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New Technologies and Challenges Joint Replacement Prof Stephen Graves Director AOA National Joint Replacement Registry.

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Presentation on theme: "New Technologies and Challenges Joint Replacement Prof Stephen Graves Director AOA National Joint Replacement Registry."— Presentation transcript:

1 New Technologies and Challenges Joint Replacement Prof Stephen Graves Director AOA National Joint Replacement Registry

2 Australian Orthopaedic Association National Joint Replacement Registry (AOA NJRR)

3 AOA NJRR Commenced in 1999 State by State implementation Fully National in 2002 Collaboration of Orthopaedic surgeons, Governments, Hospitals (Public and Private) and Industry Funded entirely By Commonwealth Quality information on Australian joint replacement surgery not available form any other source Determines the outcome in particular the risk of revision

4 Changing Rate of Joint Replacement All Joints 93.8% Hips 61.9% Knees 138.4%

5 Currently Approx 65,000 procedures p.a. In excess of $1 billion p.a. Prostheses 35% of cost and increasing Over 60% of procedures in private The rate of increase is greater in private By ,000 procedures p.a What % in private?

6 Outcomes Registry uses Revision is an indication of failure of a joint replacement procedure Proportion of Procedures undertaken that are revisions 2001 Hip 14.2%Knee 10% 2005Hip 12.1%Knee 8.2% As good or better than most countries

7 Comparison to Sweden Proportion of procedures that are revisions Australia Hip 12.1%Knee 8.2% Sweden Hip 7-8% Knee 7% Risk of Revision Surgery is better indicator of success Australia 20-25% (Estimated Hip and Knee) Sweden 10% (Hip and Knee)

8 Expenditure Implications Reducing proportion of revisions by 1% decreases revision procedures by 650 p.a. ($ 16 – 32 million) If Australia had the same rate of revision for hip and knee replacement as Sweden there would be 3250 less revisions a year ($ 81 and 162 million p.a.) Reduced by 2% p.a. since 2001

9 Why the difference Detailed in Recent Report for the Australian Centre for Health Research (ACHR) Data from AOA NJRR 2006 Annual Report Identical demographics of patients receiving joint replacement surgery Some differences in patient selection Major differences in prostheses selection Major differences in prostheses fixation Greater uptake of new prostheses technology in Australia

10 FNOF outcomes by Age Data: 1 st September 1999 to 31 st December 2005 Monoblock Modular Bipolar

11 Outcomes related to Category of Prostheses for Treatment of FNOF Modular and bipolar better than monoblock Modular and bipolar better than monoblock Differences are greatest in the younger age groups. (less than 75, and 75-84) Differences are greatest in the younger age groups. (less than 75, and 75-84) Bipolar may be better than Modular except in over 85 yr old age group Bipolar may be better than Modular except in over 85 yr old age group Cement fixation much better no matter what type of prostheses Cement fixation much better no matter what type of prostheses

12 Outcomes: Conventional Primary Total Hip Data: 1 st September 1999 to 31 st December 2005

13 Outcomes by Age & Fixation Under Over 75

14 Trends in Prosthesis Fixation Conventional Primary THR

15 Resurfacing Hip Replacement Increasing use (8.9% of primary THR 2005) Increasing use of prostheses other than the Birmingham (96.3% 2001 and 63.5% 2002)

16 Outcomes: Resurfacing V Conventional THR (OA only) Data: 1 st September 1999 to 31 st December 2005

17 Cumulative Percentage Revision by Gender Data: 1 st September 1999 to 31 st December 2005

18 Cumulative Percentage Revision by Age Data: 1 st September 1999 to 31 st December 2005

19 Approach to differences in categories of prostheses and prostheses fixation Many examples in both hip and knee replacement Many examples in both hip and knee replacement Registry identified variation in general is responded to very quickly Registry identified variation in general is responded to very quickly Complexity in understanding and determining implication of findings Complexity in understanding and determining implication of findings Best left for the profession to decide Best left for the profession to decide AOA to establish Guidelines based on Registry Data AOA to establish Guidelines based on Registry Data

20 Registry is able to compare outcomes of Individual prosthesis Least revised Least revised Most revised Most revised Those with a higher than anticipated rate of revision Those with a higher than anticipated rate of revision

21 Cemented Primary THRs Minimum 1000 Observed component years for least revised Data: 1 st September 1999 to 31 st December 2005

22 Least Revised Hybrid and Cementless Primary THRs Minimum 1000 Observed component years Less than 2% Revision at 2 years Data: 1 st September 1999 to 31 st December 2005

23 Most Revised Cementless Components Data: 1 st September 1999 to 31 st December 2005

24 Revision rates of different Resurfacing prostheses Data: 1 st September 1999 to 31 st December 2005

25 Preservation Fixed

26 Genesis II Cementless Oxinium

27 Outcomes of New Prostheses Prosthesis type Number of prostheses with CRR 3 years or less Compared to top 3 with CRR of 4 or more years and over 1000 procedures BetterSameWorse Uni Knee Cemented TKR4004 Cementless TKR12066 Cemented THR2002 Cementless THR Total

28 New Prostheses None have performed better than previously approved and well established prostheses Many have higher revision rates Some have been considerably worse All are associated with increased expenditure

29 New Prostheses Considerations Currently Class IIb Europe recently changed to Class III What clinical information should be required prior to approval ? –Clinical Trials –RSA studies Do parameters need to be set ? Is equivalence sufficient for approval ? How are minor modifications to be handled ? Innovation and development must be encouraged

30 Enhancing outcomes Focus on what is best for patient outcomes Guidelines for joint surgery using Registry information (appropriate patient and appropriate procedure)? Reduce prostheses choice? How? Remove poor performing prostheses from list? Reduce or cease funding for poor performing prostheses? Regulate differently the introduction of new prostheses? Is this experience relevant to other devices?


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