Technology enabled home-based cardiac rehabilitation among women with cardiovascular disease: A longitudinal cohort study.

Technology-enabled home-based cardiac rehabilitation (HBCR) is an emerging alternative to traditional center-based cardiac rehabilitation (CBCR), but little is known about outcomes in women. We analyzed 753 diverse and medically complex women who participated in HBCR and CBCR within an integrated health system and found both groups had similar clinical outcomes. Results suggest HBCR is a viable alternative to CBCR among women, including women with multiple comorbidities.

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.

Urgent and non-emergent telehealth care for seniors: Findings from a multi-site impact study.

INTRODUCTION: The global pandemic has raised awareness of the need for alternative ways to deliver care, notably telehealth. Prior to this study, research has been mixed on its effectiveness and impact on downstream utilization, especially for seniors. Our multi-institution study of more than 300,000 telehealth visits for seniors evaluates the clinical outcomes and healthcare utilization for urgent and non-emergent symptoms. METHODS: We conducted a retrospective cohort study from November 2015 to March 2019, leveraging different models of telehealth from three health systems, comparing them to in-person visits for urgent and non-emergent needs of seniors based on International Classification of Diseases, 10th edition diagnoses. The study population was adults aged 60 years or older who had access to telehealth and were affiliated with and resided in the geographic region of the healthcare organization providing telehealth. The primary outcomes of interest were visit resolution and episodes of care for those that required follow-up. RESULTS: In total, 313,516 telehealth visits were analysed across three healthcare organizations. Telehealth encounters were successful in resolving urgent and non-emergent needs in 84.0-86.7% of cases. When visits required follow-up, over 95% were resolved in less than three visits for both telehealth and in-person cohorts. DISCUSSION: While in-person visits have traditionally been the gold standard, our results suggest that when deployed within the confines of a patient's existing primary care and health system provider, telehealth can be an effective alternative to in-person care for urgent and non-emergent needs of seniors without increasing downstream utilization.

Comparison of Home-Based vs Center-Based Cardiac Rehabilitation in Hospitalization, Medication Adherence, and Risk Factor Control Among Patients With Cardiovascular Disease.

Importance: Prior studies have suggested that participation in home-based cardiac rehabilitation (HBCR) vs center-based cardiac rehabilitation (CBCR) results in similar clinical outcomes in patients with low to moderate risk; however, outcome data from demographically diverse populations and patients who are medically complex are lacking. Objective: To compare hospitalizations, medication adherence, and cardiovascular risk factor control between participants in HBCR vs CBCR. Design, Setting, and Participants: This retrospective cohort study was conducted among patients in Kaiser Permanente Southern California (KPSC), an integrated health care system serving approximately 4.7 million patients, who participated in CR between April 1, 2018, and April 30, 2019, and with follow-up through April 30, 2020. Data were analyzed from January 2021 to January 2022. Exposures: Participation in 1 or more HBCR or CBCR sessions. Main Outcomes and Measures: The primary outcome was 12-month all-cause hospitalization. Secondary outcomes included all-cause hospitalizations at 30 and 90 days; 30-day, 90-day, and 12-month cardiovascular hospitalizations; and medication adherence and cardiovascular risk factor control at 12 months. Logistic regression was used to compare hospitalization, medication adherence, and cardiovascular risk factor control, with inverse probability treatment weighting (IPTW) to adjust for demographic and clinical characteristics. Results: Of 2556 patients who participated in CR (mean [SD] age, 66.7 [11.2] years; 754 [29.5%] women; 1196 participants [46.8%] with Charlson Comorbidity Index ≥4), there were 289 Asian or Pacific Islander patients (11.3%), 193 Black patients (7.6%), 611 Hispanic patients (23.9%), and 1419 White patients (55.5%). A total of 1241 participants (48.5%) received HBCR and 1315 participants (51.5%) received CBCR. After IPTW, patients who received HBCR had lower odds of hospitalization at 12 months (odds ratio [OR], 0.79; 95% CI, 0.64-0.97) but similar odds of adherence to ß-blockers (OR, 1.18; 95% CI, 0.98-1.42) and statins (OR, 1.02; 95% CI, 0.84-1.25) and of control of blood pressure (OR, 0.98; 95% CI, 0.81-1.17), low-density lipoprotein cholesterol (OR, 0.98; 95% CI, 0.81-1.20), and hemoglobin A1c (OR, 0.98; 95% CI, 0.82-1.18) at 12 months compared with patients who received CBCR. Conclusions and Relevance: These findings suggest that HBCR in a demographically diverse population, including patients with high risk who are medically complex, was associated with fewer hospitalizations at 12 months compared with patients who participated in CBCR. This study strengthens the evidence supporting HBCR in previously understudied patient populations.

Optimizing anterior cruciate ligament reconstruction: Individualizing the decision-making process using data from the Kaiser Permanente ACLR Registry: 2018 OREF award paper.

Despite years of study, controversy remains regarding the optimal graft for anterior cruciate ligament reconstruction (ACLR), suggesting that a single graft type is not ideal for all patients. A large community based ACLR Registry that collects prospective data is a powerful tool that captures information and can be analyzed to optimize surgery for individual patients. The studies highlighted in this paper were designed to optimize and individualize ACLR surgery and have led to changes in surgeon behavior and improvements in patient outcomes. Kaiser Permanente (KP) is an integrated health care system with 10.6 million members and more than 50 hospitals. Every KP member who undergoes an ACLR is entered into the Registry, and prospectively monitored. The Registry uses a variety of feedback mechanisms to disseminate Registry findings to the ACLRR surgeons and appropriately influence clinical practices and enhance quality of care. Allografts were found to have a 3.0 times higher risk of revision than bone-patellar tendon-bone (BPTB) autografts. Allograft irradiation >1.8 Mrad, chemical graft processing, younger patients, BPTB allograft, and male patients were all associated with a higher risk of revision surgery. By providing feedback to surgeons, overall allograft use has decreased by 27% and allograft use in high-risk patients ≤21 years of age decreased 68%. We have identified factors that influence the outcomes of ACLR. Statement of Clinical Significance: We found that information derived from an ACLR Registry and shared with the participating surgeons directly decreased the use of specific procedures and implants associated with poor outcomes.

WITHDRAWN: Urgent and non-emergent telehealth care for seniors: Findings from a multi-site impact study.

Ahead of Print article withdrawn by publisher.

Description and Early Results of the Kaiser Permanente Southern California COVID-19 Home Monitoring Program.

INTRODUCTION: The Southern California region of Kaiser Permanente developed a COVID-19 Home Monitoring program as an alternative to hospital admission to decrease hospital bed days and mitigate the adverse effects of a surge. To date, more than 15,000 patients have been enrolled and approximately 10% of enrolled patients have been escalated to hospital care for timely treatment. Our objective is to describe our COVID-19 Home Monitoring program and present early results. METHODS: We conducted an observational retrospective study of all patients enrolled in the COVID-19 Home Monitoring program between April 13, 2020 through February 12, 2021. Data analysis conducted includes patient demographics, enrollment, entry points, length of stay, mortality, additional treatment, utilization, adherence, satisfaction, and alert triggers. RESULTS: A total of 12,461 of 13,055 patients (95.5%) recovered and completed the program, 1387 patients (10.6%) were admitted to the hospital, and 20 patients (0.2%) died while they were being monitored at home. The mortality rate at 30 days from enrollment was 1.6%. Hospital length of stay for ambulatory patients receiving oxygen only was 5.4 days compared to 3.1 days for those ambulatory patients receiving oxygen, dexamethasone, and remdesivir. CONCLUSION: COVID-19 home monitoring appears to be safe and effective. Initial data suggest it can serve as an alternative to hospitalization, decreasing hospital length of stay when patients receive therapies in the ambulatory setting otherwise reserved for the hospital. Initial results of this Home Monitoring program appear to be promising, and a longer term prospective study is warranted.

Screw and Sheath Tibial Fixation Associated With a Higher Likelihood of Deep Infection After Hamstring Graft Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Hamstring autograft anterior cruciate ligament reconstructions (ACLRs) have exhibited higher infection rates compared with bone-patellar tendon-bone (BPTB) autograft. The reason for this observed difference is unclear, warranting investigation. PURPOSE: To evaluate the association between tibial fixation, either with or without a sheath and screw construct, and the risk of deep infection after hamstring autograft ACLR, using BPTB autograft as a reference group for comparison. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Using the Kaiser Permanente ACLR Registry, we identified all primary isolated, unilateral, single-bundle ACLRs with a BPTB or hamstring autograft (January 1, 2008, to September 30, 2016). The exposure groups included the following: (1) BPTB ACLR, (2) hamstring ACLR using a screw and sheath construct for tibial fixation (HS with screw and sheath), and (3) hamstring ACLR using a method other than a screw and sheath construct for tibial fixation (HS without screw and sheath). We used logistic regression to evaluate the likelihood of 90-day postoperative deep infection using BPTB autograft as the reference group and adjusting for age, sex, and body mass index. The number needed to be exposed (NNE) was calculated. RESULTS: Of 15,671 ACLRs, 6745 (43.0%) used a BPTB graft, 2852 (18.2%) used HS with screw and sheath tibial fixation, and 6074 (38.8%) used HS without screw and sheath tibial fixation. There were 38 (0.2%) 90-day deep infections: 11 (0.2%) for BPTB, 14 (0.5%) for HS with screw and sheath, and 13 (0.2%) for HS without screw and sheath. Staphylococcus aureus for the BPTB group and Staphylococcus epidermidis in both hamstring groups were the most common infecting organisms. HS with screw and sheath had a higher likelihood of 90-day deep infection compared with BPTB ACLR (odds ratio [OR], 2.87; 95% CI, 1.29-6.38). We failed to observe a difference for HS without screw and sheath compared with BPTB ACLR (OR, 1.23; 95% CI, 0.54-2.77). The NNE was 330 and 2701 for HS with and HS without screw and sheath, respectively. CONCLUSION: Although the overall infection rate after ACLR is low, the higher likelihood of infections when sheath and screw combined are used for tibial fixation of a hamstring autograft ACLR should be a consideration when this procedure is performed.

The Association Between Tibial Slope and Revision Anterior Cruciate Ligament Reconstruction in Patients ≤21 Years Old: A Matched Case-Control Study Including 317 Revisions.

BACKGROUND: There is evidence that tibial slope may play a role in revision risk after anterior cruciate ligament reconstruction (ACLR); however, prior studies are inconsistent. PURPOSE: To determine (1) whether there is a difference in lateral tibial posterior slope (LTPS) or medial tibial posterior slope (MTPS) between patients undergoing revised ACLR and those not requiring revision and (2) whether the medial-to-lateral slope difference is different between these 2 groups. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We conducted a matched case-control study (2006-2015). Cases were patients aged ≤21 years who underwent revision surgery after primary unilateral ACLR; controls were patients aged ≤21 years without revision who were identified from the same source population. Controls were matched to cases by age, sex, body mass index, race, graft type, femoral fixation device, and post-ACLR follow-up time. Tibial slope measurements were made by a single blinded reviewer using magnetic resonance imaging. The Wilcoxon signed rank test and McNemar test were used for continuous and categorical variables, respectively. RESULTS: No difference was observed between revised and nonrevised ACLR groups for LTPS (median: 6° vs 6°, P = .973) or MTPS (median: 4° vs 5°, P = .281). Furthermore, no difference was found for medial-to-lateral slope difference (median: -1 vs -1, P = .289). A greater proportion of patients with revised ACLR had an LTPS ≥12° (7.6% vs 3.8%) and ≥13° (4.7% vs 1.3%); however, this was not statistically significant after accounting for multiple testing. CONCLUSION: We failed to observe an association between revision ACLR surgery and LTPS, MTPS, or medial-to-lateral slope difference. However, there was a greater proportion of patients in the revision ACLR group with an LTPS ≥12°, suggesting that a minority of patients who have more extreme values of LTPS have a higher revision risk after primary ACLR. A future cohort study evaluating the angle that best differentiates patients at highest risk for revision is needed.

A Comparison of Online Physician Ratings and Internal Patient-Submitted Ratings from a Large Healthcare System.

BACKGROUND: Physician online ratings are ubiquitous and influential, but they also have their detractors. Given the lack of scientific survey methodology used in online ratings, some health systems have begun to publish their own internal patient-submitted ratings of physicians. OBJECTIVE: The purpose of this study was to compare online physician ratings with internal ratings from a large healthcare system. DESIGN: Retrospective cohort study comparing online ratings with internal ratings from a large healthcare system. SETTING: Kaiser Permanente, a large integrated healthcare delivery system. PARTICIPANTS: Physicians in the Southern California region of Kaiser Permanente, including all specialties with ambulatory clinic visits. MAIN MEASURES: The primary outcome measure was correlation between online physician ratings and internal ratings from the integrated healthcare delivery system. RESULTS: Of 5438 physicians who met inclusion and exclusion criteria, 4191 (77.1%) were rated both online and internally. The online ratings were based on a mean of 3.5 patient reviews, while the internal ratings were based on a mean of 119 survey returns. The overall correlation between the online and internal ratings was weak (Spearman's rho .23), but increased with the number of reviews used to formulate each online rating. CONCLUSIONS: Physician online ratings did not correlate well with internal ratings from a large integrated healthcare delivery system, although the correlation increased with the number of reviews used to formulate each online rating. Given that many consumers are not aware of the statistical issues associated with small sample sizes, we would recommend that online rating websites refrain from displaying a physician's rating until the sample size is sufficiently large (for example, at least 15 patient reviews). However, hospitals and health systems may be able to provide better information for patients by publishing the internal ratings of their physicians.

Risk Factors for Opioid Use After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The misuse of opioid medications has contributed to a significant national crisis affecting public health as well as patient morbidity and medical costs. After orthopaedic surgical procedures, patients may require prescription (Rx) opioid medication, which can fuel the opioid epidemic. Opioid Rx usage after anterior cruciate ligament reconstruction (ACLR) is not well characterized. PURPOSE: To determine baseline utilization of Rx opioids in patients undergoing ACLR and examine demographic, patient, and surgical factors associated with greater and prolonged postoperative opioid utilization. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Primary elective ACLRs were identified using Kaiser Permanente's ACLR registry (2005-2015). We studied the association of perioperative risk factors on the number of dispensed opioid Rx in the early (0-90 days) and late (91-360 days) postoperative recovery periods using logistic regression. RESULTS: Of 21,202 ACLRs, 25.5% used at least 1 opioid Rx in the 1-year preoperative period; 17.7% and 2.7% used ≥2 opioid Rx in the early and late recovery periods, respectively. Risk factors associated with greater opioid Rx in both the early and the late periods included the following: ≥2 preoperative opioid Rx, age ≥20 years, American Society of Anesthesiologists classification ≥3, other activity at the time of injury, chondroplasty, chronic pulmonary disease, and substance abuse. Risk factors associated with opioid Rx use during the early period only included the following: other race, acute injury, meniscal injury repair, multiligament injury, and dementia/psychosis. Risk factors associated with greater opioid Rx during the late period only included the following: 1 preoperative opioid Rx, female sex, body mass index ≥25 kg/m2, motor vehicle accident as the mechanism of injury, and hypertension. CONCLUSION: A quarter of ACLR patients had at least 1 opioid Rx before the procedure, but usage dropped to 2.7% toward the end of the postoperative year. We identified several perioperative risk factors for greater and prolonged opioid usage after ACLR.

Femoral-tibial fixation affects risk of revision and reoperation after anterior cruciate ligament reconstruction using hamstring autograft.

PURPOSE: Newer fixation devices for hamstring (HS) autograft have been introduced over the years, yet the impact of these devices on ACLR outcomes requiring surgical intervention remains unclear. We sought to evaluate the risk of aseptic revision and reoperation after HS autograft ACLR according to various femoral-tibial fixation methods. METHODS: A cohort study was conducted using the Kaiser Permanente ACLR Registry. Primary isolated unilateral ACLR patients who received a HS autograft were identified (2007-2014). Fixation devices were categorized as crosspin, interference, suspensory, or combination (defined as more than one fixation device used on the same side) and femoral-tibial fixation groups used in more than 500 ACLR were evaluated. Cox proportional-hazard regression was used to evaluate the association between femoral-tibial fixation method and outcomes while adjusting for confounders. RESULTS: 6,593 primary ACLR were included. Four femoral-tibial fixation groups had more than 500 ACLR: suspensory-interference (n = 3004, 45.6%), interference-interference (n = 1659, 25.2%), suspensory-combination (n = 1103, 16.7%), and crosspin-interference (n = 827, 12.5%). After adjusting for covariates, revision risk was lower for crosspin-interference (HR = 0.43, 95% CI 0.29-0.65) and interference-interference (HR = 0.63, 95% CI 0.41-0.95) methods compared to the suspensory-interference. In contrast, reoperation risk was higher for crosspin-interference (HR = 2.13, 95% CI 1.37-3.32) and suspensory-combination (HR = 1.68, 95% CI 1.04-2.69) methods compared to suspensory-interference. CONCLUSIONS: ACLR using HS autograft appears to have the lowest risk of aseptic revision when crosspin or interference fixation is used on the femoral side and is coupled with an interference screw on the tibial side. LEVEL OF EVIDENCE: III.

Patient demographic and surgical characteristics in anterior cruciate ligament reconstruction: a description of registries from six countries.

OBJECTIVE: Findings from individual anterior cruciate ligament reconstruction (ACLR) registry studies are impactful, but how various registries from different countries compare with different patient populations and surgical techniques has not been described. We sought to describe six ACLR registry cohorts to understand variation across countries. METHODS: Five European registries and one US registry participated. For each registry, all primary ACLR registered between registry establishment through 31December 2014 were identified. Descriptive statistics included frequencies, proportions, medians and IQRs. Revision incidence rates following primary ACLR were computed. RESULTS: 101 125 ACLR were included: 21 820 in Denmark, 300 in Luxembourg, 17 556 in Norway, 30 422 in Sweden, 2972 in the UK and 28 055 in the US. In all six cohorts, males (range: 56.8%-72.4%) and soccer injuries (range: 14.1%-42.3%) were most common. European countries mostly used autografts (range: 93.7%-99.7%); allograft was most common in the US (39.9%). Interference screw was the most frequent femoral fixation in Luxembourg and the US (84.8% and 42.9%), and suspensory fixation was more frequent in the other countries (range: 43.9%-75.5%). Interference was the most frequent tibial fixation type in all six cohorts (range: 64.8%-98.2%). Three-year cumulative revision probabilities ranged from 2.8% to 3.7%. CONCLUSIONS: Similarities in patient demographics and injury activity were observed between all cohorts of ACLR. However, graft and fixation choices differed. Revision rates were low. This work, including >100 000 ACLR, is the most comprehensive international description of contemporary practice to date.

Risk of Infection After Allograft Anterior Cruciate Ligament Reconstruction: Are Nonprocessed Allografts More Likely to Get Infected? A Cohort Study of Over 10,000 Allografts.

BACKGROUND: Allograft tissue is frequently used in anterior cruciate ligament reconstruction (ACLR). It is often irradiated and/or chemically processed to decrease the risk of disease transmission, but some tissue is aseptically harvested without further processing. Irradiated and chemically processed allograft tissue appears to have a higher risk of revision, but whether this processing decreases the risk of infection is not clear. PURPOSE: To determine the incidence of deep surgical site infection after ACLR with allograft in a large community-based sample and to evaluate the association of allograft processing and the risk of deep infection. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The authors conducted a cohort study using the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry. Primary isolated unilateral ACLR with allograft were identified from February 1, 2005 to September 30, 2015. Ninety-day postoperative deep infections were identified via an electronic screening algorithm and then validated through chart review. Logistic regression was used to evaluate the likelihood of 90-day postoperative deep infection per allograft processing method: processed (graft treated chemically and/or irradiated) or nonprocessed (graft not irradiated or chemically processed). RESULTS: Of 10,190 allograft cases, 8425 (82.7%) received a processed allograft, and 1765 (17.3%) received a nonprocessed allograft. There were 15 (0.15%) deep infections during the study period: 4 (26.7%) coagulase-negative Staphylococcus, 4 (26.7%) methicillin-sensitive Staphylococcus aureus, 1 (6.7%) Peptostreptococcus micros, and 6 (40.0%) with no growth. There was no difference in the likelihood for 90-day deep infection for processed versus nonprocessed allografts (odds ratio = 1.36, 95% CI = 0.31-6.04). CONCLUSION: The overall incidence of deep infection after ACLR with allograft tissue was very low (0.15%), suggesting that the methods currently employed by tissue banks to minimize the risk of infection are effective. In this cohort, no difference in the likelihood of infection between processed and nonprocessed allografts could be identified.

Analysis of 2019 Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction From a Community-Based Registry.

BACKGROUND: Knowledge of patient characteristics, surgical fixation, graft choice, outcomes, and concurrent injuries of revision anterior cruciate ligament reconstruction (ACLR) is limited. PURPOSE: To describe the current cohort of revision ACLR captured by a community registry and the outcomes observed in the registered patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent revision ACLR registered between February 2005 and June 2014, by 200 surgeons in 46 hospitals, were evaluated. The Kaiser Permanente ACLR Registry (KPACLRR) collected data intraoperatively and postoperatively using paper forms, electronic medical records, administrative claims data, and patient-reported outcomes. The KPACLRR cohort was longitudinally followed, and outcomes were prospectively ascertained. Outcomes (ie, revisions, subsequent operative procedures, deep surgical site infections, and deep venous thrombosis) were adjudicated via a chart review. Descriptive statistics were employed. RESULTS: Of 2019 patients who underwent revision ACLR, at a median follow-up of 2.2 years (interquartile range, 1.0-3.8 years), 212 (10.5%) required subsequent operative procedures, and 86 (4.3%) were revised a second time. At the time of revision, 55.1% of the patients had at least 1 concurrent meniscal injury, and 26% of those were repairable. Cartilage injuries were present in 42.0% of patients. Deep surgical site infections occurred in 12 patients (0.6%), deep venous thrombosis occurred in 5 patients (0.3%), and 1 patient (0.1%) had a pulmonary embolism. CONCLUSION: Revision ACLR can be performed with a low short-term revision rate and relatively few complications. At the time of revision, nearly half of these patients had an irreparable meniscal injury, and slightly less than half had a cartilage injury. A large community-based ACLR registry is useful in informing surgeons of current treatment practices, prevalence of concurrent injuries, and outcomes associated with the procedures, especially infrequent procedures such as revision ACLR.

Increased Risk of Revision After Anterior Cruciate Ligament Reconstruction With Soft Tissue Allografts Compared With Autografts: Graft Processing and Time Make a Difference.

BACKGROUND: The optimal graft for anterior cruciate ligament reconstruction (ACLR) remains controversial. PURPOSE: To compare the risk of aseptic revision between bone-patellar tendon-bone (BPTB) autografts, hamstring autografts, and soft tissue allografts. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Prospectively collected ACLR cases reconstructed with BPTB autografts, hamstring autografts, and soft tissue allografts were identified using the Kaiser Permanente ACLR Registry. Aseptic revision was the endpoint. The type of graft and allograft processing method (nonprocessed, <1.8-Mrad irradiation with and without chemical processing [Allowash or AlloTrue], ≥1.8-Mrad irradiation with and without chemical processing, and chemical processing alone [BioCleanse]) were the exposures evaluated. Analyses were adjusted for age, sex, and race. Kaplan-Meier curves and Cox proportional hazards models were employed. RESULTS: The cohort included 14,015 cases: there were 8924 (63.7%) male patients, there were 6397 (45.6%) white patients, 4557 (32.5%) ACLRs used BPTB autografts, 3751 ACLRs (26.8%) used soft tissue allografts, and 5707 (40.7%) ACLRs used hamstring autografts. The median age was 34.6 years for soft tissue allografts, 24.3 years for hamstring autografts, and 22.0 years for BPTB autografts. The crude nonadjusted revision rates were 85 (1.9%) in BPTB autograft cases, 132 (2.3%) in hamstring autograft cases, and 83 (2.2%) in soft tissue allograft cases. After adjusting for age, sex, and race, compared with hamstring autografts, a higher risk of revision was found with allografts with ≥1.8 Mrad without chemical processing after 2.5 years (hazard ratio [HR], 3.88; 95% CI, 1.48-10.12) and ≥1.8 Mrad with chemical processing after 1 year (HR, 3.43; 95% CI, 1.58-7.47) and with BioCleanse processed grafts at any time point (HR, 3.02; 95% CI, 1.40-6.50). Nonprocessed allografts and those irradiated with <1.8 Mrad with or without chemical processing were not found to have a different risk of revision compared with hamstring autografts. Compared with BPTB autografts, a higher risk of revision was seen with hamstring autografts (HR, 1.51; 95% CI, 1.15-1.99) and BioCleanse processed allografts (HR, 4.67; 95% CI, 2.15-10.16). Allografts irradiated with <1.8 Mrad with chemical processing (Allowash or AlloTrue) (HR, 2.19; 95% CI, 1.42-3.38) and without chemical processing (HR, 2.31; 95% CI, 1.40-3.82) had a higher risk of revision, as did allografts with ≥1.8 Mrad without chemical processing after 2 years (HR, 6.30; 95% CI, 3.18-12.48) and ≥1.8 Mrad with chemical processing (Allowash or AlloTrue) after 1 year (HR, 5.03; 95% CI, 2.30-11.00) compared with BPTB autografts. Nonprocessed allografts did not have a higher risk of revision compared with autografts. With the numbers available, direct comparisons between the specific allograft processing methods were not possible. CONCLUSION: When soft tissue allografts are used for ACLR, processing and time from surgery affect the risk of revision. Tissue processing has a significant effect on the risk of revision surgery, which is most profound with more highly processed grafts and increases with increasing follow-up time. Surgeons and patients need to be aware of the increased risks of revision with the various soft tissue allografts used for ACLR.

Increased Risk of Revision After Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Allografts Compared With Autografts.

BACKGROUND: The use of allograft tissue for anterior cruciate ligament reconstruction (ACLR) remains controversial. PURPOSE: To compare the risk of aseptic revision between bone-patellar tendon-bone (BPTB) autografts and BPTB allografts. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A retrospective cohort study of prospectively collected data was conducted using the Kaiser Permanente ACLR Registry. A cohort of patients who underwent primary unilateral ACLR with BPTB autografts and BPTB allografts was identified. Aseptic revision was the endpoint. The type of graft and allograft processing method (nonprocessed, <1.8-Mrad, and ≥1.8-Mrad irradiation) were the exposures of interest evaluated. Age (≤21 and ≥22 years) was evaluated as an effect modifier. Analyses were adjusted for age, sex, and race. Kaplan-Meier curves and Cox proportional hazards models were employed. Hazard ratios (HRs) and 95% CIs are provided. RESULTS: The BPTB cohort consisted of 5586 patients: 3783 (67.7%) were male, 2359 (42.2%) were white, 1029 (18.4%) had allografts (nonprocessed: 155; <1.8 Mrad: 525; ≥1.8 Mrad: 288), and 4557 (81.6%) had autografts. The median age was 34.9 years (interquartile range [IQR], 25.4-44.0) for allograft cases and 22.0 years (IQR, 17.6-30.0) for autograft cases. The estimated cumulative revision rate at 2 years was 4.1% (95% CI, 2.9%-5.9%) for allografts and 1.7% (95% CI, 1.3%-2.2%) for autografts. BPTB allografts had a significantly higher adjusted risk of revision than BPTB autografts (HR, 4.54; 95% CI, 3.03-6.79; P < .001). This higher risk of revision was consistent with all allograft processing methods when compared with autografts and was also consistently higher in patients with allografts regardless of age. CONCLUSION: When BPTB allograft tissue was used for ACLR, an overall 4.54 times adjusted higher risk of revision was observed compared with surgery performed with a BPTB autograft. Whether the tissue was irradiated with either high- or low-dose radiation, chemically processed, or not processed at all made little difference in the risk of revision. The differences in the revision risk were also consistent in younger and older patients. Surgeons and patients should be aware of the increased risk of revision when a BPTB allograft is used for ACLR.

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.