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Carousel Presidents
The New Zealand National Joint Registry
The New Zealand National Joint Registry was initiated in late 1997 to establish such a registry after a unanimous decision was made by the members of the New Zealand Orthopaedic Association. Now in its eleventh year of operation, it holds over 100,000 joint arthroplasty registrations.
The registry is characterized by being a compulsory continuing professional development activity. Thus all surgeons undertaking joint arthroplasty participate by providing the required information. In addition to this the Registry was the first to collect data from Patient Generated Outcomes. The “Oxford 12” validated Hip and Knee patient questionnaires were chosen to which were added questions related to dislocation, infection, and any other complication that did not require further joint surgery. These questionnaires are sent to all registered patients six months following surgery and then at five yearly intervals thereafter. The response rate from patients has remained steady at between 70 and 75 % over the last five year period.
The Registry is primarily funded by the orthopaedic profession assisted by contributions from the New Zealand Ministry of Health and our national accident insurer and other private insurers.
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Surgeons receive six month individual reports from the Registry including information relating to:
- Number of procedures carried out
- 6 monthly and 5 year Oxford scores
- Primary revision rate (by component)
Individual surgeons can also obtain upon request their own details of:
- Reasons for revision
- Infection and dislocation rates
- Patient satisfaction outcomes.
The regular reports form an integral part of practice audit for individual surgeons.
The Registry also provides an Annual Report and includes national data on a number of parameters. (Refer: http://www.cdhb.govt.nz/njr/)
The Registry has legislative protection against discovery for potential civil (but not criminal) actions, as well as ethical approval for patient participation (after patient consent has been obtained)
Data from the registry is now being used for research work and a number of conference presentations based on registry data increases every year. Some papers have been presented for publication in international refereed journals. Some have been accepted.
Denis Atkinson, MD
President, New Zealand Orthopaedic Association
The Crisis in South African Orthopaedics: An AOA commentary
South African orthopaedics is at present in a state of crisis. We are challenged on multiple fronts, and as a consequence, many of our surgeons are looking for greener pastures elsewhere.
At present we only have 420 practicing orthopaedic surgeons to serve a population of about nearly 50 million. To compound this, some 80% of surgeons are in the private sector, looking after some 8 million people who are insured for their medical expenses. That leaves some 80 surgeons to look after the orthopaedic needs of about 42 million indigent people. Obviously this is an impossible task. As a result treatment priorities become imperative, and trauma management takes precedence. One cannot leave fractures untreated. As a result, elective surgery usually takes a back seat. As a consequence, the waiting time for a joint replacement at the Johannesburg Academic Hospital, one of the leading academic units in the country, now extends to an effective 6 years. This further impacts negatively on training programmes, with an unhealthy emphasis on trauma care, and an inadequate exposure to all aspects of elective orthopaedic surgery.
Why are we not increasing the number of orthopaedic surgeons in South Africa? Our numbers are little changed from 10 years ago, and in fact are declining slowly. Emigration has played a large role. Some 180 South African trained orthopaedic surgeons are at present providing excellent care for British patients in their National Health Service. Our surgeons are found throughout Australia, New Zealand and Canada. They have left for reasons of socio-economic insecurity, as often happens in a society of change. Crime in South Africa continues to be a real disincentive to stay, and the exaggerated global trend towards an over-regulated, socialist health care environment quickly makes other pastures greener.
We are also effectively training fewer South Africans as orthopaedic surgeons. Our training posts are competed for by trainees from the rest of Africa, and these surgeons once qualified, go back to their countries of origin, taking their skills to their own desperate areas. We acknowledge though that this development of capacity outside our country is vital to stem the flow of patients from outside South Africa into our already overloaded system. This of course does not facilitate an increase in our own orthopaedic surgeon numbers.
Within our country poor working conditions, and a distinct lack of a career path within the public hospital system drives surgeons to the private sector, where insured patients offer a better chance of reasonable remuneration for work done. This distortion of resources within our country further exacerbates socio-economic and political divisions within our healthcare system.
South African orthopaedics is not beyond salvage. We are world leaders in many aspects of orthopaedics. Our research in respect of bearing surfaces in hip replacements has been recognized by the American Hip Society. Our management of orthopaedic sepsis, especially in respect of TB and HIV is cutting edge. Our academic leaders more than hold their own when they relocate to other countries’ institutions.
In many aspects I regard South African orthopaedics as challenging. We have the developed infrastructure and training programmes comparable to the best in the first world, while we need to meet the challenges of the demands of the third world in respect of the provision of basic orthopaedic services to the indigent masses. I would suggest that this combination of first and third world makes for the unique demands of “a fourth world country”, having significant components of the first and third world, with equally challenging demands needing innovative solutions. These solutions need to be home grown, taking into account our particular needs. Don’t ever say life is boring in Africa!
Dick van der Jagt, MD
President, South Africa
A Global Orthopaedic Challenge: Fragility Fractures
Perhaps the greatest current and indeed anticipated global challenge in Orthopaedics is that of osteoporosis and its effect on individual patients and impact on health care budget. Presently, the majority of patients with osteoporosis are undiagnosed, and treatment, if at all considered, is usually not considered until they present with their second fragility fracture.
As Orthopaedic Surgeons we are often the point of first contact, and yet as a time poor profession, we most commonly treat the fracture, assuming others will address the osteoporosis.
As a profession, we should take the lead in the identification and recognition of patients presenting with this condition, promoting prevention and early diagnosis, and initiating appropriate investigations and management pathways to aid secondary prevention, hopefully limiting the subsequent fracture seen so frequently in the untreated.
Treatment is progressively being refined and most studies have indicated that treatment will decrease the risk and the time to the subsequent fragility fracture.
As Orthopaedic surgeons we should be pro-active in our practices. In our public institutions particularly we are ideally positioned to promote osteoporosis awareness and to advocate having fracture liaison personnel employed to track patients, identified as having osteoporosis, making sure they do obtain appropriate management and ongoing monitoring.
Unfortunately the vast majority of patients with Osteoporosis moving through our institutions, be it through Emergency Departments, Orthopaedic outpatient services, or even inpatient facilities, fail to receive adequate follow-up or monitoring of the osteoporosis identified at the time of their initial fragility fracture. On discharge, contact and meaningful handover of care plans to the local family physician is at best variable
Although the literature tells us that very few medical treatments can return the bone mass to normal, there is significant evidence that appropriate interventions decrease the time to and frequency of subsequent presentations of fragility fracture.
As professionals, specializing in musculoskeletal health care, we should use our public profile to lobby for appropriate funding from Government for Public Hospitals to have fracture liaison staff employed to streamline and co-ordinate care. Around the world, the challenge is being taken up, and several countries have initiated similar protocols with significant success.
John Batten, MD
President, Australian Orthopaedic Association
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