Surgeons performed more than 1.1 million joint replacements in the US in 2011. That same year, the International Consortium of Orthopaedic Registries (ICOR) was launched to help close gaps in evidence and data collection related to orthopaedic implants. The ICOR network now consists of more than 70 stakeholders and more than 30 orthopaedic registries representing 14 nations.
The December 17, 2014 edition of The Journal contains an online supplement with 14 articles highlighting the achievements of international registries and the findings from 12 ICOR-initiated registry studies. The first article in the supplement (National and International Postmarket Research and Surveillance Implementation) summarizes the findings from the 12 registry studies. The second article (A Distributed Health Data Network Analysis of Survival Outcomes) provides an overview of the data extraction processes and analytic strategies used in the studies.
Key findings from the 12 studies contained in the supplement:
- Effect of Femoral Head Size on Metal-on-HXLPE Hip Arthroplasty Outcome in a Combined Analysis of Six National and Regional Registries
There were no differences in revision risk when metal-on-HXLPE (highly cross-linked polyethylene) implants with larger and smaller femoral head sizes were compared.
- Risk of Revision Following Total Hip Arthroplasty: Metal-on-Conventional Polyethylene Compared with Metal-on-Highly Cross-Linked Polyethylene Bearing Surfaces
Non-cross-linked polyethylene was not associated with significantly worse revision outcomes when compared with metal-on-HXLPE.
- Distributed Analysis of Hip Implants Using Six National and Regional Registries: Comparing Metal-on-Metal with Metal-on-Highly Cross-Linked Polyethylene Bearings in Cementless Total Hip Arthroplasty in Young Patient
Large-head-size metal-on-metal implants were associated with increased risk of revision after two years, compared with metal-on-HXLPE implants.
Use of ceramic-on-ceramic implants with a smaller head size was associated with a higher revision risk compared with metal-on-HXLPE implants and ceramic-on-ceramic implants with head sizes >28 mm.
- Multinational Comprehensive Evaluation of the Fixation Method Used in Hip Replacement: Interaction with Age in Context
When compared with hybrid fixation, cementless fixation was associated with an approximately 58% higher risk of revision surgery in patients aged 75 years or older.
- International Comparative Evaluation of Knee Replacement with Fixed or Mobile Non-Posterior-Stabilized Implants
Mobile-bearing, non-posterior-stabilized knee designs presented a 40% higher risk of failure than that found with fixed-bearing, non-posterior-stabilized designs.
- International Comparative Evaluation of Knee Replacement with Fixed or Mobile-Bearing Posterior-Stabilized Prostheses
Compared with fixed-bearing posterior-stabilized knee prostheses, patients who received mobile bearings had an 85% higher chance of revision within the first postoperative year.
- International Comparative Evaluation of Fixed-Bearing Non-Posterior-Stabilized and Posterior-Stabilized Total Knee Replacements
Fixed non-posterior-stabilized (cruciate-retainin0 TKA performed better (with or without patellar resurfacing) than did fixed posterior-stabilized (cruciate-substituting) TKA.
- Survivorship of Hip and Knee Implants in Pediatric and Young Adult Populations: Analysis of Registry and Published Data
Reported revision rates of TKA and THA among pediatric and young-adult patients is currently similar to that for older patients, but the dearth of data makes it incumbent on registries to continue collecting and analyzing data relevant to younger populations.
This systematic review and meta-analysis concluded that surgeons performing a primary THA should use an implant that outperforms benchmarks established by the UK’s National Institute for Health and Care Excellence (NICE).
- Review of Clinical Outcomes-Based Anchors of Minimum Clinically Important Differences in Hip and Knee Registry-Based Reports and Publications
Among 19 registry reports and 1052 articles examined, only one report and two studies mentioned patient-reported outcome measures (PROMs) and minimum clinically important differences in connection with revision rates after TKA or THA.
- Implementation of Patient-Reported Outcome Measures in U.S. Total Joint Replacement Registries: Rationale, Status, and Plans
Successful collection of PROM data is possible with careful attention to selection of outcome measure(s) and minimizing the data-collection burden on physicians and patients.
According to a recent JBJS readership study among 1,000+ orthopaedic surgeons and residents, sources used for obtaining clinical orthopaedic information vary depending on one’s resident or surgeon status. For example, 9 out of 10 residents rely heavily on online journals, compared to 8 out of 10 surgeons. The reliance gap between online and print journals is much more significant among residents (94% to 68%) compared to the gap among surgeons (80% to 77%). Mobile app usage is much more common among residents, with just more than half, 52%, using them heavily for clinical orthopaedic information, compared to 36% among surgeons. As the graph shows, two other significant differences between residents and surgeons are the use of textbooks and social media sites as sources of clinical information.
…And a Geography Gap:
Surgeons outside the US and Canada are more dependent on online journals for their clinical orthopaedic information than surgeons in North America (91% international to 77% US/Canada). Textbook usage also varies greatly by geography. Within the US and Canada, only 28% of surgeons rely heavily on textbooks, while close to 60% of international surgeons rate text books high in usage. Twice the percentage of international surgeons rely heavily on social media for clinical information, compared to those within the US/Canada (5% vs. 13%).
After reading our item about Google Glass in the January OrthoBuzz, Dr. Ran Schwarzkopf, assistant clinical professor of orthopaedics at the University of California, Irvine (UCI), wrote us to explain briefly how teams of surgeons, nurses, and anesthesiologists use the technology at UCI. Dr. Schwarzkopf kindly responded to our follow-up questions in the following interview.
JBJS: Thank you, Dr. Schwarzkopf, for sharing your experiences with OrthoBuzz. First, can you tell us a bit about yourself?
Dr. Ran Schwarzkopf: I am an assistant professor in the Department of Orthopaedic Surgery at UCI, where I head the Adult Reconstruction Joint Replacement Service. I trained at NYU Hospital for Joint Diseases and completed a fellowship in adult reconstruction at Brigham and Women’s Hospital in Boston. I am part of the UCI Joint Replacement Surgical Home, which is a perioperative clinical care model jointly run by orthopaedics and anesthesiology.
JBJS: We understand that you’ve been using Google Glass in some interesting ways. How did the program get started?
Dr. Schwarzkopf: UCI has always been a pioneer in incorporating new technology into medical care. We have a long tradition of innovation and entrepreneurship. Due to the orthopaedic department’s close relationship with our anesthesia department and our successful Joint Replacement Surgical Home, we were approached by Pristine, a company that develops platforms for integrated medical systems. Together we decided to explore the use of different interactive glasses for operative applications. We started working with Google Glass as our first glass prototype, but we have also examined similar products from other companies. Together with the developers at Pristine, we designed different clinical pathways for optimizing the use of the Glass to enhance our clinical work from both the orthopaedic and anesthesiology perspectives.
JBJS: Was there a particular challenge you hoped Google Glass would help you address?
Dr. Schwarzkopf: In today’s orthopaedic operative environment, efficiency, cost reduction, and successful outcomes need to go hand in hand. We were looking to increase team interactivity and real-time communication while decreasing waste and unnecessary traffic in the operating room. We also wanted to enhance our resident learning options. Our anesthesia colleagues were looking to improve communication between their team members with real-time visuals.
JBJS: Please describe some of the things you and your colleagues have done using Google Glass?
Dr. Schwarzkopf: The orthopaedic team was able to broadcast surgery live to team members who were not inside the operating room, giving residents and visitors the ability to observe the procedure from the “surgeon’s point of view” without increasing traffic in the operating room. The surgeon was also able to view both check-lists and images on his glass view screen during the procedure. The nursing team inside the OR was able to communicate with our nurse manager without needing to exit the room or use the phone through a tablet screen outside the OR. Our anesthesia team includes an attending anesthesiologist and two residents or nurse anesthetists in two separate rooms. The anesthesiologist can observe both rooms from his tablet and can communicate with the physician/nurse inside. He can see both the monitors and the patient and help with decision making and problem solving without the need for constant paging and phone calls.
JBJS: What is the greatest benefit from this technology?
Dr. Schwarzkopf: I think the greatest benefit is the increased integration of the operating team and the streamlined processes that the technology affords us. We are able to communicate and provide oversight in a whole new way. It decreases traffic in the operating room and increases the speed of communication and care given to the patient.
JBJS: What surprised you the most about your experience with Google Glass?
Dr. Schwarzkopf: The ability to build a complex control tree, which enables one supervising physician to oversee others in a completely new way. We can now see through other peoples’ eyes and we can help and communicate in real time, without old-fashioned back-and-forth information transfer.
JBJS: By using several pairs of Google Glass simultaneously, you have been able to link surgeons, nurses, and anesthesiologists. What are the most important benefits of that type of teamwork? What barriers remain to greater collaboration?
Dr. Schwarzkopf: The ability to pair several glasses together is one of the main advantages of this new technology. We observed greater and more efficient teamwork on all sides—surgical, nursing, and anesthesia. The benefits include decreased OR traffic and cost reduction through reduced procedure times. The ability of a supervisor to see through his trainees’ eyes is priceless. We can now directly control actions beyond our immediate line of sight and we can do it without time-consuming back-and-forth communications. When you can see what your resident sees, the phrase “lost in translation” will no longer be relevant. The main barriers that remain are mostly technical, such as the hands-free or voice-activated ability to control the camera angle and “wink” control of the Glass activity. That’s being worked on as we speak.
JBJS: In honor of the 125th anniversary of JBJS this year, we are interested in what orthopaedists think might be important trends in the future. Looking ahead to the next 20 years or so, what do you think might be three significant advances or changes in orthopaedics?
Dr. Schwarzkopf: We will see significant changes in the way health care is managed and provided, mostly due to changes in regulation and federal guidelines. Resident education will incorporate more advanced methods to allow residents to improve their proficiency while still abiding by increasingly restrictive work-hour regulations. On the technological side I think we will see much more influence from the “gaming” world, like enhanced/augmented reality technology.
JBJS: Thank you very much, Dr. Schwarzkopf. We wish you continued success with all the innovations taking place at UCI.