Aims. National joint registries under-report revisions for periprosthetic joint infection (PJI). We aimed to validate PJI reporting to the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR) and the factors associated with its accuracy. We then applied these data to refine estimates of the total national burden of PJI. Methods. A total of 561 Australian cases of confirmed PJI were captured by a large, prospective observational study, and matched to data available for the same patients through the AOANJRR. Results. In all, 501 (89.3%) cases of PJI recruited to the prospective observational study were successfully matched with the AOANJRR database. Of these, 376 (75.0%) were captured by the registry, while 125 (25.0%) did not have a revision or reoperation for PJI recorded. In a multivariate logistic regression analysis, early (within 30 days of implantation) PJIs were less likely to be reported (adjusted odds ratio (OR) 0.56; 95% confidence interval (CI) 0.34 to 0.93; p = 0.020), while two-stage revision procedures were more likely to be reported as a PJI to the registry (OR 5.3 (95% CI 2.37 to 14.0); p ≤ 0.001) than debridement and implant retention or other surgical procedures. Based on this data, the true estimate of the incidence of PJI in Australia is up to 3,900 cases per year. Conclusion. In Australia, infection was not recorded as the indication for revision or reoperation in one-quarter of those with confirmed PJI. This is better than in other registries, but suggests that registry-captured estimates of the total national burden of PJI are underestimated by at least one-third. Inconsistent PJI reporting is multifactorial but could be improved by developing a nested PJI registry embedded within the national arthroplasty registry. Cite this article: Bone Jt Open 2022;3(5):367–373

Aims. The French registry for complex bone and joint infections (C-BJIs) was created in 2012 in order to facilitate a homogeneous management of patients presented for multidisciplinary advice in referral centres for C-BJI, to monitor their activity and to produce epidemiological data. We aimed here to present the genesis and characteristics of this national registry and provide the analysis of its data quality. Methods. A centralized online secured database gathering the electronic case report forms (eCRFs) was filled for every patient presented in multidisciplinary meetings (MM) among the 24 French referral centres. Metrics of this registry were described between 2012 and 2016. Data quality was assessed by comparing essential items from the registry with a controlled dataset extracted from medical charts of a random sample of patients from each centre. Internal completeness and consistency were calculated. Results. Between 2012 and 2016, 30,607 presentations in MM were recorded corresponding to 17,748 individual patients (mean age 62.1 years (SD 18.4); 10,961 (61.8%) males). BJI was considered as complex for 63% of cases (n = 19,355), and 13,376 (44%) had prosthetic joint infections (PJIs). The controlled dataset, available for 19 centres, included 283 patients. Global consistency and completeness were estimated at 88.2% and 88.9%, respectively, considering missing items in the eCRFs as negative results. Conclusion. This national registry is one of the largest prospective databases on BJI and its acceptable data quality parameters allow further use for epidemiological purposes. Cite this article: Bone Joint Res 2020;9(9):635–644

Cite this article: Bone Joint Res 2023;12(4):256–258.

The effective capture of outcome measures in the healthcare setting can be traced back to Florence Nightingale’s investigation of the in-patient mortality of soldiers wounded in the Crimean war in the 1850s. Only relatively recently has the formalised collection of outcomes data into Registries been recognised as valuable in itself. With the advent of surgeon league tables and a move towards value based health care, individuals are being driven to collect, store and interpret data. Following the success of the National Joint Registry, the British Association of Spine Surgeons instituted the British Spine Registry. Since its launch in 2012, over 650 users representing the whole surgical team have registered and during this time, more than 27 000 patients have been entered onto the database. There has been significant publicity regarding the collection of outcome measures after surgery, including patient-reported scores. Over 12 000 forms have been directly entered by patients themselves, with many more entered by the surgical teams. Questions abound: who should have access to the data produced by the Registry and how should they use it? How should the results be reported and in what forum?. Cite this article: Bone Joint J 2015;97-B:871–4

Introduction. Patient-reported outcome measures (PROMs) has gained momentum in the orthopaedic literature. The GOAL-LD (Gait Outcomes Assessment List for Limb Deformity) incorporates the framework of The WHO International Classification of Functioning, Disability and Health and correlates highly with the Paediatric Outcomes Data Collection Instrument (PODCI) when applied in a limb reconstruction setting. The Royal Children's Hospital Melbourne, Australia, supported by The University of Melbourne is designing and implementing a Limb Reconstruction Registry, prospectively enrolling patients with a number of key conditions and provide a mechanism for capturing surgical data and PROMs at regular follow-up intervals. LimbDREAM (The Limb Reconstruction Registry of Experience, Aspiration and Measures) has begun recruiting participants, and this paper serves as a narrative review of our design and implementation process. Materials & Methods. After provision of a research grant, audit was conducted to examine local case mix and estimate recruitment based on conditions selected. Literature review was focussed on (i) registries in the paediatric limb reconstruction domain and (ii) use of PROMs across conditions selected. A high-level process-flow chart was constructed in order to inform governance and staffing requirements in addition to REDCap Database structure. Local as well as scalable deployment was considered. Alpha and beta testing was performed by principal and associate investigators prior to participant recruitment. Results. Audit identified 6 condition streams for inclusion: Congenital limb deficiencies, congenital pseudarthrosis of the tibia, bone dysplasias, bone tumours, amputation, and complex deformity of other etiology. Literature review identified 20 PROMs used across these conditions, with limited validation studies and significant implementation heterogeneity. REDCap database design took longer than anticipated (planned 10 months, actual 18 months) before being recruitment ready, due to the complexity of ensuring data collection logic would work across highly diverse patient journeys. Initial recruitment across all streams has been promising. Email and text message reminders have proved helpful in increasing survey return rates. Conclusions. Prospective collection of PROMs as well as surgical data via a standardized dataset will provide the basis for future condition-specific research, with the ability to support nested trials. Implementation requires forethought with regard to time frames and staffing for non-automated steps as well as data integrity review. The next phase of the LimbDREAM project will be to integrate use of the Registry into our weekly Limb Reconstruction Meeting to ensure that operative plans and data are captured close to the point of care

Aims. National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD. Methods. We compared 17 hip fracture registries covering 20 countries (Argentina; Australia and New Zealand; China; Denmark; England, Wales, and Northern Ireland; Germany; Holland; Ireland; Japan; Mexico; Norway; Pakistan; the Philippines; Scotland; South Korea; Spain; and Sweden), setting each of these against the 20 core and 12 optional fields of the MCD. Results. The highest MCD adherence was demonstrated by the most recently established registries. The first-generation registries in Scandinavia collect data for 60% of MCD fields, second-generation registries (UK, other European, and Australia and New Zealand) collect for 75%, and third-generation registries collect data for 85% of MCD fields. Five of the 20 core fields were collected by all 17 registries (age; sex; surgery date/time of operation; surgery type; and death during acute admission). Two fields were collected by most (16/17; 94%) registries (date/time of presentation and American Society of Anesthesiologists grade), and five more by the majority (15/17; 88%) registries (type, side, and pathological nature of fracture; anaesthetic modality; and discharge destination). Three core fields were each collected by only 11/17 (65%) registries: prefracture mobility/activities of daily living; cognition on admission; and bone protection medication prescription. Conclusion. There is moderate but improving compatibility between existing registries and the FFN MCD, and its introduction in 2022 was associated with an improved level of adherence among the most recently established programmes. Greater interoperability could be facilitated by improving consistency of data collection relating to prefracture function, cognition, bone protection, and follow-up duration, and this could improve international collaborative benchmarking, research, and quality improvement. Cite this article: Bone Joint J 2023;105-B(9):1013–1019

X-Linked Hypophosphataemia (XLH) is a rare, progressive, hereditary phosphate-wasting disorder characterised by excessive activity of fibroblast growth factor 23. The International XLH Registry was established to provide information on the natural history of XLH and impact of treatment on patient outcomes. The cross-sectional orthopaedic data presented are from the first interim analysis. The XLH Registry (NCT03193476) was initiated in August 2017, aims to recruit 1,200 children and adults with XLH, and will run for 10 years. At the time of analysis (Last Patient In: 30/11/2020; Database Lock: 29/03/2021) 579 subjects diagnosed with XLH were enrolled from 81 hospital sites in 16 countries (360 (62.2%) children, 217 (37.5%) adults, and 2 subjects of unknown age). Of subjects with retrospective clinical data available, skeletal deficits were the most frequently self-reported clinical problems for children (223/239, 93.3%) and adults (79/110, 71.8%). Retrospective fracture data were available for 183 subjects (72 children, 111 adults); 50 had a fracture (9 children, 41 adults). In children, fractures tended to occur in tibia/fibula and/or wrist; only adults reported large bone fractures. Joint conditions were noted for 46 subjects (6 children, 40 adults). For adults reporting osteoarthritis, knees (60%), hips (42.5%), and shoulders (22.5%) were the most frequently affected joints. Retrospective orthopaedic surgery data were collected for 151 subjects (52 children, 99 adults). Osteotomy was the most frequent surgery reported (n=108); joint replacements were recorded for adults only. This is the largest set of orthopaedic data from XLH subjects collected to date. Longitudinal information collected during the 10-year Registry duration will generate real-world evidence which will help to inform clinical practice. Authors acknowledge the contribution of all International XLH Registry Steering Committee members

Aims. Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons. Methods. Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration. Results. Of 2,895 surgeons contributing to the NJR in 2023, 102 (4%) were female. The highest proportions of female surgeons were among those who performed elbow (n = 25; 5%), shoulder (n = 24; 4%), and ankle (n = 8; 4%) arthroplasty. Hip (n = 66; 3%) and knee arthroplasty (n = 39; 2%) had the lowest female representation. Female surgeons had been practising for a median of 10.4 years since specialist registration compared to 13.7 years for males (p < 0.001). Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (8%). A greater proportion of male surgeons worked in private practice (63% vs 24%; p < 0.001) and in multiple hospitals (74% vs 40%; p < 0.001). Conclusion. Only 4% of surgeons currently contributing cases to the NJR are female, with the highest proportion performing elbow arthroplasty (5%). Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons, and are less involved in private practice. There is a wide geographical variation in the proportion of female arthroplasty surgeons. Cite this article: Bone Jt Open 2024;5(8):637–643

Introduction. Both mobile bearing and fixed bearing unicompartmental knee arthroplasty (UKA) have demonstrated clinical success. However, much debate persists about the superiority of a single design. Currently most clinical data is based on high volume centers data, however to reduce bias, we undertook a through review of retrospective national joint registries. In this study, we aim to investigate UKA implant utilization and survivorship between 2000 and 2018. Methods. Ten annual joint registry reports of various nations were reviewed. Due to the variable statistical methods of reporting implant use and survivorship we focused on three registries: Australia (AOANJRR), New Zealand (NZJR), United Kingdom (NJR) for uniformity. We evaluated UKA usage, survivorship, utilization and revision rates for each implant. Implant survivorship was reported in the registries and was compared within nations due to variation in statistical reporting. Results. UKAs accounted for 7.24–10.3% of all primary knee surgeries. The most popular implants were, in order of popularity, the Oxford (ZimmerBiomet, Warsaw IN), ZUK (Smith & Nephew, Memphis TN / LimaCorporate, Udine, Italy), Sigma HP (DePuy, Warsaw IN), Miller-Galante (ZimmerBiomet Warsaw IN), and Preservation (DePuy, Warsaw IN) models. UKA revision rates varied by nation and ranged from 8.22%–12.8%. The Sigma HP and ZUK designs had the lowest total percent revised in the registries-Australian (3.6% and 5.1%, respectively) and New Zealand (2.5% and 1.96%, respectively)-and demonstrated among the highest 10-year survivorship in the United Kingdom registry. The United Kingdom registry reports a greater number of mobile versus fixed bearing UKA undergoing revision for dislocation and/or subluxation and instability. Conclusion. Preference for implant design as well as survivorship rates varied significantly by nation. The fixed bearing ZUK and Sigma HP implants were among the highest performing implants across the three registries

At the end of 2018, the NZ Joint Registry introduced a “Surgeon Outlier” policy, whereby each year, if an individual surgeons’ lower 95% confidence interval of their revision rate, measured in revision/100 component years(r/ocys), was above the NZ mean (0.71 r/ocys), that surgeon was required to audit their results with a nominated peer. This study investigates whether outlier surgeons also have high early (1 month and 1 year) revision rates. In 2018, 236 surgeons performed 9,186 total hip arthroplasties in NZ. At the end of 2018, 11 surgeons received notification they were outliers. Results from all surgeons for years 2016, 2017 and 2018 were combined to form the first (pre-notification) time interval, and results from years 2019, 2020 and 2021 were combined to form the second time interval (post-notification). Outlier surgeons performed 2001 total hip replacements in the first time interval and 1947 hips in the second. Early revision rates (1 month and 1 year) of both outlier and nonoutlier surgeons for both time intervals were analysed. Non-outlier surgeons had a consistent mean early revision rate of 0.75% at one month and 1.6% at one year for both time intervals. The 11 outlier surgeons had a higher earlier revision rate of 1.35% at one month and 2.45% at one year for the pre-notification time interval. These values reduced for the post-notification time interval to a revision rate of 1.23% for one month and 2.36% for one year. Poor joint registry results of individual surgeons are often attributed to a poor choice of prosthesis. This study shows early revision rates of outlier surgeons, where prosthesis selection has minimal influence, are also high. A slight improvement in early revision rates of outlier surgeons since introduction of the policy shows it is working

For all the research into arthroplasty, provision of total knee arthroplasty (TKR) services based on gender in the Australian context is yet to be explored. International literature points toward a heavily gender biased provision of TKA services, skewed away from female patients. This research has aimed to assess the current experience of Australian female patients and to explore better assessment techniques that could provide more equitable services. A retrospective cohort analysis has been conducted using pre-op PROMs data, where available, from the Australian National Joint Replacement Registry (AOANJRR), between 7 August 2018 and 31 December 2021, including: EQ VAS Health; Oxford Knee Score; joint pain; and KOOS-12. Data was adjusted for age, ASA score, BMI, primary diagnosis, public vs private hospital, surgeon gender and years of practice (as estimated from years of registry data available). Of 1,001,231 procedures performed, 27,431 were able to be analysed (12,300 male and 15,131 female). Gender-based bias against female patients reached statistical significance across all PROM scores, according to the Kruskal-Wallis test of difference (p-value <0.0001). Males were more likely to undergo TKR than females, with odds ratios remaining statistically significant when adjusted for age, ASA score, BMI, primary diagnosis, and hospital type. Numbers were further analysed for surgeon years of recorded practice and surgeon gender with mixed results. This study found that women were less likely to undergo TKR despite worse scores on every pre-op PROM available, thus we demonstrate a statistically significant gender-based bias against female patients. More effort needs to be made to identify the base of this bias and find new ways to assess patients that can provide more equitable provision of healthcare

Total hip arthroplasty (THA) is an effective treatment for symptomatic hip osteoarthritis (OA). While computer-navigation technologies in total knee arthroplasty show survivorship advantages and are widely used, comparable applications within THA show far lower utilisation. Using national registry data, this study compared patient reported outcome measures (PROMs) in patients who underwent THA with and without computer navigation. Data from Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) PROMs program included all primary THA procedures performed for OA up to 31 December 2020. Procedures using the Intellijoint HIP® navigation system were identified and compared to procedures using other computer navigation systems or conventional instrumentation only. Changes in PROM scores between pre-operative and 6-month post-operative time points were analysed using multiple regression model, adjusting for pre-operative score, patient age, gender, ASA score, BMI, surgical approach, and hospital type. There were 65 primary THA procedures that used the Intellijoint HIP® system, 90 procedures used other types of computer navigation, and the remaining 5,284 primary THA procedures used conventional instrumentation. The estimated mean changes in the EuroQol visual analogue scale (EQ VAS) score and Oxford Hip score did not differ significantly when Intellijoint® was compared to conventional instruments (estimated differences of 2.4, 95% CI [-1.7, 6.5], p = 0.245, and −0.5, 95% CI [-2.5, 1.4], p = 0.592, respectively). The proportion of patients who were satisfied with their procedure was also similar when Intellijoint® was compared to conventional instruments (rate ratio 1.06, 95% CI [0.97, 1.16], p = 0.227). The preliminary data demonstrate no significant difference in PROMs when comparing the Intellijoint HIP® THA navigation system with both other navigation systems and conventional instrumentation for primary THAs performed for OA. Level of evidence: III (National registry analysis)

Introduction. The mobile-bearing (MB) total knee arthroplasty (TKA) design was introduced with the aim of reducing polyethylene wear and component loosening seen in the fixed-bearing (FB) design. A recent joint registry study has revealed increased risk for all-cause revision, but not revision for infection, in MB-TKA. We used the New Zealand Joint Registry (NZJR) to compare all-cause revision rates, and revision rates for aseptic loosening of MB-TKA compared with fixed bearing (FB) TKA. Methods. All patients who underwent a primary TKA registered in the NZJR between the 1st January 1999 to 31st December 2021 were identified. Analysis compared MB to FB designs, with sub analysis of implants from a single company. We identified 135,707 primary TKAs, with 104,074 (76.7%) FB-TKAs and 31,633 (23.3%) MB-TKAs recorded. We examined all-cause revision rates, reasons for revision and performed survival analyses. Results. For all-comers, MB-TKA had an all-cause revision rate of 0.43/100-component-years (OCY) compared with 0.42/OCY for FB-TKA (p=0.09). The all-cause revision rate was higher for those age < 65 years (MB TKA 0.60/OCY vs. FB-TKA 0.59/OCY) compared to those > 65 years at time of primary TKA (MB-TKA 0.29/OCY vs. FB-TKA 0.32/OCY), however there was no statistically significant difference between implant design in either age group (p=0.16 and p=0.64; respectively). Similarly, there was no difference in revision rates for aseptic loosening between implant designs. Kaplan-Meier survival analysis demonstrates no statistically significant difference in revision-free survival of implants, with both MB-TKA and FB-TKA demonstrating ∼93% revision free survival at 23 years. Conclusions. Both FB- and MB-TKA demonstrated excellent survivorship, with no significant difference in all-cause revision rates or revision for aseptic loosening between implant designs

Aims. The aim of this study is to evaluate the change in incidence rate of shoulder arthroplasty, indications, and surgeon volume trends associated with these procedures between January 2003 and April 2021 in the province of Nova Scotia, Canada. Methods. A total of 1,545 patients between 2005 and 2021 were analyzed. Patients operated on between 2003 and 2004 were excluded due to a lack of electronic records. Overall, 84.1% of the surgeries (n = 1,299) were performed by two fellowship-trained upper limb surgeons, with the remainder performed by one of the 14 orthopaedic surgeons working in the province. Results. Total shoulder arthroplasty (TSA) was the most frequent procedure (32.17%; n = 497), followed by stemmed hemiarthroplasty (SHA) (27.7%; n = 428). The most frequent indication for primary shoulder arthroplasty was degenerative osteoarthritis (58.1%; n = 882), followed by acute proximal humerus fracture in 15.11% (n = 245), and rotator cuff arthropathy in 14.18% (n = 220). The overall rate of revision was 7.7% (2.8% to 11.2%). The number of TSAs and reverse shoulder arthroplasties (RSAs) has been increasing since 2016. The amount of revision cases is proportional to the number of operations performed in the same year throughout the study period. Conclusion. The incidence of shoulder arthroplasty in the Maritime Provinces has increased over the last 16 years. Revision rates are similar the those found in other large database registries. Reverse shoulder arthroplasty prevalence has increased since 2016. Cite this article: Bone Jt Open 2023;4(8):567–572

The importance of registries has been brought into focus by recent UK national reports focusing on implant (Cumberlege) and surgeon (Paterson) performance. National arthroplasty registries provide real-time, real-world information about implant, hospital, and surgeon performance and allow case identification in the event of product recall or adverse surgical outcomes. They are a valuable resource for research and service improvement given the volume of data recorded and the longitunidal nature of data collection. This review discusses the current value of registry data as it relates to both clinical practice and research. Cite this article: Bone Joint J 2023;105-B(4):356–360

Aims. To demonstrate, with concrete examples, the value of in-depth exploration and comparison of data published in National Joint Arthroplasty registry reports. Patients and Methods. The author reviewed published current reports of National Joint Arthroplasty registries for findings of current significance to current orthopaedic practice. Results. A total of six observations that demonstrate actionable or unexpected findings from joint registries are described. These include: one third to one half of all arthroplasty failures in the first decade occur in the first one to two years; infection rates after arthroplasty have not declined in the last three decades; infection after TKA is more common in men than women; outcomes of TKA are more variable in young compared with older patients; new technologies (uncemented implants and crosslinked polyethylene) have improved results of THA and a real-time shift in use of ceramic femoral heads is occurring in THA. Conclusion. These six observations may be used to better understand current practice, stimulate practice improvements or suggest topics for further study. Cite this article: Bone Joint J 2017;99-B(1 Supple A):3–7

Data of high quality are critical for the meaningful interpretation of registry information. The National Joint Registry (NJR) was established in 2002 as the result of an unexpectedly high failure rate of a cemented total hip arthroplasty. The NJR began data collection in 2003. In this study we report on the outcomes following the establishment of a formal data quality (DQ) audit process within the NJR, within which each patient episode entry is validated against the hospital unit’s Patient Administration System and vice-versa. This process enables bidirectional validation of every NJR entry and retrospective correction of any errors in the dataset. In 2014/15 baseline average compliance was 92.6% and this increased year-on-year with repeated audit cycles to 96.0% in 2018/19, with 76.4% of units achieving > 95% compliance. Following the closure of the audit cycle, an overall compliance rate of 97.9% was achieved for the 2018/19 period. An automated system was initiated in 2018 to reduce administrative burden and to integrate the DQ process into standard workflows. Our processes and quality improvement results demonstrate that DQ may be implemented successfully at national level, while minimizing the burden on hospitals. Cite this article: Bone Jt Open 2022;3(9):716–725

Aim. Aim was to compare revision rates when using single versus dual antibiotic loaded cement (ABLC) in hip fracture arthroplasty and aseptic revision hip or knee arthroplasty using data from the Dutch national joint registry (LROI). Methods. All primary cemented (hemi-)arthroplasties for acute hip fractures and cemented aseptic hip or knee revision arthroplasties, were incorporated in 3 datasets. All registered implants between 2007 and 2018 were included (minimum 2 years follow-up). Primary end-point was subsequent revision rates for infection and for any reason in the single and dual ABLC groups. Cumulative crude incidence of revision was calculated using competing risk analysis. Results. A total of 22,308 hip fracture arthroplasties, 2,529 hip revision and 7,124 knee revision arthroplasties were registered and analyzed in the study period. The majority of hip fracture patients (97.1%) was treated with single ABLC. For hip and knee revision arthroplasties dual ABLC was used in 33.8% and 25.7%. The revision rate for infection in the fracture arthroplasty group was not different between groups (0.5% versus 0.8%, p=0.27). The re-revision rate following hip or knee revision based on single versus dual ABLC was not different between groups (3.2% versus 2.8%, p=0.82 for hip revision and 1.8% versus 2.5%, p=0.36 for knee revision). In addition, the re-revision rate for any reason was not different in all three datasets. The crude cumulative revision and re-revision rates for any reason based on single ABLC versus dual ABLC showed no differences in all three datasets. The crude cumulative 7-year re-revision rate for any reason following revision THA with Gentamicin ABLC use was 11.8%, with Gentamicin + Clindamycin ABLC use 13.1% and with Erythromycin + Colistin ABLC use 14.8% (ns). The crude cumulative 9-year re-revision rate for any reason following revision TKA with Gentamicin ABLC use was 17.7% and with Gentamicin + Clindamycin ABLC use 16.5% (ns). Conclusions. In conclusion, we could not show a difference in revision rate for hip fracture arthroplasty or re-revision rates for revision hip- or knee arthroplasty with the use of dual ABLC compared to single ABLC bone cement, with 7and 9 year follow up. The low percentage of dual ABLC in hip fracture arthroplasties in our registry do not enable us to make a reliable estimation of the added value in this patient category. The results of this study do not confirm the potential benefit of dual ABLC use in revision cases

Introduction. The American Joint Replacement Registry (AJRR) was created to capture total hip (THA) and total knee arthroplasty (TKA) procedural data in order to conduct implant-specific survivorship analyses, produce risk-adjusted patient outcome data, and provide hospitals and surgeons with quality benchmarks. The purpose of this study is to compare early reports from the AJRR to other national registries to identify similarities and differences in surgeon practice and potential topics for future analysis. Methods. Hip arthroplasty data were extracted from the annual reports from the AJRR and other national registries including: the Australian registry; the New Zealand registry; the United Kingdom, Wales, and Isle of Man registry; the Norwegian registry; and the Swedish registry from 2014 to 2016. Data regarding femoral and acetabular fixation, bearing surface type, femoral head size, the use of dual mobility articulation bearings, hip resurfacing utilization, and THA revision burden were evaluated. Revision burden is defined as the ratio of implant revisions to the total number of arthroplasties performed in a given time period. Registry characteristics and patient demographic data were recorded across all registries. The results were compared between the various registries and reported using descriptive statistics. Results. In 2016, the AJRR captured data from approximately 28% of all arthroplasty procedures performed in the United States, compared to 95–98% amongst the other registries that were evaluated. Total hip arthroplasty patients in the AJRR were similar to the other registries, with a mean age of 66.6 years for primary THA compared to a range of 67.0–69.0 years amongst the other registries. The operative diagnoses varied for primary THA between the registries. Osteoarthritis was the most common diagnosis but it represented 93% of patients in the UK and Wales registry,. 79% in the AJRR and 76.5% in the Norwegian registry. THA practices in the AJRR revealed much higher usage of cementless femoral and acetabular components (93%). In comparison, the other registries reported variable rates of usage of cementless femoral and acetabular fixation including: Australian registry (63.4%); United Kingdom and Wales (38.5%); New Zealand registry (39.1%) and the Swedish registry (21.8%). In the AJRR ceramic heads (52.8%) and 36mm heads (60.2%) were most frequently used; in all other registries metal heads (52.7–69.4%) and 32mm heads (37.0–72.7%) were the most popular. Dual mobility articulations were infrequently reported by the other registries but accounted for 8% of primary THAs and 28% of revision THAs in the AJRR. In 2016 the THA revision burden was 8.6% in the AJRR compared to 8.2 – 13.8% in the other registries. Conclusion. The present study offers an early comparison of data reported by the AJRR and other national registries and identifies several differences in THA practice patterns between the United States and other countries. As the AJRR continues to grow, future studies should focus on understanding why international differences in total joint arthroplasty practice trends exist and differences in outcomes associated with these practices

This study aimed to examine the changing trends in the reasons for total hip replacement (THR) revision surgery, in one country over a twenty-one year period, in order to assess whether changes in arthroplasty practices have impacted revision patterns and whether an awareness of these changes can be used to guide clinical practice and reduce future revision rates. The reason for revision THR performed between January 1999 and December 2019 was extracted from the New Zealand Joint Registry (NZJR). The results were then grouped into seven 3-year periods to allow for clearer visualization of trends. The reasons were compared across the seven time periods and trends in prosthesis use, patient age, gender, BMI and ASA grade were also reviewed. We compared the reasons for early revision, within one year, with the overall revision rates. There were 20,740 revision THR registered of which 7665 were revisions of hips with the index procedure registered during the 21 year period. There has been a statistically significant increase in both femoral fracture (4.1 – 14.9%, p<0.001) and pain (8.1 – 14.9%, p<0.001) as a reason for hip revision. While dislocation has significantly decreased from 57.6% to 17.1% (p<0.001). Deep infection decreased over the first 15 years but has subsequently seen further increases over the last 6 years. Conversely both femoral and acetabular loosening increased over the first 12 years but have subsequently decreased over the last 9 years. The rate of early revisions rose from 0.86% to 1.30% of all revision procedures, with a significant rise in revision for deep infection (13-33% of all causes, p<0.001) and femoral fracture (4-18%, p<0.001), whereas revision for dislocation decreased (59-30%, p<0.001). Adjusting for age and gender femoral fracture and deep infection rates remained significant for both (p<0.05). Adjusting for age, gender and ASA was only significant for infection. The most troubling finding was the increased rate of deep infection in revision THR, with no obvious linked pattern, whereas, the reduction in revision for dislocation, aseptic femoral and acetabular loosening can be linked to the changing patterns of the use of larger femoral heads and improved bearing surfaces

Multiple joint registries have reported better implant survival for patients aged >75 years undergoing total hip arthroplasty (THA) with cemented implant combinations when compared to hybrid or uncemented implant combinations. However, there is considerable variation within these broad implant categories, and it has therefore been suggested that specific implant combinations should be compared. We analysed the most common contemporary uncemented (Corail/Pinnacle), hybrid (Exeter V40/Trident) and cemented (Exeter V40/Exeter X3) implant combinations in the New Zealand Joint Registry (NZJR) for patients aged >75 years. All THAs performed using the selected implants in the NZJR for patients aged >75 years between 1999 and 2018 were included. Demographic data, implant type, and outcome data including implant survival, reason for revision, and post-operative Oxford Hip Scores were obtained from the NZJR, and detailed survival analyses were performed. Primary outcome was revision for any reason. Reason for revision, including femoral or acetabular failure, and time to revision were recorded. 5427 THAs were included. There were 1105 implantations in the uncemented implant combination group, 3040 in the hybrid implant combination group and 1282 in the cemented implant combination group. Patient reported outcomes were comparable across all groups. Revision rates were comparable between the cemented implant combination (0.31 revisions/100 component years) and the hybrid implant combination (0.40 revisions/100 component years) but were statistically significantly higher in the uncemented implant combination (0.80/100 component years). Femoral-sided revisions were significantly greater in the uncemented implant combination group. The cemented implant and hybrid implant combinations provide equivalent survival and functional outcomes in patients aged over 75 years. Caution is advised if considering use of the uncemented implant combination in this age group, predominantly due to a higher risk of femoral sided revisions. The authors recommend comparison of individual implants rather than broad categories of implants

This is the second of a series of reviews of registries. This review looks specifically at worldwide registry data that have been collected on knee arthroplasty, what we have learned from their reports, and what the limitations are as to what we currently know

Introduction. Despite the increasing numbers of ankle replacements that are being performed there are still limited studies on the survival of ankle replacements and comparisons between different implants. The primary aim of this study is to link NJR data with NHS digital data to determine the true failure rates of ankle replacements. Secondary outcomes include analysis risk factors for failure, patient demographics and outcomes of individual prosthesis. Methods. A data linkage study combined National Joint Registry Data and NHS Digital data. The primary outcome of failure is defined as the removal or exchange of any components of the implanted device inserted during ankle replacement surgery. Life tables and Kaplan Meier survival charts demonstrated survivorship. Cox proportional hazards regression models with the Breslow method used for ties were fitted to compare failure rates. Results. 5,562 primary ankle replacement were recorded on the NJR. The 1-year survivorship was 98.8% (95% CI 98.4%–99.0%), 5-year survival in 2725 patients was 90.2% (95% CI 89.2%–91.1%), and 10-year survival in 199 patients was 86.2% (95% CI 84.6%–87.6%). When using a Cox regression model for all implants with over 100 implantations using the Infinity as the reference, only the Star (Hazard ratio 1.60 95% CI 0.87–2.96) and Inbone (HR 0.38 95% CI 0.05–2.84) did not produce significantly worse survivorship. Conclusion. Ankle replacements have increased in numbers over the past decade, and the currently used implants have lower failure rates than older prosthesis. It is expected that in the future the outcomes of ankle replacements will continue to improve

Hip bearing surfaces materials are typically broadly reported in national registry (metal-on-polyethylene, ceramic-on-ceramic etc). We investigated the revision rates of primary total hip replacement (THR) reported in the National Joint Registry (NJR) by detailed types of bearing surfaces used. We analysed THR procedures across all orthopaedic units in England and Wales. Our analyses estimated all-cause and cause-specific revision rates. We identified primary THRs with heads and monobloc cups or modular acetabular component THRs with detailed head and shell/liner bearing material combinations. We used flexible parametric survival models to estimate adjusted hazard ratios (HR). A total of 1,026,481 primary THRs performed between 2003–2019 were included in the primary analysis (Monobloc cups: n=378,979 and Modular cups: n=647,502) with 20,869 (2%) of these primary THRs subsequently undergoing a revision episode (Monobloc: n=7,381 and Modular: n=13,488). Compared to implants with a cobalt chrome head and highly crosslinked polyethylene (HCLPE) cup, the overall risk of revision for monobloc acetabular implant was higher for patients with cobalt chrome or stainless steel head and non-HCLPE cup. The risk of revision was lower for patients with a delta ceramic head and HCLPE cup implant, at any post-operative period. Compared to patients with a cobalt chrome head and HCLPE liner primary THR, the overall risk of revision for modular acetabular implant varied non-constantly. THRs with a delta ceramic or oxidised zirconium head and HCLPE liner had a lower risk of revision throughout the entire post-operative period. The overall and indication-specific risk of prosthesis revision, at different time points following the initial implantation, is reduced for implants with a delta ceramic or oxidised zirconium head and a HCLPE liner/cup in reference to THRs with a cobalt chrome head and HCLPE liner/cup

Electronic Health Records (EHRs) have benefits for hospitals and uptake in the UK is increasing. The National Joint Registry (NJR) monitors implant and surgeon performance and relies on accuracy of data. NJR data are used for identification of potential outliers for both mortality and revision; analyses are adjusted for age, sex, and American Society of Anaesthesiologists score (ASA) and cases with some indications are excluded from analyses. In October 2020, the Royal Devon University Hospitals NHS Foundation Trust “went live” on an EHR, almost eradicating paper from the Trust. This included stopping use of paper NJR forms by creating a bespoke electronic template. We sought to identify discrepancies between operation notes and data input to the NJR in variables that may influence potential outlier analyses. Data input to the NJR from 15/10/2020 to 18/10/2022 for hip procedures were provided by NEC Software Solutions. NJR data were compared to those recorded on operation notes. There were 1067 hip procedures recorded in the NJR (946 primary THRs). Of the primary THRs, discrepancies in indication between NJR and operation note were identified in 139 (15%) cases. Common discrepancies included cases being recorded as osteoarthritis where the true indication was acute trauma (n=63), avascular necrosis (n=14), metastatic cancer/malignancy (n=6) and 21 cases with no recorded indication. We identified 88 cases where the ASA recorded in the NJR differed from the anaesthetic chart. Other inaccuracies were identified including 23 cases missing type of procedure (e.g., primary or revision) and one where revision surgery had been recorded as primary. We identified at least 83 cases that should have been excluded from NJR mortality analyses but were not. Given the low incidence of mortality following primary THR, these cases (with increased risk of death) have the potential to incorrectly identify the hospital as a potential outlier. Discrepancies in ASA may also impact on both revision and mortality outlier calculations. We urge caution to hospitals in the implementation of EHRs and advise regular audit of data sent to the NJR

Aims. The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA). Methods. This was a data linkage study using the New South Wales (NSW) Admitted Patient Data Collection (APDC) and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), which collect data from all public and private hospitals in NSW, Australia. Patients who underwent a TKA or THA for OA between 1 January 2002 and 31 December 2017 were included. The main outcome measures were 90-day incidence rates of hospital readmission for: revision arthroplasty for PJI as recorded in the AOANJRR; conservative definition of PJI, defined by T84.5, the PJI diagnosis code in the APDC; and extended definition of PJI, defined by the presence of either T84.5, or combinations of diagnosis and procedure code groups derived from recursive binary partitioning in the APDC. Results. The mean 90-day revision rate for infection was 0.1% (0.1% to 0.2%) for TKA and 0.3% (0.1% to 0.5%) for THA. The mean 90-day PJI rates defined by T84.5 were 1.3% (1.1% to 1.7%) for TKA and 1.1% (0.8% to 1.3%) for THA. The mean 90-day PJI rates using the extended definition were 1.9% (1.5% to 2.2%) and 1.5% (1.3% to 1.7%) following TKA and THA, respectively. Conclusion. When reporting the revision arthroplasty for infection, the AOANJRR substantially underestimates the rate of PJI at 90 days. Using combinations of infection codes and PJI-related surgical procedure codes in linked hospital administrative databases could be an alternative way to monitor PJI rates. Cite this article: Bone Joint J 2022;104-B(9):1060–1066

Aims. The British Spine Registry (BSR) was introduced in May 2012 to be used as a web-based database for spinal surgeries carried out across the UK. Use of this database has been encouraged but not compulsory, which has led to a variable level of engagement in the UK. In 2019 NHS England and NHS Improvement introduced a new Best Practice Tariff (BPT) to encourage input of spinal surgical data on the BSR. The aim of our study was to assess the impact of the spinal BPT on compliance with the recording of surgical data on the BSR. Methods. A retrospective review of data was performed at a tertiary spinal centre between 2018 to 2020. Data were collated from electronic patient records, theatre operating lists, and trust-specific BSR data. Information from the BSR included operative procedures (mandatory), patient consent, email addresses, and demographic details. We also identified Healthcare Resource Groups (HRGs) which qualified for BPT. Results. A total of 3,587 patients were included in our study. Of these, 1,684 patients were eligible for BPT. Between 2018 and 2019 269/974 (28%) records were complete on the BSR for those that would be eligible for BPT. Following introduction of BPT in 2019, 671/710 (95%) records were complete having filled in the mandatory data (p < 0.001). Patient consent to data collection also improved from 62% to 93%. Email details were present in 43% of patients compared with 68% following BPT introduction. Conclusion. Our study found that following the introduction of a BPT, there was a statistically significant improvement in BSR record completion compliance in our unit. The BPT offers a financial incentive which can help generate further income for trusts. National data input into the BSR is important to assess patient outcome following spinal surgery. The BSR can also aid future research in spinal surgery. Cite this article: Bone Jt Open 2021;2-3:198–201

Aim. National Joint Replacement Registries, which are important sources for periprosthetic joint infection (PJI) data, report an average PJI incidence ranging from 0.5 to 2.0%. Unfortunately, national registries including the Dutch Arthroplasty Register (LROI), are not specifically designed to register PJI. In the Netherlands, the LROI is a nationwide population-based registry with an overall completeness of more than 95%. 3. To ensure usability and reliability of PJI data from the LROI, it is important to evaluate the quality and completeness of these data. From 2013 onwards, eight hospitals in the South-East of the Netherlands, collected their PJI data in a detailed regional infection cohort (RIC), specifically designed for this purpose. This study aimed to determine the accuracy and completeness of PJI registration (hip and knee arthroplasty) in the LROI, by comparing the LROI with the RIC. Method. All patients registered with an acute PJI in the RIC between 2014–2018 were selected for the study and were matched with the LROI. According to the Workgroup of American Musculoskeletal Infections Society (MSIS), an acute PJI was defined as at least two phenotypically identical pathogens, isolated in cultures from at least two separate tissues, obtained from the affected peri-prosthetic tissue during the DAIR treatment (debridement, antibiotics, irrigation, and retention). Only PJI occurring within 90 days after primary hip or knee arthroplasty were included. The LROI data and completeness was based on the entered procedures and documented reason for revision infection, which was not specially based on the MSIS criteria. After checks on missing and incorrectly data, the completeness of registration in the LROI was calculated by comparing the number of registrations in the LROI with data from the RIC (gold standard). Results. Of the 639 primary total hip and knee arthroplasty with a suspected PJI registered in the RIC between 2014–2018, 352 cases met the definition of acute PJI. The overall incidence was 1%. When compared with the LROI, 164 of these cases were also registered in the LROI as PJI revision, resulting in a 53% underestimation of PJI for the LROI. Conclusions. LROI data on acute PJI shows a significant underestimation, which is comparable to scarce other literature sources. To ensure reliability and usability of national PJI data, a specifically part of the LROI has to be designed for registering PJI similar to the regional cohort

Introduction. The British Spinal Registry (BSR) is a web-based database commissioned by the British Association of Spine Surgeons (BASS) in the UK. It allows auditing of spinal surgery outcomes, patient's safety and overall experience. The clinical data include patient's demographics which is entered into the Registry by medical staff, as well as patient-reported outcome measures (PROM) that is submitted to the Registry by the patient themselves at different time periods post-operatively. It has the ability to register Device and Implants as well as co-ordinate multicentre research. This study is to identify both the staff and patient compliance regarding to data submissions to the BSR at St. George's Hospital NHS Trust. Methods and Materials. Retrospective analysis of the BSR data for all spinal surgeries that was performed at SGH by the three Complex Spinal Surgery Consultants between 1st January 2017 to 31st December 2018. This study period allowed up to 12 months PROM data analysis. Staff and Patient compliance were analysed separately depend on the data they submitted. Results. 404 (n) spinal surgeries were performed over this two-year period. Surgical demographics: 39.4% (159/404) males and 56.2% (227/404) females, 4.5% (18/404) declined to be added. Age ranging from 6 to 92, mean age was 47.9. Staff compliance was 89.4% for the registration of patient data. Trauma and tumour patients were excluded as they are not required to complete any pre-operative PROMs. For the remaining patients, 35.8% (116/324) completed their baseline pre-operative PROMs. A steady decrease in patient compliance for post-operative PROMS was observed: 29.8% (2 weeks), 24.9% (6 weeks), 21.2% (6 months), 17.1% (12 months), and 16.6% (24 months). Conclusions. We identified a poor patient compliance in both pre-operative and post-operative PROMS. Patient questionnaire fatigue can occur over time which results in falling compliance to PROMS in 12 months and 24 months. Moreover, patients who do not provide an email address are less likely to fill in their PROMS. Satisfactory compliance for staff regarding to BSR utilisation are shown. Staff should aim to achieve a higher level of compliance as this will help to keep a record of all spinal surgeries that are performed and any complications that are encountered in a particular centre. Over the past three years, the BSR had introduced various schemes to drive up utilisation including a Best Practice Tariff in 2019. Part of the tariff will be withheld when staff failure to enter patients onto the Registry. Further research is needed to determine why there is such fall off especially with patient compliance and to elucidate potential measures to improve their compliance

Background and aim. Since the market withdrawal of the ASR hip resurfacing in August 2010 because of a higher than expected revision rate as reported in the Australian Joint Replacement Registry (AOAJRR), metal-on-metal hip resurfacing arthroplasty (MoMHRA) has become a controversial procedure for hip replacement. Failures related to destructive adverse local tissue reactions to metal wear debris have further discredited MoMHRA. Longer term series from experienced resurfacing specialists however, demonstrated good outcomes with excellent 10-to-15-year survivorship in young and active men. These results have recently been confirmed for some MoMHRA designs in the AOAJRR. Besides, all hip replacement registries report significantly worse survivorship of total hip arthroplasty (THA) in patients under 50 compared to older ages. The aim of this study was to review MoMHRA survivorship from the national registries reporting on hip resurfacing and determine the risk factors for revision in the different registries. Methods. The latest annual reports from the AOAJRR, the National Joint Registry of England and Wales (NJR), the Swedish Hip Registry (SHR), the Finnish Arthroplasty Registry, the New Zealand Joint Registry and the Arthroplasty Registry of the Emilia-Romagna Region in Italy (RIPO) were reviewed for 10-year survivorship of MoMHRA in general and specific designs in particular. Other registries did not have enough hip resurfacing data or long term data yet. The survivorship data were compared to conventional THA in comparable age groups and determinants for success/failure such as gender, age, diagnosis, implant design and size and surgical experience were reviewed. Results. All registries showed a significant decline of the use of MoMHRA. The AOAJRR reported a cumulative revision rate of 9.5% (95%CI: 8.9–10.1%) at 10 years for all hip resurfacings. Female gender, developmental dysplasia and femoral head sizes <49mm were significant risk factors with revision rates twice as high for head sizes <49mm compared to >55mm. In males, cumulative revision rate for all MoMHRA was 6.6% at 10 years and 7.8% at 13years with no difference in the age groups. ASR had significantly higher revision rates (23.9% at 7 years) compared to other designs. The Adept and the Mitch had the lowest revision rates at 7 years (3.6%). Cumulative revision rates for 10,750 BHR (males and females pooled) were 5.0% at 7 years, 6.9% at 10years and 8.4% at 13 years. Cumulative revision rates of THA in patients <55 years was 6.0% at 10 years and 9.4% at 13 years. Similar survivorship results were found in the Finnish, Swedish, New Zealand and RIPO registry. In the SHR, 10-year survivorship of THA in patients <50 was only around 87%. In the NJR, cumulative revision rates for all MoMHRA pooled were much less favourable (13% at 10 years – 22% in patients<50) but the revision probability of ASR was 30.4% compared to 9.0% for BHR. Surgical experience was also identified as an important determinant of success/failure. Discussion. Registries are now confirming good 10-year survivorship of certain MoMHRA designs with excellent results in males. Risk factors for revision are female gender, small head size, dysplasia and certain implant designs

Introduction. The American Joint Replacement Registry (AJRR) is the largest registry of total hip and knee arthroplasty (THA and TKA) procedures performed in the U.S. The National (Nationwide) Inpatient Sample (NIS) is a public database containing demographic estimates based on more than seven million hospitalizations annually. The purpose of this study was to analyze whether AJRR data is representative of the national experience with TJA as represented in NIS. Methods. Cohen's d effect sizes were computed to ascertain the magnitude of differences in demographics, hospital volume (in 50 patient increments), and geographic characteristics between the AJRR and NIS databases. Results. The study included [NIS: 2,316,345 vs. AAOS-AJRR: 557,684] primary THA [NIS: 3,417,700 vs. AAOS-AJRR: 809,494] TKA procedures. The magnitude of distribution, as determined by the Cohen's d effect size, showed the proportions of AJRR and NIS patients were similar based on overall sex [THAs (d=0.03) and TKAs (d=0.02)] and age [THAs (d=0.17) and TKAs (d=0.12)]. Similarly, only small differences (d=0.34 or less) were identified between databases considering hospital volume and geography. AJRR was underrepresented in Southern regions and hospitals with low procedure volume and overrepresented in Northern hospitals and those with larger volume. Both NIS and AJRR followed a similar overall trend with a majority of procedures performed at hospitals with <50 cases per year. Conclusion. Distributions across hospital volume, age, and geography were proportionally similar between the AJRR and NIS databases, which suggests that AJRR data is representative of national trends and may be generalized to the larger U.S. population

Background. Anterior cruciate ligament (ACL) reconstruction with concomitant meniscal injury occurs frequently. Meniscal repair is associated with improved long-term outcomes compared to resection but is also associated with a higher reoperation rate. Knowledge of the risk factors for repair failure may be important in optimizing patient outcomes. Purpose. This study aimed to identify the patient and surgical risk factors for meniscal repair failure, defined as a subsequent meniscectomy, following concurrent primary ACL reconstruction. Methods. Data recorded by the New Zealand ACL Registry and the Accident Compensation Corporation, the New Zealand Government's sole funder of ACL reconstructions and any subsequent surgery, was reviewed. Meniscal repairs performed with concurrent primary ACL reconstruction was included. Root repairs were excluded. Univariate and multivariate survival analysis was performed to identify the patient and surgical risk factors for meniscal repair failure. Results. Between 2014 and 2020, a total of 3,024 meniscal repairs were performed during concurrent primary ACL reconstruction (medial repair = 1,814 and lateral repair = 1,210). The overall failure rate was 6.6% (n = 201) at a mean follow-up of 2.9 years, with a failure occurring in 7.8% of medial meniscal repairs (142 out of 1,814) and 4.9% of lateral meniscal repairs (59 out of 1,210). The risk of medial failure was higher in patients with a hamstring tendon autograft (adjusted HR = 2.20, p = 0.001), patients aged 21–30 years (adjusted HR = 1.60, p = 0.037) and in those with cartilage injury in the medial compartment (adjusted HR = 1.75, p = 0.002). The risk of lateral failure was higher in patients aged ≤ 20 years (adjusted HR = 2.79, p = 0.021) and when the procedure was performed by a surgeon with an annual ACL reconstruction case volume of less than 30 (adjusted HR = 1.84, p = 0.026). Conclusion. When performing meniscal repair during a primary ACL reconstruction, the use of a hamstring tendon autograft, younger age and the presence of concomitant cartilage injury in the medial compartment increases the risk of medial meniscal repair failure, whereas younger age and low surgeon volume increases the risk of lateral meniscal repair failure

There is paucity of reliable data examining the treatment pathway for hip replacements over the life of the patient in terms of risk of revision and re-revisions. We did a retrospective observational registry-based study of the National Joint Registry, using data on hip replacements from all participating hospitals in England and Wales, UK. We included data on all first revisions, with an identifiable primary procedure, with osteoarthritis as the sole indication for the original primary procedure. Kaplan-Meier estimates were used to determine the cumulative probability of revision and subsequent re-revision after primary hip replacement. Analyses were stratified by age and gender, and the influence of time from first to second revision on the risk of further revision was explored. Between 2003, and 2019, there were 29 010 revision hip replacements with a linked primary episode. Revision rates of revision hip replacements were higher in patients younger than 55 years than in older age groups. After revision of primary total hip replacement, 21·3% (95% CI 18·6–24·4) of first revisions were revised again within 15 years, 22·3% (20·3–24·4) of second revisions were revised again within 7 years, and 22·3% (18·3–27·0) of third revisions were revised again within 3 years. After revision of hip resurfacing, 23·7% (95% CI 19·6–28·5) of these revisions were revised again within 15 years, 21·0% (17·0–25·8) of second revisions were revised again within 7 years, and 19·3% (11·9–30·4) of third revisions were revised again within 3 years. A shorter time between revision episodes was associated with earlier subsequent revision. Younger patients are at an increased risk of multiple revisions. Patients who undergo a revision have a steadily increasing risk of further revision the more procedures they undergo, and each subsequent revision lasts for approximately half the time of the previous one

Introduction. The utilization of ceramic components in Total Hip Arthroplasty has experienced an expanded acceptance by the orthopedic community. This increased acceptance has been largely due to the lower risk of fracture due to the introduction of zirconia toughened alumina ceramics. This extra-high strength ceramic composite has been proven clinically over the past 13 years and found to be much more reliable than previous ceramic materials. The goal is to verify this finding by published registry data as well as clinical outcome. Methods. Registry data on fractured ceramic components have been compared with the data received from the largest manufacturer of ceramic hip components. Additionally, the clinical outcome of ceramic on ceramic artificial hips has been evaluated. Results. The fracture rate of ceramic BIOLOX®delta ball heads is reported to be 0.001% by the manufacturer. The comparison with published registry data exhibits fracture rates of the same order of magnitude: 0.002% (1/ 52,741) by the Australian Registry (2014), 0.001% (3/230,769) by the French Health Authorities (2014), and 0.005% (1/18,090) by the Italian Emilia Romagna Registry (2014). The fracture rate of ceramic BIOLOX®delta inserts is reported to be 0.021% by the manufacturer. The comparison with published registry data again exhibits fracture rates in the same order of magnitude: 0.06% (17/27,752 implanted inserts) by the Australian Registry (2014), 0.025% (28/112,000) by French Health Authorities (2014), and 0.06% (10/14,493) by the Italian Emilia Romagna Registry (2014). Discussion. The comparison between the fracture data released by the world's largest manufacturer of ceramic hip components and the published registry data are in same order of magnitude. The fracture rate of BIOLOX®delta ball heads is very low and can be considered as negligible compared to the rate of revision due to other reasons. The comparison between the reported fracture rate of ceramic inserts of the manufacturer and registry data also yields similar results. Looking at the reasons for fracture, 82% of the liner fractures reported to the manufacturer can be most likely assigned to handling related reasons (malaligned positioning or insufficient fixation). The results clearly confirm the excellent reliability of this 4th generation ceramic even when used in the younger and more active patients. A proper handling according to the IFU is necessary to ensure its superior clinical behaviour

Aims. In recent years, the use of a collared cementless femoral prosthesis has risen in popularity. The design intention of collared components is to transfer some load to the resected femoral calcar and prevent implant subsidence within the cancellous bone of the metaphysis. Conversely, the load transfer for a cemented femoral prosthesis depends on the cement-component and cement-bone interface interaction. The aim of our study was to compare the three most commonly used collared cementless components and the three most commonly used tapered polished cemented components in patients aged ≥ 75 years who have undergone a primary total hip arthroplasty (THA) for osteoarthritis (OA). Methods. Data from the Australian Orthopaedic Association National Joint Replacement Registry from 1 September 1999 to 31 December 2022 were analyzed. Collared cementless femoral components and cemented components were identified, and the three most commonly used components in each group were analyzed. We identified a total of 11,278 collared cementless components and 47,835 cemented components. Hazard ratios (HRs) from Cox proportional hazards models, adjusting for age and sex, were obtained to compare the revision rates between the groups. Results. From six months postoperatively onwards, patients aged ≥ 75 years undergoing primary THA with primary diagnosis of OA have a lower risk of all-cause revision with collared cementless components than with a polished tapered cemented component (HR 0.78 (95% confidence interval 0.64 to 0.96); p = 0.018). There is no difference in revision rate prior to six months. Conclusion. Patients aged ≥ 75 years with a primary diagnosis of OA have a significantly lower rate of revision with the most common collared cementless femoral component, compared with the most common polished tapered cemented components from six months postoperatively onwards. The lower revision rate is largely due to a reduction in revisions for fracture and infection. Cite this article: Bone Joint J 2024;106-B(3 Supple A):121–129

The National Joint Registry (NJR) was set up by the Department of Health to collect information on all joint replacements. The NJR data is externally validated against nationally collated Hospital Episode Statistics (HES). Errors associated with the use of HES data have been widely documented. We sought to explore the accuracy of the NJR data, for a single surgeon, against a prospectively collected personal logbook. The NJR and logbook were compared over a 3-year period (01/07/2009 to 30/06/2012). Total procedure recorded in the personal logbook was 684 and in the NJR was 681. TKR in personal log book was 304 and in NJR 316, revision knee's in personal logbook 45 and in NJR 36, THR 274 in personal logbook and 271 in NJR, revision hip procedures in personal logbook 64 and 58 in NJR. Whilst the total number of procedures captured correlates closely (681 vs 684) there is more variation with the different individual procedures. This may be due to the addition of 11% of HES data used for this time period by the NJR as it is known to be inaccurate. This therefore demonstrates the importance of maintaining your own accurate records

Excessive opioid prescriptions after total joint arthroplasty (TJA) increase risks for adverse opioid related events, chronic opioid use, and increase the availability of opioids for unlawful diversion. Thus, decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications such as readmissions, emergency department (ED) visits or worsened patient reported outcomes (PROs). The purpose of this quality improvement study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications. Methods: Data originated from a statewide arthroplasty database (MARCQI). The database collects over 96% of all TJA performed in the state of Michigan, USA. Data was prospectively abstracted and included OMEs prescribed at discharge, readmissions, ED visits within 30 days and PROs. Data was collected one year before and after the creation of an opioid prescribing protocol that had decreased prescriptions by approximately 50% in opioid naive and tolerant patients. Trends were monitored using Shewhart control charts. 84,998 TJA over two-years were included. All groups showed a reduction in opioids prescribed. Importantly, no increased complications occurred concomitant to this reduction. No increases in ED visits or readmissions, and no decreases in KOOSJR/HOOSJR/PROMIS10 scores were noted in any of the groups. Using large data sets and registries can drive performance and improve quality. The MARCQI Postoperative opioid prescription recommendations and performance measures decreased total oral morphine equivalents prescribed over a large and diverse population by approximately 50% without decreasing PROs or increasing ED visits or hospital readmissions. A reduction in opioids prescribed after TJA can be accomplished safely and without an increase in complications across a large population

Aims. The current evidence comparing the two most common approaches for reverse total shoulder arthroplasty (rTSA), the deltopectoral and anterosuperior approach, is limited. This study aims to compare the rate of loosening, instability, and implant survival between the two approaches for rTSA using data from the Dutch National Arthroplasty Registry with a minimum follow-up of five years. Methods. All patients in the registry who underwent a primary rTSA between January 2014 and December 2016 using an anterosuperior or deltopectoral approach were included, with a minimum follow-up of five years. Cox and logistic regression models were used to assess the association between the approach and the implant survival, instability, and glenoid loosening, independent of confounders. Results. In total, 3,902 rTSAs were included. A deltopectoral approach was used in 54% (2,099/3,902) and an anterosuperior approach in 46% (1,803/3,902). Overall, the mean age in the cohort was 75 years (50 to 96) and the most common indication for rTSA was cuff tear arthropathy (35%; n = 1,375), followed by osteoarthritis (29%; n = 1,126), acute fracture (13%; n = 517), post-traumatic sequelae (10%; n = 398), and an irreparable cuff rupture (5%; n = 199). The two high-volume centres performed the anterosuperior approach more often compared to the medium- and low-volume centres (p < 0.001). Of the 3,902 rTSAs, 187 were revised (5%), resulting in a five-year survival of 95.4% (95% confidence interval 94.7 to 96.0; 3,137 at risk). The most common reason for revision was a periprosthetic joint infection (35%; n = 65), followed by instability (25%; n = 46) and loosening (25%; n = 46). After correcting for relevant confounders, the revision rate for glenoid loosening, instability, and the overall implant survival did not differ significantly between the two approaches (p = 0.494, p = 0.826, and p = 0.101, respectively). Conclusion. The surgical approach used for rTSA did not influence the overall implant survival or the revision rate for instability or glenoid loosening. Cite this article: Bone Joint J 2023;105-B(9):1000–1006

INTRODUCTION. The timely identification of outliers (implants, surgeons or patients) using prospectively collected registry data is confounded by many factors, including the assumption that the sampled population is representative of the entire cohort of patients. In this study we utilized a computer simulation of a joint registry to address the question: How does incomplete enrollment of patients in registries affect the reliability of identification of outliers, and what percent capture of the target population is sufficient?. MATERIALS AND METHODS. A synthetic registry was created consisting of 10,000 patients (100 surgeons), of whom, 1000 underwent joint replacement using a new implant. A predictive model for the risk of revision was created from data published by the Swedish TKR Registry and the AOANJRR. The pairing of patients, surgeons and implants was randomized and for each assignment, the probability of revision was computed. We then chose random samples of all patients in 10% increments from 10% to 100%, simulating incomplete capture of all potential cases by the registry. For each sample we calculated the number of cases of the new implant predicted to end in revision. The assignments were repeated 2000 times using implants with revision rates of 1.5%, 2.0% and 3.0% per annum vs. 1.0% for all other implants of the same class. RESULTS. The observed failure rate of the new implant averaged 2.0%, but varied from 0.7–3.8% over the 2000 trials, with 100% enrollment. With only 10% enrollment, the spread of failure rates increased to 0.0–7.8%, corresponding to a 152% increase in the variability of the observed revision rate. When enrollment was increased from 80% to 100%, the variability of the failure rate changed by only 9% from a range of 1.63% (1.23–2.86%) to 1.50% (1.30–2.80%) (90% CI). The reliability of detection of poorly performing implants improved dramatically with enrollment. With 70% enrollment, an implant with a 2.0% failure rate could be detected with 95% confidence, while a 3.0% implant became apparent with only 21% enrollment. Conversely, with even 100% enrollment it was not possible to identify implants with a 1.5% annual failure rate with 95% confidence. CONCLUSIONS. If registries collect a truly representative sample of only 50–80% of the total patient population, there will be only a slight increase in the risk of overlooking an inferior outlier, including poorly-performing implants, compared to 100% patient capture. Our results suggest that enrollment of every patient receiving a given treatment is not nearly as important as randomization of the sample subjected to analysis

Introduction. The purpose of this study was to compare implant survivorship and functional outcomes in patients undergoing reverse total shoulder arthroplasty (RTSA) for acute proximal humeral fracture (PHF) with those undergoing elective RTSA in a population-based cohort study. Methods. Prospectively collected data from the New Zealand Joint Registry from 1999 to 2021 and identified 7,277 patients who underwent RTSA. Patients were categorized by pre-operative indication, including acute PHF (10.1%), rotator cuff arthropathy (RCA) (41.9%), osteoarthritis (OA) (32.2%), rheumatoid arthritis (RA) (5.2%) and old traumatic sequelae (4.9%). The PHF group was compared with elective indications based on patient, implant, and operative characteristics, as well as post-operative outcomes (Oxford Shoulder Score [OSS], and revision rate) at 6 months, 5 and 10 years after surgery. Survival and functional outcome analyses were adjusted by age, sex, ASA class and surgeon experience. Results. Implant survivorship at 10 years for RTSA for PHF was 97.3%, compared to 96.1%, 93.7%, 92.8% and 91.3% for OA, RCA, RA and traumatic sequelae, respectively. When compared with RTSA for PHF, the adjusted risk of revision was higher for traumatic sequelae (hazard ratio = 2.29; 95% CI:1.12–4.68, p=0.02) but not for other elective indications. At 6 months post-surgery, OSS were significantly lower for the PHF group compared to RCA, OA and RA groups (31.1±0.5 vs. 35.6±0.22, 37.7±0.25, 36.5±0.6, respectively, p<0.01), but not traumatic sequelae (31.7±0.7, p=0.43). At 5 years, OSS were only significantly lower for PHF compared to OA (37.4±0.9 vs 41.0±0.5, p<0.01), and at 10 years, there were no differences between groups. Discussion and Conclusion. RTSA for PHF demonstrated reliable long-term survivorship and functional outcomes compared to other elective indications. Despite lower functional outcomes in the early post-operative period for the acute PHF group, implant survivorship rates were similar to patients undergoing elective RTSA

Aims. The Exeter V40 femoral stem is the most implanted stem in the National Joint Registry (NJR) for primary total hip arthroplasty (THA). In 2004, the 44/00/125 stem was released for use in ‘cement-in-cement’ revision cases. It has, however, been used ‘off-label’ as a primary stem when patient anatomy requires a smaller stem with a 44 mm offset. We aimed to investigate survival of this implant in comparison to others in the range when used in primary THAs recorded in the NJR. Methods. We analyzed 328,737 primary THAs using the Exeter V40 stem, comprising 34.3% of the 958,869 from the start of the NJR to December 2018. Our exposure was the stem, and the outcome was all-cause construct revision. We stratified analyses into four groups: constructs using the 44/00/125 stem, those using the 44/0/150 stem, those including a 35.5/125 stem, and constructs using any other Exeter V40 stem. Results. In all 328,737 THAs using an Exeter V40 stem, the revision estimate was 2.8% (95% confidence interval (CI) 2.7 to 2.8). The 44/00/125 stem was implanted in 2,158 primary THAs, and the ten-year revision estimate was 4.9% (95% CI 3.6 to 6.8). Controlling for age, sex, year of operation, indication, and American Society of Anesthesiologists grade demonstrated an increased overall hazard of revision for constructs using the 44/00/125 stem compared to constructs using other Exeter V40 femoral stems (hazard ratio 1.8 (95% CI 1.4 to 2.3)). Conclusion. Although the revision estimate is within the National Institute for Health and Care Excellence ten-year benchmark, survivorship of constructs using the 44/00/125 stem appears to be lower than the rest of the range. Adjusted analyses will not take into account ‘confounding by indication’, e.g. patients with complex anatomy who may have a higher risk of revision. Surgeons and patients should be reassured but be aware of the observed increased revision estimate, and only use this stem when other implants are not suitable. Cite this article: Bone Joint J 2023;105-B(5):504–510