The final straw: a qualitative study to explore patient decisions to undergo total hip arthroplasty

A synthesis of qualitative research to understand the complexity behind treatment decision-making for osteoarthritis

Objective

Osteoarthritis is the most common joint disease with treatment involving a multidisciplinary approach with pharmacological, physical therapies and surgery as options. Qualitative research can help us to understand the complexity of managing health conditions and this understanding plays a role in good clinical practice. We aimed to systematically search for, identify, and synthesise qualitative research exploring the experience of living with osteoarthritis, including decision making about joint replacement.

Methods

We comprehensively searched 4 bibliographic databases and used the methods of meta-ethnography to synthesise qualitative research findings. We screened 10 ​123 titles, 548 abstracts, and 139 full texts. We included findings from 118 reports (105 unique samples) of at least 2534 adults living with osteoarthritis around the world.

Results

We developed 7 themes: Becoming your own expert can be hard work; Living has become a careful balancing act; Medication is a double-edged sword; I have other things in my life to consider; You have to weigh up the odds of surgery; Surgery is the only effective option; and Surgery will give me a chance to live now. These findings have been drawn into a conceptual model reflecting a complex balancing act with tensions underpinning treatment decision making.

Conclusions

Osteoarthritis is framed as a world where patients become their own expert about their management and healthcare choices. Our conceptual model highlights key tensions underpinning treatment decision-making. These findings provide clinicians with insight of the complex nature of these decisions and how they can help patients through shared decision making.

Quality of knee osteoarthritis care in the Netherlands: a survey on the perspective of people with osteoarthritis

Background

Quality indicators (QIs) are used to monitor quality of care and adherence to osteoarthritis (OA) standards of care. Patient reported QIs can identify the most important gaps in quality of care and the most vulnerable patient groups. The aim of this study was to capture the perspective of people with knee OA (KOA) in the Netherlands on the quality of care received, and explore determinants related to lower achievement rates.

Methods

We sent an online survey to all members of The Dutch Knee Panel (n = 622) of the Sint Maartenskliniek Nijmegen, the Netherlands between September and October 2019. The survey consisted of a slightly adapted version of the “OsteoArthritis Quality Indicator” (OA-QI) questionnaire (18 items; yes, no, N/A); a rating of quality of KOA care on a 10-point scale; a question on whether or not one wanted to see change in the care for KOA; and an open-ended question asking recommendations for improvement of OA care. Furthermore, sociodemographic and disease related characteristics were collected. Pass rates for separate QIs and pass rates on patient level were calculated by dividing the number of times the indicator was achieved by the number of eligible persons for that particular indicator.

Results

A total of 434 participants (70%) completed the survey. The mean (SD) pass rate (those answering “Yes”) for separate QIs was 49% (20%); ranging from 15% for receiving referral for weight reduction to 75% for patient education on how to manage knee OA. The mean (SD) pass rate on patient level was 52% (23%). Presence of OA in other joints, comorbidities, and having a knee replacement were associated with higher pass rates. On average, a score of 6.5 (1.6) was given for the quality of care received, and the majority of respondents (59%) wanted change in the care for KOA. Of 231 recommendations made, most often mentioned were the need for tailoring of care (14%), more education (13%), and more empathy and support from healthcare providers (12%).

Conclusion

This study found patients are only moderately satisfied with the OA care received, and showed substantial gaps between perceived quality of care for OA and internationally accepted standards. Future research should focus on the underlying reasons and provide strategies to bridge these gaps.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08014-1.

A qualitative evidence synthesis using meta-ethnography to understand the experience of living with osteoarthritis pain

ABSTRACT

Osteoarthritis pain affects the lives of a large number of people around the world. Understanding other people's experience is integral to effective care and qualitative research can have an important part to pay in education and good clinical practice. We aimed to systematically search for, identify, and synthesise qualitative research exploring the experience of living with osteoarthritis in order to incorporate this knowledge into an educational resource. We comprehensively searched four bibliographic databases and used the methods of meta-ethnography to synthesise qualitative research findings. We screened 10123 titles, 548 abstracts and 139 full texts. We included findings from 118 reports (105 unique samples) of at least 2534 adults living with osteoarthritis around the world. We developed 7 themes from more than 600 findings: it is part of my life's tapestry; (yet) it is consuming me; it constrains my body and my occupations; I am becoming separated yet dependent; I accept, but I will not let it define me; (yet) this makes me feel less than the person I was. Our findings highlight the profound impact that osteoarthritis can have on people's lives and the struggle to hold onto a sense of self. They indicate that recognising these losses, and taking osteoarthritis seriously, is an integral part of effective healthcare. This finding may be transferable beyond this condition.

Why Do People Undergo THR and What Do They Expect to Gain-A Comparison of the Views of Patients and Health Care Professionals

Little concerted effort has been made to understand why individuals undergo total hip replacement (THR) surgery and their rehabilitation goals. Similarly, insight of views and perspective of health care professionals’ (HCPs) regarding surgery and what objective measures help them with decision-making is lacking. This patient and public involvement report aimed to explore both patients’ and HCPs’ perspectives of THR surgery. Twenty patients, 10 pre-THR, 10 post-THR, 9 physiotherapists, and 6 surgeons took part. Results suggest a consensus among patients and HCPs on pain reduction being the main reason for undergoing THR. The inability to carry out simple daily activities such as dog walking and sleep deprivation had a significant effect on patients’ mental and physical well-being. This article is the first to explore the views of THR patients and HCPs on reasons behind THR surgery amalgamated into a single report. As walking is important, wearable activity monitors are suggested as a possible motivator to enhance patient compliance to self-care rehabilitation and increase quality of life. A future research project on the use of such wearable activity monitors in enhancing mobility post-THR is therefore planned.

Aversion to Total Joint Arthroplasty: Functional Scores Predict Patient Preferences

Many patients who may benefit from total hip arthroplasty and total knee arthroplasty prefer to avoid surgery. Reasons for avoidance may include, but are not limited to, experience or dissatisfaction with prior treatment, living status, and symptom severity. Taking these variables into account, the authors sought to determine whether preoperatively collected functional scores would predict an aversion to total joint arthroplasty. A prospective cross-sectional survey was administered to consecutive patients during a 5-month period at the initial consultation for osteoarthritis of the hip or knee. Patient demographics, Hip disability and Osteoarthritis Outcome Score (HOOS), Knee injury and Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-Item Health Survey (VR-12) score, radiographic findings, and preference for or against surgical treatment for osteoarthritis were collected. Logistic regression was performed to determine factors associated with aversion to total joint arthroplasty, and receiver operating characteristic curves were used to determine an appropriate functional score cutoff associated with aversion to surgery. Twenty-two of 103 total patients (21.4%) were averse to surgery. The proportion of patients who underwent surgery was significantly smaller for those averse compared with those not averse to surgery (4.6% vs 23.5%, P<.05). Baseline characteristics, including age, radiographic scores, satisfaction with prior treatment, work status, education, living status, and VR-12 scores were similar between the groups. Functional scores were significantly higher for averse patients (KOOS, 66.6 vs 50.6, P<.001; HOOS, 73.2 vs 62.2, P<.05). Univariate logistic regression revealed a significant association between functional scores and aversion. Optimal cutoff values for all patients overall were 57.1 and 58.9, with an area under the curve of 0.73 and 0.68, for KOOS and HOOS, respectively. Initial aversion was a strong predictor of the ultimate method of treatment chosen. When controlling for other clinically important baseline characteristics, prospectively collected functional scores may be useful in predicting surgical aversion. [Orthopedics. 2020;43(3):147-153.].

Descriptions of movement experiences in the Body Awareness Rating Scale - Movement Quality and Experience evaluation. A qualitative study of patients diagnosed with hip osteoarthritis

Background: Patients' access to movement experiences is implemented in the evaluation tool Body Awareness Rating Scale - Movement Quality and Experience, with its two intertwined parts: 1) the physiotherapist's observations of movement quality; and 2) the patient's descriptions of immediate movement experiences.Objective: To study movement experiences and reflections described by patients diagnosed with hip osteoarthritis when guided to explore simple daily-life movements in this particular evaluation context.Design: An explorative qualitative study with open-ended questions following each of the 12 movements integrated into the evaluation.Methods: 35 participants diagnosed with hip osteoarthritis were included; 28 women and 7 men, aged 23-78 years. Their descriptions were audiotaped, transcribed verbatim and analyzed in accordance with qualitative content analysis.Results: The patients described experiences of a dynamic adaptation of movement strategies based on sensations from the moving body. Two interrelated categories of movement awareness were identified: 1) Experienced movement challenges, including three sub-categories; a) Lack of contact, b) Movement changed by symptoms, and c) Compensational movement habits, and 2) Movement components promoting well-being, including three sub-categories; a) Integrating balance, breathing and awareness into movement, b) Small, simple, soft and safe movements, and c) A taste of own movement resources for daily life.Conclusions: The Body Awareness Rating Scale - Movement Quality and Experience provides a platform for patients to become aware of and describe their movement habits and resources in own words, intertwined with the physiotherapist movement observations. Derived descriptions reflect a patient perspective to be implemented in therapy.

Gait analysis following release of the short external rotators during an anterior approach for total hip arthroplasty

BACKGROUND

Cadaveric and clinical studies suggest surgical release of the short external rotators is sometimes necessary to improve exposure during total hip arthroplasty (THA) using an anterior approach. The purpose of this study was to determine the impact of those surgical releases on gait following THA.

METHODS

15 patients undergoing THA using an anterior approach, anterior approach with surgical releases, or posterior approach underwent 3-D gait analysis preoperatively, and at 6 and 12 weeks postoperatively. At each time point, temporal parameters, kinematics, and kinetics were compared. The anterior approach was compared to the anterior approach cohort with surgical releases, and the surgical release cohort was compared to a posterior approach cohort. The mean change score between preoperative and 6 weeks, and 6-week to 12-week analyses were analysed.

RESULTS

There were no demographic differences between the groups. There were no significant differences between the groups for the temporal parameters and kinematic analyses at either time point comparison. The surgical release cohort had a lower hip internal rotation moment compared to the anterior approach cohort for the 6- to 12-week comparison ( p = 0.05), and compared to the posterior approach cohort for the preoperative to 6-week ( p = 0.03) and 6- to 12-week comparison ( p = 0.02).

CONCLUSION

Releasing the short external rotators during an anterior approach did not cause significant temporal and kinematic changes after THA. However, small changes in hip internal rotation moments can be expected. These findings should be correlated with patient-reported outcome measures to determine if these gait anomalies predict poor outcome following THA.

Does Surgical Approach Affect Outcomes in Total Hip Arthroplasty Through 90 Days of Follow-Up? A Systematic Review With Meta-Analysis

BACKGROUND

The choice between anterior approach (AA) and posterior approach (PA) in primary total hip arthroplasty (THA) is controversial. Previous reviews have predominantly relied on data from retrospective studies.

METHODS

This systematic review included prospective studies comparing postoperative outcomes through 90 days of AA vs PA in primary THA. Outcomes were pain severity, narcotic usage, hip function using Harris Hip Score, and complications. Random effects meta-analysis was performed for all outcomes. Efficacy data were reported as standardized mean difference (SMD) where values of 0.2, 0.5, 0.8, and 1.0 were defined as small, medium, large, and very large effect sizes, respectively. Complications were reported as the absolute risk difference (RD) where a positive value implied higher risk with AA and a lower value implied lower risk with AA.

RESULTS

A total of 13 prospective comparative studies (7 randomized) with patients treated with AA (n = 524) or PA (n = 520) were included. The AA was associated with lower pain severity (SMD = -0.37, P < .001), lower narcotic usage (SMD = -0.36, P = .002), and improved hip function (SMD = 0.31, P = .002) compared to PA. No differences between surgical approaches were observed for dislocation (RD = 0.2%, P = .87), fracture (RD = 0.2%, P = .87), hematoma (RD = 0%, P = .99), infection (RD = 0.2%, P = .85), thromboembolic event (RD = -0.9%, P = .42), or reoperation (RD = 1.3%, P = .26). Conclusions of this study were unchanged when subjected to sensitivity analyses.

CONCLUSION

In this systematic review and meta-analysis of prospective studies comparing postoperative outcomes through 90 days of AA vs PA in primary THA, patients treated with AA reported less pain, consumed fewer narcotics, and reported better hip function. No statistical differences in complication rates were detected between AA and PA. Ultimately, the choice of surgical approach in primary THA should consider preference and experience of the surgeon as well as preference and anatomy of the patient.

Comparing the anterior, posterior and lateral approach: gait analysis in total hip arthroplasty

BACKGROUND

The choice of surgical approach for total hip arthroplasty (THA) remains a contentious issue with regards to clinical outcome optimization and restoring patient function. The purpose of this study was to determine the impact of surgical approach for THA on quantitative gait analysis.

METHODS

Patients undergoing THA for primary osteoarthritis of the hip were assigned to 1 of 3 surgical approaches: anterior, posterior and lateral. Standardized implants were used at the time of surgery. Three-dimensional gait analysis was performed preoperatively and at 6 and 12 weeks postoperatively. At each time point, we compared temporal parameters, kinematics and kinetics.

RESULTS

We included 30 patients in our analysis (10 anterior, 10 posterior, and 10 lateral). The groups were similar with respect to age (p = 0.27), body mass index (p = 0.16), and Charlson Comorbidity Index score (p = 0.66). Temporal parameters were similar among the groups at all time points. The lateral cohort had higher pelvic tilt during stance on the affected leg than the anterior cohort at 6 weeks (p = 0.041). Affected leg ipsilateral trunk lean during stance was higher in the lateral group than in the other cohorts at 6 weeks (p = 0.008) and 12 weeks (p = 0.040). The anterior and posterior groups showed increased external rotation at 6 weeks (p = 0.003) and 12 weeks (p = 0.012) compared with the lateral group.

CONCLUSION

Temporal gait parameters were similar following THA for all approaches. Differences in gait kinematics and kinetics exist; however, given the small absolute differences, the clinical importance of these changes remains undetermined.

The decision-making threshold and the factors that affect it: A qualitative study of patients' decision-making in knee replacement surgery

BACKGROUND

Osteoarthritis is a significant cause of burden to the ageing population and knee replacement is a common operation for treatment of end-stage disease. We aimed to explore these factors to help understand patients' decision-making, which is critical in informing patient-centred care. These can be used to enhance decision-making and dialogue between clinicians and patients, allowing a more informed choice.

METHODS

The study consisted of two focus groups, in a patient cohort after total knee replacement followed by more in-depth interviews to further test and explore themes from the focus groups, in patients in either the deliberation stage or the decision-making stage.

RESULTS

Using qualitative research methods (iterative thematic analysis) reviewing decision-making and deliberation phases of making informed choices we found nine key themes that emerged from the study groups.

CONCLUSIONS

An awareness of the deliberation phase, the factors that influence it, the stress associated with it, preferred models of care, and the influence of the decision-making threshold will aid useful communication between doctors and patients.

A Prospective Randomized Clinical Trial in Total Hip Arthroplasty-Comparing Early Results Between the Direct Anterior Approach and the Posterior Approach

BACKGROUND

We report a prospective randomized study comparing early clinical results between the direct anterior approach (DAA) and posterior approach (PA) in primary hip arthroplasty.

METHODS

Surgeries were performed by 2 senior hip arthroplasty surgeons. Seventy-two patients with complete data were assessed preoperatively 2, 6, and 12 weeks postoperatively. The primary outcomes were the Western Ontario McMasters Arthritis Index and Oxford Hip Scores. Secondary outcome measures included the EuroQoL, 10-meter walk test, and clinical and radiographic parameters.

RESULTS

Data analyses showed no difference between DAA (n = 35) and PA (n = 37) groups when comparing total scores for primary outcomes. No significant differences were observed for 10-meter walk test, EuroQoL, and radiographic analyses. Subgroup analysis for surgeon 1 identified that the DAA group had shorter acute hospital stay, less postoperative opiate requirements, and smaller wounds. However, this was offset by increased operative time, higher intraoperative blood loss, and weaker hip flexion at 2 and 6 weeks. Subgroup analysis of items on the Western Ontario McMasters Arthritis Index and Oxford Hip Score identified that hip flexion activity favored the DAA group up to 6 weeks postoperatively. There was an 83% incidence of lateral cutaneous nerve of thigh neuropraxia at the 12-week mark in the DAA group. No neuropraxias occurred in the PA group. One dislocation occurred in each group. A single patient from the DAA group required reoperation for leg-length discrepancy.

CONCLUSION

DAA total hip arthroplasty (THA) has comparable results with PA THA. Choice of surgical approach for THA should be based on patient factors, surgeon preference, and experience.

Hierarchical structure and importance of patients' reasons for treatment choices in knee and hip osteoarthritis: a concept mapping study

OBJECTIVES

To improve patients' use of conservative treatment options of hip and knee OA, in-depth understanding of reasons underlying patients' treatment choices is required. The current study adopted a concept mapping method to thematically structure and prioritize reasons for treatment choice in knee and hip OA from a patients' perspective.

METHODS

Multiple reasons for treatment choices were previously identified using in-depth interviews. In consensus meetings, experts derived 51 representative reasons from the interviews. Thirty-six patients individually sorted the 51 reasons in two card-sorting tasks: one based on content similarity, and one based on importance of reasons. The individual sortings of the first card-sorting task provided input for a hierarchical cluster analysis (squared Euclidian distances, Ward's method). The importance of the reasons and clusters were examined using descriptive statistics.

RESULTS

The hierarchical structure of reasons for treatment choices showed a core distinction between two categories of clusters: barriers [subdivided into context (e.g. the healthcare system) and disadvantages] and outcome (subdivided into treatment and personal life). At the lowest level, 15 clusters were identified of which the clusters Physical functioning, Risks and Prosthesis were considered most important when making a treatment decision for hip or knee OA.

CONCLUSION

Patients' treatment choices in knee and hip OA are guided by contextual barriers, disadvantages of the treatment, outcomes of the treatment and consequences for personal life. The structured overview of reasons can be used to support shared decision-making.

Reasons for Treatment Choices in Knee and Hip Osteoarthritis: A Qualitative Study

OBJECTIVE

Conservative treatment modalities in osteoarthritis (OA) of the hip or knee are underused, whereas the demand for surgery is rising substantially. To improve the use of conservative treatment modalities, a more in-depth understanding of the reasons for patients' treatment choices is required. This study identifies the reasons for choice of treatment in patients with hip or knee OA.

METHODS

Semistructured in-depth interviews with 24 OA patients were held. Stratified purposive sampling was used to enrich data variation. Interviews were transcribed verbatim and subsequently coded using a thematic approach. Two independent researchers reflected on, compared, discussed, and adjusted the coding.

RESULTS

Various treatment modalities were discussed by respondents: medication, exercise, physical therapy, injections, surgery, complementary, and alternative treatment. Four key themes underlying the choice for or against a treatment modality for OA were identified: 1) treatment characteristics: expectations about its effectiveness and risks, the degree to which it can be personalized to a patient's needs and wishes, and the accessibility of a treatment; 2) personal investment in terms of money and time; 3) personal circumstances: age, body weight, comorbidities, and previous experience with a treatment; and 4) support and advice from the patient's social environment and health care providers.

CONCLUSION

The 4 identified key themes enhance the insight of health care providers into the widespread reasons influencing patients' treatment choices for knee or hip OA. This knowledge can be used in clinical practice to aid shared decision making, which may lead to optimized treatment choices for both conservative and surgical treatment.

How outcome prediction could affect patient decision making in knee replacements: a qualitative study

Background

There is approximately a 17 % dissatisfaction rate with knee replacements. Calls for tools that can pre-operatively identify patients at risk of being dissatisfied have been widespread. However, it is not known how to present such information to patients, how it would affect their decision making process, and at what part of the pathway such a tool should be used.

Methods

Using focus groups involving 12 participants and in-depth interviews with 10 participants, we examined how individual predictions of outcome could affect patients’ decision making by providing fictitious predictions to patients at different stages of treatment. A thematic analysis was used to analyse the data.

Results

Our results demonstrate several interesting findings. Firstly, patients who have received information from friends and family are unwilling to adjust their expectation of outcome down (i.e. to a worse outcome), but highly willing to adjust it up (to a better outcome). This is an example of the optimism bias, and suggests that the effect on expectation of a poor outcome prediction would be blunted. Secondly, patients generally wanted a “bottom line” outcome, rather than lots of detail. Thirdly, patients who were earlier in their treatment for osteoarthritis were more likely to find the information useful, and it was more likely to affect their decision, than patients later in their treatment pathway.

Conclusion

This research suggest that an outcome prediction tool would have most effect targeted towards people at the start of their treatment pathway, with a “bottom line” prediction of outcome. However, any effect on expectation and decision making of a poor outcome prediction is likely to be blunted by the optimism bias. These findings merit replication in a larger sample size.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1165-x) contains supplementary material, which is available to authorized users.

No differences between direct anterior and lateral approach for primary total hip arthroplasty related to muscle damage or functional outcome

PURPOSE

The aim was to compare the muscle damage and functional outcomes between patients who underwent total hip arthroplasty through a direct anterior (49 patients) or a lateral approach (50 patients).

METHODS

A randomized, controlled, prospective study. The study variables were muscle damage based on post-operative levels of serum markers (citokynes and acute phase reactants) and MRI, and Harris hip score.

RESULTS

Post-operatively, there were significantly higher mean levels in the lateral group related to interleukin 6 and 8, and tumor necrosis factor-alpha up to fourth postoperative day. By MRI at six post-operative months, the fatty atrophy in the gluteus muscles was more in the lateral group, but similar in the other muscles. The mean thickness of the tensor fasciae latae was significantly lower in the anterior group. Functional outcome was similar between groups at three and 12 post-operative months.

CONCLUSIONS

Muscle damage due to the surgical approach had no influence on functional outcome after three post-operative months. Both anterior and lateral approaches for THA are similarly safe and feasible, so the choice depends only on the preference and experience of the surgeon.

Patients' decision making in total knee arthroplasty: a systematic review of qualitative research

Objectives

A patient-centred approach, usually achieved through shared decision making, has the potential to help improve decision making around knee arthroplasty surgery. However, such an approach requires an understanding of the factors involved in patient decision making. This review’s objective is to systematically examine the qualitative literature surrounding patients’ decision making in knee arthroplasty.

Methods

A systematic literature review using Medline and Embase was conducted to identify qualitative studies that examined patients’ decision making around knee arthroplasty. An aggregated account of what is known about patients’ decision making in knee arthroplasties is provided.

Results

Seven studies with 234 participants in interviews or focus groups are included. Ten themes are replicated across studies, namely: expectations of surgery; coping mechanisms; relationship with clinician; fear; pain; function; psychological implications; social network; previous experience of surgery; and conflict in opinions.

Conclusions

This review is helpful in not only directing future research to areas that are not understood, or require confirmation, but also in highlighting areas that future interventions could address. These include those aimed at delivering information, which are likely to affect the satisfaction rate, demand, and use of knee arthroplasties.

Cite this article: Bone Joint Res 2015;4;163–169.

Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes

Total hip arthroplasty (THA) has revolutionized the treatment of hip arthritis. A number of surgical approaches to the hip joint exist, each with unique advantages and disadvantages. The most commonly used approaches include the direct anterior, direct lateral and posterior approaches. A number of technical intricacies allow safe and efficient femoral and acetabular reconstruction when using each approach. Hip dislocation, abductor insufficiency, fracture and nerve injury are complications of THA, although their relative risk varies by approach. Numerous clinical trials have sought to elicit differences in patient-reported outcomes, complication rates and return to function among the surgical approaches. This review outlines some of the technical pearls of performing a THA through either a direct anterior, direct lateral or posterior approach. A literature review outlines the impact of surgical approach on clinical outcomes and clinically relevant complication rates.

Hip Arthroplasty or Medical Management: A Challenging Treatment Decision for Younger Patients

The two main treatment options for total hip arthroplasty (THA), medical management and surgical intervention, have advantages and disadvantages, creating a challenging decision. Treatment decisions are further complicated in a younger population (≤50) as the potential need for revision surgery is probable. We examined the relationship of selected variables to the decision-making process for younger patients with symptomatic OA. Thirty-five participants chose surgical intervention and 36 selected medical management for their current treatment. Pain, activity restrictions, and total WOMAC scores were statistically significant (P < .05) for patients selecting surgical intervention. No difference in quality of life was shown between groups. Pain was the only predictor variable identified, however, activity restrictions were also influential variables as these were highly correlated with pain.

Conceptualising time before surgery: the experience of patients waiting for hip replacement

Interpretations of time underlie patients' experiences of illness and the way in which the National Health Service (NHS) is organised. In the NHS, achieving short waiting times for treatment is seen as important, and this is particularly evident in relation to chronic conditions where the time waiting in care from onset of symptoms to successful management can last months and years. One example of a chronic condition with high prevalence is osteoarthritis, estimated to affect 10% of people aged over 55 years in the UK. Osteoarthritis of the hip is particularly common, and treatments include exercise and medication. If these options do not provide enough relief from pain and functional difficulties, then joint replacement may be considered. With over 70,000 such operations conducted every year in England and Wales, processes relating to waiting times impact on many patients. This article explores how 24 patients with osteoarthritis experience time during the lead up to hip replacement surgery. We draw on data collected during longitudinal in-depth interviews with patients a median of 9.5 days before surgery and at two to four weeks post-operatively. Transcripts of audio-recorded interviews were imported into Atlas.ti^® and inductive thematic analysis undertaken. Increasing pain and deterioration in function altered the experience of time during the journey towards hip replacement. Patients made essential changes to how they filled their days. They experienced lost and wasted time and faced disruption to the temporal order of their lives. A surgical date marked in the calendar became their focus. However, this date was not static, moving because of changing perceptions of duration and real-time alterations by the healthcare system. Findings highlight that patients' experience of time is complex and multi-dimensional and does not reflect the linear, monochronic conceptualisation of time embedded in the healthcare system.

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Waiting for hip replacement disrupts the temporal order of patients' lives.

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Patients' perceptions of time are multi-dimensional and complex.

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Experiences of time differ from health services' monochronic construction of time.

Quality of sexual life after total hip arthroplasty in male patients with osteonecrosis of femoral head

BACKGROUND

Patients with osteonecrosis of the femoral head (ONFH) have a severe impact on their health status, functionality and quality of life. Sexual life is an important component of the quality of life and is still a frequently neglected domain in patients with ONFH. The aims of the study were to evaluate the influence of the disease and the total hip arthroplasty (THA) surgery on quality of sexual life (QSL) in these patients.

METHODS

A prospective, self-controlled study was done. 247 patients of ONFH who underwent unilateral or bilateral THA were asked to complete a standardized QSL questionnaire, and the score of QSL was evaluated preoperatively and at first year follow-up of post-THA operation.

RESULTS

The mean age of the patient was 46.8 (range 25-60) years. 194 cases (78.5%, 276 hips) were alcohol-induced ONFH. There is significant decrease (p = 0.026) in sexual relationship impairment on the 0-8 scale from pre-THA (5.3 ± 0.7) to post-THA (2.3 ± 0.4). There is no significant difference for effect on sexual function (p = 0.14) between pre-THA (2.3 ± 0.4) and post-THA (1.8 ± 0.3). There is significant improvement (p = 0.018) in overall sexual satisfaction degree of patients on the 1-5 scale from pre-THA (2.7 ± 0.2) to post-THA (4.7 ± 0.6), but no significant increase for sexual partner.

CONCLUSION

ONFH has impaired relationships with partner and overall sexual satisfaction degree of the male patients; THA has improved significantly relationships with partner and overall sexual satisfaction degree of the male patients, but no effect on sexual function of the patients and overall sexual satisfaction degree of sexual partner.

Heterogeneity in health status and the influence of patient characteristics across patients seeking musculoskeletal orthopaedic care - a cross-sectional study

Background

Health status is an important predictor of patient outcomes. Consequently, identifying patient predictors of health status is essential. In musculoskeletal orthopaedic care, the majority of work examining the association between patient characteristics and health status has been undertaken among hip/knee cohorts. We investigate these associations comparing findings across four musculoskeletal cohorts (hip/knee; foot/ankle; neck/back; elbow/shoulder).

Methods

Patients seeking elective musculoskeletal orthopaedic care were recruited prior to consultation. Questionnaires captured health domain status (bodily pain, physical functioning, and mental and general health) and covariates: demographics; socioeconomic characteristics; and comorbidity. Scores were compared across cohorts. Two path regression analyses were undertaken. First, domain scores were simultaneously examined as dependent variables in the overall sample. Subsequently, the model was assessed stratified by cohort.

Results

1,948 patients: 454 neck/back, 767 hip/knee, 378 shoulder/elbow, 349 foot/ankle. From stratified analyses, significant variability in covariate effects was observed. Worse bodily pain scores were associated with increasing age and female sex among hip/knee, low income among foot/ankle, and overweight/obese for foot/ankle and hip/knee. Worse mental health scores were associated with low income across cohorts except elbow/shoulder, low education within neck/back, and compared to Whites, Blacks had significantly worse scores among foot/ankle, better scores among hip/knee. Worse general health scores were observed for Asians among hip/knee, Blacks among foot/ankle, and South-Asians among elbow/shoulder and neck/back.

Conclusion

The substantial heterogeneity across musculoskeletal cohorts suggests that patient- and cohort-specific approaches to patient counsel and care may be more effective for achieving optimal health and outcomes.

Intervention focused on the patient and family for better postoperative pain relief

Hip arthroplasty results in high-intensity postoperative pain. To counter this, a multimodal approach (combining pharmacologic and nonpharmacologic strategies) is recommended. The involvement of the patient and family is also suggested, but there are few examples. The purpose of this study was to measure the effects of a patient and family-centered educational intervention (accompanying family member), promoting nonpharmacologic strategies, about pain relief, anxiety, and the pain-coping strategies used. The intervention took the family into consideration by recognizing its expertise, existence, experience, and need for hope. Thirty-three patients took part in this quasiexperimental study, all being accompanied by a significant other (control group [CG]: n = 17; experimental group [EG]: n = 16). The control group received conventional treatment and the experimental group received the intervention. The results show that EG members experienced less intense pain on postoperative days 2 (2.75 vs. 5.14; p = .001) and 4 (2.17 vs. 4.00; p = .01). EG members reported less anxiety (29.50 vs. 37.00; p = .041). EG members used significantly fewer negative pain-coping strategies, such as ignorance and dramatization. The results suggest that a patient and family-centered educational intervention (accompanying family member), promoting nonpharmacologic strategies, should be routinely used in combination with the multimodal approach. This combination improves pain management, lowers anxiety, and facilitates the use of positive postoperative coping strategies.

Determinants of demand for total hip and knee arthroplasty: a systematic literature review

BACKGROUND

Documented age, gender, race and socio-economic disparities in total joint arthroplasty (TJA), suggest that those who need the surgery may not receive it, and present a challenge to explain the causes of unmet need. It is not clear whether doctors limit treatment opportunities to patients, nor is it known the effect that patient beliefs and expectations about the operation, including their paid work status and retirement plans, have on the decision to undergo TJA. Identifying socio-economic and other determinants of demand would inform the design of effective and efficient health policy. This review was conducted to identify the factors that lead patients in need to undergo TJA.

METHODS

An electronic search of the Embase and Medline (Ovid) bibliographic databases conducted in September 2011 identified studies in the English language that reported on factors driving patients in need of hip or knee replacement to undergo surgery. The review included reports of elective surgery rates in eligible patients or, controlling for disease severity, in general subjects, and stated clinical experts' and patients' opinions on suitability for or willingness to undergo TJA. Quantitative and qualitative studies were reviewed, but quantitative studies involving fewer than 20 subjects were excluded. The quality of individual studies was assessed on the basis of study design (i.e., prospective versus retrospective), reporting of attrition, adjustment for and report of confounding effects, and reported measures of need (self-reported versus doctor-assessed). Reported estimates of effect on the probability of surgery from analyses adjusting for confounders were summarised in narrative form and synthesised in odds ratio (OR) forest plots for individual determinants.

RESULTS

The review included 26 quantitative studies-23 on individuals' decisions or views on having the operation and three about health professionals' opinions-and 10 qualitative studies. Ethnic and racial disparities in TJA use are associated with socio-economic access factors and expectations about the process and outcomes of surgery. In the United States, health insurance coverage affects demand, including that from the Medicare population, for whom having supplemental Medicaid coverage increases the likelihood of undergoing TJA. Patients with post-secondary education are more likely to demand hip or knee surgery than those without it (range of OR 0.87-2.38). Women are as willing to undergo surgery as men, but they are less likely to be offered surgery by specialists than men with the same need. There is considerable variation in patient demand with age, with distinct patterns for hip and knee. Paid employment appears to increase the chances of undergoing surgery, but no study was found that investigated the relationship between retirement plans and demand for TJA. There is evidence of substantial geographical variation in access to joint replacement within the territory covered by a public national health system, which is unlikely to be explained by differences in preference or unmeasured need alone. The literature tends to focus on associations, rather than testing of causal relationships, and is insufficient to assess the relative importance of determinants.

CONCLUSIONS

Patients' use of hip and knee replacement is a function of their socio-economic circumstances, which reinforce disparities by gender and race originating in the doctor-patient interaction. Willingness to undergo surgery declines steeply after the age of retirement, at the time some eligible patients may lower their expectations of health status achievement. There is some evidence that paid employment independently increases the likelihood of operation. The relative contribution of variations in surgical decision making to differential access across regions within countries deserves further research that controls for clinical need and patient lifestyle preferences, including retirement decisions. Evidence on this question will become increasingly relevant for service planning and policy design in societies with ageing populations.

Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: a qualitative study

BACKGROUND

Musculoskeletal disorders affect all racial and ethnic groups, including Hispanics. Because these disorders are not life-threatening, decision-making is generally preference-based. Little is known about whether Hispanics in the U.S. differ from non-Hispanic Whites with respect to key decision making preferences.

METHODS

We assembled six focus groups of Hispanic and non-Hispanic White patients with chronic back or knee pain at an urban medical center to discuss management of their conditions and the roles they preferred in medical decision-making. Hispanic groups were further stratified by socioeconomic status, using neighborhood characteristics as proxy measures. Discussions were led by a moderator, taped, transcribed and analyzed using a grounded theory approach.

RESULTS

The analysis revealed ethnic differences in several areas pertinent to medical decision-making. Specifically, Hispanic participants were more likely to permit their physician to take the predominant role in making health decisions. Also, Hispanics of lower socioeconomic status generally preferred to use non-internet sources of health information to make medical decisions and to rely on advice obtained by word of mouth. Hispanics emphasized the role of faith and religion in coping with musculoskeletal disability. The analysis also revealed broad areas of concordance across ethnic strata including the primary role that pain and achieving pain relief play in patients' experiences and decisions.

CONCLUSIONS

These findings suggest differences between Hispanics and non-Hispanic Whites in preferred information sources and decision-making roles. These findings are hypothesis-generating. If confirmed in further research, they may inform the development of interventions to enhance preference-based decision-making among Hispanics.

Minimally invasive total hip arthroplasty: a randomized controlled prospective trial

INTRODUCTION

Advantages of minimally invasive total hip arthroplasty (THA) are controversially discussed.

METHOD

In this prospective study 51 patients (52 hips) were randomly allocated to a classical lateral or a minimally invasive approach (modification of the Hardinge-approach). Operating time, intraoperative blood loss, postoperative hemoglobin, muscle enzymes CK and myoglobin were recorded. Radiologically the positioning of the prosthesis was analyzed. WOMAC- and Harris Hip Score (HHS) were assessed preoperatively, at discharge, at 6 weeks and 3 months.

RESULTS

In the minimally invasive group there was a shorter length of surgery, the scores in the WOMAC and HHS were slightly better at discharge and at the 3 months- examination, myoglobin-rise was slightly less. The positioning of the prosthesis was good in both groups. Minimally invasive THA led to a quicker recovery, at 3 months postoperative there was still a slight difference to the standard group.

CONCLUSION

If these slight differences subside has to be examined in studies with a longer follow-up.