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The Bone & Joint Journal
Vol. 106-B, Issue 6 | Pages 582 - 588
1 Jun 2024
Bertram W Howells N White SP Sanderson E Wylde V Lenguerrand E Gooberman-Hill R Bruce J

Aims

The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA).

Methods

Between 2016 and 2019, 363 patients with troublesome pain, defined as a score of ≤ 14 on the Oxford Knee Score pain subscale, three months after TKA from eight UK NHS hospitals, were recruited into the Support and Treatment After Replacement (STAR) clinical trial. Self-reported neuropathic pain and postoperative pain was assessed at three, nine, and 15 months after surgery using the painDETECT and Douleur Neuropathique 4 (DN4) questionnaires collected by postal survey.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_13 | Pages 28 - 28
7 Aug 2023
Bertram W Wylde V Glynn J Penfold C Burston A Johnson E Rayment D Howells N White S Gooberman-Hill R Whale K
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Abstract

Introduction

There is a need to develop approaches to reduce chronic pain after total knee replacement. There is an established link between disturbed sleep and pain. We tested the feasibility of a trial evaluating the clinical and cost-effectiveness of a pre-operative sleep assessment and complex intervention package for improving long-term pain after TKR.

Methodology

REST was a feasibility multi-centre randomised controlled trial with embedded qualitative study and health economics. Participants completed baseline measures and were randomised to usual care or the intervention, a tailored sleep assessment and behavioural intervention package delivered by an extended scope practitioner three months pre-operatively with a follow-up call up at four-weeks. Patient reported outcomes were assessed at baseline, one-week pre-surgery, and 3-months post-surgery.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_13 | Pages 50 - 50
7 Aug 2023
Bertram W Wylde V Howells N Shirkey B Peters T Zhu L Noble S Moore A Beswick A Judge A Blom A Walsh D Eccleston C Bruce J Gooberman-Hill R
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Abstract

Introduction

Approximately 15–20% of patients report chronic pain three months after total knee replacement (TKR). The STAR care pathway is a clinically important and cost-effective personalised intervention for patients with pain 3 months after TKR. The pathway comprises screening, assesment, onward referral for treatment and follow-up over one year. In a multicentre randomised controlled trial comparing the pathway with usual care, the pathway improved pain at 6 and 12 months. This study examined the longer-term clinical and cost-effectiveness of the STAR care pathway.

Methodology

STAR trial participants were followed-up at a median of 4 years post-randomisation. Co-primary outcomes were self-reported pain severity and interference in the replaced knee, assessed with the Brief Pain Inventory (BPI). Resource use from electronic hospital records was valued with UK reference costs.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_13 | Pages 45 - 45
7 Aug 2023
Bertram W Wylde V Woodward T Gooberman-Hill R Whitehouse M Howells N
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Abstract

Introduction

Total knee replacement (TKR) aims to reduce pain and functional limitations. Despite a good outcome for many, 15–20% patients report chronic pain three months after TKR.

The STAR Care Pathway is a clinically important and cost effective treatment to improve pain outcomes over 1 year for people with chronic pain at 3 months after total knee replacement surgery. The care pathway is delivered by specially trained Extended Scope Practitioners (ESPs).

There is a gap between research findings and translation into practice. This work shows how the STAR trial findings were implemented into NHS practice at a single centre and the further work required to enable national implementation.

Methodology

Trial findings were presented to NHS managers with a business case for an implementation pilot. Trial documentation was adapted for use in usual care using the COM-B model for behaviour change and evidence-based approaches to increase the return of postal questionnaires. Trial sites were contacted to understand their capacity to implement the intervention locally.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_13 | Pages 44 - 44
7 Aug 2023
Bertram W Howells N White S Sanderson E Wylde V Lenguerrand E Gooberman-Hill R Bruce J
Full Access

Abstract

Introduction

Total knee replacement (TKR) is a successful operation for many patients, however 15–20% of patients experience chronic post-surgical pain (CPSP). Many will experience neuropathic characteristics.

We describe the prevalence and patterns of neuropathic pain in a cohort of patients with CPSP three months after TKR.

Methodology

Between 2016–2019, 363 patients with troublesome pain, ≤14 on Oxford Knee score pain subscale, at three months after TKR from eight NHS hospitals were recruited into the Support and Treatment After Replacement (STAR) trial. Self-reported neuropathic pain was assessed at three, nine and fifteen months after surgery using painDETECT and Douleur Neuropathique 4 (DN4).


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_2 | Pages 120 - 120
1 Jan 2017
Wylde V Moore A Howells N MacKichan F Bruce J McCabe C Blom A Dieppe P Gooberman-Hill R
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Around 20% of patients who have total knee replacement find that they experience long-term pain afterwards. There is a pressing need for better treatment and management for patients who have this kind of pain but there is little evidence about how to improve care. To address this gap we are developing a complex intervention comprising a clinic to assess potential causes of a patient's long-term pain after knee replacement and onwards referral to appropriate, existing services. The Medical Research Council recommends that development of complex interventions include several stages of development and refinement and involvement of stakeholders. This study comprises the penultimate stage in the comprehensive development of this intervention. Earlier stages included a survey of current practice, focus groups with healthcare professionals, a systematic review of the literature and expert deliberation.

Healthcare professionals from diverse clinical backgrounds with experience of caring for patients with long-term pain after knee replacement were sent a study information pack. Professionals who wished to participate were asked to return their signed consent form and completed study questionnaire to the research team. Participants rated the appropriateness of different aspects of the assessment process and care pathway from 1–9 (not appropriate to very appropriate). Data were collated and a document prepared, consisting of anonymised mean appropriateness ratings and summaries of free-text comments. This document was then discussed in 4 facilitated meetings with healthcare professional held at the future trial centres. A summary report and revised care pathway was then prepared and sent to participants for further comments.

28 professionals completed the questionnaire and/or attended a meeting. Participants included surgeons, physiotherapists, nurses, pain specialists and rheumatologists. Mean appropriateness scores ranged from 6.9 to 8.4. Taking a score of 7–9 as agreement, consensus was achieved that the assessment should be performed at 3 months post-operative by an extended scope practitioner/nurse, treatment be guided by a standardised assessment of pain, and treatment individualised. There was also agreement that referrals in the care pathway to surgical review, GP and pain clinics were appropriate. Nurse-led/self-monitoring was rated lower (6.9) because of considerations about the need to ensure that patients receive appropriate support, follow-up and referral to other services.

This work demonstrates the research methods that can be used to refine the design of a complex intervention. The process and findings enable refinement of an intervention for patients with long-term pain after knee replacement. The next stage of intervention development will assess the acceptability and reliability of the assessment process, and the usability of the intervention's standard operating procedures. The intervention will then be evaluated by a larger research team in a multi-centre randomised controlled trial, starting in late 2016.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_9 | Pages 21 - 21
1 Feb 2013
Howells N Barnett A Ansari A Ahearn N Eldridge J
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This study is a prospective analysis of clinical outcome in 201 consecutive patients treated with medial patellofemoral ligament reconstruction using an autologous semitendinosus graft between October 2005 and January 2011. Patients received pre and post-operative clinical evaluation, radiological assessment and outcome scoring systems.

193 patients (92 male, 119 female) underwent 211 procedures, with mean age 26 (16–49) and follow-up 16 months (6–42 months). Indications were atraumatic recurrent patella dislocation (68%), traumatic recurrent dislocation (22.8%), instability (5%), single dislocation (2.7%) and anterior knee pain (1.4%). Trochlea dysplasia was moderate in 57% and mild in 35%.

There have been no recurrent dislocations/ subluxations. 10 patients have required further surgery. The mean pre-op Kujala Scores were 55 (SE 5.21) and post-op scores improved to mean 82 (31–100) (SE 1.18)(p < 0.001). This improvement and significance is mirrored with Oxford (27 to 41), WOMAC (76 to 93), Fulkerson (53 to 83), IKDC (46 to 75), Tegner (4.1 to 5.3) and SF12 (38 to 51) scores (p < 0.005). 93% of patients were satisfied with their operation. History of prior realignment surgery was associated with significantly worse outcomes compared to patients where MPFL reconstruction was their first realignment procedure (p < 0.05).

This series is the largest reported in the literature for any technique of MPFL surgery. This technique allows for objective intra-operative evaluation of the required graft tension to optimise patella tracking.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XIX | Pages 12 - 12
1 May 2012
Corbett L Howells N Burston B Mitchell S
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Optimal utilisation of operating theatres has a significant impact on the ability of an institution to deliver productive, value for money surgical services. With the recent introduction of the national ‘Productive Theatres’ programme and in the current economic climate it is receiving increasing attention. In addition, it improves patient satisfaction and outcomes, reduces adverse events and has positive influences on staff morale. The aim of this study was to highlight factors influencing trauma theatre utilisation in general, whilst also addressing any problems identified with a view to improving trauma services locally. We conducted a prospective analysis of activity in the trauma theatre at our institution over 1 month. Direct observation was performed by a single independent observer. In the absence of any published guidelines, all theatre lists were assessed against pre-determined standards for each component of the theatre pathway. Overall end utilisation (combined time utilised for anaesthesia and surgery) was found to be low at 65%. A number of factors were found to contribute to inefficiencies including delay in sending for patients (mean 42mins, range 0-105), prolonged patient transit times to theatre (mean 22% of all sessions), late starts to lists (mean 43 mins, range 15-105 mins) waiting for x-ray availability (mean 21mins, range 10-45) and knock on delay from previous lists. Surgeons and anaesthetists were found to be, overall, arriving on time or early for all lists. Strategies for maximising trauma theatre productivity are essential. This study has identified common issues, of potential benefit to numerous institutions when planning trauma services.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XIX | Pages 14 - 14
1 May 2012
Maclean A Howells N Blewitt N
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Scaphoid injuries remain a challenge in both diagnosis and subsequent management. Untreated scaphoid non-union leads to inevitable osteoarthritis. Non-unions are picked up via an established management pathway in out trust and treated surgically with a standardised technique of non-vascularised bone grafting and retrograde screw fixation. Patients that underwent primary screw fixation and grafting for scaphoid non-union between 2004-2008 were reviewed. These patients were followed up clinically and radiologically. They were assessed for time to union, complications, DASH score, patient satisfaction and return to work. In addition comparison was made between the use of Herbert screw and Twinfix screw fixation and between tricortical iliac crest graft and corticocancellous distal radial bone graft. Forty-two consecutive patients underwent surgery of which 35 (83%) were available for follow up. Mean follow up was 39 months (range 13-72). 31 (89%) patients had gone on to radiological union. Of those united the mean DASH score was 11. Mean time to union was 4.4 months (range 2-15 95% CI 3.3 – 5.5). 95% of patients were satisfied with their operation and would recommend it to a friend in the same situation. No significant difference in outcomes were identified between Herbert screw and Twinfix screw fixation or between iliac crest or distal radial bone grafting techniques. This study has shown encouraging results for an established protocol for management of scaphoid non-union. Outcomes are as a good as any published comparable series in the literature and provide further support to the use of this technique.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_IV | Pages 56 - 56
1 Mar 2012
Howells N Price A Carr A Rees J
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Objective

To investigate the effect of lab-based simulator training, on the ability of surgical trainees to perform diagnostic knee arthroscopy.

Method

20 orthopaedic SHOs with minimal arthroscopic experience were randomised to 2 groups. 10 received a fixed protocol of simulator based arthroscopic skills training using a bench-top knee model. Learning curves were clearly demonstrated using motion analysis equipment to monitor performance. All 20 then spent an operating list with a blinded consultant trainer. They received instruction and demonstration of diagnostic knee arthroscopy before performing the procedure independently. Their performance was assessed using the intra-operative section of the Orthopaedic Competence Assessment Project (OCAP) procedure based assessment (PBA) protocol for diagnostic arthroscopy. Performance was further quantified with a ten point global rating assessment scale.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 549 - 549
1 Oct 2010
Howells N Hughes A Livingstone J Moore A Tompsett E
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Introduction: Utilisation of day case surgery units for orthopaedic trauma is an uncommon concept. Limited reports of its use in specific orthopaedic trauma cases have been encouraging. There is currently no formal provision for day case surgery for trauma patients at our institution. The aim of this study was to identify the proportion of trauma patients that would be suitable for daycase surgery and the proportion of these that currently undergo procedures as a day case, with a view to establishing a more formalised daycase trauma service.

Methods: We undertook prospective data collection on all trauma referrals in our institution over a 1 month period in January 2008. Information was recorded for date and time of referral, admission, operation and discharge. Nature of injury, type of procedure performed, grades of surgeon involved and length, nature and reason for any pre or post-operative delay was also recorded. All patients requiring surgery were assessed on their suitability for day case as defined by pre-determined patient-related and surgery-related criteria.

Results: Of all the patients referred during the study period 129 patients required surgery. Of the operated patients 80 (62%) had a procedure suitable to be performed as a day case as defined by surgical factors. Of these, 57 (44%) patients met criteria for day surgery as defined by patient factors. Of those eligible for day case surgery (n=57), only 27% had their procedures performed as a day case. The total number of additional days spent in hospital by day case eligible patients was 69. 34 days were due to pre-operative delay and 35 were due to post operative delay. The mean number of pre operative days in hospital was 1.33(range 0–3) and post operative days 1.85 (range 0–8). There was a wide case mix of procedures performed that were deemed appropriate for day case surgery. 76% were upper limb or soft tissue procedures.The causes for pre-operative delay established two main issues. Limited dedicated operating theatre capacity for day case eligible procedures resulting in their de-prioritisation and limitations on dedicated bed availability. The cause for postoperative delay was more variable but on the whole was for reasons which with appropriate protocols could have been avoided.

Conclusions: This study has identified that a significant proportion of orthopaedic trauma workload would be appropriate to be carried out as a day case. Without an appropriate day case surgery setup, current delays are causing 69 unnecessary bed days per month in our institution. Causes for current delays are related to lack of synchrony between timing of admission and surgery and lack of appropriate discharge protocols. We are in the process of developing a plan for implementation of a dedicated day case trauma service at our institution and suggest that this may be an appropriate use of day case facilities in other trusts.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 262 - 262
1 May 2009
Howells N Auplish S Hand C Gill H Carr A Rees J
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Aim: To investigate the capacity for retention of arthroscopic technical skills.

Methods: Six consultant lower limb surgeons were given standardized instruction on how to perform an arthroscopic Bankart suture on a lab-based ALEX shoulder model. Each surgeon then performed a suture repair three times and returned to repeat the process on four consecutive occasions, approximately two weeks apart. Six months later the same surgeons returned again to repeat the entire process. They received no further tuition or instruction. Their performance was objectively assessed throughout using validated motion analysis equipment to produce learning curves using time taken, number of movements and total path length.

Results: The initial learning curves and the learning curves at 6 months were the same.

Conclusions: Arthroscopic skills were not retained over a 6 month period. The same learning curves were identified suggesting the need for regular repetition of this simulated task if the level of learning is to be maintained. This has implications for technically difficult arthroscopic procedures suggesting a minimum level of frequency is needed to maintain optimum surgical performance.