With the amount of information about joint replacement surgery increasing, many patients are choosing what implants (or even what type of operation) they want to have, not who they want to put it in. Shortly after we won the contract for the National Joint Registry, I asked an eminent knee surgeon (he was in a very smart suit) what knee implant I should have. I have always remembered his response: ‘You have put in whatever the surgeon is used to putting in’. You should not expect a surgeon to put in an implant you choose: if the surgeon has not been trained in its use, you may not get the outcome you want. If you have trawled all the information that you can find about implants and are set on having a particular implant, you may have to find a surgeon who uses it. This will probably be more difficult than you think: ask patients what they have had implanted and most won’t know. The NJR publishes lots of information about implant performance but you really need to understand the data to take a view. One type of implant may be good in men under the age of 70 but not so good in males over that age. Additionally, what appears to be a less well performing implant could get outstanding results in the hands of some surgeons. Another place to look is the website for the Orthopaedic Data Evaluation Panel (ODEP). You will be able to select implants by manufacturers and see how ODEP rate them. However, beware that an ODEP rating will tell you how many years’ worth of evidence there is for an implant and how good that evidence is: it does not give an indicator of performance.
Even though there is quite detailed information about implant performance, I made my choice of where to go based on my choice of surgeon. Having chosen the surgeon, I then asked him what implant he would use. Looking at the figures we publish each year, I saw that that implant was, on the face of it, one of the better ones but not, according to the information, the best performing one. For me, choosing the surgeon was of prime importance.
Most patients won’t be able to choose their surgeon in the way I did. I was in an NJR meeting with several eminent (suits again) surgeons and asked who, in their opinion was the best knee surgeon in the region where I lived. They all came up with the same name and at various meetings since, other surgeons, having asked me who was doing me knee replacement, confirmed that I had made an excellent choice. It does mean that I have a little way to travel and the Unfeeling One has just told me that she won’t be able to take me in or pick me up. It would appear that she has used all her holiday. Why she wasted a week helping her dad look for a new house, knowing that I might have to go into hospital sometime this year, I don’t know. If you are not in the fortunate position that I am, there are some sources of information.
If you are a hip patient and really desperate, you could always look at the Daily Mail’s Top Ten hip surgeons, ‘as voted for by other surgeons’. I know just over half (six) of this year’s top ten and they all claim that they have never been asked to vote for anyone and, indeed, they don’t know any other surgeons who have been asked to vote for them. If everyone was to insist going to the Top Ten, they may to wait a decade or so to get their operation so I am not sure what value such a list offers. In June this year, and for the first time, NJR data was used to publish consultant and hospital data. The information can be found at www.njrsurgeonhospitalprofile.org.uk/ and includes mortality rates and the numbers, and types, of operations undertaken. If you are due to have a procedure of a certain type, would you choose a surgeon that does 100 a year or someone that does 5 a year?
A few years ago, about the only thing that you could base your choice of hospital on was the cost of the car parking. Whilst there is now more information available, I am afraid that the choice is going to based on either word of mouth or pot luck. If you have the chance, speak to other patients: Arthritis Care (www.arthritiscare.org.uk) has some really good patient forums.
Be prepared when you first go to meet your surgeon and take a list of questions with you. Whilst there are many websites where you can get information about what to ask, none of them suggest asking ‘Do you contribute to national clinical audit? If not, why not?’. One of those surgeons in the Daily Mail’s Top Ten suggested to me that it should be the first question a patient asks. In England, Wales and Northern Ireland, the clinical audit is the National Joint Registry. If a surgeon doesn’t contribute data to the NJR (and they should as it is mandatory data collection), the NJR can’t identify poorly performing surgeons, hospitals, and implants, nor can we contact patients if there is subsequently an issue with their implant. From the patient’s point of view, the surgeon cannot tell you how good their outcomes are. A surgeon will not know if primary operations that they have carried out have been revised by someone else so it is impossible for them to know how good their outcomes are. Only by submitting details of all their operations to the NJR will they have accurate information about their revision rates. Don’t be afraid to ask.
Bit dry today, apologies. Didn’t get much sleep last night and am starting the early symptoms of man flu. Mind you, I can’t have had it for a while as all the Beecham’s powders given to me by the Unfeeling One expired in December 2011. I am not convinced by her reassurances that they’ll be fine as she was asking me about my will earlier on. Next blog will be about the hidden pitfalls of medical insurance. The paperwork from the hospital is due to arrive in the post tomorrow so things should get more interesting from here on in. Kneedyman.