Background:

Internet interventions provide an opportunity to encourage patients with LBP to self-manage and remain active, by tailoring advice and providing evidence-based support for increasing physical activity. This paper reports the development of the ‘SupportBack’ internet intervention, designed for use with usual primary care, as the first stage of a feasibility RCT currently underway comparing: usual primary care alone; usual care plus the internet intervention; usual care plus the internet intervention with physiotherapist telephone support.

Joint aspiration is a useful tool during preoperative workup in suspected periprosthetic infection. The aim of this study was to review efficacy of joint aspiration in our unit and compare results with the published literature.

We undertook a retrospective review of 153 consecutive patients who underwent joint aspirations for suspected periprosthetic infection between 03/2011 and 10/2012 who were identified from the hospital electronic database. As per protocol, joint fluid was sent in an EDTA tube for cell count, Paediatric blood culture bottle and the remainder in a specimen pot.

105 (69%) were TKRs and 48 (31%) were THRs. Intraoperative samples were sent as per protocol in only 40 (26%) cases. The hit rate of positive cultures was 11/153 (7%) and specimens sent in paediatric culture bottles identified more positives than if it was omitted (10.5 Vs 5.5%).

In conclusion, the hit rate of positive cultures is low in this study compared to the literature (7% Vs 33%) and this is likely due to blanket aspiration of all patients who are undergoing revision. In addition, specimens sent in paediatric culture bottles seem to identify more positives. We recommend cases are selected for aspiration according to AAOS guidelines.

Objective

The STarT Back Screening Tool (STarT) is a 9-item patient self-report questionnaire that classifies low back pain patients into low, medium or high risk of poor prognosis. When assessed by GPs, these subgroups can be used to triage patients into different evidence-based treatment pathways. The objective of this study was to translate the English version of STarT into Danish (STarT-dk) and test its discriminative validity.

Background

One untested back pain treatment model is to stratify management depending on prognosis (low, medium or high-risk). This 2-arm RCT investigated: (i) overall clinical and cost-effectiveness of stratified primary care (intervention), versus non-stratified current best practice (control); and (ii) whether low-risk patients had non-inferior outcomes, and medium/high-risk groups had superior outcomes.

Introduction

The STarT Back trial demonstrated that targeting back pain treatment according to patient prognosis (low, medium or high-risk subgroups) is effective. However, the mechanisms leading to these improved treatment outcomes remain unknown. This study aimed to identify which psychological variables included in the study were mediating treatment outcome for all patients and within the low, medium and high-risk subgroups.

Following the publication in 2007 of the guidelines from the National Institute for Health and Clinical Excellence (NICE) for prophylaxis against venous thromboembolism (VTE) for patients undergoing surgery, concerns were raised by British orthopaedic surgeons as to the appropriateness of the recommendations for their clinical practice. In order to address these concerns NICE and the British Orthopaedic Association agreed to engage a representative panel of orthopaedic surgeons in the process of developing expanded VTE guidelines applicable to all patients admitted to hospital. The functions of this panel were to review the evidence and to consider the applicability and implications in orthopaedic practice in order to advise the main Guideline Development Group in framing recommendations.

The panel considered both direct and indirect evidence of the safety and efficacy, the cost-effectiveness of prophylaxis and its implication in clinical practice for orthopaedic patients. We describe the process of selection of the orthopaedic panel, the evidence considered and the contribution of the panel to the latest guidelines from NICE on the prophylaxis against VTE, published in January 2010.

Introduction: Detecting relevant clinical subgroups of patients with non-specific LBP is a priority for research as it has potential for improving treatment effectiveness. The STarT Back Tool (SBT) was recently developed and validated to subgroup LBP patients into targeted treatment pathways in primary care. This study tested the SBT’s criterion validity against a popular existing LBP subgrouping tool – the Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ).

Methods: 244 consecutive ‘non-specific’ LBP consulters at 8 GP practices aged 18–59 years were invited to complete a questionnaire. Measures included the OMPSQ & SBT; disability (RMDQ); pain intensity (11-item NRS); duration of symptoms; and demographics. Instruments were compared using Spearman’s rank correlation, discriminant analysis of subgroups, tests for allocation agreement and predictive validity using published data.

Results: Completed SBT (9-items) and OMPSQ (24-items) data was available for 130/244 patients (53%). The correlation of SBT and OMPSQ scores was ‘excellent (rs = 0.80, p=< 0.001). Subgroup characteristics from both tools were similar particularly among the ‘low’ risk groups, however, the proportion of patients allocated to ‘low’, ‘medium’ and ‘high’ risk groups were different, with more distressed patients in the SBT’s high risk group. The SBT better predicted pain and disability at 6 months and both equally predicted time off work.

Conclusion: The SBT psychometric properties perform as well or better than the OMPSQ, but the SBT is shorter and easier to score. It is therefore an appropriate alternative for screening LBP patients in primary care.

Background: Last year we presented the STarT Back Tool, which is validated for use in Primary Care. It subgroups patients into 3 categories (high, medium and low risk) on the basis of modifiable risk factors for chronicity. We are now piloting the feasibility of using the tool as part of a new approach to sub-grouping and targeting back pain in primary care.

Methods: The physiotherapy interventions for the 3 subgroups were developed after reviewing the literature, current guidelines, the content of existing targeted treatment programmes, and convening workshops with internationally recognised experts. Both the intervention training modules, and the targeted treatments were piloted. Consecutive back pain consulters were identified using GP electronic Read Codes (weekly downloads) and invited to attend the study’s back pain clinic. Consenting patients completed a baseline questionnaire and were classified by the tool into one of 3 sub-groups.

Results: 60 patients were recruited. 50 patients were allocated to receive treatment according to their subgroup allocation and 10 patients (control group) received a triage physiotherapy assessment (usual care) to decide if they needed further physiotherapy treatment. Primary outcomes include the Roland Morris Disability Questionnaire and the Pain Catastrophising Scale. Three-month follow-up postal questionnaires are currently being administered and outcomes will be presented at the conference. Clinicians involved (GPs, and physiotherapists) will be interviewed to identify the feasibility of this approach.

Conclusions: Once feasibility is established we will take this developmental work forwards into the clinical trial arena to investigate whether this novel “sub-grouping for targeted treatment” approach provides a cost effective way of reducing long-term risk of chronic disability in patients consulting their GP with back pain.

Background: Patients with LBP, ‘at risk’ of persistent symptoms, require targeted treatment in primary care. We have therefore developed and validated a new screening tool to classify these patients into appropriate management groups.

Methods: A list of LBP prognostic indicators was compiled by reviewing published studies and analysing existing datasets. Indicators were selected for the tool according to face and construct validity, consistency and strength of association. For each indicator outcome measure (e.g. Pain Catastrophising Scale) an individual question (e.g. ‘I feel that my back pain is terrible and that it is never going to get an better’) was selected for inclusion (ROC analysis). The tool was modelled to classify patients into 3 categories of risk. The screening tool and corresponding complete scales were mailed to 244 consecutive primary care LBP consulters. Individual items were validated against complete scales. Reliability was examined on 53 responders.

Results: This new screening tool classifies patients using 9-items to cover 8 key prognostic indicators. The questionnaires returned by 131 consulters demonstrated excellent construct validity for all individual items. 33% of patients were classified as ‘high risk’ (psychosocial and physical factors), 44% ‘intermediate risk’ (physical factors alone) and 23% ‘low risk’. Discrimination between groups across relevant constructs such as pain, disability, days off work and psychological distress was highly significant. Test-retest reliability was moderate (kappa = 0.54).

Conclusions: A novel LBP screening tool has been validated in primary care and effectively classifies patients ‘at risk’ of persistent symptoms. This will facilitate appropriate targeting of treatment.

The diffusion of Fucidin, gentamicin, and clindamycin from acrylic cement was tested in an in vitro system. The activity of Fucidin was very short-lived and only against gram-positive organisms; gentamicin inhibited gram-positive and gram-negative organisms for twenty-two and eleven days respectively; clindamycin had significant action only against gram-positive organisms and retained some activity for fifty-six days. We suggest that the destruction of organisms in the tissues is more likely to be achieved by topical and intravenous administration of antibiotics during the operation than by incorporation of antibiotic in the cement.