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Adult Hip Pain & Enhanced Recovery Programme

Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCS Consultant Orthopaedic Surgeon Honorary 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 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
– Ie affecting employment

Intermediate/Secondary Referral
• <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

Any Questions?

Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCS Consultant 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 FRCS Consultant 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-surgical
Pre-operative Nutrition

48hr calorie loading
Poor predictors Low albumin & transferrin Obesity (BMI>40) Triceps fold

Prolonged surgery/stay/bleeding/transfusion

Non-surgical
• 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

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 Surgeon Honorary Senior Clinical Lecturer, University of Sussex www.benedictrogers.com

Further Info
•Hip Society Guide •BSUH Education & Research •THR Outcomes Activity Satisfaction

Benedict Rogers MA MSc DIMC DipSEM MRCGP FRCS Consultant Orthopaedic Surgeon Honorary 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/Secondary Referral
• <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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EDUCATION

Trauma & Orthopaedics
RESEARCH

Education & Research
March 2014 Benedict Rogers Consultant Orthopaedic Surgeon Honorary Senior Clinical Lecturer Lead For Research & Education

2014 AND BEYOND QUESTIONS

EDUCATION

RESEARCH 2014 AND BEYOND QUESTIONS

EDUCATION

EDUCATION

EDUCATION
• Friday am RSCH teaching (SpR & SHO)
– Survey – www.brightonorthoedcuation.com

RESEARCH

• Bimonthly Journal Club (DMR & BR)
2014 AND BEYOND

– Published 8 letters / 4 reports

• PRH teaching (incl GP trainees) • Industry sessions (Stryker, S&N)

QUESTIONS

EDUCATION

EDUCATION
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

RESEARCH 2014 AND BEYOND QUESTIONS

EDUCATION

EDUCATION
Medical Students • Lecture programme (PRH)
– Lectures online (student Central & brightorthoeducation)

RESEARCH

• Ward teaching (PRH, SOTC, RSCH) • Weekly teaching sessions by SpRs (AEB, seminar room) • Theatre attendance • Participation in Friday am teaching

2014 AND BEYOND QUESTIONS

EDUCATION

EDUCATION
To develop …. Selected Student Component (SSC)
(GMC Tomorrow’s Doctors 2009)

RESEARCH

BSMS Module 307 Jan - April 2015 (proposal deadline Aug) Max 12 students, assessment (10 min ppt) Funding - £500 (‘dry’ projects) per SSC

2014 AND BEYOND

Cadaveric Teaching
SpR and/or Cons Industry collaboration
QUESTIONS

EDUCATION

EDUCATION
• Arthroplasty Course • Brighton Trauma Conference
– Oversubscribed – ? Posters for trainees

RESEARCH 2014 AND BEYOND

• Orthopaedic MSc
– teaching, examining, supervision of theses

QUESTIONS

EDUCATION

EDUCATION
Future… • ? KSS Fracture neck of femur or FRCS viva course • More publishable topics for MSc theses
– BSUH Med Stats & Clin Librarian

RESEARCH

• More Academic Fellows
– BOA transitional fellowships? – RCS affiliated fellowships
2014 AND BEYOND

• Surgical Simulation (SB & BR)
– Joint BSUH/BSMS surgical application

• BSMS Honorary Lecturer applications for SpR
– BSMS T&O profile
QUESTIONS

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EDUCATION

RESEARCH 2014 AND BEYOND QUESTIONS

RESEARCH

EDUCATION

RESEARCH
Currently Ongoing……
• Trauma Outcomes/PROMS
– Prospective study – Systematic review

• IVDU caseload/cost

RESEARCH

• High ISS caseload
• Open fractures
– BOAST 4 audit – Upper limb 3C injuries
2014 AND BEYOND

• Trauma admissions (with SGH)
– Vs ITU trauma admissions – Vs HEMS caseload

• Ankle fracture audit

• Trauma-related amputations

• Blood transfusion in MTCs
– TARN/BTS

QUESTIONS

EDUCATION

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
RESEARCH 2014 AND BEYOND

And more….
QUESTIONS

EDUCATION

RESEARCH
Future…

RESEARCH 2014 AND BEYOND

• Complete/present/pub • On going sequence of lish ongoing work! systematic reviews – IRP projects • Provide a timetable of projects • Ongoing BSUH specific databases • KSS/BSMS wide – Open fractures collaboration
– Multi-centre studies (as NIHR pilot?) – Basic science – Trauma amputations – ?others

QUESTIONS

EDUCATION

RESEARCH
NIHR - current
– – – – – – SWIFFT (LT) WOLLF (BR) FixDT (BR & IM) OVIVA (micro- & IM) Clavicle (CH) Dinosaur (AS)

RESEARCH

NIHR –upcoming studies
– Hip Fracture protocol – Trauma Outcomes – VTE trauma

2014 AND BEYOND QUESTIONS

EDUCATION

RESEARCH 2014 AND BEYOND QUESTIONS

RESEARCH

EDUCATION

RESEARCH 2014 AND BEYOND QUESTIONS

RESEARCH
Jan 2014 Recruitment

RESEARCH

EDUCATION RESEARCH

Opened Feb 2014

“Congratulations to Carrie Ridley at Royal Sussex County who has recruited 2 patients in the first month open. “

2014 AND BEYOND QUESTIONS

EDUCATION

RESEARCH
Funding
– TARN (for Polytrauma PROMS) – CLRN (Comprehensive Local Research Network)
• Ongoing Portfolio studies

RESEARCH

– NIHR (new proposal)
• RfPB (Research for Patient Benefit) • Health Services and Delivery Research (HS&DR) Programme (deadline 15 May 2014)

2014 AND BEYOND

– Local Funding
QUESTIONS

• Local (R&D fund, SPRINT etc)

EDUCATION

RESEARCH
Future…

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

2014 AND BEYOND QUESTIONS

EDUCATION

RESEARCH
BSMS

RESEARCH

– 4th IRP (individual research project) – 2014 - x2 ongoing (trauma) – 2015 – x2 proposals submitted – Remittance - £700 per student – Potential for numerous more in future

2014 AND BEYOND QUESTIONS

EDUCATION

RESEARCH
Dept of Mechanics (Uni S)
FEA modelling (lower limb) – Dr Chang Wang

RESEARCH

Brighton MSK Research Cluster (BMRC)
• Lead Dr Sandra Sacre (Cell biologist) • BR on committee • Cell biology

2014 AND BEYOND QUESTIONS

EDUCATION

RESEARCH
Future…

RESEARCH

• T&O Ortho Research Collaborative
– Trainee led, BR advising
• Support multi-centre studies • Publication footprint • Develop NIHR grant proposals

2014 AND BEYOND

• Honorary Academic Lead HE KSS
(BR applied)

QUESTIONS

2014 AND BEYOND
• Academic Orthopaedic Unit • Develop support from BSUH R&D • Better links
– BSMS, HE KSS, NIHR, KSS Air Ambulance

EDUCATION RESEARCH 2014 AND BEYOND

• Academic fellows • Better position for formal academic unit

QUESTIONS

2014 AND BEYOND
• 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 (?)

EDUCATION RESEARCH 2014 AND BEYOND QUESTIONS

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EDUCATION

RESEARCH 2014 AND BEYOND

QUESTIONS?

Can the WOMAC score be used to predict patient satisfaction following hip replacement?
An Analysis of patient-reported outcomes for joint replacement

BA Rogers, AD Carrothers, HJ Kreder, R Jenkinson & Safe T Study Group

INTRODUCTION
Greater attention on PROMS in orthopaedic surgery Ie Oxford Scores Western Ontario and McMaster Universities (WOMAC)

Now used for Selection of patients suitable for surgery Outcome of surgery Quality of surgeon
WOMAC & Oxford scores introduced for clinical trials not 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-plot Rank Spearman does correlation exist? A receiver operating characteristic (ROC) curve analysis identify if there is a cut-off point for pre-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

THA Bearing Combinations (%)
0.2 0.2 metal-on-polyethylene ceramic-on-polyethylene metal-on-metal ceramic-on-ceramic metal-on-ceramic

8
8

84

WOMAC Pre-Op Mean SD 51 (2 – 94) 17

Satisfaction

21 (6-25) 3

Post-Op
Mean SD Delta Mean SD 38 (2 – 22) 3 1 (0 – 1) 1 13 (0 – 72) 15 22 (5 – 25) 4

RESULTS
100 90 80

R² = 0.0065

Baseline WOMAC

70 60 50 40 30 20 10 0

0

5

10

15

20

25

1 yr satisfaction

RESULTS
100 90 80

Baseline WOMAC

70 60 50 40 30 20 10 0
0 20 40 60 80 100

R² = 0.0041

1 yr WOMAC

RESULTS
Pre-Op WOMAC
1

0.75

Area Under Curve = 0.53
Sensitivity
0.5

0.25

0 0 0.25 0.5 0.75 1

1 - Specificity

RESULTS
Delta WOMAC
1

0.75

Area Under Curve = 0.43

Sensitivity

0.5

0.25

0 0 0.25 0.5 0.75 1

1 - Specificity

DISCUSSION
Scatter plots No correlation ROC analysis Pre-op WOMAC Delta WOMAC near straight line ROC curves

No cut-off in WOMAC score predicts satisfaction

RESULTS
1 year WOMAC
1

Area Under Curve = 0.67
0.75

Sensitivity

0.5

0.25

0 0 0.25 0.5 0.75 1

1 - Specificity

DISCUSSION
One year WOMAC ROC analysis Area under curve – 0.67 which represented sensitivity of 63.9% specificity of 65.9%. Better than pre-op WOMAC – but not significant cutoff poor sensitivity & specificity

DISCUSSION
To what degree can pre-operative WOMAC can be used to predict satisfaction following joint replacement?
In addition Change in WOMAC Post – Op WOMAC (!) …….No correlation with patient satisfaction after THR

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 •Daily Non-Leisure Activities •Sitting – Walking & Miscellaneous •Standing – Conditioning •Walking – Individual & Team Sports •Walking up stairs – Racquet Sports •Lifting & Carrying Heavy Objects – Water – Winter – Lawn & Garden – Housework & Home Repair – Care Giving

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 1 year THA BMI p=0.9 NO CHANGE 29.5 29.0

I YEAR POST THA: ANALGESIA
Daily analgesics for hip pain 81% pre-operatively

24% post-THA p<0.001

LESS PAIN

I YEAR POST THA: MOBILITY AIDS Mobility aids decreased post THA ‘weighted’ average 0.57 vs. 0.25 p<0.0001

BETTER MOBILITY

I YEAR POST THA: WOMAC WOMAC scores improved Pre-op 51 vs Post-op 13

(p<0.001)

BETTER WOMAC score Less Pain Less Stiffness Perceived 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 exercise Weeding ! Swimming & Cycling Dancing 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. Gender

2. Implant type
3. Bearing

DISCUSSION 1
Strengths Prospective Large complete data set (n=437) at 1 year Objective & Subjective scorings Weaknesses •Recovery not reached plateau at 1 year

DISCUSSION 2
Majority 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 Surgeon Honorary Senior Clinical Lecturer, University of Sussex www.benedictrogers.com