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Preston NJ, McHugh GA, Hensor EMA, Grainger AJ, O’Connor PJ, Conaghan PG, Stone MH, Kingsbury SR. Feasibility testing of a standardised virtual clinic for follow-up of patients after hip and knee arthroplasty. Ann R Coll Surg Engl 2023; 105:252-262. [PMID: 35975843 PMCID: PMC9974348 DOI: 10.1308/rcsann.2021.0356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Over 200,000 hip and knee total joint arthroplasties (TJAs) are performed annually in England and Wales. UK guidelines recommend regular follow-up because missed early failure can result in complex revision surgery, which places additional burden on overstretched orthopaedic services. This study evaluated the feasibility and acceptability of an expert, consensus-based, standardised virtual clinic (VC) approach for TJA follow-up. METHODS Five UK secondary care orthopaedic centres implemented a standardised VC. Feedback was obtained through patient satisfaction questionnaires and telephone interviews with arthroplasty care practitioners. Key stakeholders subsequently attended an expert discussion forum to achieve consensus on the final VC format and to address obstacles identified during testing. RESULTS From 19 June 2018 to 11 December 2018, 561 TJA patients [mean age (SD) 70 (9.4) years, 57.8% female, 69.0% hip TJA, 1-28 years postsurgery (median 5 years)] completed a VC. Of these 561 patients, 82.2% were discharged without attending an outpatient appointment and 46 (8.8%) required early face-to-face consultant review. Patient satisfaction with the VC was high (156/188; 83.0%); over 70% of patients indicated a preference for the VC. DISCUSSION This feasibility study suggested significant resource savings, including time spent by consultant orthopaedic surgeons in outpatient clinics, hospital transport and an estimated saving of up to two-thirds of usual clinic-allotted time. The expert discussion forum provided helpful feedback for supporting more efficient implementation of the VC. CONCLUSIONS A standardised VC is a feasible alternative to outpatient clinics for the follow-up of hip and knee TJA patients, and is acceptable to key stakeholders, including patients.
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Affiliation(s)
- NJ Preston
- Leeds Institute of Rheumatic and Musculoskeletal Medicine,UK
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Pinedo-Villanueva R, Kolovos S, Burn E, Delmestri A, Smith LK, Judge A, Kingsbury SR, Stone MH, Conaghan PG. Association between outpatient follow-up and incidence of revision after knee and hip replacements: a population-based cohort study. BMC Musculoskelet Disord 2023; 24:106. [PMID: 36750857 PMCID: PMC9906879 DOI: 10.1186/s12891-023-06190-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 01/23/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Follow-up visits 5 or 7 years after surgery were recommended for people having primary hip or knee replacement. The benefits of this practice to patients and the healthcare system, however, have not yet been specifically examined. The aim of this study was to investigate the association between long-term follow-up outpatient hospital visits and revision rates for patients who undergo primary knee or hip replacement surgery. METHODS Cohorts were identified for patients undergoing knee or hip replacement surgery using medical records from primary care practices within the UK Clinical Practice Research Datalink (CPRD) GOLD dataset linked to hospital records from the English Hospital Episodes Statistics (HES) data. Two groups of patients were compared in terms of revision and mortality rates: those with at least one long-term (between five and 10 years since primary surgery) follow-up visit at the orthopaedic department ('Follow-up' group), and those without ('No follow-up' group). RESULTS A total of 9856 (4349 in the Follow-up group) patients with knee replacement and 10,837 (4870 in the Follow-up group) with hip replacement were included in the analysis. For knee replacement, the incidence of revision was 3.6% for those followed-up and 0.6% for those not followed-up. An adjusted regression model confirmed the difference in the hazard ratio (HR) for revision was statistically significant (HR: 5.65 [95% CI 3.62 to 8.81]). Mortality at 4 years was lower for the Follow-up (17%) compared to the No follow-up group (21%), but this difference was not statistically significant (HR: 0.95 [0.84 to 1.07]). For hip replacement, the incidence of revision rates were 3.2 and 1.4% for the follow-up and not follow-up groups, respectively, the difference being statistically significant (HR: 2.34 [1.71 to 3.20]). Mortality was lower for the Follow-up (15%) compared to the No follow-up group (21%), but the difference was not statistically significant (HR: 0.91 [0.81 to 1.02]). CONCLUSION Patients attending follow-up orthopaedic consultations show a higher risk of revision surgery compared to those who are not followed-up. A cause for this difference could not be identified in this study but a likely explanation is that surgeons play an effective role as ultimate arbitrators when identifying patients to be included in long-term follow-up lists.
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Affiliation(s)
- Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Road, Oxford, OX3 7LD, UK.
| | - Spyros Kolovos
- grid.4991.50000 0004 1936 8948Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Road, Oxford, OX3 7LD UK
| | - Edward Burn
- grid.4991.50000 0004 1936 8948Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Road, Oxford, OX3 7LD UK
| | - Antonella Delmestri
- grid.4991.50000 0004 1936 8948Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Road, Oxford, OX3 7LD UK
| | - Lindsay K. Smith
- grid.6518.a0000 0001 2034 5266Faculty of Health and Applied Sciences, University of the West of England, Rm 2G40 Glenside Campus, Blackberry Hill, Bristol, BS16 1DD UK
| | - Andrew Judge
- grid.5337.20000 0004 1936 7603Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB UK
| | - Sarah R. Kingsbury
- grid.9909.90000 0004 1936 8403Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA UK ,grid.454370.10000 0004 0439 7412NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Martin H. Stone
- grid.454370.10000 0004 0439 7412NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Philip G. Conaghan
- grid.9909.90000 0004 1936 8403Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA UK ,grid.454370.10000 0004 0439 7412NIHR Leeds Biomedical Research Centre, Leeds, UK
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Smith LK, Garriga C, Kingsbury SR, Pinedo-Villanueva R, Delmestri A, Arden NK, Stone M, Conaghan PG, Judge A. UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE): what does analysis of linked, routinely collected national datasets tell us about mid-late term revision risk after knee replacement? BMJ Open 2022; 12:e046900. [PMID: 35264336 PMCID: PMC8915365 DOI: 10.1136/bmjopen-2020-046900] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To identify patients at risk of mid-late term revision of knee replacement (KR) to inform targeted follow-up. DESIGN Analysis of linked national datasets from primary and secondary care (Clinical Practice Research Datalink (CPRD GOLD), National Joint Registry (NJR), English Hospital Episode Statistics (HES) and Patient Reported Outcome Measures (PROMs)). PARTICIPANTS Primary elective KRs aged ≥18 years. EVENT OF INTEREST Revision surgery ≥5 years (mid-late term) postprimary KR. STATISTICAL METHODS Cox regression modelling to ascertain risk factors of mid-late term revision. HRs and 95% CIs assessed association of sociodemographic factors, comorbidities, medication, surgical variables and PROMs with mid-late term revision. RESULTS NJR-HES-PROMs data were available from 2008 to 2011 on 188 509 KR. CPRD GOLD-HES data covered 1995-2011 on 17 378 KR. Patients had minimum 5 years postprimary surgery to end 2016. Age and gender distribution were similar across datasets; mean age 70 years, 57% female. In NJR, there were 8607 (4.6%) revisions, median time-to-revision postprimary surgery 1.8 years (range 0-8.8), with 1055 (0.6%) mid-late term revisions; in CPRD GOLD, 877 (5.1%) revisions, median time-to-revision 4.2 years (range 0.02-18.3), with 352 (2.0%) mid-late term revisions.Reduced risk of revision after 5 years was associated with older age (HR: 0.95; 95% CI 0.95 to 0.96), obesity (0.70; 0.56 to 0.88), living in deprived areas (0.71; 0.58 to 0.87), non-white ethnicity (0.58; 0.43 to 0.78), better preoperative pain and functional limitation (0.42; 0.33 to 0.53), better 6-month postoperative pain and function (0.33; 0.26 to 0.41) or moderate anxiety/depression (0.73; 0.63 to 0.83) at primary surgery.Increased risk was associated with male gender (1.32; 1.04 to 1.67); when anticonvulsants (gabapentin and pregabalin) (1.58; 1.01 to 2.47) or opioids (1.36; 1.08 to 1.71) were required prior to primary surgery.No implant factors were identified. CONCLUSION The risk of mid-late term KR revision is very low. Increased risk of revision is associated with patient case-mix factors, and there is evidence of sociodemographic inequality.
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Affiliation(s)
- Lindsay K Smith
- Department of Health & Applied Sciences, University of the West of England, Bristol, UK
| | - Cesar Garriga
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah R Kingsbury
- NIHR Leeds Biomedical Research Centre, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Antonella Delmestri
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nigel K Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Martin Stone
- Orthopaedic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Andrew Judge
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Smith LK, Garriga C, Kingsbury SR, Pinedo-Villanueva R, Delmestri A, Arden NK, Stone M, Conaghan PG, Judge A. UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE): what does analysis of linked, routinely collected national data sets tell us about mid-late term revision risk after hip replacement? Retrospective cohort study. BMJ Open 2022; 12:e050877. [PMID: 35264338 PMCID: PMC8915340 DOI: 10.1136/bmjopen-2021-050877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To identify patients at risk of mid-late term revision of hip replacement to inform targeted follow-up. DESIGN Analysis of linked national data sets from primary and secondary care (Clinical Practice Research Datalink (CPRD-GOLD); National Joint Registry (NJR); English Hospital Episode Statistics (HES); Patient-Reported Outcome Measures (PROMs)). PARTICIPANTS Primary elective total hip replacement (THR) aged≥18. EVENT OF INTEREST Revision surgery≥5 years (mid-late term) after primary THR. STATISTICAL METHODS Cox regression modelling to ascertain risk factors of mid-late term revision. HR and 95% CI assessed association of sociodemographic factors, comorbidities, medication, surgical variables and PROMs with mid-late term revision. RESULTS NJR-HES-PROMs data were available from 2008 to 2011 on 142 275 THR; mean age 70.0 years and 61.9% female. CPRD GOLD-HES data covered 1995-2011 on 17 047 THR; mean age 68.4 years, 61.8% female. Patients had minimum 5 years postprimary surgery to end 2016. In NJR-HES-PROMS data, there were 3582 (2.5%) revisions, median time-to-revision after primary surgery 1.9 years (range 0.01-8.7), with 598 (0.4%) mid-late term revisions; in CPRD GOLD, 982 (5.8%) revisions, median time-to-revision 5.3 years (range 0-20), with 520 (3.1%) mid-late term revisions.Reduced risk of mid-late term revision was associated with older age at primary surgery (HR: 0.96; 95% CI: 0.95 to 0.96); better 6-month postoperative pain/function scores (HR: 0.35; 95% CI: 0.27 to 0.46); use of ceramic-on-ceramic (HR: 0.73; 95% CI: 0.56 to 0.95) or ceramic-on-polyethylene (HR: 0.76; 95% CI: 0.58 to 1.00) bearing surfaces.Increased risk of mid-late term revision was associated with the use of antidepressants (HR: 1.32; 95% CI: 1.09 to 1.59), glucocorticoid injections (HR: 1.33; 95% CI: 1.06 to 1.67) and femoral head size≥44 mm (HR: 2.56; 95% CI: 1.09 to 6.02)No association of gender, obesity or Index of Multiple Deprivation was observed. CONCLUSION The risk of mid-late term THR is associated with age at primary surgery, 6-month postoperative pain and function and implant factors. Further work is needed to explore the associations with prescription medications observed in our data.
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Affiliation(s)
- Lindsay K Smith
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, Bristol, UK
- Trauma and Orthopaedics, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, Bristol, UK
| | - Cesar Garriga
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah R Kingsbury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Antonella Delmestri
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nigel K Arden
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Martin Stone
- Orthopaedics Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Andrew Judge
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Kingsbury SR, Smith LK, Shuweihdi F, West R, Czoski Murray C, Conaghan PG, Stone MH. A comparative study of patients presenting for planned and unplanned revision hip or knee arthroplasty. Bone Joint J 2022; 104-B:59-67. [PMID: 34969282 PMCID: PMC8779949 DOI: 10.1302/0301-620x.104b1.bjj-2021-0032.r2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without. METHODS Data were collected from participants and medical records for the 12 months prior to revision. Patients with previous revision, metal-on-metal articulations, or hip hemiarthroplasty were excluded. Participants were retrospectively classified as 'Planned' or 'Unplanned' revision. Multilevel regression and propensity score matching were used to compare the two groups. RESULTS Data were analyzed from 568 patients, recruited in 38 UK secondary care sites between October 2017 and October 2018 (43.5% male; mean (SD) age 71.86 years (9.93); 305 hips, 263 knees). No significant inclusion differences were identified between the two groups. For hip revision, time to revision > ten years (odds ratio (OR) 3.804, 95% confidence interval (CI) (1.353 to 10.694), p = 0.011), periprosthetic fracture (OR 20.309, 95% CI (4.574 to 90.179), p < 0.001), and dislocation (OR 12.953, 95% CI (4.014 to 41.794), p < 0.001), were associated with unplanned revision. For knee, there were no associations with route to revision. Revision after ten years was more likely for those who were younger at primary surgery, regardless of route to revision. No significant differences in cost outcomes, length of surgery time, and access to a health professional in the year prior to revision were found between the two groups. When periprosthetic fractures, dislocations, and infections were excluded, healthcare use was significantly higher in the unplanned revision group. CONCLUSION Differences between characteristics for patients presenting for planned and unplanned revision are minimal. Although there was greater healthcare use in those having unplanned revision, it appears unlikely that routine orthopaedic review would have detected many of these issues. It may be safe to disinvest in standard follow-up provided there is rapid access to orthopaedic review. Cite this article: Bone Joint J 2022;104-B(1):59-67.
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Affiliation(s)
- Sarah R Kingsbury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Lindsay K Smith
- Faculty of Health & Applied Sciences, University of the West of England, Bristol, UK
| | - Farag Shuweihdi
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Martin H Stone
- NIHR Leeds Biomedical Research Centre, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Smith LK, Turner E, Lenguerrand E, Powell J, Palmer S. Pilot study: Is a long-term follow-up service beneficial for patients undergoing revision hip replacement surgery? Musculoskeletal Care 2020; 19:259-268. [PMID: 33085156 PMCID: PMC8518955 DOI: 10.1002/msc.1521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/10/2022]
Abstract
Purpose Total hip arthroplasty (THA) is highly successful but some patients will require later revision surgery. This pilot study evaluates the effects of long‐term follow‐up for patients undergoing revision hip replacement. Methods Consecutive patients undergoing aseptic revision of THA were recruited from a large orthopaedic unit to a single centre, observational study. Primary outcomes were changes in patient‐reported scores from pre‐revision to 12 months post‐surgery. Secondary outcomes were costs during hospital stay up to 6 months post‐revision. Participants were retrospectively allocated to two groups—those with regular orthopaedic review prior to revision (Planned revision) or those without (Unplanned revision). Results 52 patients were recruited, 7 were unrevised, one incomplete baseline questionnaires. There were 25 planned and 19 unplanned revisions with no significant differences between groups at baseline. At 12 months, 34 complete data sets were available for analysis, 17 in each group. Change scores were analysed with Mann–Whitney U test; none reached statistical significance. There was a significant difference for length of stay: Planned group 5 days (2–22), Unplanned 11 days (3–86) (Mann–Whitney U test, p = 0.023). No significant differences found for theatre time or component costs. Resource costs post‐revision surgery are presented. Conclusion This pilot study indicates that some change in methods would be required for future work. The results show that there may be some financial benefit from providing long‐term follow‐up of THA but a larger study is needed to explore these findings and to discuss the impact on recommended guidelines.
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Affiliation(s)
- Lindsay K Smith
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Bristol, UK
| | | | - Erik Lenguerrand
- Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Bristol, UK
| | - Jane Powell
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Shea Palmer
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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Rose A, Dures E, Smith LK. Hip and knee replacements: Should we follow them up? A survey of orthopaedic health professionals. Musculoskeletal Care 2020; 18:74-80. [PMID: 31925883 DOI: 10.1002/msc.1427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/05/2019] [Accepted: 08/05/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Alice Rose
- University of Bristol, Bristol, England, UK
| | - Emma Dures
- University of the West of England, Bristol, UK
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Smith LK, Dures E, Beswick AD. Systematic review of the clinical effectiveness for long-term follow-up of total hip arthroplasty. Orthop Res Rev 2019; 11:69-78. [PMID: 31308766 PMCID: PMC6613453 DOI: 10.2147/orr.s199183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/21/2019] [Indexed: 01/08/2023] Open
Abstract
Objectives: Total hip arthroplasty (THA) is highly successful but national registries indicate that average age has lowered and that younger patients are at higher risk of revision. Long-term follow-up of THA was historically recommended to identify aseptically failing THA, minimising the risks associated with extensive changes, but follow-up services are now in decline. A systematic review was conducted to search for evidence of the clinical or cost-effectiveness of hip arthroplasty surveillance. Methods: The study was registered with PROSPERO International Prospective Register of Systematic Reviews and conducted according to PRISMA guidelines; databases included MEDLINE and Embase, and all studies were quality assessed. Original studies (2005 to 2017) reporting follow-up of adults with THA in situ >5 years were included. Researchers extracted quantitative and qualitative data from each study. Results: For eligibility, 4,137 studies were screened: 114 studies were included in the final analysis, representing 22 countries worldwide. Data extracted included study endpoint, patient detail, loss to follow-up, revisions, scores and radiographic analysis. Six themes were derived from inductive content analysis of text: support for long-term follow-up, subgroups requiring follow-up, effect of materials/techniques on THA survival, effect of design, indicators for revision, review process. Main findings—follow-up was specifically recommended to monitor change (eg asymptomatic loosening), when outcomes of joint construct are unknown, and for specific patient subgroups. Outcome scores alone are not enough, and radiographic review should be included. Conclusion: There were no studies directly evaluating the clinical effectiveness of the long-term follow-up of THA but expert opinions from a range of international authors advocated its use for defined subgroups to provide patient-centred care. In the absence of higher level evidence, these opinions, in conjunction with emerging outputs from the national joint registries, should be used to inform services for long-term follow-up of THA. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/lAKW3hQGyJQ
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Affiliation(s)
- Lindsay K Smith
- Department of Trauma and Orthopaedics, Weston Area Health NHS Trust, Weston-super-Mare, North Somerset, UK
| | - Emma Dures
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK
| | - A D Beswick
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
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Czoski Murray CJ, Kingsbury SR, Arden NK, Hewison J, Judge A, Matu J, O'Shea J, Pinedo-Villanueva R, Smith LK, Smith C, Thomas CM, West RM, Wright JM, Conaghan PG, Stone MH. Towards UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE): protocol for an evaluation of the requirements for arthroplasty follow-up, and the production of consensus-based recommendations. BMJ Open 2019; 9:e031351. [PMID: 31243039 PMCID: PMC6597629 DOI: 10.1136/bmjopen-2019-031351] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Hip and knee arthroplasties have revolutionised the management of degenerative joint diseases and, due to an ageing population, are becoming increasingly common. Follow-up of joint prostheses is to identify problems in symptomatic or asymptomatic patients due to infection, osteolysis, bone loss or potential periprosthetic fracture, enabling timely intervention to prevent catastrophic failure at a later date. Early revision is usually more straight-forward surgically and less traumatic for the patient. However, routine long-term follow-up is costly and requires considerable clinical time. Therefore, some centres in the UK have curtailed this aspect of primary hip and knee arthroplasty services, doing so without an evidence base that such disinvestment is clinically or cost-effective. METHODS Given the timeline from joint replacement to revision, conducting a randomised controlled trial (RCT) to determine potential consequences of disinvestment in hip and knee arthroplasty follow-up is not feasible. Furthermore, the low revision rates of modern prostheses, less than 10% at 10 years, would necessitate thousands of patients to adequately power such a study. The huge variation in follow-up practice across the UK also limits the generalisability of an RCT. This study will therefore use a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence-based and consensus-based recommendations as to how, when and on whom follow-up should be conducted. Four interconnected work packages will be completed: (1) a systematic literature review; (2a) analysis of routinely collected National Health Service data from five national data sets to understand when and which patients present for revision surgery; (2b) prospective data regarding how patients currently present for revision surgery; (3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models and (4) a Delphi-consensus process, involving all stakeholders, to develop a policy document which includes a stratification algorithm to determine appropriate follow-up care for an individual patient. ETHICS AND DISSEMINATION Favourable ethical opinion has been obtained for WP2a (RO-HES) (220520) and WP2B (220316) from the National Research Ethics Committee. Following advice from the Confidentiality Advisory Group (17/CAG/0122), data controllers for the data sets used in WP2a (RO-HES) - NHS Digital and The Phoenix Partnership - confirmed that Section 251 support was not required as no identifiable data was flowing into or out of these parties. Application for approval of WP2a (RO-HES) from the Independent Group Advising on the Release of Data (IGARD) at NHS Digital is in progress (DARS-NIC-147997). Section 251 support (17/CAG/0030) and NHS Digital approval (DARS-NIC-172121-G0Z1H-v0.11) have been obtained for WP2a (NJR-HES-PROMS). ISAC (11_050MnA2R2) approval has been obtained for WP2a (CPRD-HES).
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Affiliation(s)
| | - Sarah R Kingsbury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Nigel K Arden
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, UK
- MRC Lifecourse Epidemiology Unit, Southampton, UK
| | - Jamie Matu
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | | | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lindsay K Smith
- Trauma and Orthopaedics, Weston Area Health NHS Trust, Weston-super-Mare, UK
| | - Chris Smith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Christine M Thomas
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Judy M Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Martin H Stone
- NIHR Leeds Biomedical Research Centre, Leeds, UK
- Department of Orthopaedic Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
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Smith LK, Lenguerrand E, Blom A, Powell J, Palmer S. Protocol for follow up of hip arthroplasty in the long term: effect on revision (WHISTLER study). Musculoskeletal Care 2017; 15:373-378. [PMID: 28394018 DOI: 10.1002/msc.1184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Total hip arthroplasty (THA) is highly successful for reducing pain and improving function, providing health-related quality of life benefit. Demand for THA is increasing with associated increase in revision hip surgery. Hip arthroplasty surveillance (long-term follow up) can identify asymptomatically failing THA to prepare for revision surgery, reducing potential for complications or complexity of surgery. However, it is unknown whether the surveillance of THA can be shown to improve the patient outcomes or reduce costs around revision surgery. With the current need to reduce unnecessary health consultations and to show the economic advantages of any service, the purpose of this study is to consider the relative effectiveness of hip arthroplasty surveillance on revision hip arthroplasty. This is a single-centre, observational study in which consecutive patients undergoing aseptic revision of THA over 12 months in a large orthopaedic unit will be considered for participation. Primary outcome measures will be change in each of three valid patient-reported scores from pre-operatively to 12 months post-surgery. Secondary outcomes will be the costs of treatment calculated using data obtained from the participants' hospital records and a self-report questionnaire. An exploratory approach will be used to investigate the effect of surveillance on the outcomes of interest. A linear mixed method model will be used to study the change in scores between baseline and 12 months. The economic evaluation will be a cost-utility analysis, which compares the value of alternative interventions by attaching costs to the quality-adjusted life years produced by each intervention.
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Affiliation(s)
- Lindsay K Smith
- Faculty of Health & Applied Sciences, University of the West of England, Glenside Campus, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Bristol, UK
| | - Ashley Blom
- Musculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Bristol, UK
| | - Jane Powell
- Faculty of Health & Applied Sciences, University of the West of England, Glenside Campus, Bristol, UK
| | - Shea Palmer
- Faculty of Health & Applied Sciences, University of the West of England, Glenside Campus, Bristol, UK
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11
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Kingsbury SR, Dube B, Thomas CM, Conaghan PG, Stone MH. Is a questionnaire and radiograph-based follow-up model for patients with primary hip and knee arthroplasty a viable alternative to traditional regular outpatient follow-up clinic? Bone Joint J 2016; 98-B:201-8. [PMID: 26850425 DOI: 10.1302/0301-620x.98b2.36424] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Increasing demand for total hip and knee arthroplasty (THA/TKA) and associated follow-up has placed huge demands on orthopaedic services. Feasible follow-up mechanisms are therefore essential. METHODS We conducted an audit of clinical follow-up decision-making for THA/TKA based on questionnaire/radiograph review compared with local practice of Arthroplasty Care Practitioner (ACP)-led outpatient follow-up. In all 599 patients attending an ACP-led THA/TKA follow-up clinic had a pelvic/knee radiograph, completed a pain/function questionnaire and were reviewed by an ACP. An experienced orthopaedic surgeon reviewed the same radiographs and questionnaires, without patient contact or knowledge of the ACP's decision. Each pathway classified patients into: urgent review, annual monitoring, routine follow-up or discharge. RESULTS In total, 401 hip and 198 knee patients were included. There was substantial agreement between the ACP and surgeon for both hip (kappa = 0.69, 95% confidence interval (CI) 0.62 to 0.76) and knee (kappa = 0.81, 95% CI 0.74 to 0.88). Positive agreement was very high for discharge and routine follow-up; however the ACP was more likely to select annual monitoring and the surgeon urgent review. DISCUSSION Review of the questionnaire/radiograph together identified all patients in need of increased surveillance, with good agreement for on-going patient management. However, review of the radiograph or questionnaire alone missed some patients with potential problems. A radiograph in conjunction with a questionnaire as a review may represent a cost effective THA/TKA follow-up mechanism. TAKE HOME MESSAGE A questionnaire and radiograph-based remote review may represent a cost-effective total joint arthroplasty follow-up mechanism; thereby reducing the considerable burden that follow-up currently places on the NHS.
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Affiliation(s)
- S R Kingsbury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Chapeltown Road, Leeds LS7 4SA, UK
| | - B Dube
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Chapeltown Road, Leeds LS7 4SA, UK
| | - C M Thomas
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK
| | - P G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Chapeltown Road, Leeds LS7 4SA, UK
| | - M H Stone
- NIHR Leeds Musculoskeletal Biomedical Research Unit, and Leeds Teaching Hospitals NHS Trust, Chapeltown Road, Leeds, LS7 4SA, UK
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