Assessment of outcome after joint replacement Presentation 11 02 2015

Measuring Outcome after hip and knee

replacement

Mr Dipak Raj, FRCSConsultant Orthopaedic Surgeon

Mr D Raj, Consultant Orthopaedic Surgeon, Pilgrim Hospital, Boston

Surgeon-reported outcome measure

valuable

Lacks comparability which limits its usefulness.

Mr D Raj, Consultant Orthopaedic Surgeon Pilgrim Hospital, Boston

Ideal outcome tool

Validated

Reproducible

Comparable


Classification of outcome measures

Subjective

Objective

Generic

Specific to a joint a disease a specific patient group Mr D Raj, Consultant Orthopaedic

Surgeon Pilgrim Hospital, Boston

Questionnaire based outcome measures

Patient reported outcome measures (PROMs)

Objective

combined



Advantages Self-administered Simple Cost effective Reproducibility Reliability Internal consistency Responsiveness to change

Terwee CB et al. J Clinical epidemiol 2007;60:34-42

Aaronson N et al. Qual Life Res 2002;11:193-205 Mr D Raj, Consultant Orthopaedic Surgeon Pilgrim Hospital, Boston


Flaws ‘floor’ and ‘ceiling’ effects Wamper KE et al.Acta Orthop 2010;81:703-7

Konan S et al.HSS J 2012;8:198-205

Misinterpretation Murray DW etal. JBJS(Br) 2007;89-B:1010-14

Cultural differences Pain and function Perception vs. true performance Fujita et al. Osteoarthrits Cartilage.2009;17:848-

55

Lavernia et al. J Arthroplasty;2012;27:1276-82 Clement ND et al.JBJS(Br);2011;93B:464-9



PROMsMeasure the patient’s perception of their abilities rather than true performance. The former may not truly reflect function as it is influenced by

Socioeconomic

Cultural and

Psychological factors Fujita et al. Osteoarthrits Cartilage.2009;17:848-55 Lavernia et al. J Arthroplasty;2012;27:1276-82 Clement ND et al.JBJS(Br);2011;93B:464-9


Performance based outcome measures

True performance


Performance based outcome measures

Performance based measure capture a different aspect of function and used on their own or alongside PROMs, are more likely to characterise fully a change in function than the use of PROMs alone

Mizner RL et al. J Arthroplasty 2011;26:728-737 Stratford PW etal. Phy Ther;2006:86:1489-96Startford PW et al. J Clin Epiodemiol.2009;62:347-52.


Other factors affecting the outcomes

Confounders

Power


Discussion 1

PROMs have several advantages; they are easy to administer and require no equipment and little specialist training. However, they do not always provide a true measure of culturally sensitive function

Fazita et al. Osteoarthritis Cartilage.2009;17:848-55.Uesugi Y et al. J Orthop Sci 2009;14:35-39.


Discussion 2

As a result of the ceiling effect, they have limitations when the outcome is being studied in younger high demand individuals

Wamper KE et al. Acta Orthop 2010;81703-7.Tijssen M et al. BMC Musculoskeletal Disord 2011;12:117.

Beaupre LA et al. BMC Musculoskeletal Disord 2014;15:192

These disadvantages may hinder the usefulness of PROMs for comparison of implants, procedures or surgical approaches.

KonanS, Haddad FS Bone and Joint Journal 2014;96B:1431-5


Discussion 3

Performance based tasks address many of these disadvantages which has proved difficult to identify with PROMs that are currently available.

Haddad FS et al. AAOS annual meeting; San Francisco:2008Cobb JP, Wilk AV, Lewis A, Amis A. AAOS aannual meeting: San

Francisco:2012


Discussion 4

There is a growing body of evidence that performance based assessments can provide useful information over and above that which is available from existing patient or physician assessed questionnaires.


Discussion 5

Clinicians should be aware of the disadvantages they offer and the limitations of commonly used questionnaire bases tools.

Konan S, Haddad FS. Measuring function after hip and knee surgery. Bone and joint Journal 2014;96B:1431-5.


Questions?


Future direction

Compliance

50/60%

Can not validate the data

How to improve compliance ?

BOA


Patient satisfaction

In ULHT series - less than 10% not happy

Perception v/s Real outcome ( an issue with PROMs)

In TKR cases this figure can go up to 20%

Toms et al.Bone Joint J. 2014 Sep;96-B(9):1227-33)

Groin pain and activity related hip pain are problem in small percentage of patintes (0.4 to 18.3%)

Swiss Med Wkly. 2014 Oct 8;144:w13974 Mr D Raj, Consultant Orthopaedic Surgeon Pilgrim Hospital, Boston

http://www.ncbi.nlm.nih.gov/pubmed/25183595


PROMs data vs Quality improvement

If you improve quality the data and outcome will be better

Ring fencing

Compliance

Hip school

Enhanced recovery programme


Revision rate high

Metal on metal

We should be using implant with long track record

For hip and knee replacement

Mr D Raj, Consultant Orthopaedic Surgeon, Pilgrim Hospital, Boston

TKR

Kaplan Meir survival 10 years

Advaced MP knee 5935 3.53 ( 2.82 -4.43)

Depuy 213284 2.66 ( 2.51 -2.82)

Nexgen 87273 3.61 ( 3.28 -3.98)

AGC 57683 3.43 (3.09 – 3.83)

NJR 11th report page 104 ( Table 3.22)


Fracture neck of femur: ImplantCemented or uncemeted

hemiarthoplasty

Oxford

292/412


Outcome measures included: complications, re-operations and mortality rates at two, seven, 30 and 365 days post-operatively.


Comparable outcomes for the two stems were seen. There were more intra-operative complications in the uncemented group (13% vs 0%), but the cemented group had a greater mortality in the early post-operative period (n = 6). There was no overall difference in the rate of re-operation (5%) or death (365 days: 26%) between the two groups at any time post-operatively. This study therefore supports the use of both cemented and uncemented stems of proven design, with an ODEP rating of 10A, in patients with an intracapsular fracture of the neck of the femur.


This study therefore supports the use of both cemented and uncemented stems of proven design, with an ODEP rating of 10A, in patients with an intracapsular fracture of the neck of the femur.

Bone Joint J 2015;97-B:94-9. Oxford

(Exeter vs Corail)


There was no difference in the mortality rate between the groups. There were significantly fewer complications in the uncemented group, suggesting that the use of this stem would result in a decreased rate of morbidity in these frail patients. Whether this relates to an improved functional outcome remains unknown

Bone Joint J. 2014 Mar;96-B(3):299-305

(Exeter / Corail)Keating, Edinburgh



Arthroscopy workshop


sharon

Sharon – Participation rate –Compliance 80%

Pre op 80%

Pt response rate 66%

met the national average

Information, Expectation

Risk and benefit

CQC – risk Mr D Raj, Consultant Orthopaedic Surgeon Pilgrim Hospital, Boston

Rapid recovery programme

Ring fencing

Younger age group validity of PROMS COMPARISON (14%)

Anxiety / depression


Assessment of outcome after joint replacement Presentation 11 02 2015

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