Trauma and Orthopaedics

Changing clinical practice in trauma and orthopaedic surgery

Trauma and Orthopaedic research at Warwick was established by Professor Griffin who has led the department to many successes. The Trauma and Orthoapedic theme is now led by Associate Professor Metcalfe, with professorial support from Kearney, Underwood, Bruce, Hutchinson and Griffin and Associate Professors Ellard and Parsons. Warwick delivers world-leading, large scale pragmatic clinical trials and clinical effectiveness studies to inform Trauma and Orthopaedic surgery, musculoskeletal pain and rehabilitation.

This primary research feeds into evidence synthesis and health economic evaluations undertaken by Warwick Evidence, led by Professor Aileen Clarke and now by Drs Paul Sutcliffe and Amy Grove, as part of Health Technology Assessments (HTA). These assessments are commissioned by NICE to improve clinical practice and outcomes for patients, with Warwick producing significant cost savings for the NHS as a result.

The challenge

For any health system there is a duty to implement guidance-led and cost-effective treatments which still achieve beneficial outcomes for patients. Large numbers of traumatic injuries are recorded each year, for example there are 1.8 million factures in England annually. Substantial savings can arise through changing the recommendation to a cheaper but equally effective treatment for even a small proportion of these cases. The key problem lies in producing appropriately robust trial evidence. With strong evidence from trials, this stands a better chance of being incorporated into national guidance and convincing healthcare practitioners to take up particular interventions.

Our approach

In order to produce high-quality trauma and orthopaedic surgery data, Warwick routinely conduct large, pragmatic, multicentre clinical trials. Key areas are:

• Tendon Injuries: The Achilles Tendinopathy Management (ATM) trial, led by Kearney, provided evidence that a common injection treatment for Achilles tendon pain was no better than a placebo injection. A further trial, UKSTAR, led by Costa and Kearney, demonstrated that the use of removable boots, instead of casts, after a tear to the Achilles tendon is more cost effective.

• Damage to knee cartilage. Waugh, Mistry, Metcalfe and others provided a HTA to help NICE assess the effectiveness and cost-effectiveness of knee Autologous Chondrocyte Implantation (ACI), a procedure to replace damaged cartilage. The HTA found better long-term results for ACI than the existing microfracture treatment, and at an appropriate cost effectiveness.

• Keyhole hip surgery. The FASHIoN trial, led by Griffin, demonstrated that keyhole surgery of the hip gave better results than best non-surgical care for people with a common painful hip condition called femoroacetabular impingement.

• Wrist fractures. Led by Costa, results demonstrated there was no difference in patients’ wrist function or quality of life from the quick and cheaper wire fixation compared to plate fixation.

• Lower limb fractures. Kearney led the Ankle Injury Rehabilitation Trial (AIR), which showed that after an ankle fracture, a removable boots, instead of a cast was more cost effective. A further trial by Costa evaluated Wound management of Open Lower Limb Fractures (WOLLF) trial compared more expensive negative pressure wound therapy to standard wound management, finding that negative pressure wound therapy did not improve self-rated disability.

• Hip replacement surgery. The Warwick Arthroplasty Trial (WAT), led by Costa and Griffin compared the clinical and cost-effectiveness of total hip replacement with resurfacing. The results highlighted that the more expensive resurfacing was also revised more often than hip replacement.

Our impact

The Warwick Medical School is a leading authority in trauma and orthopaedic surgery trials, with findings not only featured in NICE guidance but also carrying over into surgical practice. For wrist fractures, use of wires to treat fractures rose to 42% from just 12% from before trial data were published, representing a £2million cost saving to the NHS. Resulting from the 2018 WOLLF trial, an update is planned to the existing NICE guidance which is estimated to save £80 per patient for 5000 patients annually. Warwick’s HTA on ACI treatment for knees enabled NICE to change their recommendation, with the treatment being available on the NHS since 2017 and reducing chances of later osteoarthritis in patients. The WAT trial and subsequent HTA also impacted on NICE guidance in 2014, seeing hip resurfacing drop from 1 in 10 of hip treatments to 1 in 100. As patients can have an adverse reaction to hip resurfacing, this has contributed to better long-term outcomes for patients.