Developments

Ensuring we work in the best interests of patients continues to be the primary focus for the NJR, and our Board patient representatives are one of our vital facilitation links in ensuring that NJR decision-making and activity prioritisation is driven by exactly this. Further consideration has been given over this past year to how we can enable opportunities for greater patient, carer and public engagement and involvement across our workstreams and on how our networks can help to facilitate increased awareness of our important work amongst, and for, patients. 

Around 90 volunteer members have now been recruited to the NJR Patient Network – we’ve seen an excellent response to the communications promoting the opportunity externally through our channels and networks. 

Our meetings so far this year have included many topic-focused sessions, whereby patients can learn about a particular NJR activity or hear an expert view on a related topic, and then discuss how that could potentially impact them personally and the patient population more generally. We have been holding two patient network meetings each month, to share a wide range of topics in a series of consultation and discussion-based information sessions; these have been well-attended and lively and we have had some very insightful and valuable feedback from all those who have attended.

Through the network we’re focussed on developing excellent patient relationships, and we will work towards making the NJR website and channels a key source of information and case studies, by further developing and sharing our resources and by signposting those of other organisations. encouraging shared decision-making through its use, by those considering joint replacement surgery, 

Delivery of these goals will also be through the further building of external partnerships to enable the exchange of information with other patient-focused organisations. We are aiming to ensure that new materials and publications are relevant to and widely accessible by all. 

In our work this year to include the patient perspective in activities across the full range of NJR workstreams, we know that there are many who are happy to share their perspective and lived-experiences and we are currently developing these into encouraging case-studies to be shared on the NJR website and with the press media, to raise awareness and to inspire others.

We recently produced two visually engaging ‘journeys’ for our online resources – the patient surgery journey and the patient data journey, in collaboration with our patient representatives, and we are continuously extending our range of helpful resources. These are made available to past, current and prospective patients, families, carers and the wider public, and we plan to increase the development of our wider interaction with other patient network groups and agencies to assist us to increase awareness of the work of the NJR and the promotion of the registry resources more broadly. 

You can find more information on the network on our website here.

Our Data Quality Audit has been devised to assess the completeness and quality of the data submitted to the registry. This enables us to compare patient records for procedures recorded in local hospitals’ databases (e.g. Patient Administration Systems (PAS) to that in the registry, with the aim of investigating the accuracy of the number of joint replacement procedures submitted to the registry, compared to the number carried out.

The importance of the NJR Data Quality Audit is clear when considered in the context of our primary aims. To achieve those aims, there are two principal outcomes of interest to the NJR: revision surgery and mortality volumes.
 
The occurrence of revision surgery is often an indicator of either implant failure or poor surgical performance. This is determined by linking a primary joint replacement procedure to a subsequent procedure, which typically occurs some years later. Therefore, compliance with reporting revision surgical procedures is essential to estimate implant failure rates and the quality of surgical performance more accurately.

Mortality data is collected from Civil Registration data, which is obtained from NHS England, and linked to individual patient records within the registry. However, it is important to know that joint replacement is a very successful operation with a very low mortality rate, and all surgeons and hospitals have outcomes in line with the expected range.

We continue to run a semi-automated data quality audit process, which enables all hospitals to check their data on a monthly, quarterly or annual basis. This has greatly reduced the number of mismatches that have needed to be checked each time the audit is run and has now become part of the normal quality-focussed workflow. 

Through our annual NJR Data Quality Provider Awards Scheme, we reward hospitals who have achieved our stringent data quality audit targets. We have a three-tier award system, awarding gold, silver and bronze level emblems for hospitals who have been able to demonstrate quality processes in identifying and accurately capturing NJR procedures in their registry submissions. The highest level of awards, our coveted gold award, is attainable only by those who can achieve 100% compliance rates and each year we see more and more hospitals attain this impressively high level of achievement.

In our most recent audit, we were delighted to award the highest number of gold awards yet, a fantastic 251 hospitals received a gold award, 49 attained silver level and 14 achieved a bronze level award emblem. 

During 2026, we will be undertaking a national data quality audit of ankle procedures, in collaboration with the British Orthopaedic Foot and Ankle Society (BOFAS), with the aim of improving the completeness of the ankle dataset in the registry and to thereby ensure this increased ankle data pool can be used for a more accurate outcomes analysis in the future.

You can find out more about our award programme here

One of the key themes outlined in the NJR Strategic Plan is patient safety. Underpinning this work is the continual monitoring of implant, hospital and surgeon outcomes. 

We are currently developing new methodology to monitor implant outcomes. The current methodology utilised by the NJR is PTIR (patient time to incidence rate). During 2025/26, work has commenced to transition implant analysis to Kaplan-Meier. This change will provide the NJR with a more sensitive analysis with the aim of identifying implant failures earlier. Current work to refine the methodology for hip analysis is ongoing with an aim to introduce this alongside the current methodology during 2026/27. Work to develop a similar approach for knee implants is due to commence during 2026/27.

As well as monitoring implant outcomes, the NJR also undertake revision and mortality outcome analysis for hospitals and surgeons. We currently undertake this analysis for hip and knee procedures. Following completion of a retrospective audit to improve the quality and number of shoulder procedures in the NJR, work has commenced to develop routines for revision and mortality analysis for shoulder surgeons and hospitals. We are working closely with BESS to ensure that surgeons are aware of these changes and to ensure they are well supported to understand their data. 

Our online platform, NJR Connect - Data Services, functions as a single-entry, integrated data collection and reporting system for all NJR key stakeholders in hospitals. It supports surgeons, hospital management, Finance and Procurement staff, as well as implant manufacturers, through clearly defined access points and dedicated stakeholder sections, each governed by appropriate and secure access controls.   NJR Connect - Data Services enables a consistent experience of service activity for the registry across all of our stakeholder groups.

The platform is constantly evolving in terms of newly developing functionality, which empowers us to operate in an environment that enables the deployment of new features to all our stakeholders. It also provides dynamic reporting capabilities, so that system users can drill down into data to extract detailed insights, alongside providing enhanced tools for outcomes reporting, analysis and performance evaluation.
 
Enhancements to our data quality operational efficiency have included improved bulk upload capability, automated data quality audit tools, enhanced component matching, refinements to orthopaedic implant library management, streamlined data entry workflows, and the introduction of enhanced functionality to improve the searching, retrieval, editing and downloading of data, all of these collectively improving the accuracy, completeness and consistency of registry data.
 
Our most recent system developments enabling the expansion of NJR Connect - Data Services, have included:

Patient Implant Lookup Tool

We have developed a new tool within the system which provides hospital orthopaedic teams with a ‘lookup’ facility, giving the functionality to securely search and retrieve any historic NJR-recorded implant data for patients currently in their care, which entails a system search using six mandatory criteria. 
The tool supports surgical planning by providing verified information on previously implanted components. This is particularly useful in revision surgery scenarios, especially where a patient or hospital team may be uncertain of their implant history, or if their previous surgery had taken place at a different hospital.

Patient Records Management

Providing new records management functionality within the Data Entry system, accessed via NJR Connect, has increased the ability for hospitals to execute a more streamlined registry data maintenance and data access, replacing previous manual processes.

The improvements enable hospitals to search for and edit previously submitted records, create data extracts, and generate a working document showing a list of incomplete records and any mandatory data that is missing from them. This means staff can quickly identify issues and send them to the operating team, along with the list of fields that are needed to be able to submit the full record. The ability to search for multiple records will enable hospital staff to generate their own extracts for use in local audit, research projects, and procurement and to identify any surgical procedures where there may be concerns about a particular device, since a simple search will provide the details of all patients who have had the device implanted. 

Whilst not being able to access any patient identifiable information, hospital procurement and finance users will be able to use this new functionality to download all information relating to implant usage within a hospital, filtering the search by dates, surgeons, and devices (from manufacturer down to individual catalogue and batch number). This will help them with monitoring device usage and the re-ordering supplies.

These latest developments continue the NJR’s transition towards a more modern, secure and responsive digital data services platform, supporting improved registry performance, enhanced clinical governance, increased patient safety monitoring and provides greater stakeholder engagement across the orthopaedic community.

You can find out more developments to about NJR Connect - Data Services here 

The NHS Healthcare Safety Investigation Branch previously identified a requirement to reduce the number of ‘never events’ associated with joint replacement surgery in their report into ‘never event’ occurrences. The NJR was identified as a potential means by which this aim could be achieved. 

For hip surgery, a ‘never event’ is where there is a mismatch in size between the acetabular cup/liner and the head, or where different brands of head and stem are used in modular components. For a knee procedure, a ‘never event’ relates to side, e.g. a left-sided component being put into a right knee.  

To address the occurrence of this potential problem, the NJR’s data entry system was updated to enable it to detect potential ‘never events’ and to alert the data entry user to a potential issue. At the same time as warning the user, the system generates an email to NJR staff, so that this alert can be investigated. If an alert is confirmed as a genuine ‘never event’, the Consultant in Charge of the patient is then contacted by a surgeon member of the NJR clinical team to discuss and confirm the action that will need to be taken. 

A very small number of actual ‘never events’ are identified in this way each year but the number of ‘false alarms’ is considerably higher. These alarms are most often likely to be due to mistakes in the data entry process, such as having selected the wrong side for the knee operation or having input the wrong component label details when recording the implants.

As part of this focus on ‘never events’, we have worked to deliver the validation rules that are applied in data entry to an external environment, so that it can be used in support of intra-operative checks. We developed an Application Programming Interface (API) so that hospital theatre systems can interface with NJR’s checking rules. We have also developed another application that can be used on desktop or mobile devices, so that clinical teams can carry out validation checks even if their hospital does not have a compatible front-end system. To date over 120,828 checks have been carried out using the implant scanning tools. 

We’ve also more recently introduced additional functionality for condyle sides in unicondylar knee replacement - and for mismatch of manufacturers between glenoid and humeral components in primary shoulder replacement surgery. Size mismatch for knees was also introduced into the system In July 2026, and we are currently working with manufacturers to build a matrix of sizing compatibility for knees for each product so that we can introduce size matching into the tool.

For more information about how to access the NJR’s implant scanning tools, please visit our website.

With a valuable data pool of over 4.6 million procedure records, the NJR’s research activity has been continually developing over a long period of time and has led to a great number of important and impactful publications, all delivering insightful evidence about the effectiveness of joint replacement surgery procedures. The key aim of this research knowledge is being used to ensure patient safety and to continuously support the improvement of surgical outcomes for future patients.

We commission an ongoing programme of research with the University of Bristol and University of Oxford, and this focuses on four specific research topics for a detailed examination. These projects are jointly led by a clinician from the NJR team and a clinical academic from the University of Bristol, providing clinical guidance to expert statisticians in the work, to ensure that the analysis is of the highest possible quality.

The current NJR research programme consists of the four topics listed below:
•    Outcomes associated with use of all-polyethylene tibial components
•    Trends and outcomes of cement brand usage 
•    Inequalities in provision and outcomes of joint replacement performed in England
•    Outcomes associated with surgeon volumes in shoulder surgery

We also support external researchers to access and use NJR data, which is shared under strict data control measures. The NJR Research Committee reviews submissions from researchers across the country and advises and supports in ensuring that NJR data can be best used to inform and improve practice. 

A full portfolio of external research applications can be found here. Over 70% of all research projects are now led by groups external to the NJR and we continue to work closely with external researchers to improve accessibility further. Researchers seeking to access NJR data may wish to watch the presentations from our NJR Research Webinar.

The NJR Data Access Portal (DAP) was developed to streamline research applications by providing a secure working environment, including analysis tools, for researchers and other users of NJR data, whilst enabling the NJR to stringently manage and control access to our data more effectively, by providing access to the data without the need for datasets to be sent to third parties.

In recent years, we undertook a Health Data Research UK (HDR-UK) funded project to map some of our datasets to the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). This is a standardised vocabulary used in observational datasets worldwide and will allow easier interrogation of international datasets. OMOP mapped datasets are available to research applicants via the NJR Research Committee.

We also sponsor annual clinical and non-clinical funded research fellowships. 
For more information see https://www.njrcentre.org.uk/research/research-landing

The NJR PROMs working group, which is led by Professor Mark Wilkinson, Chair of the NJR’s Research Committee, oversees the NJR workstreams that involve the collection, analysis and reporting of patient reported outcome metrics.

Assessment of PROMs data quality: 
PROMs data for hip and knee replacement surgery collection forms part of a separate programme, previously managed by NHS Digital (now part of NHSE) and are not routinely collected by the NJR. We access the cumulative national PROMs data retrospectively, through an application to NHS England’s Data Access Request Service. 
Unfortunately, we were unable to secure access to useable PROMs datasets for a number of years and were disappointed to be unable to use PROMs to assess knee and hip implant performance. We have now received a more current cohort of national PROMs data and are working to assess the quality of the data prior to publication. 
 
Use of PROMs in implant reports: The NJR has routinely included the reporting of PROMs metrics in implant reports that are made available to manufacturers via the ‘NJR Supplier Feedback’ reporting service. This has meant that patient reported metrics could be considered alongside revision rates when examining the performance of an implant or construct. Increasingly, regulatory bodies internationally are requiring PROMs to be included as part of industry submissions to support device assurance, however, this has also been affected by the above-mentioned unavailability of PROMs data from NHS England.

Shoulder PROMs: For shoulder replacement joint surgery, we continue to find outcome comparison of before and after surgery challenging to understand, due to a disappointingly low rate of pre-operative PROMs submissions, although we were encouraged by a slight increase to ~30% in the last quarter of 2025. We encourage units to capture this important data from all of their patients. Response rates to post-surgery questionnaires, sent directly to patients at their home addresses, generally gives a much better response-rate, averaging at just over 80% overall.