SYMPOSIUM: 6th INTERNATIONAL CONGRESS OF ARTHROPLASTY REGISTRIES
The International Society of Arthroplasty Registries (ISAR) consists of member registries represented by managers or registry directors. The members of the society “… have a shared purpose of improving outcomes for individuals receiving joint replacement surgery worldwide. The focus of the society is to utilize the strength of cooperation and sharing of information and further enhance the capacity of individual registries to meet their own aims and objectives. The society is involved in the development of frameworks to encourage collaborative activities and provides a support network for established and developing registries” .
To realize this mission, ISAR has organized annual congresses that have attracted participants from all over the world representing different stakeholders and professions such as orthopaedic surgeons, nurses, physiotherapists, statisticians, epidemiologists, implant manufacturers, health policymakers, managers, and system developers.
This symposium contains papers presented at the 6th International Congress of Arthroplasty Registries, organized in San Francisco, CA, USA in May 2017, and focuses on registry research with clinical implications. It includes studies on implant design, long-term mortality, climate-associated infection risk, metal-on-metal (MoM) bearings, anesthesia in hip fracture patients, and patient-related risk factors for revision surgery.
The vast majority of patients who have a total joint replacement can expect a well-functioning joint for the remainder of their lives. Indeed, joint replacements performed for degenerative disorders of the hip and knee are among the most-successful surgical interventions in history [4, 12]. Improvements in implant technology, surgical techniques, and perioperative care have contributed to outstanding results for most patients. Joint registries have also played a crucial role in improving arthroplasty care as their activities have helped determine what implants and methods provide the best long-term implant survival [3, 5, 6, 8]. Registries gather data longitudinally in order to ascertain survivorship, causes of revision and reoperation, and in some settings, more-granular endpoints pertaining to pain and function. These data allow registries to report back to participating hospitals and units, in the hopes of stimulating quality-improvement interventions at the local level and improving patient care. Importantly, registries are not primarily device registers or research databases; they strive to provide an overall assessment of the care provided, ideally with a multidimensional approach, and to disseminate knowledge on best practices in their network of participating hospitals as well as internationally.
Although joint replacements generally are successful, there remains considerable room for improvement in areas like periprosthetic infections, arthroplasty for hip fractures, revision surgery, management of risk factors, and patient-reported outcomes. The prevention, diagnosis, and management of periprosthetic infections are issues of concern; the incidence of periprosthetic infection has not declined in the last three decades, the results of treatment are often poor, and the evidence for how best to treat infections is limited . Patients who undergo arthroplasty following a hip fracture have a high risk of death after surgery, and adverse events are disturbingly common . Unfortunately, few registries follow patients with hemiarthroplasty, and we might better be able to care for these vulnerable patients if more registries did so. Because restoration of function and relief of pain after revision arthroplasty (and other reoperations that might follow an index arthroplasty) are not as predictable as patients undergoing primary joint replacement, a future research focus on revision implant technology and surgical methods is warranted [13, 15]. Finally, although registry research has focused on risk factors for adverse events, we still do not know enough about whether our attempts to improve upon modifiable risk factors are having the desired effects.
While patient-reported outcome measures have limitations, they are the best available tools to measure pain, function, and health-related quality of life. Acknowledging the burden of collecting patient-reported outcomes, a gratifying number of arthroplasty registries have succeeded in setting up programs to collect such data, complementing traditional registry outcomes assessments that focus on survivorship . The fact that a large minority of patients do not experience the expected pain relief or improved function after total joint replacement—but not all patients undergo revision for these sometimes-disappointing results—mandates that we do more than simply track revisions. Just because a revision was avoided does not mean that the index arthroplasty was successful [2, 10].
ISAR also regards postmarket surveillance of implants to ensure patient safety as a high priority. The high revision rates of large-head MoM implants and their associated risk of pseudo-tumor development illustrates the need for additional efforts to avoid further marketing-driven and unrestrained introduction of new implant technology . ISAR’s lead on harmonizing methods and variable definitions used in arthroplasty registry research and the development of an International Prosthesis Library facilitates these important activities. The close collaboration of the ISAR members enables analysis of combined data, in order to examine early detection of underperforming implants and methods.
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