Seven-Year Revision Rates for Cochlear Implants in Pediatric and Adult Populations of an Integrated Healthcare System.

OBJECTIVE: We assessed three cochlear implant (CI) suppliers: Advanced Bionics, Cochlear Limited, and MED-EL, for implant revision requiring reoperation after CI placement. STUDY DESIGN: Retrospective cohort study of integrated-health-system database between 2010 and 2021. Separate models were created for pediatric (age <18) and adult (age ≥18) cohorts. PATIENTS: Pediatric (age <18) and adult (age ≥18) patients undergoing cochlear implantation within our integrated healthcare system. MAIN OUTCOME MEASURE: Revision after CI placement. Cox proportional hazard regression was used to evaluate revision risk and adjust for confounding factors. Hazard ratios (HRs) and 95% confidence intervals (CIs) are presented. RESULTS: A total of 2,347 patients underwent a primary CI placement, and Cochlear Limited was most implanted (51.5%), followed by Advanced Bionics (35.2%) and MED-EL (13.3%). In the pediatric cohort, the 7-year crude revision rate was 10.9% for Advanced Bionics and 4.8% for Cochlear Limited, whereas MED-EL had insufficient cases. In adults, the rates were 9.1%, 4.5%, and 3.3% for Advanced Bionics, MED-EL, and Cochlear Limited, respectively. After 2 years of postoperative follow-up, Advanced Bionics had a significantly higher revision risk (HR = 8.25, 95% CI = 2.91-23.46); MED-EL had no difference (HR = 2.07, 95% CI = 0.46-9.25). CONCLUSION: We found an increased revision risk after 2 years of follow-up for adults with Advanced Bionics CI devices. Although we found no statistical difference between manufacturers in the pediatric cohort, after 2 years of follow-up, there were increasing trends in the revision probability for Advanced Bionics. Further research may determine whether patients are better suited for some CI devices.

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.

Association of Sex With Risk of 2-Year Revision Among Patients Undergoing Total Hip Arthroplasty.

Importance: The worldwide population is aging and includes more female individuals than male individuals, with higher rates of total hip arthroplasty (THA) among female individuals. Although research on this topic has been limited to date, several studies are currently under way. Objectives: To evaluate the association between sex and 2-year revision after THA. Design, Setting, and Participants: This cohort study used data from statewide databases in New York and California between October 1, 2015, and December 31, 2018. Patients 18 years or older with osteoarthritis who underwent THA and had sex recorded in the database were included in the analysis. Exposure: Total hip arthroplasty. Main Outcomes and Measures: The outcome of interest was the difference in early, all-cause revision surgery rates after primary THA between women and men. The association of sex with the revision rate was examined using Cox proportional hazards regression analysis. Results: Of 132 826 patients included in the study, 74 002 (55.7%) were women; the mean (SD) age was 65.9 (11.0) years, and the median follow-up time was 1.3 years (range, 0.0-3.0 years). The 2-year revision rate was 2.5% (95% CI, 2.4%-2.6%) among women and 2.1% (95% CI, 2.0%-2.2%) among men. After adjusting for demographic characteristics, comorbidities, and facility volume, a minimal clinically meaningful difference was observed in revision rates despite women having a higher risk of all-cause revision compared with men (hazard ratio, 1.16; 95% CI, 1.07-1.26; P < .001). The risk of revision was increased among women compared with men in the subgroup of patients who were younger than 55 years (hazard ratio, 1.47; 95% CI, 1.20-1.81; P < .001). Conclusions and Relevance: In this cohort study, no clinically meaningful difference in all-cause revision rates after primary THA was found between men and women at 2-year follow-up. The modest difference in the risk of revision between men and women in a small subgroup of patients younger than 55 years suggests that the risk of revision in this population should be studied further.

The Benefits of National and Regional Arthroplasty Registries.

Since the first arthroplasty registries were established in the 1970s, they have become powerful tools in improving the efficiency of health care delivery and patient outcomes. As demonstrated over the past decades, registries can offer benefits not only to patients and surgeons but also to a variety of other stakeholders, such as hospitals, payers, and implant manufacturers. Registry data may be leveraged to address a variety of pressing concerns in the field of arthroplasty. These examples include the role of registries in (1) informing the financial aspects of an increasingly value-based payment system, (2) identifying best clinical practices, (3) improving the outcomes of individual health care providers, and (4) selecting new technologies through outlier detection and benchmarking. As registries continue to mature by improving data coverage and quality, they will play a central role in shaping the future of arthroplasty as well as orthopaedics in general.

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.

Framework To Guide The Collection And Use Of Patient-Reported Outcome Measures In The Learning Healthcare System.

BACKGROUND: Web-based collection of patient-reported outcome measures (PROMs) in clinical practice is expanding rapidly as electronic health records include web portals for patients to report standardized assessments of their symptoms. As the value of PROMs in patient care expands, a framework to guide the implementation planning, collection, and use of PROs to serve multiple goals and stakeholders is needed. METHODS: We identified diverse clinical, quality, and research settings where PROMs have been successfully integrated into care and routinely collected and analyzed drivers of successful implementation. Findings are based on key informant interviews with 46 individuals representing 38 organizations, of whom 40 participated in a webinars series, and 25 attended an in-person workshop designed to enable broad stakeholder input, review and refinement of the proposed PROMs implementation model. Stakeholders identified differing uses of PROMs to support: 1) individual patient care decisions, 2) quality improvement initiatives, 3) payer mandates, and 4) population health and research. RESULTS: The implementation framework and steps that are consistently identified by stakeholders as best practices to guide PROM capture and use are described. Of note, participants indicate that web-based informatics tools are necessary but not sufficient for PROM use, suggesting that successful PROM implementation requires integration into clinic operations and careful planning for user's analytic needs. Each of the four identified uses may require implementation modifications at each step to assure optimal use. CONCLUSIONS: The proposed framework will guide future PROM implementation efforts across learning health care systems to assure that complete PROMs are captured at the correct time, and with associated risk factors, to generate meaningful information to serve diverse stakeholders.

Reoperation Rates for Symptomatic Nonunions in Anterior Cervical Fusions From a National Spine Registry.

STUDY DESIGN: A retrospective cohort study with chart review. OBJECTIVE: To determine the reoperation rates for symptomatic nonunions for 1-level, 2-level, and 3-level anterior cervical discectomies and fusions (ACDFs) from a national spine registry. SUMMARY OF BACKGROUND DATA: There is very little data reported in the literature on reoperation rates for symptomatic nonunions after ACDFs. The reported nonunion rates are primarily based on radiographical evidence, although some of these may be asymptomatic. Similarly, there may be symptomatic patients with nonunions who elect not to have a reoperation. We think, however, data from a national spine registry provide a realistic and unbiased assessment of routine cervical spine fusion care and represent a heterogeneous population with varied indications and surgical techniques and are best suited to determine reoperations for symptomatic nonunions. METHODS: Using data from a Spine Implant Registry developed at a large integrated health care system (Kaiser Permanente), patients with ACDFs between January 2009 and December 2012 with 2-year follow-up were identified. Patient characteristics, admitting diagnosis, and number of levels fused were extracted from the registry. Reoperations for symptomatic nonunions from the index spinal procedure were identified by chart review. RESULTS: A cohort of 1054 patients with more than 2 years of follow-up were found to have reoperations for nonunions of 0.2%, 2.9%, and 6.5% for 1-level, 2-level, and 3-level ACDFs, respectively. CONCLUSION: A large cohort of ACDF patients with more than 2 years of follow-up had reoperations for nonunion rates significantly lower than reported in the literature for radiographical nonunions. We think our data add to the literature an important parameter (reoperations for nonunion rates) and provide useful information for patients, spine surgeons, and health care payers.

Meta-analysis of survival curve data using distributed health data networks: application to hip arthroplasty studies of the International Consortium of Orthopaedic Registries.

The motivating example for this paper comes from a distributed health data network, the International Consortium of Orthopaedic Registries (ICOR), which aims to examine risk factors for orthopedic device failure for registries around the world. Unfortunately, regulatory, privacy, and propriety concerns made sharing of raw data impossible, even if de-identified. Therefore, this article describes an approach to extraction and analysis of aggregate time-to-event data from ICOR. Data extraction is based on obtaining a survival probability and variance estimate for each unique combination of the explanatory variables at each distinct event time for each registry. The extraction procedure allows for a great deal of flexibility; models can be specified after the data have been collected, for example, modeling of interaction effects and selection of subgroups of patients based on their values on the explanatory variables. Our analysis models are adapted from models presented elsewhere--but allowing for censoring in the calculation of the correlation between serial survival probabilities and using the square root of the covariance matrix to transform the data to avoid computational problems in model estimation. Simulations and a real-data example are provided with strengths and limitations of the approach discussed.

Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis.

PURPOSE: To determine the rate of postoperative wound infection and the association with prophylactic antibiotic use in uncomplicated carpal tunnel release surgery. METHODS: We performed a multicenter, retrospective review of all the carpal tunnel release procedures performed between January 1, 2005, and August 30, 2007. Data reviewed included the use of prophylactic antibiotics, diabetic status, and the occurrence of postoperative wound infection. We determined the overall antibiotic usage rate and analyzed the correlation between antibiotic use and the development of postoperative wound infection. RESULTS: The rate of surgical site infections in the 3003 patients who underwent carpal tunnel release surgery (group A) was 11. Antibiotic usage data were available for 2336 patients (group B). Six patients without prophylactic antibiotics had infection, as did 5 patients with prophylactic antibiotics. This difference was not statistically significant. Of the 11 surgical site infections, 4 were deep (organ/space) and 7 superficial (incisional). The number of patients with diabetes in the overall study population was 546, 3 of whom had infections. This was not statistically different from the nondiabetic population infection rate (8 patients). CONCLUSIONS: The overall infection rate after carpal tunnel release surgery is low. In addition, the deep (organ/space) infection rate is much lower than previously reported. Antibiotic use did not decrease the risk of infection in this study population, including patients with diabetes. The routine use of antibiotic prophylaxis in carpal tunnel release surgery is not indicated. Surgeons should carefully consider the risks and benefits of routinely using prophylactic antibiotics in carpal tunnel release surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Does discharge disposition after primary total joint arthroplasty affect readmission rates?

We reviewed 90-day readmission rates for 9150 patients with a primary total hip or knee arthroplasty performed between April 2001 and December 2004. Patients with an American Society of Anesthesiologists score of 3 or greater or with perioperative complications were excluded. We correlated the readmission rate with discharge disposition to either skilled nursing facilities (SNFs) or Home. Of the 9150 patients identified, 1447 were discharged to an SNF. After statistically adjusting for sex, age and American Society of Anesthesiologists scores, total hip arthroplasty and total knee arthroplasty patients discharged to SNFs had higher odds of hospital readmission within 90 days of surgery than those discharged home (total hip arthroplasty: odds ratio = 1.9; 95% confidence interval, 1.2-3.2; P = .008; total knee arthroplasty: odds ratio = 1.6; 95% confidence interval, 1.1-2.4; P = .01). Healthy patients discharged to SNFs after primary total joint arthroplasty need to be followed closely for complications.

Reliability of the international knee documentation committee radiographic grading system.

BACKGROUND: The International Knee Documentation Committee (IKDC) forms are commonly used to measure outcomes after anterior cruciate ligament (ACL) reconstruction. The knee examination portion of the IKDC forms includes a radiographic grading system to grade degenerative changes. The interrater and intrarater reliability of this radiographic grading system remain unknown. HYPOTHESIS: We hypothesize that the IKDC radiographic grading system will have acceptable interrater and intrarater reliability. STUDY DESIGN: Case series (diagnosis); Level of evidence, 4. METHODS: Radiographs of 205 ACL-reconstructed knees were obtained at 5-year follow-up. Specifically, weightbearing posteroanterior radiographs of the operative knee in 35 degrees to 45 degrees of flexion and a lateral radiograph in 30 degrees of flexion were used. The radiographs were independently graded by 2 sports medicine fellowship-trained orthopaedic surgeons using the IKDC 2000 standard instructions. One surgeon graded the same radiographs 6 months apart, blinded to patient and prior IKDC grades. The percentage agreement was calculated for each of the 5 knee compartments as defined by the IKDC. Interrater reliability was evaluated using the intraclass correlation coefficient (ICC) 2-way mixed effect model with absolute agreement. The Spearman rank-order correlation coefficient (r(s)) was applied to evaluate intrarater reliability. RESULTS: The interrater agreement between the 2 surgeons was 59% for the medial joint space (ICC = 0.46; 95% confidence interval [CI] = 0.35-0.56), 54% for the lateral joint space (ICC = 0.45; 95% CI = 0.27-0.58), 49% for the patellofemoral joint (ICC = 0.40; 95% CI = 0.26-0.52), 63% for the anterior joint space (ICC = 0.20; 95% CI = 0.05-0.34), and 44% for the posterior joint space (ICC = 0.28; 95% CI = 0.15-0.40). The intrarater agreement was 83% for the medial joint space (r(s) = .77, P < .001), 86% for the lateral joint space (r(s) = .76, P < .001), 81% for the patellofemoral joint (r(s) = .79, P < .001), 91% for the anterior joint space (r(s) = .48, P < .001), and 69% for the posterior joint space (r(s) = .64, P < .001). CONCLUSIONS: While intrarater reliability was acceptable, interrater reliability was poor. These findings suggest that multiple raters may score the same radiographs differently using the IKDC radiographic grading system. The use of a single rater to grade all radiographs when using the IKDC radiographic grading system maximizes reliability.

Obesity and perioperative morbidity in total hip and total knee arthroplasty patients.

The incidence of obesity in 1071 total hip arthroplasty (THA) patients and 1813 total knee arthroplasty (TKA) patients and its effect on perioperative morbidity were evaluated prospectively. Fifty-two percent of TKA and 36% of THA patients were obese (body mass index >or=30). The obese patients were significantly younger, with a higher proportion of obese TKA patients being women. Higher rates of diabetes and hypertension were found in obese patients. Higher postoperative infection rates were observed in patients with body mass index 35 or higher. The odds ratio was 6.7 times higher risk for infection in obese TKA patients and 4.2 times higher for obese THA patients. The increased risk of infection in obese patients undergoing total joint arthroplasty must be realized by both the patient and surgeon.

Open Bankart repair: correlation of results with postoperative subscapularis function.

BACKGROUND: The potential weakness of the open Bankart procedure is the takedown and repair of the subscapularis tendon. It is not known to what extent this part of the procedure affects the final result. HYPOTHESIS: The function of the subscapularis muscle after surgery will be related to the patient's perception of surgical success. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 30 patients with traumatic anterior instability had an open Bankart repair by a single surgeon. These patients were observed for a mean of 4 years. At final follow-up, the patients filled out 3 self-assessment forms: the American Shoulder and Elbow Surgeons scale, the Western Ontario Shoulder Instability Index, and the Constant and Murley scale. An independent physician performed a complete physical examination. Strength testing of all muscle groups was performed and compared with the opposite normal side. RESULTS: Multiple factors were related to the patient's perception of the result. Only subscapularis function was found to have a statistically significant correlation. Of the patients, 23% had an incompetent subscapularis with a mean of 27% strength as compared with the opposite side. These patients had a positive lift-off test result and reported 57% good and excellent results; only 57% would have the surgery again. Of the patients, 77% had a normal functioning subscapularis with at least 80% strength as compared with the opposite side. These patients had a negative lift-off test result and had 91% good and excellent results; 100% would have the surgery again. The Western Ontario Shoulder Instability Index was the only scale that differentiated between a patient with subscapularis function and a patient without subscapularis function. CONCLUSION: Postoperative subscapularis function was the most critical factor in determining the patient's perception of surgical success. CLINICAL RELEVANCE: It is likely that handling of the subscapularis tendon during surgery and protection of the subscapularis in the first weeks after surgery are critical to the success of the open Bankart repair.

Does anticoagulation do more harm than good?: A comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty.

A cohort of 785 patients treated without any form of thromboprophylaxis was compared with an identical group of 957 patients treated with 6 weeks of low-dose warfarin. All complications seen within 90 days of surgery were recorded. The control group had a total complication rate of 2.2%, with a death rate from thromboembolic disease of 0.0% and a total death rate of 0.2%. The warfarin group had a total complication rate of 4.7%, with a death rate from thromboembolic disease of 0.0% and a total death rate of 0.1%. Both deaths in the control group were from cardiac disease, while the death in the warfarin group was due to a massive gastrointestinal bleeding. The warfarin group had twice the infection rate of the control group.

Fate of the anterior cruciate ligament-injured knee.

Most patients with anterior cruciate ligament (ACL) injuries do well with activities of daily living even after follow-up in the range of 5 to 15 years. Most can participate in some sports activity if they are inclined to do so, but most will have some limitations in vigorous sports, and only a few will be entirely asymptomatic. The challenge to the clinician is to understand and predict how ACL deficiency in a given patient will affect that patients's life and activities. In counseling patients about treatment after an ACL injury, the clinician can use knee ligament arthrometry measurements and pre-injury sports activity to estimate the risk of injury over the next 5 to 10 years. Meniscus, chondral, and sub-chondral injuries are not uncommon, but rarely require surgical intervention in the early phase of ACL deficiency. The prevalence of clinically significant meniscal damage increases with time, and is associated with increasing disability, surgery, and arthrosis in high-risk patients. Ligament reconstruction has not been shown to prevent arthrosis, but in prospective studies it appears to reduce the risk of subsequent meniscal injury, improve passive anteroposterior knee motion limits, and facilitate return to high-level sporting activities.