Poorer Arthroscopic Outcomes of Mild Dysplasia With Cam Femoroacetabular Impingement Versus Mixed Femoroacetabular Impingement in Absence of Capsular Repair.

PURPOSE: To compare outcomes of mild dysplasia with cam femoroacetabular impingement (FAI) vs mixed FAI with hip arthroscopy without capsular repair. METHODS: A retrospective review of a 2009 to 2010 multicenter prospective outcome study was performed comparing a cohort with mild dysplasia and cam femoroacetabular impingement (cohort D) to a cohort with mixed FAI (cohort M). Outcome measures included Nonarthritic Hip Score (NAHS) and satisfaction with minimum 2-year follow-up. RESULTS: Of 150 patients/159 hips enrolled in the initial prospective outcome study, 10 patients/10 hips had acetabular dysplasia and 8 patients met the inclusion criteria. Cohort D had 8 patients (5 female) of mean age 49.6 years with mean lateral center-edge angle (LCEA) of 19° (range, 16°-24°) demonstrating a mean change in NAHS of +20.00 at 3 months (P = .25), +14.33 at 12 months (P = .03), and -0.75 at 24 months (P = .74). Mean satisfaction was 2.88 out of 5. Cohort M had 69 patients (32 female) of mean age 38.6 years with a mean LCEA of 33° (range, 25°-38°) demonstrating a mean change in NAHS of +12.09 at 3 months (P < .0001), +20.39 at 12 months (P < .0001), and +21.99 at 24 months (P < .0001). Mean satisfaction was 3.58 out of 5. Cohort D demonstrated significantly less improvement in NAHS (P = .002) and a difference of -31.06 points compared to cohort M at minimum 2-year follow-up. Dysplasia was the only statistically significant predictor of poorer outcomes. CONCLUSION: The common combination of mild dysplasia and cam FAI has poorer outcomes than mixed FAI following arthroscopic surgery without capsular repair.

Multi-Center, Community-Based Cardiac Implantable Electronic Devices Registry: Population, Device Utilization, and Outcomes.

BACKGROUND: The purpose of this study is to describe key elements, clinical outcomes, and potential uses of the Kaiser Permanente-Cardiac Device Registry. METHODS AND RESULTS: This is a cohort study of implantable cardioverter defibrillators (ICD), pacemakers (PM), and cardiac resynchronization therapy (CRT) devices implanted between January 1, 2007 and December 31, 2013 by ≈400 physicians in 6 US geographical regions. Registry data variables, including patient characteristics, comorbidities, indication for procedures, complications, and revisions, were captured using the healthcare system's electronic medical record. Outcomes were identified using electronic screening algorithms and adjudicated via chart review. There were 11 924 ICDs, 33 519 PMs, 4472 CRTs, and 66 067 leads registered. A higher proportion of devices were implanted in males: 75.1% (ICD), 55.0% (PM), and 66.7% (CRT), with mean patient age 63.2 years (ICD), 75.2 (PM), and 67.2 (CRT). The 30-day postoperative incidence of tamponade, hematoma, and pneumothorax were ≤0.3% (ICD), ≤0.6% (PM), and ≤0.4% (CRT). Device failures requiring revision occurred at a rate of 2.17% for ICDs, 0.85% for PMs, and 4.93% for CRTs, per 100 patient observation years. Superficial infection rates were <0.03% for all devices; deep infection rates were 0.6% (ICD), 0.5% (PM), and 1.0% (CRT). Results were used to monitor vendor-specific variations and were systematically shared with individual regions to address potential variations in outcomes, utilization, and to assist with the management of device recalls. CONCLUSIONS: The Kaiser Permanente-Cardiac Device Registry is a robust tool to monitor postprocedural patient outcomes and postmarket surveillance of implants and potentially change practice patterns.

Effect of Advancing Age and Multiple Chronic Conditions on Mortality in Patients with End-Stage Renal Disease after Implantable Cardioverter-Defibrillator Placement.

CONTEXT: There is insufficient information on the effect that advancing age and multiple chronic conditions (MCC) have on mortality after placement of an implantable cardioverter-defibrillator in patients with end-stage renal disease (ESRD) vs non-ESRD. OBJECTIVE: To assess whether a differential effect of age and MCC exists between ESRD and non-ESRD. DESIGN: Population-based, retrospective cohort study using data from the national Kaiser Permanente Cardiac Device Registry of patients who underwent placement of an implantable cardioverter-defibrillator between January 1, 2007, and December 31, 2013. MAIN OUTCOME MEASURES: All-cause mortality. RESULTS: Of 7825 patients with implantable cardioverter-defibrillator placement, ESRD-affected patients constituted 4.0% of the cohort (n = 311), were similar in age (p = 0.91), and presented with a larger comorbidity burden (3.3 ± 1.3 vs 2.4 ± 1.5, p < 0.001). The effect of advancing age (every 5 years) on mortality in the ESRD cohort (hazard ratio [HR] = 1.11, 95% confidence interval [CI] = 1.03-1.20) was less than in the non-ESRD cohort (HR = 1.28, 95% CI = 1.25-1.32). Similarly, the effect of each additional comorbidity in the ESRD cohort was less (HR = 1.04, 95% CI = 0.91-1.19) than in the non-ESRD group (HR = 1.20, 95% CI = 1.16-1.25). Lastly, ESRD was independently associated with a 3-fold greater hazard of mortality. CONCLUSIONS: Advancing age and increasing number of MCC have a differential effect on mortality risk in patients with ESRD compared with their non-ESRD counterparts. Future studies should focus on assessment of nonlinear relationships of age, MCC, and naturally occurring clusters of MCC on mortality.

Multicenter outcomes of arthroscopic surgery for femoroacetabular impingement in the community hospital setting.

The purpose of this study is to determine multi-center outcomes from arthroscopic surgery for femoroacetabular impingement in the community hospital setting. A prospective design with 2-year minimum follow-up using the nonarthritic hip score (NAHS), a 100-point scale of perceived post-operative change for pain, activities of daily living, sports activities, and patient satisfaction was implemented at three community hospitals. Of 150 enrolled patients (159 hips) with mean age of 40 years (range, 12-73), there was 81% participation. Mean NAHS at preoperative was 54.9, 3 months: 66.6, 12 months: 74.9 and 24 months: 75.4. This represents a 20.5-point improvement in NAHS (P < 0.001). On the 100-point scale, pain was rated +73.5, ADL's: +76.2 and sports: +68.6. 64% of patients were satisfied with their surgical outcome. Conversion arthroplasty rate was 8.8% and complication rate was 2.5%. In conclusion, arthroscopic surgery for symptomatic femoroacetabular impingement in the community setting provides safe and successful outcomes.

A multiregional registry experience using an electronic medical record to optimize data capture for longitudinal outcomes in endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Registries have been proven useful to assess clinical outcomes, but data entry and personnel expenses are challenging. We developed a registry to track patients undergoing endovascular aortic aneurysm repair (EVAR) in an integrated health care system, leveraging an electronic medical record (EMR) to evaluate clinical practices, device performance, surgical complications, and medium-term outcomes. This study describes the registry design, data collection, outcomes validation, and ongoing surveillance, highlighting the unique integration with the EMR. METHODS: EVARs in six geographic regions of Kaiser Permanente were entered in the registry. Cases were imported using a screening algorithm of inpatient codes applied to the EMR. Standard note templates containing data fields were used for surgeons to enter preoperative, postoperative, and operative data as part of normal workflows in the operating room and clinics. Clinical content experts reviewed cases and entered any missing data of operative details. Patient comorbidities, aneurysm characteristics, implant details, and surgical outcomes were captured. Patients entered in the registry are followed up for life, and all relevant events are captured. RESULTS: Between January 2010 and June 2013, 2112 procedures were entered in the registry. Surgeon compliance with data entry ranges from 60% to 90% by region but has steadily increased over time. Mean aneurysm size was 5.9 cm (standard deviation, 1.3). Most patients were male (84%), were hypertensive (69%), or had a smoking history (79%). The overall reintervention rate was 10.8%: conversion to open repair (0.9%), EVAR revision (2.6%), other surgical intervention (7.3%). Of the reinterventions, 27% were for endoleaks (I, 34.3%; II, 56.9%; III, 8.8%; IV and V, 0.0%), 10.5% were due to graft malfunction, 3.4% were due to infection, and 2.3% were due to rupture. CONCLUSIONS: Leveraging an EMR provides a robust platform for monitoring short-term and midterm outcomes after abdominal aortic aneurysm repair. Use of standardized templates in the EMR allows data entry as part of normal workflow, improving compliance, accuracy, and data capture using limited but expert personnel. Assessment of patient demographics, device performance, practice variation, and postoperative outcomes benefits clinical decision-making by providing complete and adjudicated event reporting. The findings from this large, community-based EVAR registry augment other studies limited to perioperative and short-term outcomes or small patient cohorts.

Mortality after shoulder arthroplasty.

One year post-operative mortality among patients with primary elective total shoulder arthroplasty (ETSA) and traumatic shoulder arthroplasty (TSA) were compared to the general population of a large healthcare system. Standardized mortality ratios (SMRs) and 95% confidence intervals (CIs) were calculated. 614 ETSA patients, 1.0% one year mortality, and 168 TSA patients, 5.4% mortality rate, were evaluated. Patients with ETSA (SMR = 0.4, 95% CI 0.1-0.7) had lower odds of mortality than expected, while patients with TSA (SMR = 1.8, 95% CI 0.6-3.0) did not have higher than expected odds of mortality compared to the reference population. Understanding excess mortality following shoulder arthroplasty surgery allows providers to evaluate current practices and identify ways to optimize patients prior to surgery.