Virtual Clinics vindicated for joint replacement follow up

Patients who have a hip or knee replacement can be safely followed up via a Virtual Clinic system without the need for a face-to-face outpatient clinic consultation, experience at a Victorian hospital shows.

In 2014 the Frankston Hospital started offering all joint arthroplasty patients biennial follow up via a ‘Virtual Clinic’ program in which patients return a questionnaire (based on Oxford hip and knee score) and have an X-ray that is submitted to a reviewing orthopaedic surgeon online.

In a review of 2076 patient follow up appointments managed by the Virtual Clinics system, surgeons found that attendance rates (36%) were similar to levels seen for face-to-face follow up in outpatient clinic settings.

The main reasons for patients not participating in the Virtual Clinics were not being contactable (542 patients), patient death (129), patient too unwell or frail (102) or patients having recently seen by a surgeon (149). A further  277 were not interested in taking part in Virtual Clinic follow up.

Of the 710 patients who were reviewed via Virtual Clinics, 162 (22%) of them were deemed to require a face-to-face consultation. However, fewer than one in ten of these patients subsequently required joint revision. The most common reasons for revision were ongoing pain, progression of arthritis and loosening of the prosthesis.

“A major challenge for the ‘Virtual Clinic’ in the future is how to reduce the number of patients offered face-to-face review who do not subsequently need revision,” the review authors write in  the Australia and NZ Journal of Surgery.

“Cessation of routine follow up for asymptomatic patients, provided it is supported by the evidence, may be a solution,” they suggest.

Patients offered a face to face review tended to have higher Oxford scores for symptoms (38 vs 28 for patients not offered one) and more than 80% were symptomatic. The review also found that no asymptomatic patient was revised. Despite this, most surgeons felt the X-ray to be the most important component to consider in their review.

Two patients required a revision despite being given the ‘all clear’ by the Virtual Clinic. One of these had a fall and the other had sudden-onset loosening of the tibial prosthesis and was referred by their GP.

The surgeons who conducted the review said the results from institution-wide adoption of the Virtual Clinic system showed it could be an innovative and safe solution that would free up the time of orthopaedic surgeons to deal with the increasing workload of arthroplasties. They noted that the number of procedures done at their hospital had doubled from 200 a year in 2000 to 450 a year in 2016.

“We believe our report of this process, including noninferior patient compliance rates and outcomes compared to traditional follow up, as well as useful surgeon feedback on the matter, will provide a valuable ‘blueprint’ for those units considering the use of a ‘Virtual Clinic’ system,” they concluded.

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