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P. Hoogervorst and P. K. Horst
38.1 Introduction
The rst nationwide orthopedic implant registries were implemented between 1975 and 1995in the three Scandinavian countries and Finland with the aim to collect data on total knee arthroplasty (TKA) and total
Swedish Knee Arthroplasty Register
• Established in 1975
• First ever National Total Knee Registry
• > 275,000 procedures
Finnish National Arthroplasty Register
• Established in 1980
• > 400,000 procedures
hip arthroplasty (THA) (Delaunay
2018) (.
Fig.38.1).
2015; Malchau etal.
> The American Joint Replacement Registry (AJRR) is
considerably newer since it was established in 2010 by the American Academy of Orthopedic Surgeons. Its
Swedish Hip Arthroplasty Register
• Established in 1979
• First ever National Total Hip Registry
• > 450,000 procedures
Norwegian Arthroplasty Register
• Established in 1987
• > 200,000 procedures
38
Danish Hip Arthroplasty Register
• Established in 1995
• > 150,000 procedures
Danish Knee Arthroplasty Register
• Established in 1997
• > 100,000 procedures
New Zealand National Joint Register
• Established in 1998
• > 130,000 procedures
Australian National Joint Registry
• Established in 1999
• > 1,200,000 procedures
U.K. National Joint Registry
• Established in 2003
• The world's largest joint registry
• > 2,350,000 procedures
Slovak National Arthroplasty Register
• Established in 2003
• > 40,000 procedures
Dutch Arthroplasty Register
• Established in 2007
• > 250,000 procedures
. Fig. 38.1 Earliest registry development. (Adapted from Malchau etal. (2018); by courtesy of John Wiley & Sons)
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38
goals are to capture hip and knee arthroplasty data to conduct implant-specic survivorship analyses, pro­duce risk-adjusted patient outcome data, and provide hospitals with quality benchmarks (Etkin and Springer 2017).
Currently, the AJRR contains data on over 1.5 million procedures from 1133 hospitals, 104 ambulatory surgery centers (ASCs), and 65 private practice groups in all 50 states and the District of Columbia.
> It covers approximately 32% of all arthroplasties per-
formed nationwide.
This number is signicantly lower than the Swedish, Finnish, Norwegian, and UK registries which report a coverage of 93.8–98.1% (Swedish Knee Arthroplasty Register 2019; National Joint Registry 2019; Norwegian National Advisory Unit on Arthroplasty and Hip Frac­tures: Annual Report 2019; Finnish Arthroplasty Regis­try 2019). The AJRR collects hip and knee arthroplasty procedures in 3 data types:
5 Procedural 5 Postoperative 5 Patient-reported outcome measures (PROMs) data
Table38.1) (American Joint Replacement Regis-
(. try (AJRR) 2019)
38.2 Primary TKA
In 2018, the total number of primary TKAs registered in the American Joint Replacement Registry (AJRR) was 828,999 which amounts to 55.1% of all procedures collected.
The mean per surgeon volume of TKAs in 2018 was 44.8 with an interquartile range (IQR) of 7–56. The average age for patients undergoing TKA was
66.7years (SD 9.6). This is in line with other national registries which report a mean age at surgery of approximately 68years (National Joint Registry 2019; Norwegian National Advisory Unit on Arthroplasty and Hip Fractures: Annual Report 2019; Australian Orthopaedic Association National Joint Replacement Registry 2019; The New Zealand Joint Registry 20 Year Report 2019; Hip and Knee Replacements in Canada, 2017–2018 2019; Grimberg etal. 2019; Dutch Arthroplasty Register (LROI) 2019). The mean length of stay recorded in 2018 was 2.0 days (95% CI, 1.9–
2.0). Approximately 60–65% of all patients undergoing TKA were female. This is consistent throughout the dif­ferent age groups.
. Table 38.1 Data captured by AJRR
Proce­dural
Postoperative Comorbidities
PROMs HOOS Jr.
> Posterior stabilized (PS) designs were most commonly
used (51.6%) as compared to cruciate-retaining (CR) designs (43.8%) (.
Patient Name (last, rst)
Date of birth Social Security Number Diagnosis (ICD-9/10, CPT) Gender Race/ethnicity Height+weight/Body Mass Index Payer status
Site of Service
Surgeon Name (NPI)
Procedure Type (ICD-9/10, CPT)
Name and address (TIN, NPI)
Trainee
Date of surgery Length of stay Surgical approach Surgical technique Laterality Implants (maufacturer, lot #) Anesthesia
CJR risk variables Height+weight/body mass index Length of stay American Society of Anaesthesi­ologists score Charlson index Operative and postoperative complications
KOOS Jr. PROMIS-10 Global VR-12
Fig.38.2).
The use of these different designs varies throughout the world. Registries from The Netherlands (49.6%) (Dutch Arthroplasty Register (LROI) 2019) and Can­ada (62.5%) (Hip and Knee Replacements in Canada, 2017–2018 2019) report a more common use of PS designs, while countries like Norway (68.2%) (Norwe­gian National Advisory Unit on Arthroplasty and Hip Fractures: Annual Report 2019), UK (69.0%) (National Joint Registry 2019), and Sweden (90.8%) (Swedish Knee Arthroplasty Register 2019) report a more com­mon use of CR designs. Although the AJRR reports an improved implant survival of the CR designs com­pared to the PS designs in those over 65years of age
442
Percent of all primary total knee implants
0.1% 0.1% 0.1% 0.1% 0.1% 0.2% 0.1%
Posterior stabilized Cruciate retaining Ultracongruent Constrained
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P. Hoogervorst and P. K. Horst
. Fig. 38.2 Primary TKA
implant design, 2012–2018 (N=591,773). (Reprinted with permission from American Joint Replacement Registry [AJRR]: 2019 Annual Report. Rosemont, IL: American Academy of Orthopaedic Surgeons [AAOS], 2019 (American Joint Replace­ment Registry (AJRR) 2019))
100.0%
80.0%
60.0%
40.0%
46.4%
41.2%
42.3%
41.6% 40.6%
40.4%
4.5%4.8%4.4%4.2%3.8%2.4%1.1%
43.8%
38
52.3%
20.0%
0.0% 2012
(HR = 0.712, 95% CI, 0.658–0.770, p < 0.0001), the difference was small (<1%) and the analysis does not account for multiple confounders. To further put this nding in perspective, multiple systematic reviews and meta-analyses comparing the outcomes and complica­tions of both designs have not shown any differences besides a possible increase of postoperative range of motion in the PS group (Bercik etal. 2013; Jiang etal.
2016; Li etal. 2014; Longo etal. 2018a; Migliorini etal.
2019).
The use of mobile-bearing primary TKA designs in
the United States was reported in 7% of the cases which is more than those reported in Canada (1.9%) (Hip and Knee Replacements in Canada, 2017–2018 2019) and less than reported in Germany (15.9%) (Grimberg etal.
2019). Antioxidant polyethylene liners in the United
States were used in 23.2% of cases while either con­ventional polyethylene (UHMWPE) and highly cross­linked polyethylene liners were used in the other cases.
56.3%
2013 2014 2015
Arthroplasty Register (LROI) Norway (9.5%) (Norwegian National Advisory Unit on Arthroplasty and Hip Fractures: Annual Report 2019), and Sweden (2.4%) (Swedish Knee Arthroplasty Regis­ter 2019) that report substantially lower rates. Multiple systematic reviews evaluating the potential benet of patellar resurfacing have not resulted in unequivocal recommendations (Arirachakaran et al. 2015; Cheng etal. 2014; Grassi etal. 2018; Longo etal. 2018b) and could explain the disparities between countries.
> Comparable to other registries, in the large majority of
TKAs (91.6%) in 2018 polymethylmetacrylate (PMMA) was used for xation (Swedish Knee Arthroplasty Register 2019; National Joint Registry
2019; Finnish Arthroplasty Registry 2019; American
Joint Replacement Registry (AJRR) 2019; The New Zealand Joint Registry 20 Year Report 2019; Grimberg etal. 2019; Dutch Arthroplasty Register (LROI) 2019).
53.9%
54.0%
Year
54.8%
2016 2017 2018
54.7%
51.6%
2019), Germany (11.2%),
> Patellar resurfacing is common practice in the United
States in 90.8% of patients (Heckmann etal. 2019).
This is in contrast to other international registries such as Australia (66.6%) (Australian Orthopaedic Associa­tion National Joint Replacement Registry 2019), New Zealand (37.0%) (The New Zealand Joint Registry 20 Year Report 2019), The Netherlands (20.9%) (Dutch
The AJRR also contains data on the type of PMMA used (high viscosity vs. low viscosity). In 2012 both high­viscosity and low-viscosity cement was used equally at
46.0% and 47.9%, respectively.
> However, Kelly et al. reported that by 2017 high-
viscosity cement gained in popularity and was used in
61.3% of TKAs (Kelly etal. 2018).
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38
The difference between the two types of PMMA is that high-viscosity PMMA mixes faster and has a pro­longed working phases as compared to the low-vis­cosity PMMA (Hazelwood etal. 2015). In animal and cadaveric models, it has been shown that high-viscosity cement results in inferior trabecular cement interdigi­tation, weaker cement–implant shear strengths and is, therefore, thought to be one of the factors involved in the occurrence of aseptic loosening (Rey Jr. etal. 1987; Reading etal. 2000). An increase in the use of high­viscosity PMMA in TKAs between 2012 (46.0%) and 2017 (61.3%) has been identied (Kelly etal. 2018). The AJRR can be an important tool in evaluating whether the use of different types of PMMA is indeed inuential in the long-term survival of TKAs.
> Compared to 2017 the use of cementless xation
increased from 5.7% to 8.4%.
According to the data in the AJRR there was no dif­ference identied in survivorship between cemented and cementless TKAs for those diagnosed with primary osteoarthritis and revision as an endpoint (HR=0.92 [0.83–1.01], p=0.0917).
38.3 Primary Unicompartmental Knee
Arthroplasty (UKA) andPatellofemoral Arthroplasty (PFA)
> According to the AJRR, unicompartmental knee
arthroplasties (UKA) accounted for only 2.2% of all primary knee arthroplasties 2018.
This is far less than those numbers reported in Nor­way (14.5%) (Norwegian National Advisory Unit on Arthroplasty and Hip Fractures: Annual Report 2019), Germany (12.6%) (Grimberg etal. 2019), The Nether­lands (12.3%) (Dutch Arthroplasty Register (LROI)
2019), UK (9.1%) (National Joint Registry 2019), and
Australia (7.8)% (Australian Orthopaedic Association National Joint Replacement Registry 2019).
The use of PFAs in 2018 was even more limited
accounting to less than 0.1% of all arthroplasties per­formed which is consistent with those reported in the national registries of New Zealand, England and Wales, and Sweden (Swedish Knee Arthroplasty Register 2019; National Joint Registry 2019; The New Zealand Joint Registry 20 Year Report 2019).
Like the registry from England (National Joint
Registry 2019), the AJRR demonstrated better survivor- ship for TKAs compared to UKAs constructs in patients >65 years of age between 2012 and 2018 (HR = 6.71 (5.58–8.07), p<0.001).
38.4 Epidemiology Revision TKA fromAJRR
> The AJRR has collected data on 58,409 revision
TKAs up to 2018. In 2018, the revision burden for all TKA procedures documented in the AJRR was of
7.5% (Heckmann etal. 2019).
This proportion has been stable over the last 5years. Other registries have reported stable and similar revision burdens between 6.9% and 10.3% (Norwegian National Advisory Unit on Arthroplasty and Hip Fractures: Annual Report 2019; Australian Orthopaedic Asso­ciation National Joint Replacement Registry 2019; The New Zealand Joint Registry 20 Year Report 2019; Hip and Knee Replacements in Canada, 2017–2018 2019; Dutch Arthroplasty Register (LROI) 2019; McGrory etal. 2016).
To identify reasons for revision surgery ICD-9 or ICD-10 codes were used. The numbers reported may be difcult to adequately interpret because of catego­ries such as “other” and “other mechanical complica­tions”. Mechanical loosening was reported to be the most common reason for all knee revision surgery at
25.0% (.
Fig. 38.3). When focusing on early revision,
dened as revision <3 months after index surgery, the most common reason for revision was infection (63.2%). Loosening, infection, patellofemoral pain, and instability are consistently reported throughout the other national registries as the most common causes for revision (National Joint Registry 2019; Australian Orthopaedic Association National Joint Replacement Registry 2019; Grimberg etal. 2019; Dutch Arthroplasty Register (LROI) 2019). The infection burden for TKA reported in the AJRR between 2010 and 2015 varied from 0.80% to 1.08% (Springer etal. 2019).
The use of antioxidant liners in revision TKA has increased to 12.8%. The use of mobile-bearing designs in the revision setting has continued to hover around 18% for the past 6years.
38.5 Future Directions
Large databases and national registries have the poten­tial of being powerful instruments to not only improve the outcomes of joint replacement surgery, but also to be used as a health economic instrument. This is especially true if the registries include patient-reported outcomes and can be linked to reimbursement in health care and other insurance and societal costs (Malchau etal. 2018). However, when conducting research utilizing these instru­ments it is important to realize each type of database can vary in its methodology of data acquisition which could potentially inuence results (Bedard etal. 2018).
444
Diagnosis
Percent of all knee revisions
30.0%
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P. Hoogervorst and P. K. Horst
38
Mechanical loosening (n = 12,359)
Other mechanical complications (n = 11,127)
Infection & inammatory reaction (n = 10,155)
Other (n = 7,053)
Instability related codes (n = 6,209)
0.0%
2.9%
2.3%
5.0% 10.0% 15.0%
Articular bearing surface wear (n = 1,452)
Fracture of fracture related sequelae (n = 1,136)
. Fig. 38.3 Primary diagnosis for all knee revisions, 2012–2018
(N = 49,491). (Reprinted with permission from American Joint Replacement Registry [AJRR]: 2019 Annual Report. Rosemont, IL:
> One of the prerequisites for being useful is a coverage
and completeness of >80% of joint replacement pro­cedures performed.
Since the AJRR is currently capturing only 32% of all procedures performed, it is important to improve upon this.
In an attempt to make the various national reg­istries more uniform so results can be compared, the International Society of Arthroplasty Registries (ISAR) was established in 2004. In spite of this, it is notable that differences and disparities in the data reported, termi­nology used, and statistical analysis used remain. To utilize the trove of potential knowledge available from these registries, it is important to continue and sup­port the effort of ISAR to make the data captured and reported more interchangeable.
Take-Home Messages
5 It is imperative to increase the coverage/complete-
ness of the AJRR from only 32% to >80% to make it more reliable and representative.
5 Similar to countries like Canada and The Nether-
lands the use of posterior stabilized TKA designs is more common in the USA.
5 Contrary to other national registries patellar resur-
facing is almost standard practice in the USA.
5 UKAs accounted for only 2.2% of all primary knee
arthroplasties in 2018.
5 The revision burden for all TKA procedures docu-
mented in the AJRR was of 7.5% and has been stable over the past 5years.
25.0%
22.5%
20.5%
14.2%
12.6%
20.0% 25.0%
American Academy of Orthopaedic Surgeons [AAOS], 2019 (Amer­ican Joint Replacement Registry (AJRR) 2019))
References
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report. American Academy of Orthopaedic Surgeons (AAOS), Rosemont. Available from: http://connect. ajrr. net/2019- ajrr-
annual- report
Arirachakaran A, Sangkaew C, Kongtharvonskul J (2015)
Patellofemoral resurfacing and patellar denervation in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 23(6):1770–1781. Epub 2014/09/15
Australian Orthopaedic Association National Joint Replacement
Registry (2019) Hip, knee & shoulder annual report 2018. [cited 2020 04/24/2020]. Available from: https://aoanjrr. sahmri. com/
annual- reports- 2018
Bedard NA, Pugely AJ, McHugh M, Lux N, Otero JE, Bozic KJ
etal (2018) Analysis of outcomes after TKA: do all databases produce similar ndings? Clin Orthop Relat Res 476(1):52–63. Epub 2018/03/13
Bercik MJ, Joshi A, Parvizi J (2013) Posterior cruciate-retaining ver-
sus posterior-stabilized total knee arthroplasty: a meta-analysis. J Arthroplasty 28(3):439–444. Epub 2013/02/26
Cheng T, Zhu C, Guo Y, Shi S, Chen D, Zhang X (2014) Patellar
denervation with electrocautery in total knee arthroplasty with­out patellar resurfacing: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 22(11):2648–2654. Epub 2013/06/08
Delaunay C (2015) Registries in orthopaedics. Orthop Traumatol
Surg Res 101(1 Suppl):S69–S75. Epub 2015/01/03
Dutch Arthroplasty Register (LROI) (2019) Online LROI annual
report 2019
Etkin CD, Springer BD (2017) The American Joint Replacement
Registry-the rst 5 years. Arthroplast Today 3(2):67–69. Epub 2017/07/12
Finnish Arthroplasty Registry (2019). Available from: https://www.
thl. /far/#index
Grassi A, Compagnoni R, Ferrua P, Zaffagnini S, Berruto M,
Samuelsson K et al (2018) Patellar resurfacing versus patellar retention in primary total knee arthroplasty: a systematic review of overlapping meta-analyses. Knee Surg Sports Traumatol Arthrosc 26(11):3206–3218. Epub 2018/01/18
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Grimberg A JV, Melsheimer O, Steinbrück A (2019)
Endoprothesenregister Deutschland (EPRD). Mit Sicherheit
mehr Qualität Hazelwood KJ, O’Rourke M, Stamos VP, McMillan RD, Beigler D,
Robb WJ 3rd. (2015) Case series report: early cement-implant
interface xation failure in total knee replacement. Knee
22(5):424–428. Epub 2015/03/22 Heckmann N, Ihn H, Ste M, Etkin CD, Springer BD, Berry DJ
etal (2019) Early results from the American Joint Replacement
Registry: a comparison with other national registries. J
Arthroplasty 34(7S):S125–S34 e1. Epub 2019/02/04 Hip and Knee Replacements in Canada, 2017–2018 (2019) Canadian
Joint Replacement Registry Annual Report Jiang C, Liu Z, Wang Y, Bian Y, Feng B, Weng X (2016) Posterior
cruciate ligament retention versus posterior stabilization for total
knee arthroplasty: a meta-analysis. PLoS One 11(1):e0147865.
Epub 2016/01/30 Kelly MP, Illgen RL, Chen AF, Nam D (2018) Trends in the use of
high-viscosity cement in patients undergoing primary total knee
arthroplasty in the United States. J Arthroplasty 33(11):3460–
3464. Epub 2018/07/31
Li N, Tan Y, Deng Y, Chen L (2014) Posterior cruciate-retaining ver-
sus posterior stabilized total knee arthroplasty: a meta-analysis
of randomized controlled trials. Knee Surg Sports Traumatol
Arthrosc 22(3):556–564. Epub 2012/11/03 Longo UG, Ciuffreda M, Mannering N, D’Andrea V, Locher J,
Salvatore G etal (2018a) Outcomes of posterior-stabilized com-
pared with cruciate-retaining total knee arthroplasty. J Knee
Surg 31(4):321–340. Epub 2017/07/01 Longo UG, Ciuffreda M, Mannering N, D’Andrea V, Cimmino M,
Denaro V (2018b) Patellar resurfacing in total knee arthroplasty:
systematic review and meta-analysis. J Arthroplasty 33(2):620–
632. Epub 2017/10/17
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Karrlholm J et al (2018) Arthroplasty implant registries over
the past ve decades: development, current, and future impact. J
Orthop Res 36(9):2319–2330. Epub 2018/04/18
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porary revision burden among hip and knee joint replacement registries. Arthroplast Today 2(2):83–86. Epub 2016/01/01
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stabilized versus cruciate-retained implants for total knee arthroplasty: a meta-analysis of clinical trials. Eur J Orthop Surg Traumatol 29(4):937–946. Epub 2019/01/17
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Registry for England, Wales, Northern Ireland and the Isle of Man 2019; Available from: https://reports. njrcentre. org. uk/
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Fractures: Annual Report 2019 (2019)
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parison of 2 modern femoral cementing techniques: analysis by cement-bone interface pressure measurements, computerized image analysis, and static mechanical testing. J Arthroplasty 15(4):479–487. Epub 2000/07/07
Rey RM Jr, Paiement GD, McGann WM, Jasty M, Harrigan TP,
Burke DW etal (1987) A study of intrusion characteristics of low viscosity cement Simplex-P and Palacos cements in a bovine cancellous bone model. Clin Orthop Relat Res 215:272–278. Epub 1987/02/01
Springer BD, Etkin CD, Shores PB, Gioe TJ, Lewallen DG, Bozic KJ
(2019) Perioperative periprosthetic femur fractures are strongly correlated with xation method: an analysis from the American Joint Replacement Registry. J Arthroplasty 34(7S):S352–S3S4. Epub 2019/03/11
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US National Databases– Total Knee Arthroplasty: Lessons Learned
ChristieBergerson, DerekHolyoak, andKevinOng
Contents
39.1 Introduction – 448
39.2 Available Databases – 448
39.3 Unicompartmental Knee Arthroplasty (UKA) – 450
39.3.1 Prevalence – 450
39.3.2 Outcomes andRisk Factors – 450
39.3.3 Surgical Technique – 450
39.3.4 UKA vs. TKA – 450
39
39.4 Primary andRevision Total Knee Arthroplasty – 451
39.4.1 General Outcomes – 451
39.4.2 Comorbidities – 452
39.4.3 Surgical Technique – 455
39.4.4 Infection – 457
39.4.5 Postoperative Care – 457
39.4.6 Preventing Venous Thromboembolic Events – 458
39.4.7 Future Trends inTKA – 458
References – 460
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022 E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_39
448
C. Bergerson et al.
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39
39.1 Introduction
Motivated by the goal of improving the longevity of implants as well as reducing the incidence of compli­cations and the need for implant removal, national orthopedic registries were developed in Scandinavia in the 1970s to track revisions as a function of surgeon, patient, and implant characteristics (Malchau et al.
2002). Over the past few decades, orthopedic registries
have expanded across Europe, Canada, Australia, and New Zealand. In the United States, it was not until early 2011 that a national orthopedic registry, the American Joint Replacement Registry (AJRR), was initiated with 15 pilot sites, and now has grown substantially to 1312 sites in 50 states as of early 2020 (American Joint Replacement Registry 2020).
However, the absence of a national-based registry in the United States before then led researchers to leverage other regional or national administrative claims data sets or large clinical registries to study the epidemiology, utilization, and outcomes following various orthopedic procedures. Even though the AJRR is gaining maturity, the administrative claims data sets and large clinical reg­istries are still heavily relied upon to help evaluate less common risk factors, which may be more difcult to study in other data sets with smaller sample sizes.
Moreover, public accessibility to AJRR data is also limited. Thus, these claims data sets and large clinical registries still have their place in research (Pugely etal.
2015a, b), to help further drive the development of
hypotheses that can then be further examined in clinical studies.
39.2 Available Databases
A multitude of national or regional administrative claims databases and clinical registries are available for studying trends in total knee arthroplasty (TKA), each with its own unique data structure, collection method, sampling scheme, and geographic scope within the United States. A few of these are briey described below.
National Hospital Discharge Survey/National Hospital Care Survey
The National Hospital Discharge Survey (NHDS) was an annual survey conducted by the National Center for Health Statistics (NCHS) from 1965 to 2010 (National Center for Health Statistics 2020). This has since evolved to the National Hospital Care Survey (NHCS). The NHCS is a relatively new survey that inte­grates inpatient data formerly collected by the NHDS with the emergency department (ED), outpatient depart­ment (OPD), and ambulatory surgery center (ASC) data collected by the National Hospital Ambulatory Medical
Care Survey (NHAMCS). The integration of these two surveys along with the collection of personal identiers (protected health information) allows the linking of care provided to the same patient in the ED, OPD, ASC, and inpatient departments. The 2013–2016 unweighted inpa­tient and ambulatory NHCS data sets are now accessible through the NCHS Research Data Center. Collected information includes patient demographics, disease diag­nosis, type of procedure performed, institutional charac­teristics, and resource utilization.
National/Nationwide Inpatient Sample The National/
Nationwide Inpatient Sample (NIS) is a larger and more recent database of inpatient discharge data compared to the NHDS. The NIS was established in 1988 by the Healthcare Cost and Utilization Project (HCUP) of the Agency of Healthcare Quality and Research. Compared to the NHDS, the NIS has 25 times more records with ve to eight million records per year and also includes twice the number of hospitals. In 2012, the NIS was redesigned to capture a sample of discharges from all hospitals par­ticipating in HCUP, instead of all discharges in a 20% sample of hospitals. The NIS captures patient, payer, hos­pitalization factors, as well as information about the charges and cost for the hospitalization.
Medicare The Medicare data set is available from the
Center for Medicare and Medicaid Services (CMS) in 5% or 100% formats. The 5% data set consists of 7 compo­nents: hospital inpatient, hospital outpatient, home health agency, skilled nursing facility, hospice care, physician car­rier (Part B), and durable medical equipment. The 100% data set includes all Medicare beneciaries but does not include data from the durable medical equipment or phy­sician carrier components. A denominator le is also available to track the date of death and enrollment infor­mation for Medicare beneciaries. Patients are uniquely identied by an encrypted Medicare beneciary identica­tion number that remains consistent across all parts of the database, as well as over time, which allows follow-up of the patient. In 2017, this included data for approximately 58 million enrollees, of whom 85% were over 65years old, while the remaining enrollees who were under 65 were insured by Medicare due to their physical disabilities or end-stage renal disease (Medicare Interactive 2020).
State Inpatient Database The State Inpatient Database
(SID) comprises state discharge databases that are con­solidated into a uniform format for comparison and incor­poration into the NIS.These databases operate under the HCUP umbrella, but participation may vary by state. State inpatient databases are available for >90% of the states from HCUP.Although the data collection is similar to the NIS, some states collect additional information.
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PearlDiver PearlDiver is a health data analytics company
with one of the largest healthcare databases, incorporating over one billion US records. The data set includes private insurance claims (Humana and United Healthcare), gov­ernment claims (Medicare), and other databases in a sim­plied, de-identied format. The PearlDiver database contains information pertaining to procedure volumes, patient demographics, charges, and reimbursements.
ACS NSQIP The American College of Surgeons (ACS)
National Surgical Quality Improvement Program (NSQIP) is a surgical quality improvement program that prospectively collects 30-day morbidity and mortality data. The NSQIP originated from a 1990s Veterans Affairs (VA) System pilot program to collect risk-adjusted outcomes. The NSQIP received funding from the Agency for Healthcare Research and Quality in 1998, and then was adopted by the ACS at the end of 2004. Since the creation of the ACS NSQIP in 2005, more than 500 insti­tutions have participated in the program. Each site has a surgical clinical reviewer who is independently trained and audited. A systematic (8-day) sampling process is used to collect a subset of cases. The NSQIP collects data on more than 250 patient, operative, and outcomes vari­ables. In terms of postoperative data, NSQIP reports on 30-day, predened complications that contribute to mor­bidity and mortality.
ABOS The American Board of Orthopaedic Surgery
(ABOS) was established in 1934 to standardize orthope­dic surgical competency through the board certication process. The ABOS maintains a database of cases from board- eligible candidates (Part II certication), generally within 22 months after residency completion. The case information is self-reported by each candidate and is entered into an Internet-based system. The candidates must submit the information for all of their cases during the time period of interest. The database contains cases reported by candidates during their Part-II 6-month board collection period. Information pertaining to patient demographics, comorbidities, procedures performed, length of follow-up, and complications has been captured electronically since 1999. Complications are separated into medical (stroke, myocardial infarction, etc.) and sur­gical procedure-related (hemorrhage, implant failure, etc.) groups.
Strengths and Weaknesses
z
These data have given researchers powerful tools to eval­uate a wide variety of clinical questions, such as those related to orthopedic disease and its treatment, volume, resource utilization, costs, and complications.
> Despite an impressive sample size, large-scale data-
bases have notable limitations. Understanding the nuances of these data is critical for surgeons, patients, hospitals, and policy makers.
Many of these differences relate to trends over time, geographic variation, patient comorbidities, inpatient complications, short-term complications, long-term complications, nancial analysis, and accessibility. For example, although Medicare claims comprise one of the most robust data sets used to perform orthopedic research, the data are limited primarily to those 65years and older. On the other hand, private claims data often comprise more heterogeneous patient demographic samples, while still allowing longitudinal analysis simi­lar to that offered by Medicare claims, but employers and beneciaries may switch insurance carriers, thus potentially limiting accessibility to continuous cover­age data.
Many of these data sets are expensive to purchase, as well as complicated and labor-intensive to use. Furthermore, some data sets provide only limited fol­low-up. The NIS is not as well suited for investigating postoperative adverse outcomes because it only includes inpatient events and the NSQIP is limited due to its short 30-day follow-up.
Some disadvantages of the administrative claims data sets include lack of precision of ICD-9 (International Classication of Diseases, Ninth Revision) coding schemes. Although clinical registries typically have a more robust list of variables, with relatively precise pro­spective data input, management infrastructure, and reporting systems, they tend to have a smaller number of patients, inconsistent follow-up duration, and their nd­ings may not be generalizable to the rest of the patient population. The ABOS has limitations in terms of its narrow source of input data from a select, novice group of surgeons as well as the fact that the self-reported com­plication follow-up is limited and variable, ranging from a few weeks to 6months. The ABOS database also does not contain non-operative cases or clinical information such as certain patient demographics, medications, and comorbidity severity.
> It is important to understand the source of the data
and whether an appropriate data set is being used for
drawing the types of conclusions investigated by a
study.
An understanding of the fundamentals is necessary when interpreting conclusions or considering the use of data sets for further research.
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39.3 Unicompartmental Knee Arthroplasty
(UKA)
39.3.1 Prevalence
The prevalence of UKA in both the elderly (>65years) and younger (<65 years) populations has been studied using the 2002 to 2011 5% sample of the Medicare Part B data set, as well as the 2004 to June 2012 MarketScan Commercial and Medicare Supplemental Databases, respectively (Hansen et al. 2018). The rates of UKA increased until 2008, after which they declined. However, the data showed that males age 55 to 74 were the only group whose UKA rates appeared to be trending upwards consistently. The highest proportion of UKA procedures was observed in the South and Midwest United States. Over 95% of the recipients were white, with only 5.1% of recipients having lower socioeconomic status.
39.3.2 Outcomes andRisk Factors
UKA outcomes have also been widely examined for various patient subgroups and risk factors using various national and regional data sets. Sundaram 2019 examined the inu­ence of BMI on 30-day postoperative complications after UKA for 8209 patients in the NSQIP data set (Sundaram etal. 2019). They found that overweight and obese individ­uals who undergo UKA may not have an increased risk of 30-day postoperative complications compared to normal­weight individuals. Morbidly obese patients had a greater risk of supercial skin infection after UKA.Bovonratwet 2017 compared the outcomes between 568 outpatient and 5312 inpatient UKA in the NSQIP database (Bovonratwet etal. 2017). No signicant differences were found in any perioperative complications or any post-discharge com­plications, including 30-day re-admissions, between the outpatient and inpatient cohorts. UKA outpatient proce­dures were also found to be biased toward lower American Society of Anesthesiologists (ASA) classes.
> The authors suggested that outpatient UKA is equiv-
alent regarding complication risks, thus more patients can likely be considered safe for an outpatient UKA if appropriate clinical support is in place during the immediate postoperative period.
tors, and survivorship between RAUKA and manual UKA techniques (Vakharia et al. 2019). A total of 13,617 RAUKA and 21,444 UKA patients between 2005 and 2014 were identied in the Medicare database. Compared with manual UKA techniques, RAUKA had a signicantly lower revision incidence (0.99% vs.
4.24%). In addition, survivorship 3 years after index procedures was over 99% for RAUKA patients and
97.5% for manual UKA patients.
39.3.4 UKA vs. TKA
National databases have also been used to compare out­comes for UKA patients and TKA patients. For exam­ple, after matching 32,379 UKA patients with 250,377 TKA patients from the IBM MarketScan Commercial Database, the IBM MarketScan Medicare Supplemental Database, the Optum Clinformatics Datamart, and a United Kingdom-based primary care electronic medical record database (THIN), the following was shown:
> UKA was found to be associated with a higher risk
for long-term revision, but lower risks for persistent
pain and acute venous thromboembolism after sur-
gery (Prieto-Alhambra etal. 2019).
The authors speculated that the higher revision rate came from the surgeons being more willing to revise the UKAs. Opioid use was also found to be reduced by up to 30% in UKA patients in the 3 to 12months following surgery.
Courtney et al. studied whether Medicare should remove TKA from its inpatient-only list, similar to the policy that exists for UKA. To answer this, they compared the surgical outcomes of patients aged 65years or older who underwent TKA vs. UKA.Using the ACS- NSQIP database, they investigated factors such as comorbidities, 30-day complications, and length of stay (LOS). Based on a total of 49,136 TKA and 1351 UKA patients, TKA patients had longer LOS (2.97 vs.
1.57days) and a higher complication rate (9% vs. 3%) than UKA patients.
> The authors concluded that caution should be used
when applying UKA data to TKA patients and that a
clear difference in risk exists between the two proce-
dures in the Medicare population.
39.3.3 Surgical Technique
Robotic-assisted UKA (RAUKA) is a eld of growing interest, because of its radiographic and patient-spe­cic advantages. Vakharia etal. compared the primary and revision utilization rates, revision surgery risk fac-
Hansen etal. sought to compare the risk of complica­tions, risk of revisions, hospital re-admission, and mor­tality of TKA and UKA patients. The study population consisted of patients from the 2002–2011 5% sample of Medicare data and the 2004–2012 MarketScan Commer­cial and Medicare Supplemental Databases to further compare the procedures in patients younger vs. older