Optimizing Use of Large Databases in Joint Arthroplasty and Orthopaedics

Assessing the reproducibility of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) arthroplasty studies

BACKGROUND

Utilization of large-volume clinical registries for observational research has gained popularity in orthopaedic literature. However, concerns exist regarding inadequate reporting of methodology in this type of research. Despite these concerns, the reproducibility of such studies has not been adequately assessed in existing literature. This study aims to assess the reproducibility of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) arthroplasty studies on smoking as a risk factor for poor surgical outcomes by employing identical datasets and statistical methods.

METHODS

A systematic PubMed search between 2013 and 2023 identified ACS-NSQIP studies involving hip or knee arthroplasty and smoking as a potential risk factor for poor surgical outcomes. Each study's methods were reproduced by a trained statistician based on the reported methodology. In cases where certain steps were not explicitly stated, the statistician made informed decisions to reproduce those steps. Adjusted odds ratios (aORs) and p-values (α = 0.05) were compared between the original and reanalyzed datasets.

RESULTS

The initial search yielded 43 studies, with 11 meeting inclusion criteria resulting in the reanalysis of 268 aORs. Upon reanalysis, 12.69% of the original studies' aORs changed in interpretation, while 13.43% experienced a change in statistical significance. The average magnitude change of each aOR across all studies was 17.22%, and the sample size (N) in reanalysis varied by up to 47.84%. Among the 11 commonly cited studies, approximately one in eight objective conclusions changed in interpretation or statistical significance.

CONCLUSION

Inconsistent reproducibility exists across many arthroplasty studies that utilize the ACS-NSQIP database. These findings highlight the importance of rigorous reporting of study methodology, data collection, and statistical analyses when utilizing large-volume databases in orthopaedic research. This burden of responsibility should be shared among authors, peer reviewers, and orthopaedic journals to confirm the accuracy and validity of published database research.

LEVEL OF EVIDENCE

This study systematically reviewed and analyzed, in attempt to reproduce, published arthroplasty studies utilizing ACS-NSQIP database to assess smoking as a potential risk factor for poor surgical outcomes. All analyzed studies included Level III Evidence, therefore this current study compares reproduced Level III Evidence to the original Level III Evidence.

Does the Addition of a Tibial Stem Extender in Total Knee Arthroplasty Decrease Risk of Aseptic Loosening in Patients with Obesity? An Analysis from the American Joint Replacement Registry

Mechanical loosening is a leading cause of failure of total knee arthroplasties (TKAs) for which obesity may be a risk factor. With rising rates of obesity and increasing incidence of TKA, the identification of factors to mitigate this cause of failure is necessary. The purpose of this study is to determine if the use of a tibial stem extender (TSE) decreases the risk of mechanical loosening in patients with obesity undergoing TKA. The American Joint Replacement Registry and linked Centers for Medicare & Medicaid Services claims database were utilized to identify a patient cohort with a body mass index (BMI) of 30 kg/m2 or greater and age 65 years or older who underwent primary elective TKA between 2012 and 2021. Patients were divided into cohorts based on obesity class and TSE utilization. The estimated association of TSE use, BMI categories, and covariates with the risk of revisions for mechanical loosening in both unadjusted and adjusted settings was determined. Hazard ratios and their 95% confidence intervals for the risk of mechanical loosening were calculated. A total of 258,775 TKA cases were identified. A total of 538 of 257,194 (0.21%) patients who did not receive a TSE and one patient out of 1,581 (0.06%) with a TSE were revised for mechanical loosening. In adjusted analysis, TSE use was not protective against mechanical loosening and BMI > 40 was not a significant risk factor. Use of a TSE was not found to be protective against mechanical loosening in patients with obesity; however, analysis was limited by the small number of outcome events in the cohort. Further analysis with a larger cohort of patients with TSE and a longer follow-up time is necessary to corroborate this finding.

Miscoding in the Nationwide Inpatient Sample Database Raises Questions About Validity for Arthroplasty Research

BACKGROUND

The use of administrative databases in arthroplasty research has increased over the past decade. The Nationwide Inpatient Sample (NIS) is one of the first and most frequently used. Despite many published articles using this dataset, there exists no standardization resource accounting for the potential of biased results. The purpose of our study was to assess the amount of discordant data between clinically relevant variables and propose a standard for using this database in primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

An initial set of patients undergoing total joint arthroplasty were identified from the NIS between 2016 and 2019 using the International Classification of Diseases, 10th Revision, Procedure Coding System. All records with THA and TKA in any of the procedure variables (PR1-PR20) were included. A total of 63 relevant and consistent variables were selected for individual comparison including diagnosis-related group (1), elective (1), procedure codes (20), day of main procedure (1), and diagnosis codes (40). Descriptive statistics were used. A total of 3,562,819 patients were included in the initial set.

RESULTS

Using diagnosis-related groups, 5.3% were revision surgeries, 4.7% were not elective, 2.3% did not have THA or TKA as their primary procedure for hospitalization, and 2.9% of THA and 9.7% of TKA were bilateral. A total of 6.2% of the surgeries were done day(s) before or after admission, and 10.8% of THA and 6.3% of TKA were missing an orthopedic diagnosis for admission. Many had multiple orthopedic diagnoses for admission, 3.2% of THA and 0.7% of TKA. Overall miscoding was 23.3%.

CONCLUSIONS

Using the NIS without standardized data processing to study elective, unilateral, primary THA and TKA introduces major bias. A logical and stepwise approach to curate the data before analysis is proposed to improve research quality when using this database in hip and knee arthroplasty studies.

NSQIP data collection up to 30 postoperative days is sufficient to capture some complications in orthopedic surgeries

PURPOSE

The primary aim of this study is to determine if the 30-day follow-up period used by the National Surgical Quality Improvement Program (NSIQP) is an appropriate timeframe to capture complications after orthopedic surgeries.

METHODS

The 2019 NSQIP data were used. The independent variables were complication type. The dependent variable was days to complication. A Shapiro-Wilk test was used to determine if the data were normally distributed.

RESULTS

271,397 orthopedic cases were included. Myocardial infarction, pneumonia, ventilator over 48 h, progressive renal insufficiency, acute renal failure, stroke, and cardiac arrest had positive skewness and positive kurtosis. Deep incisional surgical site infection (SSI), organ/space SSI, wound disruption, unplanned reoperation one, unplanned reoperation two, readmission two, and readmission three had negative kurtosis and negative skewness. Complications with positive kurtosis and positive skewness are more likely to be confined to the 30-day postoperative period, whereas complications with negative skewness and negative kurtosis may be underreported within the 30-day follow-up.

CONCLUSIONS

These findings are useful in their ability to inform future orthopedic research using NSQIP which continues to generate new data for surgeons to consider for their postoperative care and complication management.

The True Dislocation Incidence following Elective Total Hip Replacement in Sweden: How Does It Relate to the Revision Rate?

(1) Background: The true dislocation incidence following THA is difficult to ascertain in population-based cohorts. In this study, we explored the cumulative dislocation incidence (CDI), the relationship between the incidence of dislocation and revision surgery, patient- and surgery-related factors in patients dislocating once or multiple times, and differences between patients being revised for dislocation or not. (2) Methods: We designed an observational longitudinal cohort study linking registers. All patients with a full dataset who underwent an elective unilateral THA between 1999 and 2014 were included. The CDI and the time from the index THA to the first dislocation or to revision were estimated using the Kaplan-Meier (KM) method, giving cumulative dislocation and revision incidences at different time points. (3) Results: 136,810 patients undergoing elective unilateral THA were available for the analysis. The 30-day CDI was estimated at 0.9% (0.9-1.0). The revision rate for dislocation throughout the study period remained much lower. A total of 51.2% (CI 49.6-52.8) suffered a further dislocation within 1 year. Only 10.9% of the patients with a dislocation within the first year postoperatively underwent a revision for dislocation. (4) Discussion: The CDI after elective THA was expectedly considerably higher than the revision incidence. Further studies investigating differences between single and multiple dislocators and the criteria by which patients are offered revision surgery following dislocation are urgently needed.

A Systematic Review of Data Collection by National Joint Replacement Registries: What Opportunities Exist for Enhanced Data Collection and Analysis?

BACKGROUND

National joint replacement registries assist surgeons and hospitals with guiding decision making and quality of care. The data points collected are essential to interpret and analyze data and to understand confounding variables and other sources of bias, which can impair retrospective observational research. The aim of this study was to review all national joint replacement registries to assess what data points are recorded, and in what manner, for primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) so that improvements can be made to enhance data collection, interpretation, and analysis.

METHODS

All national registries were identified through Internet and publication search and contacted to invite participation. Data collection forms for both primary and revision THA and TKA were requested. Data collected were entered into an Excel spreadsheet.

RESULTS

The study group for primary and revision THA consisted of 28 national registries, with 26 agreeing to participate. The study group for primary TKA consisted of 27 national registries, with 24 agreeing to participate. Patient identification details were recorded uniformly. Only a minority recorded patient details beyond American Society of Anesthesiologists and body mass index. Most registries did not record surgeon variables: who actually performed or assisted the procedure and their level of training. There was variation in the degree of detail recorded for diagnosis, mostly regarding secondary causes of osteoarthritis and fracture. The details regarding case complexity were limited. Half recorded previous operations, and fewer recorded bone defects. The location of knee arthritis, preoperative limb alignment, and deformities were rarely recorded. Surgical approach and technological adjuncts were routinely collected, but few other details on the surgical technique were recorded. Implant details and fixation were uniformly collected, although a minority recorded specific details, including cement antibiotic or cementing technique. It was uncommon to record whether additional or adjunctive procedures were concurrently performed. Approximately half the registries lacked a revision specific form. The majority recorded reoperations in addition to revision procedures. Patient, surgeon, case, and postoperative details were recorded similar to primary procedures. There was variation in the degree of details recorded for the reasons underlying the revision +/- reoperation, with most recording greater detail for infection and fracture. Many included details on case complexity and bone defects, including the severity, classification, and how the defect was managed. The majority recorded the specific revision procedure that was performed (total or partial), the fixation used, and the components removed or revised. Other specific aspects of fixation including acetabular screws, cone or sleeve use, stems, and augments were less commonly recorded.

CONCLUSION

Substantial data are recorded by all registries, although each one is different. Data solicited lack many patient factors, surgeon variables, case complexity, and surgical techniques. Separate revision forms are not universal, and many registries do not record reoperation procedures, specific causes of revision, and the revision construct.

LEVEL OF EVIDENCE

Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.