Executive Summary

A total of 78,603 patients have now undergone shoulder replacement and been entered into the registry, with about 10% of these having had both sides replaced, meaning we have 86,882 primary cases available for analysis. Perhaps more importantly, a rigorous audit of shoulder replacements and a careful collation of implant construct data has greatly improved the confidence in earlier data regarding several thousands of cases mainly involving reverse shoulder constructs and we are most grateful to the British Orthopaedic Trainee Association (BOTA) representatives who have worked diligently in their hospitals on the audit this year, and you can read more about this audit on the NJR website.

The data now extend over a 13-year period and therefore provide an unrivalled data source regarding different types and brands of shoulder implant.

We have continued to be cautious about assessing surgeon performance using this information because of a number of factors, amongst which are the relatively small numbers of cases per surgeon (compared with hips and knees) and the dramatic changes in accepted indications between the main classes of shoulder replacement.

Last year the overall number of shoulder replacements was the highest ever in the registry, but the number performed in NHS hospitals had not quite reached pre-pandemic levels. This year, the NHS has performed more cases than ever before and the overall numbers have also grown further and the overall number in 2024 is now in line with the steady growth that was occurring in the six years prior to the pandemic. Of the cases performed in 2024, 70.4% were reverse shoulder replacements. The overall pattern of revision rates has not altered a great deal compared to the previous annual report.

Performance of implants is difficult to assess in some regards because during the last decade a dramatic change has occurred in the accepted indications for reverse total shoulder replacement. In particular, many surgeons now use reverse shoulder replacements as their preferred implant even for osteoarthritis with an intact rotator cuff. As a result, we have seen a huge increase in reverse total shoulder replacements in elective surgery, as compared to all other groups (Figure 3.S3). This in turn means that the mean follow-up in different groups varies considerably and that time-dependent modes of failure may be less reliably represented by the data in some groups than in others.

This potential intrinsic bias in the data presented must be carefully considered by those who wish to avail themselves of this large dataset. Nevertheless, the large numbers presented here allow some of the most meaningful assessments available for the main shoulder replacement implant brands worldwide.

It is interesting to see that even though total numbers of shoulder replacement amount to 10% of the number of hip replacements entered each year on the registry, the proportion of cases being performed by a surgeon who does more than one per month is around 85% in 2024, which indicates an impressive degree of specialisation.

Figures 3.S5 and 3.S6 show interesting variation between the sexes in the types of implants that are used and in what circumstances. Figure 3.S7 shows that the revision rate after shoulder replacement for trauma reaches a plateau after about four years, which is perhaps unsurprising given the prevailing age of that group of patients.

It can be seen in Tables 3.S5 (a) to (h) that the division of brands in a more granular way has given a much more detailed assessment of the actual constructs being used and their varying outcomes. The data are presented so that they also differentiate between those constructs which are strictly within a brand, those where some elements may be from different brands from a single manufacturer, and also some where the different elements of the construct may be from more than one manufacturer. It is important to read the text and table notes carefully to be sure that these differences are understood.

It is clear that humeral hemiarthroplasty has significantly higher revision rates than anatomical or reverse shoulder replacements, but caution needs to be exercised in interpreting these findings. Hemiarthroplasty may be considered easier to revise and the indications for both the primary and the revision surgery may not therefore be equivalent.

Shoulder PROMs provide important additional information with which to enrich the revision outcome data. The number of patients returning PROMs questionnaires has been disappointing throughout, in part because the NHS has declined to include shoulder replacement in the national PROMs programme. This affects the willingness of NHS hospitals to collect the information, although as part of the NJR dataset these data are mandated by the NHS Standard Contract. Currently the PROMs for shoulders are collected separately by the NJR, but this has led to many hospitals feeling that they are not funded to collect these (in contrast to hip and knee PROMs, which have an associated Best Practice Tariff). This funding issue urgently needs to be incorporated into any comprehensive strategy for PROMs collection. There have also been some concerns that the cases which have completed PROMs may differ systematically from those where they were not completed. Figure 3.S10 shows this comparison, and while the two groups diverge in the initial years, it is perhaps reassuring that they appear to converge again by ten years.

Despite these concerns it is interesting to note that there are some differences in PROMs shown between the anatomic shoulder replacements and the other groups, including reverse shoulder replacements.

While the data allowing accurate designation of the construct in each procedure has been much improved by the work on the classification of shoulder implants, there remain problems with the number of reverse shoulder replacements being classed as ‘unconfirmed’. This seems to relate to the greater number and variety of components required in a reverse total shoulder construct than for other shoulder constructs. The consequence is that the analysis of reverse shoulder replacements is affected by a substantial number of missing cases.

Elbow replacement in its various forms has been entered into the registry at about 1,000 cases per annum for some years now. The split between acute trauma and elective cases, and the use of total elbow replacement versus radial head replacement, makes interpretation of the overall outcomes somewhat taxing. The results of the trauma cases are separated from the elective cases in this section of the report to allow a clearer picture to emerge.

There are now over 11,000 cases available for analysis and these patients are somewhat younger on average than those in hip or knee replacement cases, and two-thirds of them are female.

In contrast to the results for other joints, there was a dip in the numbers of cases of elective total elbow replacement even prior to COVID and the further drop during the pandemic has still not been completely reversed in the following years (Figure 3.E3). Whether this constitutes a permanent change it is not yet possible to say, but it does raise the question of whether this type of procedure may be being rendered less necessary in some patients, due perhaps to the beneficial effects of modern anti-rheumatoid treatments.

There is an obvious contrast between this and the growth of total elbow replacements in the acute trauma setting (Figure 3.E4) where it can be seen that the numbers have doubled in the last three years. While this could possibly be simply due to post-COVID recovery, this seems a little unlikely in the trauma setting and is very suggestive of changing practice.

There is a steady increase in the number of surgeons performing more than one total elbow replacement per month, but despite this, in 2024 only 37% of surgeons were performing more than six cases a year. 

For the overall number of elbow replacements (total elbows, hemiarthroplasties and radial head replacements together) it is noteworthy that the annual median number of cases per surgeon is consistently higher than the annual median number per hospital. This probably reflects the fact that many surgeons work in several hospitals, and it is to be encouraged that surgeons who do these operations should avoid doing very small numbers. However, it also raises the question of whether outcomes could be improved by locating larger numbers of cases in a smaller number of hospitals, to enable surgical teams to benefit from the experience of these increased volumes. Median numbers of cases shrink further when the count is confined to total elbow replacements, but the disparity between median hospital numbers and individual surgeon median numbers is similar. There is little doubt that elbow replacement is a technically demanding procedure and that the failure rate is higher than for the more commonly-performed replacements in other joints. Thus, if maximising experience could be achieved by re-organising the geography of delivery, that might be preferable to having each local hospital delivering such small numbers.

Looking at the results by brand, the majority of brands still on the market seem to have similar revision rates. There is a suggestion that the Coonrad Morrey implant may outlast some of the opposition. Although the numbers are small and interpretation therefore fragile, the Latitude humeral component when used with the Latitude EV ulnar component does seem to show a worrying tendency to have higher early failure rates.

It is evident that the population receiving an elbow replacement for trauma is quite different to the population receiving a similar operation for elective reasons, meaning that different mortality is to be expected over subsequent years. The spectrum of procedures also varies considerably. Nevertheless, we should remain vigilant concerning the competing risks of mortality and revision surgery in these groups because if the patients with broken elbows are seriously frail, we need to understand the full spectrum of outcomes, from both the surgical options and any potential conservative management. Critical to this debate is the need to compare like with like. The impact of a radial head replacement on the patient’s life expectancy is unlikely to equate to the impact of a total elbow replacement.

Despite representing one of the largest registry collections of elbow replacement procedures available for study, the numbers presented here are still sufficiently small, and the implanted combinations sufficiently varied, that it is difficult to draw confident conclusions about many of the outcome metrics. 

It can be seen that the number of ankle replacements performed has risen quite dramatically in the latest year (Figure 3.A3), with private cases increasing modestly and NHS cases increasing significantly. This has resulted not only in the numbers performed being greater than pre-COVID in 2023, but taking an even larger step upwards in 2024. This could simply reflect the backlog from COVID, but the increase in overall numbers (particularly in NHS hospitals) is substantial and is proportionately larger than that seen in some other joints. Indeed, in this latest year the number of ankles that have been replaced appears to be in line with the rapid increase that was occurring between 2014 and 2019, rather than simply ‘catching up’ post-pandemic.

While it is clear that many surgeons are performing relatively small numbers of ankle replacements per year, it is now the case that more than half of ankle replacements done in the latest year have been performed by surgeons who do more than one such operation per month (Figures 3.A4 and 3.A5). It can be seen in Table 3.A1 that the average number of cases performed per hospital has been increasing steadily since COVID, which should be reassuring for patients. However, the increase in average numbers performed per consultant which occurred between 2010 and 2018 does not appear to have continued over the past few years.

The dramatic move from using mobile bearing ankle implants to fixed bearing devices has continued and around 80% of operations in the most recent year have been with a fixed bearing. Figure 3.A6 shows that the cumulative revision rate of ankle replacements overall in the NJR data, at around 9% at ten years, is substantially higher than it currently is for knee or hip replacements. 

The different implant brands can be seen to have substantial variation in revision rates and as these brands have not been used uniformly over the past 14 years, those used longer ago will be affecting the longer-term revision rates for ‘all ankles’ disproportionately.

It is interesting to see in Figure 3.A8 that the revision rates at 3, 5 and 7 years have improved considerably since 2014, which mirrors the improving rates of revision in hip and knee replacements since 2008. In the case of ankles, it seems likely that the improvement largely reflects the removal of the Mobility implant from the market and the introduction of the Infinity implant at about the same time. The Infinity implant can now be seen to have one of the lower revision rates. It will be interesting to see whether revision rates continue to improve over the next few years. However, even then it would be necessary to rule out under-reporting of alternative outcomes such as ankle fusion and amputation, which still may not be fully captured in the data. 

Revision rate data needs to be interpreted cautiously in light of the other data presented in Figure 3.A7, which shows that the rate of revision varies between sexes and age groups. If there has been variation in the age or sex distribution over time this could introduce some bias into these revision rates. A cautious approach should also be applied to interpretation of revision rates between brands, for similar reasons.

As reported in previous annual reports the concern remains that some patients may be having their implant removed by operations such as amputation and ankle fusion and that because these operations may be done by non-arthroplasty surgeons and in different settings, it is less straight-forward to capture these cases. The NJR will continue to seek out such cases using audits, but it remains vital that suitable mechanisms to capture the data are embedded in any hospital where these operations are undertaken.

There are now over two million knee procedures recorded in the registry, with over 1.8 million consented and validated primary knee joint replacement procedures available for analysis. Over the last three years, consultant surgeons have performed a median of 135 knee procedures representing an increase from 111 in the last report. The majority of all primary total knee replacement (TKR) cases are now done by surgeons performing over 49 cases per year and approximately half of all primary TKR cases are now done by surgeons performing over 97 cases per year. The typical patient in 2024 was 70 years of age, had an average BMI of 30.9 and 55% were female.

There has been an impressive increase in annual knee procedures post-COVID to a record annual high of 134,652 in 2024 (Table 3.K2). NHS-funded procedures performed in NHS facilities have only just reached the numbers seen in the few years before COVID, but the main increase in volume has been in NHS-funded procedures performed in independent hospitals and also those performed there which are privately-funded. NHS-hosted and funded procedures used to account for approximately 60% of the total knee volume, they now represent less than 50%. This continues to pose questions regarding in-house NHS capacity, facilities, staffing and productivity.

By fixation type, over 90% of all primary knee replacements in the registry are all-cemented, with uncemented or hybrid types making up only 6.6% of cases in 2024, this is contrary to the higher cementless usage observed in the USA. 

Female patients represent over 55% of the TKR population and 77% of the patellofemoral population while male patients represent approximately 55% of the unicompartmental knee replacement (UKR) population. Patellofemoral patients are also typically younger than a TKR or unicondylar patient, with a median age of 58 at surgery.

The most common TKR configuration remains a cemented unconstrained (cruciate retaining) fixed bearing implant, representing about 68% of TKRs. This configuration has excellent survivorship with a revision rate of 5.28% at 20 years. The next most commonly used construct is a cemented, posterior-stabilised, fixed bearing TKR with marginally higher revision rates of 6.23% at 20 years. Revision rates at 20 years provide a reasonable benchmark but this may not be useful to surgeons because very few of these implants remain on the market in their original form. Rotating hinge implants, which are used for the most complex primary TKR cases, show <10% cumulative revision rate at ten years, which is encouraging (see Figure 3.K4 (a)).

This year’s report shows very detailed analysis of TKR brands by constraint, mobility and patella resurfacing status (Table 3.K9 (b)). It is very clear that the performance of some specific brand constructs is affected by these variables, whereas for others it is not. This makes it important for surgeons to be aware of the performance of the specific brand construct they use. The granularity of specific brand types found in ODEP ratings may help surgeons with this assessment provided that they ensure the ratings apply to the precise combination of implants that they propose to use. 

The annual number and proportion of unicondylar knee replacements has continued to rise, reaching its highest level of 14.7% in 2024. This increased usage is supported by NICE recommendations in 2020 and 2022 and by the improved revision rates of medial unicondylar replacements seen in the registry. The best performing unicondylar brands now show revision rates of 1.88% at five years and 5.03% at ten years (Table 3.K8) and are fixed bearing designs. This has been one of the factors driving a move towards fixed bearings. From the start of the registry until approximately 2015, mobile bearing options dominated the unicondylar market, but since then fixed bearing has increased consistently. Last year 69% of unicondylar procedures were fixed bearing (Table 3.K2).

In the last three years, there have been 50,329 primary unicondylar knee procedures performed by 962 consultant surgeons, giving a median of 29 cases per surgeon. The number of primary unicondylar procedures has doubled compared with 2016 and shows growth in all the surgeon volume bands >13 per annum, but with an encouraging reduction in the number done by surgeons in the lowest volume bandings (Figure 3.K1 (c)). This reflects the BASK recommendations on minimum unicompartmental knee replacement numbers and is reported in individual NJR Consultant Level Reports.

Patients receiving unicondylar knee replacements were typically five to six years younger than TKR patients, (Table 3.K3) which is something that needs to be considered when assessing revision rates given the known association with increasing revision rate and reducing age, seen for primary TKR (Figure 3.K5 (a)). 

Over 56,000 first-time revision procedures are now linked with a known primary on the registry. It is encouraging that the cumulative probability of a knee joint being revised at three and five years has continued to reduce between 2009 and 2024 (Figure 3.K3 (b)). 

The chance of re-revision after first revision is approximately 15% at ten years which is five times higher than revision rates for primary TKR. Revisions of patellofemoral and cemented unicondylar procedures have the lowest chance of re-revision (Figure 3.K6 (b)). Surgeons therefore need to weigh up the revision rate of the first procedure and the re-revision rate in considering the overall “arthroplasty life” for the patient, particularly if they are younger at the time of index procedure. 

Early revision of a primary TKR is a poor prognostic factor for further re-revision. A revision within one year of primary knee replacement has a re-revision rate of 9.1% within one year and 19.8% by five years. This highlights the importance of getting the first procedure right (Figure 3.K6 (c)).

Primary TKR and unicondylar numbers have continued to rise post-COVID with the highest volumes in the registry reported in 2024. The expected large increase in revision TKR burden has not yet been shown in reported revision numbers. The analyses in this report provide surgeons with evidence to support many TKR implant options with revision rates of under 3% at ten years and under 5% at 15 years, and unicondylar implant options with revision rates under 2% at five years and under 6% at ten years.

Up until the end of December 2024 there were almost 1.7 million primary hip replacements entered into the registry which could be used for analysis. This is a huge number with which to ascertain outcomes up to 20+ years from implantation. The numbers for many implant brands and variants now allow very precise statistical analysis. In particular, combinations of femoral and acetabular implants can be assessed in detail, including separate analysis on bearing surfaces and material as well as fixation methods. Since each of these factors appear to affect the outcome in terms of revision rate it is important that all surgeons are aware of these differences and use the detailed analyses presented in this report to choose their implants on the basis of the evidence.

Arguably, a ‘one size fits all’ philosophy for hip implants is unlikely to provide patients with a uniformly good outcome and this applies to choice of fixation, bearing size and materials, not simply to the actual size of the devices implanted. However, there are some instances where a standardised implant strategy has demonstrated excellent outcomes, suggesting that a more heterogeneous approach may not always be superior.

It is reassuring to see that the revision rates at various times after surgery continue to improve year-on-year, as has been reported over several years. A year-on-year improvement in revision rates at 3, 5, 7, 10 and 13 years can now be seen to have occurred every year since about 2008 (Figure 3.H4 (b)). The importance of this secular trend in revision rate is not only that patients can expect a better outcome from surgery now than was likely 15 years ago, but also that a benchmark based on data several years ago (such as a current ODEP rating) reflects performance which has already been exceeded by many implants. 

There are now ten cemented, ten uncemented, four hybrid and two reverse hybrid hip implant constructs presented in this report (Table 3.H8 (b)) which have 10-year cumulative revision rates less than 2%. Even the best 10-year ODEP rating (10A*) could be awarded to an implant with more than twice that revision rate, so while a 10A* hip implant might be good enough for your patient it behoves the surgeon to seek more detailed evidence to ensure this is really the case (Table 3.H8 (a) and (b)). Clearly those implants with A ratings are likely to be still further adrift of the ‘state-of-the-art’ performance.

Having recovered to annual numbers above those seen before the pandemic, it is interesting to see that almost 20% of all primary operations in the registry have been performed in the last three years. The figures also show that in the last few years since the pandemic there has been a substantial increase in cases performed in the independent sector, and this applies both to privately-funded cases and to those funded by the NHS (Figure 3.H1 (d)). This has been in part due to government policy, but a similar increase in hip replacements in NHS hospitals has not been seen, although numbers of cases in the NHS sector have now recovered more or less to pre-COVID levels. It should be borne in mind that as straight-forward NHS cases are transferred into the independent sector, the cases left in the NHS hospitals tend to be increasingly complex, medically and surgically. It would therefore not be surprising to find that these cases take longer and patients spend more time in hospital. Furthermore, the teaching opportunities for trainee surgeons are still overwhelmingly within the NHS hospitals and the transfer of simpler cases into the independent sector has a disproportionate effect on the cases available for training. All of these factors have implications for efficiency, but may also impact on the outcomes for patients in different hospitals.

The median number of hip replacements performed by a consultant surgeon is 69 per annum, and approximately two-thirds of elective unipolar hip replacements are now performed by surgeons doing more than 97 per year.

There has been a notable fall in total hip replacements performed for acute femoral neck fracture in the last few years. This was most noticeable during the pandemic, but numbers remain lower than in 2019 and the decrease has not been fully compensated by the modest rise in dual mobility hip replacements for acute trauma. This may reflect recent evidence that outcomes have not been shown to be significantly better for total hip replacement than for hemiarthroplasty for acute hip fracture patients. It is also possible that the change reflects other alterations in practice including treating the initial fracture by internal fixation.

Hip resurfacing appears to have become a niche operation in that the overall number of cases has dropped to around 800 per year and less than 0.7% of hip replacements. These operations are now nearly all being done by surgeons who perform more than one per month and sometimes much higher numbers (Figure 3.H1 (b)). There have been more ceramic-on-ceramic resurfacing operations recently, but the numbers are still small and do not yet support the suggestion that the high revision rates seen with metal-on-metal resurfacing operations have been overcome.

The position regarding dual mobility hip replacement remains uncertain and surgeons may be wise to remain circumspect about adopting this procedure as a first choice for their hip replacements. The results are difficult to interpret as there are specific potential indications for the procedure and those may occur in cases which themselves have a tendency to less good outcomes, producing selection bias. In general, the data show increased revision rates in dual mobility procedures compared to standard hip replacement. We can see that over 1,000 elective dual mobility hip procedures have been done by surgeons who perform more than 49 per year. This implies that some surgeons may be using the implants as a preferred implant rather than due to specific indications in their patients (Figure 3.H1 (b)).

The annual total number of first revision hip replacements entered in the registry decreased after 2012 and then decreased dramatically again in 2020, presumably related to the impact of the pandemic. There has been a steady increase each year since 2020 but there were still almost 1,000 fewer first revision hip operations in the latest year than before the pandemic. Apart from 2020/21 this number of first revision hip operations with a linked primary in the registry has been remarkably stable since 2012 despite the steady increase in primary hip procedures from 78,000 that year to nearly 117,000 in the latest year. This gives further reassurance that the gradual but sustained improvement in the cumulative revision rate may mean that the concerns that revision surgery may increase exponentially may not have been warranted.

Many patients having a primary hip replacement can now expect to live at least 15 years after the operation. It is therefore comforting that the cumulative revision rate at 15-years is now better than 5%, which was the 10-year rate suggested by NICE as acceptable a decade ago.

The indications for revision operations remain similar to previous reports with aseptic loosening, dislocation/subluxation, peri-prosthetic fracture and infection leading the table. Peri-prosthetic fractures can be treated by internal fixation instead of revision operations and until recently information about cases treated by internal fixation was not collected in the registry. Although these cases can now be collected in the registry, the historic cases that were not collected over the years mean that analysis of the relative incidence of this complication from these registry data are bound to be an underestimate.

Cementless hip fixation, having decreased for eight years at the expense of increasing hybrid hips, have now increased again for several years and more or less match hybrid hips in popularity. Ceramic-on-polyethylene bearings are the most common choice amongst hybrid and uncemented hip surgeons and the results suggest that in general that is a good choice. Implant material choice is not the only way of obtaining good survival though, so it is recommended that surgeons examine the results of specific constructs where numbers allow.

The analysis presented in Figures 3.H10 (a) to (m) suggests that the use of different femoral head sizes may affect the revision rate differently depending on the implant fixation used as well as the bearing surfaces used. With many of these variations the differences found in terms of revision risk are small for patients above the median age at primary operation. 

These results deal principally with revision data which is of course only one aspect of the outcome of hip replacement. Other important outcomes such as patient satisfaction, pain and patient-reported outcome scores are vital in producing a more complete picture of the outcomes of hip replacement.

Mr Andrew Porteous - Chair, Editorial Committee
Mr Tim Wilton - NJR Medical Director

This year we have attended the BOA, BASK and BHS specialist society meetings and have also had a well-attended meeting with surgeons in the north-east region. The number of cases submitted to the registry has grown considerably and is now at substantially higher annual levels than achieved prior to the pandemic. For some joint procedure types, such as unicompartmental knee replacements, the growth has been sufficient to overcome the deficit produced by the pandemic, but for the higher volume procedures such as total hip and total knee replacements there is still a substantial overall deficit, especially if the pre-pandemic steady growth had continued unabated. Nevertheless, for most joints the overall number of cases in the last year is in line with the pre-COVID predicted growth and some ‘catch-up’ of the deficit has also occurred. We are collecting substantial numbers of hip hemiarthroplasties now and hope to report on them in detail in coming years.

Due to the ongoing development of the implant classification system, we have been able to present the data about implants in a more granular form and important data about revision rates for the overall constructs in hip replacement have been made more fully available. As implant attribute data are more comprehensively uploaded by manufacturers over the rest of this year as we have been promised, we will see much more detail available in future annual reports, especially for those implant designs where there are multiple variants within a brand.

The unfortunate delays that occurred in some of our reporting last year, including the delay in some sections of the annual report, have happily been avoided this year now that the new data warehouse system has had a chance to bed in. It was felt that there was benefit to many readers from having the sections for different joints published individually and this has therefore been repeated. The additional complexities of implementing the new classification system led to delays in producing some routine monitoring, such as the implant scrutiny reports, due to the changes in classification occurring with some implant designs. For example, some manufacturers have re-classified some of their knee implants in terms of their ‘cruciate stability’ which can mean the results reported for the brand sub-types may be altered compared to previous years. Although this will lead to some implants having slightly different reported outcomes this year, the new results should be more accurate and reliable. It is hoped that these changes will also be fully embedded prior to the production of the annual report next year. We urge surgeons to examine the updated revision rates shown in this report and scrutinise the tables to make sure they are viewing results of the specific variants they use, as this will supplement other sources of information such as ODEP ratings.

The majority of ODEP ratings are awarded based on data from the NJR but there are some differences in the information surgeons can get from the NJR Annual Report compared with ODEP ratings. ODEP rates hip stems and acetabular components separately, but with the detail provided by the new component database, we can provide comparable granularity to ODEP ratings for hips as well as revision rates for the more commonly used combinations. Knees achieve ODEP ratings for the entire construct combination (femur, tibia, tibial insert, patella/no patella), which means that for a knee brand family (e.g. PFC or NexGen) there may be over thirty separate constructs that could achieve an ODEP rating. The new component database is enabling more and more granularity in knees, but including every construct in our report poses more statistical challenges and would lead to a very lengthy report that may be difficult to interpret. ODEP knee ratings are currently more granular at an individual construct level but do have issues. The ODEP ratings are voluntary and rely on companies submitting data to obtain a rating. The ratings are only updated every two to three years and may not reflect current performance. While there are plans to tighten the ODEP criteria in line with improving implant performance, the “A ratings” now represent a very low bar that does not indicate good performance. Even the “A* rating” at ten years for hips and knees probably now identifies an acceptable rather than good or excellent revision rate and surgeons have the choice of multiple hip and knee implants that have 10-year revision rates less than half the ODEP 10A* benchmark. 

We continue to experience difficulty obtaining supplementary data from NHS England that we require to perform some of our analyses and to provide context with which to interpret revision rate data more appropriately. These data feeds include the routine Hospital Episode Statistics (HES), although we have been able to obtain alternative and more accurate data from the hospitals themselves (PAS data) as these are used in our ongoing audit of all cases entered in the registry. Unfortunately, the necessary feeds also include national PROMs data and NHS England has been the sole source of those data for hips and knees for many years. We are still trying to obtain sufficiently reliable and complete PROMs data which we will then use to enrich the analyses that we produce. It is well-recognised that revision rates alone give an incomplete picture of implant (or surgical) performance and this additional PROMs information covering recent years will be invaluable to manufacturers and surgeons alike. Such information is of course also vital to enable patients to make a properly informed choice about their treatment.

This year a national database for all implantable devices has been introduced by NHS England. This database, known as the Medical Devices Outcomes Registry (MDOR), is designed to collect data about all Type 2b and Type 3 implantable devices inserted into a patient by any medical speciality. Through the database, the patient and their implants will be linked centrally, so that not only can they be traced for recall if necessary, but potential interactions between different implants and different specialities could be investigated in due course. This project at present covers a relatively small number of registries and specialities and data capture only currently applies to NHS patients in England. This sort of database could clearly prove hugely important for patient safety and to allow cross-speciality research. It is not intended that this project will supplant the NJR which will continue to collect, monitor and analyse data about joint replacement as before. These processes will continue in parallel for the foreseeable future and ultimately it is intended that the existing specialist registries will be able to access the data in the central repository to allow more elaborate analyses. When the data in MDOR is sufficiently robust and reliable it is to be hoped that the difficulties accessing that data for research and other purposes which has recently beset the NHSE supply of their other data sources is not repeated, whichever organisation may take over their responsibilities. 

It is good news that several of the development projects delayed by the pandemic are now up and running and we look forward to those coming to fruition soon.

Acknowledgements

The NJR continues to work collaboratively with our many stakeholders; the most important of these of course are the patients we serve, and whom we would like to thank for allowing us to use their data.

The NJR operational collaboration is a huge team effort. Elaine Young, NJR Director of Operations, has demonstrated the great versatility of her leadership and her team.

Many thanks also to the following without which the NJR could not function:

All members of the NJR Board and members of the NJR committees:
Executive 
Data Quality 
Editorial
Implant Scrutiny 
Medical Advisory
Regional Clinical Coordinators 
Research
Surgical Performance

Members of the 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 (NHSE)
    Welsh Government 
    Northern Ireland Executive
    Isle of Man Department of Health 
    States of Guernsey
    Independent Healthcare Providers Network Services
    Getting It Right First Time (GIRFT) 
    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) 
    Confidentiality Advisory Group (CAG)
    Association of British HealthTech Industries (ABHI)
    Computer Assisted Orthopaedic Surgery (CAOS)
    British Orthopaedic Directors Society (BODS)
    Orthopaedic Trauma Society (OTS)
    British Orthopaedic Oncology Society (BOOS)
    British Orthopaedic Trainee Association (BOTA)

We are most grateful to our NJR delivery contractors for their very valuable input into the NJR Annual Report and their many other functions. NEC Software Solutions, University of Bristol and University of Oxford teams help us refine and improve each year.

We offer our personal thanks to Vicky McCormack, Report Project Manager, NEC; and Deirdra Taylor, Associate Director of Communication and Stakeholder Engagement for getting the final report into shape.