Mapping How the World Really Does Hip Replacement

How does hip replacement practice really differ from one country to the next? Researcher Irrum Afzal joins the AHF Podcast to discuss the Global Arthroplasty Practice Survey (GAPS) — the first effort to map how surgeons worldwide actually perform total hip replacement.

Despite roughly seventy years of modern hip replacement, there's still no global consensus on the fundamentals — surgical approach, fixation, bearing surface, or the perioperative pathway. National joint registries capture some of this, but their coverage and data quality vary widely, and many countries have no registry at all. The result is that we know surprisingly little about how the operation is actually performed around the world.

Irrum Afzal, a researcher at Imperial College London and a digital health transformation specialist, is working to close that gap. Co-led with Professor Richard Field, GAPS asks surgeons of every volume and career stage to describe their real preoperative, intraoperative, and postoperative practice. It takes under ten minutes, covers the full patient journey, and is built to feed a long-term dataset that machine learning can eventually turn into research priorities and a working global consensus.

Along the way, Irrum explains how her study on the accuracy of National Joint Registry revision data shaped her thinking about data quality, why anterior approach adoption ranges from around 1% in the UK to 56% in the US, and what surgeon-reported practice data can add to what registries already collect. If you perform hip replacement, your answers help build the first real worldwide picture of the field — and the survey is open through 30 June.

Take the Survey Here: https://tinyurl.com/GAPSHIPS
Visit the Working Group: https://www.globalarthroplastypractice.com/

⏱️ Chapters:
00:00 Introduction and guest background
01:40 How a public health researcher moved into orthopaedics
02:48 Why hip revision registry data is often inaccurate
04:46 What the Global Arthroplasty Practice Survey measures
07:14 Why hip replacement practice still varies worldwide
08:42 Who runs GAPS and how to join the working group
10:08 Why surgeons should take the survey and what they gain
13:18 Using AI to turn survey responses into research priorities
14:01 How many responses GAPS needs and the June 30th deadline
16:50 What success looks like and sharing data with registries
19:05 Presenting GAPS results at the European Anterior Hip Meeting

Listen to the AHF Podcast on your preferred platform:
Buzzsprout: https://ahfpodcast.buzzsprout.com
Apple Podcasts: https://podcasts.apple.com/us/podcast/ahf-podcast/id1749521487
Spotify: https://open.spotify.com/show/5CrGJyvRiQFTCU3FFFVvHc
LinkedIn: https://www.linkedin.com/showcase/ahf-podcast
YouTube: https://www.youtube.com/@anteriorhipfoundation
Homepage: https://anteriorhipfoundation.com

This podcast is intended for educational and informational purposes only.
The content discussed does not constitute medical advice and should not be used as a substitute for professional judgment. Clinicians should rely on their own training, experience, and clinical decision-making when applying information from this discussion.

#AnteriorHipFoundation #AHFPodcast
#HipReplacement #TotalHipArthroplasty #THA #AnteriorApproach #JointRegistry #NationalJointRegistry #OrthopaedicResearch #GAPS #IrrumAfzal #HipRevision #ArthroplastyData

Transcript

Joseph M. Schwab 0:21

Hello and welcome to the AHF Podcast. I'm your host, Joe Schwab. My guest tonight is Irrum Afzal, a researcher affiliated with Imperial College London. She's the vice chair of research and innovation at the National Orthopaedic Alliance and a digital health transformation specialist at HCA UK. Irrum has built her career around outcomes and the quality of the data we use to judge our own results, including a pretty well-known study showing how often registry revision data doesn't match what actually happened in the operating room. Well, she's here to talk about the Global Arthroplasty Practice Survey or GAPS. This is the first attempt to capture a truly worldwide picture of how surgeons actually perform hip replacement. Irrum, welcome to the AHF Podcast

Irrum Afzal 1:16

Hello, and thank you for the invite invite.

Joseph M. Schwab 1:18

Um, I just wanna start off, I gave you a little bit, uh, I gave our listeners a little bit of flavor of who you are and what you do. Um, but if you could just start telling me in your own words kind of how you ended up in this world in orthopedics and how you became, uh, sort of a digital health transformation specialist.

Irrum Afzal 1:39

Sure. So I, um, I actually did work experience back when I was a university student, um, at the South West London Elective Orthopedic Center in Professor Field's research department. And while I was there, I, um, was able to see all the different kinds of projects that were going on. And from there, I, I went, did my week placement and then went back off to university. And then I would come in, um, just ad hoc when I could and continued doing some projects with some of the, uh, research fellows that were working, um, in the department. And then I remember one day, um, Prof Field asked me, um, if I was doing everything I wanted to in life and I had just told him that I'd my degree and I was going off to do the next, uh, the next, the next degree. And he said, "Where are you going to to study and what, and what will you be studying?" So I told him I was going to be studying public health at, um, Imperial College London. Um, so then from there on, I then did my... did, did projects with him and, and I've worked with him since I was, since I was a university student, um, until, till, till today. So still so-- And, and it's been, it's been a nice, uh... And I've learned a lot, um, throughout the journey. And I've, um... One of my big pieces of research was looking at the accuracy of the National Joint Registry data and seeing whether there was a discrepancy in what was recorded at the time of surgery versus what's ac- what was actually the reason for surgery for the reoperation. Um, and on the basis of that, we identified that there there were discrepancies that took, discrepancies that took, that, that were reco-recorded and reported back to the National Joint Registry. S- And then in, in place of that, what we have now implemented, so at the South West London Elective Orthopedic Center, they have a, an MDT which takes place and in that MDT they record the reason for revision, but they also then subsequently look at the reason for revision and make sure it's accurate. So they have an MDT coordinator who, who checks that and, and keeps, keeps an eye, an eye on that. So it was nice to be able to do a piece of research, but also then see, and the, the impact it has, but also see a change being implemented into actual, actual practice i- in the way the recording was done. And it's quite nice to see that it still takes place, takes place there at the South West London Elective Orthopedic Center

Joseph M. Schwab 3:57

So how did that work specifically in data quality and maybe seeing that feedback mechanism, um, put into action? How did that shape the way you think about what we know versus maybe what we think we know in hip arthroplasty?

Irrum Afzal 4:15

Um, so it definitely made me question like the, the, like the fidelity of the data, like how valid it was. Because if the incorrect data was going to the National Joint Registry, which is one of the largest registries, um, in the world, it, it sort of makes you question. And one of the things that I learned quite early on was whatever you put in is what you, what data you get out. So it was really making sure that you have to put the correct amount of data or the correct data if you want to actually see accurate results. There's no point in putting garbage in because you'll get garbage out

Joseph M. Schwab 4:45

Right. Right. And so, I mean, this kind of brings us maybe to the Global Arthroplasty Practice Survey, which is, um, something that you've been working on and is something that we're hoping you're gonna be presenting some of the preliminary data on at the upcoming, uh, European Anterior Hip Meeting in London in July. Um, tell our listeners a little bit about what that survey actually is and maybe what gaps in our knowledge you're trying to fill with it.

Irrum Afzal 5:15

Um, so the, the aim of the survey is really to find out what, what happens in practice around the world. So there's lots of different registries, um, and specifically there's approximately thirty-one different arthroplasty registries around the world. Some countries have a more robust data collection and some countries, um, it's not mandated and it's not as robust as others, and some countries just don't have registry data at all.

Joseph M. Schwab 5:40

Mm-hmm.

Irrum Afzal 5:41

So identifying that there was a gap in actually registry data is, is one thing, but also having a look at the literature and seeing what is avail-- what was out there is that there's, there was no real data collection on how, how arthroplasty or what the global variation is because each country has its own, uh, you know, ups and downs and it has its own, uh, different th- different things that it will have-- has to take into consideration. So for example, the different, you know, w- with, um, within the UK they have, you know, different cement-- they may have different cementing rules versus what the rules are and regulations are in America and in Australia. So there was no real, real overview of what actually internationally or even what happens in countries or continents. So the aim of this was really to identify the global variation and actually see what is taking place internationally. And the aim is to, to have a large cohort of surgeons as opposed to just small groups or institutions. It's really reaching out to everyone and everybody to complete the survey, to give their insights so we can really hear from whether you're an-- whether you've been doing arthroplasty for many years or whether you're someone new or whether you do fifty, fifty hips or whether you do seven hundred. We want to hear from everyone because we want to see what differences there are in practice. So if someone who's doing more hip replacements, they may have a slightly different preoperative pathway versus, uh, and a post-operative pathway versus someone who's doing slightly less.

Joseph M. Schwab 7:14

And you're used to seeing, uh, um, I mean, high volume arthroplasty when you were at SWLEOC. And, um, you know, I can say w-we've been doing hip arthroplasty, I don't wanna say exactly the same way, but roughly the way we're doing it now for about 70 years, right? This is, uh, we're- we've been doing hip replacement in this sort of way with a cup and a stem and a ball for about 70 years, and like you said, there's still no real global consensus on fundamentals, whether that's approach or fixation or bearing surfaces or positioning. Um, why do you think, since you're so close to this data, why do you think that variation has persisted for so long? Is it just regional differences or is there something else?

Irrum Afzal 8:00

Um, I think there's regional differences is one, but also there's, um, differences in, in what people are used to. So for example, with one of the things I presented, um, last year at the European Anterior Hip meeting was looking at the global uptake of the direct anterior approach, and that was really what sort of stemmed the insight into, you know, expanding this and seeing what actually happens in other parts of the patient journey because there was so much variation. Um, and with the UK only having 1%, but America having 56%. So it's, it's regional differences, but also perhaps what people are used to and what-- and if they don't want to change from what, what is normal around them, and everybody's normal is different.

Joseph M. Schwab 8:41

That's for sure. So w- tell me a little bit who is behind GAPS, and how does it connect to the other work that you do?

Irrum Afzal 8:51

So, um, behind the, the project is Professor Richard Field from London, from, from the UK. So he's co-leading the, the project with me. And then we have a working group of, um, different surgeons from across the globe, and it's been really nice. So we put a call out to ask people if they would be interested in, in being part of the, the working group. So we've had various different surgeons, um, around the world who have been able-- who have offered to, to be part of the working group. And we have a website which will be going live, so people will be able to see the, the working group, and if they'd like to also join the working group, they're, they're able to join. And the way this really, um, fits in with the work I've been doing, so I've got a real interest in, in registry data and, the, the registry aspect of big data collection. So my real interest is in h-how the National Joint Registry data was collected and, and from what I'm hoping to achieve from this is really have a big data set on global, variations of practice across the globe, and we don't want to limit it just to hip arthroplasty. Our next, um, survey, once we finish this one, is going to be the knees and the shoulders. So we really want to get a capture of the worldwide arthroplasty and then hopefully one day we'll be able to go on to soft tissue. But at, for the moment it is, is hips. Um, so that, that's where we are, and that's how we-- what we hope to achieve.

Joseph M. Schwab 10:08

So I wanna give you an opportunity to make the case directly to surgeons. Why should a busy hip surgeon, um, in practice right now take time to fill this survey out? And what do you see as it, as being in it for probably their patients?

Irrum Afzal 10:28

So I, the, the survey takes approximately five to seven, maybe 10 minutes to, to complete. Um, there's a series of questions, and what is in it for, for the surgeons is that they'll really understand. So often you'll have surgeons sitting next to each other at conferences, meetings, talking to each other, asking each other how they do, how they do practice. If they've met a colleague who's working in a different country a- after, after a while, they'll ask actually, "What are you doing and, and h- what's your practice like?" So this will really give a map and, and an overview of what, what is actually happening in different countries. So I envisage putting together a, the results and, and having this sort of like updated so people can see, you know, at a snapshot what is happening in America, in the Middle East, in Asia, in Australia. So it's really to be able to identify what is happening in a snapshot because that data isn't available, and data is power

Joseph M. Schwab 11:18

Hmm. And do you see this survey, uh, being repeated periodically or growing or changing within the field of hips? I know you talked about adding knees and shoulders and, and other elements, but do you see this survey growing over time?

Irrum Afzal 11:33

Absolutely. I would really like to-- At the moment, it's really focused on the patient journey, um, and asking questions on every aspect of the, the patient journey. But I would really like to, once I've got a basis of a, a, the survey results, I really want to look into different factors within the patient journey and look at developing this as like using this as a, a, a global consensus and reaching out to, to, to surgeons who have contributed, and their contributions will all be acknowledged. So that, that's a, a plus point for them.

Joseph M. Schwab 12:01

Yeah. Um, and obviously we got connected through the European Anterior Hip Meeting. This podcast is the Anterior Hip Foundation. What would you most wanna learn from specifically anterior approach surgeons, um, and how they answer this compared to maybe a broader population?

Irrum Afzal 12:21

Um, so I would like to see how, what differences there are in their practices, and do they so I would like to see how, what differences there are in their practices and do they do different preoperative investigations? Do they see their patients diff- uh, is there a difference in how they see their patients postoperatively? So those questions are asked within, within the survey, so it'd be really interesting to, to see those differences, to see if there's actually any difference in the number of times that anterior hip surgeon sees their patients postoperatively compared to someone who's doing a, a posterior approach. So it'll be... I, I'm looking forward to being able to see those differences and, and cause we have asked the question of what approach do, um, do you use? What is your most, is your preferred use?

Joseph M. Schwab 12:56

Mm-hmm. And you know, it, it could be maybe a bit intimidating for some people to think about this, but once the data is in, how do you turn these thousands of responses on, you know, multiple questions into something that actually changes practice or maybe sets research priorities?

Irrum Afzal 13:18

Um, so it, it's analyzing, so really picking out the key questions, analyzing the data, and then from then identifying the research priorities. So my first aim is to have a look at the whole data set and understand the, the, the core data and from, from once I've understood the core data, to then pick out the, the research priorities and be able to pick which, what questions we're answer- asking. Because from this we'll be able to, you know, do machine learning on, on the data 'cause there's so many questions and there's so much data. So with my interest in AI, I hope to be able to use this data to be able to then have a res- research output from the data. So that, that's the goal and that's how I'm gonna utilize, utilize the data.

Joseph M. Schwab 14:00

Hmm. And is there a target number of responses that you're trying to hit as sort of a minimum or a baseline?

Irrum Afzal 14:07

So scientifically, the, the, the baseline is the, the population size we need is, is 500, is after-- or 520 was what, what, my, um, statistical power, um, test told me. But I'm, I'm, I'm hoping to have 1,000. Uh, my goal is, goal is 1,000. So Professor Field has set me the target of 1,000, um, and here I am trying my hardest to, to achieve it through d- various different mechanisms.

Joseph M. Schwab 14:31

Yeah. And w- in, in the United States, anyway, we're all about incentivizing metrics. So do you get, uh, do you get a, a prize from Professor Field if you, if you get to 1,000? Or is it just the satisfaction of knowing you've done a good job collecting the data?

Irrum Afzal 14:45

Uh, just the satisfaction of knowing that I've, that I've achieved the target, that I've achieved the, uh, the thousand responses. Because one of the things that I've learnt by doing this, there's actually a lot, a lot of surveys that are going on, um, landing in people's inboxes, so really this is just another survey, this is another ask, and there is real survey fatigue. Um, you know, I, the other day, got an email from one of the British Hip Society, for example, and there were four surveys attached to that, that email. So, you know, constantly we're, constantly people are being asked to, to fill, fill surveys. So if I can achieve a thousand, I will be, be, be very happy. So I'm trying very hard.

Joseph M. Schwab 15:23

Well, and, uh, so speaking of, you know, getting surveys and, and getting, uh, data in, the, the NOA, uh, page listed a deadline of June 21st. And I checked today, it was still, still said June 21st, and, and we're a little bit after that. So I would ask you, where does the survey stand now, and what are the next steps for somebody who would wanna take part in it?

Irrum Afzal 15:44

So the survey's still open. So we've-- I've had a look at the data that's already come in, um, and the reason we had set the, the 21st of June was to be able to sort of give me enough time to be able to analyze the data so I was ready for my first presentation on the 3rd of July. But I'm hoping to be able to achieve the maximum number of respondents, so the survey's still open till the 30th of june to be able to complete the survey, and I really hope that I'll be able to get, um, just that final push of, um, of surgeons to be able to complete the survey and hopefully get a few more countries. So, so far to date, I've got 34 different countries, so if I can hit, um, if I can hit a few more different countries, um, I will be, I will be very happy.

Joseph M. Schwab 16:25

Well, and I'll do an appeal to our listeners, 'cause I know we have listeners in, in many different countries around the world. Um, you have until the 30th of June. Uh, we're gonna put a link to the survey in the description. Um, and apart from looking at a specific number of responses, I'm curious, Irrum, what does success look like from your perspective for this GAPS survey?

Irrum Afzal 16:50

Um, so for me, it's to be able to publish the data, so write publications and write papers from the data that I have collected and I've obtained, and really to see an output of it and to be able to share my findings and to hopefully make a meaningful change or be able to provide a global consensus to orthopedic surgeons, and that's success looks like. So it's really about being able to collect clean, meaningful data that I can use through AI and then write up, um, multi- hopefully multiple publications and develop upon it and have a g- have a working group and have a, have a gaps, which, which, is something that is not only limited to this year but goes on for, for a long time, is what the goal is.

Joseph M. Schwab 17:33

And just to be clear for our listeners, is this a survey that's really intended for, uh, people with an established practice, or is it available to surgeons kind of at any stage in their career?

Irrum Afzal 17:46

It's available to any, any surgeon at any stage in their career. And so we're really willing to hear from, um, a broad spectrum of surgeons. So it's, it's, it's open to everyone, and we'll be a- we'll share that in our findings too.

Joseph M. Schwab 17:59

And do you see this data feeding back to the National Joint Registry? I mean, obviously this is a UK-based, it's worldwide, but it's a UK-based, uh, a survey that you're doing. How is this gonna inform, um, what is done with maybe the National Joint Registry, maybe other national registries?

Irrum Afzal 18:20

Um, I would definitely definitely like to share my, share my results with them and, and speak to them about it and ask them how, how or if there is scope to, to collaborate or, or share the data with them, um, so that they can see actually, you know, 'cause they get, they get data from what the surgeons use, put in from their operations to every, particularly within the National Joint Registry in the UK, every hip or knee replacements ha- they have to fill out a, what's called a H1 and a K1 form, which are the, the forms that are mandatory. So every patient get, every, uh, hip or knee replacement gets recorded. But I would like to share what, what is, uh, the, the, the surgeon's perspective with the, the-- 'cause this is a surgeon's perspective is what I would like to share.

Joseph M. Schwab 19:04

Hmm. And I know you're gonna be presenting these results at the upcoming European Anterior Hip Meeting. Um, is this something that we could expect the EAHM to release, um, your, uh, e-either a publication or release a, a video of your, uh, talk so that people can actually see those results, um, if they're not able to make the meeting?

Irrum Afzal 19:28

Uh, yeah, so once, um, the meeting's done, we'll be, um, writing the first publication on the results, um, from the first, first set of data that's collected, and the presentation will a-also have I have a 15-minute slot on the, in the EAHM, so hopefully I'll be be able to y- ha- put in as much data as I can. But equally, I may not be able to have all of it in, in there. So the, uh, we'll have a first publication, but we also have a, a website that will be live with, with all the information, and it will have, um, regular updates and, and a snapshot snapshot.

Joseph M. Schwab 19:58

Um, well, Irrum, thank you for the work that you're doing, and, and thank you for joining us. And to everyone listening, if you do hip replacements, it's easy enough. Go take the survey. I did it myself. It took less than 10 minutes. It was very thorough in the questions that it asked me about my practice, about how we treat our patients, about how we, uh, approach hip replacements. And it's really just a few minutes of your time towards what I see as being the first real global picture of how we all actually practice. The link will be in the show notes, both to the website and to the survey, and it'll stay open until June 30th. Irrum, it's been a pleasure.

Irrum Afzal 20:44

Thank you so much. Thank you very much

Joseph M. Schwab 20:47

And thank you for joining me for this episode of "The AHF Podcast." As always, please take a moment to like and subscribe so we can keep the lights on and keep sharing great content just like this. Please also drop any topic ideas or feedback in the comments below. You can find "The AHF Podcast" on Apple Podcasts, Spotify, or in any of your favorite podcast apps, as well as in video form on YouTube/@anteriorhipfoundation, all one word. Episodes of "The AHF Podcast" come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips happy and healthy and registered in a survey.