U.S. Registry Identifies Goldilocks Zone for Joint Replacement Timing

This week’s AAOS congress will see data presented from a U.S. national registry, the FOREC-TJR database, that promises to inform decisions on hip and knee replacement.


The UK’s National Joint Registry rather stole the show when it yielded pivotal data that damned metal-on-metal hip prostheses. Ever since then the value of registries as an alternative to controlled trials has become recognised. Now, after  four years and, $12 million spent, a U.S. national research project funded by the Agency for Healthcare Research and Quality (AHRQ) has also delivered a valuable outcome. The output from what is called the FORCE-TJR database, will be presented at the forthcoming American Academy of Orthopedic Surgeons annual meeting (March 24-28) and represents the most comprehensive U.S. database on total hip and knee joint replacement patients and their surgical outcomes.

The project and resulting database, called , is the first on total joint replacements (TJR) to identify risk-adjusted national benchmarks, including patient risk factors, and other clinical measures, to guide surgeon and patient decisions regarding timing of surgery and optimal patient selection.

A consortium of more than 150 surgeons from representative practices across the U.S., led by researchers at the University of Massachusetts Medical School, collected information from more than 30,000 diverse TJR patients to establish a statistically significant cohort for the AHRQ-funded database. FORCE-TJR goes beyond the traditional collection of information on only implant device failure or repeat surgeries. It is the first U.S. TJR database to include PROs – patient-reported measures of pain and function pre- and post-surgery, as well as clinical measures such as readmission and infection rates, adverse events, clinical co-morbidities and other patient risk factors and demographics that may influence patient outcomes.

Research findings include:

  • Optimum timing for hip and knee replacement surgery: National benchmarks identified by FORCE-TJR data show that while there is remarkable consistency in the level of pain and disability among today’s TJR patients, those who wait too long, or have surgery too early, may not gain the highest level of improvement after TJR.
  • Comparisons of patient risk factors and outcomes: post-surgery patient pain and function, and readmission rates, are influenced by a number of pre-operative patient risk factors. FORCE-TJR’s risk-adjustment methods account for varied patient factors so surgeons can, for the first time, compare their patients’ risk factors to national data and adjust, if needed, their patient selection criteria for optimal outcomes and patient care.
  • Outcomes data on working-aged adults: Individuals under the age of 65 make up more than 40% of all TJR patients – and are the fastest-growing patient population for TJR. Prior to FORCE-TJR, outcome information was available only for Medicare-eligible patients (over 65). FORCE-TJR data shows, for the first time, that patients younger than 65 have more musculoskeletal risk factors such as multiple painful joints or low back pain than older patients. However, these younger patients can expect comparable levels of pain relief and functional outcomes that may benefit their overall quality of life.

FORCE-TJR is now serving as a comprehensive orthopedic registry, expanding to enroll surgeons and hospitals beyond the original AHRQ-funded cohort. In addition to providing access to national TJR benchmarks, the FORCE-TJR registry provides real-time patient-reported outcome scoring and comprehensive, comparative arthroplasty practice feedback and data to improve patient care, meet reporting requirements, compare performance to peer surgeons/institutions, and secure quality incentive payments.

Committee Comments 

“Total hip and knee joint replacements are the most common inpatient surgical procedures performed in the U.S., and the greatest expense of the Medicare budget,” says FORCE-TJR steering committee member Joan A. McGowan, PhD, Director of the Division of Musculoskeletal Diseases at the NIH’s National Institute of Arthritis and Musculoskeletal and Skin Diseases. “The FORCE database is the first to allow independent assessment of total joint replacement effectiveness in terms of both implant performance and improvement in patient pain and physical function.”

“With this data, for the first time, we can compare patients’ physical outcomes with varied implants, surgical approaches and follow-up programs. We have benchmarks to use to see where our patients fall on a national spectrum both pre- and post-surgery,” says Dr. David Ayers, MD, co-lead of FORCE-TJR and chair of the Department of Orthopedics and Physical Rehabilitation at UMass Medical School. “The data is invaluable for developing best practices.”

Physician comments

“The research on the original AHRQ-funded cohort will continue indefinitely as we implement annual follow-ups with those patients,” says Patricia Franklin, MD, PI, AHRQ grant and professor of Orthopedics and Quantitative Health Sciences at the UMass Medical School. “The data we’ve collected, and continue to add to, has the potential to directly influence clinical best practices, health care policy and the overall health and quality of life for more than 60 million people in the U.S. living with arthritis.”

Source: Business Wire

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