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Beard DJ, Davies LJ, Cook JA, MacLennan G, Price A, Kent S, Hudson J, Carr A, Leal J, Campbell H, Fitzpatrick R, Arden N, Murray D, Campbell MK. Total versus partial knee replacement in patients with medial compartment knee osteoarthritis: the TOPKAT RCT. Health Technol Assess 2021; 24:1-98. [PMID: 32369436 DOI: 10.3310/hta24200] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Late-stage medial compartment knee osteoarthritis can be treated using total knee replacement or partial (unicompartmental) knee replacement. There is high variation in treatment choice and insufficient evidence to guide selection. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of partial knee replacement compared with total knee replacement in patients with medial compartment knee osteoarthritis. The findings are intended to guide surgical decision-making for patients, surgeons and health-care providers. DESIGN This was a randomised, multicentre, pragmatic comparative effectiveness trial that included an expertise component. The target sample size was 500 patients. A web-based randomisation system was used to allocate treatments. SETTING Twenty-seven NHS hospitals (68 surgeons). PARTICIPANTS Patients with medial compartment knee osteoarthritis. INTERVENTIONS The trial compared the overall management strategy of partial knee replacement treatment with total knee replacement treatment. No specified brand or subtype of implant was investigated. MAIN OUTCOME MEASURES The Oxford Knee Score at 5 years was the primary end point. Secondary outcomes included activity scores, global health measures, transition items, patient satisfaction (Lund Score) and complications (including reoperation, revision and composite 'failure' - defined by minimal Oxford Knee Score improvement and/or reoperation). Cost-effectiveness was also assessed. RESULTS A total of 528 patients were randomised (partial knee replacement, n = 264; total knee replacement, n = 264). The follow-up primary outcome response rate at 5 years was 88% and both operations had good outcomes. There was no significant difference between groups in mean Oxford Knee Score at 5 years (difference 1.04, 95% confidence interval -0.42 to 2.50). An area under the curve analysis of the Oxford Knee Score at 5 years showed benefit in favour of partial knee replacement over total knee replacement, but the difference was within the minimal clinically important difference [mean 36.6 (standard deviation 8.3) (n = 233), mean 35.1 (standard deviation 9.1) (n = 231), respectively]. Secondary outcome measures showed consistent patterns of benefit in the direction of partial knee replacement compared with total knee replacement although most differences were small and non-significant. Patient-reported improvement (transition) and reflection (would you have the operation again?) showed statistically significant superiority for partial knee replacement only, but both of these variables could be influenced by the lack of blinding. The frequency of reoperation (including revision) by treatment received was similar for both groups: 22 out of 245 for partial knee replacement and 28 out of 269 for total knee replacement patients. Revision rates at 5 years were 10 out of 245 for partial knee replacement and 8 out of 269 for total knee replacement. There were 28 'failures' of partial knee replacement and 38 'failures' of total knee replacement (as defined by composite outcome). Beyond 1 year, partial knee replacement was cost-effective compared with total knee replacement, being associated with greater health benefits (measured using quality-adjusted life-years) and lower health-care costs, reflecting lower costs of the index surgery and subsequent health-care use. LIMITATIONS It was not possible to blind patients in this study and there was some non-compliance with the allocated treatment interventions. Surgeons providing partial knee replacement were relatively experienced with the procedure. CONCLUSIONS Both total knee replacement and partial knee replacement are effective, offer similar clinical outcomes and have similar reoperation and complication rates. Some patient-reported measures of treatment approval were significantly higher for partial knee replacement than for total knee replacement. Partial knee replacement was more cost-effective (more effective and cost saving) than total knee replacement at 5 years. FUTURE WORK Further (10-year) follow-up is in progress to assess the longer-term stability of these findings. TRIAL REGISTRATION Current Controlled Trials ISRCTN03013488 and ClinicalTrials.gov NCT01352247. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Loretta J Davies
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Jonathan A Cook
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Seamus Kent
- Department of Public Health, University of Oxford, Oxford, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Jose Leal
- Department of Public Health, University of Oxford, Oxford, UK
| | - Helen Campbell
- Department of Public Health, University of Oxford, Oxford, UK
| | - Ray Fitzpatrick
- Department of Public Health, University of Oxford, Oxford, UK
| | - Nigel Arden
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - David Murray
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
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Baker P, Coole C, Drummond A, Khan S, McDaid C, Hewitt C, Kottam L, Ronaldson S, Coleman E, McDonald DA, Nouri F, Narayanasamy M, McNamara I, Fitch J, Thomson L, Richardson G, Rangan A. Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study. Health Technol Assess 2020; 24:1-408. [PMID: 32930659 PMCID: PMC7520717 DOI: 10.3310/hta24450] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients' needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively. OBJECTIVES To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks. DESIGN An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process. SETTING Orthopaedic departments in NHS secondary care. PARTICIPANTS Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers. INTERVENTIONS Occupational advice intervention. MAIN OUTCOME MEASURES Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost. RESULTS A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff. LIMITATIONS Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it. CONCLUSIONS The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention. FUTURE WORK The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained. STUDY REGISTRATION Current Controlled Trials ISRCTN27426982 and PROSPERO CRD42016045235. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 45. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul Baker
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Carol Coole
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Avril Drummond
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sayeed Khan
- Make UK, The Manufacturers' Organisation, London, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Lucksy Kottam
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Sarah Ronaldson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Elizabeth Coleman
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - David A McDonald
- Whole System Patient Flow Programme, Scottish Government, Edinburgh, UK
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Fiona Nouri
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Melanie Narayanasamy
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Iain McNamara
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Judith Fitch
- British Orthopaedic Association Patient Liaison Group, Royal College of Surgeons of England, London, UK
| | - Louise Thomson
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Amar Rangan
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- York Trials Unit, Department of Health Sciences, University of York, York, UK
- Faculty of Medical Sciences, University of Oxford, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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Cook MJ, Sorial AK, Lunt M, Board TN, O'Neill TW. Effect of Timing and Duration of Statin Exposure on Risk of Hip or Knee Revision Arthroplasty: A Population-based Cohort Study. J Rheumatol 2019; 47:441-448. [PMID: 30877207 DOI: 10.3899/jrheum.180574] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To determine whether the timing and duration of statin exposure following total hip/knee arthroplasty (THA/TKA) influence the risk of revision arthroplasty. METHODS Subjects from the Clinical Practice Research Datalink, a large population-based clinical database, who had THA/TKA from 1988 to 2016, were included. Propensity score adjusted Cox regression models were used to determine the association between statin exposure and the risk of revision THA/TKA, (1) at any time, and (2) if first exposed 0-1, 1-5, or > 5 years following THA/TKA. We also investigated the effect of duration of statin exposure (< 1, 1-2, 2-3, 3-4, 4-5, > 5 yrs). RESULTS The study included 151,305 participants. There were 65,032 (43%) exposed to statins during followup and 3500 (2.3%) had revision arthroplasty. In a propensity score adjusted model, exposure to statins was associated with a reduced risk of revision arthroplasty (HR 0.82, 95% CI 0.75-0.90). Participants first exposed within 1 year and between 1 and 5 years following THA/TKA (vs unexposed) had a reduced risk of revision arthroplasty (HR 0.82, 95% CI 0.74-0.91 and HR 0.76, 95% CI 0.65-0.90, respectively). In relation to duration of statin therapy, participants exposed for more than 5 years in total (vs < 1 yr) had a reduced risk of revision (HR 0.74, 95% CI 0.62-0.88). CONCLUSION Statin therapy initiated up to 5 years following THA/TKA may reduce the risk of revision arthroplasty.
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Affiliation(s)
- Michael J Cook
- From the Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester; Institute of Genetic Medicine, Newcastle University; The Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh National Health Service (NHS) Foundation Trust, Wigan; UK National Institute for Health Research (NIHR) Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester; Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK.,M.J. Cook, MSc, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester; A.K. Sorial, MRCS, Institute of Genetic Medicine, Newcastle University; M. Lunt, PhD, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre; T.N. Board, MD, The Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh NHS Foundation Trust; T.W. O'Neill, MD, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, and Department of Rheumatology, Salford Royal NHS Foundation Trust
| | - Antony K Sorial
- From the Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester; Institute of Genetic Medicine, Newcastle University; The Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh National Health Service (NHS) Foundation Trust, Wigan; UK National Institute for Health Research (NIHR) Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester; Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK.,M.J. Cook, MSc, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester; A.K. Sorial, MRCS, Institute of Genetic Medicine, Newcastle University; M. Lunt, PhD, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre; T.N. Board, MD, The Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh NHS Foundation Trust; T.W. O'Neill, MD, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, and Department of Rheumatology, Salford Royal NHS Foundation Trust
| | - Mark Lunt
- From the Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester; Institute of Genetic Medicine, Newcastle University; The Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh National Health Service (NHS) Foundation Trust, Wigan; UK National Institute for Health Research (NIHR) Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester; Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK.,M.J. Cook, MSc, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester; A.K. Sorial, MRCS, Institute of Genetic Medicine, Newcastle University; M. Lunt, PhD, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre; T.N. Board, MD, The Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh NHS Foundation Trust; T.W. O'Neill, MD, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, and Department of Rheumatology, Salford Royal NHS Foundation Trust
| | - Tim N Board
- From the Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester; Institute of Genetic Medicine, Newcastle University; The Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh National Health Service (NHS) Foundation Trust, Wigan; UK National Institute for Health Research (NIHR) Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester; Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK.,M.J. Cook, MSc, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester; A.K. Sorial, MRCS, Institute of Genetic Medicine, Newcastle University; M. Lunt, PhD, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre; T.N. Board, MD, The Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh NHS Foundation Trust; T.W. O'Neill, MD, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, and Department of Rheumatology, Salford Royal NHS Foundation Trust
| | - Terence W O'Neill
- From the Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester; Institute of Genetic Medicine, Newcastle University; The Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh National Health Service (NHS) Foundation Trust, Wigan; UK National Institute for Health Research (NIHR) Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester; Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK. .,M.J. Cook, MSc, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester; A.K. Sorial, MRCS, Institute of Genetic Medicine, Newcastle University; M. Lunt, PhD, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre; T.N. Board, MD, The Centre for Hip Surgery, Wrightington Hospital, Wrightington Wigan and Leigh NHS Foundation Trust; T.W. O'Neill, MD, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, and Department of Rheumatology, Salford Royal NHS Foundation Trust.
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