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Setting Up Revision Hip Networks: The British Hip Society Approach
Andrew Hamer, Tim Board, Richard Holleyman and Vikas Khanduja
Networks are not new in medicine. Networks for the early recognition and treatment of cancer have been in place for many years, and as orthopaedic surgeons we are well-aware of major trauma networks. A network can be defined as ’a group of people or organisations in different places who work together and share information’.
There has been an increasing focus on quality of surgical care through the wide-ranging work of GIRFT (Getting It Right First Time), set up and led by Professor Tim Briggs. The programme has identified that in many units, small numbers of sometimes complex procedures are carried out (GIRFT report 2015) [1]. Such practices could lead to inferior outcomes and might also not be cost-effective, because loan equipment must be specially ordered in on an infrequent basis. On these grounds, it has been suggested that low volume high-complexity (LVHC) surgery such as knee and hip revision arthroplasty surgery can be improved by units working in networks.
GIRFT initially approached the British Association for Surgery of the Knee (BASK) to explore the feasibility of developing a network for revision knee surgery and the proposal was circulated to BOA members in 2019 [2]. There were two important proposals:
• Consideration should be given to revision surgery being approached on a regional basis and delivered by networks of appropriately experienced surgeons at a smaller number of locations.
• Department of Health and NHS England should encourage behaviour change (for example, through tariff funding).
BASK were engaged to run the pilot project and as a culmination of this, many units performing large numbers of revision knee cases have been recognised as Major Revision Centres (MRC). These units have now received significant funding to help set up regional multidisciplinary teams (MDTs), fund appropriate support staff and audit outcome.
The British Hip Society (BHS) has observed this process closely with interest, but similar funding for the development of revision hip networks has not been made available thus far. Nevertheless, the BHS are committed to improving the care of all patients undergoing revision hip surgery and recognise the value of networks in the achievement of this aim. The BHS also recognises that there are significant variations in the way that surgical care is delivered to patients in different parts of England, Wales and Northern Ireland (Scotland is not part of the GIRFT process). As a result, the BHS decided early on to engage with its members with the following aims:
• To establish what existing arrangements were in place for the provision of revision hip surgery across England, Wales and Northern Ireland.
• To utilise a scientific approach to understand the relationship between unit/surgeon volume and surgical outcomes.
• To develop an easy-to-use comprehensive Revision Hip Complexity Classification (RHCC) so that all the cases can be classified appropriately and outcomes measured.
• To determine what guidance would help in the delivery of high-quality revision hip surgery.
• To support BHS members in developing improved provision of revision hip surgery – building, if possible, on existing well-performing networks.
• Providing a forum for discussion of network development.
What the BHS has done so far
The BHS Revision Hip Network Advisory Panel
This was formed in 2020 with members from across England, Wales and Northern Ireland who were all nominated by colleagues. The Advisory Panel eventually consisted of 60 representatives, both BHS members and non-members. Regular meetings have taken place to discuss and advise on what was required to support the development of local revision hip networks, and this led to the development of BHS guidance documents. These in turn became known as British Hip Society Surgical Standards (BHSSS) which are described below. The Advisory Panel continues to meet to discuss how revision networks have been developed already across England, Wales and Northern Ireland, and to share best practice
Revision Hip Complexity Classification
This initiative was led by Professor Tim Board, with the intention of developing a simple, reproducible and useful classification of revision hip cases. Existing classifications were specific to certain diagnoses and it was felt that a comprehensive classification that could equally be applied to periprosthetic fractures, infection or aseptic loosening, for example, would be of value. Such a classification could be used to simplify the discussion of cases, for instance, at an MDT and for the recording of the level of case complexity that each unit was undertaking. The classification was developed using a modified Delphi process involving experienced hip surgeons and is summarised in Figure 1.
The classification has been termed the Revision Hip Complexity Classification (RHCC) and consists of three grades: H1, H2 and H3 with increasing levels of case complexity with the addition of a ‘*’ sub-categorisation for significant medical co-morbidity. The classification showed good intra- and inter-observer error in testing [3]. Further work is being undertaken to assess the utility of the RHCC in predicting outcomes and the BHS has also developed an app to further simplify adoption (Figure 2). It is hoped that the app will be launched this month and the RHCC classification will appear in the next version of the National Joint Registry MDS [4].
Joint funded BHS/ ORUK research fellowship
The BHS is committed to using data to drive and inform decision-making, and was delighted when ORUK (www.oruk.org) agreed to co-fund a research fellowship to support this activity for two years.
Richard Holleyman was appointed to this post and has so far completed a detailed analysis of NJR data, describing the volumes of revision hip arthroplasty currently performed by surgeons and hospitals, and examining in detail the variation in practice across the country. He has also outlined the rate of accrual of experience by early career arthroplasty consultants. The latter is a key consideration if any recommended or mandated volume thresholds are to be adopted, with implications for the adaptation of training pathways and consultant job planning, which is fundamental to delivering high-quality patient care. This study has been completed and is currently undergoing methodological review prior to journal submission. Further work is underway linking volumes to outcome data, including mortality, re-revision, re-operation, and serious medical complications.
BHSSS (British Hip Society Surgical Standards) documents
The BHS Revision Hip Network Advisory Panel identified several clinical and organisational areas where it was thought that agreed guidance would be of benefit. The guidance documents were all prepared by groups of experienced hip surgeons and then were reviewed by all members of the National Panel. The documents are now available on the BHS website [5].
• MDT working
Organisation and processes
IT support requirements
• Revision surgery for infection
• Revision surgery for periprosthetic fracture
• Revision surgery for aseptic loosening
• Revision for instability
• Perioperative care
• Dual consultant operating.
The future of Hip Revision Network Development
While the BHS Network Panel has done much to develop the tools necessary to help in the development of hip revision networks, the society has no mandate or power currently to effect change. The pilot project led by BASK for knee network development is observed closely by the BHS and clearly, if effective networks are developed for knee revision, it is likely that the same models will be used for hip revision. It should, however, be recognised that in many parts of the country, there are already well-developed hip revision networks which are tailored to the local circumstances in each area. Other areas of the country are in the earlier stages of hip network development, and the BHS would hope to support the units involved to set up a network appropriate to the local expertise and facilities.
One clear view expressed by the Revision Hip Network Panel is that the transfer of all patients requiring revision surgery to a central specialist ‘hub’ would be impossible and many cases will have to be dealt with in other hospitals in the network. This would apply to emergency cases such as patients with periprosthetic fractures or those with potential infection requiring debridement, antibiotics, and implant retention (DAIR). The panel view is that all cases requiring revision should be classified using the RHCC and then discussed at local MDTs, the case being escalated to regional MDTs if needed. Based on this discussion, the care of the patient may be transferred between units.
All parts of the case discussion should be recorded using the most appropriate IT system, to allow tracking of care and audit at every stage.
The revision knee network pilot project provides a fixed sum of money to help in the set-up of regional networks and their administration. The BHS is clear that similar funding will be necessary for hip network development.
Revision hip arthroplasty is costly. The current remuneration available to hospitals often falls short of the cost of each case and this inevitably makes such surgery unattractive to providers. At every stage of discussion of hip network development, the point is consistently made that appropriate funding should follow the patient, to ensure that hospitals do not lose money each time such a case is performed. Finally, while we await the mandate to develop these networks formally, we at the BHS shall continue to support existing networks and remain committed to using data to drive decision-making.
References
1. Briggs T, Getting It Right First Time (GIRFT). A national review of adult elective orthopaedic services in England – Getting It Right First Time (date last accessed 18 July 2022).
2. British Orthopaedic Association. BOA/ BASK/BHS communication about changes to knee revision surgery in England. https://www.boa.ac.uk/ resources/policy-and-positionstatements/boa-bhs-bask-letter-reclinical-model-final-pdf.html (date last accessed 8 December 2022).
3. Leong JWY, Singhal R, Whitehouse MR, Howell JR, Hamer A, Khanduja V, et al. Development of the Revision Hip Complexity Classification using a modified Delphi technique. Bone & Joint Open. 2022;3(5):423–431.
4. National Joint Registry for England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Data collection forms – The National Joint Registry. https://www.njrcentre.org.uk/ healthcare-providers/njr-datacollection-forms-k1-k2-s1-s2-h1-h2e1-e2-a1-a2/ (date last accessed 5 December 2022).
5. The British Hip Society. Revision Hip Network Information. https:// britishhipsociety.com/revision-hipnetwork-information/ (date last accessed 5 December 2022).
Andy Hamer was appointed Consultant to the Northern General Hospital in Sheffield in 1998 with a special interest in hip and knee arthroplasty and revision surgery. He was President of the British Hip Society 2021-2022, during which he led the BHS work concerning Hip Revision Networks.
Professor Tim Board is a hip surgeon at Wrightington Hospital in Lancashire. He specialises in revision and complex primary and young adult hip problems. He is chair of the British Hip Society Research Committee.
Richard Holleyman is a ST7 in T&O based in the North East. He is currently undertaking a full-time PhD studying outcomes following hip surgery, co-funded by Orthopaedic Research UK and the British Hip Society.
Vikas Khanduja is a Consultant Trauma and Orthopaedic Surgeon in Addenbrooke’s - Cambridge University Hospital NHS Foundation Trust. He is the President of the British Hip Society and Trustee of NAHR. He has been involved in the initiation of the Revision Hip Networks and strongly believes in “data driven decisions” guiding the future development of this network.
