Graphic courtesy of DePuy Orthopaedics, Inc. HealthEast Joint Replacement Registry: 20 Year Report

Transcription

1 Graphic courtesy of DePuy Orthopaedics, Inc. HealthEast Joint Replacement Registry: 20 Year Report

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3 HealthEast Joint Replacement Registry: 20 Year Report Foreword HealthEast Care System began the first community-based joint replacement registry (HJRR) in the U.S. in 1991, with a database that allowed tracking of implant use and failure rates among the 90 orthopaedic surgeons performing arthroplasty surgery in the greater metropolitan area of St. Paul, MN. Initially conceived as part of a process to better manage costs and determine which implants were most cost-efficient, it became apparent that the registry would allow insight into the same process that had proven its value in the Scandinavian joint registries. With the knowledge that a majority of total joint arthroplasties in the U.S. are performed by relatively low-volume community surgeons, the HJRR remains uniquely positioned to reflect contemporary U.S. surgical practices. The purpose of the HJRR is to maintain and improve the care of individuals undergoing joint replacement surgery by providing timely information to their surgeons and the broader orthopaedic community. With the primary outcome measure of time to revision surgery, combined with analysis of confounding factors and mortality monitoring, the HJRR can provide some realistic measure of the success of a given arthroplasty procedure in our community. In addition, the registry can evaluate the relative effectiveness of different prosthetic designs, identify patient variables that may impact implant survival, and provide the tracking mechanism necessary in the event of implant recalls. Over the 20 years of its existence, the HJRR has refined its data-gathering, data verification, and data analysis and utilizes a process design that requires no direct surgeon involvement with data input. Volunteer surgeons review each revision chart and operative note to carefully delineate the reason for revision. The HJRR capture process has been validated and more than 94% of the revision surgery is performed within the HJRR. The database is used to generate information of practical use to the surgeon, and has been demonstrated to influence surgeon behavior. Among other examples, HJRR reports on the failure rates associated with unicompartmental knee arthroplasty, hybrid and cementless total knee arthroplasty, and metal-on-metal total hip designs have led to significant declines in their respective use over the periods documented. Similarly, the HJRR allowed for rapid notification of surgeons and expedited patient care during the three significant hip implant recalls of the last decade. As it moves into the third decade, the HJRR is proud of its influential role in the development of the national American Joint Replacement Registry (AJRR) as one of the earliest participants and pilot hospitals. It will remain an important contributor to the larger national effort, particularly for certain data subsets that may be outside of the scope of the much larger AJRR. The HJRR core workgroup has published widely on its findings in the last two decades, and looks forward to the future as a compelling example of how worthwhile information and advancements in orthopaedic science can be made in the community setting. Thomas Comfort, MD St. Croix Orthopaedics Peter Daly, MD Summit Orthopedics Jack Drogt, MD Summit Orthopedics Daniel Hoeffel, MD Summit Orthopedics Terence Gioe, MD University of Minnesota 1

4 A Historical Look at Joint Registries 1991 The HealthEast Joint Replacement Registry (HJRR) is established The Swedish Knee Arthroplasty Registry is established 1969 Mayo Clinic physician Mark B. Coventry, MD, establishes the first total joint registry 1979 Research begins for the Swedish National Hip Registry The Norwegian Arthroplasty Register begins collecting hip replacement data

5 2001 Kaiser Permanente forms the National Total Joint Replacement Registry for its member providers, and the Canadian Institute for Health Information establishes the Canadian Joint Replacement Registry The statewide Virginia Joint Registry launches The American Academy of Orthopaedic Surgeons began collecting data in the American Joint Replacement Registry, with HJRR as a participant The Australian National Joint Replacement Registry receives funding, and New Zealand s National Joint Registry begins a pilot study in Christchurch The Danish Knee Arthroplasty Registry is initiated International Society of Arthoplasty Registries is established 2002 The National Joint Registry of England and Wales is founded The Food and Drug Administration launches the International Consortium of Orthopaedic Registries, including HJRR and other registries from around the globe

6 Figure 1: Registry Volumes for Hip Arthroplasty Figure 2: Registry Volumes for Total Hip Arthroplasty by Construct 4

7 Figure 3: Age Distribution for THA Patient Demographics As of December 31, 2010 there were 6,164 primary total hip arthroplasties (THA), 2,873 hip hemiarthroplasties, and 489 revision hip arthroplasties captured in the registry. Females accounted for 63% of primary cases and 62% of revision cases. 22% of primary cases and 27% of revision cases were patients < 60 years old. Osteoarthritis was the most common diagnosis among primary THA (90%) Aseptic loosening (26%) and dislocation (28%) were the most common reasons for THA revision procedures. 5

8 Figure 4: Top 5 Primary THA Diagnoses Figure 5: THA Revision Reasons Implant Design 2% of primary THA cases were cemented, 37% were hybrid, and 61% were uncemented. 28mm was the most common femoral head size for primary THA (51%) and revision THA (52%). Metal femoral heads were used the most often for primary THA cases (85%). 6

9 Figure 6: Registry Volumes for Total Hip Arthroplasty by Head Size Figure 7: THA Survival by Sex* There was no difference in the survival of THA by sex with males having a survival probability of 88% and females having a survival probability of 87%. Males Females Survival Probability Log Rank p-value = 0.76 Survival Time *Note: The shaded areas on the implant survival curves represent the 95% confidence intervals on this and all subsequent survival curves. 7

10 Figure 8: THA Survival by Age There was a significant difference in the survival of THA by age. Patients < 55 had a lower survival probability (77%) than patients 55 (90%). 55 < Survival Probability Survival Probability Log Rank p-value < Survival Time Figure 9: THA Survival by Head Size There was no difference in the survival of THA by head size with 28 mm head sizes having a survival probability of 88% and 32 mm head sizes having a survival probability of 94%. Log Rank p-value = 0.89 Survival Time 8

11 Figure 10: THA Survival by Fixation Technique There is no difference in the survival of THA by fixation technique with cemented THAs having a survival probability of 91%, hybrid THAs having a survival probability of 89% and uncemented THAs having a survival probability of 85%. Hybrid Cemented Uncemented Survival Probability Log Rank p-value = 0.98 Survival Time Figure 11: THA Survival by Design Type There is no difference in the survival of THA by design type with ceramic on ceramic THAs having a survival probability of 96%, ceramic on poly THAs having a survival probability of 97%, hybrid metal on poly THAs having a survival probability of 89%, ingrowth metal of poly THAs having a survival probability of 87%, and metal on metal THAs having a survival probability of 95%. Log Rank p-value = 0.34 Survival Probability Ceramic on poly with uncemented stem Ceramic on ceramic Hybrid with metal on poly articulation Ingrowth with metal on poly articulation Metal on metal (excluding ASR) Survival Time 9

12 Figure 12: Registry Volumes for Knee Arthroplasty Figure 13: Registry Volumes for Total Knee Arthroplasty by Construct 10

13 Figure 14: Age Distribution for TKA Patient Demographics As of December 31, 2010 there were 12,537 primary total knee arthroplasty procedures, 1,104 unicondylar knee arthroplasty procedures, and 544 revision procedures captured in the registry. Females accounted for 63% of primary knee procedures and 54% of revision procedures. Patients < 60 account for 25% of the primary and 24% of the revision knee procedures. Osteoarthritis was the most common diagnosis (98%) for primary TKA procedures. Aseptic loosening (24%) and wear/osteolysis (19%) are the most common reasons for TKA revision procedures. 11

14 Figure 15: Top 3 Primary TKA Diagnoses Figure 16: TKA Revision Reasons Implant Design 90% of all primary procedures were cemented, 1% were uncemented, and 9% were hybrid. A fixed bearing surface (90%) was used more often than a mobile bearing surface (10%). 12

15 Figure 17: UKA Revision Reasons Figure 18: TKA Survival by Sex There was a significant difference in the survival of TKA by sex. Male patients had a lower survival probability (90%) than female patients (94%). Males Females Survival Probability Log Rank p-value < Survival Time 13

16 Figure 19: TKA Survival by Age There was a significant difference in the survival of TKA by age. Patients < 55 had a lower survival probability (85%) than patients 55 (93%). 55 < 55 Survival Probability Log Rank p-value < Survival Time Figure 20: TKA Survival by Design Type There was a significant difference in the survival of TKA by design type. Cemented knee with all-poly tibia had the highest survival probability (99%) followed by cemented knees with metal-backed tibia (94%), hybrid knees (88%) and ingrowth knees (84%). Survival Probability Cemented knee with all-poly tibia Cemented knee with metal-backed tibia Hybrid knee Ingrowth knee Log Rank p-value < Survival Time 14

17 Figure 21: UKA Survival The survival probability for unicondylar knee arthroplasty was 81%. Survival Probability Survival Time Figure 22: TKA Survival by Bearing Surface There was no difference in the survival of TKA by bearing surface with fixed bearing TKAs having a survival probability of 93% and mobile bearing TKAs having a survival probability of 97%. Mobile Fixed Survival Probability Log Rank p-value = 0.75 Survival Time 15

18 Figure 23: TKA Survival by Cruciate Status There was no difference in the survival of TKA by cruciate status with posterior stabilized TKAs having a survival probability of 96% and cruciate retaining TKAs having a survival probability of 94%. Survival Probability Posterior Stabilized Cruciate Retaining Log Rank p-value =.17 Survival Time 16

19 Selected Articles of Interest Most Recent Johnson T, Tatman P, Mehle S, Gioe, T. Revision surgery for patellofemoral problems: should we always resurface? Clinical Orthopaedics and Related Research 2012; Routine patellar resurfacing performed at the time of knee arthroplasty is controversial, with some evidence of utility in both TKA (tricompartmental) and bicompartmental knee arthroplasty. However, whether one approach results in better implant survival remains unclear. We asked whether (1) routine patellar resurfacing in TKAs resulted in lower cumulative revision rates compared to bicompartmental knee arthroplasties, (2) patella-friendly implants resulted in lower cumulative revision rates than earlier designs, and (3) bicompartmental knee arthroplasties revised to TKAs had higher cumulative revision rates than primary TKAs. We compared registry data for 9530 cemented, all-polyethylene patella TKAs and 627 bicompartmental knee arthroplasties without patellar resurfacing. TKAs had a lower cumulative revision rate for patella-only revision than bicompartmental knee arthroplasties (0.8% versus 4.8%). Adjusting for age, bicompartmental knee arthroplasties were 6.9 times more likely to undergo patellar revision than TKAs. Bicompartmental knee arthroplasties had higher revision rates than TKAs. Femoral component design did not influence the cumulative revision rate. Secondary patella resurfacing in a bicompartmental knee arthroplasty carried an increased revision risk compared to resurfacing at the time of index TKA. To reduce the probability of reoperation for patellofemoral problems, our data suggest the patella should be resurfaced at the time of index surgery. Registry Methodology Gioe T, Killeen K, Mehle S, Grimm K. Implementation and Application of a Community Joint Registry: A Twelve-Year History. Journal of Bone and Joint Surgery 2006; Cost Analysis Gioe T, Sharma A, Tatman P, Mehle S. Do Premium Joint Implants Add Value? Analysis of High Cost Joint Implants in a Community Registry. Clinical Orthopaedics and Related Research 2011; Numerous joint implant options of varying cost are available to the surgeon, but it is unclear whether more costly implants add value in terms of function or longevity. We evaluated registry survival of higher-cost premium knee and hip components compared to lower-priced standard components. We compared 3462 standard TKAs to 2806 premium TKAs and 868 standard THAs to 1311 premium THAs using standard statistical methods. The cost of the premium implants was on average approximately $1000 higher than the standard implants. There was no difference in the cumulative revision rate at 7-8 years between premium and standard TKAs or THAs. In this time frame, premium implants did not demonstrate better survival than standard implants. Revision indications for TKA did not differ, and infection and instability remained contributors. Longer follow-up is necessary to demonstrate whether premium implants add value in younger patient groups. Gioe T, Sinner P, Mehle S, Ma W, Killeen K. Survival of All- Polyethylene Tibial Components in a Community Total Joint Registry. Clinical Orthopaedics and Related Research 2007; In this study, analysis of an all-polyethylene tibial component in total knee replacements revealed a survival rate of 99.5%. We estimate a cost savings for this group (compared with the group that had a metalbacked tibial component) at about $724 per patient (in 2004 dollars). If all patients over the age of seventy-five with a total knee replacement in our registry had received an all-polyethylene tibial component, the estimated cost savings for twelve years would have been just over $900,000. This article provides an excellent overview of registry history, development accomplishments and goals. The authors review the structure of the registry and the process for entering data. Comparisons with other well known registries, such as Mayo Clinic and the Swedish Knee Arthroplasty Register are discussed and limitations are reviewed. 17

20 Publications: Conference Proceedings: 1. Bert, J. M. & Killeen, K. K. A comparison of hospital length of stay versus the early transfer to a skilled nursing facility: the effect on direct costs of total joint arthroplasty. The Knee 1998; 5, Dudley T, Gioe T, Sinner P, Mehle S. Registry Outcome of Unicompartmental Knee Arthroplasty Revisions. Clinical Orthopaedics and Related Research 2008; Epub 2008 May Gardner J, Gioe T, Tatman P. Can this prosthesis be saved? Implant salvage attempts in infected primary TKA. Clinical Orthopaedics and Related Research 2011; Epub 2010 June Gioe, T. J., Daly, P., Bert, J. M., Killeen, K. K., Schwartz, S., & Huang, Z. Analysis of Early Revision in a Community Knee Implant Registry. Clinical Orthopaedics and Related Research 2004; Gioe T, Killeen K, Mehle S, Grimm K. Implementation and Application of a Community Joint Registry: A Twelve- Year History. Journal of Bone and Joint Surgery 2006; Gioe, T. J., Killeen, K. K., Hoeffel, D. P., Bert, J. M., Comfort, T. K., Scheltema, K. et al. Analysis of unicompartmental knee arthroplasty in a community-based implant registry. Clinical Orthopaedics and Related Research, 2003, Gioe T, Ma W, Mehle S, Killeen K. Survival of All- Polyethylene Tibial Components in a Community Total Joint Registry. Clinical Orthopaedics and Related Research 2007; Gioe T, Novak C, Ma W, Killeen K, Mehle S. Total Knee Arthroplasty in the Young Patient: Survivial in a Community Total Joint Registry. Clinical Orthopaedics and Related Research 2007; 464: Gioe T, Sharma A, Tatman P, Mehle S. Do Premium Joint Implants Add Value? Analysis of High Cost Joint Implants in a Community Registry. Clinical Orthopaedics and Related Research 2011; Johnson T, Tatman P, Mehle S, Gioe T. Revision Surgery for Patellofemoral Problems: Should We Always Resurface? Clinical Orthopaedics and Related Research 2012; S Bert, J. M. & Killeen, K. K. Does Discharge to Home Vs. Early Discharge to SNF Decrease Direct Costs for TJA? In American Academy of Orthopaedic Surgeons 1995 Annual Meeting, Atlanta, GA: 1995 (Podium Presentation and Scientific Exhibit) 2. Bert, J. M. & Killeen, K. K. Long Term Survivorship of Revision Unicompartmental Knee Arthroplasty. In American Academy of Orthopaedic Surgeons 2004 Annual Conference, San Francisco, CA: 2004 (Scientific Exhibit) 3. Bert, J. M. Histological Appearance of Pristine Articular Cartilage in Knee with Unicompartmental Replacement. In The Knee Society and The American Association of Hip and Knee Surgeons 2004 Annual Meeting, Dallas, TX: 2004 (Scientific Exhibit) 4. Bert, J. M., Killeen, K. K., & Hung, T. M. Simultaneous bilateral TKA and staged bilateral TKA performed during the same hospitalization: a comparison of complications and hospital charges. American Academy of Orthopaedic Surgeons 2003 Annual Meeting, New Orleans, LA: 2003 (Poster) 5. Bert J, Killeen K, Mehle S. The Use of Space Suits for TJR in a Community-Based Registry: Do They Reduce Infection Rates? American Academy of Orthopedic Surgeons 2006 Annual Meeting, Chicago, IL: 2006 (Scientific Exhibit) 6. Bert J, Killeen K, Sinner P, Mehle S. The Survivorship of Polyethylene Tibial Insert Exchange Only at the Time of Revision TKA. American Academy of Orthopedic Surgeons 2007 Annual Meeting, San Diego, CA: 2007 (Scientific Exhibit) 7. Bert J, Killeen K, Ma W, Mehle S. The Survivorship of Polyethylene Tibial Insert Exchange Only at the Time of Revision. American Academy of Orthopedic Surgeons 2008 Conference, San Fransisco, CA: 2008 (Scientific Exhibit) 8. Bert J, Tatman P, Mehle S, Killeen K. The Effect of BMI on Survivorship of Unicompartmental Knee Arthroplasty. American Association of Hip and Knee Surgeons 2009 Annual Meeting, Dallas, TX: 2009 (Scientific Exhibit) 9. Biebl J, Kimber K, Gioe T, Tatman P, Killeen K. Manufacturer Recall of Total Joint Components: The Joint Registry Process. Mid-American Orthopedic Association 2009 Annual Meeting, Amelia Island, FL: 2009 (Manuscript in Development) 18

21 10. Comfort, T. K., Killeen, K. K., Grimm, K., & Mehle, S. Survival of Uncemented versus Cemented Femoral Stems in a Community Total Hip Implant Registry. In American Academy of Orthopaedic Surgeons 2004 Annual Meeting, San Francisco, CA: 2004 (Poster) 11. Comfort T, Killeen K, Pshon N, Ma W, Mehle S. Outcomes of Elevated Acetabular Liners in a Community Hip Registry. American Academy of Orthopedic Surgeons 2006 Annual Meeting, Chicago, IL: 2006 (Podium Presentation) 12. Comfort, T. K., Killeen, K., Grimm, K., & Mehle, S. Survival of Hydroxyapatite (HA) versus Non-HA Acetabular Components in a Community Hip Registry. In American Academy of Orthopaedic Surgeons 2004 Annual Meeting, San Francisco, CA: 2004 (Podium Presentation) 13. Comfort T, Tatman P, Killeen K, Mehle S. Survival of Uncemented vs. Cemented Femoral Stems in a Community Total Hip Implant Registry. American Academy of Orthopaedic Surgeons 2011 Annual Meeting, San Francisco, CA: 2011 (Podium Presentation) 14. Comfort T, Tatman P, Mehle S, Killeen K. Do Ceramic on Polyethylene or Ceramic on Ceramic Hip Implants Add Value? Analysis of Survival in a Community Joint Registry. Mid-America Orthopaedic Association 2012 Annual Meeting, Bonita Springs, FL: 2012 (Podium Presentation) 15. Comfort T, Tatman P, Mehle S, Killeen K. Do Ceramic on Polyethylene or Ceramic on Ceramic Hip Implants Add Value? Analysis of Survival in a Community Joint Registry. American Association of Orthopaedic Surgeons 2012 Annual Meeting, San Francisco, CA: 2012 (Podium Presentation) 16. Daly, P., Gioe, T. J., Killeen, K. K., Huang, J., & Mehle, S. Revision Surgery for Patellofemoral pain: incidence in TKA with and without patellar replacement. In American Academy of Orthopaedic Surgeons 2000 Annual Meeting, Orlando, FL: 2000 (Scientific Exhibit) 17. Dudley T, Gioe T, Sinner P, Mehle S. Survivorship of UKA Revisions in a Community Joint Registry. American Academy of Orthopedic Surgeons 2008 Annual Meeting, San Francisco, CA: 2008 (Podium Presentation) 18. Dudley T, Gioe T, Sinner P, Mehle S. Survivorship of UKA Revisions in a Community Joint Registry. Mid-American Orthopedic Association 2008 Annual Meeting, Orlando, FL: 2008 (Podium Presentation) 19. Gardner J, Gioe T, Sinner P. Can This Prosthesis be Saved? Implant Salvage Attempts in Infected Primary TKA. American Academy of Orthopedic Surgeons 2009 Annual Meeting, Las Vegas, NV: 2009 (Podium presentation) 20. Gardner J, Gioe T, Sinner P. Can This Prosthesis Be Saved? Implant Salvage Attempts in Infected Primary TKA. Mid-American Orthopedic Association 2009 Annual Meeting, Amelia Island, FL: 2009 (Podium presentation) 21. Gioe, T. J., Daly, P., Bert, J. M., Killeen, K. K., Schwartz, S., & Huang, Z. Analysis of early revision in a community knee implant registry. In American Academy of Orthopaedic Surgeons 1999 Annual Meeting, Anaheim, CA: 1999 (Scientific Exhibit) 22. Gioe, T. J., Daly, P., Bert, J. M., Killeen, K. K., Schwartz, S., & Huang, Z. Analysis of early revision in a community knee implant registry. American Academy of Orthopaedic Surgeons 2004 Annual Meeting, San Francisco, CA: 2004 (Podium Presentation) 23. Gioe, T. J., Daly, P., Bert, J. M., Killeen, K. K., Schwartz, S., & Huang, Z. Analysis of early revision in a community knee implant registry. Knee Society 2004 Annual Meeting, San Francisco, CA: 2004 (Podium Presentation) 24. Gioe, T. J., Daly, P., Killeen, K., Huang, Z., & Mehle, S. Early Acetabular Component Failures in a Community- Based Total Hip Implant Registry. In American Association of Hip and Knee Surgeons 1999 Annual Meeting, Dallas, TX: 1999 (Scientific Exhibit) 25. Gioe, T. J., Killeen, K. K., Hoeffel, D. P., Bert, J. M., Comfort, T. K., Scheltema, K., Mehle S. Analysis of Unicompartmental Knee Arthroplasty in a Communitybased Implant Registry. American Academy of Orthopaedic Surgeons 2003 Annual Meeting, New Orleans, LA: 2003 (Podium Presentation) 26. Gioe, T. J., Killeen, K. K., Hoeffel, D. P., Bert, J. M., Comfort, T. K., Scheltema, K., Mehle S. Analysis of Unicompartmental Knee Arthroplasty in a Communitybased Implant Registry. Knee Society 2003 Annual Meeting, Dallas, TX: 2003 (Podium Presentation) 19

22 Conference Proceedings (continued) 27. Gioe, T. J., Killeen, K., Scheltema, K., Mehle, S., & Grimm, K. Implementation and Application of a Community Joint Registry: A Ten-Year History. In American Academy of Orthopaedic Surgeons 2004 Annual Meeting, San Francisco, CA: 2004 (Podium Presentation) 28. Gioe, T. J., Robertsson, O., Killeen, K. K., Grimm, K., & Mehle, S. An Inter-Registry Comparison of TKA in Sweden and Minnesota. In American Association of Hip and Knee Surgeons 2005 Annual Meeting, Dallas, TX: 2005 (Poster) 29. Gioe T, Ma W, Mehle S, Killeen K. Survival of All- Polyethylene Tibial Components in a Community Total Joint Registry. American Association of Hip & Knee Surgeons 2006 Annual Conference, Dallas, TX: 2006 (Podium Presentation) 30. Gioe T, Novak C, Ma W, Killeen K, Mehle S. Total Knee Arthroplasty in the Young Patient: Survival in a Community Total Joint Registry. Interim Knee Society 2006 Annual Meeting, Alexandria, VA: 2006 (Podium presentation) 31. Gioe T, Novak C, Ma W, Killeen K, Mehle S. Total Knee Arthroplasty in the Young Patient: Survival in a Community Total Joint Registry. American Academy of Hip & Knee Surgeons 2006 Annual Meeting, Dallas, TX: 2006 (Podium presentation) 32. Gioe T, Novak C, Ma W, Killeen K, Mehle S. Total Knee Arthroplasty in the Young Patient: Survival in a Community Total Joint Registry. Mid-American Orthopedic Association 2006 Annual Meeting, Boca Raton, FL: 2006 (Podium presentation) 33. Gioe T, Novak C, Ma W, Killeen K, Mehle S. Total Knee Arthroplasty in the Young Patient: Survival in a Community Total Joint Registry. American Orthopedic Academy 2006 Annual Meeting, Asheville, NC: 2006 (Poster) 36. Gioe T, Tatman P, Mehle S. Do Premium Joint Implants Add Value? Analysis of High Cost Total Joint Implants in a Community Registry. Knee Society Open Meeting 2010, New Orleans, LA: 2010 (Podium presentation) 37. Gioe T, Tatman P, Mehle S. Revision Surgery for Patellofemoral Problems: Prevalence in TKA With and Without Patellar resurfacing. Knee Society 2010 Members Only Meeting, Rochester, MN 2010 (Podium presentation) 38. Gioe T, Tatman P, Mehle S. Revision Surgery for Patellofemoral Problems: Prevalence in TKA With and Without Patellar Resurfacing. American Academy of Orthopaedic Surgeons 2011 Annual Meeting, San Diego, CA: 2011 (Podium presentation) 39. Gioe T, Tatman P, Mehle, S. Is there Value in Metalon-Metal THA? Analysis of Survival in a Community Registry. American Association of Hip and Knee Surgeons Annual Meeting 2010, Dallas, TX: 2010 (Podium presentation) 40. Hoeffel D, Daly P, Killeen K, Ma W, Mehle S. How Effective Is The Surgical treatment of THA Dislocation in the Community? American Academy of Orthopedic Surgeons 2006 Annual Meeting, Chicago, IL: 2006 (Poster) 41. Periyasamy R, Tatman P, Mehle S, Killeen K, Gioe T. Waste of Component Parts in Total Joint Arthroplasty: A Registry Study. Mid-America Orthopaedic Association 2012 Annual Meeting, Bonita Springs, FL: 2012 (Poster) 42. Wechter J, Comfort T, Tatman P, Mehle S, Gioe T. Survival of Uncemented vs. Cemented Femoral Stems in a Community Joint Implant Registry. Mid-America Orthopaedic Association 2012 Annual Meeting, Bonita Springs, FL: 2012 (Podium Presentation) 34. Gioe T, Ma W, Mehle S, Killeen K. Survival of All- Polyethylene Tibial Components in a Community Total Joint Registry. Mid-American Orthopedic Association 2007 Annual Meeting, Boca Raton, FL: 2007 (Podium presentation) 35. Gioe T, Tatman P, Mehle S. Do Premium Joint Implants Add Value? Analysis of High Cost Total Joint Implants in a Community Registry. American Association of Hip and Knee Surgeons 2009 Annual Meeting, Dallas, TX: 2009 (Poster) 20

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24 St. Paul, Minnesota /12