Pre-operative preparation of patients for total knee replacement: An action research study

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Abstract

Aims and objectives

To examine the development and impact of a multidisciplinary preparation clinic for patients undergoing total knee replacement (TKR) surgery.

Background

There is evidence to suggest that patients’ preoperative characteristics such as pain and mental state impact the long term results of TKR surgery. Preparation sessions may help in identifying and working with those patients whose preoperative status could reduce the benefits of surgery.

Method

Actions cycles were carried out to develop an information booklet and multidisciplinary Knee Clinic at an acute Trust in outer London, UK. A sample (n = 23) of patients was recruited to test changes as they were implemented.

Results

The Knee Clinic involved nurse practitioners, occupational therapists, physiotherapists and service users (patients recovered from TKR surgery). Elements of physical and social assessment and interventions were carried out using a Social Cognitive Theory framework. Patients reported they benefitted from the information booklet and attendance at the Knee Clinic.

Conclusion

A structured pre-operative information and assessment clinic can be developed using a Social Cognitive Theory framework for the benefit of patients. Further studies are required to examine and utilise psychological assessment of patients at such clinics.

Introduction

This paper examines changes made in the preparation of patients with osteoarthritis (OA) for total knee replacement (TKR) surgery at an English district general hospital utilising an action research approach. TKR surgery is clinically and cost effective for patients whose OA is not successfully managed with conservative options and around 60,000 procedures are performed in England and Wales annually (Dakin et al., 2012). On average 90% of TKR prostheses are still in situ with no radiological signs of loosening 15 years after surgery (Labek et al., 2011). However 10–20% of patients have the same or worse pain 1–7 years after their operation (Brander et al., 2003, Wylde et al., 2007) and up to one-fifth think their reduced functional ability still hampers physical activities (Wylde et al., 2007). Potentially modifiable pre-operative patient characteristics such as pain and self-efficacy beliefs may impact on longer term post-operative outcomes, reducing the overall benefits obtained by the surgical procedure (Escobar et al., 2007, van den Akker-Scheek et al., 2007).

The aim of this project was to develop, implement and evaluate a multidisciplinary preoperative Knee Clinic to address these patient characteristics.

Section snippets

Background

To identify modifiable pre-operative patient physical and psychosocial factors affecting longer term (>6 weeks) post-operative outcomes after TKR surgery and potential interventions to mediate the effects of these factors, a search of electronic databases (Cochrane, CINAHL, MEDLINE, EMBASE, PsycINFO) was performed to identify English language literature published since 2000. Older work was considered if it was seminal, such as that on self-efficacy (Bandura, 1977). Keywords included total knee

Aims and objectives

The overall aim of the project was to develop, implement and evaluate a multidisciplinary Knee Clinic to improve patient preparation for TKR surgery. This paper examines what was developed in practice and its impact on patients; a second paper explores the change process (reference to follow).

Project design

The project used an action research design. Action research is ‘a period of inquiry, which describes, interprets and explains social situations while executing a change intervention aimed at improvement

Action cycle: development of the information booklet

A 32 page patient information booklet which explained the patient pathway from listing for surgery to long term follow-up was developed through a series of action test cycles. It was designed to ensure that patients had an accurate understanding of preparation and recovery from TKR surgery to inform realistic self-efficacy and outcome expectation assessments.

The first test cycle involved collecting and examining existing patient information leaflets to identify areas for development. In

Discussion

The project demonstrates how an information booklet and a single education/assessment session can begin to address some of the patient physical and social characteristics which impact post-operative recovery, such as worse pre-operative pain (Lingard et al., 2004, Escobar et al., 2007) and function (Fitzgerald et al., 2004, Lingard et al., 2004). The test cycles demonstrated that these interventions were both feasible for clinicians and acceptable to patients. The teaching of exercises and

Conclusion

The project has demonstrated how action research can be used to make service changes and the positive impact these changes may effect on patients’ preparation for TKR surgery. The project resulted in a multidisciplinary assessment and intervention Knee Clinic with service user involvement based on a SCT framework. Such clinics are vital if the aims of current initiatives such as the Enhanced Recovery Programme are to be met and cost and patient benefits from surgery maximised.

Contributions

Research design: BL, CC, LP. Data collection: BL. Analysis: BL, CC, LP, JB. Manuscript preparation: BL, CC, LP, JB.

Conflict of Interest Statement

I confirm that there are no financial or personal relationships with other people or organisations that inappropriately influenced this work.

Ethical Approval

The acute Trust’s Research and Development Committee and the Local Research Ethics Committee approved the project.

Funding Source

No funding was sought for this study.

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