OPUS CRE Research Streams

Project Details

Work plan#1: Appropriateness of care

A prognostic tool to support decision making for total joint replacement

Chief Investigators: Peter Choong, Jane Gunn.

Associate Investigators: Jasvinder Singh, Maria Inacio, Michael Kattan.

Knowledge Gaps

Currently there is no prognostic tool in the outpatient and primary care setting allowing differentiation of patients who are likely or unlikely to benefit from Total Joint Replacement (TJR). Our group has identified important risk factors for poor patient outcomes of TJR that will inform the development of such a tool.

Current Research

In 615 consecutive cases, we identified that 15% of these individuals were non-responders to surgery at 12 months after knee TJR. A preliminary comparative study of 1,419 patients conducted with the Swedish Knee Registry confirmed a similar level of non-responder rates of 14.2%. Independent prognostic correlates of post-operative non-response were completed from which we developed a nomogram designed to predict the probability of non-response to knee TJR. The concordance index for this model was 0.74. This is the first nomogram ever applied in TJR, which includes patient related outcome measures.

Planned research:

We will test the predictive probabilities of the nomogram across centres representative of the broader knee TJR population. We will also collaborate with senior researchers from the Health Economics Research Centre at Oxford University who have a strong history of collaboration with Professor Philip Clarke of the University of Melbourne, including over 10 co-authored publications. These researchers are co-investigators on a National Institute for Health Research (NIHR) funded project to develop an ‘arthroplasty candidacy help tool’ for the UK. Specifically, this collaboration will assist with international external validation of the patient selection nomogram.

Dr Darshini Ayton will then assess the nomogram based on patient/clinician views, useability and suitability through interviews and focus groups. Further content analysis methods will be applied to validate the nomogram, surveying for existing or new trends. This will provide insight into patient and clinician views towards the nomogram, which will guide best practice towards developing a program of better care and improving communication between patients and doctors.

Final assessment the acceptability of the nomogram will be completed amongst user groups through the Australian Orthopaedic Association, the Musculoskeletal Clinician Leadership Group and other associated advisory bodies. Other similar forums will be used to assess the useability of the nomogram with international user groups. The nomogram will inform the development of a feedback intervention for surgeons as outlined in Workplan#2 and for targeting patients with a high probability of poor response to surgery as outlined in Workplan#3. While we have elected to target knee TJR for a nomogram in the first instance, future work is planned for the development of a hip TJR nomogram.

Expected outcomes and significance: 

The outcome of this work plan will be a prognostic tool for use in the primary care setting by allied health and general practitioners and specialist orthopaedic surgeons in outpatient and private settings. This unique tool will enhance the ability to predict successful patient outcomes. Moreover, this nomogram will identify modifiable risk factors to target for mitigation prior to surgery (e.g. obesity, mental health). This will have direct impact on specialist referrals and ultimately lead to containment of elective surgery waiting list numbers.

Workplan#2 Behaviour and Social Science

Decision making in total joint replacement

Chief Investigators: Anthony Scott, Michelle Dowsey.

Associate Investigators: Michael Kattan, Darshini Ayton, Ian Incoll.

Knowledge Gaps

Patients’ and surgeons’ assessments of the risks and benefits of TJR surgery don’t always align. We will investigate factors which might influence decisions, expectation and why surgeons offer surgery to inappropriate candidates have not been subjected to rigorous evaluation. Research indicates complex influences on clinicians’ decisions but few studies are based on a theoretical understanding of what drives decision-making, therefore interventions have not been carefully designed and consequently are not effective. Previous reviews of feedback interventions have shown that feedback and changes in information provided to doctors can influence their behaviour, but that their effects are variable depending on the context and the characteristics of intervention. This includes the timing and frequency of feedback, who delivers the feedback, the content of the feedback, and planned actions taken following feedback.

Current Research

We are currently conducting a first of its kind NHMRC funded study (Application 1058438 - MARKA) that examines and compares benefit and risk preferences of patients with end-stage Osteoarthritis (OA) undergoing knee TJR with surgeon preferences. The study uses discrete choice experiments (DCEs) to explore how patients balance risks and benefits, determine the extent these align with surgeons’ expectations, and explores whether guiding patients through a decision making process prior to surgery improves patient expectations, health outcomes and satisfaction. We aim to determine patient and surgeon characteristics that correlate with willingness to undergo (patients) or offer (surgeons) knee TJR through a series of structured questionnaires, administered to patients and orthopaedic surgeons including measures of personality, control, risk attitudes and optimism. The role of individual and institutional knee TJR volume and whether employed at a tertiary, rural or community facility are also being examined. The design of the DCE has been finalised with patient input, pre-tested for understanding and piloted in patients and surgeons.

Results illustrate that despite the risk of poor outcome such as moderate or severe pain at 12 months and complication rates approaching 20% in some scenarios, 95% of patients stated they would undergo knee TJR. In contrast, when surgeons were faced with the same scenarios, the opt-out rate for providing surgery was as high as 80%.

Presenting accurate unbiased information may significantly impact patient and surgeon decision making and alter behavioural biases in surgeons who may be overconfident and believe that these outcomes would not occur for ‘their’ patients.

Planned research 

While the MARKA study includes a patient-level intervention to reduce patients’ expectations, it is clear that an intervention to address surgeon behaviours and beliefs is also required. Given our group’s expertise and current research, as well as our collaboration with the Australian Orthopaedic Association, we are in a unique position to extend this research to develop and test the impact of an intervention directed at surgeons to influence surgeon-patient decision making and informed consent for knee TJR. These approaches are unique and would provide a significant insight into decision-making never before considered in TJR.

Changing surgeon behaviour requires an in-depth understanding of what determines their behaviour in order to develop a theory-based intervention. This will be achieved using participatory action research.

Discrete choices experiments will reveal the extent to which surgeon’s focus on surgical risks or post-operative patient outcomes, and the extent to which these influence their decision to recommend surgery. It will also examine how surgeons’ preferences vary according to the volume of knee TJRs performed, their personality, and locus of control, risk aversion, optimism and overconfidence. Feedback methods will be implemented and data pooled to determine how and at what point final consent is justified. The role of technology and data visualisation will also be explored in designing the feedback intervention.

After determining the design and intervention method(s), we will assess the usefulness of these changed methods with surgeons and registrars through various forums prior to implementation. In addition to the MARKA study, we have recently been awarded a University of Melbourne Faculty of Business & Economics and Medicine, Dentistry & Health Sciences Collaboration Grant to aid in this research program. This will be critical for our proposed cluster RCT to evaluate the effect of a feedback intervention on patient pain and function, alongside other associated evaluations.

Expected Outcomes and significance

Workplan #2 will provide new knowledge of the clinical and economic benefits of this feedback intervention. Ultimately, evidence-based decision-making has the potential to minimise inappropriate surgery with the potential to save millions of dollars in healthcare expenditure.

Workplan#3: Developing non-surgical alternatives for end-stage osteoarthritis

Chief Investigators: Peter O’Sullivan, Anne Smith, Michelle Dowsey.

Associate Investigator: Peter Kent, Kieran O’Sullivan.

Knowledge Gaps

There is an imperative to find alternative care pathways/interventions for the 15% of people who are unlikely to benefit from TJR. While multidisciplinary osteoarthritis (OA) chronic care programs have been shown to improve pain and function, even for those awaiting TJR, they have not been tested specifically on this group and so whether they would benefit from this traditional approach is unknown. Chronic low back pain (CLBP), shares a similar multi-dimensional risk profile to joint OA. Much effort has been directed to developing targeted treatment to subgroups of people with CLBP who have poor prognosis based on their group profiles. In keeping with this, our group has developed an individualised model of care for CLBP that effectively targets the multidimensional complexity of the disorder. While this has been adapted to OA knee, to date it is not known whether this approach is also applicable to people with end stage OA who are at risk of poor outcome from knee TJR. As knee OA appears to share similar multidimensional complexity with CLBP, such an approach may offer a promising alternative to knee TJR in those patients at risk of poor outcome with the procedure.

Current Research

We have developed and tested a promising personalised therapy approach in a small-scale, efficacy RCT in CLBP. The approach is termed ‘cognitive functional therapy’ (CFT), and is best briefly described as an integrated, personalised, behavioural approach to the identification and management of modifiable multidimensional factors underlying a person’s pain and disability. CFT comprehensively operationalises and integrates a self-management program, targeting psychological, physical and lifestyle factors. The intervention addresses these targets using a tailored plan depending on which factors are dominant for each individual. It has been proposed that patients with knee OA be considered similar to other chronic pain populations in that the pain experience may be present depending on genetic, structural, psychological, physical and lifestyle factors, which in turn influence the body and mind of the individual – Illustrated in our NHMRC (APP1035810) to date.

Planned research

Work will focus on the development and testing of personalised therapy approach for those at risk of poor outcome after knee TJR. We have adapted a personalised CFT approach from CLBP for the management of end-stage OA and will assess the effectiveness of this approach, offering a promising alternative to knee TJR in those patients at risk of poor outcome with the procedure. Whilst the significant body of evidence for existing non-surgical management options for knee OA is acknowledged, we seek to build upon this best practice, with key points of difference being, drawing on relevant models of health behaviour such as the Fear Avoidance Model and Common Sense Model to facilitate development of the patients understanding of their condition, the drivers of their pain and disability as well as opportunities for change.

Lead by Senior researchers who have developed and tested the CFT intervention in CLBP, they will provide experience in prognostic and subgrouping methodology. A post-doctoral fellow will also apply experience in mixed methods and models of health behaviour in CLBP to play a key role in understanding the application of CFT from several clinical angles in a 2 phase approach:

Phase 1: Development of an understanding of factors driving pain and disability

Phase 2: Development of a CFT intervention

Expected Outcomes and Significance

This body of work will lead to new knowledge about treatment alternatives for those patients at risk of no benefit for knee TJR that can be further tested in RCT’s. Significant reductions in healthcare costs can be expected through provision of alternatives to the primary surgical procedure and elimination of costly ongoing care after surgery.

Workplan#4 - Hospital Services Coordinated Care

Developing an enhanced recovery program for TJR

Chief Investigators: Nicholas Taylor, Peter Choong, Trisha Peel.

Associate Investigators: Michael Barrington, Stefan Lohmander.

Knowledge Gaps

The McKeon Review highlighted that practice inefficiencies and preventable surgical complications are major cost drivers in the healthcare system. The impact of enhanced recovery programs, and multidisciplinary care pathways on preventable surgical complications, on patient satisfaction and on hospital and societal costs has not been established, limiting the wider adoption of such pathways. This Workplan will address these important knowledge gaps, applying mixed methods research to develop and refine a multimodal enhanced recovery program; forming the basis for a concerted effort to improve the delivery of TJR services nationally and internationally.

Current Research

A pilot cohort study to inform this Workplan undertaken at SVHM, examining the impact of day of mobilisation on length of stay and complications. Overall, a third of patients who mobilised within the first 24 hours following TJR had a significantly shorter mean length of stay compared to patients mobilised after 24 hours. 23% experienced one or more post-operative complications. And there were significantly fewer post-operative complications in the early mobilisation group. Overall, early mobilisation was associated with a 45% reduction in post-operative complications. Our NHMRC (Application 1057736 and 502021) supported work to date has demonstrated post-operative complications occur in 24.3% of patients after TJR and were a major driver of costs.

Planned research

Workplan #4 will develop a multidisciplinary care bundle to optimise patient care following TJR using mixed methods in a staged approach to test and refine the bundle. This pragmatic research program will be rolled out in five major interlinked avenues of investigation spanning multimodal enhanced recovery, clinical and economic impact, randomised trials, tailor approaches, modelled health economic analysis, RCT and multimodal stakeholder feedback sessions.

We have received private funding to undertake a large part of this study. In addition to examining the impact on length of stay and cost-effectiveness, this portion of research is critical in informing the final stages, examining the impact of the enhanced recovery program on post-operative complications. This will happen through networks established by the research team and will be enriched by data from early stage trials. This research will be conducted in the ‘real-world’ comparing the clinical and cost-effectiveness of an enhanced recovery program to the Medical Research Council Framework.

Expected Outcomes and significance: 

Workplan#4 will provide new knowledge about the clinical and health economic benefits of and lead to the development of evidence-based guidelines for patient care following TJR. In addition, enhanced recovery programs may be associated with significant reductions in healthcare costs through decreased length of stay and reduced post-operative complications.

Transfer Theme (5)

Promote effective transfer of research outcomes into health policy and/or practice

Quality of the plan for research translation

Testing implementation models to develop new knowledge of effective approaches

Working with the Stakeholder Advisory Council, and led by our implementation expert (Prof Gunn) and Quali-expert (Dr Ayton), the Centre’s framework for implementation will be informed by PRISM (Practical, Robust Implementation and Sustainability Model). This approach recognises the complexity of working across multidisciplinary groups and will facilitate more effective implementation and the use of knowledge translation strategies through systematic testing and shared learning.

Synergies achieved by a Centre wide approach to implementation activity

Each Workplan aims to implement new knowledge while maintaining clinical relevance and focus by ensuring shared participation between expert clinicians and specialist researchers. Our strategy of early development of translation plans, including clarity and agreement over the desired impact will help to overcome the difficulties with amalgamation of knowledge that may arise from different disciplines and stakeholder groups.

Health economics and modelling

A key component of centre is the integration of health economics into medical decision-making. This economic method will be incorporated into all stages from assisting in the design of RCTs to the evaluation and translation research findings. The centre will benefit from having access to patient level data and will use health economic modelling to extrapolate our findings to the wider Australian population so that gains in cost-effectiveness can be spread across the sector. Our health economic team is strong with a proven policy translation record supported by experienced outcomes modellers, their networks, and the experience within our Stake Holder Advisory Council. The health economic program will aim to build capacity in the health economic evaluation of TJR in Australia and to strengthen ongoing international links such as with Health Economics Research Centre at University of Oxford.

Plans for promoting the Centre’s activities to the wider community

We shall capitalise on our team’s extensive experience in networking to build a strongly connected translation community to ensure high impact interventions. This will be supported by a Stakeholder Advisory Council (SAC) who will foster a two-way exchange of information between end-users and researchers. The Centre will also engage with other CREs (TRIUMPH, MABEL, NCAS) through direct CI involvement (as CIs/AIs on these CREs) to share in translational expertise, learn from others’ experiences and to extend the reach of this Centre.

Involvement of end-users and the wider community

Orthopaedic Surgeons

Practice change in TJR must be led by orthopaedic surgeons. The Centre will leverage it’s networks with various internal and external critical players and associated existing stakeholder programs to reach surgeons and trainees.

Primary Care

As past-President, Professor Jane Gunn will facilitate the transfer of knowledge from this Centre to the primary care community through Australian Association for Academic Primary Care. Using her role as foundation Chair of Victorian Primary Care Research Network, Professor Gunn will engage general practitioners in a broad spectrum of clinical settings to test the useability of the nomogram from Workplan#1.

The Community

Community Advocacy Groups: Among others, the CEO of Arthritis & Osteoporosis Victoria (AOV) is on the Centre’s Stakeholder Advisory Council and has had considerable experience driving funding and policy changes that impact those with chronic diseases including OA.

Private Health Sector

With over 50% of TJRs performed in the private sector, it is critical to include the input of private sector funders. Dr. Linda Swan is the Chief Medical Officer of Medibank Private LTD (MPL), Australia’s largest private health fund and sits on this Centre’s Stakeholder Advisory Council. This Centre will work closely with MPL to develop methods to access, analyse and interpret private hospital data that will inform our research and evaluate the impact of interventions in that sector.

Health authorities

The Victorian Department of Health and Human Services (DHHS) has auspiced a strategic advisory group, the Musculoskeletal Clinician Leadership Group: a multidisciplinary group of medical, nursing and allied health leaders whose mandate is to identify problems and solutions to assist DHHS focus its strategic efforts when dealing with MSK issues. Professor Peter Choong through his position as inaugural chair of this group and Chair of the OA Model of Care group, is in an ideal position to engage a broad range of stakeholders at the highest levels to evaluate needs, garner support and to drive change.

Broader research world through journal editorships

All Researchers will leverage their positions on the editorial boards of 17 top ranked international journals in the fields of orthopaedics and surgery (3), physiotherapy and rehabilitation (6), speciality medicine (3) primary care (3) and health economics (2) to profile the Centre’s work and also to promote further research and dialogue in this arena.

Development of the Health and Medical Research Workforce

We are strongly committed to capacity building both for the benefit of the program itself and to that of Australian medical research now and in future generations. Future leaders in the musculoskeletal field will require strong research translational capabilities and this centre with its multidisciplinary approach is ideally placed to provide the platform and networks which will help facilitate training and advancement opportunities to new researchers, particularly those with a capacity for independent research and future leadership roles

This centre will target a broad-range of key professional groups with a specific focus on orthopaedic surgeons and early/mid-career researchers from a variety of backgrounds including universities, hospitals and community clinics. Our key trans-disciplinary hub in Melbourne interacts strongly with collaborators interstate and internationally, offering graduate students, post-doctoral early/mid-career researchers unique opportunities to extend their research experiences.

We will generate a strategy for new researcher capability, mentoring and encouragement of further career development, targeting and supporting new researchers and provide mentoring strategies to integrating new researchers into the teams. We will also help facilitate collaboration with other groups in the field of research by building smart collaborations and team cohesion.

Return to Homepage


Cobos R, et al. Variability of indication criteria in knee and hip replacement: an observational study. BMC Musculoskelet Disord. 2010;11.

Dowsey MM, et al. Associations between pre-operative radiographic changes and outcomes after total knee joint replacement for osteoarthritis. Osteoarthritis Cartilage. 2012;20.

Baker PN, et al. The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales. J Bone Joint Surg Br. 2007;89.

Hoffmann TC, et al. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175.

Wylde V, et al. Patient-reported outcomes after total hip and knee arthroplasty: comparison of midterm results. J Arthroplasty. 2009;24.

Wylde V, et al. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain. 2011;152.

Riddle DL, et al. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol. 2014;66.

Strategic Review of Health and Medical Research in Australia. Consultation Paper Summary. Canberra: Department of health and Ageing, Australian Government, 2012.

Escobar A, et al. Patient acceptable symptom state and OMERACT-OARSI set of responder criteria in joint replacement. Identification of cut-off values. Osteoarthritis Cartilage. 2012;20.

Dowsey MM, et al. Associations between pre-operative radiographic osteoarthritis severity and pain and function after total hip replacement : Radiographic OA severity predicts function after THR. Clin Rheumatol. 2014.

Choong PF, et al. Obesity in total hip replacement. J Bone Joint Surg Br. 2009;91.

Dowsey MM, et al. The impact of obesity on weight change and outcomes at 12 months in patients undergoing total hip arthroplasty. Med J Aust. 2010;193.

Dowsey MM, et al. The impact of pre-operative obesity on weight change and outcome in total knee replacement: a prospective study of 529 consecutive patients. J Bone Joint Surg Br. 2010;92.

Paulsen MG, et al. Preoperative psychological distress and functional outcome after knee replacement. ANZ J Surg. 2011;81.

Escobar A, et al. Patient acceptable symptom state and OMERACT-OARSI set of responder criteria in joint replacement. Identification of cut-off values. Osteoarthritis Cartilage. 2012;20.

Dowsey MM, et al. Latent Class Growth Analysis predicts long term pain and function trajectories in total knee arthroplasty: a study of 689 patients. Osteoarthritis Cartilage. 2015.

Davies P, et al. A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations. Implement Sci. 2010;5.

Ivers N, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;6.

John OP, Donahue, E.M., Kentle, R.L. The Big Five Inventory-Versions 4a and 54. University of California, Berkeley, Institute of Peronality and Social Research. 1991;Berkeley, CA.

Pearlin LI, et al. The structure of coping. J Health Soc Behav. 1978;19.

Scheier MF, et al. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the Life Orientation Test. J Pers Soc Psychol. 1994;67.

Scott IA, et al. Foregoing low-value care: how much evidence is needed to change beliefs? Intern Med J. 2013;43.

Hill JC, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378.

CI Vibe Fersum K, et al. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial. Eur J Pain. 2013;17.

Kittelson AJ, et al. Future directions in painful knee osteoarthritis: harnessing complexity in a heterogeneous population. Phys Ther. 2014;94.

Dimitroulas T, et al. Neuropathic pain in osteoarthritis: a review of pathophysiological mechanisms and implications for treatment. Semin Arthritis Rheum. 2014;44.

Holla JF, et al. Predictors and outcome of pain-related avoidance of activities in persons with early symptomatic knee osteoarthritis: a five-year followup study. Arthritis Care Res (Hoboken). 2015;67.

Lluch Girbes E, et al. Pain treatment for patients with osteoarthritis and central sensitization. Phys Ther. 2013;93.

Riddle DL, et al. Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clin Orthop Relat Res. 2010;468.

Skou ST, et al. Knee Confidence as It Relates to Self-reported and Objective Correlates of Knee Osteoarthritis: A Cross-sectional Study of 220 Patients. J Orthop Sports Phys Ther. 2015;45.

Caneiro JP, et al. Cognitive functional therapy for the management of low back pain in an adolescent male rower: a case report. J Orthop Sports Phys Ther. 2013;43

O'Sullivan K, et al. Cognitive Functional Therapy for Disabling Nonspecific Chronic Low Back Pain: Multiple Case-Cohort Study. Phys Ther. 2015;95.

Smith AJ, et al. Pre-surgery knee joint loading patterns during walking predict the presence and severity of anterior knee pain after total knee arthroplasty. J Orthop Res. 2004;22.

Smith AJ, et al. A kinematic and kinetic analysis of walking after total knee arthroplasty with and without patellar resurfacing. Clin Biomech (Bristol, Avon). 2006;21.

Smith AJ, et al. Total knee replacement with and without patellar resurfacing: a prospective, randomised trial using the profix total knee system. J Bone Joint Surg Br. 2008;90.

unzli S, et al. Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear. BMJ Open. 2015;5.

Bunzli S, et al. Lives on hold: a qualitative synthesis exploring the experience of chronic low-back pain. Clin J Pain. 2013;29.

Feldstein AC, et al. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34.

Research Group

CRE in Total Joint Replacement - OPUS

School Research Themes

Key Contact

For further information about this research, please contact the research group leader.

Department / Centre

Surgery Research

Unit / Centre

CRE in Total Joint Replacement - OPUS