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4th Annual Report - In Figures
Author: National Joint Registry
The National Joint Registry 4th Annual Report is the formal public report of the National Joint Registry for 1st April 2006 to 31st March 2007. In addition it contains an analysis of the data held on the Registry.
The National Joint Registry (NJR) was established to improve care for patients who require hip and knee joint replacement implants and surgery. It does this by collecting data that can be used to measure the long-term effectiveness of implants used in hip and knee joint replacement surgery and information about the surgical procedures involved. Below are the the facts and figures from the report.
NJR Procedure figures for 2006
The compliance rate was 79% for procedures in the NHS and the independent sector, compared with 77% in 2005 and 60% in 2004.
415 NHS and independent sector hospitals and treatment centres were open and 393 (95%) submitted data to the NJR. On average, 112 hip replacements and 99 knee replacements were recorded per participating healthcare unit.
The NJR recorded 61,456 hip replacement procedures, of which 10% were revisions or re-operations, and 60,986 knee replacement procedures, of which 8% were revisions or re-operations.
Of the hip procedures, 65% were carried out in NHS hospitals, 25% in independent hospitals, 5% in NHS treatment centres and 4% in independent sector treatment centres.
Corresponding percentages for knee procedures were 67% in NHS hospitals, 21% in independent hospitals, 7% in NHS treatment centres and 5% in independent sector treatment centres.
Procedure Statistics
Patients with mild disease or more severe comorbidity increased from 68% in 2004 to 76% in 2006 in patients undergoing primary hip replacement, and from 74% to 82% undergoing primary knee replacement.
Cementless hip replacements increased from 21% in 2004 to 30% in 2006 and cemented replacements declined from 53% in 2004 to 48% in 2006.
155 different brands of acetabular cups and 176 brands of femoral stems were recorded, compared with 110 cups and 129 stems in 2005 and 88 cups and 101 stems in 2004. 22% of all cup and stem procedures used ‘mixed and matched’ cup-stem combinations.
54 brands of total condylar knee prostheses were recorded, with 13 unicondylar prostheses, 7 patello-femoral replacement and 12 hinged prostheses - an increase of about 50% compared with 2004.
Procedures between 1st April 2003 and 30th September 2006
The overall revision rate for primary hip replacement was 0.7% at 1 year and 1.3% at 3 years.
Procedure type was the most influential factor on implant survival following primary hip replacement. 1 year revision rates after hip resurfacing (1.6%) were five times higher than cemented total hip replacement (0.3%).
Hip resurfacing procedures still have a statistically higher revision rate within 1 year compared with cemented THR. A large number of the failures of hip resurfacing prostheses were in older female patients.
The overall revision rate for primary knee replacement was 0.4% at 1 year and 1.4% at 3 years. Revision rates at 1 year were similar between cemented total knee (0.3%) and unicondylar knee primary replacements (0.4%).
Mortality at 1 year was 1.9% after hip replacement and 1.6% after knee replacement, less than half of that observed in the matched general population, showing that joint replacement patients are a highly select group.
A thromboprophylaxis regime was prescribed for 74,868 (98%) of primary hip replacement patients and 76,581 (98%) of primary knee replacement patients. There was no difference in mortality up to 1 year between patients who were prescribed thromboprophylaxis and those who weren’t.
Average length of hospital stay
| Primary hip replacement |
9.1 days |
| Hip resurfacing |
6.3 days |
| Primary knee replacement |
8.1 days |
| Unicondylar knee replacement |
5.9 days |
NJR achievements and developments during 2006/07
Recorded 131,378 hip and knee joint replacement operations, 81% of the amount undertaken in NHS and independent healthcare units in England and Wales, bringing the total recorded on the Registry to 433,319.
Increased the number of records with patient consent to personal information being included on the Registry, from 78% in 2005 to 83% in 2006.
Increased the number of records with both patient consent and the patient’s NHS number, from 58% (shown in NJR 3rd Annual Report) to 69%.
Data capture improvements
Increased direct, on-site support for individual hospitals and treatment centres to help set up or improve processes for submitting information.
Gaining retrospective exemption from the Health and Social Care Act 2001, Section 60, which restricted use of the personal details of patients for whom a response of ‘don’t know’ had been allocated in the records.
Patients being asked for consent to provide their personal details to the NJR at the same time as giving their consent to undergo surgery.
Using Next-generation PACS To Enhance Patient Care
Across The Trust
Authors: Agfa HealthCare
 Virtually every hospital Trust in the UK is exploring the use of picture archiving and communication systems (PACS) as a means of replacing their use of hardcopy images and film archives. The choice of available systems can be daunting, however, and while all of these systems offer the ability to more efficiently manage the storage and transmission of images, hospital staff today are looking for systems that enable true operational advantages in their daily routines. At the Rotherham General Hospital (RGH) Trust, the decision was recently made to implement a next-generation image and data management solution to streamline workflows on an enterprise-wide basis and fundamentally improve the organisation and use of radiographic information. Within three months of installation, staff from across the Trust began to report significant improvements to case reporting, image-based diagnoses and treatment planning.
A simple solution to complex challenges
The chose system used at the RGH (IMPAX from Agfa HealthCare) is a web-deployable PACS for radiology that receives, distributes, archives, and displays digital images, enabling healthcare enterprises to eliminate their reliance on film. Through a digital connection to imaging systems, departmental units and hospital information systems (HIS), users within the healthcare enterprise gain an integrated view of patient data from a single screen. This clinically-relevant display allows users to not only read and review patient images, but to digital manipulate and interact with them to enhance diagnostics, analysis and treatment planning, as well as improve interdepartmental communication and organisation. This can substantially improve daily routines and enhance clinical diagnostic capabilities, while reducing the likelihood of clerical errors and misplaced film packets.
John Beeston, General Manager Clinical Radiology and Medical Physics at the RGH, described how some of these advantages have, in a short period, positively affected workflows at the Trust, “With the new PACS in place, all patient images and data are now available in digital format, instantaneously across the whole organisation. This allows multiple users to access the same files and images simultaneously from any location. The immediate advantages of this are that reports are being generated and dispatched much faster than they were previously, helping us to increase our daily turnarounds.
“Hospital staff also no longer have the problem of missing or incomplete films packets, a common issue for larger Trusts. Just as important is the ability of the system to improve communication between staff and enhance case conferencing, which is now being done both more easily and for a greater number of cases. This enables physicians and radiographers to even perform consults over the phone while looking at the same images.”
In addition to having rapid access to radiographic images, the installed PACS provides reports, technologist comments and other patient information in a consolidated display. Physicians viewing these files can then easily correct and manage patient data and integrate this information into scheduled worklists and files for grand rounds. By facilitating daily routines in this manner, the system helps staff to improve patient care and streamline patient journeys.
As Mr. Beeston continued, “One of the areas where we’ve seen a clear improvement to turnaround is the A&E department where the return times for assessment using films there has dropped from over one week to less than two days. Although we’re still gaining momentum with the system, we’ve also noticed improvements to other areas. A typical example of how patient journeys have been streamlined was a case in which a radiographer had received a GP referral for a suspected case of lung cancer. When the chest X-ray revealed a malignancy, the radiologist was able to immediately contact the medical physicians at the hospital and discuss the case details over the phone, while both were able to look at and review the X-rays and file information from the patient’s GP.
“The patient was then admitted directly for treatment, which was easily coordinated between the radiologist, pathologist and medical physician. Previously, this scenario would have entailed a number of delays in communication as the radiologist would have to send the films with the patient to the hospital, the radiologist would then have to schedule a time to meet with the medical team, and so on. In this case, we were genuinely able to influence the speed of the diagnosis and treatment pathway and it’s these kinds of efficiency gains that we’re beginning to experience on a day-to-day basis.”
Annette Talbot, PACS Application Administrator, agreed with these comments having noticed the same effects in radiology and other departments. “Since the installation of the new system, the waiting room in the radiology department has become decidedly less busy. As we’re not waiting for films to be developed or lasers to print, we’re able to receive, image and dispatch patients on a much shorter timescale; the same is becoming true for other wards and departments. Patients have definitely noticed this, as they are surprised when they no longer have to wait for a film packet. Those who have been at other Trusts without as an efficient system have definitely noticed that they are getting better service and spending less time nervously waiting for results.”
To improve diagnosis and treatment planning, IMPAX includes a range of image processing tools that enable the users to manipulate images in ways not possible with conventional film. Among some of these utilities are magnification tools to zoom in on fine details, contrast and brightness controls, and the ability to reformat axial imaging. “With the introduction of digital imaging and processing tools, our clinicians are achieving a much higher quality of diagnostics,” continued Mr. Beeston.
“Being able to adjust image contrast, make it positive or negative, and window images for on-screen comparisons are all new functions that contribute to a generational leap forward in our ability to use images for diagnosis and treatment planning. This has also begun to reduce the number of repeat X-rays performed at the hospital as the tools provided allow radiologists greater control over the depth of penetration when viewing bone structures and soft tissues. In the end, this is allowing staff to use their time much more effectively while patients are making fewer trips to the hospital to have X-rays taken.”
 So much more than bare bones
The Orthopaedics Department at the RGH is a large unit with more than 70 dedicated beds for adult and paediatric use and seven surgeons covering a variety of special interests including hip, knee, shoulder, elbow and hand surgery. Of all the Trust’s department’s, however, the orthopaedic group held the most reservations about moving over to a PACS system for filmless operations. This is not an uncommon trend among orthopaedic wards, which have a vast range of specific workflows requiring the interactive use X-ray and ultrasound films that require an intimate knowledge to replicate virtually.
“We have a considerable user base in our orthopaedics department and there were some initial concerns that installing a PACS System would hamper workflow,” said Alex Kocheta, an Orthopaedic Consultant and Hand Surgeon at the RGH.
“However, after getting past the initial learning curve at adoption, we’ve found that the hindrances we feared were never really borne out. In fact, in most cases the system has sped up our work processes in the same way it has for other departments. For instance, we no longer have the problems of lost film packets and the ability to bring up images at any time is quite useful. But for orthopaedic users, the real benefit of the system lies at the diagnostic and preoperative planning stages.”
With integrated algorithms and calculation tools, dedication orthopaedic PACS workstations can guide orthopaedic surgeons through preoperative planning and the virtual placement of implants. From a single interface, reconstructive and trauma surgeons can access patient images and transpose these onto a library of over 12,000 implant templates from 42 implant manufacturers. Specific mediCAD software modules are included for a range of operations from hip and knee surgery to osteotomy, biometry and coxometry cases. These enable significant time savings in complex operations and reduce the likelihood of complications to improve patient care.
“With regard to preoperative planning using mediCAD, it’s now possible for us to more accurately plan the type and size of implants we’ll need for both reconstructive and fracture reduction surgeries. Previously, preoperative planning of this nature was performed using an acetate sheet over the image to trace the target area. With the included mediCAD templating, however, we’re now able to draw around fracture fragments and put them in a virtually-reduced position on screen.”
“Not only does this allow for a better analysis of what size of implants will be required, but it enables us to more confidently select a treatment option in cases where two or three procedures might be appropriate. For example, I recently had a patient arrive with a very complex ankle fracture sustained during a motor-vehicle accident. Although I would prefer internal fixation in this case, I wasn’t sure whether it would be possible to safely insert a plate with sufficient screws distally into the lateral malleolus to achieve effective reduction. I was, therefore, instead leaning towards the use of an external fixator or frame. Using the templating software, I was able to explore both possibilities virtually and found that I would indeed be able to go in with internal fixation and perform treatment with confidence. In this manner, the system provided me with a much better impression of what to expect at surgery and there were no complications in the ensuing operation.”
To account for the magnification changes inherent with X-ray imaging, the orthopaedic solution also includes reference objects (30mm metal spheres) that can be used for both calibration purposes and to determine magnification power of patient images. When used in conjunction with the system’s templating functions, the system can then automatically complete complex measurements and drawings directly onto the patient X-ray with minimal user intervention.
“The template solution has been instrumental in reconstructive procedures, from small joint arthroplasties to total hip and knee replacements. When planning reconstructive procedures from film X-rays, there’s always an element of magnification that you’ll have to account for when measuring the dimensions of the patient’s bone structure. The further the bone is from the X-ray plate at the time of acquisition, the greater magnification effect.”
“This is particularly noticeable when imaging the hip joint of larger patients, which of course will have the further problem of being obscured by the fatty tissue of the buttocks. By placing metal reference spheres on a patient at the level of the bone we’re interested in, we can determine the precise level of magnification in the image and adjust bone measurements accordingly. Any problems associated with visualising the joint through layers of fatty tissues can also be resolved using the image manipulation functions. We’ve been using this method in an increasing number of both prosthetic joint replacements and trauma cases.”
Beyond preoperative planning and surgery, orthopaedic PACS users at the RGH have, in a short period, also observed several supplementary benefits enabled by their new system. Among the most important of these is improved control of their inventory. As Mr. Kocheta continues, “Using the mediCAD software for preoperative planning has a knock-on affect on orthopaedic stock management. It’s not uncommon for hospitals to keep more than £250,000 worth of implants and devices on-site, but even then you’ll often need to order-in specific components. By speeding up image acquisition and using the templating system to determine the size of the components needed, we can manage our inventory more efficiently. This has allowed us to actually reduce the volume of implants we keep in stock, which is attached to a modest cost savings.”
The next step forward
With the successful implementation of these systems at the RGH, the Trust is now planning to replace its legacy Radiology Information System (RIS). When integrated, the two systems will provide a unified view and centralised management of all patient information with bi-directional communication. As Mr. Beeston concluded, “We’re very much looking forward to upgrading our RIS system, which will provide us with an additional layer of efficiency. Among the new features our staff is interested in acquiring is voice recognition software, which will significantly reduce, or eliminate completely, the time spent transcribing reports. After completing the installation of their PACS, Agfa was our first choice for a new RIS system as well. In a very short time we’ve been able to realise tremendous time savings and we’re only tapping into the full potential of what we believe we can achieve with a next-generation PACS such as this one.”
For more information on IMPAX, please contact Alan Budge on email: alan.budge@agfa.com, or Tel: +44 (0)208 231 4872
Achilles Tendon Rupture Following Surgical Management For Tendinopathy: A Case Report
Authors: Michael R Carmont and Nicola Maffulli
Department of Trauma & Orthopaedic Surgery, University Hospital of North Staffordshire, Keele University School of Medicine, Stoke on Trent
Background
Achilles tendinopathy is understood to be a failed healing response process involving separation of collagen bundles, increase of hydrophilic extracellular matrix, haphazard neovascularisation, and absence of inflammatory cells 1,2. Patients present with pain and thickening of the tendon 3. Tendinopathy may lead to reduced tensile strength and a predisposition to rupture 4. Management aims to alleviate symptoms and reduce the theoretical risk of rupture. Conservative methods include eccentric loading exercises and the avoidance of aetiological factors 5. Operative management is utilised following the failure of non-operative methods 6,7.
We report the case of a patient who experienced an Achilles tendon rupture following surgical exploration of Achilles tendinopathy.
Case Presentation
A 44 year old retired Police Officer had a four year history of bilateral Achilles tendinopathy. The ailment had been managed conservatively with eccentric loading exercises and the avoidance of aetiological factors 5, but his symptoms failed to settle. The patient underwent surgical exploration to both tendons using a medial approach. The paratendon was excised, and fish mouth fasciotomies of the crural fascia were performed proximally 8. Small similarly sized nodules were present in both tendons. Longitudinal tenotomies were performed through the nodules within the tendons, and the tendinopathic areas were excised. The fat from Kager’s triangle was also detached from the anterior aspect of the tendon 8. Post-operatively, the patient was immobilised in a below knee synthetic cast, fully weight bearing as able. The casts were removed two weeks after surgery, and routine rehabilitation consisting of 3–4 episodes of eccentric loading exercises as limited by pain, was commenced 9. At five weeks following the operation, whilst standing on his toes, he experienced a sharp pain to his left Achilles tendon, and he was subsequently unable to weight bear.
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Figure 1:
Histology of the tendinopathic tendon at repair (Transverse plane, x 20 Magnification). Revealing scanty hypocellular degenerate tendon displaying separation of collagen fibrils (solid arrows) and disorganisation. Small pieces of fibrin (hollow arrow) were also present and there was no inflammation or neovascularisation. |
On examination the day after this episode, Simmond’s 10 and Matles’s 11 tests suggested an acute rupture of his Achilles tendon. The leg was placed in a below knee synthetic cast with the ankle in equinus, and the tendon was repaired percutaneously 12. Complete rupture of the tendon was noted at operation. Histology revealed findings consistent with Achilles tendinopathy although some of these changes may be secondary to initial surgery (Figure 1). Post-operative recovery was uneventful, and the patient recovered his full function.
Conclusion
Tendon healing occurs in three overlapping phases 3. The initial phase lasts 24 hours, and involves an intense inflammatory response with neutrophils, monocytes and macrophages. Vasoactive and chemotactic mediators stimulate vascular permeability, angiogenesis and tenocyte proliferation with type III collagen being produced. The second proliferative phase commences after a few days, with peak synthesis of type III collagen. After approximately six weeks, the remodelling phase commences, with decreased cellularity and decreased collagen and glycosaminoglycan synthesis. Consolidation occurs, and the repair tissue becomes more fibrous and the collagen fibres become aligned according to the direction of stress, and a greater proportion of type I collagen is synthesised. Eventually over the course of twelve months, during the maturation stage of healing, the fibrous repair matures into scar tissue 3.
Stretching is likely to increase collagen synthesis and improve fibre alignment leading to an increased tensile strength during healing. This should occur once the inflammatory phase of healing has settled13. Eccentric loading has been shown to produce better outcomes than with concentric loading exercises 14,15. These exercise programmes have been shown to reduce pain and improve function, although their effectiveness in the general population has recently been considered 16. Ultrasound scanning shows reduced tendon thickness and intratendinous signal 17, which can normalise following successful management 18.
Eccentric loading exercises form the basis of non-operative management, and most patients will respond if recognised early. In patients with tendinopathy recalcitrant to non-operative measures, surgical exploration leads to good results 19-22. We appreciate that there are several surgical methods, that it is not known which is the best way to remove degenerate tissue and that prolonged recovery following surgery may occur. Surgery removes adhesions and degenerate areas and other factors that influence local circulation 23.
No management is without complication, and these procedures carry a post-operative complication rate of up to 11% 24. However, we believe that Achilles tendon rupture following surgical exploration for tendinopathy has not been previously reported 25. At post-operative rehabilitation, the patient was attempting to stand on tip toes from a midstance position, thus performing an isometric loading exercise when his tendon ruptured. This was at five weeks following surgery at the end of the proliferative phase of tendon healing. Eccentric exercises are commonly performed in the rehabilitation programme following surgery for Achilles tendinopathy, they are considered safe, and we do not know why they resulted in a rupture in this particular patient. We appreciate that it may be difficult for a patient to recount the exact position and movement of the ankle at the time of rupture, our patient had already undertaken, all be it unsuccessfully, an eccentric exercise programme for his tendinopathies. Also, we cannot explain why only one tendon was affected, as both tendons were the same to visual inspection, underwent the same surgical procedure, and the same post-operative management regimen.
Authors’ Contributions
MC wrote the case report including performing the literature review. NM is an experienced Trauma & Orthopaedic Surgeon with an interest in the Achilles tendon. NM provided guidance for the literature search, the writing of the paper and also proof read the paper. Both authors have read and approved the final manuscript.
Acknowledgements
We thank the Departments of Medical Illustration and Histopathology for their assistance with this case report. Written consent was obtained from the patient for publication of the study. No funding has been received for the study.
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BMC Musculoskeletal Disorders 2007, 8:19doi:10.1186/1471-2474-8-19
© 2007 Carmont and Maffulli; licensee BioMed Central Ltd.
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