The UK Non-Arthroplasty Hip Registry

Ajay Malviya and Vikas Khanduja

Ajay Malviya is Chair – NAHR, Consultant Orthopaedic Surgeon – Northumbria Healthcare NHS Foundation Trust.

Vikas Khanduja is Past Chair – NAHR, Consultant Orthopaedic Surgeon – Addenbrooke’s, Cambridge.

The UK Non-Arthroplasty Hip Registry was established in 2012 with the support of the British Hip Society (BHS) under the leadership of Prof John Timperley, Consultant Orthopaedic Surgeon at the Princess Elizabeth Orthopaedic Centre in Exeter.

Over the last two decades there has been an exponential rise in the number of hip preservation procedures being performed in the UK, but at the time of the conception of the registry it was noted that in contrast to joint replacement surgery, there was a lack of outcomes data outside of small scale published series. However, evidence has evolved in time with the FASHIoN and FAIT randomised controlled trials led by Prof Damian Griffin (Coventry) and Prof Sion Glyn Jones (Oxford) at the forefront of world research. The results of these studies combined with longitudinal ‘real world’ data from the NAHR will be central in guiding future patient selection, treatment and improve outcomes.

NAHR Board

The board has changed over time and currently consists of six surgeons from across the country (Figure 1) who dedicate a significant amount of their time to the Registry not just by contributing patients but also by ensuring updates, improving the quality of data analyses, working on surgeon and patient compliance, maintaining finances, website development (www.nahr.co.uk) and annual reports. At the recent BHS AGM in March 2021, expansion of the NAHR Board was approved. It was decided to invite applications for the role of regional representatives (10 in total), to improve local referral pathways and surgeon engagement. It is an exciting opportunity for all surgeons to be closely involved with the NAHR.

Number of pathways, contributing surgeons and the effect of the pandemic

We currently have more than 15,000 patient pathways registered in the NAHR under 106 contributing surgeons. The latest monthly report from Amplitude (Figure 2) shows that after the initial drop in March/April 2020 in patient pathways, there was a gradual increase until a further drop due to the second wave of the pandemic in October 2020. Subsequently, there has been slow resumption of activity representing the effect of the pandemic on the provision of elective services.

Figure 2: Monthly report

Annual Report

The 6th Annual report was published in March 2021 and demonstrates the benefits of hip preservation surgery in a large cohort of patients undergoing hip arthroscopy and pelvic and femoral osteotomy for hip dysplasia. However, the report also highlights the two problems of patient and surgeon compliance which is common to all voluntary and PROMs based registries.

Unfortunately, the number of surgeons actively contributing last year has decreased to 49 compared with 59 in 2019 and 65 in 2018.

The reason is unclear given that the annual number of patients entered has continued to increase up to 2019. The NAHR user group is determining whether this represents low volume surgeons stopping hip preservation surgery or not submitting data. There remain a few high-volume surgeons contributing the majority of the data with over 58% of data submitted by only 10 surgeons (Figure 3). As entering data is not mandatory, it is likely operations are being performed by surgeons not entering data and this is an area that the Registry, the BHS as well as health care commissioners are keen to address.

Figure 3: Number of cases per surgeon

One of the greatest challenges that faces any registry that collects PROM data is patient compliance in completing the forms during follow-up. Figure 4 shows the rate of collection of the Index scores at various time intervals with the six-month collection for 2020 at around 45%. The user group in collaboration with Amplitude are looking at a variety of measures to increase completion rates and this a major focus for the NAHR over the next year.

Figure 4: i-HOT-12 Score completion

COVID-19 surveillance

The younger and medically fit patients that are typically treated in our practice with day case procedures were considered the ideal cases for the resumption of elective services. It was therefore essential that we put systems in place to ensure safe resumption of elective operating. As a team, we embedded the COVID-19 surveillance audit into the NAHR, one of the features which we will see more of as the registry matures.

As of 1st June 2020, all patients entered in the NAHR receive an additional set of questions. These include an introductory email to the patient at the time of the surgery to establish what protocols were in place to ensure that they had their intervention in a safe environment and whether they understood the implications of having an elective procedure during this time. It is followed up with a 30-day and 90-day email to establish whether they developed any COVID-19 related complications. During this period (Figure 5), of the 551 patients entered, 349 had completed their baseline scores with a 63% compliance. Of these, 298 had completed their 30-day questionnaire and 232 their 90-day questionnaire. The results are being monitored and will be presented at the BHS Annual meeting in June 2021.

Figure 5: Latest COVID-19 surveillance data

Instant reporting upgrade

From the various discussions we have had with our members, it was apparent that some have found it difficult to analyse their own data entered into the registry. At its inception in 2012, the expectation to critically analyse the data was different as the registry was in its nascency, and the initial challenge was to ensure that the data entry process was functional. It was therefore important that we improved the functionality, specifically to allow the surgeon to prepare a report for their appraisal and provide more granularity to their own data. Over the last year, we have worked on this functionality together with Amplitude and the upgrades are now in place. The NAHR members are now able to objectively examine their own data and compare outcomes with the national averages. Please use the link ‘NAHR PROCEDURE CHART’ in the reports section of the portal to access this functionality (Figure 6).

Figure 6: Reports Dashboard

This will be beneficial not just for appraisal but additionally for audits and research and to assess what works best in an individual’s service.

Research

There has been significant amounts of progress in this area. Stellar work done by the team has resulted in a number of presentations at the free paper session of the BHS Annual meeting in 2020. We have also had the first paper from NAHR published in JBJS Am reporting on outcomes of periacetabular osteotomy (PAO) with others to follow. The key message from the recent publication is that PAO is a successful surgical intervention for hip dysplasia and acetabular retroversion in the short term and with significant improvement in patientreported outcome scores maintained up to two years postoperatively.

Our study looking at the role of hip arthroscopy for femoroacetabular impingement (FAI) has shown that 67% of patients achieved improvement in scores over and above the minimum clinically important difference (MCID). Pincer pathology, high-grade chondral lesions and higher preoperative scores are predictors of lower improvement in scores. Age above 40 and high BMI are also associated with poorer outcomes. Labral repair leads to significantly better improvement in scores as compared with labral debridement.

For a registry to be able to provide this level of information in its ninth year is an achievement and the BHS and the NAHR would like to thank all the members of the user group, the surgeons, administrative staff and the patients that have contributed data to make this possible. There is no doubt that there is still an immense amount of work to be done especially around patient and surgeon compliance. We hope that continued engagement with all of these groups will continue to improve data collection and quality, allowing future reports to shed even more light on this complex area of hip surgery. An open application process for availing the NAHR dataset has been created by the user group to encourage further research (only those contributing data to the Registry regularly are eligible to apply). All research proposals are evaluated by the user group at regular intervals.

Education programme

Over the last three years, the nonarthroplasty group has secured a regular place for a ‘Topic in Focus’ at the BHS Annual Meeting and also one session at the Annual BOA meeting. There is a rolling education programme in place and for the BHS Annual meeting in June 2021, we are planning to have a case-based discussion involving AVN of the hip and periarticular pathologies around the hip (Greater trochanteric pain syndrome and Posterior hip pain) with a panel of national and international experts debating and providing insights into the management of these conditions. This will provide a different perspective to the other themes that we have been presenting thus far. In addition, the BHS Education Committee, led by Vikas Khanduja, has launched an ambitious series of webinars every month. The NAHR group has been allocated four of these sessions and we will be covering FAI, Hip Dysplasia, AVN of hip and Periarticular pathologies around the hip in detail.

The NAHR has demonstrated promising progress on several fronts and would like to obtain more feedback on how we can improve the service delivered to the surgeons. Specifically, with regards the plan to restructure the team with appointment of ten regional representatives to help champion local engagement. Please contact us if interested (nahr@britishhipsociety.com). We also have some exciting plans for research and travelling fellowships and are exploring options for a sustainable and financially viable solution. In the long-term we aim to establish and support regional and national MDTs for complex case discussion on a regular basis.

The team is a firm believer of “If you do not measure it, you cannot improve it”. We aim to create a comprehensive, self-sustaining and robust system to measure patient outcomes and improve patient care.

We would encourage all surgeons involved in hip preservation surgery to contribute, and if you are encountering difficulties assistance can be provided. The registration link is available on the NAHR website (www.nahr.co.uk).