Patient and healthcare professional perspectives on which potential prognostic factors for failure of total elbow replacement should be investigated

Patient and healthcare professional perspectives on which potential prognostic factors for failure of total elbow replacement should be investigated | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patient and healthcare professional perspectives on which potential prognostic factors for failure of total elbow replacement should be investigated Zaid Hamoodi, Lianne Kearsley-Fleet, Jamie C Sergeant, Adam C Watts This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6528667/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Aug, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 24 You are reading this latest preprint version Abstract Background Total elbow replacement is an established treatment for the painful arthritic elbow; however, total elbow replacement has higher failure rates than other joint replacements, such as hip and knee replacement. Understanding the prognostic factors associated with failure of total elbow replacement is essential for informed decision-making between patients and clinicians, patient selection, and service planning. This evaluation presents the views of patients and healthcare professionals on which potential prognostic factors that could be associated with total elbow replacement failure should be investigated. Methods This evaluation comprised of two Patient and Public Involvement (PPI) workshops and a survey. PPI workshop 1 consisted of five PPI participants who helped to develop a survey assessing the importance of potential prognostic factors to investigate. The survey was shared electronically with members of the British Elbow and Shoulder Society (BESS) and clinicians internationally. In PPI workshop 2, 15 PPI participants listed factors they thought important to investigate, and 12 completed the survey. Results Patients and healthcare professionals agreed that most factors in the survey should be investigated. More of the healthcare professionals disagreed that ethnicity (49% v 33%) and VTE prophylaxis (42% v none) are important to be investigated, whilst more of the patients disagreed that socioeconomic status is important to be investigated (54% v 17%). Patients and healthcare professionals also suggested other factors not listed in the survey. Conclusions Patients and healthcare professionals agreed on the importance of investigating most prognostic factors, but some factors were favoured by only one group. The results of this evaluation could help researchers decide which prognostic factors to investigate and which to routinely collect. Elbow Replacement Patient and Public Involvement Clinicians Prognostic Factors Figures Figure 1 Figure 2 Figure 3 Figure 4 Background A total elbow replacement (TER) is used to treat painful elbow conditions and restore function 1 . It is an important procedure in the management of end-stage elbow arthritis and severe trauma 2 . However, TER is not always successful and sometimes requires revision surgery to address complications 3 . Despite the importance of TER, little is known about which patients are more likely to require revision. In order to investigate this further, potential prognostic factors associated with TER revision can be assessed. A prognostic factor is any variable associated with a risk of a particular health outcome amongst people with a given health condition 4 . For any complex intervention such as TER, prognostic factor research may explain the differences in outcomes between patients, which may then facilitate discussions about for whom and when TER should be used 5 . Prognostic research can also inform future research, for example, developing new interventions to target a modifiable prognostic factor or using a prognostic factor to stratify a population during study recruitment or analysis. Prognostic factor studies could also pave the way to developing a prognostic model in TER that could be used to make individualised risk predictions to guide clinical decision-making 5 . There are different types of prognostic factors in healthcare, such as patient characteristics, co-morbidities, symptoms, biomarkers, genetics, or treatment factors 4 , 5 . For outcomes of TER surgery, factors can be categorised as patient factors, factors related to the TER implant used, and factors related to how, where, and by whom the surgery was performed. It can be challenging to decide which potential prognostic factors to investigate and which factors to adjust for in statistical analyses, and most published studies investigating prognostic factors associated with TER failure lack information on why prognostic factors were investigated and how prognostic factors were selected to be adjusted for in the statistical analysis 6 – 17 . Like other research fields, prognostic factor research can benefit from the involvement of patients and healthcare professionals in formulating the research objectives and study methodology 18 – 21 . Patients are the recipients of the replacement surgery, and their input is necessary for understanding what factors they consider important. The experience of healthcare professionals is also vital as they are likely to have witnessed TER failure in the patient population and may be able to provide insight into which factors could potentially impact the need for revision surgery 22 . This information could guide researchers on which factors to investigate. The involvement of patients and healthcare professionals can also lead to research projects being accepted by those communities and help with bridging the research-practice gap in healthcare 23 . This study aims to elicit opinions from patients and healthcare professionals on which potential prognostic factors for TER failure (i.e. needing revision surgery) should be investigated. The results from this study will be used to inform future prognostic factor research. Methods This study used a combination of PPI workshops and survey activities (Fig. 1 ). The PPI workshop activities included the PPI members at Wrightington, Wigan, and Leigh Teaching Hospitals NHS Foundation Trust (WWL). PPI members were contacted through the PPI team at WWL, and they include patients with lived experience of joint replacement surgery, including TER. The PPI team at WWL has been running for almost ten years and all members receive training in PPI activities when they join the group 24 . Both PPI group activities started with an introduction of all participants and researchers, followed by a presentation to introduce the study and the purpose of the meeting. The PPI activities are reported in line with the GRIPP2 (Guidance for Reporting Involvement of Patients and the Public) checklist 25 . All participants from the PPI were compensated for their time as guided by the National Institute for Health and Care Research (NIHR) payment guidance for researchers and professionals 26 . This was paid for by a grant awarded by the Dragons Den at the British Orthopaedics Trainee Association (BOTA) annual conference for PPI involvement. This evaluation was part of a National Joint Registry (NJR) study that was approved by the NJR Research Committee 27 . The University of Manchester ethics decision tool, which determines whether a project requires formal ethical approval, was used and it confirmed that no formal ethical approval is required for this evaluation. All data was handled according to General Data Protection Regulation (GDPR) 28 . PPI workshop 1 The first semi-structured PPI workshop activity was undertaken virtually in September 2022 using the Zoom (Version 5.16.2, San Jose, CA) platform and lasted 60 minutes. This PPI workshop centred on gathering patients’ opinions on which prognostic factors they considered important for investigation. Participants were informed that this information would be used to develop a survey to be shared with clinicians and with PPI participants in a second meeting. Survey activity: Two similar surveys were developed to evaluate the importance of different prognostic factors to (a) healthcare professionals and (b) patients as represented by PPI participants. These surveys were developed using both the information gathered from PPI workshop 1 and the results from a systematic review investigating the prognostic factors associated with TER failure 29 (surveys are included in Supplementary File 1 and 2). Both surveys collected the same information regarding the importance of potential prognostic factors but collected different demographic data. Demographic data for healthcare professionals included their job titles and how many years they have been in clinical practice. Demographic data for PPI participants included age, sex, and if they had a previous joint replacement surgery. The anonymous surveys were administered using Qualtrics XM (Qualtrics, Provo, UT). The information regarding prognostic factors was collected using a combination of Likert scale questions and free text boxes. The same prognostic factors were presented to healthcare professionals and PPI participants without making any assumptions regarding which factors are more likely to be relevant to clinicians or patients. The Likert scale questions included 24 factors, which were grouped into four categories: patient factors, implant factors, surgical factors, and surgeon/hospital factors. Healthcare professionals and PPI participants were asked to rate the importance of investigating the association between each potential prognostic factor and TER failure based on a 5-point Likert scale (Strongly disagree, disagree, neither agree nor disagree, agree, strongly agree). Healthcare professionals had to choose one of the answers on the scale, whilst patients had an extra option “I don’t know what this is” if they did not know what the potential prognostic factor represented. The survey also had free text boxes, which could be used to add any further prognostic factors that healthcare professionals or PPI participants considered important to investigate. The survey was shared electronically with healthcare professionals. A survey link was shared with members of BESS via email. This included surgeons and allied health practitioners involved in treating TER surgery patients. The BESS research committee shared the survey with their members on the 14th of June 2023. A reminder was sent on the 16th of June 2023. The survey link was also shared internationally on the 7th of July 2023, through an established WhatsApp group for elbow clinicians worldwide. PPI workshop 2 The second PPI workshop meeting was undertaken in October 2023 and lasted for 60 minutes. This meeting was held in person at WWL, although some participants joined online using the Zoom platform. Each PPI participant was asked to independently write a list of potential prognostic factors that they consider to be important, to allow them to consider factors important to them without being influenced by the contents of the survey. The participants were then asked to complete the survey for patients. Patients who attended the meeting face to face completed a printed version of the survey (n = 12) and remote patients completed the survey electronically (n = 3). By allowing patients to complete the survey during the PPI workshops, participants had the opportunity to ask what any of the prognostic factors were. In addition, they could choose the “I don’t know what this is” response option. For convenience, the “I don’t know what this is” response option will be labelled as “unknown” in this study. Data collection and analysis: PPI workshop meetings were facilitated by ZH, who made written anonymised field notes. The PPI lead at WWL chaired the meetings, and a research assistant produced a written record of the discussions. Descriptive analyses were performed for the results from the PPI workshop and survey responses. The results from the Likert scale questions are presented as frequencies and proportions for each response option for each prognostic factor. The data collected from PPI workshop 2 and the free text in the survey were categorised into themes agreed upon by the research team. In the results section, the outcomes are presented in three categories: patient factors, implant factors and surgical factors. The surgical factor category includes two sections from the survey: surgical factors and surgeon/hospital factors. PPI participants who chose the unknown option were excluded from the denominator used to calculate the proportion of patients who responded to that particular factor. The analysis was performed using R (Version 4.3.1). Results There were five PPI participants who attended the first PPI workshop activity (using Zoom). All participants had a previous joint replacement surgery, although none had elbow replacement surgery. The second PPI workshop was attended by 15 PPI participants (10 face-to-face and five using the Zoom platform). None of the participants in PPI workshop 2 had participated in the PPI workshop 1 meeting. The surveys were completed by 154 healthcare professionals (although six of these only partially completed the survey) and 12 PPI participants. The characteristics of those who participated in the survey are summarised in Tables 1 a (healthcare professionals) and 1b (PPI participants). Table 1 a Characteristics of healthcare professional survey participants Characteristics Number of participants (n = 154) Job title/position : Consultant surgeon Surgical trainee/resident Allied health practitioner Missing 136 (88%) 7 (6%) 5 (3%) 6 (4%) Years in clinical practice : 1–5 6–10 11–20 21–30 > 30 Missing 20 (13%) 35 (23%) 47 (31%) 37 (24%) 9 (6%) 6 (4%) Table 1 b Characteristics of PPI survey participants Characteristics Number of participants (n = 12) Age : 51–60 61–70 > 70 2 (17%) 5 (42%) 5 (42%) Gender : Female Male Nonbinary/third gender 11 (92%) 1 (8%) 0 (0%) Previous joint replacement : Elbow replacement Other joint replacement None 5 (42%) 3 (25%) 4 (33%) During the first PPI workshop, participants emphasised the importance of investigating patient and surgeon/hospital factors that could impact the failure of elbow replacement surgery. The patient factors that they highlighted included age, ethnicity, sex, co-morbidities, and the disease leading to the surgery (i.e. indication for surgery). The surgeon/hospital factors they highlighted included surgeon experience (i.e. how many years they have been practising surgery), the number of procedures the surgeon and/or hospital performs per year, and whether the surgery was performed in a hospital that specialises in joint replacements. All these potential prognostic factors were included in the survey. Some of the quotes from the patients in the initial patient involvement meeting were: “I would like to know if ethnicity would have an impact on the outcome of total elbow replacement surgery”. “I think the impact of age is very important to help decide if I would go ahead with the surgery at younger age or not”. “If the surgery was performed by an experienced surgeon, would this impact the outcome of the replacement surgery?”. Patient factors All 154 healthcare professionals and 12 PPI participants submitted a response for each patient factor listed in the survey. Eight PPI participants chose the unknown option for ASA Physical Status Classification System, two chose it for co-morbidities, one for socioeconomic status, and one indication for surgery, and this is reflected in the denominator for these questions (Fig. 2 ). PPI participants agreed or strongly agreed that most factors other than socioeconomic status and sex should be investigated. Only two participants (18%) agreed (one agreed, one strongly agreed) that socioeconomic status should be investigated as a prognostic factor, and only four participants (33%) agreed that sex should be investigated. In contrast, many of the healthcare professionals agreed or strongly agreed that socioeconomic status and sex should be investigated (49% and 66%, respectively). Ethnicity was the only patient factor for which more healthcare professionals disagreed or strongly disagreed (n = 76, 49%) than agreed or strongly agreed (n = 22, 14%) that it should be investigated as a prognostic factor. However, the majority of PPI participants (n = 8, 67%) agreed or strongly agreed that ethnicity is important be investigated as a prognostic factor. In addition to the factors included in the survey, there were several other patient factors suggested in the free text by both healthcare professionals and PPI participants, including smoking status, alcohol consumption, medication use, psychological and mental health factors, use of walking aids, living status, whether the patient is a carer for any dependent person, and activity level before surgery. Other factors suggested by healthcare professionals alone included bone health status (most suggested factor, n = 11), followed by any previous elbow surgery (second most suggested factor, n = 10) and the type of surgery (third most suggested factor, n = 10). Healthcare professionals also suggested which specific co-morbidities should be examined, with diabetes being the most suggested disease (n = 4), followed by rheumatoid arthritis (n = 3) and previous trauma (n = 3) (Table 2 ). Table 2 Other patient factors suggested by health care professional and PPI participants. Patient factors Health care professionals n = 54 PPI participants n = 15 Co-morbidities: 11* 9* • Diabetes (Hba1c level = 1) 4 1 • Medication use 3 5 • Previous trauma 3 3 • Rheumatoid arthritis 3 2 • Contralateral shoulder/elbow/wrist pathology 1 - • Metabolic disease 1 - • Neurological disorders 1 - • Opioids use 1 - • Renal 1 - • Stickler syndrome 1 - • Corticosteroid use 1 - • Cardiac condition - 1 • Depression and anxiety - 1 Elbow specific factors 13* 13* • Previous surgery and type 10 1 • Pre-operative elbow deformity and bone loss 1 - • Previous elbow infection 1 - • Skin condition 1 - • Used of intra-articular steroid injection prior to surgery 1 - • Range of movement before surgery - 5 • The time had to wait to have surgery - 1 • Preoperative pain level - 13 • Strength pre surgery - 1 Bone health 11* 3* • Osteoporosis/Bone Mineral Density (BMD) 11 3 • Vitamin D level 1 - Substance abuse 6* 4* • Smoking 5 2 • Alcohol consumption 4 2 • Recreational drugs 1 1 Activity level 13* 10* • Sporting activities (e.g., gold or tennis) 3 1 • Leisure activities 2 3 • Professional activity 2 - • Activities of daily living 1 1 • Walking aides (e.g., crutches) 6 2 • Use of Wheelchair 1 - • General physical health - 5 • Gardening - 1 • Employment status - 1 • Time left until retirement - 1 Psychological and mental factors 7* 5* • Can the patient understand what it means to live with total elbow replacement 2 3 • Pre-operative mental health/state 2 3 • IQ 1 - • Understanding the limitations of own condition 1 1 • Psychological status 3 - • Clinical team expectations - 1 • Patient expectations - 3 • Knowledge of how to how to care for new joint - 4 Rehab and post operative advice 3* 5* • Patient compliance 2 2 • Feedback following surgery - 1 • Follow up quality (if follow up was prompt and how many times was the patient seen) - 1 • Quality of Information regarding restriction about surgery - 1 • Physiotherapist experience - 1 • Language difficulties 1 - Home circumstances 2* 6* • Living alone 1 3 • Caring responsibility (caring after a child or dependant adult) 1 1 • Housing type (house, flat, bungalow, etc) - 3 • Support network for patient after surgery including at home (e.g., support at home to lift heavy items) 1 2 • Downstairs toilets - 1 * represents the unique number of participants who suggested one or more item in this category PPI participants also highlighted other patient factors which are important to patients, with pre-operative pain level being the most suggested factor (n = 13, 87%) (Table 2 ). Unlike the factors listed in the survey, which can be established prior to surgery, some of the factors suggested by PPI participants are typically not measurable at the time of surgery, such as the quality of the rehabilitation and the quality of the post-operative follow-up care. The patient’s compliance with post-operative advice is another factor that cannot be established prior to surgery and was suggested as an important factor by both healthcare professionals and PPI participants (Table 2 ). Implant factors: The section of the survey on implant factors was completed by 150 (97%) healthcare professionals and 12 (100%) PPI participants. Seven participants from the PPI group selected the unknown option for implant design, six for stem length, four for fixation type and three for implant model/design. Most healthcare professionals and PPI participants agreed or strongly agreed that all implant factors listed in the survey should be investigated. This included implant design, implant model, fixation type, and implant stem length (Fig. 3 ). Healthcare professionals also suggested other implant factors that should be investigated such as the presence of an anterior flange on the humeral implant (n = 3) and the type of cement used (n = 2) (Table 3 ). The PPI participants suggested two other factors: the material (n = 1) and size (n = 1) of the implant used. Table 3 Other implant factors suggested by Health care professional and PPI participants. Implant factors Health care professionals n = 10* PPI participants n = 2* Presence of anterior flange 3 - Type of cement used (e.g., low viscosity cement) 2 - Congruency of the implant articulation 1 - Implant manufacturers 1 - Length of the flange 1 - Implant material/metal type 1 - Number of implant size choices 1 - Polyethylene design and thickness 1 - Stem shape 1 - Implant material/metal type - 1 Size of the implant used - 1 * represents the unique number of participants who suggested one or more item in this category Surgical factors: One hundred and forty-eight healthcare professionals (96%) responded to all the surgical factors listed in the survey and the majority agreed or strongly agreed that all bar one of those factors should be investigated. The only surgical factor that healthcare professionals predominantly strongly disagreed (26%), disagreed (16%), or neither agreed/disagreed (41%) should be investigated is the use of venous thromboembolism (VTE) prophylaxis (Fig. 4 ). Of the 12 PPI participants who responded to the surgical factors, 11 selected the unknown option for Tranexamic Acid (TXA), five for VTE prophylaxis, three for surgical approach, surgical technique, and surgeons’ volume, two for hospital volume, and one for the use of antibiotics, surgeon’s volume, and surgeon’s grade. Of the PPI participants who chose Likert response options, most agreed or strongly agreed that all the surgical factors listed in the survey were important to be investigated as prognostic factors. Several other factors were suggested by health care professional and PPI participants, which were categorised into factors related to implant position, cementation of the implant, the use of antibiotics, intra-operative factors, surgeon/patient factors and other factors, as summarised in Table 4 . Intra-operative factors and surgeon/hospital factors were the most suggested factors. Intra operative factors were suggested by 12 healthcare professionals whilst surgeon/hospital factors were suggested by six PPI members and six healthcare professionals. Implant positioning was suggested by eight healthcare professionals and cementation technique by six healthcare professionals. Table 4 Other surgical factors suggested by Health care professional and PPI participants. Surgical factors Health care professionals n = 23 PPI participants n = 6 Intra-operative factors 12* 0 • Radial head replacement or excision or denervation 5 - • Tourniquet use 3 - • Collateral ligament repair 1 - • Common flexor and common extensor origin repair 1 - • Loan vs own instruments 1 - • Rotational stability 1 - • The type of bone graft used (e.g., allografts vs autograft) 1 - • Ulnar nerve management 1 - Implant positioning 8* 0 • Bone contact with anterior flange 3 - • Implant alignment (Axis of components vs axis of canal) 3 - • Restoration of centre of rotation 3 - • Radial column support/Lateralisation of the ulna humeral articulation 1 - Cementation 6* 0 • Cementing technique 5 - • If the cement was pressurised 1 - • The use of cement plug 1 - Antibiotics use 4* 0 • Antibiotics dose 1 - • Antibiotics type 2 - • Antibiotics duration 1 - • The use of local antibiotics 1 - Surgeon and hospital factors 6* 6* • Surgeon’s training type (Academic, Public, or fellowship trained) 2 1 • Specialised vs non-specialised orthopaedic hospitals 1 1 • If surgery performed at a major trauma centre 2 - • Surgery out of hours 1 - • Theatre team experience (e.g., specialised scrub nurse team) 2 - • Hospital length of stay - 1 • Type of anaesthetic used - 2 • If the procedure was performed in the independent sector or NHS - 1 * represents the unique number of participants who suggested one or more item in this category Discussion Most published studies investigating prognostic factors associated with TER failure lack information on how the prognostic factors investigated were chosen. The choice of such prognostic factors may be based on the opinion of the research team and influenced by which variables are available in a dataset. As a result, the choice of those factors may be subject to the researchers’ personal biases and fail to account for the views of patients and healthcare professionals. The involvement of patients is likely to highlight factors that are important to them when discussing their treatment and rehabilitation with healthcare professionals and the input from healthcare professionals has the advantage of gaining insight from the clinical experience of the healthcare community. Therefore, knowledge of these factors could not only help inform research but also facilitate better-informed decision-making between patients and healthcare professionals. This study shows that patients and healthcare professionals agree on the importance of investigating most of the factors that were included in the survey based on the published literature and PPI input. However, higher proportions of healthcare professionals than patients disagreed with the importance of ethnicity and higher proportion of patients disagreed that socioeconomic status should be investigated. Socioeconomic status and ethnicity may be used in medical research to check for inequalities by assessing disparity in access to services, such as replacement surgery 30 – 35 . Although most patients in this study disagreed that socioeconomic status is an important prognostic factor, they have suggested investigating factors which can be used to establish socioeconomic status, including occupation, living arrangements, and some educational elements 36 . Several studies have examined socioeconomic status as a prognostic factor in total knee replacement and total hip replacement and reported that lower socioeconomic status is associated with adverse events and worse patient-reported outcomes but there is no reported association with revision surgery 30 – 32 , 37 . Evidence on the association between ethnicity and failure of TER has also been reviewed but the overall quality of evidence was ranked as very low. The understanding of patients' and healthcare professionals' perceptions of socioeconomic status and ethnicity, and the relationship between them, may benefit from further investigation 30 . Both healthcare professionals and patients suggested other factors not listed in the survey (i.e., not yet investigated and not highlighted by the first PPI workshop). Pre-operative pain level was suggested by most patients as an important prognostic factor to investigate. The association between pre-operative pain level and outcomes of TER is yet to be evaluated and could be addressed in future research. The most frequently suggested factors from healthcare professionals were bone health, previous surgery to the elbow, intra-operative factors, and the positioning of the implant. There is very low-quality evidence, from one study each, reporting previous surgery to the elbow and the positioning of the humeral implant to be associated with TER failure 13 , 14 . The association between TER failure and the remaining factors is yet to be investigated. Studies are needed to evaluate the impact of factors that are deemed important by patients and healthcare professionals. The results from this study could be used to support researchers in choosing which prognostic factors to investigate and where to utilise available resources. The results from this study may also support decisions around which data to routinely collect. Data on some of the prognostic factors in the survey are included in routinely collected data such as national joint registries: for example, the National Joint Registry (NJR) directly collects age, ASA, hand dominance, indication for surgery, sex/gender, weight or BMI, surgical approach, the use of VTE prophylaxis, primary surgeons’ grade, and implant fixation type. Other factors such as hospital/surgeon’s volume, implant design, and implant model can be indirectly collected or estimated. The results from this study suggest other prognostic factors that patients and healthcare professionals considered important, such as occupation, antibiotics use, tranexamic acid use, and implant stem length. However, adding more compulsory items to data collection might increase the burden on the organisation collecting the data, which may impact compliance. If the data collection is not compulsory, this might lead to a high proportion of missing data, as experienced with availability of data on weight and BMI in studies published from the NJR 38 . The other difficulty that can arise is how to classify the data collected. For example, what is the best method to classify the patient’s occupation so that it can be used meaningfully in research and care. Therefore, careful justification is required before it can be implemented on large scales such as joint registries. However, such factors could be collected and evaluated now in prospective cohort studies. There are limitations to the PPI workshop activities as they only included five participants in PPI workshop 1 and 15 participants in PPI workshop 2. Advertising the study to a larger population of patients could have resulted in more participants, however, PPI workshops allowed more time for engagement and discussions with the participants, which meant that the researchers could better understand patient's opinions. In contrast, using the survey to collect healthcare professionals' input was an efficient method to involve many healthcare professionals from across the world; however, it was not possible to discuss the rationale for their selection of prognostic factors. The free text boxes were added to capture additional information from healthcare professionals. Although participants in the PPI represented a variety of replacement surgeries, all but one participant were female, and they were all over the age of 50 years old. This study therefore does not necessary reflect the opinions of younger and/or male patients. This study was able to capture the opinions from surgeons with different levels of experience as measured by the years in clinical practice, but other healthcare professionals only represented 5% of participants who completed the survey. Conclusion The involvement of patients and healthcare professionals experienced in joint replacement surgery is vital in understanding their views on which potential prognostic factors should be researched. The results of this study could support researchers and administrators in deciding which prognostic factors to collect data on, to investigate or to account for in analyses. Abbreviations BESS British Elbow and Shoulder Society BOTA British Orthopaedic Trainee Association GDPR General Data Protection Regulation GRIPP2 Guidance for Reporting Involvement of Patients and the Public NIHR National Institute for Health and Care Research NJR National Joint Registry PPI Patient and Public Involvement TER Total elbow replacement TXA Tranexamic Acid WWL Wrightington, Wigan, and Leigh Teaching Hospitals NHS Foundation trust VTE Venous Thromboembolism Declarations Ethics approval and consent to participate: This evaluation was part of a National Joint Registry (NJR) study that was approved by the NJR Research Committee 27 . The University of Manchester ethics decision tool, which determines whether a project requires formal ethical approval, was used and it confirmed that no formal ethical approval is required for this evaluation. All data was handled according to General Data Protection Regulation (GDPR). Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing Interests: Adam C Watts has a consultancy agreement with Stryker Ltd. and is a member of the Editorial Board of NJR. The remaining authors have no conflict of interest. Funding: The authors disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: funding from the RCSEng/NJR joint Research fellowship grant, and financial support from the John Charnley Trust. The research team at the University of Manchester was supported by the Centre for Epidemiology Versus Arthritis (UK grant number 21755). LKF is additionally supported by Versus Arthritis (23126). Author's contributions: ZH, LKF, ACW, and JCS provided the idea of the topic. ZH designed and wrote the study. All authors read, provided feedback, input into the methodology, and approved the final manuscript. LKF, ACW and JCS contributed to this work equally. Acknowledgements: We would like to thank the British Elbow and Shoulder Society (BESS) research committee for sharing the survey with BESS members. We are very grateful to the members of the PPI team and Patient Research Advisory Group (PPI) at Wrightington, Wigan, and Leigh Teaching Hospitals NHS Foundation trust (WWL) for their valuable input into this study. We would like to especially thank Ms Helen Spickett (Research sponsorship Management at WWL) and Ms Alison Hegarty (Research Assistant at WWL) for their support in organising and conducting the PPI workshop activities. The authors would like to acknowledge the Centre for Epidemiology Versus Arthritis (Arthritis Research UK Grant No. 21755), who provided the infrastructure support for the study. 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Caprari E, Porsius JT, D'Olivo P, Bloem RM, Vehmeijer SBW, Stolk N, et al. Dynamics of an orthopaedic team: Insights to improve teamwork through a design thinking approach. Work. 2018;61(1):21–39. Gray-Burrows KA, Willis TA, Foy R, Rathfelder M, Bland P, Chin A, et al. Role of patient and public involvement in implementation research: a consensus study. BMJ Qual Saf. 2018;27(10):858–64. Robinson T, Bailey C, Morris H, Burns P, Melder A, Croft C, et al. Bridging the research–practice gap in healthcare: a rapid review of research translation centres in England and Australia. Health Res Policy Syst. 2020;18(1):117. Patient Research Advisory Group/PPI. Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust; [Available from: https://www.wwl.nhs.uk/patient-research-advisory-group-ppi Staniszewska S, Brett J, Simera I, Seers K, Mockford C, Goodlad S, et al. GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research. BMJ. 2017;358:j3453. Payment guidance for researchers and professionals National Institute for Health and Care Research Website [updated July. 2023. 1.4:[Available from: https://www.nihr.ac.uk/documents/payment-guidance-for-researchers-and-professionals/27392 Guidance for Using Patient Data Health Research Authority. [Available from: https://www.hra.nhs.uk/covid-19-research/guidance-using-patient-data/#research UK GDPR guidance and resources. Information commissioner's office website; [Available from: https://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/ Hamoodi Z, Gehringer CK, Bull LM, Hughes T, Kearsley-Fleet L, Sergeant JC, et al. Prognostic factors associated with failure of total elbow arthroplasty. Bone Joint Res. 2024;13(5):201–13. Hinman A, Bozic KJ. Impact of payer type on resource utilization, outcomes and access to care in total hip arthroplasty. J Arthroplasty. 2008;23(6 Suppl 1):9–14. Fortin PR, Clarke AE, Joseph L, Liang MH, Tanzer M, Ferland D, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum. 1999;42(8):1722–8. Agabiti N, Picciotto S, Cesaroni G, Bisanti L, Forastiere F, Onorati R, et al. The influence of socioeconomic status on utilization and outcomes of elective total hip replacement: a multicity population-based longitudinal study. Int J Qual Health Care. 2007;19(1):37–44. Smith MC, Ben-Shlomo Y, Dieppe P, Beswick AD, Adebajo AO, Wilkinson JM, et al. Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data. Osteoarthr Cartil. 2017;25(4):448–54. Alvarez PM, McKeon JF, Spitzer AI, Krueger CA, Pigott M, Li M et al. Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities. JBJS Reviews. 2022;10(3). Smith MC, Ben-Shlomo Y, Dieppe P, Beswick AD, Adebajo AO, Wilkinson JM, et al. Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data. Osteoarthritis Cartilage. 2017;25(4):448–54. Psaki SR, Seidman JC, Miller M, Gottlieb M, Bhutta ZA, Ahmed T, et al. Measuring socioeconomic status in multicountry studies: results from the eight-country MAL-ED study. Popul Health Metrics. 2014;12(1):8. Ellis HB, Howard KJ, Khaleel M. Influence of socioeconomic status on outcome of joint replacement surgery. Curr Orthop Pract. 2010;21(2):132–7. Evans JT, Mouchti S, Blom AW, Wilkinson JM, Whitehouse MR, Beswick A, et al. Obesity and revision surgery, mortality, and patient-reported outcomes after primary knee replacement surgery in the National Joint Registry: A UK cohort study. PLoS Med. 2021;18(7):e1003704. Additional Declarations No competing interests reported. Supplementary Files S1File.pdf S1 File. Healthcare professional survey S2File.pdf S2 File. PPI survey Cite Share Download PDF Status: Published Journal Publication published 30 Aug, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Revision requested 14 Jun, 2025 Reviews received at journal 11 Jun, 2025 Reviews received at journal 08 Jun, 2025 Reviewers agreed at journal 31 May, 2025 Reviewers agreed at journal 30 May, 2025 Reviewers agreed at journal 28 May, 2025 Reviews received at journal 26 May, 2025 Reviewers agreed at journal 26 May, 2025 Reviewers agreed at journal 26 May, 2025 Reviews received at journal 21 May, 2025 Reviews received at journal 16 May, 2025 Reviewers agreed at journal 15 May, 2025 Reviewers agreed at journal 14 May, 2025 Reviewers agreed at journal 14 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers agreed at journal 12 May, 2025 Reviewers agreed at journal 11 May, 2025 Reviews received at journal 09 May, 2025 Reviewers agreed at journal 30 Apr, 2025 Reviewers agreed at journal 28 Apr, 2025 Reviewers invited by journal 28 Apr, 2025 Editor assigned by journal 28 Apr, 2025 Submission checks completed at journal 27 Apr, 2025 First submitted to journal 25 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6528667","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":449701757,"identity":"6add62c2-e57e-4156-85a4-160916223c67","order_by":0,"name":"Zaid Hamoodi","email":"data:image/png;base64,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","orcid":"","institution":"Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre, Manchester","correspondingAuthor":true,"prefix":"","firstName":"Zaid","middleName":"","lastName":"Hamoodi","suffix":""},{"id":449701758,"identity":"5dd330ae-9cf9-4535-91bc-36530dac4a45","order_by":1,"name":"Lianne Kearsley-Fleet","email":"","orcid":"","institution":"Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester Academic Health Science Centre, Manchester","correspondingAuthor":false,"prefix":"","firstName":"Lianne","middleName":"","lastName":"Kearsley-Fleet","suffix":""},{"id":449701760,"identity":"c0fff7e0-0903-4dac-be20-f4e5ca49487b","order_by":2,"name":"Jamie C Sergeant","email":"","orcid":"","institution":"Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester","correspondingAuthor":false,"prefix":"","firstName":"Jamie","middleName":"C","lastName":"Sergeant","suffix":""},{"id":449701762,"identity":"789715b9-b607-4575-bb46-ba2adb09b14d","order_by":3,"name":"Adam C Watts","email":"","orcid":"","institution":"Health Research Institute, Edge Hill University","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"C","lastName":"Watts","suffix":""}],"badges":[],"createdAt":"2025-04-25 11:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6528667/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6528667/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-025-06186-0","type":"published","date":"2025-08-30T15:57:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82162236,"identity":"0021e054-9ddf-4c97-b3c7-89c51f8fb2ab","added_by":"auto","created_at":"2025-05-07 08:42:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":68062,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThe structure of the study activities\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6528667/v1/a957e10c8b1f089fdc16f11d.png"},{"id":82162237,"identity":"c9e8a42b-fa69-4653-ab4d-e80d6f5b9edb","added_by":"auto","created_at":"2025-05-07 08:42:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":110849,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePatient and healthcare professional responses to whether the association between patient factors and failure of total elbow arthroplasty is important to be investigated (survey results)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6528667/v1/3a4e34482a51f978bd06054b.png"},{"id":82162241,"identity":"b358300e-ec7a-473f-8e11-76de16ae77fb","added_by":"auto","created_at":"2025-05-07 08:42:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":75452,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePatient and healthcare professional responses to whether the association between this implant factor and failure of total elbow arthroplasty is important to be investigated (survey results)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6528667/v1/77584e0b243cbecf9d5dad51.png"},{"id":82162239,"identity":"96128bd3-1aaa-42dd-9058-87364ce88582","added_by":"auto","created_at":"2025-05-07 08:42:58","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":120150,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePatient and healthcare professional responses to whether the association between this surgical or surgeon/hospital factors and failure of total elbow arthroplasty is important to be investigated (survey results)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6528667/v1/e940e3536930569c22093be3.png"},{"id":90344858,"identity":"94481fe7-ff1b-4391-954f-2e955c6040f7","added_by":"auto","created_at":"2025-09-01 16:06:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1605000,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6528667/v1/563ace80-1bbf-4480-b1be-be4193dd028d.pdf"},{"id":82162830,"identity":"6551af1b-7542-477c-ae13-b7baac3c6232","added_by":"auto","created_at":"2025-05-07 08:50:58","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1279925,"visible":true,"origin":"","legend":"\u003cp\u003eS1 File. Healthcare professional survey\u003c/p\u003e","description":"","filename":"S1File.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6528667/v1/b18e6606230df357b4f70def.pdf"},{"id":82162244,"identity":"a7f8aca8-9e0f-4886-ae37-8d3acfb3264d","added_by":"auto","created_at":"2025-05-07 08:42:58","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":1277285,"visible":true,"origin":"","legend":"\u003cp\u003eS2 File. PPI survey\u003c/p\u003e","description":"","filename":"S2File.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6528667/v1/493db7ba41845a276b649ddb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patient and healthcare professional perspectives on which potential prognostic factors for failure of total elbow replacement should be investigated","fulltext":[{"header":"Background","content":"\u003cp\u003eA total elbow replacement (TER) is used to treat painful elbow conditions and restore function\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. It is an important procedure in the management of end-stage elbow arthritis and severe trauma\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. However, TER is not always successful and sometimes requires revision surgery to address complications\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Despite the importance of TER, little is known about which patients are more likely to require revision.\u003c/p\u003e \u003cp\u003eIn order to investigate this further, potential prognostic factors associated with TER revision can be assessed. A prognostic factor is any variable associated with a risk of a particular health outcome amongst people with a given health condition\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. For any complex intervention such as TER, prognostic factor research may explain the differences in outcomes between patients, which may then facilitate discussions about for whom and when TER should be used\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Prognostic research can also inform future research, for example, developing new interventions to target a modifiable prognostic factor or using a prognostic factor to stratify a population during study recruitment or analysis. Prognostic factor studies could also pave the way to developing a prognostic model in TER that could be used to make individualised risk predictions to guide clinical decision-making\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere are different types of prognostic factors in healthcare, such as patient characteristics, co-morbidities, symptoms, biomarkers, genetics, or treatment factors\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. For outcomes of TER surgery, factors can be categorised as patient factors, factors related to the TER implant used, and factors related to how, where, and by whom the surgery was performed. It can be challenging to decide which potential prognostic factors to investigate and which factors to adjust for in statistical analyses, and most published studies investigating prognostic factors associated with TER failure lack information on why prognostic factors were investigated and how prognostic factors were selected to be adjusted for in the statistical analysis\u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLike other research fields, prognostic factor research can benefit from the involvement of patients and healthcare professionals in formulating the research objectives and study methodology\u003csup\u003e\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Patients are the recipients of the replacement surgery, and their input is necessary for understanding what factors they consider important. The experience of healthcare professionals is also vital as they are likely to have witnessed TER failure in the patient population and may be able to provide insight into which factors could potentially impact the need for revision surgery\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. This information could guide researchers on which factors to investigate. The involvement of patients and healthcare professionals can also lead to research projects being accepted by those communities and help with bridging the research-practice gap in healthcare\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study aims to elicit opinions from patients and healthcare professionals on which potential prognostic factors for TER failure (i.e. needing revision surgery) should be investigated. The results from this study will be used to inform future prognostic factor research.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study used a combination of PPI workshops and survey activities (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The PPI workshop activities included the PPI members at Wrightington, Wigan, and Leigh Teaching Hospitals NHS Foundation Trust (WWL). PPI members were contacted through the PPI team at WWL, and they include patients with lived experience of joint replacement surgery, including TER. The PPI team at WWL has been running for almost ten years and all members receive training in PPI activities when they join the group\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Both PPI group activities started with an introduction of all participants and researchers, followed by a presentation to introduce the study and the purpose of the meeting. The PPI activities are reported in line with the GRIPP2 (Guidance for Reporting Involvement of Patients and the Public) checklist\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. All participants from the PPI were compensated for their time as guided by the National Institute for Health and Care Research (NIHR) payment guidance for researchers and professionals\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. This was paid for by a grant awarded by the Dragons Den at the British Orthopaedics Trainee Association (BOTA) annual conference for PPI involvement.\u003c/p\u003e \u003cp\u003eThis evaluation was part of a National Joint Registry (NJR) study that was approved by the NJR Research Committee \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. The University of Manchester ethics decision tool, which determines whether a project requires formal ethical approval, was used and it confirmed that no formal ethical approval is required for this evaluation. All data was handled according to General Data Protection Regulation (GDPR)\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePPI workshop 1\u003c/h2\u003e \u003cp\u003eThe first semi-structured PPI workshop activity was undertaken virtually in September 2022 using the Zoom (Version 5.16.2, San Jose, CA) platform and lasted 60 minutes. This PPI workshop centred on gathering patients\u0026rsquo; opinions on which prognostic factors they considered important for investigation. Participants were informed that this information would be used to develop a survey to be shared with clinicians and with PPI participants in a second meeting.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurvey activity:\u003c/h3\u003e\n\u003cp\u003eTwo similar surveys were developed to evaluate the importance of different prognostic factors to (a) healthcare professionals and (b) patients as represented by PPI participants. These surveys were developed using both the information gathered from PPI workshop 1 and the results from a systematic review investigating the prognostic factors associated with TER failure\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e (surveys are included in Supplementary File 1 and 2). Both surveys collected the same information regarding the importance of potential prognostic factors but collected different demographic data. Demographic data for healthcare professionals included their job titles and how many years they have been in clinical practice. Demographic data for PPI participants included age, sex, and if they had a previous joint replacement surgery. The anonymous surveys were administered using Qualtrics XM (Qualtrics, Provo, UT).\u003c/p\u003e \u003cp\u003eThe information regarding prognostic factors was collected using a combination of Likert scale questions and free text boxes. The same prognostic factors were presented to healthcare professionals and PPI participants without making any assumptions regarding which factors are more likely to be relevant to clinicians or patients. The Likert scale questions included 24 factors, which were grouped into four categories: patient factors, implant factors, surgical factors, and surgeon/hospital factors. Healthcare professionals and PPI participants were asked to rate the importance of investigating the association between each potential prognostic factor and TER failure based on a 5-point Likert scale (Strongly disagree, disagree, neither agree nor disagree, agree, strongly agree).\u003c/p\u003e \u003cp\u003eHealthcare professionals had to choose one of the answers on the scale, whilst patients had an extra option \u0026ldquo;I don\u0026rsquo;t know what this is\u0026rdquo; if they did not know what the potential prognostic factor represented. The survey also had free text boxes, which could be used to add any further prognostic factors that healthcare professionals or PPI participants considered important to investigate.\u003c/p\u003e \u003cp\u003eThe survey was shared electronically with healthcare professionals. A survey link was shared with members of BESS via email. This included surgeons and allied health practitioners involved in treating TER surgery patients. The BESS research committee shared the survey with their members on the 14th of June 2023. A reminder was sent on the 16th of June 2023. The survey link was also shared internationally on the 7th of July 2023, through an established WhatsApp group for elbow clinicians worldwide.\u003c/p\u003e\n\u003ch3\u003ePPI workshop 2\u003c/h3\u003e\n\u003cp\u003eThe second PPI workshop meeting was undertaken in October 2023 and lasted for 60 minutes. This meeting was held in person at WWL, although some participants joined online using the Zoom platform. Each PPI participant was asked to independently write a list of potential prognostic factors that they consider to be important, to allow them to consider factors important to them without being influenced by the contents of the survey. The participants were then asked to complete the survey for patients. Patients who attended the meeting face to face completed a printed version of the survey (n\u0026thinsp;=\u0026thinsp;12) and remote patients completed the survey electronically (n\u0026thinsp;=\u0026thinsp;3). By allowing patients to complete the survey during the PPI workshops, participants had the opportunity to ask what any of the prognostic factors were. In addition, they could choose the \u0026ldquo;I don\u0026rsquo;t know what this is\u0026rdquo; response option. For convenience, the \u0026ldquo;I don\u0026rsquo;t know what this is\u0026rdquo; response option will be labelled as \u0026ldquo;unknown\u0026rdquo; in this study.\u003c/p\u003e \u003cp\u003eData collection and analysis:\u003c/p\u003e \u003cp\u003ePPI workshop meetings were facilitated by ZH, who made written anonymised field notes. The PPI lead at WWL chaired the meetings, and a research assistant produced a written record of the discussions.\u003c/p\u003e \u003cp\u003eDescriptive analyses were performed for the results from the PPI workshop and survey responses. The results from the Likert scale questions are presented as frequencies and proportions for each response option for each prognostic factor. The data collected from PPI workshop 2 and the free text in the survey were categorised into themes agreed upon by the research team. In the results section, the outcomes are presented in three categories: patient factors, implant factors and surgical factors. The surgical factor category includes two sections from the survey: surgical factors and surgeon/hospital factors.\u003c/p\u003e \u003cp\u003ePPI participants who chose the unknown option were excluded from the denominator used to calculate the proportion of patients who responded to that particular factor. The analysis was performed using R (Version 4.3.1).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThere were five PPI participants who attended the first PPI workshop activity (using Zoom). All participants had a previous joint replacement surgery, although none had elbow replacement surgery. The second PPI workshop was attended by 15 PPI participants (10 face-to-face and five using the Zoom platform). None of the participants in PPI workshop 2 had participated in the PPI workshop 1 meeting.\u003c/p\u003e \u003cp\u003eThe surveys were completed by 154 healthcare professionals (although six of these only partially completed the survey) and 12 PPI participants. The characteristics of those who participated in the survey are summarised in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003ea (healthcare professionals) and 1b (PPI participants).\u003c/p\u003e \n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ea Characteristics of healthcare professional survey participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of participants (n\u0026thinsp;=\u0026thinsp;154)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eJob title/position\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eConsultant surgeon\u003c/p\u003e\n \u003cp\u003eSurgical trainee/resident\u003c/p\u003e\n \u003cp\u003eAllied health practitioner\u003c/p\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e136 (88%)\u003c/p\u003e\n \u003cp\u003e7 (6%)\u003c/p\u003e\n \u003cp\u003e5 (3%)\u003c/p\u003e\n \u003cp\u003e6 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears in clinical practice\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e1\u0026ndash;5\u003c/p\u003e\n \u003cp\u003e6\u0026ndash;10\u003c/p\u003e\n \u003cp\u003e11\u0026ndash;20\u003c/p\u003e\n \u003cp\u003e21\u0026ndash;30\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e20 (13%)\u003c/p\u003e\n \u003cp\u003e35 (23%)\u003c/p\u003e\n \u003cp\u003e47 (31%)\u003c/p\u003e\n \u003cp\u003e37 (24%)\u003c/p\u003e\n \u003cp\u003e9 (6%)\u003c/p\u003e\n \u003cp\u003e6 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eb Characteristics of PPI survey participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of participants (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003e51\u0026ndash;60\u003c/p\u003e\n \u003cp\u003e61\u0026ndash;70\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2 (17%)\u003c/p\u003e\n \u003cp\u003e5 (42%)\u003c/p\u003e\n \u003cp\u003e5 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eNonbinary/third gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e11 (92%)\u003c/p\u003e\n \u003cp\u003e1 (8%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious joint replacement\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eElbow replacement\u003c/p\u003e\n \u003cp\u003eOther joint replacement\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e5 (42%)\u003c/p\u003e\n \u003cp\u003e3 (25%)\u003c/p\u003e\n \u003cp\u003e4 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\u003c/br\u003e\n\u003cp\u003eDuring the first PPI workshop, participants emphasised the importance of investigating patient and surgeon/hospital factors that could impact the failure of elbow replacement surgery. The patient factors that they highlighted included age, ethnicity, sex, co-morbidities, and the disease leading to the surgery (i.e. indication for surgery). The surgeon/hospital factors they highlighted included surgeon experience (i.e. how many years they have been practising surgery), the number of procedures the surgeon and/or hospital performs per year, and whether the surgery was performed in a hospital that specialises in joint replacements. All these potential prognostic factors were included in the survey. Some of the quotes from the patients in the initial patient involvement meeting were:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;I would like to know if ethnicity would have an impact on the outcome of total elbow replacement surgery\u0026rdquo;.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;I think the impact of age is very important to help decide if I would go ahead with the surgery at younger age or not\u0026rdquo;.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;If the surgery was performed by an experienced surgeon, would this impact the outcome of the replacement surgery?\u0026rdquo;.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003ePatient factors\u003c/h3\u003e\n\u003cp\u003eAll 154 healthcare professionals and 12 PPI participants submitted a response for each patient factor listed in the survey. Eight PPI participants chose the unknown option for ASA Physical Status Classification System, two chose it for co-morbidities, one for socioeconomic status, and one indication for surgery, and this is reflected in the denominator for these questions (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). PPI participants agreed or strongly agreed that most factors other than socioeconomic status and sex should be investigated. Only two participants (18%) agreed (one agreed, one strongly agreed) that socioeconomic status should be investigated as a prognostic factor, and only four participants (33%) agreed that sex should be investigated.\u003c/p\u003e \u003cp\u003eIn contrast, many of the healthcare professionals agreed or strongly agreed that socioeconomic status and sex should be investigated (49% and 66%, respectively). Ethnicity was the only patient factor for which more healthcare professionals disagreed or strongly disagreed (n\u0026thinsp;=\u0026thinsp;76, 49%) than agreed or strongly agreed (n\u0026thinsp;=\u0026thinsp;22, 14%) that it should be investigated as a prognostic factor. However, the majority of PPI participants (n\u0026thinsp;=\u0026thinsp;8, 67%) agreed or strongly agreed that ethnicity is important be investigated as a prognostic factor.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn addition to the factors included in the survey, there were several other patient factors suggested in the free text by both healthcare professionals and PPI participants, including smoking status, alcohol consumption, medication use, psychological and mental health factors, use of walking aids, living status, whether the patient is a carer for any dependent person, and activity level before surgery. Other factors suggested by healthcare professionals alone included bone health status (most suggested factor, n\u0026thinsp;=\u0026thinsp;11), followed by any previous elbow surgery (second most suggested factor, n\u0026thinsp;=\u0026thinsp;10) and the type of surgery (third most suggested factor, n\u0026thinsp;=\u0026thinsp;10). Healthcare professionals also suggested which specific co-morbidities should be examined, with diabetes being the most suggested disease (n\u0026thinsp;=\u0026thinsp;4), followed by rheumatoid arthritis (n\u0026thinsp;=\u0026thinsp;3) and previous trauma (n\u0026thinsp;=\u0026thinsp;3) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOther patient factors suggested by health care professional and PPI participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth care professionals\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;54\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePPI participants n\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCo-morbidities:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e11*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e9*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Diabetes (Hba1c level\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Medication use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Previous trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Rheumatoid arthritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Contralateral shoulder/elbow/wrist pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Metabolic disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Neurological disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Opioids use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Renal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Stickler syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Corticosteroid use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Cardiac condition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Depression and anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElbow specific factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e13*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e13*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Previous surgery and type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Pre-operative elbow deformity and bone loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Previous elbow infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Skin condition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Used of intra-articular steroid injection prior to surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Range of movement before surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; The time had to wait to have surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Preoperative pain level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Strength pre surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e11*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Osteoporosis/Bone Mineral Density (BMD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Vitamin D level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstance abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e6*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e4*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Alcohol consumption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Recreational drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivity level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e13*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e10*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Sporting activities (e.g., gold or tennis)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Leisure activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Professional activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Activities of daily living\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Walking aides (e.g., crutches)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Use of Wheelchair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; General physical health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Gardening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Employment status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Time left until retirement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological and mental factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e7*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Can the patient understand what it means to live with total elbow replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Pre-operative mental health/state\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; IQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Understanding the limitations of own condition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Psychological status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Clinical team expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Patient expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Knowledge of how to how to care for new joint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRehab and post operative advice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Patient compliance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Feedback following surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Follow up quality (if follow up was prompt and how many times was the patient seen)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Quality of Information regarding restriction about surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Physiotherapist experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Language difficulties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome circumstances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e6*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Living alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Caring responsibility (caring after a child or dependant adult)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Housing type (house, flat, bungalow, etc)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Support network for patient after surgery including at home (e.g., support at home to lift heavy items)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Downstairs toilets\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*\u003cb\u003erepresents the unique number of participants who suggested one or more item in this category\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePPI participants also highlighted other patient factors which are important to patients, with pre-operative pain level being the most suggested factor (n\u0026thinsp;=\u0026thinsp;13, 87%) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Unlike the factors listed in the survey, which can be established prior to surgery, some of the factors suggested by PPI participants are typically not measurable at the time of surgery, such as the quality of the rehabilitation and the quality of the post-operative follow-up care. The patient\u0026rsquo;s compliance with post-operative advice is another factor that cannot be established prior to surgery and was suggested as an important factor by both healthcare professionals and PPI participants (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImplant factors:\u003c/p\u003e \u003cp\u003eThe section of the survey on implant factors was completed by 150 (97%) healthcare professionals and 12 (100%) PPI participants. Seven participants from the PPI group selected the unknown option for implant design, six for stem length, four for fixation type and three for implant model/design. Most healthcare professionals and PPI participants agreed or strongly agreed that all implant factors listed in the survey should be investigated. This included implant design, implant model, fixation type, and implant stem length (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHealthcare professionals also suggested other implant factors that should be investigated such as the presence of an anterior flange on the humeral implant (n\u0026thinsp;=\u0026thinsp;3) and the type of cement used (n\u0026thinsp;=\u0026thinsp;2) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The PPI participants suggested two other factors: the material (n\u0026thinsp;=\u0026thinsp;1) and size (n\u0026thinsp;=\u0026thinsp;1) of the implant used.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOther implant factors suggested by Health care professional and PPI participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth care professionals\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;10*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePPI participants\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;2*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of anterior flange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of cement used (e.g., low viscosity cement)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongruency of the implant articulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant manufacturers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of the flange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant material/metal type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of implant size choices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolyethylene design and thickness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStem shape\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant material/metal type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize of the implant used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*\u003cb\u003erepresents the unique number of participants who suggested one or more item in this category\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \n\u003cp\u003eSurgical factors:\u003c/p\u003e \n\u003cp\u003eOne hundred and forty-eight healthcare professionals (96%) responded to all the surgical factors listed in the survey and the majority agreed or strongly agreed that all bar one of those factors should be investigated. The only surgical factor that healthcare professionals predominantly strongly disagreed (26%), disagreed (16%), or neither agreed/disagreed (41%) should be investigated is the use of venous thromboembolism (VTE) prophylaxis (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Of the 12 PPI participants who responded to the surgical factors, 11 selected the unknown option for Tranexamic Acid (TXA), five for VTE prophylaxis, three for surgical approach, surgical technique, and surgeons\u0026rsquo; volume, two for hospital volume, and one for the use of antibiotics, surgeon\u0026rsquo;s volume, and surgeon\u0026rsquo;s grade. Of the PPI participants who chose Likert response options, most agreed or strongly agreed that all the surgical factors listed in the survey were important to be investigated as prognostic factors.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSeveral other factors were suggested by health care professional and PPI participants, which were categorised into factors related to implant position, cementation of the implant, the use of antibiotics, intra-operative factors, surgeon/patient factors and other factors, as summarised in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Intra-operative factors and surgeon/hospital factors were the most suggested factors. Intra operative factors were suggested by 12 healthcare professionals whilst surgeon/hospital factors were suggested by six PPI members and six healthcare professionals. Implant positioning was suggested by eight healthcare professionals and cementation technique by six healthcare professionals.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOther surgical factors suggested by Health care professional and PPI participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth care professionals\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;23\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePPI participants\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntra-operative factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e12*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Radial head replacement or excision or denervation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Tourniquet use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Collateral ligament repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Common flexor and common extensor origin repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Loan vs own instruments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Rotational stability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; The type of bone graft used (e.g., allografts vs autograft)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Ulnar nerve management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant positioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e8*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Bone contact with anterior flange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Implant alignment (Axis of components vs axis of canal)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Restoration of centre of rotation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Radial column support/Lateralisation of the ulna humeral articulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e6*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Cementing technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; If the cement was pressurised\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; The use of cement plug\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotics use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Antibiotics dose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Antibiotics type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Antibiotics duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; The use of local antibiotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgeon and hospital factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e6*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e6*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Surgeon\u0026rsquo;s training type (Academic, Public, or fellowship trained)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Specialised vs non-specialised orthopaedic hospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; If surgery performed at a major trauma centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Surgery out of hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Theatre team experience (e.g., specialised scrub nurse team)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Hospital length of stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Type of anaesthetic used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; If the procedure was performed in the independent sector or NHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*\u003cb\u003erepresents the unique number of participants who suggested one or more item in this category\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMost published studies investigating prognostic factors associated with TER failure lack information on how the prognostic factors investigated were chosen. The choice of such prognostic factors may be based on the opinion of the research team and influenced by which variables are available in a dataset. As a result, the choice of those factors may be subject to the researchers\u0026rsquo; personal biases and fail to account for the views of patients and healthcare professionals. The involvement of patients is likely to highlight factors that are important to them when discussing their treatment and rehabilitation with healthcare professionals and the input from healthcare professionals has the advantage of gaining insight from the clinical experience of the healthcare community. Therefore, knowledge of these factors could not only help inform research but also facilitate better-informed decision-making between patients and healthcare professionals.\u003c/p\u003e \u003cp\u003eThis study shows that patients and healthcare professionals agree on the importance of investigating most of the factors that were included in the survey based on the published literature and PPI input. However, higher proportions of healthcare professionals than patients disagreed with the importance of ethnicity and higher proportion of patients disagreed that socioeconomic status should be investigated. Socioeconomic status and ethnicity may be used in medical research to check for inequalities by assessing disparity in access to services, such as replacement surgery\u003csup\u003e\u003cspan additionalcitationids=\"CR31 CR32 CR33 CR34\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Although most patients in this study disagreed that socioeconomic status is an important prognostic factor, they have suggested investigating factors which can be used to establish socioeconomic status, including occupation, living arrangements, and some educational elements\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Several studies have examined socioeconomic status as a prognostic factor in total knee replacement and total hip replacement and reported that lower socioeconomic status is associated with adverse events and worse patient-reported outcomes but there is no reported association with revision surgery\u003csup\u003e\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Evidence on the association between ethnicity and failure of TER has also been reviewed but the overall quality of evidence was ranked as very low. The understanding of patients' and healthcare professionals' perceptions of socioeconomic status and ethnicity, and the relationship between them, may benefit from further investigation\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBoth healthcare professionals and patients suggested other factors not listed in the survey (i.e., not yet investigated and not highlighted by the first PPI workshop). Pre-operative pain level was suggested by most patients as an important prognostic factor to investigate. The association between pre-operative pain level and outcomes of TER is yet to be evaluated and could be addressed in future research. The most frequently suggested factors from healthcare professionals were bone health, previous surgery to the elbow, intra-operative factors, and the positioning of the implant. There is very low-quality evidence, from one study each, reporting previous surgery to the elbow and the positioning of the humeral implant to be associated with TER failure\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The association between TER failure and the remaining factors is yet to be investigated. Studies are needed to evaluate the impact of factors that are deemed important by patients and healthcare professionals. The results from this study could be used to support researchers in choosing which prognostic factors to investigate and where to utilise available resources.\u003c/p\u003e \u003cp\u003eThe results from this study may also support decisions around which data to routinely collect. Data on some of the prognostic factors in the survey are included in routinely collected data such as national joint registries: for example, the National Joint Registry (NJR) directly collects age, ASA, hand dominance, indication for surgery, sex/gender, weight or BMI, surgical approach, the use of VTE prophylaxis, primary surgeons\u0026rsquo; grade, and implant fixation type. Other factors such as hospital/surgeon\u0026rsquo;s volume, implant design, and implant model can be indirectly collected or estimated. The results from this study suggest other prognostic factors that patients and healthcare professionals considered important, such as occupation, antibiotics use, tranexamic acid use, and implant stem length. However, adding more compulsory items to data collection might increase the burden on the organisation collecting the data, which may impact compliance. If the data collection is not compulsory, this might lead to a high proportion of missing data, as experienced with availability of data on weight and BMI in studies published from the NJR\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. The other difficulty that can arise is how to classify the data collected. For example, what is the best method to classify the patient\u0026rsquo;s occupation so that it can be used meaningfully in research and care. Therefore, careful justification is required before it can be implemented on large scales such as joint registries. However, such factors could be collected and evaluated now in prospective cohort studies.\u003c/p\u003e \u003cp\u003eThere are limitations to the PPI workshop activities as they only included five participants in PPI workshop 1 and 15 participants in PPI workshop 2. Advertising the study to a larger population of patients could have resulted in more participants, however, PPI workshops allowed more time for engagement and discussions with the participants, which meant that the researchers could better understand patient's opinions. In contrast, using the survey to collect healthcare professionals' input was an efficient method to involve many healthcare professionals from across the world; however, it was not possible to discuss the rationale for their selection of prognostic factors. The free text boxes were added to capture additional information from healthcare professionals.\u003c/p\u003e \u003cp\u003eAlthough participants in the PPI represented a variety of replacement surgeries, all but one participant were female, and they were all over the age of 50 years old. This study therefore does not necessary reflect the opinions of younger and/or male patients. This study was able to capture the opinions from surgeons with different levels of experience as measured by the years in clinical practice, but other healthcare professionals only represented 5% of participants who completed the survey.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe involvement of patients and healthcare professionals experienced in joint replacement surgery is vital in understanding their views on which potential prognostic factors should be researched. The results of this study could support researchers and administrators in deciding which prognostic factors to collect data on, to investigate or to account for in analyses.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBESS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBritish Elbow and Shoulder Society\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBOTA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBritish Orthopaedic Trainee Association\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGDPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Data Protection Regulation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGRIPP2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGuidance for Reporting Involvement of Patients and the Public\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Institute for Health and Care Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNJR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Joint Registry\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient and Public Involvement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTER\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTotal elbow replacement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTXA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTranexamic Acid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWWL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWrightington, Wigan, and Leigh Teaching Hospitals NHS Foundation trust\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVTE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVenous Thromboembolism\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e This evaluation was part of a National Joint Registry (NJR) study that was approved by the NJR Research Committee \u003csup\u003e27\u003c/sup\u003e. The University of Manchester ethics decision tool, which determines whether a project requires formal ethical approval, was used and it confirmed that no formal ethical approval is required for this evaluation. All data was handled according to General Data Protection Regulation (GDPR).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e Adam C Watts has a consultancy agreement with Stryker Ltd. and is a member of the Editorial Board of NJR. The remaining authors have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: funding from the RCSEng/NJR joint Research fellowship grant, and financial support from the John Charnley Trust. The research team at the University of Manchester was supported by the Centre for Epidemiology Versus Arthritis (UK grant number 21755). LKF is additionally supported by Versus Arthritis (23126).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026apos;s contributions:\u003c/strong\u003e ZH, LKF, ACW, and JCS provided the idea of the topic. ZH designed and wrote the study. All authors read, provided feedback, input into the methodology, and approved the final manuscript. LKF, ACW and JCS contributed to this work equally.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe would like to thank the British Elbow and Shoulder Society (BESS) research committee for sharing the survey with BESS members. We are very grateful to the members of the PPI team and Patient Research Advisory Group (PPI) at Wrightington, Wigan, and Leigh Teaching Hospitals NHS Foundation trust (WWL) for their valuable input into this study. We would like to especially thank Ms Helen Spickett (Research sponsorship Management at WWL) and Ms Alison Hegarty (Research Assistant at WWL) for their support in organising and conducting the PPI workshop activities. The authors would like to acknowledge the Centre for Epidemiology Versus Arthritis (Arthritis Research UK Grant No. 21755), who provided the infrastructure support for the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBen-Shlomo Y, Blom A, Boulton C, Brittain R, Clark E, Dawson-Bowling S et al. National Joint Registry Annual Reports. The National Joint Registry 19th Annual Report 2022. London: National Joint Registry \u0026copy; National Joint Registry. 2022.; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacken AA, Prkic A, Kodde IF, Lans J, Chen NC, Eygendaal D. Global trends in indications for total elbow arthroplasty: a systematic review of national registries. EFORT Open Rev. 2020;5(4):215\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrkic A, Welsink C, The B, van den Bekerom MPJ, Eygendaal D. Why does total elbow arthroplasty fail today? A systematic review of recent literature. Arch Orthop Trauma Surg. 2017;137(6):761\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiley RD, Hayden JA, Steyerberg EW, Moons KG, Abrams K, Kyzas PA, et al. Prognosis Research Strategy (PROGRESS) 2: prognostic factor research. PLoS Med. 2013;10(2):e1001380.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrognosis Research in Healthcare. In: Riley RD, van der Windt D, Croft P, Moons KGM, editors. Concepts, Methods, and Impact. Oxford University Press; 2019. 01 Feb 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarco R, Streubel PN, Morrey BF, Sanchez-Sotelo J. Total Elbow Arthroplasty for Distal Humeral Fractures: A Ten-Year-Minimum Follow-up Study. J Bone Joint Surg Am. 2017;99(18):1524\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorton ZM, Prasad G, Konstantopoulos G, Morgan ML, Cresswell T, Espag MP, et al. Mid- to long-term survivorship of the cemented, semiconstrained Discovery total elbow arthroplasty. J Shoulder Elb Surg. 2021;30(7):1662\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGriffin JW, Werner BC, Gwathmey FW, Chhabra AB. Obesity is associated with increased postoperative complications after total elbow arthroplasty. J Shoulder Elb Surg. 2015;24(10):1594\u0026ndash;601.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIk\u0026auml;valko M, Tiihonen R, Skytt\u0026auml; ET, Belt EA. Long-term survival of the Souter-Strathclyde total elbow replacement in patients with rheumatoid arthritis. J Bone Joint Surg Br. 2010;92(5):656\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrukhaug Y, Hallan G, Dybvik E, Lie SA, Furnes ON. A survivorship study of 838 total elbow replacements: a report from the Norwegian Arthroplasty Register 1994\u0026ndash;2016. J Shoulder Elb Surg. 2018;27(2):260\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoff C, Kunkle B, Li X, Friedman RJ, Eichinger JK. Assessing the hospital volume-outcome relationship in total elbow arthroplasty. J Shoulder Elb Surg. 2022;31(2):367\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanchez-Sotelo J, Baghdadi YMK, Morrey BF. Primary Linked Semiconstrained Total Elbow Arthroplasty for Rheumatoid Arthritis: A Single-Institution Experience with 461 Elbows Over Three Decades. J bone joint Surg Am volume. 2016;98(20):1741\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSch\u0026ouml;ni M, Drerup S, Angst F, Kyburz D, Simmen BR, Goldhahn J. Long-term survival of GSB III elbow prostheses and risk factors for revisions. Arch Orthop Trauma Surg. 2013;133(10):1415\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah BM, Trail IA, Nuttall D, Stanley JK. The effect of epidemiologic and intraoperative factors on survival of the standard Souter-Strathclyde total elbow arthroplasty. J Arthroplasty. 2000;15(8):994\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViswanath AI, Frampton CM, Poon PC. A review of the New Zealand National Joint Registry to compare the outcomes of Coonrad-Morrey and Latitude total elbow arthroplasty. J Shoulder Elb Surg. 2020;29(4):838\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOwyang D, Bakhsh A, Brewer D, Boughton OR, Cobb JP. Patient and Public Involvement Within Orthopaedic Research: A Systematic Review. J Bone Joint Surg Am. 2021;103(13):e51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel VA, Shelswell J, Hillyard N, Pavitt S, Barber SK. A study of the reporting of patient and public involvement and engagement (PPIE) in orthodontic research. J Orthodont. 2020;48(1):42\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiggane AM, Olsen M, Williamson PR. PPI in research: a reflection from early stage researchers. Res Involv Engagem. 2019;5(1):35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrett J, Davey Z, Matley F, Butcher H, Keenan J, Catton D, et al. Impact of patient and public (PPI) involvement in the Life After Prostate Cancer Diagnosis (LAPCD) study: a mixed-methods study. BMJ Open. 2022;12(11):e060861.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson EC, Horwood J, Gooberman-Hill R. Conceptualising time before surgery: the experience of patients waiting for hip replacement. Soc Sci Med. 2014;116(100):126\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaprari E, Porsius JT, D'Olivo P, Bloem RM, Vehmeijer SBW, Stolk N, et al. Dynamics of an orthopaedic team: Insights to improve teamwork through a design thinking approach. Work. 2018;61(1):21\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGray-Burrows KA, Willis TA, Foy R, Rathfelder M, Bland P, Chin A, et al. Role of patient and public involvement in implementation research: a consensus study. BMJ Qual Saf. 2018;27(10):858\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobinson T, Bailey C, Morris H, Burns P, Melder A, Croft C, et al. Bridging the research\u0026ndash;practice gap in healthcare: a rapid review of research translation centres in England and Australia. Health Res Policy Syst. 2020;18(1):117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatient Research Advisory Group/PPI. Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust; [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wwl.nhs.uk/patient-research-advisory-group-ppi\u003c/span\u003e\u003cspan address=\"https://www.wwl.nhs.uk/patient-research-advisory-group-ppi\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStaniszewska S, Brett J, Simera I, Seers K, Mockford C, Goodlad S, et al. GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research. BMJ. 2017;358:j3453.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePayment guidance for researchers and professionals National Institute for Health and Care Research Website [updated July. 2023. 1.4:[Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nihr.ac.uk/documents/payment-guidance-for-researchers-and-professionals/27392\u003c/span\u003e\u003cspan address=\"https://www.nihr.ac.uk/documents/payment-guidance-for-researchers-and-professionals/27392\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuidance for Using Patient Data Health Research Authority. [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.hra.nhs.uk/covid-19-research/guidance-using-patient-data/#research\u003c/span\u003e\u003cspan address=\"https://www.hra.nhs.uk/covid-19-research/guidance-using-patient-data/#research\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUK GDPR guidance and resources. Information commissioner's office website; [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/\u003c/span\u003e\u003cspan address=\"https://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamoodi Z, Gehringer CK, Bull LM, Hughes T, Kearsley-Fleet L, Sergeant JC, et al. Prognostic factors associated with failure of total elbow arthroplasty. Bone Joint Res. 2024;13(5):201\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHinman A, Bozic KJ. Impact of payer type on resource utilization, outcomes and access to care in total hip arthroplasty. J Arthroplasty. 2008;23(6 Suppl 1):9\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFortin PR, Clarke AE, Joseph L, Liang MH, Tanzer M, Ferland D, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum. 1999;42(8):1722\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgabiti N, Picciotto S, Cesaroni G, Bisanti L, Forastiere F, Onorati R, et al. The influence of socioeconomic status on utilization and outcomes of elective total hip replacement: a multicity population-based longitudinal study. Int J Qual Health Care. 2007;19(1):37\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith MC, Ben-Shlomo Y, Dieppe P, Beswick AD, Adebajo AO, Wilkinson JM, et al. Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data. Osteoarthr Cartil. 2017;25(4):448\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlvarez PM, McKeon JF, Spitzer AI, Krueger CA, Pigott M, Li M et al. Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities. JBJS Reviews. 2022;10(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith MC, Ben-Shlomo Y, Dieppe P, Beswick AD, Adebajo AO, Wilkinson JM, et al. Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data. Osteoarthritis Cartilage. 2017;25(4):448\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePsaki SR, Seidman JC, Miller M, Gottlieb M, Bhutta ZA, Ahmed T, et al. Measuring socioeconomic status in multicountry studies: results from the eight-country MAL-ED study. Popul Health Metrics. 2014;12(1):8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEllis HB, Howard KJ, Khaleel M. Influence of socioeconomic status on outcome of joint replacement surgery. Curr Orthop Pract. 2010;21(2):132\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvans JT, Mouchti S, Blom AW, Wilkinson JM, Whitehouse MR, Beswick A, et al. Obesity and revision surgery, mortality, and patient-reported outcomes after primary knee replacement surgery in the National Joint Registry: A UK cohort study. PLoS Med. 2021;18(7):e1003704.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Elbow, Replacement, Patient and Public Involvement, Clinicians, Prognostic Factors","lastPublishedDoi":"10.21203/rs.3.rs-6528667/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6528667/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTotal elbow replacement is an established treatment for the painful arthritic elbow; however, total elbow replacement has higher failure rates than other joint replacements, such as hip and knee replacement. Understanding the prognostic factors associated with failure of total elbow replacement is essential for informed decision-making between patients and clinicians, patient selection, and service planning. This evaluation presents the views of patients and healthcare professionals on which potential prognostic factors that could be associated with total elbow replacement failure should be investigated.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis evaluation comprised of two Patient and Public Involvement (PPI) workshops and a survey. PPI workshop 1 consisted of five PPI participants who helped to develop a survey assessing the importance of potential prognostic factors to investigate. The survey was shared electronically with members of the British Elbow and Shoulder Society (BESS) and clinicians internationally. In PPI workshop 2, 15 PPI participants listed factors they thought important to investigate, and 12 completed the survey.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePatients and healthcare professionals agreed that most factors in the survey should be investigated. More of the healthcare professionals disagreed that ethnicity (49% v 33%) and VTE prophylaxis (42% v none) are important to be investigated, whilst more of the patients disagreed that socioeconomic status is important to be investigated (54% v 17%). Patients and healthcare professionals also suggested other factors not listed in the survey.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePatients and healthcare professionals agreed on the importance of investigating most prognostic factors, but some factors were favoured by only one group. The results of this evaluation could help researchers decide which prognostic factors to investigate and which to routinely collect.\u003c/p\u003e","manuscriptTitle":"Patient and healthcare professional perspectives on which potential prognostic factors for failure of total elbow replacement should be investigated","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 08:42:54","doi":"10.21203/rs.3.rs-6528667/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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