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J Arthroplasty. 2018 Mar;33(3):661-667. doi: 10.1016/j.arth.2017.10.034. Epub 2017 Oct 26.

Treatments of Missing Values in Large National Data Affect Conclusions: The Impact of Multiple Imputation on Arthroplasty Research.

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Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut.
Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.
Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut.



Despite the advantages of large, national datasets, one continuing concern is missing data values. Complete case analysis, where only cases with complete data are analyzed, is commonly used rather than more statistically rigorous approaches such as multiple imputation. This study characterizes the potential selection bias introduced using complete case analysis and compares the results of common regressions using both techniques following unicompartmental knee arthroplasty.


Patients undergoing unicompartmental knee arthroplasty were extracted from the 2005 to 2015 National Surgical Quality Improvement Program. As examples, the demographics of patients with and without missing preoperative albumin and hematocrit values were compared. Missing data were then treated with both complete case analysis and multiple imputation (an approach that reproduces the variation and associations that would have been present in a full dataset) and the conclusions of common regressions for adverse outcomes were compared.


A total of 6117 patients were included, of which 56.7% were missing at least one value. Younger, female, and healthier patients were more likely to have missing preoperative albumin and hematocrit values. The use of complete case analysis removed 3467 patients from the study in comparison with multiple imputation which included all 6117 patients. The 2 methods of handling missing values led to differing associations of low preoperative laboratory values with commonly studied adverse outcomes.


The use of complete case analysis can introduce selection bias and may lead to different conclusions in comparison with the statistically rigorous multiple imputation approach. Joint surgeons should consider the methods of handling missing values when interpreting arthroplasty research.


adverse outcomes; complete case analysis; large data; missing values; multiple imputation; unicompartmental knee arthroplasty

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