Safety of disinvestment in mid- to late-term follow-up post primary hip and knee replacement: The UK SAFE evidence synthesis and recommendations

Kingsbury, Sarah R; Smith, Lindsay K; Czoski Murray, Carolyn J; Pinedo-Villanueva, Rafael; Judge, Andrew; West, Robert; Smith, Chris; Wright, Judy M; Arden, Nigel K; Thomas, Christine M; Kolovos, Spryos; Shuweihdi, Farag; Garriga, Cesar; Bitanihirwe, Byron KY; Hill, Kate; Matu, Jamie; Stone, Martin; Conaghan, Philip G

Abstract

Background: Joint replacement surgery has revolutionised the management of degenerative joint disease. Increasing demand for surgery and post-surgical reviews has overwhelmed orthopaedic services and, consequently, many centres have reduced or stopped follow-up. Such disinvestment is without an evidence base and raises questions regarding the consequences to patients. Objectives: To produce evidence-and consensus-based recommendations as to how, when and on whom follow-up should be conducted. Our research question was ‘Is it safe to disinvest in mid-to late-term follow-up of hip and knee replacement?’. Methods: The study comprised three complementary evidence synthesis work packages to inform a final consensus process. Work package 1 was a systematic review of the clinical effectiveness and cost-effectiveness literature. Work package 2 used routine national data sets (i.e. the Clinical Practice Research Datalink–Hospital Episode Statistics, Hospital Episode Statistics–National Joint Registry–patient-reported outcome measures) to identify pre, peri and postoperative predictors of mid-to late-term revision, and prospective data from 560 patients to understand how patients present for revision surgery. Work package 3 used a Markov model to simulate the survival, health-related quality of life and NHS costs of patients following hip or knee replacement surgery. Finally, evidence from work packages 1–3 informed a face-to-face consensus panel, which involved 32 stakeholders. Results: Our overarching statements are as follows: (1) these recommendations apply to post primary hip and knee replacement follow-up; (2) the 10-year time point in these recommendations is based on a lack of robust evidence beyond 10 years; and (3) in these recommendations, the term ‘complex cases’ refers to individual patient and surgical factors that may increase the risk of replacement failure. Our recommendations are as follows: for Orthopaedic Data Evaluation Panel 10A* (ODEP-10A*) minimum implants, it is safe to disinvest in routine follow-up from 1 to 10 years post non-complex hip and knee replacement provided that there is rapid access to orthopaedic review; (2) for ODEP-10A* minimum implants in complex cases or non-ODEP-10A* minimum implants, periodic follow-up post hip and knee replacement may be required from 1 to 10 years; (3) at 10 years post hip and knee replacement, clinical and radiographic evaluation is recommended; and (4) after 10 years post hip and knee replacement, frequency of further follow-up should be based on the 10-year assessment (note that ongoing rapid access to orthopaedic review is still required) [Stone M, Smith L, Kingsbury S, Czoski-Murray C, Judge A, Pinedo-Villanueva R, et al. Evidence-based follow-up recommendations following primary hip and knee arthroplasty (UK SAFE). Orthop Proc 2020;102–B:13. https://doi.org/10.1302/1358-992X.2020.5.013]. Limitations: The current absence of data beyond 10 years restricted the evidence base. Conclusions: For ODEP-10A* prostheses, the UK SAFE programme demonstrated that it is safe to disinvest in routine follow-up in the 1-to 10-year period after non-complex hip and knee replacement. At 10 years, clinical and radiographic review is recommended. Complex cases, implants not meeting the 10A* criteria and follow-up after revision surgery are not covered by this recommendation.

• Journal Article Type: Article
• Acceptance Date: May 6, 2022
• Online Publication Date: Jun 28, 2022
• Publication Date: Jun 28, 2022
• Deposit Date: Jun 28, 2022
• Publicly Available Date: Jun 29, 2022
• Journal: Health and Social Care Delivery Research
• Print ISSN: 2755-0060
• Electronic ISSN: 2755-0079
• Publisher: NIHR Journals Library
• Peer Reviewed: Peer Reviewed
• Volume: 10
• Issue: 16
• Pages: 1-172
• DOI: https://doi.org/10.3310/KODQ0769
• Keywords: orthopaedic services; Joint replacement surgery; orthopaedic services; orthopaedics; arkov mode; complex cases; hip replacement; knee replacement; degenerative joint disease; UK SAFE evidence synthesis
• Public URL: https://uwe-repository.worktribe.com/output/9664822
• Publisher URL: https://www.journalslibrary.nihr.ac.uk/hsdr/KODQ0769#/abstract