Post on 29-May-2017
Adult Hip Pain &
Enhanced Recovery Programme
Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCS
Consultant Orthopaedic SurgeonHonorary Senior Clinical Lecturer, University of Sussex
www.benedictrogers.com
• BOA/RCSEng guide for adult hip pain
• Enhancing recovery after hip replacement– Non-surgical– Surgical
Adult Hip Pain
1. High value care pathway
2. Guide of commissioning
History
• Pain: – Groin, medial thigh, Greater Trochanter
• Radiating to knee/thigh
• Impact on ADL & Sports
NB Isolated GT pain – settles in 71%
Examination
• Hip Tenderness
• “Irritability”
Examination
• Gait• Palpation • Leg length• N/V status
– ?spine exam
Examination
• Thomas Test (time permitting!)
• ROM– Hip extended– Hip Flexed
Investigation
• AP Pelvis only• No other imaging needed before
referral
Emergency Hip ReferralHip pain & Systemic symptoms
Infection signsPrimary malignancy
Severe muscle spasmHistory of fall
Sudden inability to WB
Immediate Hip Referral
• Severe pain• Unresponsive to analgesia• Persistent loss of function
– Ie affecting employment
• <40yrs persistent pain– 12 weeks non-surgical treatment
• All adults– Irritable & stiff hip– Sleep, ADLs
Intermediate/Secondary Referral
• Independent of XR findings, age, smoking, obesity etc
• Before Prolonged functional limitation/pain
• Co-morbidities (local/systemic) optimised
Intermediate/Secondary Referral
Any Questions?
Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCSConsultant Orthopaedic Surgeon
Honorary Senior Clinical Lecturer, University of Sussex
www.benedictrogers.com
Enhanced Recovery Programme
Non-surgical vs Interventions
Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCSConsultant Orthopaedic Surgeon
Honorary Senior Clinical Lecturer, University of Sussex
www.benedictrogers.com
Non-surgical• Patient education
– Ideas– Concerns– Expectations
– Patient vs Surgeon !
• Peri-operative Hb– Iron - pre-op– Intraop
• Tranexamic Acid• Hypotension• Spinal
Non-surgicalPre-operative Nutrition
48hr calorie loading
Poor predictorsLow albumin & transferrinObesity (BMI>40)Triceps fold
Prolonged surgery/stay/bleeding/transfusion
• Pre-emptive Analgesia
• Local infiltration analgesia– NSAID– LA– Adrenaline
• ASA grade• Hip ‘precautions’• Dressings• Peri-operative
rehabilitation• Team approach• Same day
mobilization• All patient groups
Non-surgical
Surgical• Muscle splitting not muscle cutting
• Minimal Invasive Surgery (MIS)– No clear difference in outcomes– ‘Patient’ size – Risks
• Component position• Nerve injury
Thank you
Any Questions?
Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCS
Consultant Orthopaedic SurgeonHonorary Senior Clinical Lecturer, University of Sussex
www.benedictrogers.com
Further Info•Hip Society Guide
•BSUH Education & Research
•THR OutcomesActivitySatisfaction
Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCSConsultant Orthopaedic SurgeonHonorary Senior Clinical Lecturer
www.benedictrogers.com
BOA British Hip Society,
RCSEng
• High Value Care Pathway• Guide of commissioning
History
• Pain: Groin, medial thigh, GT• Radiating to knee/thigh• Impact on ADL & Sports• Isolated GT pain – settles in 71%
Examination
• Hip Tenderness• Irritability
Investigation
• AP Pelvis only• No other imaging needed before referral
Emergency Hip Referral
• Hip pain & Systemic symptoms• Infection signs• Primary malignancy• Severe muscle spasm• History of fall• Sudden inability to WB
Immediate Hip Referral
• Severe pain• Unresponsive to analgesia• Persistent loss of function
– Affecting employment
Intermediate/SecondaryReferral
• <40yrs persistent pain• All adults
– Irritable & stiff hip– Sleep, ADLs
• Independent of XR findings, age, smoking, obesity etc
• Before Prolonged functional limitation/pain• comorbidities
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Trauma & Orthopaedics
Education & Research
March 2014
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Benedict RogersConsultant Orthopaedic SurgeonHonorary Senior Clinical LecturerLead For Research & Education
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EDUCATION
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• Friday am RSCH teaching (SpR & SHO)– Survey – www.brightonorthoedcuation.com
• Bimonthly Journal Club (DMR & BR)– Published 8 letters / 4 reports
• PRH teaching (incl GP trainees)• Industry sessions (Stryker, S&N)
EDUCATION
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2014 AND
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For future….. – Better coordination all teaching ‘episodes’ & feedback– SHO & GPVTS trainees– Cross-site (IT support/teleconference facilities)
Get SMART board working!– Session(s) by Tom Roper (Clin Librarian)– Requests…..
More cases by trainees (please encourage!)Update website – any new reviews etc
EDUCATION
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Medical Students• Lecture programme (PRH)
– Lectures online (student Central & brightorthoeducation)
• Ward teaching (PRH, SOTC, RSCH)• Weekly teaching sessions by SpRs (AEB,
seminar room)• Theatre attendance• Participation in Friday am teaching
EDUCATION
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To develop ….Selected Student Component (SSC)
(GMC Tomorrow’s Doctors 2009)
BSMS Module 307Jan - April 2015 (proposal deadline Aug)Max 12 students, assessment (10 min ppt)Funding - £500 (‘dry’ projects) per SSC
Cadaveric TeachingSpR and/or ConsIndustry collaboration
EDUCATION
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• Arthroplasty Course• Brighton Trauma Conference
– Oversubscribed– ? Posters for trainees
• Orthopaedic MSc – teaching, examining, supervision of theses
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Future…• ? KSS Fracture neck of femur or FRCS viva course• More publishable topics for MSc theses
– BSUH Med Stats & Clin Librarian • More Academic Fellows
– BOA transitional fellowships?– RCS affiliated fellowships
• Surgical Simulation (SB & BR)– Joint BSUH/BSMS surgical application
• BSMS Honorary Lecturer applications for SpR– BSMS T&O profile
EDUCATION
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RESEARCH
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RESEARCH
• Trauma Outcomes/PROMS– Prospective study– Systematic review
• Trauma admissions (with SGH)– Vs ITU trauma admissions– Vs HEMS caseload
• Ankle fracture audit
• Trauma-related amputations
• IVDU caseload/cost
• High ISS caseload
• Open fractures– BOAST 4 audit– Upper limb 3C injuries
• Blood transfusion in MTCs– TARN/BTS
Currently Ongoing……
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RESEARCH
• Systematic reviews– Aspirin for VTE in
THR/TKR– Polytrauma Outcomes– Dignity outcomes
• Editorial articles– Open Fracture Mm– External Fixation
review– Developing a research
portfolio– Dignity in surgery
And more….
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RESEARCH
• Complete/present/publish ongoing work!
• Provide a timetable of projects
• KSS/BSMS wide collaboration– Multi-centre studies
(as NIHR pilot?)– Basic science
• On going sequence of systematic reviews– IRP projects
• Ongoing BSUH specific databases– Open fractures– Trauma amputations– ?others
Future…
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NIHR - current– SWIFFT (LT)– WOLLF (BR)– FixDT (BR & IM)– OVIVA (micro- & IM)– Clavicle (CH)– Dinosaur (AS)
NIHR –upcoming studies– Hip Fracture protocol– Trauma Outcomes– VTE trauma
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RESEARCH
Jan 2014Recruitment
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RESEARCH
“Congratulations to Carrie Ridley at Royal Sussex County who has recruited 2 patients in the first month open. “
Opened Feb 2014
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Funding– TARN (for Polytrauma PROMS)– CLRN (Comprehensive Local Research Network)
• Ongoing Portfolio studies
– NIHR (new proposal)• RfPB (Research for Patient Benefit)• Health Services and Delivery Research
(HS&DR) Programme (deadline 15 May 2014)– Local Funding
• Local (R&D fund, SPRINT etc)
RESEARCH
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RESEARCH
• More personnel GCP trained
• Recruit to all suitable T&O portfolio studies
• Develop team of T&O research nurses, currently– Carrie West– Laura Behar
• Grant proposals• Lead centre for
portfolio study– NIHR Research
Design Service• Biostatistician• Health Economist• User involvement
Future…
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BSMS– 4th IRP (individual research project)– 2014 - x2 ongoing (trauma)– 2015 – x2 proposals submitted– Remittance - £700 per student– Potential for numerous more in future
RESEARCH
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Dept of Mechanics (Uni S)FEA modelling (lower limb) – Dr Chang Wang
Brighton MSK Research Cluster (BMRC)• Lead Dr Sandra Sacre (Cell biologist)• BR on committee• Cell biology
RESEARCH
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• T&O Ortho Research Collaborative– Trainee led, BR advising
• Support multi-centre studies• Publication footprint• Develop NIHR grant proposals
• Honorary Academic Lead HE KSS(BR applied)
RESEARCH
Future…
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• Academic Orthopaedic Unit• Develop support from BSUH R&D• Better links
– BSMS, HE KSS, NIHR, KSS Air Ambulance• Academic fellows• Better position for formal academic unit
2014 AND BEYOND
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• Academic Department of Surgery– Funding sources– 0-5 yrs Europe (Horizon 2020 - €20 bn!)– 5-10 yrs Europe/Industry– 10-15 yrs BSMS via central funding (?)
2014 AND BEYOND
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QUESTIONS?
RESEARCH2014 AN
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An Analysis of patient-reported outcomes for joint replacement
BA Rogers, AD Carrothers, HJ Kreder, R Jenkinson& Safe T Study Group
Can the WOMAC score be used to predict patient satisfaction following hip replacement?
INTRODUCTIONGreater attention on PROMS in orthopaedic surgery
Ie Oxford ScoresWestern Ontario and McMaster Universities
(WOMAC)
Now used forSelection of patients suitable for surgeryOutcome of surgeryQuality of surgeon
WOMAC & Oxford scoresintroduced for clinical trialsnot specifically for PROMS
INTRODUCTION
Is the same true for WOMAC score?.....
AIM
To what degree can pre-operative WOMAC can be used to predict
satisfaction following joint replacement?
METHODS•SAFET study – commenced 2007 (ongoing)
•‘Safe Activities Following Elective THA’•Study design and power calculation
•2 high volume arthroplasty academic centers•Sunnybrook Health Sciences Centre•London Health Sciences Centre
•N=460, prospective consecutive series•primary diagnosis osteoarthritis•≤ 80 years of age and consent capacity
•primary THA •Standardized post-op rehabilitation protocol•Independent Data Collection
•Pre-operative & one year post THA
METHODS
Scatter-plotRank Spearman
does correlation exist?
A receiver operating characteristic (ROC) curve analysis
identify if there is a cut-off point forpre-operative WOMAC delta WOMAC
...that predicts post-op patient satisfaction?
PRE-OP DEMOGRAPHICS RESULTS
•Study N=460
•Mean age surgery 62.7 years (range: 25-80)
•Mean BMI 29.5
SURGICAL DATA
WOMAC Satisfaction
Pre-Op
Mean 51 (2 – 94) 21 (6-25)
SD 17 3
Post-Op
Mean 13 (0 – 72) 22 (5 – 25)
SD 15 4
Delta
Mean 38 (2 – 22) 1 (0 – 1)
SD 3 1
RESULTS
RESULTS
RESULTS
Area Under Curve = 0.53
RESULTS
DISCUSSIONScatter plots
No correlation
ROC analysis
Pre-op WOMACDelta WOMAC
near straight line ROC curves
No cut-off in WOMAC score predicts satisfaction
RESULTS
Area Under Curve = 0.67
One year WOMAC ROC analysisArea under curve – 0.67which represented
sensitivity of 63.9% specificity of 65.9%.
Better than pre-op WOMAC – but not significant cutoffpoor sensitivity & specificity
DISCUSSION
To what degree can pre-operative WOMAC can be used to predict
satisfaction following joint replacement?
NONE
In additionChange in WOMACPost – Op WOMAC (!)
…….No correlation with patient satisfaction after THR
DISCUSSION
Questions
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Patient Activity Levels Pre and One-Year Post Total
Hip Arthroplasty
BA Rogers, AD Carrothers, HJ Kreder, R Jenkinson& Safe T Study Group
INTRODUCTION
•Anecdotal evidence suggests patients aspire to higher activity levels post THA 11,13
•Patients THA expectations have been shown to outweigh surgeons
•‘Direct to Consumer’ advertisements using athletes
AIM
Compare patient’s number and
amount of activities at a pre-
operative baseline and one-year post
THA
METHODS – Data Collected 1
• Activity data - MLTPAQ27
– Minnesota Leisure Time Physical Activity Questionnaire
– 50 activity categories analysis in addition to actual time spent engaged in each activity
– Initial pilot studies• Validation• Highly reliable THA pop (r>0.8) 28
Activity data - MLTPAQ• Activity Category
– Walking & Miscellaneous– Conditioning– Individual & Team Sports– Racquet Sports– Water– Winter– Lawn & Garden– Housework & Home Repair– Care Giving
•Daily Non-Leisure Activities•Sitting•Standing•Walking•Walking up stairs•Lifting & Carrying Heavy Objects
Pre-operative Morbidities Known to Affect Exercise
1 YEAR POST THA RESULTS
• Analysis n=437
95% patients complete data
219 female; 218 male
I YEAR POST THA: BMI
Pre-operative BMI 29.51 year THA BMI 29.0
p=0.9
NO CHANGE
I YEAR POST THA: ANALGESIA
Daily analgesics for hip pain
81% pre-operatively 24% post-THAp<0.001
LESS PAIN
I YEAR POST THA: MOBILITY AIDS
Mobility aids decreased post THA
‘weighted’ average 0.57 vs. 0.25p<0.0001
BETTER MOBILITY
I YEAR POST THA: WOMAC
WOMAC scores improved Pre-op 51 vs Post-op 13 (p<0.001)
BETTER WOMAC scoreLess PainLess StiffnessPerceived Better Function
I YEAR POST THA: ADLs
Increased times performing basic daily activities (ADLs)
Ie standing, walking, climbing stairs; respective p=0.005, p=0.03, p=0.03
Except heavy lifting (p =0.6)
BETTER ADL
ACTIVITIES POST THA 1
Small increases in participation post THA
Walking for pleasure and exerciseWeeding !Swimming & CyclingDancing
Not statistically significant
ACTIVITIES POST THA 3
Popular retirement activities (ie golf) did not increase after hip replacement
ACTIVITIES POST THA 4
Overall activity status not related to
1. Gender2. Implant type3. Bearing
DISCUSSION 1Strengths
ProspectiveLarge complete data set (n=437) at 1 yearObjective & Subjective scorings
Weaknesses
•Recovery not reached plateau at 1 year
DISCUSSION 2Majority patients do not return to
activities stopped due to hip osteoarthritis
Hip replacement before a patient either drops their activity level or gains significant weight through inactivity?
SUMMARY THA is a surgical procedure for pain relief
Best predictor of activity post THA ……….immediate pre-operative activity
Secondary functional gain cannot be guaranteed
Thank you
Any Questions?
Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCS
Consultant Orthopaedic SurgeonHonorary Senior Clinical Lecturer, University of Sussex
www.benedictrogers.com