To describe the prevalence and incidence of Methicillin-resistant Staphylococcus aureus (MRSA) colonisation during the patient journey for patients admitted to orthopaedic and trauma wards, we carried out a prospective audit at the University Hospital of North Staffordshire NHS Trust, England. The Study Population comprised patients admitted to the trauma and elective orthopaedic wards, with an expected stay of 48 hours or more between March and May 2003. Patients were swabbed for MRSA colonisation on ward admission, transfer to another ward and discharge from hospital. Elective patients undergoing major joint surgery were also swabbed at a pre-operative assessment clinic. Colonised patients were treated depending on individual risk assessment. Five hundred and fifty-nine eligible patients were admitted to hospital. Of these, 323 (101 elective, 192 trauma and 30 non-orthopaedic) patients were included in the study, of whom 28 elective patients (28%), 43 trauma patients (22%), and seven non-orthopaedic patients (23%) were colonised with MRSA at any time during the audit period. Of the 80 patients identified as negative for MRSA colonisation at pre-assessment screening and included in the audit, ten (9.5%) were found to be colonised on admission. There is a high prevalence of MRSA colonisation in patients admitted to the orthopaedic and trauma wards in our setting. A policy of pre-admission screening, though able to identify MRSA carriage does not guarantee that patients are not colonised in the period between screening and admission. Consideration should be given to screening all patients for MRSA who are admitted to an orthopaedic ward.
Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function. Two hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001-2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient-based measures of EuroQol and SF-36. All outcomes were measured pre-operatively and 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications.Introduction
Methods
Orthopaedic surgeons vary in their surgical approaches to total knee arthroplasty. The aim of this investigation was to compare outcomes after two different surgical approaches. The study was a prospective single-centre longitudinal randomized controlled trial. A sub-vastus approach was compared with a medial para-patellar approach. Participating surgeons elected to randomize their patients to one of the two types of approach. Outcomes included the Knee Society (KS) Clinical Rating System, WOMAC Osteoarthritis Index, SF-36, and EuroQol (measured at 1, 6, 12 and 52 weeks post-operatively compared to baseline) complications, surgeon rated ease of exposure, and proportion of patients who had a lateral release. Two hundred and thirty one patients were randomized to the two approaches. One hundred and sixteen patients were randomized to the sub-vastus approach. At one week compared to baseline, range of motion, KS global, KS knee, and KS pain scores were significantly better in the sub-vastus group. At six weeks, the medial para-patellar group tended to have better outcomes, but not statistically significantly. At fifty-two weeks compared to baseline, the WOMAC global and pain scores, the SF36 physical function and role-physical scores, and the EuroQol utility and pain score were significantly better in the sub-vastus group. Surgeons reported the ease of exposure in the sub-vastus group was significantly worse on average. This trial is the largest of its kind to date, and the first, so far as we are aware, to compare clinical outcomes of different surgical approaches at one year post-operatively. The sub-vastus approach to total knee arthroplasty was more effective than a medial para-patellar approach at both one week and fifty-two weeks post-operatively in patients whose surgeons considered either approach would be suitable. However, surgeons reported worse ease of exposure in the sub-vastus group.
We have attempted to describe the epidemiology of femoral fractures in children in the West Midlands region of the National Health Service in England. Our source of data was the Regional Hospital Episode Statistics database for the years 1991-2 to 2001-2. Cases were defined as emergency hospital admissions in patients aged under 16 years, with a diagnostic code of femoral fractures in any field, and resident in the West Midlands. Between 1991-2 and 2001-2, 3272 children aged under 16 years with femoral fractures were admitted to hospital. The crude incidence during this period decreased from 0.33 to 0.22 femoral fractures/1000/year. Those caused by traffic accidents decreased by 43%, and by falls by 29%. The peak age-gender-specific incidence (0.91/1000/year) was in two-year-old boys, and this was 50% higher than in the next highest age-gender group. In the first year of life, the incidence in boys and girls was the same. Thereafter the rate in boys exceeded that in girls, varying from 1.6 times at 11 years to 4.7 times at 14 years. Falls accounted for 49% of the fractures, varying from 77% in one-year-olds to 26% in eight-year-old children. Traffic accidents were responsible for 26% of fractures varying from 55% in ten-year-old to 2% in one-year-old children. Maltreatment was recorded in 1.3% of all cases, and in 8.5% of children under one year. Twice as many fractures were seen in May to August than in January (winter). The rates of fractures were associated with deprivation for all age-gender groups. Fractures of the shaft accounted for 58% of all fractures, varying from 70% in three-year-old to 34% in 13-year-old children. Our findings show that there has been a decrease in the incidence of femoral fractures during the 1990s and early 2000s. Two-year-old boys had twice the rate than any other single-year age-gender group. More deprived areas had much higher rates which suggests the potential for greater prevention. A relatively low rate of maltreatment was recorded compared with that in some other studies.
To evaluate patient satisfaction and expectations of surgery following forefoot arthroplasty.
Between October 1993 and June 1999, forefoot arthroplasty (Kate/Kessel/Kay procedure) was performed or directly supervised by the senior author (D. McBride) in a cohort of 55 patients. All had inflammatory arthritis and had failed non-operative management. The clinical result was assessed using a self-administered patient satisfaction questionnaire. The questionnaire asked patients to rate their level of satisfaction in terms of pain relief, wound healing, stiffness and appearance. The patients expectations from the surgery in terms of their level of disability and the achievement of the operation in addition to their pain experience following their operation was assessed.
Median time to follow-up was 41 months (range seven to seventy-seven). Forty-three of the 55 patients returned the completed questionnaire. The median age at operation of the respondents was 59 years (range 42 to 69) compared with 49 years (range 44 to 63) for the non-respondents. Of the 43 respondents, 30 were female and 13 male. In terms of their expectations of the surgery, 20 (47%) stated that the operation had achieved what they had expected while 10 (23%) considered the operation to have achieved more than they had expected. The level of disability following their operation was as expected in 21 (49%), more than expected in 11 (26%) and less than expected in four (9%). 23 (55%) noted no change to their walking capacity while it had increased in 11 (26%) and decreased in eight (19%). There were two wound haematomas, five superficial wound infections and three cases of delayed wound healing which extended the post-operative hospital stay. Seventy-nine percent of patients however reported complete satisfaction with their wound healing. In those patients that had reported having had pain (n=31) at some time following their operation, two (7%) had experienced it for less than seven days, four (13%) for between one and four weeks, one (3%) for between one and three months and 23 (77%) for more than three months.
Overall patients were generally satisfied with their operation in terms of pain relief, wound healing and appearance. Additionally, in the majority of patients, the achievements of the procedure and the associated disability were as expected. Previous authors have outlined the various surgical factors, which are said to lead to a good outcome. Whilst it is important to bear these factors in mind we have found that some of our patients appeared to have a good result when these criteria were not met. While other patients meeting these criteria were not necessarily satisfied. This suggests areas for further research.
Sickle-cell disease (SCD) is probably the commonest cause of avascular necrosis worldwide, and its prevalence appears to be rising in developed countries. Avascular necrosis of the humeral head is a common complication but has not been previously studied in detail. We have reviewed 138 patients with SCD for clinical, radiological and functional abnormalities of the shoulder, using a radiological classification designed for avascular necrosis of the shoulder. Radiographic lesions, frequently bilateral, were found in 28% and only 53% of patients had normal shoulder function. The management of this relatively common complication is difficult. Joint replacement is likely to fail and early diagnosis is important.
