MRSA colonisation increases the risk of acquiring a surgical site infection (SSI). Screening identifies such patients and provides them with suitable eradication treatment prior to surgery to decrease their risk of infection. Our aim was to determine whether receiving effective eradication therapy decreases the risk of infection in a patient previously screening positive for MRSA to that of someone screening negative. 1061 patients underwent elective total knee or hip replacement between March 2008 and July 2010. 1047 had pre-operative screening for MRSA and MSSA using nasal and perineum swabs. If positive for MRSA they underwent a course of eradication treatment and were required to provide a negative swab result prior to undertaking surgery. However during the time of this study those screening positive for MSSA did not receive eradication treatment. Surgical site infections were recorded and the rate of infection, relative risk and odds ration were calculated.Introduction
Methods
We conducted a prospective randomised controlled trial. 45 patients (total of 47 elbows) underwent either a formal open release or a percutaneous tenotomy (24 open, 23 percutaneous). All patients had pre-operative assessment by the DASH (Disability of the Arm, Shoulder and Hand) scoring system. The surgery was performed by 1 surgeon (BN Muddu). Both groups were followed up for a minimum of 12 months and re-assessed using the DASH scores, time for return to work and patient satisfaction. Statistical analysis using Mann-Whitney and repeated measures ANOVA were performed. The groups were similar in respect of demographic and pre-test variables. Statistical analyses using Mann-Whitney showed significant differences for patient satisfaction (p=0.012), time to return to work (p=0.0001), improvements in DASH Score (p=0.002) and improvement in sporting activities (p=0.046). There was a trend to improvement in work related activity. Repeated measures ANOVA comparing the pre-operative data for each group were also significant for standardized DASH scores (p=0.0082) and sporting activities (p=0.043). Our study has shown that there is a significant difference in outcome in the two patient groups. Those patients undergoing a percutaneous release returned to work on average 3 weeks earlier and their symptoms as shown from their DASH scores improved significantly more than those undergoing an open procedure. The percutaneous procedure is a quicker, simpler procedure to perform than an open procedure. Our study has shown that patients have significantly better outcome measures after a percutaneous procedure.
Radiological examination is a useful tool in assessing osteoarthritis (OA) in the knee. We have compared the extent of osteoarthritis in the knee graded on radiographs and by intraoperative observation to determine if there is significant difference with relevance to preop-erative planning. Radiographs for fifty-eight patients were graded for OA under blind conditions using the Ahlback classification system and direct measurement of the medial and lateral joint spaces. Intraoperative assessment of the corresponding joint surfaces was performed under blind conditions by a separate surgeon and graded using the Outerbridge classification system. OA was found to be more common in the medial compartment than the lateral, both on radiographs and intraoperatively. Spearman correlation coefficient for the medial compartment comparing joint space narrowing and intraoperative assessment was −0.545. For the lateral compartment the Spearman correlation coefficient was lower at –0.406. Positive predictive values for OA in the medial and lateral compartments on radiography were 90% and 66.67% respectively. Negative predictive values for OA in the medial and lateral compartments on radiography were 44.74% and 34.69% respectively.
To assess the percentage of patients with an osteoporotic distal radial fracture who had any subsequent investigation or treatment for osteoporosis, and to compare this to the gold standard, all patients seen in a hospital fracture clinic with an osteoporotic fracture should be advised of the possibility of osteoporosis and their primary care team informed of the need for follow-up (Royal College of Physicians, National Osteoporosis Society and The Advisory Group on Osteoporosis). All patients over 50 years old who sustained a distal radial fracture and a subsequent fractured neck of femur after simple falls, over a 7-year period, were included. Evidence of any treatment for, or investigation of, osteoporosis between the initial radial fracture and subsequent neck of femur fracture was recorded. 74 patients met the above criteria. 7 male and 67 female, median age 83 (54 to 99). Eight percent of cases were on treatment for osteoporosis at time of first fracture. A further 8% had evidence of treatment for, or investigation of, osteoporosis commenced by time of their 2nd fracture. 84% of patients received no advice, investigation or treatment. As orthopaedic surgeons we have a duty to inform the primary care team of the need to follow-up patients with osteoporotic fractures. There is a significant cost benefit both to the patient and the health service. We aim to introduce a system whereby a letter is automatically sent to the GP informing them that their patient has been seen in fracture clinic with an osteoporotic distal radial fracture. The letter will also advise them of the current Royal College and Government guidelines on investigation and treatment of osteoporosis. We aim to repeat the audit cycle after a 5-year period with the new system in place.
