hospital activity (Part Four), the National Joint Registry has a new, dedicated online annual report website 'NJR. Reports' to host and share all the NJR's annual ...
HIPS KNEES ANKLES ELBOWS SHOULDERS PROMs
11th Annual Report
2014 National Joint Registry for England, Wales and Northern Ireland ISSN 2054-183X (Online)
Surgical data to 31 December 2013
Prepared by The NJR Editorial Board NJRSC Members Mick Borroff Michael Green Professor Paul Gregg Professor Alex MacGregor Mr Martyn Porter Mr Keith Tucker Nick Wishart NJR RCC Network Representatives Mr Colin Esler Mr Peter Howard Mr Alun John Mr Matthew Porteous Orthopaedic Specialists Mr Andy Goldberg NJR Research Fellows Mr Jeya Palan Healthcare Quality Improvement Partnership NJR Management Team and NJR Communications Rebecca Beaumont James Thornton Elaine Young Northgate Information Solutions (UK) Ltd NJR Centre, IT and data management Victoria McCormack Anita Mistry Dr Claire Newell Dr Martin Pickford Martin Royall Mike Swanson University of Bristol NJR Statistical support, analysis and research team Professor Yoav Ben Shlomo Professor Ashley Blom Dr Emma Clark Professor Paul Dieppe Dr Linda Hunt Garry King Dr Michèle Smith Professor Jon Tobias Pad Creative Ltd (design and production) This document is available in PDF format for download from the NJR Reports website at www.njrreports.org.uk Additional data and information can also be found as outlined on page 16.
This document is available in PDF format for download from the NJR website at www.njrcentre.org.uk
National Joint Registry for England, Wales and Northern Ireland | 11th Annual Report
Contents 8
Chairman’s introduction Foreword from the Chairman of the Editorial Board
10
Executive summary
12
Part 1: Annual progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Part 2: Clinical activity 2013. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Additional information on the NJR Reports website . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Part 3: Outcomes after joint replacement 2003 to 2013. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Part 4: Trust-, Local Health Board- and unit-level activity and outcomes 2013. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Part 3 Outcomes after joint replacement 2003 to 2013
23
3.1 Summary of data sources and linkage
23
3.2 Outcomes after primary hip replacement
26
3.2.1
Overview of primary hip surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.2.2
Revisions after primary hip surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.2.3
Revision after hip surgery with a ‘competing risk’ of death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.2.4
Revisions after primary hip surgery for the main stem-cup brand combinations. . . . . . . . . . . . . . . . . . . . . . . 49
3.2.5
Revisions for different causes after primary hip surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.2.6
Mortality after primary hip surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.2.7
In-depth study: Short-term mortality after hip replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.2.8
Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
73
3.3 Outcomes after primary knee replacement 3.3.1
Overview of primary knee surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.3.2
Revisions after primary knee surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
3.3.3
Mortality after primary knee surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
3.3.4
In-depth study: Short-term mortality following primary knee surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
3.3.5 Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
122
3.4 Outcomes after primary ankle replacement 3.4.1
Overview of primary ankle surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
3.4.2
Revisions after primary ankle surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
3.4.3
Mortality after primary ankle surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
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3
Part 3 tables
4
Table 3.1
Summary description of datasets used for survivorship analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Table 3.2
Composition of person-level datasets for survivorship analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Table 3.3
Numbers and percentage of primary hip replacements of each type of fixation and within each fixation sub-group, by bearing surface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Table 3.4
Percentages of primary hip replacements in each calendar year that use each fixation type and for each fixation group, the percentages within each bearing surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Table 3.5
Distribution of consultant surgeon and unit caseload for each fixation type . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Table 3.6
Distribution of age at primary hip replacement (in years) and gender, for all procedures and for each type of fixation and bearing surface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Table 3.7
Kaplan-Meier estimates of the cumulative percentage probability of revision (95% CI), by year from the primary operation, for all cases and by fixation and bearing surface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Table 3.8
Kaplan-Meier estimates of the cumulative percentage probability of revision (95% CI), by gender and age, at 1, 3, 5, 7 and 10 years from the primary operation, for each fixation group and main bearing surface. . . . 43
Table 3.9
Kaplan-Meier estimates of the cumulative percentage probability of revision (95% CI) at 1, 3, 5, 7 and 10 years after the primary operation, for the most commonly used cup-stem brand combinations (group sizes >2500, or >1,000 in the case of resurfacings). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Table 3.10
Kaplan-Meier estimates of the cumulative percentage probability of revision (95% CI) at 1, 3, 5, 7 and 10 years after the primary operation for the most commonly used cup-stem brand combinations (group size >10,000) with further subdivision by main bearing surface; results are shown only for the bearing surface sub-groups with >1,000 procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Table 3.11
Revision rates for each indication, expressed as numbers per 1,000 patient-years (95% CIs), for all cases and by fixation and bearing surface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Table 3.12
Revision rates for each indication, expressed as numbers per 1,000 patient-years, overall and by time interval from primary operation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Table 3.13
Kaplan-Meier estimates of the cumulative percentage mortality (95% CI), at different time points after primary operation, for all cases and by age/gender.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Table L1
90 day mortality by age and gender. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Table L2
Changes in mortality over time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Table L3
Univariable and multivariable analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Table L4
Additional multivariable models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Table L5
Change in the use of thromboprophylaxis with time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Table L6
Change in the use of spinal anaesthesia with time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Table L7
Charlson comorbidities found in HES in the 5 year period prior to the primary operation . . . . . . . . . . . . . . . . 70
Table L8
Results from imputation models for BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Table 3.14
Numbers and percentage of primary knee replacements by fixation method and bearing type. . . . . . . . . . . . 78
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National Joint Registry for England, Wales and Northern Ireland | 11th Annual Report
Table 3.15
Percentage of all primary knee replacements performed each year by method of fixation and within each method of fixation, the percentage breakdown of each bearing type. . . . . . . . . . . . . . . . . . . . . . 79
Table 3.16
Distribution of consultant surgeon and unit caseload for each fixation type . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Table 3.17
Age (in years) and percentage male at primary operation for different types of knee replacement; by fixation and bearing type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Table 3.18 (a)
Kaplan-Meier estimates of the cumulative percentage probability of first revision (95% CI) at specified times after primary knee replacement, by fixation and bearing type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Table 3.18 (b)
Kaplan-Meier estimates of the cumulative percentage probability of first revision (95% CI) at specified times after primary knee replacement, by age and gender, for each fixation and bearing group. . . . . . . . . . . 93
Table 3.19
Revision rates (95% CI), expressed as number of revisions per 1,000 patient-years, for each recorded reason for first knee revision. Rates shown are for all revised cases and by fixation type . . . . . . . . . . . . . . . . 99
Table 3.20
Revision rates (95% CI), expressed as number of revisions per 1,000 patient-years, for each recorded reason for first knee revision. Rates shown are for each fixation/bearing surface sub-group. . . . . . . . . . . . . 101
Table 3.21
Revision rates (95% CI) broken down by time period in which primary was revised, expressed as number of revisions per 1,000 patient-years, for each recorded reason for first knee revision. . . . . . . . . . . . . . . . . . 103
Table 3.22
Kaplan-Meier estimated cumulative percentage probability of first revision (95% CI) of a primary total knee replacement by main type of implant brand at the indicated number of years after primary operation. . . . . .104
Table 3.23
Kaplan-Meier estimates of the cumulative percentage probability of first revision (95% CI) of a primary unicompartmental knee replacement by main type of implant brand at the indicated number of years after primary operation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Table 3.24
Kaplan-Meier estimates of the cumulative percentage probability of first revision (95% CI) of a total knee replacement at the indicated number of years after primary operation, by main implant brands and type of fixation and constraint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Table 3.25
Kaplan-Meier estimated cumulative percentage probability (95% CI) of a patient dying at the indicated number of years after a primary knee joint replacement operation by age group and gender. . . . . . . . . . . . 112
Table L9
45-day mortality by age and gender. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118
Table L10
Changes in mortality by year of primary operation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Table L11
Cox ‘proportional hazards’ models of 45-day mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Table 3.26
Numbers of primary ankles by ankle brand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Table 3.27
Indications for the 29 (first) revisions following primary ankle replacement . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Table 3.28
Kaplan-Meier estimates of the cumulative percentage mortality (95% CI), by gender and age, at 90 days and 1, 2 and 3 years from the primary operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
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5
Part 3 figures
6
Figure 3.1
Temporal changes in percentages of each fixation method used in primary hip replacements. . . . . . . . . . . . 30
Figure 3.2
Temporal changes in percentages of each bearing surface used in (a) cemented, (b) uncemented, (c) hybrid and (d) reverse hybrid primary hip replacements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Figure 3.3
Temporal changes in revision rates: Kaplan-Meier estimates of cumulative percentage probability of revision for (a) each year of primary operation and (b) over the first three years . . . . . . . . . . . . . . . . . . . . . . . 34
Figure 3.4
Comparison of cumulative probability of revision (Kaplan-Meier estimates) for cemented hips with different bearing surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Figure 3.5
Comparison of cumulative probability of revision (Kaplan-Meier estimates) for uncemented hips with different bearing surfaces.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Figure 3.6
Comparison of cumulative probability of revision (Kaplan-Meier estimates) for hybrid hips with different bearing surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Figure 3.7
Comparison of cumulative probability of revision (Kaplan-Meier estimates) for reverse hybrid hips with different bearing surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Figure 3.8
Cumulative probability of revision (Kaplan-Meier) for the whole cohort of hips broken down by (a) age at primary and (b) age separately for each gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Figure 3.9
Comparisons between Kaplan-Meier estimates for revision (solid lines) and cumulative incidence function (CIF, dashed lines) which makes adjustment for the competing risk of death; separate comparions are made for age groups
