Deep prosthetic joint infection:A qualitative study of the impact on patients and their experiences of revision surgery

OBJECTIVES: Around 1% of patients who have a hip replacement have deep prosthetic joint infection (PJI) afterwards. PJI is often treated with antibiotics plus a single revision operation (1-stage revision), or antibiotics plus a 2-stage revision process involving more than 1 operation. This study aimed to characterise the impact and experience of PJI and treatment on patients, including comparison of 1-stage with 2-stage revision treatment. DESIGN: Qualitative semistructured interviews with patients who had undergone surgical revision treatment for PJI. Patients were interviewed between 2 weeks and 12 months postdischarge. Data were audio-recorded, transcribed, anonymised and analysed using a thematic approach, with 20% of transcripts double-coded. SETTING: Patients from 5 National Health Service (NHS) orthopaedic departments treating PJI in England and Wales were interviewed in their homes (n=18) or at hospital (n=1). PARTICIPANTS: 19 patients participated (12 men, 7 women, age range 56–88 years, mean age 73.2 years). RESULTS: Participants reported receiving between 1 and 15 revision operations after their primary joint replacement. Analysis indicated that participants made sense of their experience through reference to 3 key phases: the period of symptom onset, the treatment period and protracted recovery after treatment. By conceptualising their experience in this way, and through themes that emerged in these periods, they conveyed the ordeal that PJI represented. Finally, in light of the challenges of PJI, they described the need for support in all of these phases. 2-stage revision had greater impact on participants’ mobility, and further burdens associated with additional complications. CONCLUSIONS: Deep PJI impacted on all aspects of patients’ lives. 2-stage revision had greater impact than 1-stage revision on participants’ well-being because the time in between revision procedures meant long periods of immobility and related psychological distress. Participants expressed a need for more psychological and rehabilitative support during treatment and long-term recovery

Secondary prevention of fractures after hip fracture:a qualitative study of effective service delivery

There is variation in how services to prevent secondary fractures after hip fracture are delivered and no consensus on best models of care. This study identifies healthcare professionals' views on effective care for the prevention of these fractures. It is hoped this will provide information on how to develop services.Hip fracture patients are at high risk of subsequent osteoporotic fractures. Whilst fracture prevention services are recommended, there is variation in delivery and no consensus on best models of care. This study aims to identify healthcare professionals' views on effective care for prevention of secondary fracture after hip fracture.Forty-three semi-structured interviews were undertaken with healthcare professionals involved in delivering fracture prevention across 11 hospitals in one English region. Interviews explored views on four components of care: (1) case finding, (2) osteoporosis assessment, (3) treatment initiation, and (4) monitoring and coordination. Interviews were audio-recorded, transcribed, anonymised and coded using NVivo software.Case finding: a number of approaches were discussed. Multiple methods ensured there was a 'backstop' if patients were overlooked. Osteoporosis assessment: there was no consensus on who should conduct this. The location of the dual energy X-ray absorptiometry (DXA) scanner influenced the likelihood of patients receiving a scan. Treatment initiation: it was felt this was best done in inpatients rather request initiation in the post-discharge/outpatients period. Monitoring (adherence): adherence was a major concern, and participants felt more monitoring could be conducted by secondary care. Coordination of care: participants advocated using dedicated coordinators and formal and informal methods of communication. A gap between primary and secondary care was identified and strategies suggested for addressing this.A number of ways of organising effective fracture prevention services after hip fracture were identified. It is hoped that this will help professionals identify gaps in care and provide information on how to develop services

Understanding the pain experience in hip and knee osteoarthritis – an OARSI/OMERACT initiative

SummaryObjectiveTo examine the pain experience of people with hip or knee osteoarthritis (OA), particularly changes over time and most distressing features.MethodFocus groups in individuals aged 40+ years with painful hip or knee OA obtained detailed descriptions of OA pain from early to late disease. A modified Patient Generated Index (PGI) was used to assess the features of OA pain that participants found most distressing. Content analysis was performed to examine response patterns; descriptive statistics were used to summarize PGI responses.ResultsMean age of the 143 participants (52 hip OA; 91 knee OA) was 69.5 years (47–92 years); 60.8% were female and 93.7% Caucasian. Participants described two distinct types of pain – a dull, aching pain, which became more constant over time, punctuated increasingly with short episodes of a more intense, often unpredictable, emotionally draining pain. The latter, but not the former, resulted in significant avoidance of social and recreational activities. From PGI responses, distressing pain features were: the pain itself (particularly intense and unpredictable pain) and the pain's impact on mobility, mood and sleep.ConclusionsTwo distinct pain types were identified. Intermittent intense pain, particularly when unpredictable, had the greatest impact on quality of life

Home health monitoring around the time of surgery: a qualitative study of patients’ experiences before and after joint replacement

Objectives: Hip and knee replacements are common major elective surgical interventions with over 200,000 performed annually in the UK. Not all patients achieve optimal outcomes or experience problems or delays in recovery. The number of patients needing these operations are set to increase and routine clinical monitoring is time and resource consuming for patients and healthcare providers, therefore innovative evaluation of surgical outcomes are needed. The aim of this qualitative study was to capture the patient experience of living with a novel home monitoring sensing system during the period around joint replacement. Setting: One secondary care hospital in the South West, UK Participants: 13 patients, (8 female, 63-89y) undergoing total hip or knee replacement enrolled into the study Design: Qualitative study with thematic analysis. The system remained in situ for up to 12 weeks after their surgery and comprised a group of low powered sensors monitoring the environment (temperature, light and humidity) and activity of people within the home. Patients were interviewed at two timepoints: before and after surgery. Interviews explored views about living with the technology, its acceptability as well as attitudes towards health technology. Results: Three main themes emerged: installation of home sensing technology on the journey to surgery; the home space and defining unobtrusiveness and pivotal role of social support networks Conclusions: Patients who agreed to the technology found living with it acceptable. A home sensing system that monitors the environment and activity of the people in the home could provide an innovative way of assessing patients’ surgical outcomes. At a time, characterised by reduced mobility, functional limitations and increased pain, patients in this study relied on informal and formal supportive networks to help maintain the system through the busy trajectory of the perioperative period. Strengths and limitations of this study • In-depth one-to-one interviews provided insight into patients’ real experiences and views as they lived with the technology in their own homes • Although the sample size was small, lacked ethnic diversity and only included people willing to have technology installed in their homes, there was good diversity in age and gender and some diversity in patients undergoing hip and knee replacement • Use of thematic analysis enabled robust analysis of data, including focus on the acceptability of the technology in real health-related circumstances