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P. Hoogervorst and P. K. Horst
38.1 Introduction
The rst nationwide orthopedic implant registries
were implemented between 1975 and 1995in 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 etal.
> 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 etal. (2018); by courtesy of John Wiley & Sons)

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38
goals are to capture hip and knee arthroplasty data to
conduct implant-specic 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 signicantly 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
Table38.1) (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
66.7years (SD 9.6). This is in line with other national
registries which report a mean age at surgery of
approximately 68years (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 etal. 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 65years 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
https://t.me/medicina_free
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 etal. 2013; Jiang etal.
2016; Li etal. 2014; Longo etal. 2018a; Migliorini etal.
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 etal.
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 benet of
patellar resurfacing have not resulted in unequivocal
recommendations (Arirachakaran et al. 2015; Cheng
etal. 2014; Grassi etal. 2018; Longo etal. 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
etal. 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 etal. 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 etal. 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 etal. 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. etal. 1987;
Reading etal. 2000). An increase in the use of highviscosity PMMA in TKAs between 2012 (46.0%) and
2017 (61.3%) has been identied (Kelly etal. 2018). The
AJRR can be an important tool in evaluating whether
the use of different types of PMMA is indeed inuential
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 identied 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) andPatellofemoral
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 etal. 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 fromAJRR
> 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 etal. 2019).
This proportion has been stable over the last 5years.
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
etal. 2016).
To identify reasons for revision surgery ICD-9 or
ICD-10 codes were used. The numbers reported may
be difcult 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,
dened 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 etal. 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 etal. 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 6years.
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 etal. 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 inuence results (Bedard etal. 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 & inammatory 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 5years.
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-
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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
etal (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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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
etal (2019) Early results from the American Joint Replacement
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Kelly MP, Illgen RL, Chen AF, Nam D (2018) Trends in the use of
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US National Databases– Total
Knee Arthroplasty: Lessons
Learned
ChristieBergerson, DerekHolyoak, andKevinOng
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 andRisk Factors – 450
39.3.3 Surgical Technique – 450
39.3.4 UKA vs. TKA – 450
39
39.4 Primary andRevision 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 inTKA – 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 difcult 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 etal.
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 briey 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 identiers
(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 beneciaries 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 beneciaries. Patients are uniquely
identied by an encrypted Medicare beneciary identication 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 65years 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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39
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 simplied, de-identied 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, predened 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 certication
process. The ABOS maintains a database of cases from
board- eligible candidates (Part II certication), 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 65years
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 beneciaries 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
Classication 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 6months. 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 (>65years)
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 andRisk 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 inuence of BMI on 30-day postoperative complications after
UKA for 8209 patients in the NSQIP data set (Sundaram
etal. 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 supercial skin infection after UKA.Bovonratwet
2017 compared the outcomes between 568 outpatient and
5312 inpatient UKA in the NSQIP database (Bovonratwet
etal. 2017). No signicant 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 identied in the Medicare database.
Compared with manual UKA techniques, RAUKA
had a signicantly 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 etal. 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 12months 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
65years 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.
1.57days) 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-specic advantages. Vakharia etal. compared the primary
and revision utilization rates, revision surgery risk fac-
Hansen etal. 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
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