Publications and OPUS Blog

OPUS Blog - Science Explained

We're very excited to share our research with you and look forward all our future scientific publications and accompanied blog articles. Below is a list of our current publications, some with their accompanied blog summary. You can also have a look at all other aspects of our research to get to know more about our Work PlansStaffPhD Projects that are currently available, our regular Newsletters and our Community Engagement.

"Barriers and facilitators to orthopaedic surgeons' uptake of decision aids for total knee arthroplasty: a qualitative study."

Bunzli, S., et al. (2017), BMJ Open 7(11): e018614.

Blog Article

The combined efforts of five OPUS researchers has resulted in the BMJ Open publication: “Barriers and facilitators to orthopaedic surgeons’ uptake of decision aids for total knee arthroplasty: a qualitative study”. Qualitative research is an emerging area in Orthopaedics, and this unique study involving one-on-one interviews with Orthopaedic Surgeons is one of only a few such studies in the literature.

The use of decision aids can assist surgeons in determining if a specific patient is likely to respond to Total Knee Arthroplasty (TKA) or not, and assist patients in weighing up the risks and benefits of surgery. Before implementing a decision aid into clinical practice, it is important to understand why or why not surgeons might use one. So, we designed a qualitative study to find out.

We performed twenty face-to-face interviews for orthopaedic surgeons who regularly perform TKA in a Melbourne hospital using questions constructed on the Theoretical Domains Framework to explore the barriers and facilitators to using a decision aid. Their responses were grouped together as themes. We discovered that most surgeons perceived their own patient outcomes were better than those described in the literature but most acknowledged a lack of objective feedback about their patient outcomes. Surgeons expressed difficulty assessing patient-related factors known to influence TKA outcomes, relying on their ‘gut-feelings’ about the patient. While the surgeons first prioritised their own skills and judgement in making decisions, they believed decision aids could enhance communication and patient informed consent. Concerns were expressed that decision aids could lead to mandatory cut-offs that would exclude some patients from surgery. Cut-offs that surgeons considered ‘acceptable risk for non-response’ were patient-dependent. When considering this risk, surgeons also took into consideration the perceived lack of effective alternatives to surgery

Now that we know the basic limitations for uptake of decision aids, we can plan multifaceted strategies to ensure orthopaedic surgeons can and will use a TKA decision aid. Audit/feedback methods and policy change could be reviewed and implemented to address current decision-making biases and to increase uptake. It may also be important to ensure there are avenues surgeons can access to provide effective non-operative treatments for end-stage osteoarthritis which may also enhance uptake.

You can check out this open-access publication here:

Journal Abstract

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.

"What Is the Impact of Advancing Age on the Outcomes of Total Hip Arthroplasty?"

Murphy, B. P. D., et al. (2017), J Arthroplasty.

Blog Article

Our 2017 Medical Degree Research Project (MDRP) student Ben Murphy has had his research accepted for publication in The Journal of Arthroplasty. His publication entitled “What Is the Impact of Advancing Age on the Outcomes of Total Hip Arthroplasty?” highlights the increasing global demand for total hip arthroplasty amongst the elderly. However, it is still unknown how successful this operation is for those who are at the end stages of life. So Ben looked into the risks and benefits for older patients undergoing this procedure.

Using SMART registry data Ben compared the risks and benefits of Total Hip Arthroplasty (THA) in patients older than 80 years of age versus those who were younger than 80. Those above the age of 80 had 3 times greater odds of experiencing a post-operative medical complication and of all-cause mortality. The older group also had an increased length of acute hospital stay and were almost 4 times more likely to be discharged to a rehabilitation facility rather than directly home. Despite the increased risk demonstrated in the elderly, improvements in physical functioning were equivalent across both age groups. This highlights the need to carefully balance the benefits of surgery against the increased risk of adverse outcomes when considering THA in older patients.

Ben also received a merit award for his oral presentation on his research at this year's St Vincent’s Surgical Forum.

If you’re interested in more details, methods or information regarding Ben's research you can check it out here:

Journal Abstract

BACKGROUND: The global demand for total hip arthroplasty (THA) is increasing, underscoring its moniker as the "operation of the century." However, debate still exists as to whether the elderly who undergo the operation achieve the same outcomes as those younger. In this study, we sought to investigate the association between older age and the risks and benefits of THA. METHODS: In this study, we aimed to compare the risks and benefits of THA of those aged >/=80 years vs those <80 years. We analyzed the physical status component of the Short-Form 12 Health Survey, complications within 12 months, all-cause mortality, length of hospital stay (LOS), and discharge to rehabilitation in 2457 cases of primary THA using multivariate modeling. RESULTS: There was no difference in improvement of those older vs the younger group in physical functioning. However, the older group had 2.87 times greater odds of experiencing a post-operative medical complication and 3.49 times the rate of all-cause mortality (P < .001). Additionally, the older group encountered an additional median 0.21-day increase in LOS and had 3.93 times greater odds of being discharged to rehabilitation rather than home (P < .001). We were unable to demonstrate any difference between groups in terms of post-operative surgical or wound-related complications. CONCLUSION: The elderly stand to gain equivalent benefits from THA as those younger in terms of physical functioning. However, this benefit needs to be balanced against the increased risk of post-operative medical complications, increased LOS, increased requirement for rehabilitation, and ultimately the increased risk of mortality.

Other Recent Publications

Babazadeh, S., et al. (2018). "Gap Balancing Sacrifices Joint-Line Maintenance to Improve Gap Symmetry: 5-Year Follow-Up of a Randomized Controlled Trial." J Arthroplasty 33(1): 75-78.

BACKGROUND: Gap balancing (GB) has been noted to sacrifice joint-line maintenance to improve gap symmetry. This study aims to determine whether this change affects function or quality of life in the midterm. METHODS: A prospective blinded randomized controlled trial was completed with 103 patients randomized to measured resection (n = 52) or GB (n = 51). Primary outcome measured was femoral component rotation. Secondary outcomes measured were joint-line change, gap symmetry, and function and quality-of-life outcomes. RESULTS: At 5 years, 83 of 103 patients (85%) were assessed. There was no significant difference between groups in terms of functional or quality of life outcomes. A subgroup analysis revealed that there was no significant association between those with asymmetrical flexion and/or extension or medial and/or lateral gaps during knee replacement and subsequent functional outcomes. No significant difference was detected with those with an elevated joint line and postoperative function. CONCLUSION: In the midterm, the resultant change in joint-line and maintained gap symmetry noted with GB does not result in significant change to function or quality of life.

Singh, J. A., et al. (2017). "Consensus on draft OMERACT core domains for clinical trials of Total Joint Replacement outcome by orthopaedic surgeons: a report from the International consensus on outcome measures in TJR trials (I-COMiTT) group." BMC Musculoskelet Disord 18(1): 45.

BACKGROUND: There are no core outcome domain or measurement sets for Total Joint Replacement (TJR) clinical trials. Our objective was to achieve an International consensus by orthopaedic surgeons on the OMERACT core domain/area set for TJR clinical trials. METHODS: We conducted surveys of two orthopaedic surgeon cohorts, which included (1) the leadership of international orthopaedic societies and surgeons (IOS; cohort 1), and (2) the members of the American Academy of Orthopaedic Surgeons' Outcome Special Interest Group (AAOS-Outcome SIG), and/or the Outcome Research Interest Group of the Orthopaedic Research Society (ORS; cohort 2). Participants rated OMERACT-endorsed preliminary core area set for TJR clinical trials on a 1 to 9 scale, indicating 1-3 as domain of limited importance, 4-6 being important, but not critical, and 7-9 being critical. RESULTS: Eighteen survey participants from the IOS group and 69 participants from the AAOS-Outcome SIG/ORS groups completed the survey questionnaire. The median (interquartile range [IQR]) scores were seven or higher for all six proposed preliminary core areas/domains across both groups, IOS and AAOS-Outcome SIG/ORS, respectively: pain, 8 [8, 9] and 8 [7, 9]; function, 8 [8, 8] and 8 [7, 9]; patient satisfaction, 8 [7, 9] and 8 [7, 8]; revision surgery, 7 [6, 9] and 8 [6, 8]; adverse events, 7 [5, 8] and 7 [6, 9]; and death, 7 [7, 9] and 8 [5, 9]. Respective median scores were lower for two additional optional domains: patient participation, 6.5 [5, 7] and 6 [5, 8]; and cost, 6 [5, 7] and 6 [5, 7]. CONCLUSIONS: This study showed that two independent surveys dervied from three groups of orthopaedic surgeons with international representation endorsed a preliminary/draft OMERACT core domain/area set for Joint Replacement clinical trials.

Dowsey, M. M., et al. (2017). "Variations in pain and function before and after total knee arthroplasty: a comparison between Swedish and Australian cohorts." Osteoarthritis Cartilage 25(6): 885-891.

OBJECTIVE: Preoperative pain and function is viewed as an important predictor of total knee arthroplasty (TKA) outcomes. We examined whether variations in pain and function outcomes existed at 12 months between two centres in Sweden and Australia, and whether this was explained by variations in patient presentation for TKA. METHODS: This was a retrospective analysis of prospectively collected data. Patients from one centre in Australia (St. Vincent's Hospital (SVH), N = 516) and in Sweden (Trelleborg (TBG), N = 899) who underwent primary TKA between 2012 and 2013. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) was analysed pre- and 12 months' post TKA from which non-response to surgery was determined using the OMERACT-OARSI criteria. Multiple linear regression analysis was used to examine the relationship between change in pain and function and surgery centre, adjusting for preoperative patient characteristics and surgical technique. RESULTS: Despite worse preoperative outcomes in all subscales of the WOMAC for the SVH cohort, there were no clinically meaningful differences in 12-month WOMAC subscales nor change in WOMAC subscales between SVH and TBG. Almost identical proportions of patients were considered OMERACT-OARSI responders, 85.7% (SVH) and 85.9% (TBG), however for the SVH cohort 25 (4.9%) were moderate and 417 (80.8%) were high responders, compared to the TBG cohort of which 225 (25%) were moderate and 547 (60.9%) were high responders. CONCLUSION: Despite differences in preoperative presentation between 2 countries, improvements in pain and function and the proportion of individual who responded to TKA surgery at 1 year were similar. Factors related to poor response to TKA surgery require further elucidation.

Singh, J. A., et al. (2017). "Patient Endorsement of the Outcome Measures in Rheumatology (OMERACT) Total Joint Replacement (TJR) clinical trial draft core domain set." BMC Musculoskelet Disord 18(1): 111.

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 trial.

Singh, J. A., et al. (2017). "Achieving Consensus on Total Joint Replacement Trial Outcome Reporting Using the OMERACT Filter: Endorsement of the Final Core Domain Set for Total Hip and Total Knee Replacement Trials for Endstage Arthritis." J Rheumatol 44(11): 1723-1726.

OBJECTIVE: Discussion and endorsement of the OMERACT total joint replacement (TJR) core domain set for total hip replacement (THR) and total knee replacement (TKR) for endstage arthritis; and next steps for selection of instruments. METHODS: The OMERACT TJR working group met at the 2016 meeting at Whistler, British Columbia, Canada. We summarized the previous systematic reviews, the preliminary OMERACT TJR core domain set and results from previous surveys. We discussed preliminary core domains for TJR clinical trials, made modifications, and identified challenges with domain measurement. RESULTS: Working group participants (n = 26) reviewed, clarified, and endorsed each of the inner and middle circle domains and added a range of motion domain to the research agenda. TJR were limited to THR and TKR but included all endstage hip and knee arthritis refractory to medical treatment. Participants overwhelmingly endorsed identification and evaluation of top instruments mapping to the core domains (100%) and use of subscales of validated multidimensional instruments to measure core domains for the TJR clinical trial core measurement set (92%). CONCLUSION: An OMERACT core domain set for hip/knee TJR trials has been defined and we are selecting instruments to develop the TJR clinical trial core measurement set to serve as a common foundation for harmonizing measures in TJR clinical trials.


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