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Daw R, Armstrong C. The role of the advanced clinical practitioner in arthroplasty care. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:362-366. [PMID: 37083377 DOI: 10.12968/bjon.2023.32.8.362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Demand for joint arthroplasty surgery in the UK has increased significantly over the past 10 years. Advanced clinical practitioner (ACP) roles in arthroplasty care, typically fulfilled by expert nurses or physiotherapists, have been developed to alleviate service pressures and facilitate care for the growing number of patients undergoing arthroplasty surgery. There are numerous different models of ACP-led services both in the UK and internationally, driven by local service and population needs. ACPs in arthroplasty care will be involved throughout the patient journey, including pre-operative assessment, peri-operative care and long-term surveillance. ACPs in arthroplasty care will develop expertise across all four pillars of advanced clinical practice and have the potential to influence and contribute to the development of guidance and policy for the future of arthroplasty care delivery, ensuring best quality, evidence-based practice is achieved.
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Affiliation(s)
- Rachael Daw
- Senior Educationalist, Royal College of Physicians, London
| | - Catherine Armstrong
- Advanced Physiotherapy Practitioner in Orthopaedics, Liverpool University Hospitals Foundation Trust, Liverpool
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Kingsbury SR, Smith LKK, Pinedo-Villanueva R, Judge A, West R, Wright JM, Stone MH, Conaghan PG. Mid- to late-term follow-up of primary hip and knee arthroplasty: the UK SAFE evidence-based recommendations. Bone Jt Open 2023; 4:72-78. [PMID: 37051733 PMCID: PMC9999142 DOI: 10.1302/2633-1462.42.bjo-2022-0149.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
To review the evidence and reach consensus on recommendations for follow-up after total hip and knee arthroplasty. A programme of work was conducted, including: a systematic review of the clinical and cost-effectiveness literature; analysis of routine national datasets to identify pre-, peri-, and postoperative predictors of mid-to-late term revision; prospective data analyses from 560 patients to understand how patients present for revision surgery; qualitative interviews with NHS managers and orthopaedic surgeons; and health economic modelling. Finally, a consensus meeting considered all the work and agreed the final recommendations and research areas. The UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE) recommendations apply to post-primary hip and knee arthroplasty follow-up. The ten-year time point is based on a lack of robust evidence beyond ten years. The term 'complex cases' refers to individual patient and surgical factors that may increase the risk for arthroplasty failure. For Orthopaedic Data Evaluation Panel (ODEP) 10A* minimum implants, it is safe to disinvest in routine follow-up from one to ten years post-non-complex hip and knee arthroplasty provided there is rapid access to orthopaedic review. For ODEP 10A* minimum implants in complex cases, or non-ODEP 10A* minimum implants, periodic follow-up post-hip and knee arthroplasty may be required from one to ten years. At ten years post-hip and knee arthroplasty, clinical and radiological evaluation is recommended. After ten years post-hip and knee arthroplasty, frequency of further follow-up should be based on the ten-year assessment; ongoing rapid access to orthopaedic review is still required. Complex cases, implants not meeting the ODEP 10A* criteria, and follow-up after revision surgery are not covered by this recommendation.
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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. K. Smith
- UK Faculty of Health & Applied Sciences, University of the West of England, Bristol, UK
| | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
- Tommy’s National Centre for Maternity Improvement, London, UK
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Judy M. Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Martin H. Stone
- NIHR Leeds Biomedical Research Centre, Leeds, UK
- 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
- Leeds Teaching Hospitals NHS Trust, 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 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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Lewis PM, Khan FJ, Feathers JR, Lewis MH, Morris KH, Waddell JP. Uncemented total hip arthroplasty can be used safely in the elderly population. Bone Jt Open 2021; 2:293-300. [PMID: 33940937 PMCID: PMC8168545 DOI: 10.1302/2633-1462.25.bjo-2021-0006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Aims “Get It Right First Time” (GIRFT) and NHS England’s Best Practice Tariff (BPT) have published directives advising that patients over the ages of 65 (GIRFT) and 69 years (BPT) receiving total hip arthroplasty (THA) should receive cemented implants and have brought in financial penalties if this policy is not observed. Despite this, worldwide, uncemented component use has increased, a situation described as a ‘paradox’. GIRFT and BPT do, however, acknowledge more data are required to support this edict with current policies based on the National Joint Registry survivorship and implant costs. Methods This study compares THA outcomes for over 1,000 uncemented Corail/Pinnacle constructs used in all age groups/patient frailty, under one surgeon, with identical pre- and postoperative pathways over a nine-year period with mean follow-up of five years and two months (range: nine months to nine years and nine months). Implant information, survivorship, and regular postoperative Oxford Hip Scores (OHS) were collected and two comparisons undertaken: a comparison of those aged over 65 years with those 65 and under and a second comparison of those aged 70 years and over with those aged under 70. Results Overall revision rate was 1.3% (13/1,004). A greater number of revisions were undertaken in those aged over 65 years, but numbers were small and did not reach significance. The majority of revisions were implant-independent. Single component analysis revealed a 99.9% and 99.6% survival for the uncemented cup and femoral component, respectively. Mean patient-reported outcome measures (PROMs) improvement for all ages outperformed the national PROMs and a significantly greater proportion of those aged over 65/69 years reached and maintained a meaningful improvement in their OHS earlier than their younger counterparts (p < 0.05/0.01 respectively). Conclusion This study confirms that this uncemented THA system can be used safely and effectively in patient groups aged over 65 years and those over 69 years, with low complication and revision rates. Cite this article: Bone Jt Open 2021;2(5):293–300.
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Affiliation(s)
- Peter M Lewis
- Prince Charles and Royal Glamorgan Hospitals, Cwm Taf Morgannwg University Health Board, South Wales, UK
| | - Faiz J Khan
- Prince Charles and Royal Glamorgan Hospitals, Cwm Taf Morgannwg University Health Board, South Wales, UK
| | | | - Michael H Lewis
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Keith H Morris
- Biomedical Sciences Department, Cardiff Metropolitan University, Cardiff, UK
| | - James P Waddell
- Division of Orthopaedics, St Michael's Hospital, Toronto, Canada
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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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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] [Grants] [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.
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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
| | - AD Beswick
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
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