Individuals' expectations and challenges following total hip replacement: a qualitative study

Treatment options for patients with pilonidal sinus disease: PITSTOP, a mixed-methods evaluation

Background

There is no consensus on optimal management of pilonidal disease. Surgical practice is varied, and existing literature is mainly single-centre cohort studies of varied disease severity, interventions and outcome assessments.

Objectives

A prospective cohort study to determine: • disease severity and intervention relationship • most valued outcomes and treatment preference by patients • recommendations for policy and future research.

Design

Observational cohort study with nested mixed-methods case study. Discrete choice experiment. Clinician survey. Three-stage Delphi survey for patients and clinicians. Inter-rater reliability of classification system.

Setting

Thirty-one National Health Service trusts.

Participants

Patients aged > 16 years referred for elective surgical treatment of pilonidal disease.

Interventions

Surgery.

Main outcome measures

Pain postoperative days 1 and 7, time to healing and return to normal activities, complications, recurrence. Outcomes compared between major and minor procedures using regression modelling, propensity score-based approaches and augmented inverse probability weighting to account for measured potential confounding features.

Results

Clinician survey: There was significant heterogeneity in surgeon practice preference. Limited training opportunities may impede efforts to improve practice. Cohort study: Over half of patients (60%; N = 667) had a major procedure. For these procedures, pain was greater on day 1 and day 7 (mean difference day 1 pain 1.58 points, 95% confidence interval 1.14 to 2.01 points, n = 536; mean difference day 7 pain 1.53 points, 95% confidence interval 1.12 to 1.95 points, n = 512). There were higher complication rates (adjusted risk difference 17.5%, 95% confidence interval 9.1 to 25.9%, n = 579), lower recurrence (adjusted risk difference -10.1%, 95% confidence interval -18.1 to -2.1%, n = 575), and longer time to healing (>34 days estimated difference) and time to return to normal activities (difference 25.9 days, 95% confidence interval 18.4 to 33.4 days). Mixed-methods analysis: Patient decision-making was influenced by prior experience of disease and anticipated recovery time. The burden involved in wound care and the gap between expected and actual time for recovery were the principal reasons given for decision regret. Discrete choice experiment: The strongest predictors of patient treatment choice were risk of infection/persistence (attribute importance 70%), and shorter recovery time (attribute importance 30%). Patients were willing to trade off these attributes. Those aged over 30 years had a higher risk tolerance (22.35-34.67%) for treatment failure if they could experience rapid recovery. There was no strong evidence that younger patients were willing to accept higher risk of treatment failure in exchange for a faster recovery. Patients were uniform in rejecting excision-and-leave-open because of the protracted nursing care it entailed. Wysocki classification analysis: There was acceptable inter-rater agreement (κ = 0.52, 95% confidence interval 0.42 to 0.61). Consensus exercise: Five research and practice priorities were identified. The top research priority was that a comparative trial should broadly group interventions. The top practice priority was that any interventions should be less disruptive than the disease itself.

Limitations

Incomplete recruitment and follow-up data were an issue, particularly given the multiple interventions. Assumptions were made regarding risk adjustment.

Conclusions and future work

Results suggest the burden of pilonidal surgery is greater than reported previously. This can be mitigated with better selection of intervention according to disease type and patient desired goals. Results indicate a framework for future higher-quality trials that stratify disease and utilise broad groupings of common interventions with development of a patient-centred core outcome set.

Trial registration

This trial is registered as ISRCTN95551898.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/17/02) and is published in full in Health Technology Assessment; Vol. 28, No. 33. See the NIHR Funding and Awards website for further award information.

Parental Caregiver Expectations and Satisfaction Following Hip Reconstruction and Spinal Fusion in Children With Cerebral Palsy

Children with severe (Gross Motor Function Classification System [GMFCS] IV-V) cerebral palsy (CP) exhibit profound physical and developmental impairments and require assistance for all activities of daily living. No curative treatments exist although surgical procedures to correct underlying hip and spine deformities can improve their quality of life. Despite the efficacy of these surgeries, little is known regarding parental caregivers' expectations specific to surgical outcomes and their satisfaction with surgical outcomes. The purpose was to explore parental caregiver expectations and satisfaction with hip and spine surgeries that their children with GMFCS IV-V CP underwent. Variations among preoperative expectations, changes in expectations over time, and the relationship of expectations on caregiver satisfaction were examined. A qualitative descriptive approach with conventional content analysis was utilized. Three preoperative caregiver expectation themes were identified: increasing functionality, increasing comfort, and maintaining health and averting crisis. These themes were still present at 5-year follow-up; however, more caregivers refocused their expectations from improving function to providing palliation. A clear relationship between expectations and caregiver satisfaction, however, was not identified. A deeper understanding surrounding caregiver expectation and satisfaction following surgical procedures is needed.

Hip and Knee Replacement Patients' Experiences With an Orthopaedic Patient Navigator: A Qualitative Study

Hip and knee replacement surgery is common, yet more than 10% of patients who undergo total hip replacement (THR) and total knee replacement (TKR) report postsurgery dissatisfaction. Recommendations for improving patient experience after total joint replacement surgery include increasing support to patients, including having a patient navigator available to patients before and after surgery. This article reports on THR and TKR patients' experiences of using an orthopaedic patient navigator. We employed qualitative description to understand THR and TKR patients' experiences of interacting with an orthopaedic patient navigator in a community teaching hospital. Telephone interviews were conducted with 15 purposefully selected total joint replacement patients (TKR: n = 11; THR: n = 4) who had at least one contact with the navigator. Interview transcripts were analyzed using thematic analysis. Patients described receiving physical support services, emotional support services, informational support services, and care coordination services from the patient navigator. All interactions with the patient navigator were positive. Knowing the patient navigator was available for any future concerns also provided indirect benefits of reassurance, comfort, and security. Patients described these direct and indirect benefits as potentially having long-lasting and resilient positive effects. An orthopaedic patient navigator can have a positive impact on patients' THR and TKR experience and fill gaps in support identified in earlier studies. Addressing patients' complex and varied care needs is well suited to a clinical nurse specialist in the role. Investing in an orthopaedic patient navigator provides reassurance to patients that their needs are a priority and will be addressed in a timely manner.

Patient decision-making and regret in pilonidal sinus surgery: a mixed-methods study

AIM

Little is known about optimal management strategies for pilonidal sinus disease (PSD). We conducted a mixed-methods study to understand why patients make, and sometimes regret, treatment decisions.

METHOD

We conducted longitudinal semi-structured interviews at the time of surgery and 6 months later with 20 patients from 13 UK hospitals. Framework analysis was performed, and themes were mapped to (1) the coping in deliberation framework and (2) an acceptability framework. Results were triangulated with those from structured survey instruments evaluating shared decision-making (SDM, best = 9) at baseline and decision regret (DR, most regret = 100) at 6 months.

RESULTS

Nine of 20 patients were not offered a choice of treatment, but this was not necessarily seen as negative (SDM median 4; range 2-4). Factors that influenced decision-making included previous experience and anticipated recovery time. Median (range) DR was 5 (0-50). Those with the highest DR (scores 40-50) were, paradoxically, also amongst the highest scores on SDM (scores 4). Burden of wound care and the disparity between anticipated and actual recovery time were the main reasons for decision regret.

CONCLUSION

To minimize regret about surgical decisions, people with PSD need better information about the burden of wound care and the risks of recurrence associated with different surgical approaches.

Review and synthesis of the experience of patients following total hip or knee arthroplasty in the era of rapidly decreasing hospital length of stay

AIM

The hospital length of stay for orthopedic surgery has been decreasing during the last couple of decades. Therefore, this study was performed to explore the postoperative experiences of adult/older patients (age ≥20 years) with osteoarthritis who underwent total hip or knee arthroplasty, focusing on the first 6 weeks following discharge.

METHODS

A systematic literature search on qualitative studies was conducted using six databases, such as Medline, CINAHL and Mednar. Verbatim interview data and themes or subthemes related to the patients' experience after discharge were extracted. Content analysis was used to code interview data. Codes similar in meaning were grouped, and subcategories were formed. These subcategories were then grouped into categories.

RESULTS

Sixteen qualitative studies with 253 participants were analyzed. In total, 136 codes were generated and formed 29 subcategories. Six categories were generated: (a) postoperative pain and medication; (b) difficulty in performing activities of daily living; (c) appreciation for support and difficulties associated with receiving support; (d) variability in recovery process and information-seeking; (e) lack of patient-centered care; and (f) transportation problems and social isolation.

CONCLUSION

Our review suggests that prospective patients and their caregivers need individually tailored presurgical education and advanced planning for postsurgical reduced mobility.

Patients' narratives of patient education in physiotherapy after total hip arthroplasty

OBJECTIVE

The aim of this study was to explore patients' narratives of patient education in physiotherapy after a total hip arthroplasty (THA).

METHOD

The data was collected via open thematic interviews from ten patients who had had a primary THA. The interviews were analysed using a qualitative, narrative method.

RESULTS

Three story models of patient education in physiotherapy were identified: Supportive patient education in physiotherapy, Co-operative patient education in physiotherapy and Contradictory patient education in physiotherapy. The emphasis of narration in the first story model was on the trust in the guidance, functioning interaction in the second and insufficient patient education in physiotherapy in the third story model.

DISCUSSION

According to the results of this study, patients with THA experience functioning interaction and trust in the patient education in physiotherapy as enhancing the rehabilitation process. Conversely insufficient patient education about exercising and follow-up physiotherapy made the patients feel insecure and according to them might have slowed down the rehabilitation process. These findings can be utilized in planning and improving patient education in physiotherapy after THA.

Misconceived expectations: Patient reflections on the total knee replacement journey

INTRODUCTION

Fifty per cent of patients consent for total knee replacement (TKR) with unrealistic expectations about what it involves and can achieve. A framework is needed to help surgeons identify key knowledge gaps and misconceptions that can be targeted during the informed consent process. In this qualitative study, we explored knowledge gaps and misconceptions by asking patients to reflect on their expectations along the TKR journey.

METHODS

Eligible adults were ≥18 years, 12-month post-TKR and had completed a validated expectations questionnaire pre-TKR as part of a joint replacement registry. To capture a variety of perspectives, people with a range of pre-TKR expectation scores were invited. In interviews, participants reflected on anticipated and actual experiences and unexpected experiences they had along the way. Transcripts were analysed through inductive thematic analysis. Recruitment ceased when thematic saturation was reached.

ETHICS APPROVAL

Ethical approval for this study was granted by the St Vincent's Hospital Melbourne Ethics Committee (LRR 077/18).

RESULTS

In the final sample (n = 20; 50% female; median age = 72 years; contralateral TKR = 11), all participants described instances where their anticipated and actual experiences diverged, including high expectations of improvements in pain/function (pre-surgical optimism), lacking awareness about anaesthetic procedures (perioperative misunderstandings), feeling unprepared for the length of the recovery period (post-operative misestimations) and trying to make sense of ongoing functional limitations (long-term misattributions).

DISCUSSION AND CONCLUSION

These findings are captured in a preliminary framework of therapeutic misconception. Although future research is needed to test this framework prospectively in larger, more generalisable samples, surgeons can consider these key knowledge gaps and misconceptions when consenting for TKR.

Functional movement compensations persist in individuals with hip osteoarthritis performing the five times sit-to-stand test 1 year after total hip arthroplasty

Background

Methods to quantify and evaluate function are important for development of specific rehabilitation interventions. This study aimed to evaluate functional movement compensation in individuals with hip osteoarthritis performing the five times sit-to-stand test and change following total hip arthroplasty. To this end, trajectories of the body’s center of mass in the medial-lateral and anterior-posterior dimensions were quantified prior to and 1 year after total hip arthroplasty and compared to a healthy control group.

Methods

Twenty-eight individuals with hip osteoarthritis and 21 matched healthy controls were enrolled in this prospective study. Within 1 month prior to and 1 year after total hip arthroplasty, performance on the five times sit-to-stand test was evaluated using three-dimensional motion analysis and perceived pain using a visual analog scale. The center of mass trajectories for the medial-lateral and the anterior-posterior dimensions were identified, and the area under the curve was calculated, respectively. Repeated measures ANOVA were used to evaluate differences in the area under the curve, between pre- and postoperative performance, and between participants with hip osteoarthritis and controls.

Results

Preoperatively, individuals with hip osteoarthritis displayed a larger contralateral shift (p < 0.001) and forward displacement of the center of mass (p = 0.022) compared to controls. After surgery, deviations in both dimensions were reduced (medial-lateral p = 0.013; anterior-posterior p = 0.009). However, as compared to controls, the contralateral shift of the center of mass remained larger (p = 0.010), indicative of persistent asymmetric limb loading. Perceived pain was significantly reduced postoperatively (p < 0.001).

Conclusions

By quantifying the center of mass trajectory during five times sit-to-stand test performance, functional movement compensations could be detected and evaluated over time. Prior to total hip arthroplasty, individuals with hip osteoarthritis presented with an increased contralateral shift and forward displacement of the center of mass, representing a strategy to reduce pain by unloading the affected hip and reducing required hip and knee extension moments. After surgery, individuals with total hip arthroplasty displayed a persistent increased contralateral shift as compared to controls. This finding has implications for rehabilitation, where more focus must be directed towards normalizing loading of the limbs.

Preoperative Expectations Associated With Postoperative Dissatisfaction After Total Knee Arthroplasty: A Cohort Study

INTRODUCTION

Unfulfilled expectations, assessed postoperatively, have been consistently associated with dissatisfaction after total knee arthroplasty (TKA). However, identifying these expectations preoperatively has been a challenge. We aimed at identifying specific expectations that are most likely to affect postoperative dissatisfaction.

METHODS

We included all patients in our institutional registry with a body mass index of <40 kg/m who underwent primary unilateral TKA and had a minimum 2-year follow-up. Preoperatively, patients completed the 19-item Hospital for Special Surgery Expectations Survey, Short Form-12, Knee Injury and Osteoarthritis Outcomes Score and EuroQol 5-D. Two years postoperatively, patients reported their dissatisfaction on five domains. We estimated logistic regression models to identify the expectation items associated with each domain.

RESULTS

A total of 2,279 TKA patients (mean age: 65.3 ± 9.2 years; mean body mass index: 30.2 ± 5.9 kg/m) met our inclusion/exclusion criteria. The association between expectations and dissatisfaction was domain specific, that is, subsets of 4 to 5 items were markedly associated with each dissatisfaction domain, and these expectations differed depending on the dissatisfaction domain examined. Of those, expectations predicting dissatisfaction on multiple domains included kneeling ability and leg straightening and participation in recreation and sports.

DISCUSSION

We identified a subset of expectations most likely to affect dissatisfaction after TKA. Our findings should inform preoperative patient education approaches on those expectations to realistically orient patient expectations and increase satisfaction.

LEVEL OF EVIDENCE

Level II.

Needs of Chinese patients undergoing home-based rehabilitation after hip replacement: A qualitative study

Background

The needs of Chinese patients undergoing home-based rehabilitation after hip replacement surgery remain unclear. In this study, we qualitatively investigated the needs of Chinese patients undergoing home-based rehabilitation after hip replacement surgery.

Methods

A total of 21 participants undergoing home-based rehabilitation after hip replacement surgery were included in this study. Individual semi-structured interviews involving all participants were performed to determine the needs and experiences of this patient population during home-based rehabilitation. Data were subjected to qualitative content analysis.

Results

The patients had numerous needs during rehabilitation. Three substantive themes, namely, the need to obtain health-related knowledge, the need to obtain care and support, and the needs of those who cannot perform self-care, were identified from the qualitative data. The participants shared valuable insights into their needs during home-based rehabilitation after hip replacement and provided potential suggestions.

Conclusions

Patients undergoing home-based rehabilitation after hip replacement have several strong needs and lack proper guidance. The initial and continuous engagement of rehabilitation professionals and the establishment of related policies based on patient’s needs are potential approaches for improving the effectiveness of home-based rehabilitation after hip replacement.

Patient education in physiotherapy in total hip arthroplasty (THA) - The perspective of physiotherapists

BACKGROUND AND PURPOSE

There is limited knowledge about patients' and physiotherapists' perceptions of patient education in physiotherapy in hip arthroplasty. The aim of this study was to describe physiotherapists' conceptions of the patient education in physiotherapy needed by patients undergoing total hip arthroplasty.

METHODS

The data for this qualitative study were collected using group and individual semi-structured interviews. Seven physiotherapists were interviewed. The research data were analyzed using a phenomenographic method.

RESULTS

Three categories of patient education in physiotherapy in hip arthroplasty were produced and the categories formed a hierarchy. The narrowest descriptive category was Schematic physiotherapy complying with the protocol. Identifying individual rehabilitation needs was the second category, and the third, widest category was Coaching home rehabilitation. The differences between the categories were described in four themes: 1) Moving; 2) Exercising; 3) Interaction in relation to patient; and 4) Health care system.

CONCLUSION

According to the results, patient education in physiotherapy optimally aims to identify patients' individual rehabilitation needs, advice on coping at home and especially helping patients to be prepared for and capable of long rehabilitation for which they are themselves responsible. These findings resulting from descriptive categories can be utilized in developing education methods and physiotherapists' competence in patient education.

A "Journey to regain life" after joint replacement surgery: A qualitative descriptive study

BACKGROUND

Prolonged preoperative waiting times from six months to two years for joint replacement surgery are detrimental to patients' quality of life due to increasing physical dysfunction, pain, joint stiffness, worsening mental health, and limited independence in daily life.

AIM

This study explored the perceptions of elderly patients undergoing joint replacement surgery.

METHOD

A qualitative descriptive design guided by the social cognitive theory was used to conduct repeated semi-structured interviews with 14 elderly participants at a local acute tertiary hospital in Singapore.

FINDINGS

Three themes emerged from the data: (1) beginning of pain, (2) finding a solution, and (3) recovering from old body.

CONCLUSIONS

While considering the cultural beliefs of the participants, the study highlighted the elderly participants' journey to regain life by sharing their experiences during the pre-operative, intra-operative and post-operative periods. In each of these phases, the triadic determinants of the social cognitive theory highlighted the importance of the interplay between the environment, person and behaviour.

Expectations and experiences of patients with osteoarthritis undergoing total joint arthroplasty: An integrative review

BACKGROUND

The effectiveness of educational interventions for osteoarthritic patients undergoing total joint arthroplasty remains inconclusive. It is essential to understand the educational needs of these patients from their perspectives.

AIM

The aim of this study was to systematically summarize and synthesize osteoarthritic patients' expectations and experiences in undergoing total joint arthroplasty to identify their educational needs.

DESIGN

An integrative review was conducted.

METHODS

Twenty studies (13 qualitative and 7 quantitative), published between 2006 and 2016, were independently appraised by 2 reviewers using the Critical Appraisal Skills Programme checklist for qualitative studies and the Joanna Briggs Institute Critical Appraisal Tools for quantitative studies. Data were analysed using thematic analysis, and the findings were synthesized in a narrative summary.

RESULTS

Six themes describing patients' preoperative and post-operative educational needs were identified: (1) preoperative anxiety, (2) unrealistic expectations of recovery, (3) post-operative pain, (4) regaining functional abilities, (5) physical and psychological sense of loss, and (6) lack of continuity of care.

CONCLUSION

This review is the first to capture the osteoarthritic patients' educational needs from their perspectives. The biopsychosocial model can address the multidimensionality (biological, psychological, and social) of patients' educational needs. A robust infrastructure supporting interprofessional collaborative practice and continuity of care should be adopted to enhance current educational efforts.

Assessing functional recovery shortly after knee or hip arthroplasty: a comparison of the clinimetric properties of four tools

BACKGROUND

Following hip or knee arthroplasty, it is clinically warranted to get patients functional as quickly as possible. However, valid tools to assess function shortly after knee or hip arthroplasty are lacking. The objective was to compare the clinimetric properties of four instruments to assess function shortly after arthroplasty.

METHODS

One hundred eight patients undergoing hip or knee arthroplasty were assessed preoperatively, 1 and 2 days postoperatively, and 2 and 6 weeks postoperatively with the Timed Up and Go (TUG), Iowa Level of Assistance Scale (ILAS), Postoperative Quality of Recovery Scale (PQRS), and Readiness for Hospital Discharge Scale (RHDS). Descriptive data, floor and ceiling effects, responsiveness, interpretation and construct validity were determined.

RESULTS

Only the ILAS and RHDS support subscale demonstrated floor or ceiling effects. A large deterioration from preoperative to postoperative, followed by large improvements after surgery were seen in the TUG and ILAS scores. The RHDS personal status subscale and the PQRS pain and function dimensions demonstrated large improvements after surgery. Changes in the RHDS global scale and personal status subscale, PQRS pain dimension and TUG were significantly related to patient perceived improvement. Minimal important changes were obtained for the RHDS global (1.1/10) and personal status subscale (2.3/10), and the TUG (43.4 s at 6 weeks). For construct validity, the PQRS function dimension and RHDS were moderately related to the TUG or ILAS. The correlation between TUG and ILAS was high from preoperative to postoperative day 2, but substantially decreased at 2 and 6 weeks.

CONCLUSIONS

The TUG and RHDS personal status subscale demonstrated the best clinimetric properties to assess function in the first 6 weeks after hip or knee arthroplasty.

Postoperative Patient Education in Physiotherapy after Hip Arthroplasty: Patients' Perspective

OBJECTIVE

The objective of the present study was to explore postoperative patient education in physiotherapy from total hip arthroplasty (THA) patients' perspectives, which has been a little-studied area of research. The usefulness of rehabilitation protocols after THA has been debated over the years, and there are no clear guidelines for physiotherapy after THA METHODS: The data for the present qualitative study were collected from nine patients with THA by using individual interviews at the hospital after surgery. The interviews were audio-recorded and analysed by using a phenomenographic method RESULTS: Four different categories of postoperative patient education in physiotherapy after hip arthroplasty were produced: trust while in hospital; preparing for going home; managing at home; and regaining physical fitness. These categories were analysed through the following themes: moving; exercising; and interaction between the patient and the physiotherapist CONCLUSIONS: The postoperative patient education in physiotherapy was constructed hierarchically. According to patients' conceptions, the combination of moving and exercising elements that focused on recovery at home after the operation was essential. This requires a trusting relationship between the patient and the physiotherapist. Two critical aspects can be identified: (i) how the role of moving could shift towards preparing for going home and (ii) widening the perspective from preparing for going home to managing at home. Copyright © 2016 John Wiley & Sons, Ltd.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Trajectories of need: understanding patients' use of support during the journey through knee replacement

PURPOSE

To explore how the process of undergoing and recovering from knee replacement surgery alters patients' experiences and use of their support networks.

METHODS

Ten patients having knee replacement surgery for osteoarthritis were invited to take part in in-depth interviews prior to surgery and 2-4 weeks, 6 and 12 months post-operatively. Transcripts were analyzed using Interpretative Phenomenological Analysis.

RESULTS

Three superordinate themes were identified: (1) relationships with health professionals over the knee replacement journey; (2) implications for informal relationships and support networks and (3) providing support to others.

CONCLUSIONS

Transformation from a person with osteoarthritis to someone recovering from a surgical intervention can lead to alterations in the source, type and level of support people receive from others, and can also change the assistance that they themselves are able to offer. Findings highlight the value of the concept of interdependence to our understanding of participants' experiences. Activity undertaken by informal support networks assists participants to cope with the consequences of osteoarthritis and surgery, and fills in the gap when more formal support is lacking. However, it is essential that provision of care is individually tailored and that formal support is adequate at times when informal support networks are unavailable. Implications for Rehabilitation Activity undertaken by informal support networks can help patients who undergo knee replacement cope with the consequences of their operation; filling the void when support from health professionals is lacking. Contact with health professionals after surgery enhances confidence and offers reassurance; helping to facilitate the recovery process from knee replacement. Findings highlight, from patients' own perspectives, the potential value of post-operative physiotherapy received soon after surgery and the possible role of long-term follow up. Missing or ill-timed support from health professionals can have negative psychosocial consequences for patients going through joint replacement.

Patient-reported factors influencing return to work after joint replacement

BACKGROUND

An increasing number of patients in the working population are undergoing total hip and knee replacement for osteoarthritis and the timing and success of return to work (RTW) is becoming increasingly important as a measure of success for these patients. There is limited understanding of the patient variables that determine the ability to RTW.

AIMS

To explore the factors influencing RTW following hip and knee replacement from the patient's perspective.

METHODS

A cross-sectional population-based postal survey carried out with patients of working age after hip and knee replacement surgery in a UK teaching hospital. Free text comments were collected regarding the experiences of patients returning to work following hip and knee replacement. Qualitative thematic analysis was undertaken to identify the factors influencing RTW from the patient's perspective.

RESULTS

From the patients' perspective three key factors were identified that influenced RTW. Patients reported an improved physical and psychological performance at work after surgery in comparison to pre-operative functioning, although there was a lack of informed advice regarding RTW after surgery. Workplace support and adaptation of the job role enhanced the experience of RTW.

CONCLUSIONS

Return to work is influenced by a combination of patient, clinician and occupational factors. The relationship between each of these needs to be explored in greater depth through further qualitative work to gain a wider understanding of the variables influencing patients' RTW following hip and knee replacement.

Understanding the patient-reported factors determining time taken to return to work after hip and knee arthroplasty

PURPOSE

The key factors underscoring safe and early return to work after hip (THA) or knee (TKA) arthroplasty are poorly defined. The aim of this study was to evaluate the effect of patient-reported variables upon time taken to return to work after THA or TKA in a working population.

METHODS

Questionnaires asking about employment history, education, general health and experiences of returning to work after THA and TKA were administered by post and at outpatients' clinic.

RESULTS

One hundred and two from 272 eligible patients, of whom 52 had undergone THA and 50 TKA, were recruited sequentially. In total, 83 patients were employed pre-operatively and 80 returned to work at median 12 (2-64) weeks. Those in more manual occupations (p = 0.001) without pre-operative sick leave due to their hip or knee arthritis (p = 0.016) and a higher level of qualification (p = 0.041) returned to employment significantly quicker than the rest of the cohort. THA patients report a greater improvement in terms of performance at work (63 vs 44 %, p = 0.007) and job prospects (50 vs 36 %, p = 0.046) as compared with patients after TKA.

CONCLUSIONS

Patients with pre-operative sick leave, basic or no qualifications and more physically demanding occupations take longer to return to work. Operating patients before their arthritis forces them to become unemployed would improve their chances to return to work. Hip arthroplasty patients have a greater perceived benefit in terms of performance at work and job prospect. A more tailored return to work time predictions to allow a faster return to work and avoid frustration.

LEVEL OF EVIDENCE

IV.

Physical activity and experience of total knee replacement in patients one to four years postsurgery in the dominican republic: a qualitative study

OBJECTIVE

Musculoskeletal disorders are the second leading cause of years lived with disability globally. Total knee replacement (TKR) offers patients with advanced arthritis relief from pain and the opportunity to return to physical activity. We investigated the impact of TKR on physical activity for patients in a developing nation.

METHODS

As part of the Operation Walk Boston surgical mission program, we interviewed 18 Dominican patients (78% women) who received TKR about their level of physical activity after surgery. Qualitative interviews were conducted in Spanish, and English transcripts were analyzed using content analysis.

RESULTS

Most patients found that TKR increased their participation in physical activities in several life domains, such as occupational or social pursuits. Some patients limited their own physical activities due to uncertainty about medically appropriate levels of joint use and postoperative physical activity. Many patients noted positive effects of TKR on mood and mental health. For most patients in the study, religion offered a framework for understanding their receipt of and experience with TKR.

CONCLUSION

Our findings underscore the potential of TKR to permit patients in the developing world to return to physical activities. This research also demonstrates the influence of patients' education, culture, and religion on patients' return to physical activity. As the global burden of musculoskeletal disease increases, it is important to characterize the impact of activity limitation on patients' lives in diverse settings and the potential for surgical intervention to ease the burden of chronic arthritis.

A prospective study of the association of patient expectations with changes in health-related quality of life outcomes, following total joint replacement

BACKGROUND

Patient expectations regarding surgery may be related to outcomes in total joint replacement (TJR). The aim of this study was to determine the association of patient expectations with health related quality of life (HRQoL) outcomes measured by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form 12 (SF-12) and satisfaction with current symptoms measured on a 4-point Likert scale, one year after surgery, adjusting for Body Mass Index (BMI), age, gender, joint, education, previous intervention and baseline scores.

METHODS

Consecutive patients preparing for TJR of the knee or hip due to primary osteoarthritis (OA) in 15 hospitals in Spain were recruited for the study. Patients completed questionnaires before surgery and 12 months afterwards: five questions about expectations before surgery; an item to measure satisfaction; two HRQoL instruments-WOMAC and SF-12; as well as questions about sociodemographic information. To determine the association of patient expectations at baseline, with changes in HRQoL 12 months after surgery and with satisfaction, general linear models and logistic regression analysis were performed.

RESULTS

A total of 892 patients took part in the study. Patients who had higher pain relief or ability to walk expectations improved more in HRQoL at 12 months. Moreover, patients with high daily activity expectations were more satisfied.

CONCLUSIONS

Patients with higher baseline expectations for TJR, improved more in HRQoL at one year and had more likelihood to be satisfied than patients with lower expectations, adjusted for BMI, age, gender, joint, education, previous intervention and HRQoL baseline scores.

Factors relating to perioperative experience of older persons undergoing joint replacement surgery: an integrative literature review

PURPOSE

The purpose of this literature review was to examine factors relating to the perioperative experience of older persons undergoing total hip and knee replacement surgery resulting from osteoarthritis.

METHOD

A literature search was undertaken using databases CINAHL, PubMed, Scopus and Web of Science to provide relevant research articles. Articles were included if they examined the factors relating to the HRQOL, QOL and perioperative experience of older persons undergoing joint replacement surgery resulting from osteoarthritis. The use of Joanna Briggs Institute's critical appraisal checklist facilitated a systematic appraisal of studies with regard to the scientific rigor of the studies.

RESULTS

Twenty-two publications were categorized into one main theme: "factors relating to perioperative experience" subcategorized into eight subthemes: "waiting time", "pain and disability", "mental health", "race/ethnicity, age and gender", "body image", "coping and social support", "patient education" and "care continuity".

CONCLUSION

There is a need to conduct further research to examine the perioperative experience of older persons undergoing joint replacement surgery, in particular, the lived perioperative experience of a diverse race, ethnicity and culture in an Asian population. Implications for Rehabilitation Healthcare services should remain focused on reducing waiting time as prolonged waiting time for joint replacement surgery was detrimental to patients' HRQOL. Healthcare professionals need to identify strategies to improve the perioperative pain experience through patient education on pain management and positive social support to support the process of recovery. Patients' expectations of pain and their process of recovery were closely linked to patient education. One model of patient education that was seen to be successful and linked to good post-operative outcomes was care continuity model. Being actively involved in the care continuity results in better post-operative outcomes for the patient and their family.

Predictors of outcomes of recovery following total hip replacement surgery: A prospective study

Objectives

To investigate psychosocial and biomedical outcomes following total hip replacement (THR) and to identify predictors of recovery from THR.

Methods

Patients with osteoarthritis (OA) on the waiting list for primary THR in North West England were assessed pre-operatively and at six and 12 months post-operatively to investigate psychosocial and biomedical outcomes. Psychosocial outcomes were anxiety and depression, social support and health-related quality of life (HRQoL). Biomedical outcomes were pain, physical function and stiffness. The primary outcome was the Short-Form 36 (SF-36) Health Survey Total Physical Function. Potential predictors of outcome were age, sex, body mass index, previous joint replacement, involvement in the decision for THR, any comorbidities, any complications, type of medication, and pre-operative ENRICHD Social Support Instrument score, Hospital Anxiety and Depression scores and Western Ontario and McMaster Universities osteoarthritis index score.

Results

The study included 206 patients undergoing THR. There were 88 men and 118 women with a mean age of 66.3 years (sd 10.4;36 to 89). Pain, stiffness and physical function, severity of OA, HRQoL, anxiety and depression all improved significantly from pre-operative to 12-month assessment (all p < 0.001), with the greatest improvement occurring in the first six months (all p < 0.001). The predictors that were found to influence recovery six months after THR were: pain (p < 0.001), anxiety (p = 0.034), depression (p = 0.001), previous joint replacement (p = 0.006) and anti-inflammatory drugs (p = 0.012).

Conclusions

The study identified the key psychosocial and biomedical predictors of recovery following THR. By identifying these predictors, we are able to identify and provide more support for patients at risk of poor recovery following THR.

Cite this article: Bone Joint Res 2013;2:248–54.

"Let's talk about OA pain": a qualitative analysis of the perceptions of people suffering from OA. Towards the development of a specific pain OA-Related questionnaire, the Osteoarthritis Symptom Inventory Scale (OASIS)

INTRODUCTION

Pain is the primary outcome measurement in osteoarthritis, and its assessment is mostly based on its intensity. The management of this difficult chronic condition could be improved by using pain descriptors to improve analyses of painful sensations. This should help to define subgroups of patients based on pain phenotype, for more adapted treatment. This study draws upon patients' descriptions of their pain, to identify and understand their perception of osteoarthritis pain and to categorize pain dimensions.

METHODS

This qualitative study was conducted with representative types of patients suffering from osteoarthritis. Two focus groups were conducted with a sample of 14 participants, with either recent or chronic OA, at one or multiple sites. Focus groups were semi-structured and used open-ended questions addressing personal experiences to explore the experiences of patients with OA pain and the meanings they attributed to these pains.

RESULTS

TWO MAIN POINTS EMERGED FROM CONTENT ANALYSES: -A major difficulty in getting patients to describe their osteoarthritis pain: perception that nobody wants to hear about it; necessity to preserve one's self and social image; notion of self-imposed stoicism; and perception of osteoarthritis as a complex, changing, illogical disease associated with aging. -Osteoarthritis pains were numerous and differed in intensity, duration, depth, type of occurrence, impact and rhythm, but also in painful sensations and associated symptoms. Based on analyses of the verbatim interviews, seven dimensions of OA pain emerged: pain sensory description, OA-related symptoms, pain variability profile, pain-triggering factors, pain and physical activity, mood and image, general physical symptoms.

SUMMARY

In osteoarthritis, pain analysis should not be restricted to intensity. Our qualitative study identified pain descriptors and defined seven dimensions of osteoarthritis pain. Based on these dimensions, we aim to develop a specific questionnaire on osteoarthritis pain quality for osteoarthritis pain phenotyping: the OsteoArthritis Symptom Inventory Scale (OASIS).

Measuring expectations in orthopaedic surgery: a systematic review

BACKGROUND

Advances in the surgical treatment of musculoskeletal conditions have resulted in an interest in better defining and understanding patients' expectations of these procedures, but the best ways to do this remain a topic of considerable debate.

QUESTIONS/PURPOSES

(1) What validated instruments for the assessment of patient expectations of orthopaedic surgery have been used in published studies to date? (2) How were these expectation measures developed and validated? (3) What unvalidated instruments for the assessment of patient expectations have been used in published studies to date?

METHODS

A systematic literature search was performed using the OVID Medline and EMBASE databases, in duplicate, to identify all studies that assessed patient expectations in orthopaedic surgery. Sixty-six studies were ultimately included in the present review.

RESULTS

Seven validated expectation instruments were identified, all of which use patient-reported questionnaires. Five were specific to a particular procedure or affected anatomic location, whereas two were broadly applicable. Details of reliability and validity testing were available for all but one of these instruments. Forty additional unvalidated expectation assessment tools were identified. Thirteen were based on existing clinical outcome tools, and the others were study-specific, custom-developed tools. Only one of the unvalidated tools was used in more than one study.

CONCLUSIONS

Several validated expectation instruments have been developed for use by patients undergoing orthopaedic surgery. However, many tools have been reported without evidence of testing and validation. The wide range of untested instruments used in single studies substantially limits the interpretation and comparison of data concerning patient expectations.

Functional improvements desired by patients before and in the first year after total hip arthroplasty

BACKGROUND

In the field of rehabilitation, patients are supposed to be experts on their own lives, but the patient's own desires in this respect are often not reported. Our objectives were to describe the patients' desires regarding functional improvements before and after total hip arthroplasty (THA).

METHODS

Sixty-four patients, 34 women and 30 men, with a mean age of 65 years, were asked to describe in free text which physical functions they desired to improve. They were asked before surgery and at three and 12 months after surgery. Each response signified one desired improvement. The responses were coded according to the International Classification of Functioning, Disability and Health (ICF) to the 1st, 2nd and 3rd category levels. The frequency of the codes was calculated as a percentage of the total number of responses of all assessments times and in percentage of each time of assessment.

RESULTS

A total of 333 responses were classified under Part 1 of the ICF, Functioning and Disability, and 88% of the responses fell into the Activities and Participation component. The numbers of responses classified into the Activities and Participation component were decreasing over time (p < 0.001). The categories of Walking (d450), Moving around (d455), and Recreation and leisure (d920) included more than half of the responses at all the assessment times. At three months after surgery, there was a trend that fewer responses were classified into the Recreation and leisure category, while more responses were classified into the category of Dressing (d540).

CONCLUSIONS

The number of functional improvements desired by the patients decreased during the first postoperative year, while the content of the desires before and one year after THA were rather consistent over time and mainly concerned with the ability to walk and participate in recreation and leisure activities. At three months, however, there was a tendency that the patients were more concerned about the immediate problems with putting on socks and shoes.