 EDITORIAL

What are the key drivers that change practice?

F. S. Haddad From The British Editorial Society of Bone and Joint Surgery, London, United Kingdom

 F. S. Haddad, BSc MD (Res), FRCS (Tr&Orth), Professor of Orthopaedic Surgery, Editor-in-Chief The Bone and Joint Journal, 22 Buckingham Street, London, WC2N 6ET, UK. Correspondence should be sent to Professor F. S. Haddad; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B7. 36546 $2.00 Bone Joint J 2015;97-B:869–70.

VOL. 97-B, No. 7, JULY 2015

This month’s issue of The Bone & Joint Journal revisits some of the fundamental issues that will underpin the success of trauma and orthopaedic surgery over the next few years. Breakwell et al1 update us on the genesis and function of the British Spine Registry (BSR). This is one of the fledgling professionrun registries in the United Kingdom, following in the footsteps of the Non Arthroplasty Hip Registry and the National Ligament Registry. If they succeed in getting support and compliance from clinicians and patients, they are likely to generate very useful data that will influence future practice. These registries are to be commended on their attempts to link observational data with patient-reported outcome measures (PROMS). Matt Costa and his team, who have done wonderful work over the years to improve research methodology and encourage robust trials in the United Kingdom, provide an update on how to improve the quality of the evidence base for fractured neck of femur surgery.2 If the orthopaedic community follows their lead, we will have much stronger clinical and economic evidence for our choices. While we always aspire to ensure evidence is at level 1, Chris Pearce et al3 highlight the point that there are always issues that level 1 studies do not necessarily address, and that cases that are excluded from big studies may be as important as those that are studied. It would appear that the management of calcaneal fractures still presents difficult questions that will require more focused studies. Hanssen et al4 debunk one of the great myths of peri prosthetic infection in their paper on seronegative infections and hip and knee arthroplasty with normal erythrocyte sedimentation rate and c-reactive protein levels. It is clear that our ability to diagnose periprosthetic infection is improving, but there is still a long way to go. All of these papers rightfully put the outcomes of their patients at the heart of their work. The result of all our interventions is

under scrutiny and patients will increasingly influence the type of research undertaken, how it is undertaken and how the results are acted upon. Patients are increasingly participating in a shared decision-making process. Such empowerment has seen a clear shift in measuring health outcomes from the clinician’s to the patient’s perspective. The routine use of PROMs by healthcare organisations reflect a growing recognition of the importance of patient perspectives in improving treatments.5-7 We have now adopted PROMS into our daily lives and work, and it will only be a matter of time before patient-reported experiences (PREMs) play a greater role in our research, our strategies, and our day-today clinical practice.8,9 In order to measure the rate of success after orthopaedic surgery, we will need to agree upon and harmonise the appropriate PREMs and PROMs to use across studies and continents, and we will need to define the meaningful differences required to measure the success of any treatment. We will also need to develop more refined means of case-mix adjustment in order that these outcome measures can be usefully interpreted and acted upon. Until this happens, there be will concerns that PROMs are being used beyond their means due to a poor understanding of their limitations.

References 1. Heywood C, Birch N, Cole AA, Breakwell LM. Should we all go to the PROM? The first two years of the British Spine Registry. Bone Joint J 2015;97-B:871–874. 2. Fernandez MA, Griffin XL, Costa ML. Hip fracture surgery: improving the quality of the evidence base. Bone Joint J 2015;97-B:875–879. 3. Pearce CJ, Wong KL, Calder JDF. Calcaneal fractures: selection bias is key. Bone Joint J 2015;97-B:880–882. 4. McArthur BA, Abdel MP, Taunton MJ, Osmon DR, Hanssen AD. Seronegative infections in hip and knee arthroplasty: periprosthetic infections with normal erythrocyte sedimentation rate and C-reactive protein level. Bone Joint J 2015;97-B:939–944. 5. Hossain FS, Konan S, Patel S, Rodriguez-Merchan EC, Haddad FS. The assessment of outcome after total knee arthroplasty: are we there yet? Bone Joint J 2015;97-B:3–9. 869

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6. Baker PN, Deehan DJ, Lees D, et al. The effect of surgical factors on early patient-reported outcome measures (PROMS) following total knee replacement. J Bone Joint Surg [Br] 2012;94-B:1058–1066. 7. Judge A, Arden NK, Price A, et al. Assessing patients for joint replacement: can pre-operative Oxford hip and knee scores be used to predict patient satisfaction following joint replacement surgery and to guide patient selection? J Bone Joint Surg [Br] 2011;93-B:1660–1664.

8. El Miedany Y, El Gaafary M, Youssef S, Ahmed I, Palmer D. The arthritic patients’ perspective of measuring treatment efficacy: Patient Reported Experience Measures (PREMs) as a quality tool. Clin Exp Rheumatol 2014;32:547–552. 9. Weldring T, Smith SM. Patient-Reported Outcomes (PROs) and Patient-Reported Outcome Measures (PROMs). Health Serv Insights 2013;6:61–68.

THE BONE & JOINT JOURNAL

What are the key drivers that change practice?

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