Purpose of the study and background

The CONNECT trial evaluated a theory-based intervention to increase low back pain patients' adherence to treatment recommendations through physiotherapists' communication behaviour. Bridging the gap between evidence and evidence-based practice, we aimed to develop an implementation intervention to support physiotherapists in translating the CONNECT communication training into practice.

Introduction

Many surgeons are familiar with the audible change in the sound pitch while hammering a rasp in a long bone during surgeries like Hip Arthroplasty. We have developed a hypothesis indicating that there is a relationship between that sound change and the development of micro-fracture and subsequently full fracture.

Introduction

Proper femoral reaming is a key factor for a successful outcome in cementless hip arthroplasty. Good quality reaming minimizes risks of intra-operative femoral fracture during reaming and prevents poor fitting of the implant which can lead to subsidance of the stem postoperativly. Determining the quality of reaming is largely a subjective skill and dependant on the surgeon's experience with no documented intraoprative method to assess it objectively.

Introduction Epidemiological studies have revealed that the incidence of Achilles tendon rupture is increasing and is especially high in middle age. Similarly, in horses, the superficial digital flexor tendon (SDFT) is often injured with older horses being most at risk. Tendons which play a role in elastic energy storage, such as the human Achilles tendon and equine SDFT, are much more susceptible to degenerative change and subsequent rupture than non-energy storing positional tendons, such as the human anterior tibialis tendon and the equine common digital extensor tendon (CDET). These energy storing tendons are required to operate with small safety margins and are likely therefore to incur high levels of micro-damage. The ability to repair micro-damage depends on the capacity for matrix turnover which requires both the capability to synthesise and degrade matrix components. In a previous study we have shown that the levels of matrix degrading enzymes (matrix metalloproteinases) differ significantly between the SDFT and CDET (Faram et al., 2004, Proc. BORS, Bristol) and that some matrix metalloproteinases (MMP-3) increase significantly with increasing age (Eissa et al., 2004, Proc. BSMB, Bristol). The aim of this study was to test the hypothesis that MMP derived fragments of collagen resulting from collagen breakdown are present at higher levels in the energy storing SDFT than the CDET and increase significantly with increasing age.

Methods The SDFT and CDET were harvested from the left forelimb of horses (n=20) ranging in age from skeletal maturity to senescence (5 – 30 years) and tissue from the mid-metacarpal level of each tendon analysed. A commercially available radioimmunoassay kit (Oxford Biosystems) was used to measure levels of the C-terminal telopeptide of type I collagen (ICTP). In addition, DNA levels were measured by a fluorometric assay using Hoechst 33258 dye to give an indication of tissue cellularity and collagen-linked fluorescence was measured to give an indication of the age of the collagen in the matrix. Statistical significance (p = 0.05) was evaluated using a general linear model (SPSS software) to compare tendons (SDFT and CDET) and to determine changes with age.

Results The levels of ICTP were approximately four times higher (p=0.001) in the CDET compared to the SDFT and in both tendons appeared to decrease with increasing age. DNA levels were significantly (p< 0.001) higher in the SDFT than the CDET and these levels did not change significantly with age. The collagen-linked fluorescence was significantly (p< 0.001) higher in the SDFT than the CDET and decreased significantly (p=0.006) with age in both tendons.

Discussion The results demonstrate that the SDFT is more cellular than the CDET and may therefore be expected to be more metabolically active. Contrary to this, collagen-linked fluorescence is higher in the SDFT suggesting that the matrix is older and furthermore the levels of collagen fragments are much lower in the SDFT suggesting that the collagen within the matrix is turned over more rapidly in the CDET than the SDFT. The changes in collagen-linked fluorescence and ICTP levels suggest than collagen turnover decreases with ageing and low turnover may be responsible for SDFT degneration.

We examined the rates of infection and colonisation by methicillin-resistant Staphylococcus aureus (MRSA) between January 2003 and May 2004 in order to assess the impact of the introduction of an MRSA policy in October 2003, which required all admissions to be screened. Emergency admissions were treated prophylactically and elective beds ring-fenced. A total of 5594 admissions were cross-referenced with 22 810 microbiology results. The morbidity, mortality and cost of managing MRSA-carrying patients, with a proximal fracture of the femur were compared, in relation to age, gender, American Society of Anaesthesiologists grade and residential status, with a group of matched controls who were MRSA-negative.

In 2004, we screened 1795 of 1796 elective admissions and MRSA was found in 23 (1.3%). We also screened 1122 of 1447 trauma admissions and 43 (3.8%) were carrying MRSA. All ten ward transfers were screened and four (40%) were carriers (all p < 0.001). The incidence of MRSA in trauma patients increased by 2.6% per week of inpatient stay (r = 0.97, p < 0.001). MRSA developed in 2.9% of trauma and 0.2% of elective patients during that admission (p < 0.001). The implementation of the MRSA policy reduced the incidence of MRSA infection by 56% in trauma patients (1.57% in 2003 (17 of 1084) to 0.69% in 2004 (10 of 1447), p = 0.035). Infection with MRSA in elective patients was reduced by 70% (0.56% in 2003 (7 of 1257) to 0.17% in 2004 (3 of 1806), p = 0.06). The cost of preventing one MRSA infection was £3200.

Although colonisation by MRSA did not affect the mortality rate, infection by MRSA more than doubled it. Patients with proximal fractures of the femur infected with MRSA remained in hospital for 50 extra days, had 19 more days of vancomycin treatment and 26 more days of vacuum-assisted closure therapy than the matched controls. These additional costs equated to £13 972 per patient.

From this experience we have been able to describe the epidemiology of MRSA, assess the impact of infection-control measures on MRSA infection rates and determine the morbidity, mortality and economic cost of MRSA carriage on trauma and elective orthopaedic wards.