Decision making for knee replacement: Variation in treatment choice for late stage medial compartment osteoarthritis

BackgroundPatients with medial unicompartmental osteoarthritic disease of the knee requiring arthroplasty can be treated with either Total or Unicompartmental Knee Replacement (TKR or UKR). Currently, the decision to choose one operation over another is not well defined and may depend on the profile of the surgeon consulted. We tested the hypothesis that different surgeons will select different treatment for identical patients requiring knee replacement.MethodFour different surgeons, representing four different levels of expertise, made a forced choice decision of whether they would perform TKR or UKR based on radiographs alone and subsequent additional clinical information including gender and age, in 140 patients. Individual surgeon repeatability was tested by repeat assessment 3 months later.ResultsThe knee surgeon from the UKR design centre would have performed a UKR in up to 88% of the patients. The remaining surgeons would have performed UKR in 29–48% of patients; a variation in decision making of up to 59%. Additional clinical information had little effect on decision making with surgeons maintaining their radiographic based choice in 80 to 87% of cases. The repeatability study showed high within surgeon consistency for treatment choice.ConclusionSurgeons, given identical information, do not concur on treatment for patients with the same pathology. The decision making process appears heavily influenced by radiographic findings but individual surgeons are consistent with their own treatment choice. The study shows that consensus treatment for medial osteoarthritis of the knee remains in question.     

Disparities in the utilization of high-volume hospitals for total hip replacement

ObjectiveHigher hospital surgical volumes have been associated with lower complication rates following total-hip replacement. The objective of this study was to identify the characteristics of patients who undergo total-hip replacement at high-volume hospitals and their differences from those who receive care at low-volume hospitals.MethodsDischarge data from patients undergoing total hip replacement in California from 1995 to 2005 were analyzed. Hospitals were classified into 3 tiers of low, intermediate, or high surgical volume. The relationships between race/ethnicity and income to utilization of low-volume and high-volume hospitals were examined by creating logistic regression models that include patient covariates such as age, gender, and comorbidity.ResultsThis study analyzed 138399 cases of primary total-hip replacements during the study period. Patients of Hispanic ethnicity, or black or Asian race had higher relative risk ratios for being treated at a low-volume center compared to white patients.ConclusionsThere are disparities in the characteristics of patients receiving care at hospitals performing a high volume or low volume of total-hip replacements. Hispanic ethnicity, and black and Asian race were statistically significant predictors of utilization of a low-volume hospital.     

Revision knee replacement surgery in the NHS: A BASK surgical practice guideline

BackgroundRevision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making.AimTo provide guidelines for surgeons and units delivering revision KR services.MethodsA formal consensus process was followed by BASK’s Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data.ResultsThere are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR.This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model.ConclusionsRevision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.     

The use of navigation to achieve soft tissue balance in total knee arthroplasty — A randomised clinical study

BackgroundAchieving soft tissue balance is an operative goal in total knee arthroplasty. This randomised, prospective study compared computer navigation to conventional techniques in achieving soft tissue balance.MethodsForty one consecutive knee arthroplasties were randomised to either a non-navigated or navigated group. In the non-navigated group, balancing was carried out using surgeon judgement. In the navigated group, balancing was carried out using navigation software. In both groups, the navigation software was used as a measuring tool.ResultsBalancing of the mediolateral extension gap was superior in the navigation group (p = 0.001). No significant difference was found between the two groups in balancing the mediolateral flexion gap or in achieving equal flexion and extension gaps.ConclusionsComputer navigation offered little advantage over experienced surgeon judgement in achieving soft tissue balance in knee replacement. However, the method employed in the navigated group did provide a reproducible and objective assessment of flexion and extension gaps and may therefore benefit surgeons in training.Level of evidenceLevel I, RCT.     

Medical treatment decision-making in rural cancer patients: A qualitative systematic review and meta-synthesis

ObjectiveRural cancer patients have unique care needs which may impact upon treatment decision-making. Our aim was to conduct a qualitative systematic review and meta-synthesis to understand their perspectives and experiences of making treatment decisions.MethodsA systematic search of MEDLINE, PsycINFO, CINAHL and RURAL was conducted for qualitative studies in rural cancer patients regarding treatment decision-making. Articles were screened for relevance, and data from the included articles were extracted and analysed using meta-thematic synthesis.ResultsTwelve studies were included, with 4 themes and 9 subthemes identified. Many studies reported patients were not given a choice regarding their treatment. Choice, if given, was influenced by personal factors such as finances, proximity to social supports, convenience, and their personal values. Patients were also influenced by the opinions of others and cultural norms. Finally, it was reported that patients made choices in the context of seeking the best possible medical care and the patient-clinician relationship.ConclusionsIn the rural context, there are universal and unique factors that influence the treatment decisions of cancer patients.Practical implicationsOur findings are an important consideration for clinicians when engaging in shared decision-making, as well as for policymakers, to understand and accommodate the unique rural perspective.     

Does surgical volume affect outcome after primary and revision knee arthroplasty? A systematic review of the literature

BackgroundIn 2009 there were 72,980 primary and 4565 revision knee arthroplasties performed in England and Wales [1]. Given the large number of procedures done annually any factors that may influence outcome and benefit the patient must be considered seriously.ObjectivesTo find out whether a relationship exists between hospital and surgical volume and patient outcomes for primary and revision knee arthroplasty. A systematic review of the literature was performed to evaluate the current evidence using the PRISMA criteria [2].Data sourcesA computerised literature search was performed on the electronic databases PubMed, Medline, Embase and CINAHL between 1973 and 2011.Study eligibility criteriaAll abstracts, in the English language, pertaining to either surgical or hospital volume and outcome after primary and revision knee arthroplasty between 1973 and 2011 were considered. Outcomes of interest included morbidity, mortality, clinical and economic outcomes.ConclusionsBoth the orthopaedic and surgical specialties literature demonstrates a clear and consistent relationship between both surgeon and hospital volume with outcome, higher volume being associated with improved patient outcomes. In view of the literature consideration should be given to whether all orthopaedic operations should be carried out by all surgeons in all hospitals.     

The impact of a preoperative information leaflet on expectation management,satisfaction and patient outcomes in patients undergoing knee arthroscopy

BackgroundThis study examined the effects of a patient information leaflet on outcomes related to patient satisfaction following knee arthroscopy.MethodsCohort study of patients listed for knee arthroscopy under the care of a single surgeon over a nine-month period (May 2017–January 2018) following the introduction of an information leaflet as an adjunct to the consent process. Outcome data was collected postoperatively through telephone follow-up. Outcome measures included feelings of involvement with decision-making, expectations being met, satisfaction, postoperative pain numerical rating scales and the Forgotten Joint Score-12.ResultsFifty-five patients were consented by the operating surgeon, of which 28 (50.9%) received a leaflet and 27 (49.1%) did not. Patients who received the information leaflet felt more involved in and informed about the decision to have an operation than patients who did not (p = 0.016), however there were no differences in any other outcomes between patients who did and did not receive a leaflet (p > 0.05).ConclusionsThe use of an information leaflet as an adjunct to the preoperative consultation is an effective way of helping patients feel more involved in the surgical decision-making process, however this does not influence overall outcome or satisfaction metrics.     

Cultural challenges to engaging patients in shared decision making

ObjectiveEngaging patients in their health care through shared decision-making is a priority embraced by several national and international groups. Missing from these initiatives is an understanding of the challenges involved in engaging patients from diverse backgrounds in shared decision-making. In this commentary, we summarize some of the challenges and pose points for consideration regarding how to move toward more culturally appropriate shared decision-making.DiscussionThe past decade has seen repeated calls for health policies, research projects and interventions that more actively include patients in decision making. Yet research has shown that patients from different racial/ethnic and cultural backgrounds appraise their decision making process less positively than do white, U.S.-born patients who are the current demographic majority.ConclusionWhile preliminary conceptual frameworks have been proposed for considering the role of race/ethnicity and culture in healthcare utilization, we maintain that more foundational and empirical work is necessary. We offer recommendations for how to best involve patients early in treatment and how to maximize decision making in the way most meaningful to patients. Innovative and sustained efforts are needed to educate and train providers to communicate effectively in engaging patients in informed, shared decision-making and to provide culturally competent health care.     

Systematic evidence-based review: outcomes from exome and genome sequencing for pediatric patients with congenital anomalies or intellectual disability

PurposeExome and genome sequencing (ES/GS) are performed frequently in patients with congenital anomalies, developmental delay, or intellectual disability (CA/DD/ID), but the impact of results from ES/GS on clinical management and patient outcomes is not well characterized. A systematic evidence review (SER) can support future evidence-based guideline development for use of ES/GS in this patient population.MethodsWe undertook an SER to identify primary literature from January 2007 to March 2019 describing health, clinical, reproductive, and psychosocial outcomes resulting from ES/GS in patients with CA/DD/ID. A narrative synthesis of results was performed.ResultsWe retrieved 2654 publications for full-text review from 7178 articles. Only 167 articles met our inclusion criteria, and these were primarily case reports or small case series of fewer than 20 patients. The most frequently reported outcomes from ES/GS were changes to clinical management or reproductive decision-making. Two studies reported on the reduction of mortality or morbidity or impact on quality of life following ES/GS.ConclusionThere is evidence that ES/GS for patients with CA/DD/ID informs clinical and reproductive decision-making, which could lead to improved outcomes for patients and their family members. Further research is needed to generate evidence regarding health outcomes to inform robust guidelines regarding ES/GS in the care of patients with CA/DD/ID.     

Patient preferences on general health and colorectal cancer screening decision-making: Results from a national survey

ObjectiveWe examined patient preferences regarding colorectal cancer (CRC) screening decision-making and factors associated with these preferences among screening-eligible US adults.MethodsThrough a national survey of 1595 US adults ages 40–75 (response rate: 31.3%), we measured general medical decision-making and CRC screening decision-making preferences (0–100, 100 = highest desire for involvement) and preferred control level over three CRC screening decisions (whether to screen, what method to use, and when to screen). Analyses focused on respondents aged 45–75 at average CRC risk (N = 1062).ResultsRespondents expressed strong desire for involvement in general medical decision-making and CRC screening decision-making (Mean = 68.1, 64.4). Over half of respondents reported preferring having equal control as their providers over whether to screen, what method to use, and when to screen. Women and people with higher education expressed higher desire for involvement in general medical decision-making. For CRC screening decision-making, variations exist in preferred level of involvement and control by race/ethnicity, educational attainment, insurance status, and recency of routine checkup.ConclusionMost respondents preferred a collaborative process of CRC screening decision-making, while variations existed across subgroups.Practice implicationsProviders should assess patients’ values and preferences and involve them in CRC screening decision-making at a level they are comfortable with.     

Provision of revision knee surgery and calculation of the effect of a network service reconfiguration: An analysis from the National Joint Registry for England,Wales, Northern Ireland and the Isle of Man

BackgroundRevision knee replacement (KR) is technically challenging, expensive, and outcomes can be poor. It is well established that increasing surgeon and unit volumes results in improved outcomes and cost-effectiveness for complex procedures. The aim of this study was to 1) describe the current provision of revision KR in England, Wales and Northern Ireland at the individual surgeon and unit level and 2) investigate the effect on workload of case distribution in a network model.MethodsCurrent practice was mapped using NJR summary statistics containing all revision KR procedures performed over a three-year period (2016–2018). Units were identified as revision centres based on threshold volumes. Units undertaking < 20 revisions per year were classified as Primary Arthroplasty Units (PAUs) in calculations on the effect of workload centralisation.ResultsRevision KR was performed by 1353 surgeons at 232 NHS sites. The majority of surgeons and units were low-volume; > 1000 surgeons performed < 7 and 125 sites performed < 20 procedures per year. Reallocation of work from these 125 PAUs (1235 cases, 21% of total workload) to a network model with even redistribution of cases between centres undertaking revision surgery would result in an additional average annual case increase of 11 per unit per year (range six to 14).ConclusionsRevision KR workload re-allocation would lift all revision centres above a 30 per year threshold and would appear to be a manageable increase in workload for specialist revision KR centres. Case complexity and local referral agreements will significantly affect the real increase in workload; these factors were not incorporated here.     

Building ground for didactics in a patient decision aid for hip osteoarthritis. Exploring patient-related barriers and facilitators towards shared decision-making

ObjectiveThe aim of the present study was to explore patient-related barriers and facilitators towards shared decision-making (SDM) during routine orthopedic outpatient consultations as part of the process of developing a patient decision aid (PDA) for patients with hip osteoarthritis (OA).MethodsConsultations comprising nineteen hip OA patients referred to an orthopedic surgeon for treatment decision-making were observed, audio recorded and transcribed. Iterative thematic analysis proceeded, based on a taxonomy of generic patient-related barriers towards SDM grounded in the Theory of Planned Behavior (TPB).ResultsA targeted taxonomy provided a structured overview of 26 factors influencing hip OA patients’ intention to engage in SDM. Patients’ perceived ability to change the agenda of the visit emerged as seminal factor and was added to the generic taxonomy.ConclusionUsing a TPB-based taxonomy, we were able to identify and structure generic and context specific SDM barriers. Addressing patients’ communication self-efficacy should be included as didactic feature in PDAs.Practice implicationsPDAs for hip OA should be designed for the broad spectrum of decision-making support needs occurring throughout the continuum of the disease. The provided taxonomy may contribute as guidance within implementation strategies that aim to support patients’ intentions to engage in SDM.     

股骨颈骨折人工髋关节假体置换治疗进展

目的：探讨人工髋关节假体置换在股骨颈骨折中的应用现状及其治疗进展。方法：查阅近年相关文献,并对人工髋关节假体置换的常规术式及其手术时间、术中出血、术后并发症、关节功能评分等进行对比分析。结果：常用术式以双极股骨头置换术和全髋置换术为主;全髋置换术较单、双极股骨头置换术平均手术时间长,术中出血多,术后并发症发生率低,关节功能恢复好;对高龄股骨颈骨折的术式选择存在较多争议。结论：人工髋关节假体置换术可以有效地改善股骨颈骨折引起的疼痛及功能障碍,其术式选择应视患者病情、年龄、全身状况等因素综合考虑。     

Investigation and management of prosthetic joint infection in knee replacement: A BASK Surgical Practice Guideline

BackgroundThe burden of knee replacement prosthetic joint infection (KR PJI) is increasing.KR PJI is difficult to treat, outcomes can be poor and it is financially expensive and limited evidence is available to guide treatment decisions.AimTo provide guidelines for surgeons and units treating KR PJI.MethodsGuideline formation by consensus process undertaken by BASK's Revision Knee Working Group, supported by outputs from UK-PJI meetings.ResultsImproved outcomes should be achieved through provision of care by revision centres in a network model. Treatment of KR PJI should only be undertaken at specialist units with the required infrastructure and a regular infection MDT.This document outlines practice guidelines for units providing a KR PJI service and sets out:

• •The necessary infrastructure required to provide a high-quality KR PJI service
• •The MDT composition — who and when
• •The KR PJI care pathway
• •Medical and surgical treatment strategies
• •The indications for referral to tertiary units (Major Revision Centres)
• •Outcome metrics and auditable standards

ConclusionsKR PJI patients treated within the NHS should be provided the best care possible. This report sets out guidance and support for surgeons and units to achieve this.     

Key elements of optimal treatment decision-making for surgeons and older patients with colorectal or pancreatic cancer: A qualitative study

ObjectiveTo identify key elements of optimal treatment decision-making for surgeons and older patients with colorectal (CRC) or pancreatic cancer (PC).MethodsSix focus groups with different participants were performed: three with older CRC/PC patients and relatives, and three with physicians. Supplementary in-depth interviews were conducted in another seven patients. Framework analysis was used to identify key elements in decision-making.Results23 physicians, 22 patients and 14 relatives participated. Three interacting components were revealed: preconditions, content and facilitators of decision-making. To provide optimal information about treatments’ impact on an older patient’s daily life, physicians should obtain an overall picture and take into account patients’ frailty. Depending on patients’ preferences and capacities, dividing decision-making into more sessions will be helpful and simultaneously emphasize patients’ own responsibility. GPs may have a valuable contribution because of their background knowledge and supportive role.ConclusionStakeholders identified several crucial elements in the complex surgical decision-making of older CRC/PC patients. Structured qualitative research may also be of great help in optimizing other treatment directed decision-making processes.Practice implicationsSurgeons should be trained in examining preconditions and useful facilitators in decision-making in older CRC/PC patients to optimize its content and to improve the quality of shared care.     

GP referral of patients with osteoarthritis for consideration of total joint replacement: a longitudinal study

Background

Individuals with hip or knee osteoarthritis (OA) are referred to orthopaedic surgeons if considered by their GP as potential candidates for total joint replacement (TJR). It is not clear which patients end up having this surgery.

Aim

The aim of the study was to investigate symptom variation in individuals with OA newly referred by GPs to an orthopaedic surgeon for consideration for TJR, and to determine the predictors of having this procedure.

Design and setting

A longitudinal study of patients at a regional orthopaedic centre with follow-up at 3, 6, and 12 months by postal questionnaire.

Method

GP referrals of patients with OA to orthopaedic surgeons were consecutively sampled. Of the 431 eligible patients, 257 (59.6%) were recruited. Validated measurement tools were used to measure pain, physical functioning, severity of OA, and health-related quality of life.

Results

Over half the participants were in constant pain, taking pain medication more than once per day. Only 67 of 134 (50%) hip and 40 of 123 (33%) knee patients had a TJR within 12 months. Those who had a replacement had been diagnosed with OAfora shorter time, reported more frequent pain, were more likely to use a walking stick, and had worse pain, stiffness, and physical functioning.

Conclusion

Many individuals considered for TJR ultimately may not have surgery, and more effective strategies of management need to be developed between primary and secondary care to achieve better outcomes and to improve quality of care.     

The effect of preoperative oral antibiotic use on the risk of periprosthetic joint infection after primary knee or hip replacement: a retrospective study with a 1-year follow-up

ObjectivesAntibiotics are used for various reasons before elective joint replacement surgery. The aim of this study was to investigate patients' use of oral antibiotics before joint replacement surgery and how this affects the risk for periprosthetic joint infection (PJI).MethodsPatients having a primary hip or knee replacement in a tertiary care hospital between September 2002 and December 2013 were identified (n = 23 171). Information on oral antibiotic courses purchased 90 days preoperatively and patients' chronic diseases was gathered. Patients with a PJI in a 1-year follow-up period were identified. The association between antibiotic use and PJI was examined using a multivariable logistic regression model and propensity score matching.ResultsOne hundred and fifty-eight (0.68%) cases of PJI were identified. In total, 4106 (18%) joint replacement operations were preceded by at least one course of antibiotics. The incidence of PJI for patients with preoperative use of oral antibiotics was 0.29% (12/4106), whereas for patients without antibiotic use it was 0.77% (146/19 065). A preoperative antibiotic course was associated with a reduced risk for subsequent PJI in the multivariable model (OR 0.40, 95% CI 0.22–0.73). Similar results were found in the propensity score matched material (OR 0.34, 95% CI 0.18–0.65).ConclusionsThe use of oral antibiotics before elective joint replacement surgery is common and has a potential effect on the subsequent risk for PJI. Nevertheless, indiscriminate use of antibiotics before elective joint replacement surgery cannot be recommended, even though treatment of active infections remains an important way to prevent surgical site infections.