The meetings are conducted. 'online' using a videoconference platform. (WebEx, Cisco, Feltham, UK), which allows each user to share the computer desktop.
Research
DOI: 10.1308/rcsbull.2017.66
PeerRev
The East Midlands Specialist Orthopaedic Network: the future of revision arthroplasty? It really is good to talk.
Benjamin Bloch Consultant Orthopaedic Surgeon Martin Raglan Orthopaedic Specialty Registrar Andrew Manktelow Consultant Orthopaedic Surgeon Peter James Consultant Orthopaedic Surgeon City Hospital Campus, Nottingham University Hospitals NHS Trust
66
PeerRev
T
he number of revision arthroplasties performed each year is growing. In 2015, 8,925 revision hip arthroplasties and 5,873 revision knee arthroplasties were performed in England and Wales.1 Between 2005 and 2010, the number of revision hip arthroplasties rose by 49.1% and revision knee arthroplasties by 92.1%.2 This number is predicted to rise by 31% and 332% respectively by 2030.3 It is perhaps a concern that many surgeons and units perform small numbers of revisions. The Getting It Right First Time (GIRFT) report suggested that about 80% of surgeons carrying out revision knee surgery and 60% of surgeons carrying out revision hip surgery perform fewer than 10 procedures per year.2 In the report, a recommendation was made that specialist networks be set up to support revision arthroplasty. It is hoped that specialist orthopaedic networks will have sufficient activity, share experience and promote best practice and will ultimately provide both improved clinical outcomes for patients and financial benefits for the healthcare economy as a whole. NHS England defines all types of revision hip and knee replacements as specialised orthopaedic services.4 In March 2014, NHS England invited bids to run a pilot revision network. Nottingham Elective Orthopaedic Service (NEOS), part of Nottingham University Hospitals NHS Trust (NUH), was successful and the East Midlands Specialist Orthopaedic Network (EMSON) was set up on a ‘hub-and-spoke’ model, with NUH as the hub. Meetings were held with the local units: Sherwood Forest Hospitals NHS Foundation Trust (SFH), Grantham and District Hospital (GDH), Lincoln County Hospital (LCH) and Boston Pilgrim Hospital (BPH). Together, these hospital trusts provide specialist orthopaedic services to a population of approximately four million people. An initial operating framework was agreed and meetings started on a weekly basis in January 2015. We present the early experiences of setting up and running a revision network and suggest this as a useful tool for discus-
RESEARCH Research
Table 1 Referrals to the East Midlands Specialist Orthopaedic Network by hospital Hospital
Referrals Hip
Knee
Boston Pilgrim Hospital
1
1
Management plan alterations
Loan kit needed
0
0
Grantham and District Hospital
9
7
12
9
Lincoln County Hospital
18
28
35
34
Sherwood Forest Hospitals NHS Foundation Trust
14
15
17
7
Nottingham University Hospitals NHS Trust
35
38
10
9
(n)
77
89
74
59
(%)
46
54
43
35
Total:
sion of these complicated and frequently challenging cases. METHODS Following the successful bid, specialist revision surgeons travelled to the surrounding hospitals to meet with interested consultant colleagues to seek their views, encourage their involvement and request their support. A more formal meeting with all local revision hip and knee surgeons was held subsequently, at which referral frameworks and protocols were agreed. A dedicated network coordinator was recruited and appointed. EMSON meets on a weekly basis, with referrals emailed in advance to the network coordinator via a secure NHSmail email address and using a standard pro forma (Figure 1). The meetings are conducted ‘online’ using a videoconference platform (WebEx, Cisco, Feltham, UK), which allows each user to share the computer desktop and to control the selection of radiographs displayed to the other participants. The meeting is chaired by a revision hip surgeon (ARJM) and a revision knee surgeon (PJJ) in a teleconference facility at NUH. It is attended at NUH by other arthroplasty surgeons and a specialist orthopaedic microbiologist. Other specialties such as radiology, plastic surgery, vascular or general surgery can be called upon as required. Surgeons at the ‘spoke’ hospitals can dial in from their own hospital
or from any other remote location. EMSON discussions and a proposed management plan are recorded on the referral proforma, signed by the appropriate chair and returned to be included as a permanent record in the patient’s notes. In the first 6 months of EMSON, 165 patients were discussed, involving 166 arthroplasties. The breakdown of the referrals and numbers is shown in Table 1. Of the cases discussed, 54% (89/166) have been for revision knee arthroplasties. One patient had both a problematic hip and knee replacement. In 43% of the cases (72/166), there was a recommendation to change the management plan in some way following discussion in the meeting. The majority of these changes were relatively minor and may have involved suggesting a different implant or ensuring that a standby option was available but not altering the planned surgery significantly. However, in several cases, there has been a significant alteration to the treatment plan, including changing the planned procedure from a single-stage to a two-stage approach, cancelling planned revision surgery to aspirate the affected joint and obtain a microbiological diagnosis prior to revision, and even changing the joint to be operated on. Following discussion, seven cases (4%) have been transferred to NUH for revision surgery. Analysis of the operative plan and the theatre inventories at each 67
Research
PeerRev
Table 2 Revision arthroplasty activity levels between 1 April 2014 and 31 March 2015 by hospital (source: National Joint Registry Surgeon and Hospital Profile; www.njrsurgeonhospitalprofile.org.uk) Hospital
Revision THR
Revision TKR
Nottingham University Hospitals NHS Trust
114
92
Sherwood Forest Hospitals NHS Foundation Trust
31
36
Lincoln County Hospital
22
21
Boston Pilgrim Hospital
61
15
Grantham and District Hospital
5
8
Total
233
172
THR, total hip replacement; TKR, total knee replacement
hospital revealed that, in 59 cases (35%), extra loan kit, not normally kept on the shelf, was likely to be required. DISCUSSION ‘Networking’ in orthopaedics is not a new concept, with successful ‘hub-and-spoke’ arrangements being used in the Major Trauma Network in England5 as well as multidisciplinary team management of periprosthetic infection6 and metal-on-metal implants.7 This is, however, to our knowledge the first time that a revision arthroplasty network has been reported in the literature. There has been much discussion regarding the number of procedures a surgeon undertakes per year in order to have the best outcomes. There is certainly evidence to support minimum numbers in primary total hip arthroplasty8 and it is suggested that both hospital and surgeon volume influence the revision rate of unicompartmental knee arthroplasty.9 Khatod et al have also shown that surgical experience has an effect on re-revision rates following revision hip arthroplasty,10 and both surgeon and hospital volume have been shown to influence the outcome of revision knee arthroplasty.11 Although the number of operations an individual surgeon carries out is likely to be important, the GIRFT report recommends that the specialist societies issue guidance regarding minimum numbers at unit level.2 There is less evidence regarding what constitutes a high-volume centre. In a recent review of the evidence surrounding revision knee arthroplasty, Hamilton et al12 have 68
found that the definition of a low-volume surgeon can be as few as ten cases per year, whereas the definition of a high-volume centre can be more than 200 cases per year. Although it is relatively easy to obtain such high numbers of primary joint arthroplasties, even large specialist centres will struggle to perform over 200 of both revision hip and knee arthroplasties per year. Looking at the hospitals that make up EMSON, there is clearly a major difference in revision activity. NUH, as the hub, per-
Both surgeon and hospital volume have been shown to influence the outcome of revision knee arthroplasty forms significantly more revision arthroplasties than the spoke hospitals (Table 2). Use of a specialist orthopaedic network such as EMSON is a useful way to build up a critical mass of revision arthroplasty cases, as well as to improve communication between the hospitals, facilitate discussion between revision arthroplasty surgeons and, when required, facilitate the transfer of patients to a more appropriate surgical environment.
The expectation is that this will improve outcomes, reduce costs and deliver the highest quality of specialist orthopaedic care to all patients within the region. Initial difficulties
There have been significant logistical difficulties with setting up the revision network. There have been issues around access and integration of the various picture archive and communications systems and in finding a suitable day of the week to hold the meetings. It is a time-consuming process, taking up to two hours each week, and it has been difficult to free up all the region’s revision surgeons at the same time each week to discuss cases. Consultant job plan reviews have been undertaken to accommodate this meeting, but there is no ‘best’ time for such a meeting to be held. It is important to recognise this commitment in a consultant’s planned activities and timetable. The WebEx portal allows surgeons to dial in remotely from home or other locations, thus potentially improving attendance. Even at the hub hospital, some cases have not been presented owing to surgeon non-availability when the meeting clashes with other commitments. When this occurs, efforts have been made to discuss cases retrospectively. Similarly, cases are discussed retrospectively when an urgent revision procedure has been required and it is not practical to wait until the next meeting. There have been logistical information technology issues as well, which have needed to be overcome to ensure that all surgeons can connect to the WebEx interface via their NHS hospital computers. NHS England had set a target of 100% of all revisions undertaken at the spoke hospitals being discussed by March 2015. This was unfortunately not achieved, predominantly because of difficulties making contact with one of the hospitals, despite multiple attempts by our consultant chairmen and network coordinator. Although this hospital has now started contributing to the meeting, it has raised the question of how to encourage engagement with the network and whether
PeerRev
incentives or sanctions can be imposed on those hospitals or surgeons that fail to engage. It may be that financial inducement and consequences in the form of a revision arthroplasty best-practice tariff would help in this regard, as suggested in the GIRFT report.2 It should be noted that there has been excellent early ‘buy-in’ from all the region’s revision arthroplasty surgeons, with continued regular attendance, even when those surgeons do not themselves have cases to discuss. This demonstrates commitment to the concept and an appreciation of the potential benefits of a specialist orthopaedic network.
Research
Figure 1 The East Midlands Specialist Orthopaedic Network referral pro forma
East Midlands Specialist Orthopaedic Network (EMSON) Referral Pro Forma Patient details
Network referral date
Urgent/routine
Presentation
Breach date:
6 min./12 min.
Extended specialist needed (e.g. plastic surgery) State type
Surgical history (date of primary, implant, complications, previous returns to theatre, soft tissue concerns)
Current history/concerns
Future direction
The GIRFT report states that there is a need to rationalise the number of hospitals undertaking revision procedures.2 In the first six months, we have not seen many patients transferred after discussion at the network level, but this may be because these are patients about whom a decision has already been made to operate and the presenting surgeon is prepared to perform the case. Transfer of cases remains a definite option for a variety of reasons, whether increased experience, help from other medical, surgical or intensive care specialties or decreased use of loan kit. Referring surgeons are also encouraged to come to NUH with the possibility of joint operating being available and encouraged. Interestingly, the two senior authors (ARJM and PJJ) have also noticed an 18% increase in tertiary referrals to their clinics from the other network hospitals since EMSON started compared with the same time period in 2015. We will continue to monitor this trend as this may well lead to a decrease in the unit numbers of revision arthroplasty being performed at the spoke hospitals. We do not feel that all revision arthroplasties should be, or need to be, performed in specialist centres, for both logistical and financial reasons. Under current remuneration, it can be difficult for hospitals to cover the costs of revision arthroplasty13,14 and a specialist hospital taking such a large
Comorbidities (including relevant medications, allergies, BMI)
Patient views/preference
Investigation Blood tests (date) X-ray (date) FBC ESR CRP Other Clinician’s proposed plan (optional) Network proposals
Other (date)
Specialist equipment needed (e.g. loan kit)
Signed:
(Chair)
increase in revision work could be financially disadvantaged, both through losing money in the revision arthroplasty and the loss of other elective surgical capacity which is generally more profitable. Our spoke hospitals also perform enough revision arthroplasties to support specialist and experienced arthroplasty surgeons. However, we suggest that
consideration be given to the concentration of particular types of revision arthroplasty in specialist centres and, for example, with the presence of microbiologists with a specialist orthopaedic infection interest in the hub hospital, it would be prudent for these cases to be transferred to the unit best able to deal with them. Surgical factors such as complex 69
Research
PeerRev
implant removal, availability of instrumentation and inventory and the management of soft-tissue defects may also need to be considered when identifying patients who might best be transferred. Other non-surgical issues, such as critical care facilities and other medical specialty support availability, can also be taken into account; one of the cases transferred following discussion had severe renal impairment prior to surgery and was therefore transferred more owing to the availability of dialysis support at NUH than any surgical consideration. Similarly, one of the major costs of revision arthroplasty is in the loan of rarely used instrumentation for isolated cases. The GIRFT report has a stated aim of decreasing revision loan kit usage by 90%, thus potentially saving £21 million per year.2 For this reason, we suggest that more complicated cases that are likely to require specialist instrumentation should, in future, be transferred to the hub hospital where the required instrumentation is likely to be available. The hub hospitals may need to increase their available inventory to deal with this potential activity. It is likely that EMSON will be expanded in future and separate meetings will be set up covering other orthopaedic subspecialties such as shoulder and elbow and foot and ankle surgery. Surgeon feedback
Surgeons taking part in EMSON have been asked for their feedback, which has generally been very positive. The comments have stated that EMSON has improved surgical confidence and helped with planning. In one case, the surgeon suggested that until EMSON started he had not had anyone else readily available to discuss complicated cases with. In this regard, we have noticed that EMSON has also become a forum for discussing more complex primary arthroplasties as well, and this is actively encouraged. One early criticism was that it was thought that NUH was not presenting all of their revision cases. This was not the 70
intention when EMSON was set up. We feel that it is important in maintaining clinician engagement that all hospitals are treated equally. We endeavour to ensure that there is no suggestion that the hub is somehow ‘checking up’ on the spoke hospitals. There are certainly time considerations and the pressures of attempting to discuss up to ten cases every week resulted in a reduction in the percentage of NUH’s cases that were being discussed initially. Steps have now been taken to rectify this. CONCLUSION We feel that a specialist revision network is an ideal way to discuss cases, improve links between the local district general hospitals and specialist hospitals and, most importantly, to improve patient care. Although we have not as yet seen many patients transferred from the meeting to NUH, we have seen an increase in direct tertiary referrals from the spoke hospitals. Longer term, we plan to investigate whether patient outcomes are improved and whether the network has had financial benefits for the local health economy. We feel that the concepts involved in EMSON are very much in keeping with the current orthopaedic thinking outlined in the GIRFT report.2 We also feel that patient care in these difficult and complex operations can only be improved by such peer-reviewed discussion and planning.
References 1. National Joint Registry. 12th Annual Report, 2015: Surgical Data to 31 December 2014. Hemel Hempstead: National Joint Registry for England, Wales, Northern Ireland and the Isle of Man; 2015. 2. Briggs T. Getting It Right First Time: Improving the Quality of Orthopaedic Care within the National Health Service in England. Stanmore: Royal National Orthopaedic Hospital; 2012. 3. Patel A, Pavlou G, Mujica-Mota RE, Toms AD. The epidemiology of revision total knee and hip arthroplasty in England and Wales. Bone Joint J 2015; 97-B: 1,076–1,081. 4. NHS England. NHS Standard Contract for Specialised Orthopaedics (Adult). Schedule 2 – The Services A. Service Specifications. NHS England/D10/S/a. NHS England, (2013). 5. Metcalfe D, Bouamra O, Parsons NR et al. Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres. Br J Surg 2014; 101(8): 959–964. 6. Ibrahim MS, Raja S, Khan MA et al. A multidisciplinary team approach to two-stage revision for the infected hip replacement: a minimum five-year follow-up study. Bone Joint J 2014; 96-B: 1,312–1,318. 7. Berber R, Pappas Y, Khoo M et al. A new approach to managing patients with problematic metal hip implants: the use of an internet-enhanced multidisciplinary team meeting. J Bone Joint Surg Am 2015; 97(4) :e20. doi: 10.2106/JBJS.N.00973. 8. Ravi B, Jenkinson R, Austin PC et al. Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study. BMJ 2014; 348: g3284. 9. Baker P, Jameson S, Critchley R et al. Center and surgeon volume influence the revision rate following unicondylar knee replacement. An analysis of 23,400 medial cemented unicondylar knee replacements. J Bone Joint Surg Am 2013; 95(8): 702–709. 10. Khatod M, Cafri G, Inacio MCS et al. Revision total hip arthroplasty: factors associated with re-revision surgery. J Bone Joint Surg Am 2015; 97(5): 359–366.
Acknowledgements
We are very grateful to and are keen to acknowledge the contribution and commitment of the consultants who submit cases to and participate in EMSON: these include A Broodryk, M Hatton, K Sehat, P Szypryt, T Westbrook, (all NUH), A Aladin, R Chari, V Desai, S Kulkarni, B Srinivasan (all SFH), P Antapur, D Gale, M Rowsell (all LCH), A Othman (GDH), H Minhas (BPH). We would also like to particularly acknowledge the work of our coordinator, Laura Mends, and our manager, Mike Bullock, who was instrumental in the setting up of EMSON.
11. Critchley RJ, Baker PN, Deehan DJ. Does surgical volume affect outcome after primary and revision knee arthroplasty? A systematic review of the literature. Knee 2012; 19(5): 513–518. 12. Hamilton DF, Howie CR, Burnett R et al. Dealing with the predicted increase in demand for revision total knee arthroplasty: challenges, risks and opportunities. Bone Joint J 2015; 97-B: 723–728. 13. Vanhegan IS, Malik AK, Jayakumar et al. A financial analysis of revision hip arthroplasty: the economic burden in relation to the national tariff. J Bone Joint Surg Br 2012; 94-B: 619–623. 14. Kallala RF, Vanhegan IS, Ibrahim MS et al. Financial analysis of revision knee surgery based on NHS tariffs and hospital costs: does it pay to provide a revision service? Bone Joint J 2015; 97-B: 197–201.
