Enhanced Recovery Programme & Hip referrals

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


Enhanced Recovery Programme

Non-surgical vs Interventions

Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCSConsultant Orthopaedic Surgeon

Honorary Senior Clinical Lecturer, University of Sussex


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?




Further Info•Hip Society Guide

•BSUH Education & Research

•THR OutcomesActivitySatisfaction

Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCSConsultant Orthopaedic SurgeonHonorary Senior Clinical Lecturer


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

http://www.brightonorthoedcuation.com/

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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

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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

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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

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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

• 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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Jan 2014Recruitment

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“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)

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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

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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

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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

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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

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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 (?)

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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

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


Popular retirement activities (ie golf) did not increase after hip replacement


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?




Enhanced Recovery Programme & Hip referrals

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