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The Bone & JoinT Journal
736
K. Svensson,
O. Rolfson,
M. Mohaddes,
H. Malchau,
A. Erichsen
Andersson
From Department
of Orthopaedics,
Institute of Clinical
Sciences, Sahlgrenska
Academy, University
of Gothenburg,
Gothenburg, Sweden
Correspondence should be
sent to K. Svensson; email:
karin. am. svensson@ vgregion.
se
© 2020 The British Editorial
Society of Bone & Joint Surgery
doi:10.1302/0301-620X.102B6.
BJJ-2019-1383.R1 $2.00
Bone Joint J
2020;102-B(6):736–743.
ARTHROPLASTY
Reecting on and managing the emotional
impact of prosthetic joint infections on
orthopaedic surgeons—a qualitative study
Aims
To investigate the experience and emotional impact of prosthetic joint infection (PJI) on
orthopaedic surgeons and identify holistic strategies to improve the management of PJI
and protect surgeons’ wellbeing.
Methods
In total, 18 prosthetic joint surgeons in Sweden were recruited using a purposive sampling
strategy. Content analysis was performed on transcripts of individual in- person interviews
conducted between December 2017 and February 2018.
Results
PJI had a negative emotional impact on Swedish surgeons. Many felt guilt, stress, and a
sense of failure, and several aspects of PJI management were associated with psychoso-
cial challenges. Peer support was reported as the most important coping strategy as was
collaborating with infectious disease specialists.
Conclusion
Our study afrms that there is a negative emotional impact of PJI on surgeons which can
be minimized by improved peer support and working in multidisciplinary teams. Based on
the surgeons’ experiences we have identied desired improvements that may facilitate the
management of PJI. These may also be applicable within other surgical specialties dealing
with postoperative infections, but need to be evaluated for their efcacy.
Cite this article: Bone Joint J 2020;102-B(6):736–743.
Introduction
Prosthetic joint infections (PJIs) are complex in
their pathogenesis and clinical management. In
Sweden, approximately 33,000 primary total hip
and knee arthroplasties are performed annually
and PJI is the most common reason for early reop-
eration.1,2 PJI is associated with patient suering
and great costs. Although the incidence of PJI is
uncertain, it is expected to become an even greater
problem in the future.3-6 This is due to increased
demands for arthroplasty and the development of
antibiotic resistance.7,8
There are diculties in detecting, diag-
nosing, and treating PJI. Patients can present
with non- specic symptoms and current recom-
mendations on diagnostic criteria are incon-
sistently adopted.9 Surgical treatments such as
preserving or exchanging implants are used with
varied success.10,11 In turn, there are a multitude
of opinions on the most appropriate surgical
treatment with seemingly conicting evidence on
best practice.12
Given the aforementioned uncertainties in diag-
nostics and treatment of PJI and their great conse-
quences for the patient, there may be a concurrent
negative impact on orthopaedic surgeons too.
Coping with adverse events (AEs) has been
studied in other medical specialties, and feelings
such as guilt, frustration, fear, and distress have
been reported.13-15 The negative impact of AEs
can aect surgeons’ professional and personal
life.14,15 We identied one other study investigating
the impact of PJI on surgeons.16 Our study is of
a similar approach but aimed to investigate the
experiences and emotional impact throughout the
entire management process, including the planning
of treatment, and sought to identify what improve-
ments surgeons desired to improve management
of PJI and protect their wellbeing.
VOL. 102-B, No. 6, JuNe 2020
Reflecting on and managing the emotional impact of pRosthetic joint infections on oRthopaedic suRgeons 737
Table I. Demographic data of the study participants with experience in managing prosthetic joint infection (PJI).
Participant Sex Age, yrs Range of experience of PJI, yrs Cases per year* Hospital, n Hospital type†
P1 Male 64 > 20 0 to 5 1 District
P2 Male 63 > 20 11 to 20 1 District
P3 Female 52 10 to 20 11 to 20 2 Regional
P4 Male 40 < 10 11 to 20 2 Regional
P5 Male 67 > 20 11 to 20 2 Regional
P6 Male 44 < 10 11 to 20 2 Regional
P7 Male 44 < 10 0 to 5 3 District
P8 Male 46 10 to 20 0 to 5 3 District
P9 Male 52 10 to 20 11 to 20 3 District
P10 Male 62 > 20 6 to 10 4 County
P11 Male 50 10 to 20 11 to 20 5 District
P12 Female 50 10 to 20 11 to 20 5 District
P13 Male 74 > 20 6 to 10 6 County
P14 Male 40 < 10 6 to 10 6 County
P15 Male 41 < 10 11 to 20 6 County
P16 Male 51 10 to 20 6 to 10 7 County
P17 Female 45 10 to 20 11 to 20 8 County
P18 Female 59 10 to 20 6 to 10 9 District
*Patients reported but are not to be interpreted as ‘individual’ infections as each patient might feature a recurrent infection.
†In Sweden, county hospitals are the smallest, capable of routine arthroplasty procedures and less complex revision procedures; district hospitals
are bigger and often provide revision surgery; regional hospitals are highly specialized and serve as referral units for complicated cases of
prosthetic joint infection.
Methods
Study population. The study population was identied using
purposive sampling to maximize variation and identify exper-
tise.17 Purposive sampling enables the identication of partic-
ipants or a group with a variety of knowledge or experience
within the phenomena of interest. Consultant surgeons and
associate specialists with any experience of managing patients
with hip or knee PJI were recruited, and the study had no ex-
clusion criteria. In total, 11 orthopaedic units in Sweden were
approached in October 2017. There were 18 prosthetic joint sur-
geons (14 male, four female) from nine of these units who vol-
unteered to participate, at which point we reached data satura-
tion based on data replication or recurrence in the interviews.18
Data replication in certain categories, such as the importance
of colleagues, occurred prior to the eighteenth interview. Data
from other categories, however, such as desired improvements,
remained versatile throughout multiple interviews; as we want-
ed to validate emerging data in subsequent interviews, the
study group was increased to 18 participants. Table I shows the
demography of participants.
Data collection. In- depth qualitative research interviews were
conducted in order to generate our data. This type of inter-
view is characterized by the intention to understand the world
of the participants, giving the possibility to collect rich data
to acquire a deep understanding of the experiences and emo-
tional impact on surgeons dealing with PJI.19 A semi- structured
interview guide was constructed by the research team. All in-
terviews started with the same question: “What experience do
you have of revision surgery due to PJI of the hip?” Further,
the following areas were covered in the interviews: profession-
al experience, diagnostics, treatment setup, emotional impact,
doctor- patient relationship, support needs, and the facilitating
factors in PJI management. All interviews were conducted in
person by KS between December 2017 and February 2018.
They lasted between 16 and 60 minutes. Interviews were audio
recorded, anonymized, and transcribed verbatim by a third par-
ty. Consent was obtained prior to the interviews. The study was
approved by the Regional Ethical Review Board in Gothenburg
(dnr1190-16).
Data analysis. Data were analyzed using content analysis
according to Graneheim and Lundman,20 illustrated sche-
matically in Figures 1a and 1b (for study data, see Table II).
‘Meaning units’ were extracted from the interviews in accord-
ance with the study aim, and then condensed and labelled with
a code. The codes were grouped together, and data were pro-
cessed into categories and themes which were discussed with-
in the study group. KS returned to the interviews and meaning
units continuously during the process for verication.
KS and AEA had no experience as prosthetic joint surgeons
whereas OR, MM, and HM had varied experience of it, allowing
for several perspectives to be captured. Interviewees were sent
the results of the content analysis and invited to comment on the
ndings to increase trustworthiness. Quotes were profession-
ally translated from Swedish to English by a third party. We did
not use any specic theory to interpret the data and the study is
placed under the constructivist research paradigm.21 We used
the Standards for Reporting on Qualitative Research (SRQR)
checklist when writing our report.22
Results
Four main themes were identied during the process of PJI
management (Figures 2 and 3). The emotional aspects of each step
of PJI management in Figure 2 are summarized into categories
alongside their corresponding theme. Figure 3 illustrates themes
and categories of emotional aspects throughout the process which
are not linked to a certain step of PJI management. Table III gives
an overview of feelings reported by the surgeons.
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K. SVENSSON, M. MOHADDES, O. ROLFSON, H. MALCHAU, A. ERICHSEN ANDERSSON
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Fig. 1
a) The analytical process as described by Graneheim and Lundman20 . b) The abstraction process described by Graneheim and Lundman.20
Table II. Example of analysis.
Meaning unit Condensed meaning unit Code Category Theme
“You can feel a knot in your stomach and feel
that you need to apologize”
Feeling uneasy and feeling the
need to apologize
Responsibility and an
uneasy feeling
The feeling of
guilt
Caring for patients
with PJI
PJI, prosthetic joint infection.
The challenging road towards a diagnosis - difculties in ver-
ifying the infection and conveying the diagnosis. Adequate
sampling, and trusting the microbiological department’s nd-
ings and advice, were important, as diagnostic tools could be
unreliable. Surgeons reported that not getting objective verica-
tion of PJI and determining causative pathogens felt frustrating.
“The problem begins when you have a strong clinical suspi-
cion which you can’t conrm with cultures, but you still believe
there’s an infection…It’s frustrating if you can’t get any further
notice but have to rely on your intuition. What you really want
is evidence, as the consequences of a deep infection can be
fairly extensive for the patient.”- Participant (P) 7.
Deciding on the diagnosis of PJI, conveying bad news, and
balancing information without unnecessarily alarming the
patient, was dicult. An uncertain diagnosis generated the
feeling of insuciency. Therefore, some described the feeling
of relief once a diagnosis was established despite recognizing
its implications for the patient.
Managing uncertainty and the emotional impact of diag-
nostic difculties. Many felt frustration and insecurity when
moving forward with an uncertain diagnosis. Working together
with colleagues and infectious disease (ID) doctors was impor-
tant for making decisions and coping emotionally. “We discuss
infections a great deal, especially in the team…We almost al-
ways check with one another.” – P11. Surgeons also relied on
previous experiences and consulted colleagues or centres with
greater expertise.
Accepting the diagnosis - a change of attitude. Accepting
the diagnosis of PJI was hard. “I think the most dicult thing
is raising the question [about PJI]…It’s dicult to accept that
something you do can become infected; accepting it is almost
like dealing with grief.”- P4. Surgeons believed that there was
potential for neglect of symptoms and the avoidance of further
investigation. However, participants described a greater ac-
ceptance and awareness for PJI in contemporary orthopaedic
practice. The less hierarchical structure among surgeons today
made it easier to discuss cases between colleagues. “If you have
problems with wounds or leaking wounds after a week, you
usually tackle it as a prosthetic joint infection. I didn’t do that
ten years ago; instead I treated it with antibiotics and hoped it
was nothing.”- P14
Tailoring a treatment plan - balancing the patient’s condi-
tions and needs with treatment options. Surgeons agreed
that individualized, patient- centred management was a priority
when choosing treatment. “During treatment, you take into ac-
count the patient’s personality, pain threshold, ability to accept
poor function, social situation, and what the patient actually
wants.”- P1.
Surgeons identied that there was limited or inconsistent
evidence for dierent treatment options, and that this was prob-
lematic and could lead to varying opinions between clinicians
within one unit. However, two surgeons felt that PJI treatment
was more or less standardized and that decision- making was
not a challenge.
Choice of revision method was based on tradition, education,
and what the surgeon thought would give the best result. All but
one surgeon preferred a two- stage procedure for deep infection.
Exceptions could be made, but surgeons otherwise used the
VOL. 102-B, No. 6, JuNe 2020
Reflecting on and managing the emotional impact of pRosthetic joint infections on oRthopaedic suRgeons 739
Fig. 2
Themes and categories during the process of prosthetic joint infection (PJI) management.
Fig. 3
Themes and categories of emotional aspects throughout the process of
prosthetic joint infection (PJI) management.
Table III. Reported feelings associated with prosthetic joint infection
management.
Feelings associated with PJI management
Worry
Frustration
Distress
Insufciency
Guilt
Anxiety
Discomfort
Sadness
Uncertainty
Stress
Fear
Insecurity
Disappointment
Hopelessness
Usefulness
Relief
PJI, prosthetic joint infection.
method of their particular preference. “Sometimes I almost imme-
diately feel that it’s better for the patient to have a two- stage revi-
sion, or at least it makes me feel more secure.”- P6. The surgeon
who used the one- stage method felt that taking care of patients
was easier, knowing that this strategy was less burdensome.
Planning the treatment and complicating factors. Surgeons
felt that it was important that patients received clear plans ear-
ly on in their care. This could be dicult due to uncertainty
or conicting opinions. “This is a patient who is particularly
vulnerable and very exposed; a patient like this requires in-
volvement and continuity…The worst thing is when these pa-
tients are passed back and forth between colleagues who have
dierent opinions. That creates a huge sense of insecurity.”- P1.
Congested appointment and operation schedules made it di-
cult and stressful to nd time for the expedited management
of PJI patients, sometimes leading to rushed decisions and re-
scheduling of elective procedures. Surgeons noted that due to
a lack of available orthopaedic appointments, patients went to
their general practitioner (GP) instead, and therefore risked PJI
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K. SVENSSON, M. MOHADDES, O. ROLFSON, H. MALCHAU, A. ERICHSEN ANDERSSON
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being missed. Surgeons experienced that there was limited un-
derstanding for PJI within the broader healthcare community.
Everyone agreed that multidisciplinary collaboration was
needed for an optimal treatment approach. “In the past, patients
were passed back and forth between the orthopaedic clinic and
the ID clinic, as no one wanted to take responsibility for the
infection.”- P7. Collaborating with ID specialists was seen
as necessary to provide safe care. “You need an ID specialist
who you feel you can trust, because I think it’s dangerous if
we, as orthopaedic surgeons, manage it with antibiotic treat-
ment. I really don’t think that’s any good. This calls for team-
work.”- P16. However, feeling insecure about, and questioning
the knowledge of, ID specialists or the microbiology lab was
reported. One surgeon sometimes bypassed the local ID special-
ists and contacted the university hospital for advice.
Some patients developed depression during treatment. Main-
taining the patient’s faith during the resolution of infection
was dicult, while surgeons also feared persistent infections.
“When patients suer mentally, this also aects the doctor in
the role of being positive, supportive, and having a profes-
sional approach.”- P12. The uncertainty of the nal outcome
was distressing and failure was disappointing, worrying, and
frustrating. However, when treatment succeeded surgeons felt
useful being able to help their patient.
The relationship between surgeon and patient - preparing
the patient for what lies ahead and understanding his or her
needs. Surgeons reported that patients, despite preoperative in-
formation and informed consent, did not expect PJI. “Patients
are put in a challenging situation when they have been expect-
ing the operation to be successful and it isn’t.”- P10. Patient
participation was deemed important, and understanding the pa-
tient’s thoughts and fears was essential in order to counsel them
appropriately. However, lack of sucient time sometimes made
it dicult to do this well. Ensuring continuity was perceived
to be important for both surgeon and patients, but described as
being nearly impossible to achieve due to the rotational nature
of the sta schedule. “I think continuity is more important, that
the same doctor is responsible for the treatment and the entire
process. As far as the patient is concerned, this is far more im-
portant than who wields the knife.”- P11.
Surgeons felt compassion for their patients, acknowledged
their ill- being and suering, and highlighted the need for
a committed and responsive team. They wanted to support
their patients as much as possible and recognized the patient’s
need to talk to someone. “There’s plenty of scope for feelings
of guilt for both the patient and the doctor.”- P4. However,
it was suggested that by referring the patient to a coun-
sellor, surgeons could protect themselves from getting too
emotionally involved.
The impact of the patient-surgeon relationship. Surgeons
could nd solace in meeting their patient if they had a good
relationship. “If you create a condence- lled relationship, it
also alleviates the painful experience for me...You get to follow
them for a long time and so, in one way or another, regard-
less of whether you want to or not, you become friends.”- P1.
Many patients showed an understanding towards the multifac-
eted cause of PJI and did not seek a scapegoat. However, some
surgeons reported on the experience of being blamed for it.
“What I sometimes nd most dicult is relatives who are very
obstinate and somewhat accusatory when there’s a feeling that
it’s our fault… What did you do wrong, have you made a mis-
take?”- P1. Sometimes patients requested referrals to a univer-
sity hospital thinking that the surgeons there were better. One
surgeon experienced gaining trust more easily having trained at
a university hospital.
Many felt that dealing with PJI in their ‘own’ patient was
more intrusive, associated with sadness, disappointment, and
feelings of defeat and failure. Also, for some, maintaining the
trust their patient once had for them felt dicult. In contrast,
taking on the responsibility of a colleague’s patient felt easier
than having to face one’s own perceived mistakes or failures.
“It’s slightly easier to take over other people’s patients, as you
know that you don’t need to feel guilty about being involved in
something that went wrong.”- P17.
Caring for patients with PJI - the feeling of guilt. Many sur-
geons discussed the feeling of guilt. “You can feel a knot in
your stomach and feel that you need to apologize.”- P4. Some
reasoned that feeling this way was irrational, yet questioned
themselves in whether they could have done something dier-
ent. Surgeons scrutinized their role in the process, and worried
and ruminated about their patient, even at home, but not to the
extent that it had a severe negative impact on their personal life.
However, professionally, it led to a more restrictive selection of
patients for primary procedures.
Coping with difcult feelings and the need for emotional
support. PJI was associated with anxiety and disappointment.
Finding a way to emotionally deal with complications, such as
talking to colleagues, was considered essential. “It’s really dif-
cult dealing with PJI if you don’t have a group of colleagues
to talk to.”- P10. Many felt the need to talk about their cases
and surgeons who had collegial support felt it was easier to deal
with PJI. “Discussing things with colleagues is a form of ac-
knowledgement, as you don’t feel that you are alone in your
lack of knowledge.”- P3. Many often felt it suced to talk to
colleagues for emotional support, but one surgeon wished to
have the opportunity to talk to an outsider.
Accepting PJI was dicult for inexperienced surgeons. “At
the beginning of my career, I had trouble sleeping and facing
complications was really tough.”- P11. More senior surgeons
reported that this often became easier with experience; however,
experienced surgeons also felt worried. “The more experienced
you are, the more frightened and more careful you are when you
meet an infected patient.”- P11.
Moving forward. The organization of PJI management at the
participating units diered. Figure 4 is based on the surgeons’
suggestions for facilitating and optimizing PJI management.
In regard to facilitating the detection of PJI, surgeons
desired programmes to standardize follow- up; special-
ized wound units; increased accessibility for patients;
better educated GPs; and clear referral paths. Many wished
for better collaboration between surgeons, committed ID
doctors, and the microbiological laboratory during diagnos-
tics and further management. Scheduled conferences were
also mentioned as a suggested improvement. Some felt
centralizing PJI care would be benecial for both surgeons
and patients and that this would improve collaboration with
VOL. 102-B, No. 6, JuNe 2020
Reflecting on and managing the emotional impact of pRosthetic joint infections on oRthopaedic suRgeons 741
Fig. 4
Suggested factors that may contribute to facilitating the management of prosthetic joint infection (PJI). ID, infectious disease.
ID doctors. “One improvement could be that some hospitals
focus on infections. Surgeons unused to infections wouldn’t
need to feel worried or feel a sense of failure.”- P7. However,
smaller well- functioning centres feared they would lose their
expertise.
Surgeons noted that introducing new technologies for
the diagnosis and treatment of PJI needed to be done in an
evidence- based manner, which was not always perceived to be
the case. One surgeon worried about the increasing dependency
on the commercial companies behind technological advances as
they were not believed to be knowledgeable enough on PJI and
instead mainly worked in their own interests.
Discussion
Our study illustrates the psychosocial challenges and nega-
tive emotional impact which the diagnosis, management,
and follow- up of patients with PJI may have on orthopaedic
surgeons. The transferability of our results beyond Swedish
arthroplasty surgeons may be limited, as global, cultural, and
healthcare dierences need to be considered. However, we
believe that our results can transfer to healthcare systems similar
to Sweden. Our study ndings are largely consistent with a
British study conducted by Mallon et al16 suggesting that PJI
is dicult to manage, independent of the study setting. Also,
many feelings reported were comparable with those previously
described in other physicians dealing with AEs.13-15 Our results
may not be applicable in private healthcare systems where indi-
vidual results are attributed more specically to the individual
surgeon’s practice; and where a surgeon may be subject to
litigation. We speculate that there is a greater negative impact
and pressure on surgeons in such a system.
Although the exact mechanism by which a patient developed
PJI may be unknown, the aetiology of approximately 80% of
infections have been attributed to seeding at the time of surgery
and 20% related to non- surgical factors such as haematogenous
spread.23 This may explain the surgeons’ feelings of guilt.
The results of this study do not aim to improve treat-
ment outcomes, nor will they have a vast health econom-
ical impact. Hopefully they will add another dimension to
the understanding and awareness of the surgeon’s situation
and the importance of a team- based approach. Multidisci-
plinary approaches, desired by all our participants, have
previously been correlated to better treatment outcome.11
Knowledgeable ID specialists were considered crucial for
treatment success and surgeons wished for an increased
collaboration between the departments. Our results also
reiterate the importance of peer support for the individual
surgeon.13,14,16,24 In contrast to other studies, there were
no reports of an accusatory culture among colleagues;
rather scheduled conferences to discuss challenges to their
patients with PJI were brought up as a desired improve-
ment by several surgeons.13-15 This may be due to a collegial
and proactive ethos among Swedish orthopaedic surgeons
dealing with PJI. Working in teams of surgeons with varied
experience provides a forum for knowledge transfer and is
empowering for individual surgeons. All surgeons in our
study discussed their cases with colleagues. This approach
was also reported by Mallon et al16 but they also suggested
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K. SVENSSON, M. MOHADDES, O. ROLFSON, H. MALCHAU, A. ERICHSEN ANDERSSON
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The BONe & JOiNT JOurNaL
that cases were handled in a more insular fashion at some
British departments.
PJI has a negative impact on both patients and surgeons.4,16
Our study does not mean to diminish the patient suering.
However, we believe it is of importance to also highlight the
clinician’s perspective. We hope that all units dealing with any
type of postoperative infections may nd value in the suggested
facilitating factors (Figure 4), such as working in multidisci-
plinary teams; scheduling time for collegial guidance; receiving
emotional support; and increasing the general understanding
for PJI patients in healthcare organizations; and that the imple-
mentation of these may lead to changes in practice which
benet both patients and surgeons. However, the ecacy of
these suggestions does require evaluation. Moreover, improved
patient education (and surgeon education in communicating
risks, results, and treatments) may be important to set the appro-
priate level of expectations including the potential complica-
tions in arthroplasty surgery.
Although we did not specically question participants in
regards to burnout, we could not identify any clear signs of it
in our study. Swedish surgeons were happy with the emotional
support they received from their colleagues and, as noted by
Mallon et al,16 openly discussing PJI with colleagues and the
multidisciplinary team may serve as a protective factor. At
the same time we identied the need for formal professional
support and encourage hospitals to oer it to their sta.
A limitation in this study may be the paucity of female
surgeons included in the sample, though this is proportionate
to the orthopaedic surgeon population in Sweden. This may
explain the diculty to recruit more female interviewees.
Female clinicians may be more willing to openly discuss AEs.25
However, we do not believe that our results are aected by this
as we could not identify any overall dierences in emotional
impact between male and female participants.
This study contributes to current PJI research and highlights
the importance of continuing mixed- method studies to estab-
lish best practice. Our results may also be applicable to other
surgical specialties dealing with postoperative infections, but
this needs to be conrmed in further studies.
In conclusion, our study arms that there is a negative
emotional impact of PJI on surgeons. Receiving peer support
was regarded as the most important coping strategy. We have
identied desired improvements that may further facilitate the
management of PJI. These may also be applicable within other
surgical specialties dealing with postoperative infections, but
need to be evaluated for their ecacy.
Take home message
- Prosthetic joint infection (PJI) has an emotional impact on
orthopaedic surgeons.
- Facilitating factors, such as working in multidisciplinary
teams, scheduling time for collegial guidance, receiving emotional
support, and increasing the general understanding for PJI patients in
health care organizations, were identied as desired improvements.
Supplementary material
Interview protocol for surgeons.
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Author information:
K. Svensson, MD, Orthopaedic Resident
O. Rolfson, MD, PhD, Professor, Consultant Orthopaedic Surgeon
M. Mohaddes, MD, Associate Professor, Consultant Orthopaedic Surgeon
Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska
Academy, University of Gothenburg, Gothenburg, Sweden; Mölndal
Hospital, Sahlgrenska University Hospital, Mölndal, Sweden.
H. Malchau, MD, PhD, Professor, Harvard Medical School, Harvard
University, Boston, Massachusetts, USA; Consultant Orthopaedic Surgeon,
Sahlgrenska University Hospital, Mölndal, Sweden.
A. Erichsen Andersson, RN, CNOR, PhD, Associate Professor, Senior
Lecturer, Nurse Consultant, Department of Orthopedics, Sahlgrenska
University Hospital, Gothenburg, Sweden; Institute of Health and Care
Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg,
Sweden.
Author contributions:
K. Svensson: Conceived and designed the study, Acquired and interpreted
the data, Carried out the analysis, Prepared the original draft, Revised and
edited the paper, Approved the nal version.
O. Rolfson: Conceived and designed the study, Carried out the analysis,
Revised and edited the paper, Approved the nal version.
M. Mohaddes: Conceived and designed the study, Carried out the analysis,
Revised and edited the paper, Approved the nal version.
H. Malchau: Carried out the analysis, Revised and edited the paper,
Approved the nal version.
A. Erichsen Andersson: Conceived and designed the study, Carried out the
analysis, Revised and edited the paper, Approved the nal version.
Funding statement:
This study was funded by regional research grants (ALFGBG-719961) and
the Doktor Felix Neuberghs foundation. The funders were not involved in
any part of the study preparation or implementation.
Although none of the authors has received or will receive benets for
personal or professional use from a commercial party related directly
or indirectly to the subject of this article, benets have been or will
be received but will be directed solely to a research fund, foundation,
educational institution, or other non- prot organization with which one or
more of the authors are associated.
ICMJE COI statement:
The authors declare no conicts of interest.
Acknowledgements:
We would like to thank the study participants for sharing their experiences.
Ethical review statement:
The study was approved by the Regional Ethical Review Board in
Gothenburg (dnr1190-16).
This article was primary edited by K. Logishetty and rst proof edited by
G. Scott.
