J. T. Patton

What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement

Objectives To investigate the factors which influence patient satisfaction with surgical services and to explore the relationship between overall satisfaction, satisfaction with specific facets of outcome and measured clinical outcomes (patient reported outcome measures (PROMs)). Design Prospective cohort study. Setting Single National Health Service (NHS) teaching hospital. Participants 4709 individuals undergoing primary lower limb joint replacement over a 4-year period (January 2006–December 2010). Main outcome measures Overall patient satisfaction, clinical outcomes as measured by PROMs (Oxford Hip or Knee Score, SF-12), satisfaction with five specific aspects of surgical outcome, attitudes towards further surgery, length of hospital stay. Results Overall patient satisfaction was predicted by: (1) meeting preoperative expectations (OR 2.62 (95% CI 2.24 to 3.07)), (2) satisfaction with pain relief (2.40 (2.00 to 2.87)), (3) satisfaction with the hospital experience (1.7 (1.45 to 1.91)), (4) 12 months (1.08 (1.05 to 1.10)) and (5) preoperative (0.95 (0.93 to 0.97)) Oxford scores. These five factors contributed to a model able to correctly predict 97% of the variation in overall patient satisfaction response. The factors having greatest effect were the degree to which patient expectations were met and satisfaction with pain relief; the Oxford scores carried little weight in the algorithm. Various factors previously reported to influence clinical outcomes such as age, gender, comorbidities and length of postoperative hospital stay did not help explain variation in overall patient satisfaction. Conclusions Three factors broadly determine the patients overall satisfaction following lower limb joint arthroplasty; meeting preoperative expectations, achieving satisfactory pain relief, and a satisfactory hospital experience. Pain relief and expectations are managed by clinical teams; however, a fractured access to surgical services impacts on the patients hospital experience which may reduce overall satisfaction. In the absence of complications, how we deliver healthcare may be of key importance along with the specifics of what we deliver, which has clear implications for units providing surgical services.

Predicting the cost-effectiveness of total hip and knee replacement: A health economic analysis

The aim of this study was to perform a cost-utility analysis of total hip (THR) and knee replacement (TKR). Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine of the modern era, has recently come under scrutiny. The National Health Service (NHS) has competing demands, and resource allocation is challenging in times of economic restraint. Patients who underwent THR (n = 348) or TKR (n = 323) between January and July 2010 in one Scottish region were entered into a prospective arthroplasty database. A health-utility score was derived from the EuroQol (EQ-5D) score pre-operatively and at one year, and was combined with individual life expectancy to derive the quality-adjusted life years (QALYs) gained. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences. The number of QALYs gained was higher after THR than after TKR (6.5 vs 4.0 years, p < 0.001). The cost per QALY for THR was £1372 compared with £2101 for TKR. The predictors of an increase in QALYs gained were poorer health before surgery (p < 0.001) and younger age (p < 0.001). General health (EQ-5D VAS) showed greater improvement after THR than after TKR (p < 0.001). This study provides up-to-date cost-effectiveness data for total joint replacement. THR and TKR are extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions.

Femoral replacement for salvage of periprosthetic fracture around a total hip replacement

A total of 20 patients with a mean age of 72 (range: 36-91) were managed with replacement of the proximal (15) or total (5) femur for salvage of a periprosthetic femoral fracture with bone loss. A mean 12.5 years had elapsed between primary total hip replacement and surgery and the mean follow-up was 48 months (range: 12-116 months). Clinical outcome was assessed using the Toronto Extremity Salvage Score (mean: 68, range: 32-98) and Short Form 36 (SF-36; mean Physical Component Score (PCS): 53, range: 44-62; mean Mental Component Score (MCS): 51, range: 41-64). No prostheses were radiologically loose. There were six major complications; three patients suffered a postoperative dislocation; two patients had persistent deep infection (present preoperatively); and one patient suffered a fracture of their femur distal to the femoral stem of a proximal femoral replacement. Endoprosthetic replacement of the femur is a reasonable salvage option for patients with periprosthetic fracture and bone loss, with good clinical results. It allows immediate weight bearing and does not rely on bony union for success.

Dealing with the predicted increase in demand for revision total knee arthroplasty: challenges, risks and opportunities

Worldwide rates of primary and revision total knee arthroplasty (TKA) are rising due to increased longevity of the population and the burden of osteoarthritis. Revision TKA is a technically demanding procedure generating outcomes which are reported to be inferior to those of primary knee arthroplasty, and with a higher risk of complication. Overall, the rate of revision after primary arthroplasty is low, but the number of patients currently living with a TKA suggests a large potential revision healthcare burden. Many patients are now outliving their prosthesis, and consideration must be given to how we are to provide the necessary capacity to meet the rising demand for revision surgery and how to maximise patient outcomes. The purpose of this review was to examine the epidemiology of, and risk factors for, revision knee arthroplasty, and to discuss factors that may enhance patient outcomes.

Lengthening the moment arm of the patella confers enhanced extensor mechanism power following total knee arthroplasty

We investigated whether a postulated biomechanical advantage conferred to the extensor mechanism by a change in knee implant design was detectable in patients by direct physical testing. 212 TKA patients were enrolled in a double blind randomized controlled trial to receive either a traditional implant or one which incorporated new design features. Extensor mechanism power output and physical performance on a battery of timed functional activities was assessed pre‐operatively and then at 6, 26, and 52 weeks post‐operatively. Significantly enhanced power output was observed in both groups post‐arthroplasty; however, the new design implant group demonstrated a greater change in power output than the traditional implant group. Posthoc testing of between group differences highlighted greater improvement at all post‐operative assessments. At 52 weeks, patients receiving the implant with the postulated biomechanical advantage achieved 116% of the power output of their contralateral limb, whereas patients with the traditional design achieved 90%. No between group difference was detected in the patients time to complete functional tasks. Thus, patients receiving a knee implant of a modern design (theoretically able to confer a mechanical advantage to the extensor mechanism) were found to generate significantly greater extensor power than those receiving a traditional implant without the postulated mechanical advantage.

Validation of the English language Forgotten Joint Score-12 as an outcome measure for total hip and knee arthroplasty in a British population

Aims To validate the English language Forgotten Joint Score‐12 (FJS‐12) as a tool to evaluate the outcome of hip and knee arthroplasty in a United Kingdom population. Patients and Methods All patients undergoing surgery between January and August 2014 were eligible for inclusion. Prospective data were collected from 205 patients undergoing total hip arthroplasty (THA) and 231 patients undergoing total knee arthroplasty (TKA). Outcomes were assessed with the FJS‐12 and the Oxford Hip and Knee Scores (OHS, OKS) preoperatively, then at six and 12 months post‐operatively. Internal consistency, convergent validity, effect size, relative validity and ceiling effects were determined. Results Data for the TKA and THA patients showed high internal consistency for the FJS‐12 (Cronbach &agr; = 0.97 in TKAs, 0.98 in THAs). Convergent validity with the Oxford Scores was high (r = 0.85 in TKAs, r = 0.79 for THAs). From six to 12 months, the change was higher for the FJS‐12 than for the OHS in THA patients (effect size d = 0.21 versus ‐0.03). Ceiling effects at one‐year follow‐up were low for the FJS‐12 with just 3.9% (TKA) and 8.8% (THA) of patients achieving the best possible score. Conclusion The FJS‐12 has strong measurement properties in terms of validity, internal consistency and sensitivity to change in TKA and THA patients. Low ceiling effects and good relative validity allow the monitoring of longer term outcomes, particularly in well‐performing groups after total joint arthroplasty.

Total femoral replacement for salvage of periprosthetic fractures

Patients with complex periprosthetic fracture patterns of the femur may ultimately require amputation. Some authors have described the use of mega-endoprostheses as a salvage procedure. This study reports functional outcome, complications, and implant and patient survival after total femoral replacement (TFR) for salvage of periprosthetic fracture of the femur. A prospective database of 20 consecutive patients who underwent TFR for salvage of a periprosthetic fracture was compiled. Patient demographics, mobility information, and preoperative and postoperative Short Form 12-item Survey (SF-12) and 1-year Toronto Extremity Salvage Score (TESS) data were recorded. Postoperative complications were obtained from the hospital database and patient medical notes. One patient was lost to follow-up and was excluded from analysis. The study included 8 men and 11 women, with a mean age of 68.4 years. No significant difference was noted in the prefracture physical (4.4; P=.13) or mental (0.3; P=.78) component scores of the SF-12 compared with 1-year scores. The TESS at 1 year was 69%. However, patients were more likely to require a walking aid postoperatively (P<.0001). One-fourth of the patients had a postoperative medical complication. In addition, 1 patient had a dislocation and 2 patients had a periprosthetic infection. The implant survival rate was 86% at 10 years; however, the 10-year mortality rate was 58%. Although TFR for salvage of a periprosthetic fracture of the femur offers good functional outcome and implant survival, it is at the expense of postoperative complications, and TFR is associated with a high long-term mortality rate.

Making the Oxford Hip and Knee Scores meaningful at the patient level through normative scoring and registry data

Objectives The Oxford Hip and Knee Scores (OHS, OKS) have been demonstrated to vary according to age and gender, making it difficult to compare results in cohorts with different demographics. The aim of this paper was to calculate reference values for different patient groups and highlight the concept of normative reference data to contextualise an individual’s outcome. Methods We accessed prospectively collected OHS and OKS data for patients undergoing lower limb joint arthroplasty at a single orthopaedic teaching hospital during a five-year period. T-scores were calculated based on the OHS and OKS distributions. Results Data were obtained from 3203 total hip arthroplasty (THA) patients and 2742 total knee arthroplasty (TKA) patients. The mean age of the patient was 68.0 years (sd 11.3, 58.4% women) in the THA group and in 70.2 (sd 9.4; 57.5% women) in the TKA group. T-scores were calculated for age and gender subgroups by operation. Different T-score thresholds are seen at different time points pre and post surgery. Values are further stratified by operation (THA/TKA) age and gender. Conclusions Normative data interpretation requires a fundamental shift in the thinking as to the use of the Oxford Scores. Instead of reporting actual score points, the patient is rated by their relative position within the group of all patients undergoing the same procedure. It is proposed that this form of transformation is beneficial (a) for more appropriately comparing different patient cohorts and (b) informing an individual patient how they are progressing compared with others of their age and gender. Cite this article: Bone Joint Res 2015;4:137–144

Predicting the cost-effectiveness of total hip and knee replacement

The aim of this study was to perform a cost-utility analysis of total hip (THR) and knee replacement (TKR). Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine of the modern era, has recently come under scrutiny. The National Health Service (NHS) has competing demands, and resource allocation is challenging in times of economic restraint. Patients who underwent THR (n = 348) or TKR (n = 323) between January and July 2010 in one Scottish region were entered into a prospective arthroplasty database. A health-utility score was derived from the EuroQol (EQ-5D) score pre-operatively and at one year, and was combined with individual life expectancy to derive the quality-adjusted life years (QALYs) gained. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences. The number of QALYs gained was higher after THR than after TKR (6.5 vs 4.0 years, p < 0.001). The cost per QALY for THR was £1372 compared with £2101 for TKR. The predictors of an increase in QALYs gained were poorer health before surgery (p < 0.001) and younger age (p < 0.001). General health (EQ-5D VAS) showed greater improvement after THR than after TKR (p < 0.001). This study provides up-to-date cost-effectiveness data for total joint replacement. THR and TKR are extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions.

Patient-reported outcome metrics following total knee arthroplasty are influenced differently by patients’ body mass index

PurposeThis study investigated the impact of body mass index (BMI) on improvement in patient outcomes (pain, function, joint awareness, general health and satisfaction) following total knee arthroplasty (TKA).MethodsData were obtained for primary TKAs performed at a single centre over a 12-month period. Data were collected pre-operatively and 12-month postoperatively with the Oxford Knee Score (OKS) measuring pain and function, the EQ-5D-3L measuring general health status, the Forgotten Joint Score-12 (FJS-12) measuring joint awareness and a single question on treatment satisfaction. Change in scores following surgery was compared across the BMI categories identified by the World Health Organization (< 25.0, 25.0–29.9, 30.0–34.9, 35.0–39.9 and ≥ 40.0). Differences in postoperative improvement between the BMI groups were analysed with an overall Kruskal–Wallis test, with post hoc pairwise comparisons between BMI groups with Mann–Whitney tests.ResultsOf 402 patients [mean age 70.7 (SD 9.2); 55.2% women] 15.7% were normal weight (BMI < 25.0), 33.1% were overweight (BMI 25.0–29.9), 28.2% had class I obesity (BMI 30.0–34.9), 16.2% had class II obesity (BMI 35.0–39.9), and 7.0% had class III obesity (BMI ≥ 40.0). Postoperative change in OKS (n.s.) and EQ-5D-3L (n.s.) was not associated with BMI. Higher BMI group was associated with less improvement in FJS-12 scores (p = 0.010), reflecting a greater awareness of the operated joint during activity in the most obese patients. Treatment satisfaction was associated with BMI category (p = 0.029), with obese patients reporting less satisfaction.ConclusionsIn TKA patients, outcome parameters are influenced differently by BMI. Our study showed a negative impact of BMI on postoperative improvement in joint awareness and satisfaction scores, but there was no influence on pain, function or general health scores. This information may be useful in terms of setting expectations expectation in obese patients planning to undergo TKA.Level of evidenceLevel 1.