Could better information and support before and after surgery transform joint replacement results?

Published by Arthritis Research UK | Arthritis Today | Spring 2017 | No 172

Joint replacements improve the quality of life of thousands of people with arthritis in the UK each year. More than 104,000 knee replacements and 98,000 hip replacements were performed during 2015 alone.

We know many of you have already benefited from this surgery, telling us how a new hip or knee has got you moving again, cut down on your pain and helped you to get the most out of life. However, there's still vital work to be done to help even more people to experience positive outcomes after joint replacement surgery, which is why Arthritis Research UK is funding extensive research in this area.

Recently published results from a long-term study into the benefits and limitations of knee replacement surgery give us valuable insight into where future resources should be directed. The study confirmed surgery was a highly effective treatment for knee pain, which also improved knee function. It also suggested there are key factors that can help to predict if a joint replacement is going to be successful.

Nigel Arden, Professor in Rheumatic Diseases at the University of Oxford, explains: "Research indicates the difference between a good or a bad outcome after knee replacement surgery has far more to do with the individual characteristics of the patient, than with the surgical team or the implant used. The information, advice and support given to the patient before and after the operation is crucial, as is an understanding of everything that might affect a person’s recovery.

"Knee replacements are already very successful, but we want to make them even better. Not everyone does well after surgery; around 80% of patients are satisfied with the outcome of their operation. The holy grail for our research is to be able to identify the remaining 20% before surgery, so we can intervene early and get positive results for those people too."

For better outcomes, we need better pre-operative information and care

"We’ve found better pre-operative care has a positive influence on surgical outcomes. This can be achieved in part by giving tailored advice and encouraging people to prepare for surgery, for example by doing the right exercises, perhaps losing some weight and building muscle strength around the joints. However, we need to work on personalising treatment far more than we do now."We need to work on personalising treatment far more than we do now."Nigel Arden, Professor in Rheumatic Diseases at the University of Oxford

"There are key risk factors we can do something about if we work with the patient before surgery. For example, if a person is suffering from depression they're more likely to have problems with post-operative pain. By treating the depression first, we can improve outcomes.

"Thoroughly assessing the nature of the patient’s pre-operative pain would also be a major step forwards. There’s a big difference between nerve-related or neuropathic pain and the mechanical pain arising from an injury. Effective treatment of neuropathic pain beforehand also leads to better results.

A positive attitude and realistic expectations

"Finally, an investment in high-quality information and advice that helps to manage the patient’s expectations before their surgery is crucial. Research shows a positive attitude towards the operation usually means a positive result. However, those positive expectations need to be appropriate and realistic. If you’re 80 years old, a new hip may not mean you can climb trees again but it will enable you to get back to playing bowls!

"Most people measure success by asking ‘has this new knee allowed me to do the things I enjoy doing and improved my quality of life?’ Sitting down with the patient and talking about what they want to be able to do and how feasible that is can also influence results.

"We should target research at what we can do to help the 20%. It’s a number we should be able to improve on by working closely with patients before and after their surgery."

Personalised information and advice available to everyone

This need for people considering joint replacement surgery to have access to better and more personalised information has inspired a project currently underway at the University of Sheffield and the University of Bristol. National Joint Registry data about almost two million hip and knee replacement operations is being used to create an interactive online tool for patients which can predict the risks and benefits of surgery, taking into account their age, sex, height, weight and general health. It's hoped the decision-making tool will help thousands of people every year to make an informed choice about whether surgery is right for them.

Mark Wilkinson, Professor of Orthopaedics at the University of Sheffield, who's leading the study, explains: "It’s vital a person facing a decision about joint replacement has a good understanding of all the choices available. To weigh up the positive impact a new joint can have on quality of life against the risk of complications a patient needs easy access to personalised information which directly relates to their own circumstances."It’s vital a person facing a decision about joint replacement has a good understanding of all the choices available."Mark Wilkinson, Professor of Orthopaedics at the University of Sheffield

"The potential risks and benefits of surgery vary greatly from person to person, but this isn’t often reflected in pre-operative information. We’re taking existing data about the outcomes of hip and knee replacements and making it relevant and useful for people facing surgery in the future."

The team is creating two versions of the online tool; one for the patient to work through with their doctor, whilst another simpler version will be available for use at home. The project will offer valuable insight to both patients and healthcare professionals by demonstrating how a change in one area, for example a patient losing weight or opting for a different type of prosthesis, is likely to affect the risks of surgery, as well as its impact on quality of life.

Patient groups are playing a substantial role in the development of the tool, ensuring the needs of people with arthritis are kept at the heart of the project. Professor Wilkinson says: "We want to give people with arthritis access to the information they want and need to know, in a user-friendly format. So, we’re gathering feedback from people of all ages, with all types of arthritis, at every stage to ensure this is a resource which really works for patients. People with arthritis are contributing their thoughts and ideas on everything, from the way the online tool looks, to the questions asked and the language used.

"As the project progresses we’ll be road-testing at clinics to get a feel for how it works in the real world. By improving patient information and advice before surgery we hope to be able to improve the outcomes of joint replacement surgery for even more people."

Intensive physiotherapy for those at risk

Meanwhile a research team led by Professor of Orthopaedics and Trauma at the University of Edinburgh Hamish Simpson is exploring whether intensive post-operative physiotherapy can improve outcomes for patients identified as at risk of a poor outcome after knee surgery. He explains: "Knee replacements aren't only one of the most effective surgical treatments available, they also have high patient satisfaction ratings. Most people do well after surgery with current levels of support.

"However, our research is focused on improving outcomes for those people who fall into the 20% who aren't happy with their knee post-surgery. Our aim is to identify problems and intervene early to get those people who might have fallen into that category a far better result. We want to make sure as many people as possible can enjoy life with their knee replacement."

334 people who've had knee replacements because of osteoarthritis across England and Scotland are involved in the study. Each patient was assessed six weeks after surgery using the Oxford knee score, which asks people to rate levels of pain and their ability to move and use their knee, and identified as being at risk of a poor outcome.

Professor Simpson continues: "Half of the patients received routine care, which typically means the patient has left hospital after a single physiotherapy assessment, with suggested exercises to do at home, followed by a review meeting three months later. The second group was offered 18 intensive physiotherapy sessions over six weeks; one face-to-face session each week with a physiotherapist with the patient committing to two more sessions a week at home.

"We'll assess each patient a year after their surgery to find out if this early, targeted treatment has improved their pain levels, knee functionality and satisfaction, as compared to those who received routine care. We expect to report preliminary results later this year.

"We’ve designed the programme to be practical and easy to roll out. It'd be cost effective too, as dissatisfied patients are often dealing with ongoing pain and gross stiffness which can only be treated with either another operation or long-term physiotherapy, at significant cost to the NHS.

"If early intensive physiotherapy is shown to be beneficial this approach has the potential to improve levels of pain and knee function in more than 15,000 people every year."

If you’re preparing for a joint replacement or recovering from surgery, we have a range of information and advice to help you to keep moving and get the best results possible.

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