Research Impact Report - Project 541
Studying outcomes in hip surgery using national datasets
Principal Investigator Richard Holleyman
Duration 36 Months
Hip Fracture Project
Hip fracture is the most common serious injury in older people, occurring in more than 65,000 annually in the U.K. Although hip fractures only account for 1 in 5 fractures in elderly patients with weakened (‘osteoporotic’) bone, they account for the majority of fracture-related healthcare expenditure and mortality in both genders over the age of 50 years. As the population ages in the U.K., along with much of the western world, the incidence of hip fracture is predicted to significantly increase.
Deep wound infection can affect up to 1 in 20 patients and is amongst the deadliest of complications following such injuries. The risk of death following such infections is up to 50%, carrying a poorer prognosis than many cancers. This compares to 30% for those patients who do not develop an infection.
This project aims to use data from the National Hip Fracture database (NHFD) along with routinely collected data from U.K. hospital admissions, to study surgical site infections following hip fracture surgery. Infection is a relatively rare event such that the ability of individual surgeons and centres to acquire cases and surgical experience is limited. Existing studies are largely limited to small numbers of patients from individual or small groups of surgical centres. This is a problem because findings of statistical analyses in these small cohorts risk being prone to errors or findings which may not be applicable to other geographic regions.
This study will solve the above problem by allowing infection to be studied in many thousands of patients which will help to more definitively identify which patients are more likely to get infections and to look at potential targets which could be addressed to lower patient risk.
The project was adapted in response to the COVID-19 pandemic, a particular focus of this work which has now been completed is studying the impact of the new coronavirus (which causes COVID-19) on patients with hip fractures as emerging evidence has shown that patients who contract COVID-19 around the time of their hip fracture are at even greater risk of dying during their admission (almost 1 in 4) compared to those who do not.
Revision Hip Arthroplasty Project
Hip replacement is one of the most common and successful operations performed in the UK for patients with arthritis. Whilst a hip replacement lasts many years for most patients, some (up to 5% after 10 years) may require complex ‘re-do’ surgery such as when infection develops, the components become loose, or the bone around the implant fractures. Revision is often more complex than primary surgery and associated with greater technical demands, costs, and higher complication rates. Furthermore, in the UK there is great disparity in what constitutes a ‘revision practice’ with some surgeons and centres performing many, and some performing very few such surgeries annually which may adversely impact learning curves and outcomes according to evidence emerging from other countries and surgical specialties. Thus, there is a need to investigate these associations and other determinants of outcome in the UK to inform the delivery of high-quality care for patients.
This project will use national datasets to explore in detail the volume of revision hip arthroplasty currently performed in the UK by surgeons and hospitals, and will look in detail at the variation in practice nationally. We will then describe the numbers of patients who experience rare but serious (for example, risk to life) or more common but less serious complications. Finally, we will look to model the relationship between patient and health system factors to see if risks are greater in certain groups, or where operations are done in low numbers by hospitals. This will help provide information for patients to make more informed choices about risk, and also for hospitals and surgeons so they are able to ensure that surgery is as safe as possible for patients.
This research will make an impact for:
- By providing evidence for discussions with clinicians and informed consent regarding the specific risks of complications (e.g., COVID-19, surgical site infection (SSI) following hip fracture, re-operation) and resultant sequelae (e.g. increased mortality).
- By allowing potential interventions if any key modifiable risk factors are identified e.g., risk factors for infection, surgeon volume thresholds.
- By describing outcomes following hip operations (e.g., arthroscopy) and providing evidence to allow patients to ‘weigh up’ benefits vs. risks – e.g. following hip arthroscopy, providing numbers for the probability of experiencing an improvement in their patient reported outcomes.
- Generating evidence on outcomes following complex revision hip replacement surgery will provide much needed information to support the delivery of this type of surgery in the UK.
- Provide evidence to support informed discussions with patients and relatives regarding the above.
- Evidence from this project will provide information on COVID-19 and SSI incidence and risk factors using national cohorts which will help support local departments to audit against national data.
- Identification of any modifiable risk factors may help inform clinicians regarding potential interventions to attempt to reduce the risk of SSI.
- Data from this project concerning revision hip arthroplasty numbers will be valuable to surgical healthcare delivery networks in configuring their services.
- Connecting with new people and a charity at the front line of orthopaedic research.
- Completion of a higher degree and advancing my understanding of epidemiology and data science through projects with patient benefit as their principal objective.
Fundamental problem trying to address
To use routinely collected health data to address the following:
- Identify risk factors for surgical site infection in hip fracture patients and the resultant outcomes.
- Report patient outcomes of young adult hip surgery and their determinants using national registry data as current evidence is mostly limited to small case series from specialist centres.
- Report the numbers and outcomes of revision hip arthroplasty performed in the UK with a particular focus on the impact of surgeon and centre experience.
Aims & Objectives
- Describe the impact of COVID-19 on mortality after hip fracture using a national cohort (National Hip Fracture Database).
Analysis complete & article submitted for peer review at Bone and Joint Journal.
Presented at British Hip Society 2022.
- Apply cox modelling to describe the impact of COVID-19 on mortality displacement following hip fracture.
Analysis complete & writing up manuscript.
- Describe the determinants and outcomes of surgical site infection after hip fracture surgery using a national cohort (National Hip Fracture Database).
Analysis in progress.
Young adult hip surgery
- Describe the early outcomes of hip arthroscopy for femoroacetabular impingement (FAI) using data from the UK Non-Arthroplasty Hip Registry (NAHR).
Analysis complete & paper submitted for peer review and revisions invited – KSSTA Journal.
- Describe early outcomes following arthroscopic chondral procedures in the hip using data from the UK Non-Arthroplasty Hip Registry (NAHR).
Analysis complete & article submitted for peer review.
- Describe and compare early outcomes of arthroscopic labral repair and debridement using data from the UK Non-Arthroplasty Hip Registry (NAHR).
Analysis complete & paper accepted by to Bone and Joint Open Journal.
- Describe the impact of surgeon volume on outcomes following hip arthroscopy using data from the UK Non-Arthroplasty Hip Registry (NAHR).
Analysis in progress & preliminary results presented at British Hip Society 2021.
- Describe the numbers (volume) of hip revision surgery operations undertaken in the UK with a focus on volumes undertaken by individual consultants and hospital trusts.
Analysis in progress.
Preliminary analyses presented at British Hip Society 2021.
Continuing work on analyses and writing up manuscript.
- Describe the impact of surgeon and centre volume on outcome (focused on post-operative mortality and re-revision risk) following revision hip surgery using data from the National Joint Registry linked to hospital episode statistics.
Approved by NJR research committee & awaiting sign off and data release from HQIP.
- Describe the incidence and outcomes of COVID-19 following arthroplasty in England during the pandemic (using National Joint Registry cohort).
Application ‘approved in principle’ by NJR, awaiting HQIP governance review.
Team members & other funders
Comparison of early outcomes of arthroscopic labral repair OR debridement: a study using the U.K. Non-Arthroplasty Hip Registry Dataset.
RJ Holleyman, S Lyman, M Bankes, TN Board, JL Conroy, CW McBryde, A Andrade, A Malviya, V Khanduja
- Accepted by Bone and Joint Open Journal and currently proofing.