We’re all well aware of the challenges facing funding of the NHS. With the recent election still fresh in mind, the process of how funds are allocated within the NHS has been discussed at length, with almost everyone holding an opinion about which areas are most deserving of retaining, increasing or decreasing funding levels.

With increased pressures on the NHS due to an ever-increasing older population, there is arguably a degree of management required to ensure that those who are deemed most deserving are able to receive access to treatment, ahead of those who are perhaps regarded as less suitable, or less in need of surgery.

So, how can suitability be effectively and fairly judged?

One idea that has been mooted is that those who are prepared to demonstrate that they have done everything they can to ensure that their overall health is as good as it can be, are given preferential access over those who indulge in damaging lifestyle habits. An example of this is the refusal of the NHS to offer orthopaedic treatments such as knee and hip replacements to those who are smokers, or who are classed as obese.

Access to additional NHS funding for joint replacements

When patients require certain treatments on the NHS, doctors can make a request to their local Clinical Commissioning Group (CCG) to receive extra funding for this. According to information sourced by Arthritis Research UK, tens of thousands of these requests were made in the past year, and around half of these were approved. With requests for funding growing year on year, there are a significant number each year that are not able to benefit from this additional CCG funding.

The chief executive of NHS Clinical Commissioners, Julie Wood explains that, “unfortunately, the NHS does not have unlimited resources, and ensuring that patients get high-quality care against a backdrop of spiralling demand and increasing financial pressures is one of the biggest issues CCGs face.” This is exactly why the NHS are having to impose additional criteria (such as being a non-smoker and not being obese) to help identify which patients are most deserving of funding for the operations they require.

Some CCGs have introduced guidelines to help identify the more disabled patients, which means patients will only be approved for hip and knee replacement operations if they are in such pain that sleeping and incapable of performing simple, everyday activities. The concern is that delaying surgery till that point only results in higher treatment costs overall and a less than optimal outcome for the patient.

Ultimately, despite the NHS wanting to offer support, treatment and operations to all who require them, there will always be a limit to what is achievable when demand outstrips supply. While this continues to be the case, the NHS will argue that the only way forward is to set additional stipulations and criteria in which to evaluate patients, so they can try and fairly assess how to prioritise available NHS funding for joint replacements.

Robots have featured quite frequently in the news recently, with most people seeing the security robot ‘drown’ in the office complex in America. While this made us smile and the media delighted at the opportunity to share some witty headlines about the robot’s demise, it was an illustration of just how far we have come with robotic technology. Security robots are an exciting new development, designed to help make modern day lives better and easier. Robots are being increasingly used in surgery. There is now good evidence that prostate and other forms of abdominal surgery are safer and more effective when robots are used. The world of orthopaedics is no stranger to this idea either.

Robotic Joint Replacement from Mako

According to the Bone and Joint Journal, “the use of robots in orthopaedic surgery is an emerging field that is gaining momentum”. Although it is relatively early days at the moment, medical professionals are recognising the benefits that robotic technology can bring. If all goes to plan, it will be able to help with accuracy of operations and with this increased accuracy, faster recovery, better function and the hope that the new joint will function well for longer.

Robotic equipment is a considerable investment, but the benefits should be significant to the patient. What robotic orthopaedics is missing at the moment is robust data. This is always the case when something new is introduced. Already we have some data indicating that hip replacement components can be implanted more accurately. As more units invest in robotic technology, more data will emerge confirming improved accuracy of component placement and link this to faster recovery and improved functional outcome.

What types of operation are best suited to robotic assistance?

Partial knee and hip replacements are amongst the first commonly performed orthopaedic operations to take advantage of the potential benefits of robotic and computer-assisted technology. Malalignment of hip and knee components can cause instability, increased wear, loosening and early failure, requiring revision surgery. Modern robotic technology uses computer mapping on CT scans of the joint to plan the optimal position into which the components should be implanted. The robot acts as an extension of the surgeon’s eyes and hands and guides the surgeon to ensure to components go in the pre-planned position, potentially using smaller incisions, with less soft tissue trauma.

One of the reasons that hip and knee replacements are at the forefront of robotic technology is because demand for these operations is rising. The ‘baby boomers’ are now reaching an age where their joints are typically starting to wear out, stopping them carrying on with the activities they enjoy. At the moment joint replacement is the only way to get these patients back to their sports and activities to help improve their quality of life. The use of robots to improve the positioning of the new joint will hopefully make these operations even more reliable and successful.

Investing in the future

Many orthopaedic surgeons like Mr Bridle are interested in the potential that robotics can bring to the profession, it feels like an exciting development within the industry and one that can help make orthopaedic operations even more of a sure thing for patients.

In the world of orthopaedic surgery, it is always encouraging to see when new clinical trials are set up, as they help to develop, strengthen and expand our knowledge. Trials are welcomed as they offer a unique insight into how patients respond to treatments, surgical methods, aftercare, medication and so on.

joint infectionThe University of Bristol is currently running a new trial which is designed to look specifically at the risk of developing an infection after patients have been fitted with prosthetic joints. If patterns can be identified, steps can be taken to address these, which will ensure that patient care and rehabilitation is improved even further.

Understanding the problem

If patients have undergone a total hip or knee replacement, the risk of developing serious side effects are small, but when they do occur, they can be very problematic. To put it into perspective, the number of patients who develop periprosthetic joint infection (PJI) is only 1%, however, if you’re in that 1% then it is a very unpleasant experience. Antibiotic treatment alone is not successful. Sometimes the joint can be salvaged with further surgery to remove the infected soft tissues, along with a course of powerful antibiotics.

Usually, the artificial joint needs to be removed and replaced with a new one, either as a one or two stage procedure. The orthopaedic community has long debated whether a one or two stage approach is preferable. If this is not successful the joint may need to be permanently removed and very rarely an amputation may even be required. So, for that 1% who develop PJI, the implications can be life changing.

What is the new trial all about?

The trial is being funded by the National Institute for Health Research, an organisation that works with the NHS and funds “health and care research and translate discoveries into practical products, treatments, devices and procedures”.

The University of Bristol is planning to investigate patients with infected joints in this clinical trial, which will be comparing one-stage with two-stage revision for the hip. As well as infection eradication, one of the key things the trial will be looking to understand is how the patients feel afterwards; both in terms of physical elements such as pain, mobility, dexterity and joint stiffness; and also emotional elements such as how they feel in themselves.

The surgical approach taken in each case will also be reviewed, to understand if there are any differences in terms of how expensive the different approaches are versus their outcomes, and also the level of complications experienced with each approach.

The final element is an open dialogue with both patients and surgeons. How did they feel the process went? Was it a positive or negative overall experience? What could have made the process better? How are they left feeling afterwards?

This is a very important study, as we have very little prospective data in this area. We will look forward to the results to see if there are any changes that can be made to our approach to this problem to treat the infection successfully and in particular improve the overall patient experience.

Joint replacement specialist Mr Simon Bridle is highly experienced in treating patients that have experienced PJI. Alongside his colleague, Mr Philip Mitchell, and their outstanding medical team, they often are referred patients that have experienced an infection after a hip and knee replacement and require management and revision surgery to produce the best possible outcome. To arrange a consultation with Mr Simon Bridle, call 020 8947 9524.

Eamonn Holmes double joint replacementIf you’re considering having your knee or hip replaced it’s a really big decision. Questions such as how much pain to expect, how long will it take to recover, what complications might there be, are all things that would need to be explored thoroughly before you make the decision to commit to the operation. But what about people who are recommended to have BOTH joints replaced at the same time?

It’s always helpful when someone in the public eye chooses to have the same operation you’re considering, as you’ll get the chance to hear firsthand how another person has approached the decision-making process and how they have found the overall experience.

It has been reported that Eamonn Holmes recently had a double hip replacement, and although he was anxious in the lead-up the operation, he is an advocate of the approach. Living with a joint that needs replacing can yield a whole host of problems; in Eamonn Holmes’ case his hip problems were affecting many other parts of his body too: “people think hip problems mean hip pain but it can also mean knee, ankle, foot, back, neck, shoulder and head pain. I had all those and more.” Having both hips replaced has given him a new lease of life – greater mobility, less pain in other areas and a more positive outlook on his health. Recovery may have been challenging at times – but definitely worth it.

Why would people choose to have both joints operated on simultaneously?

It’s a matter of personal choice. Some would prefer to have one joint fixed, recover fully from that and then fix the second once you’ve healed from the first. Others would prefer to have everything done in a single time period. Admittedly, in the short term it will be harder to have both done at the same time, but in the longer term, it is just one period of rehabilitation.

Eamonn Holmes is quoted as giving his reasons for having both done at the same time as he wanted to get it all over and done with in one go: “I couldn’t have faced all the pain and disruption of major surgery to then have it happening all over again a few months later.”

Who is suitable for a double joint replacement?

Given the added strain on your body of having two joints replaced, rather than just one, there are certain requirements that patients must meet to be considered suitable. Double joint replacements are not recommended for people over the age of 75, for example, and as a rule of thumb, “patients must be in excellent physical condition, aside from the arthritis, and have no underlying health problems.”

Positive approach to rehabilitation

You might think that if you have both knees or both hips replaced you should expect a lengthy period of bed rest – think again. You will start to get out of bed with the physiotherapists the day after the operation and you will be encouraged to begin physical rehabilitation very quickly. The sooner you begin working your new joints and encouraging the muscles to work again, the faster you’ll begin to heal and your new joints will begin working in tandem with the rest of your body.

If you need both hips or both knees replaced then the most sensible starting point is to draw up a list of pros and cons of having both done together or staggering them. You’ll soon be able to identify which option looks best for you, but if you’re in any doubt, don’t make the decision alone. Your GP or surgeon will be able to help outline fully the benefits versus the risks so that you can make an informed decision, ideally with the help of family and/or friends who will be supporting you through whichever option you choose.

osteoarthritis and lifestyle changesOsteoarthritis is a condition that affects how your joints work, causes pain, stiffness and eventually even deformity of the joint. A joint affected by osteoarthritis begins to slowly degenerate as changes begin to occur to the cartilage that surrounds the joints.

The cartilage starts to become thinner and rougher in texture, while simultaneously the bone beneath begins to thicken. The tissues surrounding the joint recognise that something is wrong and begin to try and correct the issue, which causes more challenges for the troubled joint as the additional activity can cause the joint to swell.

Finally, the ligaments around the joint also react by beginning to thicken and harden – this is because they are trying to stabilise the joint. The net result is this can really impact on the mobility of the joint and can cause sufferers a lot of pain and discomfort.

In the orthopaedic community, it is widely agreed that osteoarthritis is a condition that can be influenced by lifestyle choices. There are many factors that can lead to the start of osteoarthritis, including poor diet and lack of regular exercise, but the good news is that if people understand these lifestyle choices and the repercussions that they can have on their joints further down the line, care can be taken earlier to mitigate against the risk of developing the condition.

Osteoarthritis is linked to how your body deals with calorie intake and overall level of exercise

According to research undertaken by Arthritis Research UK, there is a link between metabolism and osteoarthritis. The implication of this is that by improving your dietary choices and introducing more regular exercise into your weekly routine, this can have a significant positive impact in how possible it is to delay or prevent osteoarthritis from developing.

Those who have a poor diet – one that lacks balance and does not contain enough of the key vitamins, nutrients and minerals – are at risk of being more susceptible to developing conditions such as osteoarthritis that may not occur so readily in a healthier individual. Coupled with this, poor diet is often linked with a more sedentary lifestyle. When these conditions occur and the body is not given the optimum conditions needed to produce energy, it attempts to compensate by generating a greater amount of glucose (the body’s natural sugars). When this happens, the body also generates more lactic acid, which causes the cartilage around joints to become inflamed, experience restricted mobility and cause discomfort. This is the onset of osteoarthritis.

What can be done if osteoarthritis is too far advanced to address with diet and exercise changes?

If you are experiencing advanced osteoarthritis then you may wish to consider a replacement joint. The joint is replaced with man-made components, which is usually highly successful in relieving the pain of osteoarthritis. This is a significant operation, so is not a decision that should be taken lightly, however patients who have suffered from serious osteoarthritis are generally able to achieve a much higher quality of life if they opt for surgery to help address the issues affecting their joints.

It is important to arrange to see an orthopaedic specialist like Mr Simon Bridle sooner rather than later to establish whether or not surgery is your best option or if there are other lifestyle changes that should be explored first. He will be able to assess your condition and make recommendations for a treatment programme, aimed at tackling discomfort and lack of mobility, so you can enjoy optimal function.

Enhanced recovery programme after joint replacementWhen you have undergone a significant operation such as a hip or knee replacement it is important to give due thought and consideration to how you will approach the recovery period. The approach you take can have a real difference in terms of how quickly you heal and how successful your overall rehabilitation is.

It is widely accepted that the best place for recovery is within the comfort of your own home, with the support and encouragement of medical and care professionals and a supportive network of friends and family wherever possible.

Although not all patients are suitable, an enhanced recovery programme (ERP) has become the optimal care pathway for patients undergoing joint replacement surgery. This evidence-based approach aims to ensure that patients are fit and well enough to be discharged as soon as possible after having their operation as research has shown that this means a shorter recovery time. Mr Simon Bridle performs hip and knee replacements at the Fortius Joint Replacement Clinic at the Bupa Cromwell Hospital, where the approach to patient care is based on the principles of enhanced recovery.

Safe at home – with an interlocking network of support

In a recent report entitled ‘Getting it right first time’, the British Orthopaedic Association stresses that the best approach to effective patient rehabilitation appears to be where the patient and the medical, care and health professionals work collaboratively together: ‘the anecdotal information gathered at the many meetings held across the country suggested strongly that better outcomes appear linked to more successful working relationships’. So once the patient is back in their own home, it is important to ensure that all the care providers are clear about the chosen path to rehabilitation, as this will mean everyone is aligned in their approach.

The research behind these findings is extensive and during the study period, authors of the report claim to have ‘travelled 16,935 miles and met 1634 surgeons and 409 managers’.

Preparing your home for enhanced recovery programme

Recovering at home may require a few changes to ensure that your home is a suitable environment to aid in your rehabilitation. The Fortius team at the BUPA Cromwell will advise you about this at your pre-operative visit. Things the team will consider and advise about include:

  1. Physiotherapy / recommended exercise – do you have an area that is large enough (and safe enough; for example, no trip hazards, etc) to undertake the exercises required to build your muscles back up to strength?
  2. Caring for the wound / incision do you know what the warning signs are that you should look out for when caring for a healing wound? Troublesome signs can include pain, redness, swelling, an unusual smell. It’s important to know when to reach out to medical professionals if you suspect the wound is not healing as well as it should be.
  3. Adapting your home – it may be necessary to make small, medium or large modifications to your home to aid in your recovery. Depending on how long the expected recovery time is and how restricted you are in terms of mobility, making a few changes can make the world of difference to how independent you can be in the days, weeks and months after your operation.

hip replacement successThe health risks of smoking are well documented, and thanks to clear warnings on packet labels and health service advertising campaigns, awareness of the dangers of smoking are better understood than they have ever been. Although the implications of smoking on the lungs and respiratory system are clearly understood, many people don’t realise that smoking can impact on many other areas of health and well-being. In fact, many people probably don’t realise that there could be a connection between smoking and hip replacement success.

Pioneering smoking research

According to new research undertaken by NYU (New York University) Langone, there is a link found between stopping smoking prior to hip replacement surgery and the overall success of the surgery. Although this research is yet to be corroborated by larger medical trials, the results are encouraging and support what many medical professionals already believe.

Patients who stopped smoking to enhance their recovery prospects saw a variety of benefits versus those who continued smoking. NYU Langone’s research concluded that “patients experienced better surgical outcomes and fewer adverse events including hospital readmissions, surgical site infections, and blood clots if they were enrolled in a smoking cessation program prior to surgery.”

The report suggests that merely suggesting that patients stop smoking is unlikely to be effective enough, it suggests that the real chance of success lies in offering a ‘smoking cessation’ programme to proactively and collaboratively help smokers quit ahead of their surgery.

Preparing for hip replacement success

Orthopaedic specialist Mr Simon Bridle supports the theory of this research and recommends that quitting smoking ahead of undergoing major surgery such as a hip replacement is likely to have a positive impact on the speed and quality of recovery.

There are in fact, several lifestyle changes that should be considered in order to make your recovery as good as possible. Eating more healthily is a good idea to improve overall health and nutrition, as it undertaking a regular programme of exercise. If you’re carrying more weight than is ideal for your frame then trying to lose a bit of weight is also sensible, as it will make overall mobility easier once you’re adapting to your new joint.

According to US company PeerWell, there is a handy checklist of six different things that you should consider setting up/undertaking before undergoing hip replacement surgery. This checklist is as follows:

  • Ensure you have support of family and friends – a network of available and willing helpers is crucial when you’re in the immediate recovery phase and are not yet as mobile as you will be when you’re fully recovered
  • Eat a healthy and balanced diet – it is important to ensure your body is getting the right balance of vitamins, minerals and nutrients
  • Exercise appropriately – ensuring that key muscle groups are worked out before and during recovery. Although everyone has heard of ‘rehabilitation’, the phrase ‘prehabilitation’ is being heard more and more at the moment. The theory of ‘pre-hab’ is that beginning an exercise regime to strengthen important muscles before surgery gives the body a head start on its recovery
  • Positive mental attitude – thinking positively and keeping a healthy frame of mind regarding your recovery is a great way to power through the early days and keep thinking ahead to the benefits your new hip will yield
  • “Failing to prepare is preparing to fail” – it is sensible to prepare your home for your recovery to give yourself less physical obstacles to overcome when moving around the home. Consider bulk preparing meals and freezing them too, so that some of the day to day tasks you will need to undertake are already taken care of.

hip replacement implants

Brexit has left many Britons with an air of uncertainty surrounding things where we have previously used products, labour or skills from other countries within Europe. The medical industry is no different, so it is important to help patients understand what, if anything, the effect that leaving the EU will have on their medical requirements.

Although some EU laws have received a bad press, others have been welcomed and the UK has benefitted from some legislation passed in EU courts. Regulation of medical ‘devices’ is one such law whereby revisions have been made that provide UK patients with a higher degree of safety than before it was amended. The law governing medical devices now places a higher level of regulation upon a vast range of items. ‘Devices’ in this sense is a broad term covering a wide variety of things which are given to patients to benefit from their health. This ranges from smaller items such as plasters, contact lenses and pregnancy tests, to high value items such as hip replacements, x-ray machines and pacemakers.

The aim of these enhanced regulations is to ensure a consistency with safety testing so that all EU citizens can be reassured regarding the medical devices they use or are fitted with. It also encourages ‘free and fair trade of the products throughout the EU’; meaning components are readily available from trusted suppliers.

These changes have been come about because of cases whereby non-regulated components have been used in devices such as breast implants and hip replacements, and the revised laws are designed to ensure this does not happen again.

Historical issues

Breast implants made by the company PIP are a well-known example of where old legislation failed the consumer. PIP manufactured its own silicone, rather than use the more expensive medically-approved silicone. The result was that thousands of women in the UK received implements containing potentially harmful chemicals, many of whom have had to have their implants removed or replaced as a result.

The same is true for hip replacements. A company called 3M fell foul of using components that were not as heavily regulated as they should have been. During the 1990’s they produced a copy of the widely used Charnley hip, which performed very badly and was more likely to come loose and need further re-work, compared with more rigorously tested alternatives. DePuy Orthopaedics developed a metal-on-metal joint replacement called an Articular Surface Replacement (ASR) which contained components that had not undergone the rigorous medical testing they should have done. The result here was that tiny fragments wore off the synthetic joint and entered the surrounding muscle and tissue, some even entered the bloodstream.

Necessary reassurance

The UK also has a National Joint Registry (NJR) and something called Beyond Compliance. The NJR records all hips implanted in England and Wales and identifies when they require revision, allowing surgeons to distinguish between different implants and choose designs with a low failure rate. Beyond Compliance allows new designs which are developed to be monitored before general release. Newly developed hip replacement implants are implanted in a controlled manner by selected centres, before general release. Beyond Compliance is “a service to support the safe and stepwise introduction of new or modified implantable medical devices.”

For patients who wish to undergo a hip replacement, be reassured that orthopaedic surgeons such as Mr Simon Bridle only operate using devices that have undergone the comprehensive medical testing required before these products are released to the EU marketplace. This will continue to be the case, regardless of the UK’s status within the EU.

rise in hip replacementsWe hear a lot about medical treatments, practices and patient care in the news, and it doesn’t always come with a positive slant. This can be worrying for patients who are waiting for operations, and may result in them feeling anxious about what to expect.

The financial strain placed on the NHS is well documented, and those who are fighting for additional funding are quick to point out how financial deficits can impact on patient care. A recent report published by the King’s Fund looked at various types of operations and the associated patient care, with a view to assessing just how affected these areas are by the acknowledged funding issues. One of these areas was elective hip replacements, so we were interested to see what the findings yielded.

Findings of the King’s Fund report

The King’s Fund research analysed four key areas:

  1. Genito-urinary medicine (GUM),
  2. District nursing,
  3. Elective hip replacement and
  4. Neonatal services

The results were interesting and differed by area. There were indeed serious challenges faced by GUM and district nurses that the report was able to directly link to funding issues. Neonatal services were standing firm, with the report suggesting that they “appear to have largely maintained quality and access despite a number of longstanding pressures”. Finally, those opting for elective hip replacement surgery were found to be growing significantly in numbers, with patients consistently happy with the outcome of their operation.

This level of satisfaction is encouraging for anyone who is considering this type of operation, and probably due in part to the fact that hip replacements are one of the oldest types of surgery. The current approach to hip replacements dates back to techniques pioneered by surgeons in the 1960s, and they have been undertaken regularly since that time.

Looking into this further, the increase in patients seeking hip replacement operations hasn’t just increased a bit – the rise in hip replacements is massive. The report outlines that “despite funding pressures on England’s NHS, elective hip replacements increased by 90 per cent in the six years to 2016”.

Is it all good news for those waiting for hip replacements?

For orthopaedic surgeons such as Mr Bridle, it is encouraging to see that the report highlights just how happy the majority of patients are following their hip replacements; in fact they say that “patients are overwhelmingly happy with the outcome”. This high level of patient satisfaction is something that those working in orthopaedics are extremely proud of.

Despite this, the report outlined two areas that are a threat to the current system. Firstly, mounting pressures of other departments who work to support, or work in tandem with, orthopaedics put these departments at risk. Secondly, waiting times are increasing – no doubt due to the marked increase in demand.

This feeling of positively following hip replacements is well documented; in the March issue of the Journal of Bone & Joint Surgery, the results of a recent study carried out by researchers at the Cleveland Clinic were published. Employing a standard Quality of Life measurement, the clinicians found that hip replacements can improve patients’ meaningful quality of life for at least five years following the operation.

At times of considerable financial pressure across the NHS, with satisfaction levels with this type of operation so high, if you are considering a hip replacement operation this knowledge should be reassuring and help put your mind at rest.

Increasing numbers of patients are requiring hip replacement surgery and they are one of the most successful operations of their kind, with evidence that the operation gives patients a marked improvement in their quality of life. As with all operations, there are clear risks and rewards that patients must understand before opting for surgery. With this in mind, surgeons are continually learning and exploring more and more about the factors that lead to successful – and less successful – outcomes. It is this process of continual knowledge development that helps push medical technology forwards.

With this in mind, surgeons are continually learning and exploring more and more about the factors that lead to successful – and less successful – outcomes. It is this process of continual knowledge development that helps push medical technology forwards.

spinal problems and hip replacement successWe are fortunate that across our own health service and those in some other countries around the world, there are opportunities to gather and analyse patient data, which can help identify trends and patterns in patient recovery. Results from data collected by the NYU Langone Medical Center/New York University School of Medicine indicate that those with spinal problems have greater issues with hip replacement recovery: “people with spinal deformity also requiring a total hip replacement are at greater risk for dislocation or follow-up revision surgery”.

What this means is that issues that would not usually be seen in the recovery period following a ‘normal’ hip replacement are more likely to present themselves in patients with spinal deformities. The recovery time is likely to be longer, there is a higher chance they will face more complex challenges and in the longer term they are more likely to have to undergo a second phase of surgery to correct a problem caused by the spinal abnormality.

Does that mean that people with spinal deformities are not suitable for total hip replacements?

The answer to this is no – people suffering a deformity of the spine would be classed as a higher risk category, a factor which should be flagged at consultation stage. With this knowledge of a pre-existing condition, the approach taken to their hip replacement surgery would just need to be more bespoke, and tailored more to the needs of the individual and their specific spinal complaint.

How different are the risks?

The study looked at over 100 individuals who had undergone almost 140 hip replacements (some individuals had both hips replaced). In this research sample, patients who had an underlying spinal abnormality demonstrated a greater risk that the new hip would become dislocated. The rate of dislocation was 8% in the group with spinal issues, compared with just 1% in patients without. Although both are small percentages when the total research population is considered, the difference between the two groups is significant.

The NHS in the UK is pushing for greater levels of ‘joined up care’ across the whole organisation, which is a more integrated way of managing patient care and rehabilitation. Findings such as this will mean that there will be a greater need for joined up working across orthopaedic and spinal units, ensuring that patients who are in a higher risk category get the more tailored care and support they require.