible for 299 (238-534 [70-1923]) beds. The mean (SD) number of consultant hours per week was 5.54 (4.62), delivered by a median of 1.0 (1.0-2.5 [0.2-7.0]) consultant. Overnight cover was provided by 20 (15%) acute pain services, and weekend cover by 39 (29%). Acute pain services commonly (in 50 (35%) hospitals) had roles in addition to acute pain management. Most teams (105, (77%)) reviewed medical patients and patients with chronic pain (in 131, (96%) teams). Half of the services (56, (49%)), reported that they were part of an integrated acute and chronic pain service, however, 83 (59%) did not have any members who work in chronic pain clinics. The majority (79, (70%)) were able to access a nominated chronic pain consultant for advice. Provision of acute pain services throughout the UK is highly variable. The majority do not meet core UK standards.

The cost-effectiveness of patient-controlled analgesia vs. standard care in patients presenting to the Emergency Department in pain, who are subsequently admitted to hospital.

The clinical effectiveness of patient-controlled analgesia has been demonstrated in a variety of settings. However, patient-controlled analgesia is rarely utilised in the Emergency Department. The aim of this study was to compare the cost-effectiveness of patient-controlled analgesia vs. standard care in participants admitted to hospital from the Emergency Department with pain due to traumatic injury or non-traumatic abdominal pain. Pain scores were measured hourly for 12 h using a visual analogue scale. Cost-effectiveness was measured as the additional cost per hour in moderate to severe pain avoided by using patient-controlled analgesia rather than standard care (the incremental cost-effectiveness ratio). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. The cost per hour in moderate or severe pain averted was estimated as £24.77 (€29.05, US$30.80) (bootstrap estimated 95%CI £8.72 to £89.17) for participants suffering pain from traumatic injuries and £15.17 (€17.79, US$18.86) (bootstrap estimate 95%CI £9.03 to £46.00) for participants with non-traumatic abdominal pain. Overall costs were higher with patient-controlled analgesia than standard care in both groups: pain from traumatic injuries incurred an additional £18.58 (€21.79 US$23.10) (95%CI £15.81 to £21.35) per 12 h; and non-traumatic abdominal pain an additional £20.18 (€23.67 US$25.09) (95%CI £19.45 to £20.84) per 12 h.

Characteristics of pain in hospitalized medical patients, surgical patients, and outpatients attending a pain management centre.

BACKGROUND: The characteristics and psychological impact of pain suffered by medical inpatients has been relatively under-investigated. The aim of this study was to compare the pain experience of medical, surgical inpatients, and patients attending a pain management centre. Some aspects of the quality of pain scoring and prescribing were also audited. METHODS: Medical inpatients with significant pain (moderate or severe pain on a verbal rating scale) were assessed using a battery of psychometric questionnaires. Comparator samples of surgical inpatients and patients attending the pain management centre were recruited. RESULTS: The prevalence of significant pain did not differ between the medical group (n=37) and the surgical group (n=38) (16.7% and 19.9%). Chronic pain was common in the medical group (54%) and the surgical group (50%). There were no differences in psychometric variables between the medical and surgical groups. Clinically significant scores for anxiety and depression (HADS ≥11) were common in all groups (30-38%). There was less concordance between patient-reported pain scores and nurse-recorded pain scores in the medical group than the surgical group and analgesic prescribing differed between the two groups. CONCLUSIONS: The characteristics of pain in the medical and surgical groups were similar, with high levels of anxiety and depression. The pain management group differed from the inpatient groups, with higher levels of psychopathology and poorer coping. These findings provide some insight into the complex nature of pain in hospital inpatients, and may inform where limited resources should be utilized to provide greatest patient benefit.

Posttraumatic ankle arthrosis.

Until there is a total ankle implant developed that stands the test of time, ankle arthrodesis will continue to be the gold standard in the operative treatment of the arthritic ankle joint. Ankle arthrodesis techniques include minimally invasive methods that can be performed via arthroscopy or with miniarthrotomy. Extensile techniques include extra-articular fusions, the transfibular approach, removal of both malleoli, and the Blair fusion. An ankle arthrodesis can be fixated utilizing either internal or external fixation. The form of fixation chosen depends on availability and surgeon preference and/or experience, and most importantly, which is the optimal method for the patient. Although ankle arthrodesis is the mainstay treatment for posttraumatic arthrosis, innovations and technical improvements have resulted in reconstructive alternatives for ankle arthritis, including distraction ankle arthroplasty, supramalleolar osteotomy, and total ankle replacement. Advances in biomaterials and instrumentation have allowed for the evolution of arthrodesis techniques as evidenced by the myriad of techniques reported in the literature.

Percutaneous injuries in a high-volume podiatric surgical residency program.

Percutaneous injuries (i.e., needlesticks) are a possible occupational hazard to all residents performing invasive procedures. Transmission of blood-borne pathogens has become a potential risk in these injuries. As such, the purpose of this investigation was to assess the frequency and circumstances involving percutaneous injuries in the podiatric surgical resident. A survey of 20 present residents from July 1991 to July 1999 was conducted to assess percutaneous injuries. These residents participated in 19,505 surgical cases in this timeframe; 16,185 were podiatric cases and 3,347 were nonpodiatric. Using a two-part questionnaire to assess the circumstances surrounding any percutaneous injury, 80% of the residents reported at least one percutaneous injury during their training. A total of 33 were injuries reported for the 19,505 cases. The incidence of injury per surgical case was 0.17% overall, and 0.14% for foot and ankle cases. Analysis of the data showed a median = 2, mode = 2, and a mean = 1.63 injuries per resident with a range of 0-5. When analyzing the circumstances involving the injuries, most injuries were self-inflicted (66.7%), occurred during wound closure (72.7%), and were caused by a nonhollow bore needle or instrument (81.8%). Also, no correlation could be made to the time of day during which the procedure was performed, the year of residency training, or the number of cases that the resident performed that day before the injury occurred. Interestingly, over 67% of the injuries occurred to the resident's left hand. Although 97% of the injuries were reported to the employee health officer, the patient and resident were screened for HIV and hepatitis B or C in only 78.8% of the cases. In those tested, no resident was exposed to HIV or hepatitis B or C.

Mechanical comparison of two extensor tendon repairs of ankle tendons.

Complete disruption of the extensor tendons is commonly encountered with lacerations to the dorsal aspect of the ankle. The purpose of this study was to compare two tendon repairs (modified Krackow and Kessler-Tajima) to determine which repair was stronger in an anatomical cadaver model. Twenty tendons (10 extensor hallucis longus and 10 tibialis anterior tendons) from 10 fresh-frozen cadaver legs were lacerated and then repaired with either a modified Krackow or Kessler-Tajima repair. Each tendon repair was tested for gap formation and maximum load failure. Results showed that the mean force to produce gap formation in the modified Krackow repair was 64.7 N in the extensor hallucis longus and 82.3 N with the tibialis anterior. Mean gap formation for the Kessler-Tajima in the extensor group was 26.0 N and the tibialis anterior was 41.8 N. This represented a 40% and 50% greater resistance to gap formation for the modified Krackow in these groups. With maximum load failure, the mean for the modified Krackow was 99.5 N for the extensor hallucis longus and 126.8 N for the tibialis anterior, while the Kessler-Tajima was 45.6 N and 72.1 N for these groups. This represented a 45% and 58% greater difference in the maximum load failure for the modified Krackow. Statistical analysis using a Student's t-test (p < .05) showed that there was a significant statistical difference between the two repairs for gap formation and maximum load failure. The authors conclude that the modified Krackow is stronger than the Kessler-Tajima repair.

Cricoid pressure: which hand?

We studied 20 anaesthetic assistants applying simulated cricoid pressure with the left or right hand in random order. Simulated cricoid pressure was continued for up to 5 min with one hand and then, after resting, with the other hand. Applied pressure was measured at intervals and the subjects were blind to the results. Nineteen assistants were right-handed and all routinely applied cricoid pressure with their right hand. Mean (SD) force applied during simulated 'awake' cricoid pressure was 13.8 (5.7) N with either left or right hand, and during 'anaesthetised' cricoid pressure it was initially 25.1 (8.2) N and 24.7 (8.8) N with left or right hand, respectively. Mean force was maintained above 20 N and below 30 N throughout the study period with either hand. Force applied with the left hand was significantly lower than with the right hand but the difference was clinically insignificant (0.4 N). Inadequate or excessive force was more frequently associated with use of the left hand (p < 0.0001). Cricoid pressure was released before 5 min in three cases, two left-handed and one right-handed. Our results demonstrate that anaesthetic assistants apply a lower force than is classically taught and are able to maintain the force with either hand for a sustained period. Application with the left hand is justified where clinically indicated but may have a lower margin for error than when applied with the right hand.

Proximal shortening lesser metatarsal osteotomy: a mathematical-geometric basis.

Reconstruction and restoration of the lesser metatarsal parabola after an iatrogenic complication of a lesser metatarsal osteotomy provides a difficult surgical dilemma for the foot and ankle surgeon. This study's purpose was to determine if a formula could be developed, through a geometric and mathematical basis, for the proximal shortening lesser metatarsal osteotomy to aid the surgeon in determining the amount of bone needed to be resected to correct the deformity. This study was divided into three parts. In part I, 15 lesser metatarsals (metatarsals 2, 3, and 4) harvested from fresh frozen cadavers had shortening proximal osteotomies performed. This osteotomy removes a cylindrical piece of bone that is perpendicular to the metatarsal shaft from the proximal aspect of the lesser metatarsal to create axial shortening of the metatarsal and changes the relationship of the metatarsal head to the weightbearing surface. These metatarsals had five radio-opaque markers placed into them and were radiographed pre- and postosteotomy. These markers created a pre- and postgeometric graphic plotting for the changes in length, height, and dorsiflexion. Computer graphing was then utilized to analyze changes in height, length, and dorsiflexion of each metatarsal. Formulas were created from these plottings to determine the actual change in height, length, and dorsiflexion for a set amount of bone removed. The formulas created from these data were: Length: Actual change = Bone removed *0.95; Height: Actual change = Bone removed *0.54; and Dorsiflexion: Actual change = Bone removed *0.44 mm/deg. In part II of study, 15 identical saw bone lesser metatarsals were used to verify the formulas, by taking out the amount of bone needed for 0.5-mm increment change, starting at 1.0 mm and increasing to 8.0 mm. Techniques used were identical to part one. Part III was performed to demonstrate that the formula would be reproducible for height when there is a difference in the angulation of the metatarsal. Fifteen identical sawbones where plotted in plaster at declinations ranging from 8 degrees to 42 degrees. Then the osteotomy was performed removing 4.0 mm of sawbone from each specimen using the same technique as parts I and II. All parts and the formulas were statistically analyzed using a bivariate regression model, which showed that the formulas were valid for length, height, and dorsiflexion with a 95% confidence. With these experimental models, the authors found reproducible formulas that hopefully could aid the surgeon in determining the amount of bone they needed to resect to effect correction of this difficult reconstruction.

Isolated medial cuneiform fracture: review of the literature and report of two cases.

The authors present two unusual cases of isolated medial cuneiform fracture. Both fractures were difficult to see on plain films and therefore diagnosed with ancillary tests (computed tomography and magnetic resonance imaging). Treatment was nonweightbearing cast immobilization, in which both patients healed within twelve weeks of treatment without complication and returned to full work related activities.

Peroneus brevis tendon rupture with tophaceous gout infiltration.

The authors present a patient with a history of chronic lateral ankle instability and pain. Physical and diagnostic evaluation revealed anterior ankle instability and peroneus brevis weakness. An MRI showed an attenuated anterior-talofibular ligament and a longitudinal tear of the peroneus brevis tendon. Surgical exploration exhibited tophaceous gout within the tear of the peroneus brevis as well as within the attenuated anterior-talofibular ligament. Presented is an unusual case of a longitudinal tear of the peroneus brevis tendon with tophaceous gout infiltration.

Is glass visible on plain radiographs? A cadaver study.

Eighteen randomly selected pieces of nonleaded glass from a collection of 30 pieces from broken bottles of four known color types found on the streets of Houston were sorted into four sets with one control. The purpose of this study was to determine if regular glass is visible on plain radiographs and whether color, location, or volume of these fragments had any effect on the detection of nonleaded glass. These sets were then placed into a fresh-frozen cadaver foot and ankle with a history of insulin-dependent diabetes and peripheral vascular disease. This foot was radiographed utilizing four standard foot projections. Five examiners read these five sets of radiographs twice and recorded the number seen. Overall sensitivity for all of the examiners was 90% with an overall false-positive rate of 10%. Intraobserver and interobserver Pearson's correlation coefficients showed that there was reliability between the first and second readings and between observers. The authors concluded that regular nonleaded glass is radiographically visible and that factors such as color and location of the glass have no effect on its detection, while a volume of less than 15 mm3 may have an effect on the detection of glass.

The use of ultrasound in the foot and ankle.

Ultrasonography is an underutilized tool in the armamentarium of the foot and ankle surgeon. The purpose of this article is to review and illustrate the different applications of musculoskeletal ultrasonography of the foot and ankle. The advantages and disadvantages of this imaging modality are described.

Enchondroma as a cause of midfoot pain.

Enchondroma is a common bone tumor of the foot. It is often reported in the phalanges and distal metatarsals. The authors, however, present a rare case study of two patients with enchodromas as the cause of midfoot pain. One case presented in the lateral cuneiform which to the authors' knowledge is the first reported case in the literature. Two cases are presented with their surgical management including autogenous calcaneal graft and follow-up.

Use of ultrasonography versus magnetic resonance imaging for tendon abnormalities around the ankle.

A prospective study was performed on 28 patients who underwent surgery for tendon disorders around the ankle. Preoperatively, all patients had real-time, high resolution ultrasonography performed with a 7.5 or 10 mHz transducer. Twenty of these patients also had a preoperative magnetic resonance imaging (MRI) examination of the ankle. A total of 54 tendons were inspected intraoperatively, revealing a total of 24 intrasubstance or complete tendon tears. These surgical findings were compared with the ultrasound and MRI findings, from which the sensitivity, specificity, and accuracy were calculated for both modalities. Ultrasound produced results with a sensitivity measurement of 100%, specificity of 89.9%, and accuracy of 94.4%. MRI produced results with a sensitivity measurement of 23.4%, specificity of 100%, and accuracy of 65.75%. Ultrasound results were more sensitive and accurate than MRI in the detection of ankle tendon tears in our study.

Ankle fracture classification: a comparison of reliability of three X-ray views versus two.

Our hypothesis was that malleolar ankle fractures could be classified with two radiographic views as reliably as with three views. Four different observers independently evaluated 99 sets of ankle radiographs. The examiners classified the ankle fractures by using both the Lauge-Hansen and Danis-Weber systems. The interobserver and intraobserver variations were analyzed by kappa statistics. With regard to intraexaminer reliability, the examiners demonstrated excellent accord in classifying the fractures in the Danis-Weber system with either three views or two views. The kappa values were comparable. In the Lauge-Hansen system, three examiners demonstrated excellent accord and one examiner demonstrated good accord in classifying the fractures. Similar kappa values were generated when examiners classified fractures with either three views or two views. With regard to interexaminer reliability, good to excellent accord was demonstrated overall among the four examiners when they used the Danis-Weber system with either three views or two views. The examiners were in good agreement when they used the Lauge-Hansen system. Similar kappa values were generated whether the examiners used three views or two views. Three radiographic views are usually ordered for evaluation of an acute ankle injury. Previous studies have shown that only two views are needed for diagnosis of a malleolar ankle fracture. This study demonstrates that malleolar ankle fractures can be classified with two views, lateral or mortise, with a reliability as good as that achieved with three views. The best agreement is achieved with lateral and mortise views.

Nonunion of a Hawkin's group II talar neck fracture without avascular necrosis.

The authors present an unusual case of talar neck nonunion without avascular necrosis following a Hawkin's group II fracture. A review of the literature and treatment of this rare complication are discussed. The nonunion was treated by debridement and iliac crest bone grafting to the defect and external electrical bone stimulation. The deformity of the rearfoot caused by the fracture nonunion was addressed by using a triple arthrodesis utilizing the Synthes 7.3-mm cannulated screw system.

Ultrasonographic-surgical correlation of ankle tendon tears.

This study evaluates the accuracy of ultrasonography in detecting ankle tendon tears of the peroneal, posterior tibial, and flexor digitorum longus tendons based on operative findings and clinical follow-up. A prospective study was performed in 33 patients with clinically suspected tendon injury. Sixty-eight tendons were evaluated sonographically. The diagnosis of an intrasubstance tear was made when disruption of uniform tendon architecture by hypoechoic linear or globular clefts was observed. Criteria used to diagnose complete tendon rupture included discontinuity or gap within the tendon or complete nonvisualization of the tendon. Treatment decisions were based on a combination of clinical parameters and imaging studies. Twenty-six patients had the presence or absence of tear confirmed at surgery. Five patients had a final diagnosis based on clinical findings, and two were lost to follow-up. Of the 68 tendons evaluated sonographically, 54 were directly inspected at surgery; 20 were found to be torn and 34 were intact. Ultrasonography was able to identify all tears correctly with an accuracy of 93%, a sensitivity of 100%, and a specificity of 88%. The positive and negative predictive values were 83% and 100%, respectively. The combined accuracy, sensitivity, and specificity of ultrasonography in detecting tendon tears in all patients evaluated both surgically and by clinical follow-up were 94%, 100%, and 90%, respectively.

Navicular body fractures: computerized tomography findings and mechanism of injury.

The case reports of five patients with signs and symptoms of a fracture of the tarsal navicular body are presented. Each patient underwent a computerized tomography examination to determine the extent of this fracture. Based on the computerized tomography findings, surgical or conservative management was carried out. The computerized tomography examination, combined with the patient's history, has shed new light on a previously undescribed mechanism of injury for this fracture.

Morton's neuroma. Update on diagnosis and imaging.

The diagnosis of Morton's neuroma is usually made from evaluation of a patient's subjective complaints, clinical findings, and exclusion of other differential diagnoses. Occasionally, when other neurological conditions exist or when the clinical findings are atypical, various imaging techniques may be helpful in the diagnosis of interdigital neuromas. This article will discuss these techniques and briefly review this common lower extremity disorder.