February 2001 Bulletin

AAOS studies feasibility of joint registry

National data can identify problems, successes, influence surgeons’ behavior

The AAOS Board of Directors has approved studying the feasibility of establishing a national total joint registry.

Orthopaedic surgeons in the United States need to be able to better evaluate what works and what doesn’t on a continuous feedback process, William J. Maloney, MD, professor of orthopaedic surgery, chief of service, Washington University, St. Louis, Mo., told the AAOS Board of Directors workshop in December.

Instead, orthopaedists in the U.S. learn about successes and failures by reading journals or by word-of-mouth and sometimes the recognition comes long after a device or technique has been widely used.

Dr. Maloney said a national registry would pool patients and evidence-based information, influence the behavior of orthopaedists and improve health care. The registry could be a research tool and it could generate questions that need to be answered.

As the population ages and the number of joint replacements increases it is becoming more imperative that orthopaedists have accurate information on techniques, materials and risk factors, Dr. Maloney said.

He recommended that the AAOS take the initiative in developing the registry to ensure confidentiality of the data contributors.

Dr. Maloney points to the Swedish National Hip Arthroplasty Register, started more than 20 years ago, which describes the epidemiology of total hip replacement surgery in Sweden and identifies, by studying revisions, the risk factors for poor outcomes related to the patient, the implant and the surgical technique. The hip replacement register is financed by the Swedish National Board of Health and Welfare, but is directed by a professional committee.

The goal is to improve on a continuous basis the quality of hip replacement surgery. By comparing their results with the national average, orthopaedic surgeons can decide whether their technique or choice of implant is adequate.

Annual feedback of information from the registry is credited with a decline in revisions in cemented prosthesis.

There are 400,000 joint replacement procedures in the United States annually and a revision rate of 16 to 17 percent in the hip and 7 to 8 percent in the knee, said Dr. Maloney. While in Sweden, where far fewer hip replacements are performed, he says the revision rate is approximately half of that in the U.S.

The Swedish registry also is credited with focusing on improving surgical technique rather than experimenting with new implants.

A registry is another effective way of analyzing hip replacement surgery because it has the potential to monitor our entire patient population, Dr. Maloney said.

In June 2000, the Canadian Institute of Health Information (CIHI) and the Canadian Orthopaedic Association announced the creation of a national registry on hip and knee joint replacements.

Robert Bourne, MD, who chairs the National Advisory Committee of the newly created Canadian Joint Replacement Registry, said more than 37,000 hip and knee joint replacements are performed in Canada each year. He estimates that 10-12 percent of patients require subsequent replacements as a result of implant wear and breakage. "Presently, the reasons for replacing an implant cannot be determined from existing data," he said. "By identifying reasons for implant wear and breakage, we can reduce the need for subsequent hip and knee replacements which will potentially create savings to Canada’s health care system."

Kiren Handa, senior analyst at CIHI, said a data collection form and computer system has been developed and physicians across Canada are being encouraged to participate. Handa expects data to start coming to the registry in April; reports will be issued annually.

The Canadian registry will be managed by CIHI with guidance of the National Advisory Committee including representatives of the Canadian Orthopaedic Association, Canadian Orthopaedic Foundation, the Arthritis Foundation and Health Canada.

A newly formed registry in Ontario also will provide data to the national registry. Last March, the Ontario government announced that it will invest $2 million annually in the Ontario Joint Replacement Network, which is an initiative of the Ontario Orthopaedic Association, Ontario Hospital Association and Ontario Ministry of Health and Long Term Care. It is also chaired by Dr. Bourne. The registry is an outgrowth of a pilot project in southwest Ontario
in 1997.

The ministry said the registry will improve surgical procedures and the types of devices used for implants and will reduce waiting times by improving the collection of patient information to help physicians and surgeons make informed referral decisions. Dr. Bourne said physicians will use handheld computers to collect data and speed reporting.

The demand for hip and knee replacements increased by an average 7.3 percent annually from 1994 to 1998, due mainly to the Ontario’s aging population and the higher incidence of arthritis and osteoporosis.

Several other countries are developing joint registries—the United Kingdom, Australia and New Zealand. Norway has a relatively longstanding registry.

AAOS Board members were enthusiastic about the potential of improving joint replacement results through continuous feedback of results and reducing costs for revision surgery. They approved the formation of a work group, which will report to the Board in May.

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