Original Article

What do patients know about their joint replacement implants?

Scottish Medical Journal 2014, Vol. 59(3) 158–161 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933014542390 scm.sagepub.com

Zaid Abu Al-Rub1, Muhammad Hussaini2 and Craig H Gerrand3

Abstract Background and aims: Following a hip or knee replacement, patients may have little information about their prosthesis. This can lead to anxiety in the face of media reports about failing implants or misconceptions about how to live with a joint replacement. The aim of this study was to determine the level of understanding amongst patients who had undergone joint replacement in order to inform the development of an educational intervention. Methods and results: A cross-sectional, questionnaire-based survey. The survey was administered to patients attending an orthopaedic arthroplasty follow up clinic between June 2012 and October 2012. Patients were selected in a convenience sampling manner and had all undergone joint replacement at least three months prior to the survey. Responses were available from 52 patients; 49/52 (94%) of patients did not know what model of joint replacement they had and 44/52 (85%) did not know what materials the implant was made from. There was wide variation in recall of advice about activity restrictions. Conclusion: Whilst patients used the internet and other sources to look for advice, this survey suggests the most appropriate educational intervention for this population would involve written information including advice about type of implant, activity restrictions, dental treatment and airport security detectors.

Keywords Arthroplasty, hip arthroplasty, knee education, patient, replacement

Introduction Although hip and knee replacement surgery is highly successful, the early failure of certain types of joint replacement, and the associated intense media interest, have caused concern amongst patients about their procedures and their implants.1 Consequently, we have noticed an increasing number of enquiries from patients concerned about their implants. In our centre, preoperative education programmes for patients focus mainly on the procedure and rehabilitation, but do not necessarily discuss the implant in detail or how to live with a joint replacement. Patients may also obtain information from a wide range of staff in the hospital and in the community, from the internet and from other initiatives such as the Orthocard.2 Furthermore, it is recognised that patients may not understand or retain information, and have a poor understanding of orthopaedic terminology.3,4 Therefore, we considered it likely that patients who have had joint replacement might have a relatively low level of knowledge about

their implants, might be concerned following media reports about failing joint replacements and might like more information. The aim of this study was to ascertain what patients who have had joint replacements attending clinics in our hospital know about their implant. The specific objectives included determining their knowledge about the implant, the materials it was made from, activity restrictions, advice about dental treatment and metal detectors. Furthermore, we aimed to find out whether there was a demand for more information and how this might be delivered.

1 Trust Doctor in Orthopaedics, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, UK 2 Medical Student, Newcastle University Medical School, UK 3 Consultant Orthopaedic Surgeon, Department of Orthopaedics, Freeman Hospital, Newcastle Upon Tyne NHS Foundation Trust, UK

Corresponding author: Craig H Gerrand, Consultant Orthopaedic Surgeon, Department of Orthopaedics, Freeman Hospital, Newcastle Upon Tyne, NE7 7DN. Email: [email protected]

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Methods This was a cross-sectional, questionnaire-based survey. The questionnaire contained 17 questions including demographic items, items about the name and make of the implant, knowledge of materials, recall about activities which patients had been told to modify, about those which patients chose to modify, the source of that information, where patients actively sought information and free text responses. The survey was piloted and refined before administration. The study was a service evaluation for which specific ethical committee approval was not required. The survey was administered to patients attending an orthopaedic arthroplasty follow-up clinic between June 2012 and October 2012. Patients were selected in a convenience sampling manner by one of the authors or a clinical nurse specialist and were asked to complete the survey in the clinic. All respondents had undergone their joint replacement at least three months prior to taking part in the survey.

Results Surveys from 52 patients were available for this analysis. The median age was in the eighth decade (Figure 1) and 28 respondents (54%) were female. In total, respondents had undergone 79 joint replacements, (53 knee and 26 hip replacements), with 22 (42%) patients having undergone more than one joint replacement. The time since the last procedure ranged from 3–6 months to more than 5 years (Figure 2). The majority of respondents (49, 94%) did not know what model of joint replacement they had and 44 (85%) did not know what materials (e.g. stainless steel or polyethylene) their implant was made from. Advice about activity restriction came from a number of sources, most often surgeons (12/35, 34%), nurses (10/35, 29%), physiotherapists (6/35, 17%), occupational therapists (6/35, 17%) and in one case (1/35, 3%) from a

Figure 1. Age distribution of respondents.

General Practitioner (GP). Patients recalled being advised to avoid crossing their legs (18/47, 38%), running (14/44, 32%), sitting in a low chair (12/46, 26%), bending (9/45, 20%), sleeping on the operated side (7/ 45, 16%), getting into a bath (7/43, 16%), driving (6/45, 13%), swimming (6/42, 14%) and sexual intercourse (4/ 45, 9%). Furthermore, as a result of their joint replacement, patients chose to avoid running (32/49, 65%), sitting in a low chair (15/46, 33%), crossing their legs (14/46, 30%), bending (12/45, 27%), swimming (12/44, 27%), getting into a bath (11/44, 25%), sleeping on the operated side (7/46, 15%), driving (4/43, 9%) and sexual intercourse (3/43, 7%). In terms of the impact on daily life, 20/51 (39%) had received advice about dental work and 14/52 (27%) had had problems with airport or other security systems because of their implant. When asked about information provision, 25/52 (48%) of patients had an Orthocard and 33/52 (63%) patients stated they would like more information about their implant. The preferred method of communication was mail for 28/42 (67%) respondents, internet for 10 (24%) and in the clinic for four (10%). Patients said that they would preferentially look for information about their implant in the hospital, at their doctor’s surgery and on websites rather than on the television, in magazines or newspapers or from relatives. Press reports about joint replacements had been seen by 16/ 52 (31%) patients. Of these, eight left comments. These included ‘Metal on metal not a good idea - glad I haven’t got it’, ‘Steel on steel problem - mine ceramic on steel’, ‘Certain metals can cause problems wondered what mine was made of’, ‘Problems with some hips - glad mine wasn’t affected’.

Discussion This study investigated what patients who had undergone hip or knee replacement knew about their implants. We have demonstrated that the overall level

Figure 2. Time elapsed since last surgery.

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Scottish Medical Journal 59(3)

of knowledge in this sample was low, that there was a demand for more information, and that media reports about failed implants may cause anxiety, particularly if it is not known if the patient’s own implant is at risk of failure. Furthermore, patients modify their activities in a variable way depending on what they choose or what they remember being told not to do. We believe these are novel and important findings which are helpful when considering the provision of information to this group of patients. Recognising that there was a need to improve information provision, the Joint Action Orthocard initiative made registration cards available to patients in order that they would have a record of their surgery and be able to present it to clinical staff or security staff at airports. We had been successful in promoting the card in our centre, with a reasonably high uptake in this sample of patients (48%). The fact that the three patients who knew what implants they had in situ all had Orthocards suggests that this might have been a helpful approach. Unfortunately, the scheme has been discontinued for financial reasons this year. The fact that orthopaedic implants are detected by metal detectors in airports is well recognised.5 This can be an inconvenience to patients after joint replacement, and affected a significant proportion (27%) of the patients in our survey. Antibiotic prophylaxis when patients with joint replacement undergo dental treatment is important where there is intercurrent infection,6 but fewer than half of patients (39%) had any recollection of being advised about this. Recall about advice relating to what activities patients should or should not do after joint replacement is highly variable. This may reflect poor retention of information, but may also represent an inconsistent approach between clinical staff. There is very little evidence about the value of recommending activity restrictions after joint replacement and practice varies as a result.7 There was a difference between the activities patients remembered being told to avoid and those which they chose to avoid. For example, although 18/47 (32%) of patients recalled being advised to avoid running, 32/49 (65%) reported choosing to do so as a result of their joint replacement. Patients collect information about their joint replacements from a number of sources, but hospital-based professionals appear to be the dominant source. Patients look for information in the hospital, or at their doctors’ surgery. Despite the fact that patients reported looking for information on the internet, there was a strong preference for written information compared with the internet or email. We recognise that our population may be less likely to use the internet than others. Although this is a small sample of patients selected in a convenience method in the clinic, we believe it is likely to be representative of our patient population. There is a risk however, that there is a bias towards

patients who are more regular attendees or that our findings would not apply to other centers with different arrangements for information provision. We did not formally collect the number of patients who refused to complete the survey, which is a further limitation, but refusal was unusual. Although further qualitative work in this area might be of interest, our intention was to rapidly obtain data which would help us improve the information available to patients.

Conclusion We have shown that patients usually do not know what implants they have in situ after hip or knee replacement and that this can lead to anxiety in the face of media reports. Information provision could be improved by giving patients information about the devices they have implanted and by developing consistent messages about living with a joint replacement including activity restrictions, activation by metal detectors and advice about dental treatment. Although patients may find information on the internet, there is a preference for written information. Acknowledgements The authors wish to thank Suzanne Osborne and Sylvia Pott, Arthroplasty Nurse Specialists.

Declaration of conflicting interests The authors declare that there is no conflict of interest.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References 1. Mail Online. Toxic metal hip implants ‘could affect thousands more people than PIP breast scandal’, http:// www.dailymail.co.uk/health/article-2107640/Toxic-metalhip-implants-affect-thousands-people-PIP-breast-scandal. html (2013, accessed 7 July 2013). 2. The Orthocard – don’t leave home without yours, http:// www.jointaction.org.uk/Campaigns.aspx?camp_id¼19 (2013, 3 Aug 2013). 3. Bagley CHM, Hunter AR and Bacarese-Hamilton IA. Patients’ misunderstanding of common orthopaedic terminology: the need for clarity. Ann R Coll Surg Engl 2011; 93: 401–404. 4. McCormack D, Evoy D, Mulcahy D, et al. An evaluation of patients comprehension of orthopaedic terminology: implications for informed consent. J R Coll Surg Edinburgh 1997; 42: 33–35. 5. Johnson AJ, Naziri Q, Hooper HA, et al. Detection of total hip prostheses at airport security checkpoints: how has heightened security affected patients? J Bone Joint Surg [American volume] 2012;94:e44.

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6. Joint prostheses and dental treatment: British National Formulary, https://www.evidence.nhs.uk/formulary/bnf/ current/5-infections/51-antibacterial-drugs/table-2-summaryof-antibacterial-prophylaxis/joint-prostheses-and-dentaltreatment (2013, accessed 3 Aug 2013).

7. Youm T, Maurer SG and Stuchin S. Postoperative management after total hip and knee arthroplasty. J Arthroplast 2005; 20: 322–324.

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What do patients know about their joint replacement implants?

Following a hip or knee replacement, patients may have little information about their prosthesis. This can lead to anxiety in the face of media report...
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