Surgery (St Vincent's) - Research Publications

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    Sham surgery: justified but practical? A systematic review of sham surgery trials in orthopaedics
    Bunzli, S ; Dowsey, MM ; Choong, PF (Academy of Science of South Africa, 2018)
    BACKGROUND: An increasing trend for sham surgery trials in minor orthopaedic procedures has been observed. Trial outcomes have changed the practice landscape of these procedures. However, there has been no sham surgery trial in a major orthopaedic procedure. The aims of this systematic review were to consider the ethics of sham surgery trials; to describe orthopaedic sham surgery trials conducted to date; and to consider the challenges that will need to be overcome in order to conduct sham surgery trials for major orthopaedic procedures in the future. METHODS: A systematic review of the literature and clinical trial registries was undertaken. Trials with a published main findings paper underwent a risk of bias assessment using the Cochrane Collaboration risk of bias tool, in addition to an ethical assessment based on the work of Horng and Miller. RESULTS: We identified 22 sham surgery trials for minor orthopaedic procedures that have been completed, terminated, or are currently in process. Among the ten trials with a published main findings paper, only one was free from risk of bias; all others were at risk of bias. According to the ethical assessment, the benefits of a sham control were outweighed by the risks in all but two of the ten trials. Across the 22 trials with published and unpublished main findings, participant recruitment within reasonable timeframes, as well as the low threshold for crossover from the sham were recurring challenges. CONCLUSIONS: Researchers are obliged to carefully consider the feasibility of conducting a sham surgery trial in a major orthopaedic procedure, before drawing on limited research funds. Exploring the conditions under which patients and surgeons would find participation in a sham surgery trial acceptable, and simulating trial costs based on patient and surgeon preferences may assist funders, assessors and ethics boards to determine whether to support the conducting of future sham surgery trials in major orthopaedic procedures.
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    Review of knee arthroscopic practice and coding at a major metropolitan centre
    Lisik, JP ; Dowsey, MM ; Petterwood, J ; Choong, PFM (WILEY, 2017-05)
    BACKGROUND: Arthroscopic knee surgery has been a topic of significant controversy in recent orthopaedic literature. Multiple studies have used administrative (Victorian Admitted Episodes Dataset and Centre for Health Record Linkage) data to identify trends in practice. This study explored the usage and reporting of arthroscopic knee surgery by conducting a detailed audit at a major Victorian public hospital. METHODS: A database of orthopaedic procedures at St Vincent's Hospital Melbourne was used to retrospectively identify cases of knee arthroscopy from 1 December 2011 to 1 April 2014. Procedures were categorized as diagnostic or interventional, and native and prosthetic joints were analysed separately. Procedure codes were reviewed by comparing a registrar, auditor and hospital coders for agreement. RESULTS: Of the 401 cases for analysis, 375 were conducted in native knees and 26 in prosthetic joints. Of native knees, 369 (98.4%) were considered interventional. The majority of these were conducted for meniscal pathology (n = 263, 70.1%), osteoarthritis (OA) (n = 25, 6.7%) and infection (n = 28, 7.6%). Comparison of codes assigned by different parties were found to be between 57% (k = 0.324) and 70% (k = 0.572) agreement, but not statistically significant. CONCLUSIONS: In this study, the most common indication for arthroscopy was meniscal pathology. Arthroscopy was rarely performed for OA in the absence of meniscal pathology. Diagnostic arthroscopy was rarely performed in the native knee, and fair to moderate agreement existed between parties in assigning Medicare Benefits Schedule procedure codes.
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    Impact of surgical experience on outcomes in total joint arthroplasties
    Wilson, MD ; Dowsey, MM ; Spelman, T ; Choong, PFM (WILEY-BLACKWELL, 2016-12)
    BACKGROUND: Outcomes of primary total hip and knee arthroplasties performed by consultant surgeons were compared with those performed by orthopaedic trainees. Furthermore, outcomes of these procedures performed by senior trainees were compared with those performed by junior trainees. METHODS: Data from the St Vincent's Melbourne Arthroplasty Outcomes Registry and the surgical log kept by trainees were reviewed to investigate if an association exists between surgical experience and clinical outcomes following primary total hip and knee arthroplasties. Multivariate logistic regression analyses were conducted to produce odds ratios with 95% confidence intervals to assess these relationships. RESULTS: Arthroplasties performed by trainees were not significantly different from those performed by consultant surgeons in regards to medical, surgical and wound complications. Trainee-performed primary total hip arthroplasties were associated with a 30% increase in the risk of requiring a transfusion compared with consultant cases. Primary total knee arthroplasties performed by junior trainees were associated with a 50% increase in the risk of developing a wound complication compared with those performed by senior trainees. CONCLUSIONS: Overall, senior orthopaedic trainees working independently and junior orthopaedic trainees under supervision as the primary surgeon have the ability to achieve a level of clinical outcomes similar to a consultant surgeon. Junior trainees with supervision have the ability to achieve a level of clinical outcomes similar to senior trainees. These findings can be used to further improve orthopaedic training to reduce adverse events during supervised surgery.
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    Functional and clinical outcomes following anterior hip replacement: a 5-year comparative study versus posterior approach
    Balasubramaniam, U ; Dowsey, M ; Ma, F ; Dunin, A ; Choong, P (WILEY, 2016-07)
    BACKGROUND: With the evolution of total hip joint replacement techniques, there has been a trend towards minimally invasive surgery. The anterior approach (AA) to total hip arthroplasty has been widely associated with less soft tissue damage. The aim of our study was to compare clinical and 1-year functional outcomes for AA hip arthroplasty versus a posterior approach (PA). METHOD: We retrospectively reviewed 92 (50 anterior and 42 posterior) total hip replacements performed at our centre between 2006 and 2011. Clinical outcomes were recorded from hospital medical records and clinical audit system. Range of motion analysis, Harris hip score (HHS) and Short Form-12 score were recorded pre-operatively and at the 12-month follow-up marks. Additionally, we reviewed operative time, length of stay, discharge destination, complications, return to theatre and readmission rates. RESULTS: The results of our study revealed significantly shorter average hospital length of stay for the AA versus PA (4.2 versus 6.0 days, P = 0.004). Interestingly, our study also showed significantly shorter operating time with the AA (83.0 versus 91.8 min, P = 0.048) and lower return to theatre rates (0 versus 9.5%, P = 0.026). Finally, multivariate analysis showed AA to be associated with higher HHS and pre-operative body mass index to be associated with lower HHS at 12-month post-operation (P = 0.02 and <0.001, respectively). CONCLUSIONS: Our study showed improved HHS at 12 months as well as reduced hospital length of stay, operating time and return to theatre with an AA when compared with a PA.
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    What is the role of catheter antibiotic prophylaxis for patients undergoing joint arthroplasty?
    Scarlato, R-M ; Dowsey, MM ; Buising, KL ; Choong, PFM ; Peel, TN (WILEY, 2017-03)
    BACKGROUND: Antimicrobial prophylaxis at the time of urinary catheter insertion and removal is commonly administered in patients undergoing joint arthroplasty, despite the lack of evidence to support this practice. The rationale is the theoretical risk of prosthetic joint infection arising from bacterial seeding from the urinary tract at the time of catheterization. In an era of antimicrobial stewardship, further assessment is warranted. METHODS: This study aimed to investigate the incidence of catheter-associated (CA) bacteriuria and bacteraemia in patients undergoing total joint arthroplasty and to assess the antimicrobial susceptibility of any isolated microorganisms. This prospective observational study undertaken over a 6-month period (May to October 2014) included 99 patients undergoing elective primary hip and knee arthroplasty at St Vincent's Hospital, Melbourne. Urine specimens were collected at insertion and removal of urinary catheters along with blood cultures upon urinary catheter removal. RESULTS: Overall 98% of the cohort received catheter antimicrobial prophylaxis for urinary catheter insertion and removal; the majority of patients received gentamicin (94%). Bacteriuria on catheter insertion had an incidence of 4.4%. The incidence of CA bacteriuria was 1.3%. All cultured organisms were sensitive to commonly used antibiotics including cephazolin. There were no cases of bacteraemia with urinary catheter removal. Increasing age, American Society of Anesthesiologists status and female gender were associated with the development of bacteriuria. CONCLUSION: The incidence of CA bacteriuria and bacteraemia with antimicrobial prophylaxis is low. This study provokes discussion about the requirement of catheter prophylaxis in this surgical context and the utility of preoperative urine screening.
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    The immediate post-operative radiograph is an unreliable measure of coronal plane alignment in total knee replacement
    Petterwood, J ; Dowsey, MM ; Rodda, D ; Choong, PFM (FRONTIERS MEDIA SA, 2014)
    BACKGROUND: Restoration of a neutral mechanical axis is a primary goal of total knee replacement (TKR). A mechanical axis within 3° of neutral has been correlated with improved implant longevity, function, and patient satisfaction. We hypothesize that the immediate post-operative radiograph is an unreliable method of measuring alignment following TKR surgery. METHODS: Seventy-five consecutive patients had supine X-rays performed on day two post-operatively followed by standing long-leg radiographs (LLRs) 6 weeks post-operatively. Correlation was sought between the mechanical axis measured on the LLR and surrogate markers of alignment on the post-operative X-ray including component alignment and an estimation of anatomical alignment using the available length of femoral and tibial shafts. Inter- and intra-observer reliabilities were assessed. RESULTS: The mean mechanical axis on the LLR was 180.5 (SD 3.0, range 175.1-187.1). Mean offset between anatomical axis and mechanical axis was 6.4°. The mean anatomical axis measured on the short-leg X-ray was 174.9 (SD 2.4, range 169.5-181.3). Mechanical axis on the LLR was compared to the anatomical axis measured on the short-leg radiograph (SLR) + 6° with an interclass correlation coefficient of 0.588 (p < 0.001). The level of disagreement between the short- and long-leg X-rays was assessed using the Bland-Altman method and demonstrated clinically important discrepancies of 5 or more degrees in 9% of cases. Inter- and intra-observer agreements were high on all measures (p < 0.001). CONCLUSION: The long-leg weight bearing X-ray is an essential tool to accurately assess coronal plane alignment post TKR. While the immediate post-operative X-ray taken supine provides useful information to the surgeon on any immediate complications, our results indicate that it cannot be relied upon to determine correct restoration of the mechanical axis.
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    The effect of mindfulness training prior to total joint arthroplasty on post-operative pain and physical function: study protocol for a randomised controlled trial
    Dowsey, MM ; Castle, DJ ; Knowles, SR ; Monshat, K ; Salzberg, MR ; Choong, PFM (BioMed Central, 2014-06-05)
    BACKGROUND: Osteoarthritis is a leading cause of disability in developed nations. In Australia it afflicts 16.5% of the adult population. Total joint arthroplasty is considered the treatment of choice for end stage osteoarthritis. The number of total joint arthroplasties undertaken in Australia has doubled over the last decade (more than 80,000 procedures in 2011). The incidence of pre-operative psychological distress in this group of patients is reported between 30% and 60% and pre-operative psychological distress is associated with poorer pain and functional outcomes after surgery. This study will use a mindfulness-based psychological intervention to enhance outcomes in people undergoing total joint arthroplasty and, in addition, will test hypotheses about coping with chronic illness in an aged population. This study is the first of its kind and will provide a greater understanding of the role of a mental health enhancement program on the physical recovery of total joint arthroplasty patients. METHODS/DESIGN: One hundred and fifty people with end-stage arthritis on the waiting list for total hip or knee arthroplasty will be recruited and randomly allocated to one of two groups using computer-generated block randomisation. A randomised controlled trial adhering to CONSORT guidelines will evaluate the efficacy of a mindfulness training program (weekly group-based classes in mindfulness practice, 2 ½ hours, for 8 weeks plus a 7-hour Saturday session in Week 6) prior to total joint arthroplasty, compared to a "standard care" group who will undergo routine total joint arthroplasty. Primary outcomes will be evaluated by a blinded examiner at baseline, 3 and 12 months post-surgery, using a validated self-reported pain and physical function scale. Secondary outcomes will include i) a range of validated measures of psychological wellbeing and ii) health economic analysis. All analyses will be conducted on an intention to treat basis using linear regression models. Health economic modelling will be applied to estimate the potential cost-effectiveness of mindfulness training and total joint arthroplasty.
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    Patient Endorsement of the Outcome Measures in Rheumatology (OMERACT) Total Joint Replacement (TJR) clinical trial draft core domain set
    Singh, JA ; Dowsey, M ; Choong, PF (BMC, 2017-03-15)
    BACKGROUND: A patient- and surgeon-Delphi-derived Outcome Measures in Rheumatology (OMERACT) draft core domain set for total joint arthroplasty (TJR) trials was recently developed. Our objective was to obtain further patient stakeholder endorsement of draft core domain set for TJR clinical trials. METHODS: We surveyed two patient groups: (1) OMERACT patient partners; and (2) patients who had undergone hip or knee TJR. Patients received an introductory email with explanations about the core domain set and instructions to rate the core domains, i.e., important aspects, of OMERACT TJR clinical trial draft core domain set. Rating was on a nominal scale, where 1-3 indicated a domain of limited importance, 4-6 an important, but not critical domain, and 7-9 a critical domain. We used Mann-Whitney test (a non-parametric test) to compare the distribution of ratings between the two groups. RESULTS: Thirty one survey participants from the OMERACT patient partner group and 118 knee/hip TJR patients responded with response rates of 66 and 80%, respectively. Majority of the survey respondents were female, 87 vs. 53%, and were 55 years or older, 57 vs. 94%. Median (interquartile range [IQR]) scores for six core domains by OMERACT and knee/hip TJR patient groups were, respectively: pain, 8 [8, 9] and 9 [8, 9]; function, 9 [8, 9] and 9 [8, 9]; patient satisfaction, 8 [8, 9] and 8 [7, 9]; revision surgery, 7 [7, 8] and 7 [5, 9]; adverse events, 8 [7, 9] and 8 [6, 9]; and death, 9 [6, 9] and 9 [4, 9]. No statistically significant differences in rating were noted for any of the six core domains between the two groups (p ≥ 0.31). Among the additional domains, ratings for patient participation did not differ by group (p = 0.98), but ratings for cost were significantly different (p = 0.005). Patients provided qualitative feedback regarding core domains, and did not propose any modifications to the draft core domain set. CONCLUSIONS: Two separate patient stakeholder groups endorsed the OMERACT TJR draft core domain set for TJR trials.
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    Barriers and facilitators to orthopaedic surgeons’ uptake of decision aids for total knee arthroplasty: a qualitative study
    Scott, A ; Bunzli, S ; French, S ; Choong, P ; Dowsey, M (BMJ Publishing Group, 2017-11)
    Objectives: The demand for total knee arthroplasty (TKA) is increasing. Differentiating who will derive a clinically meaningful improvement from TKA from others is a key challenge for orthopaedic surgeons. Decision aids can help surgeons select appropriate candidates for surgery, but their uptake has been low. The aim of this study was to explore the barriers and facilitators to decision aid uptake among orthopaedic surgeons. Design: A qualitative study involving face-to-face interviews. Questions were constructed on the Theoretical Domains Framework to systematically explore barriers and facilitators. Setting: One tertiary hospital in Australia. Participants: Twenty orthopaedic surgeons performing TKA. Outcome measures: Beliefs underlying similar interview responses were identified and grouped together as themes describing relevant barriers and facilitators to uptake of decision aids. Results: While prioritising their clinical acumen, surgeons believed a decision aid could enhance communication and patient informed consent. Barriers identified included the perception that one’s patient outcomes were already optimal; a perceived lack of non-operative alternatives for the management of end-stage osteoarthritis, concerns about mandatory cut-offs for patient-centred care and concerns about the medicolegal implications of using a decision aid. Conclusions: Multifaceted implementation interventions are required to ensure that orthopaedic surgeons are ready, willing and able to use a TKA decision aid. Audit/ feedback to address current decision-making biases such as overconfidence may enhance readiness to uptake. Policy changes and/or incentives may enhance willingness to uptake. Finally, the design/implementation of effective non-operative treatments may enhance ability to uptake by ensuring that surgeons have the resources they need to carry out decisions.