• Outlier trusts on National Joint Registry cited infection rates and issues with training and supervision
  • Data shows nine units as outliers two years in a row
  • National hip and knee revision rates have improved every year since 2011 

Outlier trusts for orthopaedic surgery have blamed above average infection rates, a need for closer supervision of trainees, and frail and overweight patient cohorts for their results.

HSJ analysis of National Joint Registry data showed seven NHS units and two private hospitals had high rates of revisions to hip and knee procedures for two consecutive years.

Three NHS units and one private hospital had outlying revision rates for knee surgery in both 2018 and 2019. Three further NHS units and another private hospital had outlying rates for hip replacement revisions in both years. A further NHS hospital was an outlier for both knee and hip surgery in both years. 

Three trusts – Mid Cheshire Hospitals Foundation Trust, Weston Area Health Trust and Western Sussex Hospitals FT – said infections were a factor in their revision rates.

Weston said it has put measures, such as ring-fencing elective beds and screening for MSSA, into place to address this. Mid Cheshire said its consultants now discuss all potential cases of infection with microbiologists. Western Sussex Hospitals FT said its surgical site infection prevention efforts had been recognised with a national award. 

Mid Cheshire also cited other factors contributing to its outlier status, including the training of senior orthopaedic trainees and new consultant learning curves. It said potential revision cases are now discussed at monthly meetings, where post-operative X-rays are critiqued. All proposed revisions and complex cases are discussed before surgery.

Meanwhile, University Hospital Southampton FT said its 2018 audit highlighted issues with the supervision of non-consultant level surgeons. The trust said stricter supervision requirements were implemented immediately and a full service review was carried out.

A spokesman said the trust continues to review outlier data and holds regular team meetings to discuss individual cases.

The knee outliers were: Guy’s Hospital in London (run by Guy’s and St Thomas’ FT); Heatherwood Hospital in Ascot (run by Frimley Health FT); Leighton Hospital in Crewe (run by Mid Cheshire Hospitals FT); St Richard’s Hospital in Chichester (run by Western Sussex Hospitals FT); and King Edward VII’s Hospital in London.

The hip outliers were: Wansbeck Hospital in Ashington (run by Northumbria Healthcare FT); Weston Hospital in Weston-Super-Mare (run by Weston Area Health Trust); Southampton General Hospital (run by University Hospital Southampton FT); St Richard’s Hospital in Chichester; and BMI The Meriden Hospital in Coventry.

St Richard’s was an outlier for both hip and knee revisions in 2018 and 2019.

Guy’s and St Thomas’ FT, Northumbria Healthcare FT, and Western Sussex Hospitals FT also said frail and overweight patient cohorts were a factor in their revision rates. The NJR methodology does not adjust for BMI or frailty.

A GSST spokesman said: “The patient cohort were well above the national average body mass index for knee replacement and had a high level of complex deformity.” 

Northumbria Healthcare FT said its Wansbeck site treated higher risk patients than other units in the trust. It added that some techniques have been updated in line with best practice.

Western Sussex Hospitals FT said its very frail population was susceptible to peri-prosthetic fractures.

Several trusts noted patella (kneecap) surgery as a reason for revision. GSST and Frimley Health FT said they now resurface the patella as standard.

BMI The Meriden Hospital said it uses national joint registry data to “constantly improve services”. A King Edward VII’s Hospital spokesman said the unit scrutinises and reports all clinical outcomes, and investigates when trends are identified.

John Skinner, vice president elect and honorary treasurer at the British Orthopaedic Association, was optimistic about the outlier trusts improving.

He told HSJ: “When a hospital is identified as an outlier, it triggers closer scrutiny and audit of that hospital’s performance. For patients, this should be reassuring because if there are any problems, if the data’s wrong or if the patient mix is unusual, these can be identified.

“Patients can be reassured that the revision rates for hip and knee replacement has fallen every year since 2011.”


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