Executive summary (across all report areas)

Executive summary

Professor Mike Reed - Chairman, Editorial Board 

This year our annual report is based on 2,835,101 records and we maintain our position as the largest registry in the world. We are presenting joint replacement up to 15 years of follow-up, with data on hips, knees, shoulders, elbows and ankle replacements. A further quarter of a million records were added this year.

Progress and achievements

In order to provide high-quality registry data and feedback to the orthopaedic community, patients and other stakeholders, the NJR has made great progress in improving data quality. The data quality process works by matching information held in the NJR with information held on hospital systems in order to accurately capture every relevant procedure, and make sure it is recorded and used for analysis. This process has been running successfully since 2015 in the NHS and from 2016 in the private sector, and this has been a key component in our strategy in recent years. This year saw the launch of the pilot of an automated data quality system which will directly compare a hospital’s reported activity and NJR activity, and produce queries so that any discrepancies can be reviewed. This automation will allow the NJR to perform the audit in a more efficient and streamlined way, and will reduce some of the burden placed upon both Trust and NJR staff in manually checking data. Automation also includes an early alarm for low/non-compliance, enabling timely action to address this. Looking forward, we will extend the quality audit into shoulders, elbows and ankles, and work to bring these joints on board has already commenced.

With improvements in registry-wide data quality we can now offer better information to patients considering surgery about their own particular risks and benefits. For hip and knee replacements, a Patient Decision Support Tool has been developed using NJR data, for use by patients and also clinical staff so that they can input details of their own personal circumstances to estimate their individual patient outcome, benefits of surgery and risks regarding mortality and revision surgery, based on a number of relevant metrics. This is an exciting development and I recommend that you go online and see how the tool works. It is likely that as traction gains, patients will be interacting with this and no doubt will come to consultations better equipped to share in their treatment plans with this information. The Patient Decision Support Tool can be found at www.njrcentre.org.uk/njrcentre/Patients/Patient-Decision-Support-Tool

For the first time, this year surgeon and hospital performance data will be produced over a rolling 10-year period, rather than the whole life of the registry. Thus, historical data will now no longer be used and a more up-to-date assessment of contemporary practice will be presented in surgeon and hospital level data.

In order to allow wider participation in research using NJR data, a research Data Access Portal has been developed. More detailed information on this is provided in Part 1 of this report.

It has been a busy year for research outputs with this year’s NJR Research Fellows producing high quality and prize winning work in journals such as The Lancet. NJR data have been used across a wide range of topics and some of these are detailed in Part 4 of this report. Many more of the publications can be found in Appendix 4 in the downloads section of reports.njrcentre.org.uk .

As always, the NJR and its committees have been visible at both national and international meetings with a presence at the specialist society conferences including BOA Congress, EFORT, BESS, BHS, BASK EHS, EORS and ISAR and other societies’ events being planned for later this year.

Main headlines from the data

For hip replacement we now have well over one million procedures, some with over 15 years of follow-up. Hip surgeons are performing an average of 60 joint replacements per year. This year’s report confirms the increasing trend for hybrid hip replacement over the last five years. Three and five year revision rates have reduced over the last ten years, after the peak of metal-on-metal, and the introduction of NJR clinician feedback since 2008. The data is structured to show the effect of patient and implant factors on revision estimates. For example, patient factors include gender and age at time of surgery, while implant factors include type of fixation, brand, bearing and head size. Ceramic-on-polyethylene looks encouraging with longer follow-up, and as a bearing choice this is increasing. Young women form the group that are most likely to be revised. Reassuringly the numbers of revisions performed each year has decreased since 2012 despite higher numbers of primaries. For those joints that are revised, the longer the primary lasts, the lower the chance of re-revision.

There are over one million knee replacement procedures contributing to the registry and we add to it with over 100,000 new cases per year. Surgeons are performing around 40 cases per year on average. Although the patient groups are not necessarily comparable, the results show the lowest revision rates for cemented unconstrained fixed bearing TKR and cemented TKR with monobloc polyethylene tibias. The revision rates in cemented TKRs that are posterior-stabilised and those that have mobile bearings remain higher. The revision rates for UKRs remain substantially higher than for TKR, this is most marked in the patellofemoral replacement group.

This year’s report showcases an increasing dataset in both the shoulder and elbow registries with both revision and perioperative mortality being included. Data shows that reverse polarity shoulder replacement has increased further and now dominates practice at 57% while proximal humeral hemiarthroplasty continues to diminish. Usefully, PROMs data is provided and can be interpreted alongside revision rates. More elective humeral hemiarthoplasties are being revised earlier and while it can be argued this revision is an easier operation to perform, the PROMs data in this report does suggest lower change scores are being achieved in the specific patient groups that receive a hemiarthoplasty.

We now have over 5,000 ankle operations recorded on the registry, the majority of which are uncemented implants. There is a cumulative percentage of revision at seven years following a primary ankle replacement of 8.51%, but there is a belief that not all revisions are being entered, and both the British Orthopaedic Foot and Ankle Society (BOFAS) and the NJR encourage surgeons to complete forms for all revisions, conversion of an ankle replacement to an arthrodesis, and amputations, which are mandatory requirements.

Concluding acknowledgements

There is considerable additional information available online and I would encourage you to explore the NJR’s dedicated annual report website at reports.njrcentre.org.uk. The website offers a helpful interactive platform for Part Two of the report, which is the descriptive NJR data; supporting appendices; and, when published, the latest NJR Patient and Public Guides to the annual report.

The NJR continues to work with many stakeholders; the most important, of course, are the patients, who I would like thank for allowing the NJR to use their data.

The NJR is a huge team effort. Many thanks also to the following without which the NJR could not function:

All members of the NJR Steering Committee

Members of the NJR sub-committees:
Data Quality
Editorial Board
Implant Scrutiny
Medical Advisory
Regional Clinical Coordinators
Surgical Performance

Members of Data Access Review Group

Members of the NJR Patient Network

Other organisations:
Medicines and Healthcare products Regulatory Agency (MHRA)
Care Quality Commission (CQC)
NHS England
NHS Digital
NHS Improvement
British Orthopaedic Association (BOA)
British Hip Society (BHS)
British Association for Surgery of the Knee (BASK)
British Elbow and Shoulder Society (BESS)
British Orthopaedic Foot and Ankle Society (BOFAS)
European Orthopaedic Research Society (EORS)
Healthcare Quality Improvement Partnership (HQIP)
Northgate Public Services (UK) Ltd
University of Bristol
University of Oxford
Confidentiality Advisory Group
Association of British HealthTech Industries (ABHI)

On a personal note I would particularly like to thank Laurel Powers-Freeling, Chairman of the NJR and Elaine Young, NJR Director of Operations.

Northgate Public Services, University of Bristol and University of Oxford teams have done a first class job, as always. 

Particular personal thanks to Vicky McCormack and Deirdra Taylor for getting the final report into shape.

Martyn Porter stepped down this year having served for over 15 years on the steering committee and led a huge variety of projects to support the NJR. We are hugely indebted to him, and he is greatly missed across the breadth of the NJR’s activities.

Professor Mike Reed

Chairman of the NJR Editorial Board