Commentary & Perspective

Commentary & Perspective on
"A Centralized Total Joint Replacement Registry Using Web-Based Technologies"
by C. Röder, MD, et al.

Commentary & Perspective by
Daniel J. Berry, MD*,
Mayo Clinic, Rochester, Minnesota

A United States National Total Joint Registry has been proposed, and planning for pilot projects for implementation has begun¹. Pioneered in Scandinavia, national registries can provide important epidemiological data about total joint replacement, serve as an early warning system for problem procedures or implants, and provide feedback to surgeons that helps them choose techniques or implants with superior performance². Implementation of a registry that provides information on the implants and surgical techniques used in the United States would be of maximal clinical relevance to American orthopaedic surgeons and their patients.

As the proposal for a national registry goes forward, one must consider the factors that are important in making such an undertaking practical, informative, useful, and successful.

Registries are most successful when they capture virtually all of the patients in the desired study population. Thus, a national registry would need to be designed such that it would register reliably, at the time of operation, all patients treated with total joint replacement.

The level of detail of collected information is critical: attempting to collect too much information would lead to incomplete data sets or would become so cumbersome that patients would not be enrolled; collecting too little essential information would undermine the value of the registry. Essential operative information includes patient demographic information, laterality of the surgical site, prosthesis design, and prosthesis fixation type. Improved methods are needed to ensure that the process of entering prosthetic design information into a registry would be unequivocal and simple. As electronic means of automatically collecting accurate and complete information are improved, the scope of data collection that is practical may increase, which is the suggestion made by Röder et al.

Unequivocal, clinically relevant endpoints are needed to provide concrete noncontroversial definitions of implant failure. The only such unambiguous endpoints of failure probably are revision or reoperation, both of which require hospital-based treatment and therefore could be captured and documented at reoperation. A large national registry cannot attempt to collect detailed postoperative functional information, as this requires much more data entry and secondary elective patient contacts than could be reliably achieved in large, mobile populations. The main goal of a registry, therefore, would be to define the survivorship of implants in the United States, as they are used in the United States, thereby allowing surgeons to choose the most successful implants for their patients.

The greatest cost of a registry is in obtaining and entering data³. The costs of managing, analyzing, and interpreting the data are far less. By restricting data collection to a simple data set that includes information that is already collected by most hospitals for billing purposes, the cost of data collection could be reduced. If each hospital was required to submit these straightforward data, and if the data could be transferred electronically to the database, the cost of data collection could be minimized and decentralized. The Scandinavian joint registries have been successful with this model, and only with a similar model could a registry meet its essential goals within a reasonable cost structure for the registry itself.

A national joint registry and institution-specific registries would provide different but complementary data. A national registry could document survivorship of implants used in this country in all patients. The breadth and universality of such information would be far greater than could be achieved by a single institution. On the other hand, institutional databases could provide the tools for detailed investigation of specific aspects of joint replacement on a level that could never practically be provided by a national registry. Institutional databases provide much more detailed preoperative clinical information, operative information, postoperative clinical information, and radiographic information. Obtaining this level of detail is completely impractical on a national level, for reasons of time, cost, accuracy, and completeness.

A national joint registry would provide the unique opportunity to gain information that is only available from a broad perspective that includes the entire landscape of joint replacement in the United States. This ongoing evaluation could provide much information that would further optimize joint replacement. With the huge number of joint replacement operations that are anticipated to be performed in the next several decades, modest improvements of already successful operations will lead to tremendous benefits to society and to patients.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. The author received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (DePuy/Johnson and Johnson). In addition, a commercial entity (DePuy/Johnson and Johnson) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Maloney WJ. National joint replacement registries: has the time come? J Bone Joint Surg Am. 2001;83:1582-5.
2. Herberts P, Malchau H. Long-term registration has improved the quality of hip replacement: a review of the Swedish THR Register comparing 160,000 cases. Acta Orthop Scand. 2000;71:111-21.
3. Berry DJ, Kessler M, Morrey BF. Maintaining a hip registry for 25 years. Mayo Clinic experience. Clin Orthop. 1997;344:61-8.

Copyright © 2004 by the The Journal of Bone and Joint Surgery, Inc.