This paper follows a cohort of patients who underwent Kinemax total knee replacements in an early NHS Treatment Centre in a different region from their local hospital. After three years, survival for aseptic loosening was 85% and after five 81%. The five year survival of this prosthesis in the National Joint Register is 95%. The five year review is now compared with a consecutive series of Kinemax total knee replacements performed at the patients’ local hospital which is 95%. In addition to an inferior survivorship from aseptic loosening, a further 5% of the cohort from the treatment centre underwent patellar resurfacing compared to 1% from the local unit.
The surgeons operating at the Treatment Centre were recruited from Scandinavia by a locum agency, Scanloc, generally visited the UK for a fortnight, were not experienced with the prostheses they were given to implant and discharged their patients back to base hospital. Concurrently patients from Bristol underwent knee replacements at the same Treatment Centre but the revision rate of those patients was a quarter of those reported in this study1. A report commissioned by the South West Health Authority concluded that the denominator of the three year review was incorrect so that the rate of revision was overestimated, the research methodology was poor and the threshold for revision was low. It is difficult to understand the robustness of the last suggestion as this report obtained consent to review the notes and radiographs of ten of the fourteen cases revised and was unable to interview any of the patients.
The authors now address the denominator and provide comparative data from their own unit. The logistics of data collection in a study of this type are formidable, data is inevitably incomplete and it is easy to criticise the research methodology. None the less, the findings are similar to other comparative studies of NHS and Independent Treatment Centres from Exeter and Bristol1,2.
This paper finds no difference in the functional outcomes between National Health and Treatment Centre which concurs with observations from comparative studies of elective surgery from the London School of Hygiene and Tropical Medicine3,4 however the critical question is the overall result. When the disappointing results of revision knee arthroplasty are considered, it is likely that the cohort from the treatment centre fare worse. There were major difficulties in establishing outcomes from the early Independent Treatment Centres because of commercial confidentiality and they are now required to record their cases in the National Joint Register which uses revision as the outcome measure but Hospital Episode Statistics that record interventions other than revision are patchy.
Inevitably a paper of this nature straddles the margins of the science of clinical outcome and the politics of health care provision. The principles that emerge are applicable to both. These principles are that anything less than the highest standard of primary joint replacement is unacceptable for patients and expensive for the health care provider. This standard is best achieved by experienced surgeons who are familiar with the prostheses they are using and have feedback on their outcome by follow up of their patients. The basic certificate of completion of training (CCT) implies that the holder has been involved on average in 25 knee replacements in the UK and in many European countries even less. In the German speaking countries, surgeons intending to work in the public sector serve a further six to ten years after CCT before totally independent practice. Without further training, nascent surgeons newly armed with their CCT are likely to need the support of senior colleagues and the stability of working in one unit to minimise the complications of their early learning curve. Most of these principles were breached in the early treatment centres and it is to be hoped that the lessons learned from the experience reported in this paper are incorporated into future commissioning rather than rejected as politically inconvenient.
Gordon Bannister, Professor of Orthopaedic Surgery, University of Bristol, UK.
1. Bannister G, Ahmed M, Bannister M, Bray R, Dillon P, Eastaugh-Waring. Early complications of total hip and knee replacement: a comparison of outcomes in a regional orthopaedic hospital and two independent treatment centres. Ann R Coll Surg Engl 2010;92:610-14.
2. Ciampolini J, Hubble MJ. Early failure of total hip replacements implanted at distant hospitals to reduce waiting lists. Ann R Coll Surg Engl 2005;87:31-5.
3. Chard J, Kuczawski M, Black N, van der Meulen J. Outcomes of elective surgery undertaken in independent sector treatment centres and NHS providers in England: audit of patient outcomes in surgery. BMJ 2011;19:343.
4. Browne J, Jamieson L, Lewsey J, van der Meulen J, Copley L, Black N. Case-mix & patients' reports of outcome in Independent Sector Treatment Centres: Comparison with NHS providers. BMC Health Serv Res 2008;8:78.