Changing demographics and an ageing population have influenced an increased demand for arthroplasty surgery globally in the past three decades. The National Joint Registry for England, Wales and Northern Ireland (National Joint Registry (NJR), 2022) has recorded an increase of total hip replacement procedures from 42 484 to 98 649 and knee replacement procedures from 41 584 to 106 572 between 2004 and 2019; shoulder replacement procedures have also increased from 2545 in 2012 (when they were first added to the registry) to 7660 in 2019. These trends are also reflected in Scotland, and the Scottish Arthroplasty Project (2020) report numbers of hip, knee and shoulder replacements increasing between 2001 and 2019 from 4219 to 7929, 3343 to 7720 and 234 to 543, respectively.
Similar patterns have also been recorded internationally (Swedish Arthroplasty Register, 2021; Australian Orthopaedic Association National Joint Replacement Registry, 2022; Canadian Institute for Health Information, 2022; New Zealand Joint Registry, 2023). These increasing numbers, coupled with pressures on services from changing government targets and relative funding and staff cuts, have meant that new models for providing care for these patient groups are essential to improve access to services and reduce waiting times. In 2020, due to the effects of the COVID-19 pandemic on elective surgical procedures, there was a sudden decline in arthroplasty procedures across all groups (NJR, 2022) this has since resulted in soaring waiting times for routine procedures and further emphasised the requirement for efficient models of care delivery.
Arthroplasty clinics, where advanced clinical practitioners (ACPs) have substituted for surgeons for routine postoperative care, were originally pioneered in the UK in the 1980s and have since been replicated worldwide. The aim of these services has been to reduce pressure on surgeon clinics, allowing them to more effectively manage complex and new patients (Murphy and Radovanovic, 2021). Although the efficiency and efficacy of these services have not been extensively researched, studies have indicated that they are safe and effective, and that patient satisfaction is equal or superior to that of surgeon-led clinics (Walton et al, 2008; Kennedy et al, 2010; Fan et al, 2014, Murphy and Radovanovic, 2021). To date, ACP-led arthroplasty services have primarily targeted patient cohorts undergoing lower-limb arthroplasties, as these have been the major areas of demand. In recent years, however, as prostheses have evolved, and a broader range of presenting complaints can be effectively managed, numbers of upper limb arthroplasties, particularly in the shoulder, have significantly risen, and specialist ACP-led services for these cohorts have been developed to meet the emerging demands.
Although much of the evidence discussing ACP-led arthroplasty care has focused on advanced practice physiotherapists (Walton et al, 2008; Kennedy et al, 2010), many services in the UK and globally also employ advanced nurse practitioners (Fan et al, 2014). In fact, the membership of the Arthroplasty Care Practitioners Association (ACPA) consists of more than two-thirds of nurses (see Table 1) according to unpublished ACPA data. Although many of the roles and responsibilities of advanced nurses and physiotherapists in these settings will be the same, there may be advantages to either profession that favour their employment. No studies have been identified that have compared the relative benefits of the different parent professions, and the decision of who to employ would appear to be dependent on the local service requirements and design.
Table 1. Arthroplasty Care Practitioners Association membership by parent profession
| Profession | Percentage |
|---|---|
| Nurses | 72% |
| Physiotherapists | 28% |
Regardless of the parent profession the role domains of the ACP in arthroplasty care will include expertise in clinical practice, professional organisation and leadership, research and scholarship, and education and professional development (Kennedy et al, 2010) a skill-set clearly commensurate with the four pillars of advanced clinical practice set out in the Multiprofessional Framework (MPF) for Advanced Clinical Practice (Health Education England (HEE), 2017):
- Clinical practice
- Leadership and management
- Education
- Research.
Aims
Despite being well-established for a number of years there has been very little written about the role of the ACP in arthroplasty care, reflecting a dearth of evidence to support the efficacy of the role, services provided and benefits to patient care and experience. This article aims to present an informative commentary on the contemporary practice of the ACP in arthroplasty care, based on available literature and the authors' experience and observations.
Clinical practice
In arthroplasty care ACPs will perform many roles traditionally undertaken by the surgeon, including history taking, clinical decision making and care planning management (Kennedy et al, 2010). In keeping with the definition of advanced clinical practice (HEE, 2017), ACPs in arthroplasty care are frequently involved throughout the entire patient journey from pre-operative assessment, peri-operative care to long-term post-operative surveillance.
Pre-operative care
Postoperative inpatient length of stay has significantly decreased in recent years due to the evolution of rapid recovery protocols. To achieve this there is a greater burden of service requirement for pre-operative care to ensure that safe discharge will be possible (Mohler et al, 2021). Through evaluation of electronic medical record time-logs in the USA, Mohler et al (2021) identified that more than 50% of the pre-operative activity prior to total joint arthroplasty was undertaken by specialist nurses. Anecdotally, this pattern is reflected in many UK centres, where arthroplasty care practitioners are frequently responsible for pre-operative assessment of patients to evaluate their fitness for surgery, provide necessary education regarding procedures and post-operative protocols, to make referrals for post-operative care packages and rehabilitation, and to support discharge arrangements. In some centres ACPs may also obtain patient consent for surgery (with appropriate training), frequently based on their own assessment of the patient and clinical reasoning, but with the agreement of the consultant surgeon.
Peri-operative care
The Perioperative Care Collaborative (PCC) (2007) defined three roles for non-medically qualified staff in theatre. These were the scrub practitioner in minor surgery, the surgical first assistant (SFA) and the surgical care practitioner (SCP). Although scrub practitioner and surgical first assistant roles are quite clearly defined by the PCC, the extended role of the SCP continues to develop and, frequently employed in arthroplasty care, may be fulfilled by ACPs. SCPs are registered healthcare professionals who have:
‘Extended the scope of their practice to work as members of the surgical team. They can perform surgical intervention as well as preoperative and postoperative care, under the supervision and direction of a consultant, although not independently.’
Royal College of Surgeons of England (RCSE), 2013
The General Medical Council (GMC, 2013) suggested that when a medical practitioner delegates elements of patient care to a colleague they must be:
‘Satisfied that the person providing the care has the appropriate qualifications, skills and experience to provide safe care for patients.’
As with all ACP roles, when non-medically qualified health professionals are working in an extended role providing surgical assistance, practitioners must ensure that they remain within the limits of their competence, skill and experience (Nursing and Midwifery Council, 2018; Health and Care Professions Council, 2012). ACPs working in SCP roles must therefore have the requisite experience and education to satisfactorily demonstrate their competency in the appropriate areas of surgical practice. The RCSE developed the Curriculum Framework for Surgical Care Practitioners (RCSE, 2014) on which the higher education establishments base their training programmes and SCPs are required to demonstrate generic core revalidation in keeping with their professional bodies, in addition to more detailed role-specific learning and practical skills assessment.
Postoperative care
Models of ACP-led postoperative clinics vary in design and the autonomy afforded to the ACP (Lovelock and Broughton, 2018); however, there is generally agreement that the intention is to reduce the burden of follow-up on surgeon-led orthopaedic clinics and improve the patient experience (Murphy and Radovanovic, 2021). ACPs contribute to all stages of postoperative care from early review to long-term surveillance and this may be alongside consultant-led clinics, entirely independent or in combination at different phases of recovery. The role of the ACP will include patient assessment, physical examination and ordering X-rays (which are usually routinely required at follow-up) as well as requesting any additional investigations such as blood tests or ultrasound scans. ACPs can also usually evaluate the need for, and refer to, other services such as physiotherapy, occupational therapy and podiatry or orthotics.
In order to independently fulfil the service and care requirements of patients undergoing arthroplasty surgery, ACPs require advanced clinical skills and expertise in relevant musculoskeletal patient assessment and evaluation and interpretation of investigations, including plain film radiographs. Specialist training in image interpretation is often a requirement for individuals undertaking such roles. In the UK there is no specified or standardised educational route to competency in the specialised skills required for the ACP in arthroplasty care. ACPA has developed a competency framework that may provide guidance on training for the role and also run bespoke image interpretation courses to provide a valuable adjunct to locally agreed and accredited negotiated work-based learning for the development of clinical assessment and image interpretation skills. The support of expert colleagues is also vital to the teaching and assessment of an individual's capabilities in the workplace (Kennedy et al, 2010; Fan et al, 2014).
One of the key roles of long-term follow-up clinics in arthroplasty care is to identify complications, particularly in asymptomatic patients and instigate risk management as necessary (Czoski Murray et al, 2019). It is therefore vital that the ACP working autonomously in this scenario understands the scope of normal presentations in their patient cohort and the presentation of possible complications, which may or may not be symptomatic, including infection and aseptic prosthetic loosening. Studies have shown that ACPs can effectively identify when patients need orthopaedic consultant review, therefore having the potential to initiate early investigation and treatment of complications (Walton et al, 2008; Fan et al, 2014). Effective management of patients with identified complications relies on a multidisciplinary approach. Clear and efficient referral pathways between the ACP and consultant clinics and open communication within teams are fundamental to the success of these models of care.
Research
Often considered to be the forgotten pillar of ACP, research is frequently a driving factor for the development and ongoing requirement of the ACP role in arthroplasty care. As well as the opportunity to review clinical progress, clinical encounters offer an opportunity to evaluate outcomes and collect data (Lovelock and Broughton, 2018). ACPs in arthroplasty care are often responsible for essential data collection at all stages of the patient journey, contributing to clinical trials and working in collaboration with partners in industry and joint registries to inform evaluation and development of prostheses and procedures. Data collection might include a variety of objective clinical measurements and patient reported outcome measures (PROMS), which the arthroplasty ACP must be competent in implementing and evaluating.
Research at every stage of the patient journey has been a key to the success of arthroplasty surgery over recent years, ensuring continuous improvement in prostheses, procedures and patient experience and outcomes (Lovelock and Broughton, 2018; Czoski Murray et al, 2019, NJR, 2022). Part of the arthroplasty ACP role may involve informing patients about potential research projects, obtaining patient consent for participation in research and collecting data for research outcomes. To support their contribution to this field of work the extended skill set of the arthroplasty ACP must include knowledge of and competency in research procedures, ethics and governance, requiring additional learning and mandatory training such as Good Clinical Practice certification (National Institute for Health and Care Research, 2022).
Audit and service evaluation are also integral to the ACP role and to ensuring the quality of patient care. Independent ACP clinics and services must meet the same standards as consultant-led services, working within local and national practice guidelines where required. Evidence demonstrating the efficacy of ACP services and the contribution of the ACP role to patient care is also vital to the future development of services and for patient confidence and reassurance.
Education
The ACP in arthroplasty care must develop an advanced skill set encompassing all four pillars of ACP, and to meet the requirements of the multiprofessional framework (HEE, 2017), this should be at Master's level or equivalent. Self-awareness and reflection are essential for the individual to recognise their own learning needs to satisfy the specific requirements of their role. Supervision from experienced colleagues and support for continued professional development are also critical for developing the novice to meet the ACP requirements and for sustained development throughout their career (HEE, 2020; 2021). Voluntary membership of the Arthroplasty Care Practitioners Association (ACPA) also provides networking and development opportunities, and educational support to advanced clinical practitioners working in arthroplasty settings (ACPA, 2023). Further support, communities of practice, and educational opportunities are also offered by the general and specific orthopaedic societies with interests in arthroplasty surgery. Table 2 provides a list.
Table 2. Special interest groups and societies to support the advanced clinical practitioner in arthroplasty care
| ▪ Association of Surgical Care Practitioners | https://www.aoscp.co.uk |
| ▪ British Orthopaedic Association | https://www.boa.ac.uk |
| ▪ British Hip Society | https://britishhipsociety.com |
| ▪ British Association for Surgery of the Knee | https://baskonline.com |
| ▪ British Elbow and Shoulder Society | https://bess.ac.uk |
Experienced arthroplasty ACPs are experts in the field with breadth and depth of clinical and professional knowledge related to their area of practice. Due to their unique position, working almost exclusively with a specific patient cohort, arthroplasty ACPs rapidly gain extensive ‘patient mileage’ and are at the forefront of clinical and policy developments, making them well placed to offer education and advice to junior colleagues and the extended multidisciplinary team. Through sharing their experience and knowledge widely, within their own employing trust and beyond, arthroplasty ACPs are able to ensure that best practice is embedded throughout the patient experience and that appropriate care is given at all stages.
Along with their knowledge and experience, the presence of the ACP throughout the patient journey means that they are the keystone to patient education, offering evidence-based advice and information as required. There is increasing appreciation of the benefits of emotional and physical support to potentially improve functional outcomes following arthroplasty (Lovelock and Broughton, 2018) and the ACP role in patient education, often acting as a first point of contact for queries and concerns, encompasses this.
Leadership and management
As the role of the ACP in arthroplasty care often incorporates responsibility for the management of pre-operative preparation and postoperative follow-up for arthroplasty services, it falls within their remit to regularly review these services and instigate the changes necessary to ensure that they are providing the best possible care and meeting the needs of the patient population. The ACP with responsibility for arthroplasty clinics must ensure that the services offered are in keeping with local and national guidelines and that patients can make contact with appropriately skilled professionals in the right place, at the right time.
As highlighted by Wood (2021), it should be acknowledged that leadership is not just about service management, but should also encompass clinical and professional leadership, as well as leadership in health policy and health systems. Many ACPs in arthroplasty care have firmly established their clinical expertise and therefore they may have surpassed the level of expert, as outlined by Benner (1984), and developed their leadership to the level of ‘advanced expert’ or ‘international influencer’, as described in the Derby Model (Mortimore et al, 2021). There are several examples of ACP-led regional and national developments and contributions to national policy in the arthroplasty community, demonstrating the potential impact of this influential group of professionals.
Locally, collaboration with other professionals and services is vital to the efficient running of arthroplasty services and the ACP requires excellent leadership and communication skills to uphold the best possible experience and outcome for their patient cohort. The ACP in arthroplasty care may also apply their leadership and communication skills more broadly, advocating for patients and professionals alike.
Future developments
There is ongoing debate in orthopaedic communities regarding the long-term follow-up of patients following arthroplasty surgery, in terms of the frequency, duration, location and personnel involved in reviewing patients. Recent guidelines from the National Institute for Clinical Excellence (NICE), 2020) were inconclusive about recommendations and there continues to be considerable variation in practice with different suggestions for follow-up routine depending on the type of implant for example (British Orthopaedic Association, 2012).
Despite these challenges it is understood that follow-up is essential and ACPs have an important role in providing efficient best quality services for patients. For many years there has been a move towards providing a virtual clinic model for routine arthroplasty follow-up care (Lovelock and Broughton, 2018). This enables patients who have a well-functioning arthroplasty to have a remote follow up appointment, often involving an X-ray, without the need to attend the orthopaedic centre for a face-to-face consultation. In the post-COVID-19 pandemic era this is an area that is becoming more appealing to patients, especially those who are deemed medically vulnerable. ACPs are ideally placed to provide this virtual link and to provide a triaging portal for patients to get in touch if their arthroplasty is causing concern.
With increasing demand on orthopaedic services, secondary to waiting-list pressures and staff shortages, ACPs in arthroplasty care may also have an important role to play in facilitating effective pre-operative care and assessment and enhancing patient pathways. To date, there has been very little discussion, in policy or literature, about the role of the ACP in the earlier stages of the patient journey, so further investigation will be required to support development in this area.
If ACPs are to continue to play an essential role in arthroplasty care services it is vital that they continue to develop in line with the multiprofessional framework for ACP (HEE, 2017), demonstrating the required capabilities in practice. Development of specific capabilities and guidance for this group of practitioners would facilitate a move towards standardisation of practice and equitable provision of patient care.
Limitations and recommendations
As outlined previously, there is currently a limited evidence base to support the role of the ACP in arthroplasty care and therefore it is only possible to present a limited picture of current practice. This article is a commentary based on current evidence but does not represent a systematic review of the current evidence base. It would seem that ACPs offer safe and efficient care for patients throughout their journey, but further research is required to reinforce this and to demonstrate service quality, cost-effectiveness and patient satisfaction at all stages of the patient experience.
Conclusion
Advanced practice roles in arthroplasty care have been long established and are frequently fulfilled by nurses or physiotherapists. The ACP in arthroplasty care will require a skill set that encompasses expertise across all four pillars of the HEE (2017) framework and in many cases will develop beyond the level of expert to influence patient care. The ACP is integral to patient experience throughout all stages of their journey and will continue to be vital to the delivery of efficient and cost-effective services as they evolve in the future. Further enquiry into the efficacy, cost-effectiveness and patient-satisfaction with ACP-led services would be beneficial to support future development of the role.
KEY POINTS
- Advanced clinical practitioners (ACPs) can play an important role in arthroplasty care throughout the patient journey
- Although well established in practice, there is currently limited evidence to support the ACP role in arthroplasty care
- ACP roles in arthroplasty care require competence in all four pillars of advanced clinical practice
- Development of ACPs in arthroplasty care is supported locally by expert practitioners and nationally by special interest groups such as the Arthroplasty Care Practitioners Association
- Further research is required to demonstrate effectiveness and efficacy of ACP services in arthroplasty care
CPD reflective questions
- This article discusses how advanced clinical practitioner (ACP) roles in arthroplasty care meet the capabilities of ACP. How does your own role challenge you to develop across the four pillars of ACP?
- Multidisciplinary team (MDT) working is essential to the ACPs role in arthroplasty care. How do you collaborate with the MDT to ensure patient-centred care?
- This article has discussed how special interest groups and societies can support education and development for ACPs in arthroplasty care. How do you interact with groups such as these to develop in your own role?