Complications after Surgery For Painful Hip Osteoarthritis: A Qualitative Study with Patients and Surgeons

Background
Painful osteoarthritis affects 8.75 million people in the UK, and over 600 million people globally. For hip osteoarthritis, joint replacement surgery becomes an option if pain and limitations cannot be adequately managed through exercise, information, weight loss and medication. Around 70,000 people undergo hip replacement annually in the UK, but this is a major operation with known risks including deep infection in the operated joint. Deep infection affects 1% of patients who have had hip replacement. Infection is treated with antibiotics and further surgery, which is invasive and involves long stays in hospital and ongoing medication. Given that patients undergo initial hip replacement in the hope of alleviating pain and functional limitations, the development of infection and further treatment may cause considerable physical and psychological distress. Understanding the impact of infection after hip replacement has the potential to inform management strategies and information for patients who are considering hip replacement.
Methods
In a qualitative study we interviewed 19 patients who had developed deep infection after hip replacement and 12 consultant orthopaedic surgeons who specialise in infection. Potential participants were identified in 5 hospitals and were approached by letter and information sheet. Those interested in taking part were asked to contact the study researcher, who then interviewed patients in their own homes and surgeons at their place of work or by telephone. Participants provided their written informed consent prior to interview. Using a topic guide, in-depth interviews with patients explored their experience of infection, treatment and recovery. Interviews with surgeons explored decisions about treatment. Interviews were audio-recorded, transcribed and imported into QSR NVivo qualitative software. Data were analysed using constant comparison. Transcripts were coded, a coding framework developed and refined with 20% of transcripts double coded for rigour. Coded data were inductively grouped into categories and Data sets were compared and contrasted.
Results
Patients with deep joint infection described pain, loss in mobility, loss of valued activities, changes to their home environments or moving into care, negative impact on personal relationships, and economic burden including inability to work. Patients also reported physical and psychological trauma associated with surgery and antibiotic treatment. When describing preferences for types of treatment, patients valued these issues above concerns about difference in efficacy of eradication of infection. Patients identified a need for additional support after surgery, particularly for those undergoing longer term treatment. Patients had strong preferences for treatment, emphasising side effects of antibiotics, impact of surgery and duration of treatment as key. Surgeons’ decisions were focused on patient characteristics and the nature of the infection, and often their preferred method for treating infection changed during their years in practice. During patients’ recovery surgeons’ were concerned about the return of infection and the patients’ mobility and functionality.
Conclusion
Deep joint infection has a profound impact on physical, psychosocial and economic aspects of patients’ lives. Surgeons focus on tailoring treatment and care for individual patients with the ultimate goal of eradicating infection, however this is not always possible and long-term antibiotic management of the infection is then likely. Patients sometimes find themselves in worse circumstances than those which led to their first hip replacement operation. The study highlights a clear need for provision of additional support for patients who develop infection after joint replacement surgery, and for better information for patients before choosing to undergo initial hip replacement.