An Interrupted Time Series Analysis Measuring the Impact of Research and Education on Clinical Practice: Decreasing Allograft Use in Young Patients Using a Registry to Track Outcomes.

BACKGROUND: We sought to evaluate whether allograft utilization for primary anterior cruciate ligament reconstruction (ACLR) within our health-care system changed following the implementation of an allograft reduction intervention and whether revision rates within the health-care system changed following the initiation of the intervention. METHODS: We conducted an interrupted time series study using data from Kaiser Permanente's ACL Reconstruction Registry. In our study, we identified 11,808 patients who were ≤21 years of age and underwent primary ACLR from January 1, 2007, through December 31, 2017. The pre-intervention period (15 quarters) was January 1, 2007, through September 30, 2010, and the post-intervention period (29 quarters) was October 1, 2010, through December 31, 2017. Poisson regression was used to evaluate trends over time in 2-year revision rates according to the quarter in which the primary ACLR was performed. RESULTS: Allograft utilization increased pre-intervention from 21.0% in 2007 Q1 to 24.8% in 2010 Q3. Utilization decreased post-intervention from 29.7% in 2010 Q4 to 2.4% in 2017 Q4. The quarterly 2-year revision rate increased from 3.0 to 7.4 revisions per 100 ACLRs pre-intervention and decreased to 4.1 revisions per 100 ACLRs by the end of the post-intervention period. Poisson regression found an increasing 2-year revision rate over time pre-intervention (rate ratio [RR], 1.03 [95% confidence interval (CI), 1.00 to 1.06] per quarter) and a decreasing rate over time post-intervention (RR, 0.96 [95% CI, 0.92 to 0.99]). CONCLUSIONS: In our health-care system, we saw a decrease in allograft utilization following the implementation of an allograft reduction program. During the same period, a decrease in the ACLR revision rate was observed. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

The Association Between Cement Viscosity and Revision Risk After Primary Total Knee Arthroplasty.

BACKGROUND: Recent case series have reported early failure with the use of high-viscosity cement (HVC) in total knee arthroplasty (TKA). We evaluated revision risk after TKA with HVC compared with medium-viscosity cement (MVC) in a large cohort. METHODS: We conducted a cohort study using data from Kaiser Permanente's Total Joint Replacement Registry. Patients who underwent fully cemented primary TKA for osteoarthritis were identified (2001-2018). Only posterior-stabilized, fixed-mobility designs of the 3 highest-volume implant systems (DePuy PFC, Zimmer NexGen, and Zimmer Persona) were included to mitigate confounding from implant characteristics. Palacos (Zimmer/Heraeus) and Simplex (Stryker) cements comprised the HVC and MVC exposure groups, respectively. Propensity score-weighted Cox proportional hazards regression was used to evaluate risk for any revision during follow-up and risk for revision from aseptic loosening specifically. RESULTS: The final cohort comprised 76,052 TKAs, 41.1% using MVC. The crude 14-year cumulative revision probability was 4.55% and 5.12% for TKA with MVC and HVC, respectively. In propensity score-weighted Cox models, MVC compared with HVC had a lower risk of any revision (hazard ratio = 0.82, 95% confidence interval = 0.70-0.95) while no difference was observed for revision from aseptic loosening (hazard ratio = 0.80, 95% confidence interval = 0.56-1.13). CONCLUSION: While we observed a lower risk for any revision with the use of Simplex MVC compared with Palacos HVC, we did not observe a difference in revision for aseptic loosening specifically. Given the widespread use of HVC, additional research to investigate other HVC and potential mechanisms for failure outside of loosening is warranted. LEVEL OF EVIDENCE: Level III.

Occupation-related Cervical Spine Disease in Orthopaedic Surgeons.

INTRODUCTION: Musculoskeletal injury can substantially affect orthopaedic surgeons and productivity. The objective of this study was to assess occupation-related neck pain and cervical radiculopathy/myelopathy among orthopaedic surgeons and to identify the potential risk factors for injury. METHODS: An online survey was sent to orthopaedic surgeons via their state orthopaedic society. The survey consisted of items related to orthopaedic practices, such as the number of arthroscopic procedures done and the use of microscopes/loupes. The prevalence, potential causes, and reporting practices of neck pain and cervical radiculopathy/myelopathy among orthopaedic surgeons were also assessed. RESULTS: There were 685 responses from surgeons representing 27 states. A total of 59.3% of respondents reported neck pain and 22.8% reported cervical radiculopathy. After adjusting for age and sex, surgeons performing arthroscopy had an odds ratio of 3.3 (95% confidence interval: 1.4 to 8.3, P = 0.007) for neck pain. Only five of the surgeons with neck pain and one of the surgeons with cervical radiculopathy/myelopathy had ergonomic evaluations. CONCLUSION: Neck pain and cervical radiculopathy/myelopathy are common among orthopaedic surgeons. Associated factors included older age, higher stress levels, and performing arthroscopy. Cervical injuries are rarely reported, and ergonomic workplace evaluations are infrequent.

A Strategic Approach to Introducing New Technology Into Orthopaedic Practices.

Orthopaedic surgeons have a strong legacy for the early of adoption of new technologies that promise to advance patient care. Such technologies are being developed at an extraordinary pace, leveraging advances in orthobiologics and cartilage restoration, surgical navigation, robotic surgery, 3-D printing, and manufacturing of customized implants and sensors. The functionality provided by this revolution is impressive, promising substantial benefits for patients. However, the value of these technologies resides not in their "newness" but in the ability to improve outcomes for patients and reduce overall costs of care. Deciding whether a new technology brings value to an orthopaedic practice can be difficult, especially in an environment of rising health care costs, abundant choice, competition, consumer pressures, variable quality in supporting data, and a shifting regulatory landscape. In this article, we explore the drivers for orthopaedic companies, institutions, and care providers to develop, evaluate, and incorporate new technology. We outline the technology innovation cycle and the major demographic and psychosocial characteristics of adopter groups. We introduce factors considered in evaluating new technologies, such as patient safety, product efficacy, regulatory issues, and their value. Finally, we summarize the ethical concerns associated with new technology, alongside education and training, network security, financial remuneration and informed consent. This article aims to empower orthopaedic surgeons with a balanced and critical approach to ensure the adoption of new technologies in a safe, effective, and ethical manner.

The Association Between Race/Ethnicity and Revision Following ACL Reconstruction in a Universally Insured Cohort.

BACKGROUND: There have been few large studies involving multiethnic cohorts of patients treated with anterior cruciate ligament reconstruction (ACLR), and therefore, little is known about the role that race/ethnicity may play in the differential risk of undergoing revision surgery following primary ACLR. The purpose of this study was to evaluate whether differences exist by race/ethnicity in the risk of undergoing the elective procedure of aseptic revision in a universally insured cohort of patients who had undergone ACLR. METHODS: This was a retrospective cohort study conducted using our integrated health-care system's ACLR registry and including primary ACLRs from 2008 to 2015. Race/ethnicity was categorized into the following 4 groups: non-Hispanic white, black, Hispanic, and Asian. Multivariable Cox proportional-hazard models were used to evaluate the association between race/ethnicity and revision risk while adjusting for age, sex, highest educational attainment, annual household income, graft type, and geographic region in which the ACLR was performed. RESULTS: Of the 27,258 included patients,13,567 (49.8%) were white, 7,713 (28.3%) were Hispanic, 3,725 (13.7%) were Asian, and 2,253 (8.3%) were black. Asian patients (hazard ratio [HR] = 0.72; 95% confidence interval [CI] = 0.57 to 0.90) and Hispanic patients (HR = 0.83; 95% CI = 0.70 to 0.98) had a lower risk of undergoing revision surgery than did white patients. Within the first 3.5 years postoperatively, we did not observe a difference in revision risk when black patients were compared with white patients (HR = 0.86; 95% CI = 0.64 to 1.14); after 3.5 years postoperatively, black patients had a lower risk of undergoing revision (HR = 0.23; 95% CI = 0.08 to 0.63). CONCLUSIONS: In a large, universally insured ACLR cohort with equal access to care, we observed Asian, Hispanic, and black patients to have a similar or lower risk of undergoing elective revision compared with white patients. These findings emphasize the need for additional investigation into barriers to equal access to care. Because of the sensitivity and complexity of race/ethnicity with surgical outcomes, continued assessment into the reasons for the differences observed, as well as any differences in other clinical outcomes, is warranted. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral Tunnel Drilling Method: Risk of Reoperation and Revision After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The femoral tunnel in anterior cruciate ligament reconstruction (ACLR) can be created by the transtibial (TT) or tibial-independent (TI) methods. An anatomically located femoral tunnel can be more consistently achieved by TI methods, which include the anteromedial portal and lateral (outside-in, retrodrill) techniques. Nonanatomic graft placement in ACLR can result in postoperative instability and meniscal or chondral injury. An anatomically located graft is subjected to higher postoperative physiologic forces than one placed nonanatomically. PURPOSE: To examine isolated primary ACLR and determine the risk of aseptic revision and reoperation based on femoral tunnel drilling method. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The ACLR registry of an integrated US health care system was used to identify primary isolated unilateral ACLRs from 2009 to 2014. Multivariable Cox proportional hazard regression models were used to evaluate risk for aseptic revision for graft failure and aseptic reoperation for meniscal or chondral injury according to femoral tunnel drilling method: TI versus TT. Models included age, sex, body mass index (BMI), race, graft type, and femoral fixation type as covariates. RESULTS: The cohort included 19,059 patients with primary ACLR. The mean age was 28.9 years (SD, 11.5), 6991 patients (36.8%) were younger than 22 years, 11,795 patients (61.9%) were male, 7648 patients (40.1%) had a BMI less than 25 kg/m2, 8913 patients (46.8%) were white, and 7357 patients (38.6%) received an allograft. Median follow-up was 2.30 years (interquartile range, 1.08-3.77). TI techniques were used for 12,342 (64.8%) of the ACLRs, and the TT method was used for 6717 (35.2%). Use of TI techniques increased from 33.6% of all ACLRs in 2009 to 83.4% in 2014. After adjustment for covariates, the TI group had a higher risk for aseptic revision than the TT group (hazard ratio [HR], 1.28; 95% CI, 1.04-1.56), and this risk was 1.41 times higher in patients younger than 22 years specifically. The 5-year cumulative reoperation probability was lower in the TI group (4.50%; 95% CI, 3.78%-5.36%) compared with the TT group (5.06%; 95% CI, 4.31-5.94%). After adjustment for the covariates, no difference in risk for aseptic reoperation was observed (HR, 1.08; 95% CI, 0.85-1.39). CONCLUSION: In the largest known study of its type examining femoral tunnel drilling method for primary ACLR, after adjustment for age, sex, BMI, race, graft type, and femoral fixation, TI techniques were found to carry higher risk of aseptic revision compared with the TT method, while no difference was observed in risk for aseptic reoperation.

Isolated ACL versus multiple knee ligament injury: associations with patient characteristics, cartilage status, and meniscal tears identified during ACL reconstruction.

OBJECTIVES: The objectives of this study were to determine (1) if patients undergoing reconstruction of an isolated anterior cruciate ligament (ACL) tear had different characteristics (age, gender, body mass index [BMI]) than patients undergoing ACL reconstruction (ACLR) with multiple knee ligament (MKL) tears and (2) whether there was a difference in prevalence of articular cartilage injury and meniscus tears between these two groups. METHODS: Patients undergoing primary ACLR between February 2005 and June 2013 were identified through an ACLR registry. Patients were grouped by whether they had an isolated ACL tear or an ACL tear associated with another knee ligament tear. The study cohort was analyzed to identify differences in patient characteristics and cartilage/meniscus injury patterns between the groups. RESULTS: Of the 21,377 ACLR cases enrolled in the registry during the study period, 2.5% (n = 549) had MKL tears. The MKL group had more males (73.2% vs. 62.8%, p < 0.001) than the isolated ACL group. The MKL group also had a higher percentage of patients with a BMI greater than 30 (31.1% vs. 22.7%, p = 0.0002). When adjusting for these variables, any articular cartilage injury was equal in the two groups (OR = 1.01, CI 0.82-1.25, p = 0.922), while medial femoral condyle injury was less common in the MKL group (OR = 0.73, CI = 0.56-0.07, p = 0.28). The likelihood of any meniscus tear was lower in the MKL group (OR = 0.56, CI = 0.47-0.67, p < 0.001) as was the likelihood of medial meniscus tears (OR = 0.53, CI = 0.44-0.65, p < 0.001). CONCLUSIONS: When comparing patients with MKL tears versus isolated ACL tears at ACLR, there was a higher percentage of males and patients with BMI over 30 in the MKL group. Medial femoral condyle articular cartilage injury, any meniscus tear, and medial meniscus tears were less common in patients with MKL injury compared to patients with isolated ACL tears.

Efficacy of Prophylactic Antibiotics in Simple Knee Arthroscopy.

PURPOSE: To determine the association between the use of preoperative antibiotics and the risk of postoperative infection after simple knee arthroscopy. METHODS: The electronic medical records of a large integrated health care organization were used to identify patients who underwent simple knee arthroscopy between 2007 and 2012. Patient demographics, potential infection risk factors, and antibiotic administration data were extracted. Simple knee arthroscopy included debridement, meniscectomy, meniscus repair, synovectomy, microfracture, and lateral release. Complex knee arthroscopy, septic knees, and cases involving fractures were excluded. Deep infection was defined as a positive synovial fluid culture or signs and symptoms of infection and gross pus in the knee. Superficial infection was defined as clinical signs of infection localized to a portal site and treatment with an antibiotic. RESULTS: Of 40,810 simple knee arthroscopies, 32,836 (80.5%) received preoperative antibiotics and 7,974 (19.5%) did not. There were 25 deep infections in the antibiotic group (0.08%) and 11 in the no-antibiotics group (0.14%) (risk ratio = 0.55, 95% confidence interval: 0.27 to 1.12, P = .10). There were 134 superficial infections in the antibiotic group (0.41%) and 32 in the no-antibiotics group (0.40%) (risk ratio = 1.01, 95% confidence interval: 0.29 to 1.49, P = .93). CONCLUSIONS: In our large sample of patients who underwent simple knee arthroscopy, there was no association between preoperative antibiotic use and postoperative deep or superficial infection rates at the 95% confidence level (P = .05). There was an association between preoperative antibiotic use and a decreased deep infection rate at the P = .10 level. LEVEL OF EVIDENCE: Level IV, case series.

Surgical Technique Trends in Primary ACL Reconstruction from 2007 to 2014.

BACKGROUND: The surgical technique for anterior cruciate ligament (ACL) reconstruction has evolved as a result of improved understanding of ligament biomechanics, anatomy, device development, and failed reconstructions. Studies on surgical technique preferences have been limited to surgeon surveys, which are subject to selection and recall bias. The purpose of this study was to evaluate ACL reconstruction surgical technique and yearly revision rate trends in a community-based setting. METHODS: A population-based epidemiological study was conducted using data on primary ACL reconstruction procedures registered in an ACL reconstruction registry from 2007 to 2014. Changes in the incidence rates of different types of femoral tunnel drilling methods, different types of grafts and graft fixation, and revisions were studied. Adjusted incidence rate ratios (IRRs) are provided. RESULTS: Of the 21,686 ACL reconstructions studied, 72.4% were performed by sports medicine fellowship-trained surgeons. The incidence rate of femoral tunnel drilling via a tibial tunnel decreased at an adjusted rate of 26% per year (IRR = 0.74, 95% confidence interval [CI] = 0.71 to 0.78), from 56.4% to 17.6% during the study period. The incidence rate of medial portal drilling increased from 41.3% to 65.1% at an adjusted rate of 11% per year (IRR = 1.11, 95% CI = 1.09 to 1.13), and the incidence rate of drilling through a lateral approach increased from 2.3% to 17.3% at an adjusted rate of 53% per year (IRR = 1.53, 95% CI = 1.39 to 1.67). There was no change in the use of hamstring autograft, bone-patellar tendon-bone autograft, or tibial tendon allograft. Use of first-generation bioabsorbable femoral and tibial fixation decreased for all graft types. For soft-tissue grafts, usage of suspensory metal femoral fixation increased 12% to 13% per year (IRR = 1.12, 95% CI = 1.09 to 1.15 for tibial tendon grafts; IRR = 1.13, 95% CI = 1.10 to 1.15 for hamstring grafts). For bone-patellar tendon-bone autografts, the use of femoral fixation with interference biocomposite screws increased 7% per year (IRR = 1.07, 95% CI = 1.04 to 1.10). On the tibial side, utilization of biocomposite screws increased for all graft types. No association was found between revision rate and the year of the primary operation. CONCLUSIONS: Surgeons changed their femoral tunnel drilling technique over the study period, whereas the incidence rates of specific graft utilization remained stable. There has been a shift away from first-generation bioabsorbable fixation and increasing use of biocomposite fixation across all graft types. Early cumulative revision rates remained stable.

Prevalence and Incidence of Cartilage Injuries and Meniscus Tears in Patients Who Underwent Both Primary and Revision Anterior Cruciate Ligament Reconstructions.

BACKGROUND: Previous studies have found differences in meniscus and cartilage injury rates between groups of patients after primary and revision anterior cruciate ligament reconstructions (ACLRs). This study examined a cohort of individual patients who underwent primary and subsequent revision ACLR to determine the incidence of cartilage and meniscus disease. PURPOSE: To describe the prevalence and incidence of meniscus and articular cartilage injuries in patients who underwent primary and then subsequent revision ACLR as well as indicate differences in the management of these injuries. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent primary and then revision ACLR from February 2005 to September 2011 were identified using a community-based registry. Patient and procedure characteristics were obtained, and descriptive statistics were used to evaluate the study sample. RESULTS: There were 261 patients who underwent primary and then subsequent revision ACLR during the study period. The median age was 18 years at primary ACLR and 20 years at revision ACLR. Revision ACLR was performed for instability in 256 patients (98%) and for infection in 5 patients (2%). The prevalence of cartilage injuries increased from 14.9% at primary ACLR to 31.8% at revision ACLR. The prevalence of meniscus tears decreased from 54.8% at primary ACLR to 43.7% at revision ACLR. The prevalence of lateral meniscus tears was 32.2% at primary ACLR but only 18.4% at revision ACLR, while the prevalence of medial meniscus tears was the same at primary and revision ACLRs (32.6%). Patients who underwent meniscus tear treatment at primary ACLR had a 70.8% prevalence of meniscus tears at revision ACLR. CONCLUSION: In this community-based sample followed from primary ACLR to revision ACLR, the prevalence of articular cartilage injuries increased, while the prevalence of meniscus injuries decreased. The higher prevalence of articular cartilage injuries at revision ACLR may represent new injuries. The lower prevalence of meniscus tears at revision ACLR may be caused by susceptible menisci being injured and treated at primary surgery or by changes in knee kinematics or injury exposure patterns.

Factors associated with meniscus repair in patients undergoing anterior cruciate ligament reconstruction.

BACKGROUND: Meniscus injuries are common in patients with anterior cruciate ligament (ACL) tears. Patient demographics, surgeon characteristics, and concurrent diagnostic factors affecting the prevalence of meniscus repairs in patients undergoing ACL reconstruction (ACLR) by community-based orthopaedic surgeons have not been fully studied. HYPOTHESIS: Patient (age, sex, race, and body mass index [BMI]), surgeon (sports medicine fellowship training status and case volume), and injury characteristics (1 or both menisci injured, injury location, and concurrent cartilage injury) and surgical venue (case volume) are associated with a higher likelihood of meniscus repair. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A cross-sectional study using data from a large community-based ACLR registry was performed. Patients with a meniscus injury and primary ACLR between February 2005 and June 2010 were included in the study. Meniscus repair rates by patient, surgeon, and injury characteristics were described. Associations were evaluated using generalized linear models. RESULTS: During the study period, 5712 primary ACLRs with a meniscus tear diagnosis were registered. There was 1 torn meniscus in 4248 (74.4%) patients, and both menisci were torn in 1464 (25.6%) patients. Medial meniscus tears were repaired in 1192 (31.2%) of 3818 cases; the remaining 2626 (68.8%) tears were not repaired, underwent alternative treatment (meniscectomy, trephination, rasped), or were left in situ. Lateral meniscus tears were repaired in 893 (26.6%) of 3358 cases; the remaining 2465 (73.4%) tears underwent alternative treatment or were left in situ. Adjusted models showed that younger patient age (P < .001), lower patient BMI (P < .001), surgeon's sports medicine fellowship training (P < .001), higher surgeon case volume (P < .001), higher surgical venue volume (P = .019), and medial meniscus tears (P < .001) were all associated with a higher likelihood of a meniscus repair. CONCLUSION: Younger patient age, lower patient BMI, surgeon's sports medicine fellowship training, higher surgeon case volume, and higher site volume are associated with a higher likelihood of a meniscus repair in patients undergoing primary ACLR in a large cohort from a community-based ACLR registry.