By: Irrum Afzal, Sarkhell Radha, Sulaiman Alazzawi, Vipin Asopa, Richard Field and Philip Mitchell, South West London Elective Orthopaedic Centre
Multidisciplinary team (MDT) meetings in orthopaedic surgery are evolving. The goals of these meetings include patient optimisation, surgical planning and discharge arrangements on an individual patient basis. In line with British Hip Society, British Association Surgery of the Knee and GIRFT guidelines, the South West London region and parts of the Kent-Surrey-Sussex region set up a regional MDT meeting. Our model follows the ‘hub-and-spoke’ model with the South West London Elective Orthopaedic Centre (SWLEOC) being the hub.
Staying true to the National Orthopaedic Alliance drive to share best practice amongst orthopaedic providers, we highlight below how the implementation of our regional revision MDT holds great value.
Each MDT meeting starts promptly at 8:00am every Wednesday morning and is chaired by Mr.Philip Mitchell, Regional Revision Network Lead. The meetings are undertaken in a hybrid format – those wishing to attend in person can do so at SWLEOC, and those wishing to attend virtually are able to do so through MS Teams. In each weekly meeting there is attendance from Consultant Trauma and Orthopaedic Surgeons from six different hospitals, Consultant Radiologists, the Research Manager from the Academic Surgical Unit Research and Outcome Department, the Surgical Site Infection Nurse and the MDT Administrator.
A comprehensive ‘terms of reference’ and ‘standard operating procedures’ are adhered to by the consultants operating within our network and all those of whom attend the meeting. Following the ‘hub-and-spoke’ model, the vast majority of revision arthroplasty is undertaken at the South West London Elective Orthopaedic Centre. Any emergency revision cases are undertaken at satellite sites but are discussed and reviewed at the regional MDT. Revisions for infection are undertaken at our satellite site, St George’s Hospital
We are a very heterogeneous group and this is a strength of our MDT meeting. We have surgeons of varying levels of experience, different levels of seniority, different skill sets, different ethnic backgrounds, different genders, and different cultural and socioeconomic backgrounds. The terms of reference set out the advisory role and responsibilities to promote shared decision making and learning for surgeons undertaking joint reconstruction and revision arthroplasty within the South West London network with the provision to provide safe, effective, caring, responsive, well-led care whilst remaining professional and respectful.
Since implementation of the MDT meeting in January 2019, over 500 patients with painful joint replacements have been discussed. A proforma has been developed and is completed prior to meeting for all cases capturing all pertinent information including patient demographics, patient medical history, any clinical information including presenting problem and clinical examinations and any information regarding special investigations including blood results. Upon comprehensive discussion and debate, all cases for upcoming revision arthroplasty are graded according to R1, R2, or R3 complexity scale. The outcome of the MDT discussion is documented and circulated to all attendees. The operating surgeon and patient are also notified in writing of the discussion.
In addition, the MDT also reviews all post-operative revision arthroplasty imaging. Each case is graded through a new classification system of: X1 (x-ray satisfactory, routine follow-up), X2 (x-ray satisfactory, enhanced follow- up required), X3 (imaging reviewed – further investigations or intervention required).
Confirmation of the pre-operative plan and actual surgical intervention is reviewed and audited. In addition, confirmation of indication of revision at the time of operation is reviewed and validated for accuracy with benefits to the unit, individual surgeon and the NJR.
As MDTs continue to evolve, it is positive news that implementing our regional revision MDT meeting facilitates pre-operative revision arthroplasty discussion and post-operative quality assurance processes. This has enabled surgeons to educate, reflect on their practice and ensure that the highest standards of care are being provided to patients.