Organisation, data evaluation, interpretation and effect of arthroplasty register data on the outcome in terms of revision rate in total hip arthroplasty

Development of application and surgical technique of total knee arthroplasties: a systematic comparative analysis using worldwide registers

PURPOSE

The aim was to compare total knee arthroplasty (TKA) between countries with regard to epidemiologic data and surgical technique by the use of worldwide registers and compare findings with a previous report after one decade.

METHODS

A systematic search was carried out in November 2022 and compared to previous reports from 2010. We extracted data regarding implanted TKAs, patients' age distribution, procedure types, fixation and revision rates. After identification of 28 national arthroplasty registers, 8of them, namely Australia, Canada, Denmark, England and Wales, New Zealand, Norway, Scotland and Sweden, offered sufficient data and were included in final analysis.

RESULTS

A large variation was found in the annual number of implantations per 100,000 inhabitants with a range from 77 to 210.2 (mean 132.8). The fixation type varied strongly as well, e.g. over 95% of totally cemented TKAs in Sweden versus 61.2% cemented fixation in Denmark. Another significant difference was the use of patellar resurfacing in TKA, ranging from 47.3% (Canada) using a patellar button in TKA to less than 5% (Sweden). Within the period of one decade, the mean overall number of annual implantations increased (10%), whilst relative number of revisions decreased, the use of cemented TKA decreased from 87 to 74%, and the use of patella button remained largely inhomogeneous.

CONCLUSION

Comparison of arthroplasty registers revealed large differences regarding the annual number of primary TKAs per inhabitant as well as primary TKA procedure types with an increase of annual implantations, decrease of relative number of revisions, and a decrease of the use of cemented systems over the period of one decade.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Battle of the titans: Survivorship analysis of the 3 most common types of uncemented femoral stems used across national registries

Background

Although many institutions utilize uncemented stems as routine in performing total hip arthroplasty (THA), many surgeons continue to rely on outcomes reported in the literature in the form of small cohorts and patient series when analyzing survivorship for specific implants. The purpose of this study was to identify and analyze the survivorship of the 3 most common uncemented stem types (as opposed to brands) used across multiple national joint registries.

Methods

A review of data available from all national joint registries was carried out in July 2022. Analysis of each individual registry and classified uncemented implants into the seven different uncemented stem types. The 3 most common stem types were identified, and average cumulative revision rates calculated. Metal on metal bearings surface implants were excluded from this study due to high revision rates across all implant types.

Results

Our detailed review identified 6 out of 13 (NJR, AOANJRR, LROI, EPRD, MARCQI and the NZJR) international registries reporting implant specific survivorship on uncemented femoral stems; including 960,328 uncemented stems across all registries. The most common type of stem used was type 3c, accounting for 61% (583,724), followed by type 1 stems with 23% (217,897) and type 2 stems with 8% (79,257). Cumulative revision rates at 13 years follow-up for these stems ranged from 6.9% to 7.9%.

Conclusion

Although all stem types have comparable revision rates across all registries, the most common uncemented stem reported was the type 3c, tapered rectangular fully coated stem. Furthermore, out of all type 3c, the Müller design philosophy with full hydroxyapatite coating seems to be the most sought after worldwide. In this study we can conclude, thus far, that there does not appear to clinical or statistical differences in revision rates between the different stem types.

Level of evidence

III.

Supramalleolar osteotomies for ankle arthritis: a systematic review

INTRODUCTION

We investigated the mid-term outcomes of supramalleolar osteotomies regarding "survivorship" [before ankle arthrodesis (AA) or total ankle replacement (TAR)], complication rate and adjuvant procedures required.

MATERIAL AND METHODS

PubMed, Cochrane and Trip Medical Database were searched from January 01, 2000. Studies reporting on SMOs for ankle arthritis, in minimum of 20 patients aged 17 or older, followed for a minimum of two years, were included. Quality assessment was performed with the Modified Coleman Methodology Score (MCMS). A subgroup analysis of varus/valgus ankles was performed.

RESULTS

Sixteen studies met the inclusion criteria, with 866 SMOs in 851 patients. Mean age of patients was 53.6 (range 17-79) years, and mean follow-up was 49.1 (range 8-168) months. Of the arthritic ankles (646 ankles), 11.1% were classified as Takakura stage I, 24.0% as stage II, 59.9% as stage III and 5.0% as stage IV. The overall MCMS was 55.2 ± 9.6 (fair). Eleven studies (657 SMOs) reported on "survivorship" of SMO, before arthrodesis (2.7%), or total ankle replacement (TAR) (5.8%) was required. Patients required AA after an average of 44.6 (range 7-156) months, and TAR after 36.71 (range 7-152) months. Hardware removal was required in 1.9% and revision in 4.4% of 777 SMOs. Mean AOFAS score was 51.8 preoperatively, improving to 79.1 postoperatively. Mean VAS was 6.5 preoperatively and improved to 2.1 postoperatively. Complications were reported in 5.7% (44 out of 777 SMOs). Soft tissue procedures were performed in 41.0% (310 out of 756 SMOs), whereas concomitant osseous procedures were performed in 59.0% (446 out of 756 SMOs). SMOs performed for valgus ankles failed in 11.1% of patients, vs 5.6% in varus ankles (p < 0.05), with disparity between the different studies.

CONCLUSIONS

SMOs combined with adjuvant, osseous and soft tissue, procedures, were performed mostly for arthritic ankles of stage II and III, according to the Takakura classification and offered functional improvement with low complication rate. Approximately, 10% of SMOs failed and patients required AA or TAR, after an average of just over 4 years (50.5 months) after the index surgery. It is debatable whether varus and valgus ankles treated with SMO reveal different success rates.

Short-stem hip arthroplasty in Australia and the Netherlands: a comparison of 12,680 cases between the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Dutch Arthroplasty Register (LROI)

BACKGROUND AND PURPOSE

We compared the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Dutch Arthroplasty Register (LROI) regarding patient, prosthesis, and procedure characteristics as well as revision rates for uncemented short-stem total hip arthroplasties (THAs).

PATIENTS AND METHODS

All THAs with an uncemented short-stemmed femoral component performed between 2009 and 2021 were included from the AOANJRR (n = 9,328) and the LROI (n = 3,352). Kaplan-Meier survival analyses and multivariable Schemper's weighted Cox regression analyses with data from 2009-2021 and 2015-2021 were performed with overall revision as endpoint.

RESULTS

In Australia, the proportion of male patients (51% vs. 40%), patients with ASA III-IV score (30% vs. 3.7%), BMI ≥ 30.0 (39% vs. 19%), and femoral heads of 36 mm (58% vs. 20%) were higher than in the Netherlands. Short-stem THAs in Australia and the Netherlands had comparable 10-year revision rates (3.4%, 95% confidence interval [CI] 2.9-4.0 vs. 4.8%, CI 3.7-6.3). Multivariable Cox regression analyses with data from 2009-2021 showed a higher risk for revision of short-stem THAs performed in the Netherlands (HR 1.8, CI 1.1-2.8), whereas the risk for revision was comparable (HR 0.9, CI 0.5-1.7) when adjusted for more potential confounders using data from 2015-2021.

CONCLUSION

Short-stem THAs in Australia and the Netherlands have similar crude and adjusted revision rates, which are acceptable at 10 years of follow-up.

Higher use of fixed-bearing over mobile-bearing and posterior-stabilized over medial pivot designs in total knee arthroplasty (TKA): a systematic comparative analysis using worldwide arthroplasty registers from England and Wales, Australia, Norway, New Zealand, Germany and Switzerland

INTRODUCTION

The aim of this study was to compare the use of mobile-bearing, fixed-bearing, posterior-stabilized (PS) and medial pivot design to describe epidemiological differences and subsequent outcomes.

MATERIALS AND METHODS

A systematic literature search was performed using the NORE website to identify the relevant arthroplasty registers. Inclusion criteria were the following: (1) reports had to be publicly available, (2) reports had to be written in German or English language, (3) differentiation between mobile- and fixed-bearing, posterior-stabilized, and if possible, medial pivot designs had to be possible from the present reports, and (4) data had to be reported for at least three consecutive years and the latest report had to be from the year 2020 to retrieve recent data.

RESULTS

Six registries (England and Wales, Australia, Norway, New Zealand, Germany, Switzerland) offered sufficient data according to the inclusion criteria. In all countries, the dominant type of bearing used for total knee arthroplasty (TKA) was fixed-bearing, with percentages ranging from 60.8% to 84.1% in 2018, 63.6% to 85.7% in 2019 and 66.2% to 87.4% in 2020. A large variation was observed concerning mobile-bearing design, which showed a range from 2.8% to 39.2% in 2018, 2.6% to 36.4% in 2019 and 2.9% to 33.8% in 2020. Some variation was found regarding the use of PS TKA, as its percentage frequency ranged from 9.7% to 29.2% in 2018, 9.8% to 29.4% in 2019 and 10.1% to 28.5% in 2020. Medial pivot design had a share of 9.1% in 2018, 8.6% in 2019 and 8.4% in 2020 in Australia, while it only accounted for 1.4% in 2018, 2.1% in 2019 and 2.5% in 2020 in Germany.

CONCLUSION

The comparison of arthroplasty registers from England and Wales, Australia, Norway, New Zealand, Germany and Switzerland revealed large differences regarding the application of posterior-stabilized designs, but also common ground considering the overwhelming use of fixed-bearing inserts, which, when inserted correctly, eradicate the potential complication of bearing dislocation. Arthroplasty registers offer a real-world clinical perspective with the aim to improve quality and patient safety.

Assessment of the Value of Registries in Shoulder Arthroplasty Using Reverse Arthroplasty as an Example

INTRODUCTION

As a consequence of the Swedish model, endoprosthesis registers have become increasingly important worldwide. Due to the increasing number of joint replacements at the shoulder, these are being increasingly included in the register databases - in addition to interventions at the hip and knee joint. In this study, the value of endoprosthesis registers is investigated, using the example of shoulder endoprosthetics and including a comparison with clinical studies.

MATERIAL AND METHODS

The annual reports of 32 different endoprosthesis registers with data on hip, knee and/or shoulder arthroplasty were analysed. The number of operations and demographic patient data for all areas of endoprosthetics were examined. In addition, a more detailed consideration of variables such as the primary diagnosis, the cause of the revision, the revision rate depending on risk factors and patient-reported outcome measures (PROM scores) was carried out exclusively for the shoulder joint endoprostheses. Using the example of the inverse shoulder prosthesis, clinical studies were compared to registry data with special regard to the revision rate.

RESULTS

A total of 20 endoprosthesis registers could be included, 9 of these collected data on shoulder arthroplasty. The main primary diagnoses were osteoarthritis (40.6%), rotator cuff defect arthropathy (30.2%) and fractures (17.6%). The most commonly used shoulder joint endoprosthesis was the inverse prosthesis (47.3%). The proportion of revision surgeries in total shoulder arthroplasty operations was less than 10% in all registers. In addition to the revision rate, the PROM scores were sometimes used in the registers to evaluate the success of the prosthesis. Compared to registry data, clinical studies showed more heterogeneous data with a significantly higher revision rate of over 10% in long-term follow-up - using the example of the inverse shoulder prosthesis.

CONCLUSION

Register data are a valuable source of information in shoulder arthroplasty and can make a significant contribution to the quality assurance of endoprosthetic treatments. Compared to clinical studies, they primarily provide data on durability of different endoprosthesis and give lower revision rates. Clinical studies use PROM scores and clinical and radiological examinations to focus only on individual implants and surgical centres on the one hand and much more on the functional results on the other.

Preoperative and Perioperative Predictors of Length of Hospital Stay after Primary Total Hip Arthroplasty-Our Experience on 743 Cases

The aim of this retrospective investigation is to evaluate the correlation between several preoperative and perioperative factors and the length of hospital stay in patients that underwent elective total hip arthroplasty with overnight admission. Medical records of patients that underwent THA from the beginning of 2016 to the end of 2018 were retrospectively screened. Demographics, comorbidities, whole blood count, intraoperative details, and length of postoperative stay were retrieved. The association between clinical, laboratory and surgical factors and the length of hospital stay was explored by means of negative binomial and logistic regression models. The median length of postoperative hospital stay was four days (Inter Quartile Range, IQR 3, 5). After univariate regression a stepwise multivariate regression showed that operative time (p = 0.001), the preoperative serum creatinine (p < 0.001), the intraoperative blood loss (p = 0.04) and the use of an anterolateral approach (p < 0.001) were found to correlate significantly with the increase of the hospitalization length, while no significant correlation was found for all the other features. Multivariable model fitted through logistic regression (LOS below or over the median value of four days) had an Area Under the Curve (AUC) of 0.748. Our analysis suggests a significant role played by different preoperative and perioperative variables in influencing the length of hospital stay.

The T Cell Repertoires from Nickel Sensitized Joint Implant Failure Patients

Nickel (Ni²⁺) is one of the most common allergens, affecting around 10–15% of the general population. As the demand for orthopedic implant surgery rises, the number of surgical revisions due to joint implant failure also increases. There is evidence that some patients develop joint failure due to an immune response to a component of the implant, and we have found that Ni²⁺ is an especially important cause. Hence, understanding the mechanisms by which Ni²⁺ allergy induces joint implant failure becomes a critical research question. The structural basis of Ni²⁺ activation of pathogenic T cells is still not clear. The purpose of this study was to characterize Ni²⁺-reactive T cell repertoires derived from the peripheral blood of joint failure patients due to Ni²⁺ sensitization using single-cell sequencing techniques. We stimulated the proliferation of Ni²⁺ -reactive T cells from two implant failure patients in vitro, and sorted them for single-cell VDJ sequencing (10× genomics). We identified 2650 productive V-J spanning pairs. Both TCR α chains and β chains were enriched. TRBV18 usage is the highest in the P7 CD4+ population (18.1%), and TRBV5-1 usage is the highest in the P7 CD8+ population (12.1%). TRBV19 and TRBV20-1 segments are present in a high percentage of both P7 and P9 sequenced T cells. Remarkably, the alpha and beta chain combination of TRAV41-TRBV18 accounts for 13.5% of the CD4+ population of P7 patient. Compared to current Ni specific T cell repertoire studies of contact dermatitis, the Vα and Vβ usages of these joint implant failure patients were different. This could be due to the different availability of self-peptides in these two different tissues. However, TRBV19 (Vβ17) was among frequently used TCR β chains, which are common in previous reports. This implies that some pathogenic T cells could be similar in Ni²⁺ hypersensitivities in skin and joints. The alignment of the TCR CDR3β sequences showed a conserved glutamic acid (Glu) that could potentially interact with Ni²⁺. The study of these Ni²⁺ specific TCRs may shed light on the molecular mechanism of T cell activation by low molecular weight chemical haptens.

Completeness and capture rate of publicly funded arthroplasty procedures in the New Zealand Joint Registry

BACKGROUND

Registry-based studies have become more common due to the availability of a large study cohort. However, the validity of findings is dependent on the completeness of the registry. This study aimed to validate the capture rate of the New Zealand Joint Registry (NZJR) by matching procedures that have been recorded separately via clinical coding by the New Zealand Government's National Surgical Site Infection Improvement Programme (SSIIP).

METHODS

The National Health Index, a unique identification code for all patients, was combined with the arthroplasty procedure performed (primary total knee arthroplasty (TKA), primary total hip arthroplasty (THA), revision TKA or revision THA) and operation side. Publicly funded procedures recorded in the NZJR were matched with procedures recorded by the SSIIP on a record-by-record basis. This identified the total number of arthroplasty procedures performed in New Zealand, which was used as the denominator value to calculate the procedure capture rate of the NZJR.

RESULTS

Between 2013 and 2018, 24 556 primary TKA, 28 970 primary THA, 2107 revision TKA and 4263 revision THA procedures were recorded by both datasets. The NZJR recorded 95.5% of primary TKA procedures, 96.3% of primary THA procedures, 97.1% of revision TKA procedures and 95.2% of revision THA procedures.

CONCLUSION

The NZJR recorded >95% of publicly funded arthroplasty procedures. In contrast, there were inaccuracies in clinical coding by hospitals, particularly with revision procedures, demonstrating the benefits of an arthroplasty registry. However, data recorded by an infection surveillance programme may supplement arthroplasty registry data to strengthen the quality of research.

The PROMIS Global Health Questionnaire Correlates With the QuickDASH in Patients With Upper Extremity Illness

BACKGROUND

The objective of this study is to evaluate the construct validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health instrument by establishing its correlation to the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire in patients with upper extremity illness.

METHODS

A cohort of 112 patients completed a sociodemographic survey and the PROMIS Global Health and QuickDASH questionnaires. Pearson correlation coefficients were used to evaluate the association of the QuickDASH with the PROMIS Global Health items and subscales.

RESULTS

Six of the 10 PROMIS Global Health items were associated with the QuickDASH. The PROMIS Global Physical Health subscale showed moderate correlation with QuickDASH and the Mental Health subscale. There was no significant relationship between the PROMIS Global Mental Health subscale and QuickDASH.

CONCLUSIONS

The consistent finding that general patient-reported outcomes correlate moderately with regional patient-reported outcomes suggests that a small number of relatively nonspecific patient-reported outcome measures might be used to assess a variety of illnesses. In our opinion, the blending of physical and mental health questions in the PROMIS Global Health makes this instrument less useful for research or patient care.

The Mark Coventry Award: Patellofemoral Arthroplasty Results in Better Range of Movement and Early Patient-reported Outcomes Than TKA

BACKGROUND

Controversy exists over the surgical treatment for severe patellofemoral osteoarthritis. We therefore wished to compare the outcome of patellofemoral arthroplasty (PFA) with TKA in a blinded randomized controlled trial.

QUESTIONS/PURPOSES

In the first 2 years after surgery: (1) Does the overall gain in quality of life differ between the implants based on the area under the curve of patient-reported outcomes (PROs) versus time? (2) Do patients obtain a better quality of life at specific points in time after PFA than after TKA? (3) Do patients get a better range of movement after PFA than after TKA? (4) Does PFA result in more complications than TKA?

METHODS

Patients were eligible if they had debilitating symptoms and isolated patellofemoral disease. One hundred patients were included from 2007 to 2014 and were randomized to PFA or TKA (blinded for the first year; blinded to patient, therapists, primary care physicians, etc; quasiblinded to assessor). Patients were seen for four clinical followups and completed six sets of questionnaires during the first 2 postoperative years. SF-36 bodily pain was the primary outcome. Other outcomes were range of movement, PROs (SF-36, Oxford Knee Score [OKS], Knee injury and Osteoarthritis Outcome Score [KOOS]) as well as complications and revisions. Four percent (two of 50) of patients died within the first 2 years in the PFA group (none in the TKA group), and 2% (one of 50) became ill and declined further participation after 1 year in the PFA group (none in the TKA group). The mean age at inclusion was 64 years (SD 8.9), and 77% (77 of 100) were women.

RESULTS

The area under the curve (AUC) up to 2 years for SF-36 bodily pain of patients undergoing PFA and those undergoing TKA was 9.2 (SD 4.3) and 6.5 (SD 4.5) months, respectively (p = 0.008). The SF-36 physical functioning, KOOS symptoms, and OKS also showed a better AUC up to 2 years for PFA compared with TKA (6.6 [SD 4.8] versus 4.2 [SD 4.3] months, p = 0.028; 5.6 [SD 4.1] versus 2.8 [SD 4.5] months, p = 0.006; 7.5 [SD 2.7] versus 5.0 [SD 3.6] months, p = 0.001; respectively). The SF-36 bodily pain improvement at 6 months for patients undergoing PFA and those undergoing TKA was 38 (SD 24) and 27 (SD 23), respectively (p = 0.041), and at 2 years, the improvement was 39 (SD 24) and 33 (SD 22), respectively (p = 0.199). The KOOS symptoms improvement at 6 months for patients undergoing PFA and those undergoing TKA was 24 (SD 20) and 7 (SD 21), respectively (p < 0.001), and at 2 years, the improvement was 27 (SD 19) and 17 (SD 21), respectively (p = 0.023). Improvements from baseline for KOOS pain, SF-36 physical functioning, and OKS also differed in favor of PFA at 6 months, whereas only KOOS symptoms showed a difference between the groups at 2 years. No PRO dimension showed a difference in favor of TKA. At 4 months, 1 year, and 2 years, the ROM change from baseline for patients undergoing PFA and those undergoing TKA was (-7° [SD 13°] versus -18° [SD 14°], p < 0.001; -4° [SD 15°] versus -11° [SD 12°], p = 0.011; and -3° [SD 12°] versus -10° [SD 12°], p = 0.010). There was no difference in the number of complications. During the first 2 postoperative years, there were two revisions in patients undergoing PFA (one to a new PFA and one to a TKA).

CONCLUSIONS

Patients undergoing PFA obtain a better overall knee-specific quality of life than patients undergoing TKA throughout the first 2 years after operation for isolated patellofemoral osteoarthritis. At 2 years, only KOOS function differs between patients undergoing PFA and those undergoing TKA, whereas other PRO dimensions do not show a difference between groups. The observations can be explained by patients undergoing PFA recovering faster than patients undergoing TKA and the functional outcome being better for patients undergoing PFA up to 9 months. Patients undergoing PFA regain their preoperative ROM, whereas patients undergoing TKA at 2 years have lost 10° of ROM. We found no differences in complications.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Hospitals' adoption of medical device registers: Evidence from the German Arthroplasty Register

BACKGROUND

Hospitals in many countries do not record and analyze artificial hip and knee joint surgeries systematically, leading to a lack of reliable quality assurance data. Arthroplasty registers have the potential to alleviate this and improve quality of care and health care expenditures. In Germany, the current introduction of the Arthroplasty Register acts as a prototype for various medical device registers. However, participation is voluntary for hospitals in most countries, leading to problems with nonadoption.

PURPOSE

Implementing successful registers requires adoption by most relevant hospitals. Therefore, we assess variables influencing medical device register adoption.

METHODOLOGY

We collect longitudinal data from 343 hospitals that are potential adopters of the German Arthroplasty Register in two surveys. The first survey on the implementation process is conducted in 2014; the second survey is conducted in 2016 to collect data on actual adoption of the surveyed hospitals in 2014. The survey data are matched with published hospital characteristics and administrative data. The hypotheses are tested with a mediated regression model, using partial least squares structural equation modeling.

FINDINGS

Hospital specialization positively affects adoption, directly and indirectly, depending on top management support and user involvement. Quality benefits and hospital size impact adoption positively; economic benefits impact adoption negatively.

CONCLUSION

Important factors influencing adoption of medical device registers for the first time were revealed in this study, providing a starting point to influence adoption proactively and avoid nonadoption.

PRACTICE IMPLICATIONS

The results provide important guidelines for decision-makers at hospitals, registers, and health insurance companies and policy makers about how to foster register adoption and encourage hospitals toward adopting medical device registers.

Advantages and limitations of national arthroplasty registries. The need for multicenter registries: the Rempro-SBQ

While the value of national arthroplasty registries (NAR) for quality improvement in total hip arthroplasty (THA) has already been widely reported, some methodological limitations associated with observational epidemiological studies that may interfere with the assessment of safety and efficacy of prosthetic implants have recently been described in the literature.

Among the main limitations of NAR, the need for at least 80% compliance of all health institutions covered by the registry is emphasized; completeness equal or greater than 90% of all THA performed; restricted data collection; use of revision surgery as the sole criterion for outcome; and the inability of establishing a definite causal link with prosthetic dysfunction.

The present article evaluates the advantages and limitations of NAR, in the light of current knowledge, which point to the need for a broader data collection and the use of more structured criteria for defining outcomes.

In this scenario, the authors describe of idealization, conceptual and operational structure, and the project of implantation and implementation of a multicenter registry model, called Rempro-SBQ, which includes healthcare institutions already linked to the Brazilian Hip Society (Sociedade Brasileira de Quadril [SBQ]). This partnership enables the collection of more reliable and comprehensive data at a higher hierarchical level, with a significant reduction in maintenance and financing costs. The quality improvement actions supported by SBQ may enhance its effectiveness and stimulate greater adherence for collecting, storing, interpreting, and disseminating information (feedback).

Clinical Outcome Reporting in Youth ACL Literature Is Widely Variable

Background:

Advances in anterior cruciate ligament (ACL) reconstruction procedures in pediatric and adolescent patients have resulted in an increase in recent clinical studies on this topic. However, the consistency with which outcome measures are reported in this demographic is unknown.

Purpose:

To document outcome reporting patterns of youth ACL reconstruction studies in high-impact journals.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

All articles published in 5 high-impact orthopaedic journals from 2010 to 2016 were reviewed to identify those reporting clinical outcomes of young patients who underwent ACL reconstruction. Studies that were nonclinical, reported on patients older than 18 years, or included fewer than 10 patients were excluded. Outcome measures used in all included studies were recorded.

Results:

Seventeen studies encompassing 772 subjects (mean age, 14.3 years; range, 6.3-18.0 years) were analyzed. Eight studies (47%) reported on Tanner stage of subjects, while 1 study reported skeletal age. Ten studies (59%) clearly documented the presence or absence of surgical complications. Range of motion was reported in 65% of studies. Leg-length discrepancy and angular deformity were each reported in 76% of studies, with 12% quantifying results through radiographic measurements. Ligament testing was variably defined by inclusion of instrumented testing (65%), Lachman test (53%), and pivot-shift test (53%). Fourteen studies (82%) explicitly reported on the rate of ACL rerupture, while 71% reported on the rate of revision surgery. Rate of return to preinjury activity was reported in 8 studies (47%), of which 2 defined criteria for return to sport and 3 defined the level of competitive sport. Patient-reported outcome measures (PROMs) were used variably. For the 3 most commonly reported PROMs (Lysholm, International Knee Documentation Committee, and Tegner), 24% of studies reported all 3 PROMs, 35% of studies reported 2 PROMs, and 6% of studies reported 1 PROM in isolation. A pediatric-specific PROM was reported in 1 of the 17 studies.

Conclusion:

Studies on pediatric ACL reconstruction published in high-impact journals unreliably defined subjects’ skeletal maturity, inconsistently reported on objective outcome measures, and used disparate adult-validated PROMs to assess subjective outcomes. These findings highlight the need for standardized, pediatric-specific outcome measures to be applied in future studies evaluating ACL reconstruction in children and adolescents.

Data Quality in Institutional Arthroplasty Registries: Description of a Model of Validation and Report of Preliminary Results

BACKGROUND

Arthroplasty registries are a relevant source of information for research and quality improvement in patient care and its value depends on the quality of the recorded data. The purpose of this study is to describe a model of validation and present the findings of validation of an Institutional Arthroplasty Registry (IAR).

METHODS

Information from 209 primary arthroplasties and revision surgeries of the hip, knee, and shoulder recorded in the IAR between March and September 2015 were analyzed in the following domains. Adherence is defined as the proportion of patients included in the registry, completeness is defined as the proportion of data effectively recorded, and accuracy is defined as the proportion of data consistent with medical records. A random sample of 53 patients (25.4%) was selected to assess the latest 2 domains. A direct comparison between the registry's database and medical records was performed.

RESULTS

In total, 324 variables containing information on demographic data, surgical procedure, clinical outcomes, and key performance indicators were analyzed. Two hundred nine of 212 patients who underwent surgery during the study period were included in the registry, accounting for an adherence of 98.6%. Completeness was 91.7% and accuracy was 85.8%. Most errors were found in the preoperative range of motion and timely administration of prophylactic antibiotics and thromboprophylaxis.

CONCLUSION

This model provides useful information regarding the quality of the recorded data since it identified deficient areas within the IAR. We recommend that institutional arthroplasty registries be constantly monitored for data quality before using their information for research or quality improvement purposes.

Mid- to Long-term Results of Supramalleolar Osteotomy

BACKGROUND

Good clinical and radiographic short-term results have been reported for patients who underwent realignment surgery of the hindfoot for treatment of early- and mid-stage ankle osteoarthrosis (OA). However, no mid- to long-term results have been reported. The aim of this study was to gain a better insight into the indications and contraindications for realignment surgery.

METHODS

Two hundred ninety-four patients (298 ankles) underwent realignment surgery between December 1999 and June 2013. Kaplan-Meier survival analysis was performed with total ankle replacement and arthrodesis of the ankle joint as endpoints. A Cox proportional hazards model was performed to identify risk factors for failure. The mean time to follow-up was 5.0 ± 3.7 years.

RESULTS

The overall 5-year survival rate was 88%. Thirty-eight patients (12.9%) underwent either secondary total ankle replacement or ankle arthrodesis (30 total ankle replacements, 8 ankle arthrodesis). Risk factors for failure following realignment surgery were age at the time of surgery and a Takakura score of 3b preoperatively.

CONCLUSION

Realignment surgery of the hindfoot was an excellent treatment option for young and physically active patients with early to mid-stage ankle OA.

LEVEL OF EVIDENCE

Level IV, prospective observational study.

Policies to foster quality improvement registries: lessons from the Swedish case

BACKGROUND AND OBJECTIVES

Multi-institutional quality improvement registries (QI registries) are a promising approach to quality improvement. They are also used for clinical research, public quality reporting and other valuable purposes. The aim of this study was to identify elements and outcomes of national policies to promote registries in Sweden and to compare them with recent policies in the USA.

METHODS

This case study draws on previous studies of Swedish registries and on interviews, observations and document studies conducted in Sweden and the USA.

RESULTS

In Sweden, registries are fostered by favourable patient data regulation and an indirect control approach combining government funding with soft regulation and professional self-governance. This enables the development of high-quality QI registries which are used for improvements by engaged clinicians, for clinical research and for decision support for practitioners and stakeholders. For example, Riks-HIA/Swedeheart achieved improved outcomes in cardiac intensive care, SCAAR/Swedeheart was used in a unique registry-based randomized trial, and the Swedish Rheumatology Quality Register provides a Web interface for patient encounters and clarifies adverse effects of biologic drugs. Still, the system has persistent limitations, especially the administrative burden on participants. In the USA, Medicare's programme for qualified clinical data registries and other recent changes mirror Swedish policies. Automated data capture is a US advantage, but uncertain funding and complex data regulations stall registry development in the USA.

CONCLUSION

The findings of this study indicate that tailor-made data regulation and a soft regulatory policy approach foster high-quality QI registries with multiple meaningful uses. These findings offer a framework for further cross-country comparative study to evaluate registry policies.

A Community-Based Hip Fracture Registry: Population, Methods, and Outcomes

Cases of hip fracture recorded from 1/2009 to 12/2011 were ascertained using the Kaiser Permanente Hip Fracture Registry. The registry collects information on patient, procedure, surgeon, facility, and surgical outcomes. The population (N = 12,562) was predominantly white, women, and older (≥ 75 years), and 32% had at least 5 comorbidities. The average length of follow-up was 1.1 years. Hemiarthroplasty was the most common procedure (33.1%). Most fractures were treated by medium-volume surgeons at high-volume facilities. The 90-day readmission rate was 22.1%, and the mortality rate was 12.3%.

Supercharging irradiated allografts with mesenchymal stem cells improves acetabular bone grafting in revision arthroplasty

PURPOSE

The procedure of bone allografting associated with a reinforcement device is widely used for acetabulum revision. However in absence of biologic fixation of the allograft, failure of the reconstruction may occur. We made the hypothesis that it would be possible to load these grafts with bone marrow derived mesenchymal stem cells (MSC) to rescue the osteogenic capacity of an allogenic dead bone and therefore enhance incorporation of allografts with the host bone and decrease the number of failures related to the allograft.

METHOD

We identified 60 patients who had undergone acetabular component revision for aseptic failure of cemented implants associated with massive periacetabular osteolysis and Paprosky type 3A or 3B classification (without pelvic discontinuity) between 1996 and 2001. The study group of 30 patients received MSCs in the allograft and at the host graft junction. The average total number of MSCs received by each patient was 195,000 cells (range 86,000-254,000 cells). The control group of 30 patients had no MSCs in the allograft. Patients were matched for the size of periacetabular osteolysis (Paprosky type 3A or 3B). We compared the evolution of the allografts and evaluated cup migration and revision of the hips as end points at a minimum of 12 years or until failure.

RESULT

Better radiographic graft union rates and less allograft resorption were observed with allografts loaded with stem cells. Allograft resorption was significantly decreased in the group with allograft loaded with MSCs (1.2 cm(2) -range 0-2.3 cm(2)-of resorption on radiographs in the group with MSCs; versus 6 cm(2), range 2.1-8.5 cm(2) in the group without MSCs). The rate of mechanical failure was highest (p = 0.01) among the 30 patients with allograft without stem cells (9/30; 30 %) compared with no failures for patients with allograft loaded with stem cells. Revision of the cup was necessary in nine patients in the control group. No revision was performed in the 30 patients of the study group with MSCs.

CONCLUSION

For acetabular defect reconstruction, loading the allograft with MSCs has resulted in a lower rate of failure as compared with allograft without MSCs.

The value of computed tomography based navigation in revision total hip arthroplasty

PURPOSE

This study investigates the accuracy of a computed tomography (CT)-based navigation system for accurate acetabular component placement during revision total hip arthroplasty (THA).

METHODS

We performed a retrospective review of 30 hips in 26 patients who underwent cementless revision THA using a CT-based navigation system; the control group consisted of 25 hips in 25 patients who underwent cementless primary THA using the same system. We analysed the deviation of anteversion and inclination angles among the pre-operative plan, intra-operative records from the navigation system and data from postoperative CT scans.

RESULTS

There were no significant differences between groups (P < 0.05) in terms of mean deviation between pre-operative planning and postoperative measurements or between intraoperative records and postoperative measurements.

CONCLUSION

CT-based navigation in revision THA is a useful tool that enables the surgeon to implant the acetabular component at the precise angle determined in pre-operative planning.

Health policy implications of outcomes measurement in orthopaedics

An emphasis on "value" over volume in health care is driving new healthcare measurement, delivery, and payment models. Orthopaedic surgery is a major contributor to healthcare spending and, as such, is the focus of many of these new models. WHERE ARE WE NOW?: An evaluation of "value" in orthopaedics requires information that has not traditionally been collected as part of routine clinical practice. If value is defined as patient outcomes in relation to healthcare costs, we need to collect information about both. In orthopaedics, patient-reported functional status is not routinely measured, and a poor understanding of the costs associated with the provision of musculoskeletal care limits our ability to quantify and report on financial measures. WHERE DO WE NEED TO GO?: To improve the value of musculoskeletal care, we need to focus on both improving outcomes and controlling costs. To improve outcomes, orthopaedists must agree on a set of outcome measures for appropriate care and advocate for their collection through the use of registries. Orthopaedic registries in several countries provide best practices for this information collection and sharing. In the United States, we should make comparable investments in registries to measure patient-reported outcomes. To address escalating costs, we need to improve the accuracy of cost data by applying modern cost accounting processes. HOW DO WE GET THERE?: Orthopaedists should take a leadership position in the promotion and implementation of value-based health care by advocating for the use of registries to measure risk-adjusted patient specific outcomes, negotiating with payors for value-based payment incentives and applying modern cost accounting processes to control costs rather than waiting for public and private payors to define components of the value equation that will affect how orthopaedic surgeons are evaluated and compensated in the future.

Revision surgery after total joint arthroplasty: a complication-based analysis using worldwide arthroplasty registers

The authors performed a complication-based analysis of total knee (TKA), total hip (THA), and total ankle arthroplasty (TAA) using worldwide arthroplasty registers. We extracted data with respect to reason for revision surgery and pooled causes. The most common causes for revisions in THA were aseptic loosening (55.2%), dislocation (11.8 %), septic loosening (7.5%), periprosthetic fractures (6%), and others. The most common causes in TKA were aseptic loosening (29.8%), septic loosening (14.8%), pain (9.5%), wear (8.2%), and others. The most common causes in TAA were aseptic loosening (38%), technical errors (15%), pain (12%), septic loosening (9.8%), and others. Revisions in TKA and THA differ with respect to type of complication. However, in case of TAA, higher rates of technically related complications are reported.

Application and surgical technique of total knee arthroplasties: a systematic comparative analysis using worldwide registers

PURPOSE

The aim of this study was to compare total knee arthroplasty (TKA) procedures between different countries with regard to epidemiological data and surgical technique by reference to the worldwide arthroplasty registers.

METHODS

A systematic search was carried out using the EFORT website to identify the relevant arthroplasty registers. We extracted data with respect to the number of implanted TKAs, patients' age distribution, procedure types, and revision rates. After identification of 28 national arthroplasty registers, 11 offered sufficient data regarding the above mentioned parameters and were therefore included in the final analysis.

RESULTS

A large variation was found in the annual number of primary TKA implantations per inhabitant with a reported range from 30 to 199 per 100,000 (mean 106). The fixation method varied strongly between the different registers as well, e.g. 90 % of totally cemented TKAs in Sweden, England and Wales, Slovakia, and New Zealand versus 54 % cemented fixation in Australia. Another significant difference between included countries was observed with respect to the use of patellar resurfacing in TKA. Whilst the Danish knee arthroplasty register reports a percentage of 72 % using a patellar button in TKA the register from Norway reports only a minority of 2 %.

CONCLUSIONS

The comparison of arthroplasty registers revealed large differences regarding the annual number of primary TKAs per inhabitant and primary TKA procedure types. These variations may be explained by several factors such as patient demographics (prevalence of osteoarthritis) and national conditions such as healthcare systems (insurance status), number or availability of performing surgeons, medical facilities and surgeon-dependent factors such as definition of indications, education, tradition and experience.

[Revision rates in journal publications on joint prostheses with noticeably high failure rates in register data sets]

BACKGROUND AND AIM OF STUDY

The value of outcome quality data from clinical studies is an issue of controversial debate particularly in the context of adverse events. The aim of this study is to present and evaluate the data available from clinical studies for products that show inferior outcome in registers and to assess the possibility to draw valid conclusions from these data. STUDY DESIGN AND ANALYTICAL METHODS: Based on a structured literature research, a comparative analysis was made of the revision rates of 12 products showing significantly inferior average results in registers. The primary outcome parameter was the revision rate for any reason calculated using a standardized methodology and the parameter of revisions per 100 observed component years.

RESULTS

For 5 out of 12 products not a single comparable study was available and relatively few data were available for the remaining products. A conventional meta-analysis revealed that only three products showed results that were comparable with those from registers. For 75% of products good results were published. There was not a single case where it would have been possible to identify or isolate the problems that had led to the underperformance observed on the basis of clinical studies alone.

DISCUSSION

Clinical sample-based studies are not a suitable and reliable means to recognize potential product or handling problems and avoid risks for patients and physicians. In this respect registers can provide an essential contribution.

Perioperative mortality in hip fracture patients treated with cemented and uncemented hemiprosthesis: a register study of 11,210 patients

PURPOSE

Adverse events associated with the use of bone cement for fixation of prostheses is a known complication. Due to inconclusive results in studies of hip fracture patients treated with cemented and uncemented hemiprostheses, this study was initiated.

METHODS

Our study is based on data reported to the Norwegian Hip Fracture Register on 11,210 cervical hip fractures treated with hemiprostheses (8,674 cemented and 2,536 uncemented).

RESULTS

Significantly increased mortality within the first day of surgery was found in the cemented group (relative risk 2.9, 95 % confidence interval 1.6-5.1, p=0.001). The finding was robust giving the same results after adjusting for independent risk factors such as age, sex, cognitive impairment and comorbidity [American Society of Anesthesiologists (ASA) score]. For the first post-operative day the number needed to harm was 116 (one death for every 116 cemented prosthesis). However, in the most comorbid group (ASA worse than 3), the number needed to harm was only 33.

CONCLUSIONS

We found increased mortality for the cemented hemiprosthesis the first post-operative day compared to uncemented procedures. This increased risk is closely related to patient comorbidity estimated by the patient's ASA score.

Application and survival curve of total hip arthroplasties: a systematic comparative analysis using worldwide hip arthroplasty registers

PURPOSE

The aim of the study was to compare primary total hip arthroplasty (THA) implantations between different countries in terms of THA number per inhabitant, age, and procedure type and to compare the survival curve including all THAs using hip arthroplasty registers.

METHODS

THA registers were compared between different countries with respect to the number of primary implantations per inhabitant and age, procedure type and survival curve. We performed a literature search for all national hip arthroplasty registers providing annual reports for 2009 or, if not available, a more recent period. The data from these reports were analysed in terms of number, age distribution and procedure type of primary THAs and survival curves.

RESULTS

We identified nine hip arthroplasty registers, which comprised sufficient data to be included. A large variation was found in the annual number of primary THA implantations per inhabitant. The procedure type varied greatly as well, e.g. in Sweden 67 % are cemented THAs whereas in Emilia-Romagna (Italy) 89 % are cementless THAs.

CONCLUSIONS

This study revealed large differences in terms of the annual number of primary THAs per inhabitant and primary THA procedure type across countries. These data can be used to rank local primary THA implantations within an international context.

Data preparation techniques for a perinatal psychiatric study based on linked data

Background

In recent years there has been an increase in the use of population-based linked data. However, there is little literature that describes the method of linked data preparation. This paper describes the method for merging data, calculating the statistical variable (SV), recoding psychiatric diagnoses and summarizing hospital admissions for a perinatal psychiatric study.

Methods

The data preparation techniques described in this paper are based on linked birth data from the New South Wales (NSW) Midwives Data Collection (MDC), the Register of Congenital Conditions (RCC), the Admitted Patient Data Collection (APDC) and the Pharmaceutical Drugs of Addiction System (PHDAS).

Results

The master dataset is the meaningfully linked data which include all or major study data collections. The master dataset can be used to improve the data quality, calculate the SV and can be tailored for different analyses. To identify hospital admissions in the periods before pregnancy, during pregnancy and after birth, a statistical variable of time interval (SVTI) needs to be calculated. The methods and SPSS syntax for building a master dataset, calculating the SVTI, recoding the principal diagnoses of mental illness and summarizing hospital admissions are described.

Conclusion

Linked data preparation, including building the master dataset and calculating the SV, can improve data quality and enhance data function.

Revision rate of Birmingham Hip Resurfacing arthroplasty: comparison of published literature and arthroplasty register data

PURPOSE

Hip resurfacing arthroplasty has gained popularity for treating young and active patients who have arthritis. There are two major data sources for assessing outcome and revision rate after total joint arthroplasty: sample-based clinical trials and national arthroplasty registers. The purpose of this study was to evaluate the outcome of the Birmingham Hip Resurfacing (BHR) arthroplasty in terms of revision rate as reported in clinical studies and recorded by national arthroplasty registers.

METHODS

A comprehensive literature research was performed from English-language, peer-reviewed journals and annual reports from national joint arthroplasty registers worldwide. Only publications from MEDLINE-listed journals were included. The revision rate was used as the primary outcome parameter. In order to allow for direct comparison of different data sets, calculation was based on revisions per 100 observed component years. For statistical analysis, confidence intervals (CI) were calculated.

RESULTS

A total of 18,708 implants, equivalent to 106,565 observed component years, were analysed in the follow-up studies. The register reports contained 9,806 primary cases corresponding to 44,294 observed component years. Statistical analysis revealed a significant difference in revisions per 100 observed component years between the development team (0.27; CI: 0.14-0.40) and register data (0.74; CI: 0.72-0.76).

CONCLUSION

The BHR arthroplasty device shows good results in terms of revision rate in register data as well as in clinical studies. However, the excellent results reported by the development team are not reproducible by other surgeons. Based on the results of our study, we believe that comprehensive national arthroplasty registers are the most suitable tool for assessing hip arthroplasty revision rate.

The outcome of the cementless tapered SL-Plus stem: an analysis of arthroplasty register data

PURPOSE

The aim of this study is to evaluate the outcome of the cementless SL-Plus stem in worldwide arthroplasty register datasets.

METHODS

A structured analysis was conducted the registered data about the SL-Plus stem manufactured by Smith&Nephew including published data from Australia as well as previously unpublished datasets from the Registers of Lombardia, Italy and Valdoltra, Slovenia. A total of 75% of the data analysed had not been published so far. The primary outcome measure was the revision rate, calculated in revisions per 100 observed component years. We evaluated a total of 10,684 primary and 122 revision surgeries with an average follow-up period of four years.

RESULTS

All datasets showed good and reproducible results for treatment with the SL-Plus stem. An average of 0.31 revisions per 100 observed component years had been reported, which is considerably below the worldwide average (1.29) found for total hip arthroplasty independent of the product. The results of a large centre did not essentially deviate from the revision rates in Lombardia, where the numbers of cases per department are relatively low on average.

CONCLUSIONS

There were no indications for product defects or relevant errors in application. The SL-Plus stem can be considered a high-quality product that ensures good results also in the hands of less experienced surgeons. Data from even young registers can substantially contribute to the assessment of implants, even with the short follow-up periods. These datasets particularly allow for valid assessment of safety issues and can therefore make an essential contribution to the solution of problems of current relevance.

Validity of published outcome data concerning Anatomic Graduated Component total knee arthroplasty: a structured literature review including arthroplasty register data

PURPOSE

Total knee arthroplasty (TKA) as a treatment for end-stage osteoarthritis of the knee shows good results in terms of patient satisfaction. For the assessment of outcome and revision rate after total joint arthroplasty, there are two major data sources: clinical studies and national arthroplasty registers. The purpose of this study was to analyse the outcome of Anatomic Graduated Component (AGC) TKA reported in clinical studies and to perform a comparison with the outcome reported by national arthroplasty registers.

METHODS

A systematic literature review was performed using standardised methodology in order to determine the outcome and revision rate of AGC TKA. In a comprehensive meta-analysis of clinical studies and worldwide register results we examined the quality of the basic data and the occurrence and influence of potential bias factors. Confidence intervals were calculated to determine the statistical significance of differences.

RESULTS

We found significant differences as regards the revision rate measured in revisions per 100 observed component years. Compared to worldwide register data it turned out to be significantly lower in clinical studies published by the implant development team. Actually, they reported a revision rate of 0.18 revisions per 100 observed component years, whereas annual reports of national arthroplasty registers report 0.74 revisions per 100 observed component years. A comparison of the results from national arthroplasty registers of different countries revealed a significantly higher revision rate for Denmark in relation to worldwide register data.

CONCLUSIONS

A conventional meta-analysis of clinical studies is affected by the influence of the development team and therefore subject to bias. For the assessment of outcome arthroplasty register data should be rated as superior and, being used as reference data for the detection of potential bias factors in the clinical literature, could make an essential contribution to the quality of scientific meta-analysis.