Copyright 2019 - Clinical Commissioning Groups Association

An Update on Trauma and Orthopaedics - Mr John F Nolan MBBS FRCS FRCS(Orth)

We all like to get value for our money.

Over the last 15 years, Trauma and Orthopaedics has led the development of outcome databases in medicine and these now encompass almost all joint replacement surgeries and hip fractures, as well as non-arthroplasty surgery, including ligament reconstruction.

Although originally developed to offer outcome data on implants, the evolution of these increasingly mature and substantial databases is having a significant effect on the way that we, as orthopaedic surgeons practise, with most individuals and departments becoming increasingly aware of the visibility and transparency of the outcomes of their surgical endeavors amongst their peers, their national associations and more widely on NHS websites.

There can be no doubt that all of this has been good for patients and over the last 10 years, the National Joint Registry has clearly demonstrated a 50% reduction in mortality, following hip replacement surgery.

As upwards of 80,000 hip and 90,000 knee replacements now take place every year, implant longevity is important and again the best implants, put in well, are performing better than ever.

The National Joint Registry (NJR), which includes data on over 800,000 hip and 740,000 knee replacements, has recently been taking a close look at the excessive variability of cost of the same prostheses to different hospitals, even within the National Health Service.

The project offers the potential to rationalise and lower the costs of implants to the NHS, leading to more cost effective care.

Patient Reported Outcome Measures (PROMS) and Patient Reported Experience Measures (PREMS) have provided us with details of our patients’ perspective of their “journey” and their quality of life improvements, whilst studies specifically analysing Quality Adjusted Life Years (QALYS) after joint replacement, have confirmed the extraordinary value of this surgery in health economic terms.

NICE has set the threshold for a QALY at around £30,000, with a QALY of less than £10,000 for most hip replacements and in many cases amounting to as little as £1500.

Innovation and prosthesis development remain important for the future and the “Beyond Compliance” initiative from the British Orthopaedic Association (BOA) offers implant manufacturers the opportunity to go over and above the simple requirements of CE marking, facilitating an almost forensic analysis of early results and offering timely identification of any problems. Given the somewhat chequered history of some new implants, the potential benefits to patients are clear.

In the longer term, manufacturers can apply to the Orthopaedic Data Evaluation Panel (ODEP), setup at the request of The National Institute of Health and Care Excellence (NICE), for the award of an implant rating, based on multiple outcome studies. The level of rating awarded is dependent on the quality of evidence available for any prosthesis and includes an assessment of the numbers of implants being considered and the duration of follow-up. After 10 or more years, prostheses are eligible for the coveted 10A* rating, indicating a minimum cohort of 500 hips/knees at the start of the study (consisting of data from beyond the developing centre and from more than 3 centres/surgeons) with a minimum of ten years follow up and an actual revision rate of less than 5%. All deaths, loss to follow up, failures and indications for revisions recorded. A maximum of 20% loss to follow-up is permitted.

As expected, large volume data has facilitated reflective practice leading to the wider adoption of demonstrably more successful techniques, with the use of those implants with better track records now being adopted more widely by the orthopaedic community. The parallel development of more consistent and successful anaesthesia, has contributed to enhanced patient recovery after major surgery and significantly shorter hospital stays.

One-shot spinal anaesthesia associated with either sedation or a light general anaesthetic and local infiltration of longer-acting local anaesthetic agents during the procedure has facilitated early mobilization of patients. Most can walk, fully weight-bearing just 2 or 3 hours after surgery, leading to a reduction in the incidence of thrombotic events, rapid subsequent progress through the patient pathway and safe discharge home from hospital, often after as little as 2 or 3 days.

As local anaesthetics continue to develop, the prospect of significant numbers of hip and maybe even knee replacement patients being treated as day cases becomes a genuine proposition.

In the upper limb, regional an aesthesia, for example brachial plexus blocks, have already transformed the pathway for many patients, with far fewer requiring overnight stays in hospital.

Whilst these trends are set to continue, they depend heavily on established and reliable support services, particularly physiotherapy, being readily available within the communities into which the patients are to be discharged.

“Getting It Right First Time” (GIRFT) represents another example of an exemplar initiative, coming from the British Orthopaedic Association. By collecting a range of outcome data from all the acute hospitals in the country that provide orthopaedic services, a number of outcome parameters have been analysed, (including infection rates), thereby helping to address unwarranted variations between hospitals.

Further, evidence for the concentration of complex procedures in specialist centres is leading to the establishment of hub and spoke networks and whilst some patients are required to travel to regional units, the outcomes of their surgical interventions are improved and costs are reduced.

Increasingly, service funding will need to take account of the concentration of complex cases at specialist units; historically these have been relatively poorly remunerated by tariff, to make this model sustainable.

Perhaps not surprisingly, in these austere times, The Department of Health has shown a great interest in the GIRFT initiative, with methodology being translated to provide similar analyses within other surgical (and medical) disciplines.

Whilst major orthopaedic surgery in grossly obese patients can present real challenges to the surgical, anaesthetic and nursing teams, there is considerable evidence that overweight or moderately obese patients continue to benefit from joint replacement surgery. Their otherwise poor mobility and their pain may lead them to comfort eat and significant weight reduction is often at best difficult and in practice, unobtainable.

Skeletal trauma continues to challenge with its increasing complexity as our population ages and the number of older patients with multiple co-morbidities (and polypharmia), presenting with skeletal failure of one sort or another escalates. Once again, the established registers have helped determine the best surgical interventions for different groups of (eg. hip fracture) patients.

At the other end of the energy spectrum for trauma, Level 1 Trauma Centres offer comprehensive care to multiply injured patients and are associated with demonstrably lower morbidity and mortality rates, once again a result of the development of specialist regional services.

The future is rosy.

Modern bearing surfaces such as ceramics and highly cross-linked polyethylenes are associated with much better wear characteristics than predecessor materials, as demonstrated both in vitro and more importantly, in vivo and the very real expectation of greater prosthetic longevity, even in younger and more active patients.

Technological advances, including 3D printing techniques offer the ultimate of truly bespoke implants when required and when combined with increasingly biocompatible materials such as trabecular metal, provide solutions for complex reconstructions in the presence of very abnormal anatomy.

All this whilst providing great value for money!

John Nolan

Content provided by
Mr John F Nolan MBBS FRCS FRCS(Orth)

Consultant Trauma and Orthopaedic Surgeon
Norfolk and Norwich University Hospital NHS Foundation Trust
Past President, British Hip Society

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