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1.
Article in English | MEDLINE | ID: mdl-38538034

ABSTRACT

OBJECTIVES: As workload increases, surgical care for patients with bone metastases is increasingly decentralised, with a shift in management away from primary bone tumour units to local centres. We must ensure that patients have similar outcomes regardless of where they receive their treatment. The aim was to develop and validate a set of quality outcome indicators (QOIs) to evaluate treatment success for patients undergoing surgery for bone metastases. METHODS: Outcome recommendations were adapted from the literature and field tested in a retrospective patient cohort to determine feasibility. The provisional outcome indicators were assessed during a modified RAND/Delphi consensus process by a group of patients, relatives and healthcare professionals with validated targets added. RESULTS: 1534 articles were reviewed. 38 quality objectives were extracted and assessed for feasibility using clinical records for 117 patients. 28 provisional outcome indicators proceeded to expert consensus and were reviewed by a group of 22 panellists including 10 patients and 4 relatives/carers. After two rounds, 15 QOIs were generated, with validated targets based on expert consensus. These included specific statements such as 'surgery improves pain and reduces the need for morphine, target: at follow-up, pain is documented in 80% of individuals and 50% of these have reduced need for morphine'. CONCLUSIONS: The published evidence and guidelines were adapted into a set of outcome indicators validated by patients, their family/carers and healthcare professionals. These can be used to compare care between centres and identify units of excellence in maximising good outcome after surgery for bone metastases.

2.
Orthop Rev (Pavia) ; 15: 75359, 2023.
Article in English | MEDLINE | ID: mdl-37405274

ABSTRACT

Purpose: Primary total knee arthroplasty (TKA) is an effective treatment which is increasing in use for both elderly and younger patients. With the overall increasing life span of the general population, the rate of revision TKA is projected to increase significantly over the coming decades. Analyses from the national joint registry of England and Wales support this prediction with an increase in primary TKA of 117% and an increase in revision TKA of 332% being forecast by 2030. Bone loss presents a challenge in revision TKA so an understanding of the aetiology and principles behind this is essential for the surgeon undertaking revision. The purpose of this article is to review the causes of bone loss in revision TKA, discuss the mechanisms of each cause and discuss the possible treatment options. Methods: The Anderson Orthopaedic Research Institute (AORI) classification and zonal classification of bone loss are commonly used in assessing bone loss in pre-operative planning and will be used in this review. The recent literature was searched to find advantages and limitations of each commonly used method to address bone loss at revision TKA. Studies with the highest number or patients and longest follow-up period were selected as significant. Search terms were: "aetiology of bone loss", "revision total knee arthroplasty", "management of bone loss". Results: Methods for managing bone loss have traditionally been cement augmentation, impaction bone grafting, bulk structural bone graft and stemmed implants with metal augments. No single technique was found to be superior. Megaprostheses have a role as a salvage procedure when the bone loss is deemed to be too significant for reconstruction. Metaphyseal cones and sleeves are a newer treatments with promising medium to long term outcomes. Conclusion: Bone loss encountered at revision TKA presents a significant challenge. No single technique currently has clear superiority treatment should be based on a sound understanding of the underlying principles.

3.
Article in English | MEDLINE | ID: mdl-34130998

ABSTRACT

OBJECTIVES: Patients with metastatic bone disease (MBD) should receive the same standard of care regardless of which centre they are treated in. The aim was to develop and test a set of quality performance indicators (QPIs) to evaluate care for patients with MBD referred to orthopaedics. METHODS: QPIs were adapted from the literature and ranked on feasibility and necessity during a modified RAND/Delphi consensus process. They were then validated and field tested in a retrospective cohort of 108 patients using indicator-specific targets set during consensus. RESULTS: 2568 articles including six guidelines were reviewed. 43 quality objectives were extracted and 40 proceeded to expert consensus. After two rounds, 18 QPIs for MBD care were generated, with the following generating the highest consensus: 'Patients with high fracture risk should receive urgent assessment' (combined mean 6.7/7, 95% CI 6.5 to 6.8) and 'preoperative workup should include full blood tests including group and save' (combined mean 6.7/7, 95% CI 6.5 to 6.9). In the pilot test, targets were met for 5/18 QPIs (mean 52%, standard deviation 22%). The median deviation from projected target was -14% (interquartile range -11% to -31%, range -74% to 11%). The highest scoring QPI was 'adults with fractures should have surgery within 7 days' (target 80%:actual 92%). CONCLUSIONS: The published evidence and guidelines were adapted into a set of validated QPIs for MBD care which can be used to evaluate variation in care between centres. These QPIs should be correlated with outcome scores to determine whether they can act as predictors of outcome after surgery.

6.
BMJ Open ; 9(2): e021614, 2019 02 20.
Article in English | MEDLINE | ID: mdl-30787073

ABSTRACT

OBJECTIVES: To assess a targeted 'therapy as required' model of post-discharge outpatient physiotherapy provision. Specifically, we investigated what proportion of patients accessed post-discharge physiotherapy following total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether accessing therapy was associated with post-arthroplasty patient reported outcomes and whether it was possible to predict which patients would access post-discharge physiotherapy from pre-operative data. DESIGN: Prospective, observational, longitudinal cohort study. SETTING: Single National Health Service orthopaedic teaching hospital in the UK. PARTICIPANTS: 1395 patients undergoing total hip arthroplasty and 1374 patients undergoing total knee arthroplasty. PRIMARY AND SECONDARY OUTCOME MEASURES: Self-reported access of post-discharge physiotherapy, the Oxford Hip or Knee Score, EuroQol 5-dimension questionnaire and post-operative surgical episode satisfaction metric. RESULTS: 662 (48.2%) patients with TKA and 493 (35.3%) patients with THA accessed additional post-discharge physiotherapy. Patient-reported outcomes (p<0.001) and surgical episode satisfaction (p=0.001) in both THA and TKA were higher in patients that did not participate in post-discharge physiotherapy. Regression models using pre-operative symptom burden and demographic data predicted post-discharge therapy access with an accuracy of only 17% greater than chance in patients with THA and 7% greater than chance in patients with TKA. CONCLUSIONS: In a choice-based service model of 'therapy as required' following hip and knee arthroplasty only a third of THA and half of TKA patients accessed post-discharge therapy. Patients who did not access physiotherapy reported greater post-operative outcomes. This variation in the need for post-discharge physiotherapy suggests that targeting of rehabilitation may be a cost-effective model, however it was not possible to reliably predict which patients would access post-discharge physiotherapy from pre-operative data.


Subject(s)
Arthroplasty, Replacement, Hip/rehabilitation , Arthroplasty, Replacement, Knee/rehabilitation , Health Services Accessibility/statistics & numerical data , Physical Therapy Modalities/statistics & numerical data , Aged , Female , Humans , Longitudinal Studies , Male , Middle Aged , Patient Satisfaction/statistics & numerical data , Prospective Studies , Surveys and Questionnaires , United Kingdom
7.
BMJ Open ; 2(4)2012.
Article in English | MEDLINE | ID: mdl-22786947

ABSTRACT

OBJECTIVES: This study set out to pursue means of reducing mismatch in schoolboy rugby players. The primary objective was to determine whether application of previously reported thresholds of height and grip strength could be used to distinguish those 15-year-old boys appropriate to play under-18 school rugby from their peers. A secondary objective was to obtain normative data for height, weight and grip strength and to assess the variation within that data of current schoolboy rugby players. DESIGN: Cross-sectional cohort study. SETTING: 3 Scottish schools and 'Regional Assessment Centres' organised by the Scottish Rugby Union. PARTICIPANTS: 472 rugby playing youths aged 15 years (Regional Assessment Centres) and 382 schoolboys aged between 12 and 18 years (three schools). OUTCOME MEASURES: Height, weight and grip strength. RESULTS: 97% of 15-year-olds achieved the height and grip strength thresholds based on previous reported values. Larger mean values and wide variation of height, weight and grip strength were recorded in the schoolboy cohort. However, using the mean values of the cohort of 17-year-olds as a new threshold, only 7.7% of 15-year-olds would pass these thresholds. CONCLUSIONS: Large morphological variation was observed in schoolboy rugby players of the same age. Physical maturity tests described in earlier literature as pre-participation screening for contact sports were not applicable to current day 15-year-old rugby players. New criteria were measured and found to be better at identifying those 15-year-old players who had sufficient physical development to play senior school rugby.

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