General Orthopedics Research Articles

Avaliação da reprodutibilidade da classificação AO/Asif para fraturas diafisárias do úmero

ObjectiveTo evaluate the reproducibility of the AO/Asif classification for humeral shaft fractures. MethodsConsecutive radiographs of the arm in both anteroposterior and lateral view from 60 patients with humeral shaft fractures were analyzed. Six observers who were familiar with the AO/Asif classification (three shoulder and elbow surgery specialists and three general orthopedists) were selected to make the analysis, which was done at three different times. The data were subjected to statistical analysis using the kappa coefficient. ResultsThe intra and interobserver concordance was statistically significant in all the analyses. ConclusionsAll the evaluators showed concordance between the three evaluations that was considered to be statistically significant. However, the highest values were found among the specialists.

Evaluation of the reproducibility of the AO/ASIF classification for humeral shaft fractures

ObjectiveTo evaluate the reproducibility of the AO/Asif classification for humeral shaft fractures. MethodsConsecutive radiographs of the arm in both anteroposterior and lateral view from 60 patients with humeral shaft fractures were analyzed. Six observers who were familiar with the AO/Asif classification (three shoulder and elbow surgery specialists and three general orthopedists) were selected to make the analysis, which was done at three different times. The data were subjected to statistical analysis using the kappa coefficient. ResultsThe intra and interobserver concordance was statistically significant in all the analyses. ConclusionsAll the evaluators showed concordance between the three evaluations that was considered to be statistically significant. However, the highest values were found among the specialists.

Obituary: A Remembrance of Henry Phil Gross MD (1930-2014).

Obituary: A Remembrance of Henry Phil Gross MD (1930-2014).

Temporomandibular joint dysfunction.

Temporomandibular disorders- commonly known as TMJ dysfunction or Costen’s syndromeare an important entity in both medical and dental practice. Moreover, in medical practice they are encountered across a wide range of specialties including general medicine, ENT and orthopedics. It is therefore worthwhile looking into the various implications of the problem and the management strategies thereof.

Publication trend in the Indian Journal of Orthopaedics: What is published and why?

Background:Factors influencing publication of manuscripts in reputed journals have never been studied to the best of our knowledge. This study was conducted to evaluate the trend in publication within the Indian Journal of Orthopaedics (IJO).Materials and Methods:A cross-sectional study was conducted by accessing the online database of the IJO. All the issues available online were included. Published articles were classified into one of the following thirteen categories: (i) Basic Sciences (ii) trauma (upper limb and lower limb) (iii) infections (iv) pediatric orthopedics (v) arthroplasty (vi) arthroscopy (vii) spine surgery (viii) musculoskeletal oncology (ix) hand and microvascular surgery (x) adult reconstruction (including the Ilizarov technique) (xi) general orthopedics and miscellaneous (xii) letter to editor (xiii) book review. A scatter diagram was plotted to study the individual trends.Results:A total of 2213 articles from 110 issues published between 1967 and 2014 were studied. Total number of articles per issue have increased over the years. Publications in the fields of trauma, adult reconstruction, arthroscopy and hand and microvascular surgery have increased steadily. Arthroplasty and spine surgery have recorded dramatic increase in publication. On the other hand, publications in the rest of the fields have declined of which the greatest fall is noted in the field of musculoskeletal oncology.Conclusions:Trend in publication with the IJO has changed over years with more articles being published in arthroplasty and Spine surgery. Despite advances, publication in the field of musculoskeletal oncology has fallen.

Identifying and selecting new procedures for health technology assessment: a decade of nice experience in the United Kingdom.

The aim of this study was to analyze the experience of the National Institute for Health and Care Excellence (NICE) in identifying new procedures entering the United Kingdom (UK) healthcare system, for assessment and publication of recommendations on their use. This system is designed to provide guidance in an area where regulation is lacking worldwide. Retrospective analysis of all procedures notified to the Interventional Procedures Programme (NICE) between 2002 and 2012. Notifications were analyzed year by year for their source (who notified them), clinical specialties involved, and whether guidance was subsequently published. A total of 1,094 procedures were notified by clinicians (51 percent), and by others, including hospitals (6 percent), horizon scanners (5 percent), patients (4 percent), private health insurers (4 percent), and medical device manufacturers (3 percent). Guidance was published on 44 percent of procedures notified to the program. There was a decrease in the numbers of procedures notified during 2003-2012 (p = .049). There were notifications across all specialties, with the largest numbers in general surgery (125), urology (104), orthopedics (99), interventional radiology (93), cardiology (82), and obstetrics and gynecology (82). The "open" NICE Web portal allows anyone to notify new procedures, aiming to maximize the opportunity of identifying all those procedures entering clinical practice. This has resulted in identification of large numbers of procedures from across the whole range of medical specialties. The fact that similar proportions of procedures notified from diverse sources have been selected for assessment and publication of practice recommendations suggests that this inclusive approach is worthwhile.

Surgical Trends in the Treatment of Superior Labrum Anterior and Posterior (SLAP) Lesions of the Shoulder. Analysis of Data from the American Board of Orthopaedic Surgery Certification Examination Database

Objectives:After failure of conservative treatment, surgical repair has long been the primary treatment option for unstable superior labrum anterior and posterior (SLAP) lesions of the shoulder. There is growing evidence supporting both biceps tenotomy and tenodesis as effective alternative treatments for SLAP lesions. The surgical trends among recent graduates, however, have not been evaluated. The goal of this study was to determine the rates of SLAP repair, biceps tenodesis, and biceps tenotomy for patients with isolated SLAP tears. As a secondary goal, we aimed to determine the rates of SLAP repair, biceps tenodesis, and biceps tenotomy for patients with SLAP tears undergoing concomitant rotator cuff repair.Methods:A query of the American board of orthopaedic surgery (ABOS) certification examination database was performed from 2002-2011. The database was searched for patients with isolated SLAP lesions undergoing SLAP repair, biceps tenodesis, or biceps tenotomy. The database was then queried a second time for patients with SLAP lesions undergoing concomitant arthroscopic rotator cuff repair, to determine the rates of SLAP repair, biceps tenodesis, or biceps tenotomy.Results:From 2002-2011 there were 8,963 cases reported for treatment of an isolated SLAP lesion, and 1540 cases reported for the treatment of SLAP lesion with concomitant rotator cuff repair. Over the study period, for patients with isolated SLAP lesions the proportion of SLAP repairs decreased from 69.3% to 44.8% (p<0.0001), while the proportion of biceps tenodesis increased from 0.2% to 9.3% (p<0.0001) and the proportion of biceps tenotomy increased from 0.4% to 1.7% (p=0.018). For patients undergoing concomitant rotator cuff repair, similar trends were observed as the proportion of SLAP repairs decreased from 60.2% to 15.3% (p<0.0001), while the proportion of those undergoing biceps tenodesis or tenotomy increased from 1.2% to 20.3% (p<0.0001). There was also a significant difference in the mean age of patients undergoing SLAP repair (37.1 years of age) vs biceps tenodesis (48.7 years of age) vs biceps tenotomy (55.7 years of age) (p <0.0001). Surgeons with a declared subspecialty in Shoulder and Elbow surgery performed biceps tenodesis for 17% of isolated SLAP tears, whereas candidates with a declared subspecialty in Hand and Upper Extremity, Sports Medicine, and General Orthopaedics utilized biceps tenodesis in 2-3% of cases involving isolated SLAP tears (p<0.05).Conclusion:Practice trends for orthopaedic board candidates indicate the proportion of SLAP repairs has decreased over time with an expected increase in biceps tenodesis and tenotomy. Increased patient age correlates with likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair. Candidate surgeons with subspecialty training in Shoulder and Elbow surgery perform more biceps tenodesis for isolated SLAP tears as compared to other subspecialty trained surgeons.

Outcome Scores—What They Do and Do Not Say

This paper addresses a topic that is probably not of great interest to the general orthopaedist who reads The Journal of Bone and Joint Surgery . Many readers will glance at this paper and dismiss it with a disparaging remark about another hand surgery tempest in a teapot. But, in this era of reporting outcomes for science and business, there are a few points that all of us can take from this article that apply to all outcome rating systems. ### Point 1: Define what it is that you are reporting, and correlate the findings with the severity of the starting point. The proverbial “sow’s ear” must be described. The authors looked at a number of outcome measures that are in use to assess how good a result can be following reconstruction of Flatt type-II and IV thumbs. While we all know what a good result is when we see it, it is not so easy to quantify how much less than a good result our efforts produce. ### Point 2: Give proper attribution to coauthors and mentors. The authors of this paper chose to limit …

Who needs an orthopedic trauma surgeon? An analysis of US national injury patterns

Many hospitals in the United States are seeking to obtain and maintain trauma credentialing. Assessment of trauma center success has traditionally focused on mortality without directed measure of surgical subspecialization. However, survival alone may not be a sufficient marker of success with modern health care. The purpose of this study was to determine the number of trauma patients nationally who would benefit from subspecialized care by an orthopedic traumatologist. A list of musculoskeletal DRG International Classification of Diseases-9th Rev. codes representing injuries warranting care by subspecialized orthopedic traumatologists was generated by survey to each of two cohorts: one consisting of 10 subspecialized orthopedic traumatologists and one consisting of 10 nontraumatologists. The 2006 National Inpatient Sample data set was used to estimate the national volume of patients sustaining an orthopedic injury and the number requiring subspecialty orthopedic trauma care, as defined by the DRG International Classification of Diseases-9th Rev. lists generated by our survey. Survey response rate was 100%. In 2006, 2,068,349 patients sustained a traumatic injury; 46.7% of these had an orthopedic injury. Our cohort of subspecialized orthopedic traumatologists identified 25.7% of all trauma patients as requiring an orthopedic traumatologist. Our cohort of general orthopedists identified 13.5% of all trauma patients as requiring an orthopedic traumatologist. Rates of polytrauma, injury severity, and treatment at trauma centers were similar between the two groups. Between 13.5% and 25.7% of all injured patients should, if resources permit, receive subspecialty orthopedic trauma care. The magnitude of this figure highlights the importance, from a public health perspective, of policy interventions aimed at better coordinating the field of orthopedic traumatology. Detailed outcome measures beyond mortality and triage guidelines suggesting which patients should receive subspecialty orthopedic trauma care should be developed. In addition, resources, including fellowship training, should be allocated in a methodical manner that matches supply to the national demand for this type of care. Economic/decision analysis, level IV.

National Access to Care for Children With Fractures

Access to health care for many pediatric orthopaedic patients is becoming more difficult. In some communities, children with fractures have limited access to care regardless of insurance status. The purpose of this study was to determine the level of difficulty in obtaining access to care for children with fractures nationally and compare our results to the published results of a national survey in 2006. Five orthopaedic offices were identified in each state using an internet search with Google maps by typing "general orthopedics" under the search heading for each state. Each office was contacted with a scripted phone call describing a fracture in a 10-year-old boy that does not involve the growth plate. The office was then told the patient has Medicaid insurance. If no appointment was given, the reason was recorded and the office was asked to refer us to another orthopaedic surgeon. A second phone call was made to the same office a few days later using the same script but the office was told the patient has a private preferred-provider organization insurance. If no appointment was given, the reason was recorded. Of the 250 (23.6%) offices across the country, 59 would see a pediatric fracture patient with Medicaid. 41.3% (79/191) of the offices refusing the patient stated that they do not accept Medicaid patients. Of the 250, 205 (82%) of the offices across the country would see a pediatric fracture patient with a private preferred-provider organization insurance. The 10 states with lowest Medicaid reimbursement offered an appointment 6% of the time, whereas the 10 best reimbursing states offered an appointment 44% of the time. The access to care for children with fractures is becoming more difficult across the country. Compared with the published data in 2006, the number of offices willing to see a child with private insurance has decreased from 92% to 82%. The number of offices willing to see a child with a fracture and Medicaid insurance has decreased from 62% to 23% over the same time span.

Extremity soft tissue tumor surgery by surgical specialty: A comparison of case volume among oncology and non-oncology-designated surgeons

We sought to characterize the extent of extremity soft tissue tumor (ESTT) resections among surgical specialties, hypothesizing that substantial variation exists in the number of ESTT resections performed by specialty. We queried the UHC-AAMC database for data from 85 institutions for years 2007-2009. We abstracted data on total number of musculoskeletal (MSK) procedures, number of subcutaneous (SQ), deep, and malignant ESTT resections, and anatomic site of resection. Data were available for 4,682 practitioners including the following specialties: general surgery (GS, N = 2,195), plastic surgery (PS, N = 792), surgical oncology (SO, N = 533), general orthopedics (GO, N = 1,079), and orthopedic oncology (OO, N = 83). The mean number of all MSK procedures performed per year was 19.0 ± 2.3 GS, 179.6 ± 3.0 PS, 32.4 ± 6.2 SO, 798.6 ± 115.4 GO, and 482.9 ± 6.5 OO (P = 0.001). SQ ESTT resections per year were similar among specialties (1.7 ± 0.3 GS, 2.7 ± 0.3 PS, 2.4 ± 0.4 SO, 1.7 ± 0.5 GO, 4.7 ± 0.2 OO), while deep and malignant resections were more likely performed by OO (combined deep and malignant: 0.9 ± 0.1 GS, 2.0 ± 0.4 PS, 9.9 ± 0.6 SO, 5.8 ± 0.3 GO, and 63.6 ± 8.1 OO, P = 0.001). Adjusting for number of physicians in the database, of the total deep and malignant ESTT resections, 9.4% were performed by GS, 7.7% by PS, 26.0% by SO, 30.8% by GO, and 26.0% by OO. Nearly 50% of deep and malignant ESTT resections are performed by non-oncology-designated surgeons. Approximately 17% are performed by practitioners who complete an average of one to two of these procedures per year. These findings may have significant implications for quality of care in soft tissue tumor surgery.

Tumors for the general orthopedist: how to save your patients and practice

It is likely that most orthopedic surgeons will see a patient with a benign or a malignant musculoskeletal tumor sometime during their career. However, because of the rarity of these entities, many surgeons may benefit from a review of how to evaluate a patient with a bone lesion or a soft-tissue mass. A logical approach is necessary for the evaluation of imaging studies as well as in the workup of children and adults with a possible tumor. It is important to have a good working relationship with a musculoskeletal radiologist to assist in interpreting the images. If the treatment algorithms lead to a conclusive diagnosis of a benign bone tumor, benign soft-tissue mass, or metastatic bone disease, the orthopedic surgeon may choose to definitively treat the patient. If the workup indicates an indeterminate lesion, it may be prudent to discuss the situation with an orthopedic oncologist or transfer the care of the patient to a physician with more specialized knowledge. A careful, logical workup is needed before surgery to limit risks to the patient and optimize the chances for a favorable outcome.

Perfil dos idosos em situação de violência atendidos em serviço de emergência em Recife-PE

OBJETIVO: Determinar o perfil da violência sofrida pelo idoso atendido em serviço de emergência do Hospital da Restauração (HR), em Recife-PE. METODOLOGIA: Estudo epidemiológico, descritivo, quantitativo de corte transversal. Foram analisados todos os prontuários médicos referentes aos atendimentos em cirurgia geral, ortopedia e clínica médica realizados na emergência de adultos do HR entre 1º de janeiro e 31 de dezembro de 2007, disponibilizados pelo Serviço de Arquivo Médico, totalizando 72.232 prontuários. RESULTADOS: Do total de prontuários analisados, foram registrados 79 casos de violência contra o idoso. Destes, 63,3% do sexo masculino. A faixa etária predominante foi compreendida entre 60-70 anos (72,2%). Em 81,1% dos prontuários, não houve registro sobre vínculo empregatício ou situação previdenciária do agredido. Em relação ao local de residência da vítima, a maioria (46,8%) residia em Recife-PE. Quanto ao levantamento de dados sobre o agressor, quando este foi citado (3,7%), todos pertenciam ao sexo masculino, sendo notificada a relação com a vítima em um único caso (filho). O tipo de violência mais frequente foi a física (97,5%). Quanto à natureza da lesão, a mais comum foi a contusão (27,8%). Os sítios de lesão mais acometidos foram a face (35,4%), crânio (31,6%) e extremidades (22,8%). Em relação ao instrumento, os contundentes foram os mais utilizados (29,1%), seguido dos perfuro-cortantes (19%). O mês de janeiro prevaleceu com o maior número de atendimentos (21,6%) e os casos de violência ocorreram principalmente na sexta-feira (16,1%), quarta-feira (17,7%), sábado (17,7%) e domingo (17,7%). CONCLUSÃO: O idoso vítima de violência foi principalmente homem, com faixa etária de 60-70 anos. O tipo de violência mais frequente foi a física, especialmente contusão em face ou crânio, ocorrendo mais no fim de semana.

Service Quality and Performance in the Public Health-Care Sector

The purpose of this article is to evaluate service quality and service performance relationship in the health-care sector using respective developed multidimensional scales. Data were collected from 400 inpatient respondents, using stratified sampling method from five departments, namely general medicine, surgery, pediatrics, orthopedics, gynecology, and ENT of a tertiary hospital (North India). The results confirm significant relationship among subdimensions of physical environment quality and interaction quality (service quality) and four service performance measures, namely waiting time, patient satisfaction, patient loyalty, and image in public hospitals.

Introducing Levels of Evidence to the Journal of Orthopaedic Trauma

Beginning this month, the Journal is introducing the routine reporting of a level of evidence rating with all therapeutic, prognostic, diagnostic, and economic studies. The level of evidence system is an evidence-based medicine tool that applies a hierarchal rating to a study's strength of evidence based on its study design. Many readers are quite familiar with this tool, as its use has become widespread in medicine and orthopaedics. The purpose of this editorial is to briefly outline the new process for assigning the level of evidence, the rationale for its use, and future directions for the Journal. For all new manuscript submissions, authors will be asked to include a level of evidence rating as part of the structured abstract. An online level of evidence calculator and reference table has been developed to simplify the process. Once a manuscript is accepted for publication, an evidence-based orthopaedic section editor will confirm the level of evidence. The rating system is summarized in Table 1.TABLE 1: Levels of Evidence by Study TypeThe purpose of implementing the level of evidence system is primarily 3-fold. First, this rating system provides a concise description of a study's design, which allows readers to quickly identify potential high impact research. Second, drawing attention to a study's design may encourage authors to clarify their primary research question and to elevate the strength of their studies by including control groups or prospective study designs when possible. Finally, the widespread use of the levels of evidence rating system in other orthopaedic journals and subspecialty meetings has created a readership that is accustomed to obtain this information in a manuscript's abstract. Currently, leading journals in general orthopaedics, sports, pediatrics, and shoulder and elbow surgery have adopted the use of this rating system for their published manuscripts. Despite the benefits and enthusiasm for the levels of evidence rating system in the orthopaedic literature, we realize that there are limitations of the current system. Because it is based primarily on the study's design, other important quality criteria are not directly considered. Furthermore, level I studies are not possible for every clinical situation, particularly in trauma populations. For some research questions, a well-designed level III or IV study remains important to generate hypotheses and to fuel further research. This is demonstrated in the present issue by the prospective level IV study from Paul et al providing early data on the effects of fracture pattern and trochanteric entry nailing on gait parameters in intertrochanteric hip fractures. Finally, introducing the levels of evidence rating system to the Journal will serve as a springboard for several other Journal led innovations to promote evidence-based orthopaedic traumatology. In the near future, we will begin to offer evidence-based reports for select high impact articles as an adjunct resource for the Journal's readership. These Advanced Clinical Evidence reports will be available online and will provide an independent critical appraisal in a journal club friendly format. We encourage comments and feedback throughout the implementation process of the levels of evidence rating system and the other proposed changes.

Characteristic personality in orthopaedic outpatients

Orthopaedic pathology might have both physical and psychological components; however, there has been no large-scale study investigating personalities in the general orthopaedics population. The purpose of this study is to determine the characteristic personality in orthopaedic outpatients. In this study, 3,743 (61.7%) among 6,069 consecutive outpatients consented to answer the Japanese MPI questionnaires, and 1,112 orthopaedic outpatients (O group) and 2,631 outpatients seen in other departments (NO [non-orthopaedic] group) were enrolled in this study. We determined three scores such as introversion/extroversion (E score), neuroticism (N score), and lie detection (L score), and defined a score exceeding the mean + 2SD in accordance with the results of the general Japanese adult population (therefore, N score ≥42 or L score ≥32) as indicating eccentric personality and determined the percentages of eccentric personality patients. All data were used to compare the two groups. The result of this study showed no significant differences between the two groups for E, N, or L scores, but the percentage of eccentric personality patients was significantly higher in the O group (p < 0.001). The percentage of eccentric personality was 10.8% among orthopaedic patients, which was approximately twice as high as among those presenting to other departments (5.5%). In conclusion, it was determined that the personalities of orthopaedic patients and non-orthopaedic patients were similar, but the percentage having eccentric personality was approximately twice as high among patients with orthopaedic diseases. We suggest that it would be advisable to keep this information in mind when treating patients who visit orthopaedics departments.

New Addition to ORTHOPEDICS

ORTHOPEDICS is excited to announce the addition of our new Ask the Experts column, the fi rst installment of which is presented in the current issue. The Ask the Experts column taps into the experience and expertise of key opinion leaders in the fi eld of orthopedics. Each month, a different panel of experts will answer how they would manage and treat a diffi cult case presentation. The column will help provide the general orthopedist with a better understanding of the different approaches available. Spearheaded by Section Editor John D. Kelly IV, MD, the column will offer insight into the different approaches and thought processes physicians use for the diagnosis and treatment of diffi cult orthopedic issues. Dr Kelly believes that the column will be of great service to orthopedists and will offer physicians a quick and easy reference for diffi cult cases. The column will be concise and condensed to favor usability and readability. In this day and age of convulsive scheduling, this is a time-effi cient way for orthopedists to research diffi cult cases they are facing and to disseminate information on how other orthopedists would manage these injuries. Topics are based on medical issues that are challenging and all too common. Over the upcoming year, the column will present cases that focus on a variety of topics, including cartilage, infection, tumor, the knee, sports medicine, total knee arthroplasty, trauma and fracture management, the spine, the upper extremity, and total hip arthroplasty.

Infections associated with spinal implants

Spinal infections represent a difficult challenge to treating clinicians. Infections in the presence of implants are even more so. In this review the literature appears to reflect a change of practice in which the aim is to retain implants if possible. The newer spinal procedures such as disc replacements pose different problems largely due to the more difficult access. The situation in the spine is more difficult than in general orthopaedics when dealing with infection due to the requirement for stability and to protect neurological function. The main thrust of management, therefore, is early diagnosis and a high index of suspicion followed by adequate if not radical management in a multidisciplinary setting. In the event prevention is better than cure and therefore consideration of the various mechanisms to avoid infection must be taken. There are some 'novel' considerations for the avoidance of infection alongside the tried and tested techniques. There are also new procedures for wound closure and the elimination of dead space.

Management of a Rare Complication After Screw Fixation of a Pediatric Tibial Spine Avulsion Fracture: A Case Report With Follow-Up to Skeletal Maturity

Avulsion of the tibial spine is functionally equivalent to rupture of the anterior cruciate ligament in an adolescent athlete. It therefore presents to general orthopaedists as well as a wide variety of orthopaedic subspecialty surgeons, including traumatology sports medicine, and pediatrics. Restoration of normal knee kinematics is dependent on anatomic reduction and fixation of the avulsed fragment. Because this injury is typically sustained by the skeletally immature patient, epiphyseal fixation is ideal to avoid physeal injury, which can lead to angular limb deformity. We present a case, the first report to our knowledge, of coronal plane deformity in a lower extremity after open reduction and internal fixation of a tibial spine avulsion fracture. A successful treatment plan using hemiepiphysiodesis and guided growth is used with 20-month follow-up to skeletal maturity.

European survey of chronic pain patients: results for Germany

Objectives:This ongoing pan-European patient survey is being conducted to explore how chronic pain patients perceive their condition and the coping strategies they use to help deal with the pain.Methodology:Participating doctors – general practitioners (GPs), pain specialists and orthopaedists – selected patients suffering from chronic pain who routinely visited their practices. Doctors provided details of individual pain diagnoses and treatment which were entered into a questionnaire. Each patient then answered additional questions about pain experience, pain therapy, possible areas for improvement and any coping strategies used. Completed questionnaires were sent to a healthcare-focused global consultancy for analysis and evaluation.Results:The most common diagnosis was chronic back pain, in 61% of the 6435 patients. Using a five-point verbal rating scale (VRS), 70% of participants rated the intensity of their pain as moderate or severe. Approximately half were receiving monotherapy. The more intense the pain was, the higher the percentage of patients receiving combination therapy. The most frequently used combinations were NSAIDs/non-opioids with weak or strong opioids. Approximately two out of three patients received non-pharmacological treatment in addition to their pain medication. Almost all the patients (90%) perceived their pain intensity to be higher than it should be under successful pain management, and 30% were dissatisfied with their current treatment. Insufficient pain relief was the reason in most cases, but 29% of dissatisfied responders cited the side effects of medication. About half the patients identified a medium to high need for improvement in their ability to work, sleep and carry out general activities. For each specialisation, the more severe the pain, the fewer patients who were satisfied with their current pain treatment. More patients with severe and extreme pain were satisfied with treatment by a pain specialist than with a GP or orthopaedist. For all three specialisations, the most frequent combination used was NSAIDs/non-opioids with weak opioids, but pain specialists prescribed more strong opioids and fewer NSAIDS/non-opioids than the other groups. Overall, 35% of the survey subjects took pain medication not prescribed by their doctor, and coping strategies included reading, participating in sports and listening to music.Conclusion:High levels of dissatisfaction, which increase proportionately with the intensity of pain, could adversely affect the chances of successful outcomes.