Improvements in Quality, Safety and Costs Associated with Use of Implant Registries Within a Health System.

BACKGROUND: Clinical quality registries (CQRs) are intended to enhance quality, safety, and cost reduction using real-world data for a self-improving health system. Starting in 2001, Kaiser Permanente established several medical device CQRs as a quality improvement initiative. This report examines the contributions of these CQRs on improvement in health outcomes, changes in clinical practice, and cost-effectiveness over the past 20 years. METHODS: Eight implant registries were instituted with standardized collection from the electronic health record and other institutional data sources of patient characteristics, medical comorbidities, implant attributes, procedure details, surgical techniques, and outcomes (including complications, revisions, reoperations, hospital readmissions, and other utilization measures). A rigorous quality control system is in place to improve and maintain the quality of data. Data from the Implant Registries form the basis for multiple quality improvement and patient safety initiatives to minimize variation in care, promote clinical best practices, facilitate recalls, perform benchmarking, identify patients at risk, and construct reports about individual surgeons. RESULTS: Following the inception of the Implant Registries, there was an observed (1) reduction in opioid utilization following orthopedic procedures, (2) reduction in use of bone morphogenic protein during lumbar fusion allowing for cost savings, (3) reduction in allograft for anterior cruciate ligament reconstruction and subsequent decrease in organizationwide revision rates, (4) cost savings through expansion of same-day discharge programs for joint arthroplasty, (5) increase in the use of cement fixation in the hemiarthroplasty treatment of hip fracture, and (6) organizationwide discontinuation of an endograft device associated with a higher risk for adverse outcomes following endovascular aortic aneurysm repair. CONCLUSION: The use of Implant Registries within our health system, along with clinical leadership and organizational commitment to a learning health system, was associated with improved quality and safety outcomes and reduced costs. The exact mechanisms by which such registries affect health outcomes and costs require further study.

Risk of Revision and Reoperation After Quadriceps Tendon Autograft ACL Reconstruction Compared With Patellar Tendon and Hamstring Autografts in a US Cohort of 21,973 Patients.

BACKGROUND: The use of quadriceps tendon (QT) autografts has increased in the past 10 years. However, there remains a dearth of large studies examining the effects of graft selection on anterior cruciate ligament reconstruction (ACLR) that includes QT grafts. PURPOSE: To evaluate the risk of subsequent surgical outcomes, including revision and reoperation, for a large cohort of patients with primary ACLR according to autograft selection. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Data from a US health care system ACLR registry were used to conduct a cohort study. Primary isolated autograft ACLRs were identified (2012-2021). The exposure of interest was autograft type: QT, bone-patellar tendon-bone (BPTB), and hamstring tendon (HT). Multivariable Cox regression models were used to evaluate the risk of aseptic revision (defined as a subsequent surgery where removal and replacement of the original graft for noninfectious reasons was required) and risk of aseptic reoperation (defined as any subsequent surgery for noninfectious reasons where the graft was left intact) according to autograft selection. RESULTS: The study sample comprised 21,973 ACLRs performed by 290 surgeons at 53 hospitals. QT, BPTB, and HT autografts were used in 1103 (5.0%), 9519 (43.3%), and 11,351 (51.7%) ACLRs, respectively. In adjusted models, no significant differences were observed in revision risk (hazard ratio [HR], 1.06; 95% CI, 0.60-1.89; P = .837) or reoperation risk (HR, 1.00; 95% CI, 0.70-1.43; P = .993) within 4 years of follow-up when comparing QT ACLR with BPTB ACLR. Additionally, no differences in 4-year revision (HR, 0.62; 95% CI, 0.34-1.12; P = .111) or reoperation (HR, 1.24; 95% CI, 0.85-1.80; P = .262) risks were observed when comparing QT ACLR with HT ACLR. HT ACLRs were noted to have a higher risk of revision (HR, 1.52; 95% CI, 1.25-1.84; P < .001) compared with BPTB ACLRs but a lower risk of reoperation (HR, 0.86; 95% CI, 0.75-0.98; P = .024). CONCLUSION: In this large multicenter study using data from an ACLR registry, the authors found no difference in the risk of revision or reoperation when QT was compared with BPTB or HT autograft with the numbers available, but they did find a 1.5 times higher risk of revision when HT autograft was compared with BPTB autograft. Surgeons may use this information when choosing the appropriate graft for ACLR in their patients.

Unipolar Hemiarthroplasty, Bipolar Hemiarthroplasty, or Total Hip Arthroplasty for Hip Fracture in Older Individuals.

BACKGROUND: Practice patterns regarding the use of unipolar hemiarthroplasty, bipolar hemiarthroplasty, and total hip arthroplasty (THA) for femoral neck fractures in older patients vary widely. This is due in part to limited data stipulating the specific circumstances under which each form of arthroplasty provides the most predictable outcome. The purpose of this study was to investigate the patient characteristics for which unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA might be preferable due to a lower risk of all-cause revision. METHODS: A U.S. health-care system's hip fracture registry was used to identify patients ≥60 years old who underwent unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA for hip fracture from 2009 through 2021. Unipolar and bipolar hemiarthroplasty were compared with THA within patient subgroups defined by age (60 to 79 versus ≥80 years) and American Society of Anesthesiologists (ASA) classification (I or II versus III); patients with an ASA classification of IV or higher were excluded. Multivariable Cox proportional hazard regression analysis was used to evaluate all-cause revision risk while adjusting for confounders, with mortality considered as a competing risk. RESULTS: There were 14,277 patients in the final sample (median age, 82 years; 70% female; 80% White; 69% with an ASA classification of III; median follow-up, 2.7 years), and the procedures included 7,587 unipolar hemiarthroplasties, 5,479 bipolar hemiarthroplasties, and 1,211 THAs. In the multivariable analysis of all patients, both unipolar (hazard ratio [HR] = 2.15, 95% confidence interval [CI] = 1.48 to 3.12; p < 0.001) and bipolar (HR = 1.92, 95% CI = 1.31 to 2.80; p < 0.001) hemiarthroplasty had higher revision risks than THA. In the age-stratified multivariable analysis of patients aged 60 to 79 years, both unipolar (HR = 2.17, 95% CI = 1.42 to 3.34; p = 0.004) and bipolar (HR = 1.69, 95% CI = 1.08 to 2.65; p = 0.022) hemiarthroplasty also had higher revision risks than THA. In the ASA-stratified multivariable analysis, patients with an ASA classification of I or II had a higher revision risk after either unipolar (HR = 3.52, 95% CI = 1.87 to 6.64; p < 0.001) or bipolar (HR = 2.31, 95% CI = 1.19 to 4.49; p = 0.013) hemiarthroplasty than after THA. No difference in revision risk between either of the hemiarthroplasties and THA was observed among patients with an age of ≥80 years or those with an ASA classification of III. CONCLUSIONS: In this study of hip fractures in older patients, THA was associated with a lower risk of all-cause revision compared with unipolar and bipolar hemiarthroplasty among patients who were 60 to 79 years old and those who had an ASA classification of I or II. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Can Dual Mobility Cups Reduce Revision and Dislocation Risks? An Analysis of 107,528 Primary Total Hip Arthroplasties in the United States.

BACKGROUND: Dual mobility acetabular cups (DMC) were designed to increase the effective femoral head size and improve stability with the goal of reducing revision risk at the potential cost of polyethylene thickness. We sought to evaluate revision risk following primary elective total hip arthroplasty with DMC compared to highly cross-linked polyethylene (XLPE). METHODS: A cohort study was conducted using data from a Kaiser Permanente's total joint arthroplasty registry. Patients ≥18 years who underwent primary elective total hip arthroplasty using DMC, unipolar Metal-on-XLPE (MoXLPE), or unipolar Ceramic-on-XLPE (CoXLPE) were identified (2010 to 2021). The final sample comprised 2,219 DMC, 48,251 MoXLPE, and 57,058 CoXLPE. Multiple Cox proportional hazard regressions were used to evaluate aseptic revision and any dislocation regardless of revision within 6 years follow-up. RESULTS: In adjusted analyses, no differences in aseptic revision risk were observed for MoXLPE (hazard ratio [HR] = 1.04, 95% confidence interval [CI] = 0.72 to 1.51) or CoXLPE (HR = 0.98, 95% CI = 0.69 to 1.40) compared to DMC. No differences in dislocation risk were observed for MoXLPE (HR = 1.42, 95% CI = 0.93 to 2.15) or CoXLPE (HR = 1.25, 95% CI = 0.84 to 1.87) compared to DMC. CONCLUSIONS: In a US-based cohort, 6-year aseptic revision risk of DMC was similar to metal or ceramic femoral head unipolar constructs. Furthermore, no difference in dislocation risk was observed. Continued longer-term follow-up may reveal if there is a reduced risk of dislocation that comes at the cost of increased late revision. LEVEL OF EVIDENCE: Level III.

The use of antibiotic-loaded bone cement and systemic antibiotic prophylactic use in 2,971,357 primary total knee arthroplasties from 2010 to 2020: an international register-based observational study among countries in Africa, Europe, North America, and Oceania.

BACKGROUND AND PURPOSE: Antibiotic-loaded bone cement (ALBC) and systemic antibiotic prophylaxis (SAP) have been used to reduce periprosthetic joint infection (PJI) rates. We investigated the use of ALBC and SAP in primary total knee arthroplasty (TKA). PATIENTS AND METHODS: This observational study is based on 2,971,357 primary TKAs reported in 2010-2020 to national/regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, the Netherlands, New Zealand, Norway, Romania, South Africa, Sweden, Switzerland, the UK, and the USA. Aggregate-level data on trends and types of bone cement, antibiotic agents, and doses and duration of SAP used was extracted from participating registries. RESULTS: ALBC was used in 77% of the TKAs with variation ranging from 100% in Norway to 31% in the USA. Palacos R+G was the most common (62%) ALBC type used. The primary antibiotic used in ALBC was gentamicin (94%). Use of ALBC in combination with SAP was common practice (77%). Cefazolin was the most common (32%) SAP agent. The doses and duration of SAP used varied from one single preoperative dosage as standard practice in Bolzano, Italy (98%) to 1-day 4 doses in Norway (83% of the 40,709 TKAs reported to the Norwegian arthroplasty register). CONCLUSION: The proportion of ALBC usage in primary TKA varies internationally, with gentamicin being the most common antibiotic. ALBC in combination with SAP was common practice, with cefazolin the most common SAP agent. The type of ALBC and type, dose, and duration of SAP varied among participating countries.

Use of Preoperative CT Scans and Patient-Specific Instrumentation May Not Improve Short-Term Adverse Events After Shoulder Arthroplasty: Results from a Large Integrated Health-Care System.

Ongoing innovation leads to a continuous influx of new technologies related to shoulder arthroplasty. These are made available to surgeons and marketed to both health-care providers and patients with the hope of improving outcomes. We sought to evaluate how preoperative planning technologies for shoulder arthroplasty affect outcomes. Methods: This was a retrospective cohort study conducted using data from an integrated health-care system's shoulder arthroplasty registry. Adult patients who underwent primary elective anatomic or reverse total shoulder arthroplasty (2015 to 2020) were identified. Preoperative planning technologies were identified as (1) a computed tomography (CT) scan and (2) patient-specific instrumentation (PSI). Multivariable Cox regression and logistic regression were used to compare the risk of aseptic revision and 90-day adverse events, respectively, between procedures for which technologies were and were not used. Results: The study sample included 8,117 procedures (in 7,372 patients) with an average follow-up of 2.9 years (maximum, 6 years). No reduction in the risk of aseptic revision was observed for patients having either preoperative CT scans (hazard ratio [HR] = 1.22; 95% confidence interval [CI] = 0.87 to 1.72) or PSI (HR = 1.44; 95% CI = 0.71 to 2.92). Patients having CT scans had a lower likelihood of 90-day emergency department visits (odds ratio [OR] = 0.84; 95% CI = 0.73 to 0.97) but a higher likelihood of 90-day venous thromboembolic events (OR = 1.79; 95% CI = 1.18 to 2.74). Patients with PSI use had a higher likelihood of 90-day deep infection (OR = 7.74; 95% CI = 1.11 to 53.94). Conclusions: We found no reduction in the risk of aseptic revision with the use of these technologies. Patients having CT scans and PSI use had a higher likelihood of venous thromboembolism and deep infection, respectively. Ongoing research with extended follow-up is being conducted to further examine the effects of these technologies on patient outcomes. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association between same-day discharge shoulder arthroplasty and risk of adverse events in patients with American Society of Anesthesiologists classification ≥3: a cohort study.

BACKGROUND: Same-day discharge for shoulder arthroplasty (SA) is well-supported in the literature; however, most studies have focused on healthier patients. Indications for same-day discharge SA have expanded to include patients with more comorbidities, but safety of same-day discharge in this population remains unknown. We sought to compare outcomes following same-day discharge vs. inpatient SA in a cohort of patients considered higher risk for adverse events, defined as an American Society of Anesthesiologists (ASA) classification of ≥3. METHODS: Data from Kaiser Permanente's SA registry were utilized to conduct a retrospective cohort study. All patients with an ASA classification of ≥3 who underwent primary elective anatomic or reverse SA in a hospital from 2018 to 2020 were included. The exposure of interest was in-hospital length of stay: same-day discharge vs. ≥1-night hospital inpatient stay. The likelihood of 90-day post-discharge events, including emergency department (ED) visit, readmission, cardiac complication, venous thromboembolism, and mortality, was evaluated using propensity score-weighted logistic regression with noninferiority testing using a margin of 1.10. RESULTS: The cohort included a total of 1814 SA patients, of whom 1005 (55.4%) had same-day discharge. In propensity score-weighted models, same-day discharge was not inferior to an inpatient stay SA regarding 90-day readmission (odds ratio [OR] = 0.64, one-sided 95% upper bound [UB] = 0.89) and overall complications (OR = 0.67, 95% UB = 1.00). We lacked evidence in support of noninferiority for 90-day ED visit (OR = 0.96, 95% UB = 1.18), cardiac event (OR = 0.68, 95% UB = 1.11), or venous thromboembolism (OR = 0.91, 95% UB = 2.15). Infections, revisions for instability, and mortality were too rare to evaluate using regression analysis. CONCLUSIONS: In a cohort of over 1800 patients with an ASA of ≥3, we found same-day discharge SA did not increase the likelihood of ED visits, readmissions, or complications compared with an inpatient stay, and same-day discharge was not inferior to an inpatient stay with regard to readmissions and overall complications. These findings suggest that it is possible to expand indications for same-day discharge SA in the hospital setting.

Direct Anterior Versus Posterior Approach for Total Hip Arthroplasty Performed for Displaced Femoral Neck Fractures.

OBJECTIVES: To compare perioperative, 90-day, and 1-year postoperative complications and outcomes between the direct anterior approach (DAA) and the posterior approach for total hip arthroplasty in geriatric patients with displaced femoral neck fractures (FNFs). DESIGN: Retrospective cohort study. SETTING: Multicenter Health care Consortium. PATIENTS: Seven-hundred and nine patients 60 years or older with acute displaced FNFs between 2009 and 2021. INTERVENTION: Total hip arthroplasty using either DAA or posterior approach. MAIN OUTCOME MEASUREMENTS: Rates of postoperative complications including dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. Secondary outcome measures included ambulation capacity at discharge, ambulation distance with inpatient physical therapy, discharge disposition, and narcotic prescription quantities (morphine milligram equivalents). RESULTS: Through a multivariable regression analysis, DAA was associated with significantly shorter operative time ( B = -6.89 minutes; 95% confidence interval [CI] -12.84 to -0.93; P = 0.024), lower likelihood of blood transfusion during the index hospital stay (adjusted odds ratios = 0.54; 95% CI 0.27 to 0.96; P = 0.045), and decreased average narcotic prescription amounts at 90 days (B = -230.45 morphine milligram equivalents; 95% CI -440.24 to -78.66; P = 0.035) postoperatively. There were no significant differences in medical complications, dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. CONCLUSION: When comparing the DAA versus posterior approach for total hip arthroplasty performed for displaced FNF, DAA was associated with shorter operative time, lower likelihood of blood transfusion, and lower 90-day postoperative narcotic prescription amounts. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk of Aseptic Revision and Periprosthetic Fracture Following Bipolar Versus Unipolar Hemiarthroplasty.

Hemiarthroplasty is currently the most common treatment for displaced femoral neck fractures in the elderly. While bipolar hemiarthroplasty was developed to reduce the risk of acetabular erosion that is associated with traditional unipolar hemiarthroplasty, meta-analyses have reported similar outcomes for bipolar and unipolar hemiarthroplasty devices. The primary objective of this study was to evaluate the risks of aseptic revision and periprosthetic fracture following bipolar versus unipolar hemiarthroplasty in a large integrated health-care system in the United States. Methods: We conducted a retrospective cohort study using data from the hip fracture registry of an integrated health-care system. Patients aged ≥60 years who underwent hemiarthroplasty for hip fracture between 2009 and 2019 were included. The primary outcome measure was aseptic revision, and the secondary outcome measure was revision for periprosthetic fracture. Cause-specific Cox proportional hazards regression was performed, with mortality considered as a competing event. In the multivariable analysis, estimates were adjusted for potential confounders such as age, sex, race/ethnicity, body mass index, American Society of Anesthesiologists classification, femoral fixation, surgeon volume, type of anesthesia, and discharge disposition. Results: The study sample included 13,939 patients who had been treated with hemiarthroplasty by 498 surgeons at 35 hospitals. The mean follow-up time was 3.7 ± 2.9 years. The overall incidence of aseptic revision at 5 years following hemiarthroplasty was 2.8% (386). In the multivariable analysis controlling for potential confounders, bipolar hemiarthroplasty was associated with a lower risk of aseptic revision than unipolar hemiarthroplasty (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.59 to 0.94; p = 0.012). Rates of revision for periprosthetic fracture were similar between the bipolar and unipolar devices (HR, 0.79; 95% CI, 0.58 to 1.10; p = 0.16). Conclusions: In this study of hemiarthroplasty for hip fracture in elderly patients, bipolar designs were associated with a lower risk of aseptic revision than unipolar designs. In contrast to prior research, we did not find any difference in the risk of periprosthetic fracture between the 2 designs. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Patient Optimization: Outcomes from Elective Total Joint Arthroplasty in a Large US Healthcare System.

INTRODUCTION: Patient factors are known to affect outcomes in arthroplasty surgery. A preoperative program to address modifiable factors may aid in more appropriate patient selection. We sought to assess patient selection and 90-day postoperative outcomes for total joint arthroplasty (TJA) candidates before and after implementation of a preoperative optimization protocol. METHODS: A retrospective time-trend study using data from an integrated healthcare system's total joint replacement registry was done. The study sample consisted of patients aged 18 years or older who underwent primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis between 2009 and 2019. Patients were divided into two cohorts: procedures performed from 2009 to 2013 ("preoptimization protocol") and those from 2015 to 2019 ("postoptimization protocol"); 2014 was excluded because an evidence-based preoperative patient optimization protocol was progressively implemented throughout the year. Patient characteristics, optimization factors, and 90-day outcomes (including emergency department [ED] visits, readmission, all-cause revision, deep infection, venous thromboembolism, and mortality) were compared between the two cohorts using the Pearson chi-square test or Wilcoxon test. RESULTS: The study sample included 25,925 THA and 60,484 TKA. In the THA cohort, 10,364 (40.0%) and 15,561 (60.0%) were from the preoptimization and postoptimization cohorts, respectively. The postoptimization THA cohort saw lower rates of ED visits (12.1% vs. 9.4%, P < 0.001) and readmissions (5.6% vs. 3.8%, P < 0.001). In the TKA cohort, 24,054 (39.8%) and 36,430 (60.2%) were from the preoptimization and postoptimization cohorts, respectively. The postoptimization TKA cohort saw lower rates of ED visits (13.1% vs. 11.9%, P < 0.001), readmissions (5.6% vs. 3.0%, P < 0.001), all-cause revisions (0.5% vs. 0.3%, P = 0.003), venous thromboembolism (1.3% vs. 0.9%, P < 0.001), and mortality (0.3% vs. 0.2%, P = 0.011). DISCUSSION: An evidence-based protocol to improve patient selection based on modifiable patient factors was adopted by orthopaedic surgeons in the system and utilization of the protocol before TJA was associated with fewer postoperative complications over time. LEVEL OF EVIDENCE: Level IV.

No difference in revision risk between autologous hamstring graft less than 8 mm versus hybrid graft 8 mm or larger in anterior cruciate ligament reconstruction.

PURPOSE: Hamstring autograft (HA) is commonly used for primary anterior cruciate ligament reconstruction (ACLR). However, if the harvested HA is inadequate in diameter, it is often augmented with an allograft tendon, forming a hybrid graft (HY). This study sought to evaluate aseptic revision risk following HA versus HY ACLR. METHODS: A retrospective cohort study was performed using data obtained from our healthcare system's ACLR registry. Patients ≤ 25 years of age who underwent primary isolated ACLR were identified (2005-2020). Graft type and diameter size was the primary exposure of interest: < 8 mm HA and ≥ 8 mm HY. A secondary analysis was performed to examine 7 mm HA and 7.5 mm HA vs ≥ 8 mm HY. Propensity score-weighted Cox proportional hazard regression was used to evaluate the risk of aseptic revision. RESULTS: The study sample included 1,945 ACLR: 548 ≥ 8 mm HY, 651 7 mm HA, and 672 7.5 mm HA. The crude cumulative aseptic revision probability at 8-years for ≥ 8 mm HY was 9.1%, 11.1% for 7 mm HA, and 11.2% for 7.5 mm HA. In adjusted analysis, no difference in revision risk was observed for < 8 mm HA (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.72-1.82), 7 mm HA (HR 1.23, 95% CI 0.71-2.11), or 7.5 mm HA (HR 1.16, 95% CI 0.74-1.82) compared to ≥ 8 mm HY. CONCLUSION: In a US-based cohort of ACLR patients aged ≤ 25 years, we failed to observe any differences in aseptic revision risk for HA < 8 mm compared to HY ≥ 8 mm. Augmentation of a HA as small as 7 mm is not necessary to prevent a revision surgery. LEVEL OF EVIDENCE: Level III.

Risk for surgical interventions following endovascular aneurysm repair with Endologix AFX or AFX2 Endovascular AAA Systems compared with other devices.

OBJECTIVE: To evaluate the risk for 90-day returns to care and long-term subsequent surgical interventions after primary endovascular aneurysm repair (EVAR) with an Endologix AFX Endovascular AAA System compared with three other high-volume endograft devices. METHODS: We conducted a matched cohort study using data from Kaiser Permanente's Endovascular Stent Graft Registry. Patients aged ≥18 years who underwent primary EVAR for AAA in the health care system from January 1, 2011, to December 31, 2017, comprised the eligible study sample. The treatment group included patients who received an Endologix AFX or AFX2 device (n = 470). Patients who received one of three other high-volume endograft devices used within the health care system comprised the eligible comparison group (n = 2122). These patients were 2:1 propensity score matched without replacement to patients who received an Endologix device based on a number of patient and procedural characteristics. After the application of matching, conditional logistic regression was used to evaluate the likelihood for 90-day emergency department visit and readmission. Cause-specific Cox regression was used to evaluate the long-term risk of endoleak, graft revision, secondary reintervention (not including revision), conversion to open repair, and rupture during follow-up. Cox proportional hazards regression was used to evaluate the risk of mortality (overall and aneurysm related). RESULTS: The final matched study sample included 470 patients who received an Endologix AFX or AFX2 device and 940 patients who received a different high-volume device. compared with the other devices, AFX/AFX2 had a higher risk for type III endoleak (hazard ratio [HR], 38.79; 95% confidence interval [CI], 14.51-103.67), revision surgery >1 year after the primary EVAR (HR, 4.50; 95% CI, 3.10-6.54), rupture (HR, 6.52; 95% CI, 1.73-24.63), and aneurysm-related mortality (HR, 2.43; 95% CI, 1.32-4.47) was observed with the use of AFX/AFX2. CONCLUSIONS: In our matched cohort study, patients who received an Endologix AFX System during their primary EVAR had a higher risk for several adverse longitudinal outcomes, as well as aneurysm-related mortality, when compared with patients who received other high-volume devices. Patients who have received these devices should be monitored closely after EVAR.

Similar rates of revision surgery following primary anatomic compared with reverse shoulder arthroplasty in patients aged 70 years or older with glenohumeral osteoarthritis: a cohort study of 3791 patients.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA), initially indicated for cuff tear arthropathy, is increasingly used to treat elderly patients with primary glenohumeral osteoarthritis (GHOA) and an intact rotator cuff. This is often done to avoid revision surgery in elderly patients for rotator cuff failure with anatomic total shoulder arthroplasty (TSA) despite traditionally good outcomes of TSA. We sought to determine whether there was a difference in outcomes in patients aged ≥70 years who received RTSA vs. TSA for GHOA. METHODS: A retrospective cohort study was conducted using data from a US integrated health care system's shoulder arthroplasty registry. Patients aged ≥70 years who underwent primary shoulder arthroplasty for GHOA with an intact rotator cuff were included (2012-2021). RTSA was compared with TSA. Multivariable Cox proportional hazard regression was used to evaluate all-cause revision risk during follow-up, whereas multivariable logistic regression was used to evaluate 90-day emergency department (ED) visits and 90-day readmissions. RESULTS: The final study sample comprised 685 RTSA patients and 3106 TSA patients. The mean age was 75.8 years (standard deviation, 4.6 years), and 43.4% of patients were men. After accounting for confounders, we observed no significant difference in all-cause revision risk for RTSA vs. TSA (hazard ratio, 0.79; 95% confidence interval [CI], 0.39-1.58). The most common reason for revision following RTSA was glenoid component loosening (40.0%). Over half of revisions following TSA were for rotator cuff tear (54.0%). No difference based on procedure type was observed in the likelihood of 90-day ED visits (odds ratio, 0.94; 95% CI, 0.71-1.26) and 90-day readmissions (odds ratio, 1.32; 95% CI, 0.83-2.09). CONCLUSION: RTSA and TSA for GHOA with an intact rotator cuff in patients aged ≥70 years had a similar revision risk, as well as a similar likelihood of 90-day ED visits and readmissions. Although revision risk was similar, the most common causes of revision were different, with rotator cuff tears in TSA patients and glenoid component loosening in RTSA patients.

Prolonged Opioid Usage Following Hip Fracture Surgery in Opioid-Naïve Older Patients.

BACKGROUND: While the risk of long-term dependence following the opioid treatment of musculoskeletal injury is often studied in younger populations, studies in older patients have centered on short-term risks such as oversedation and delirium. This study investigated prolonged opioid usage after hip fracture in older individuals, focusing on prevalence, risk factors, and changes over time. METHODS: In this retrospective cohort study of 47,309 opioid-naïve patients aged ≥ 60 years who underwent hip fracture surgery (2009 to 2020), outpatient opioid use was evaluated in 3 postoperative time periods: P1 (day 0 to 30 postsurgery); P2 (day 31 to 90); and P3 (day 91 to 180). The primary outcome was prolonged outpatient opioid use, defined as having one or more opioid prescriptions dispensed in all 3 time periods. RESULTS: The incidence of prolonged opioid usage among patients surviving to P3 was 6.3% (2,834 of 44,850). Initial prescription quantities decreased over time, as did the risk of prolonged opioid usage (from 8.0% in 2009 to 3.9% in 2019). In the multivariable analyses, risk factors for prolonged opioid usage included younger age, women, current/former smoking, fracture fixation (as compared to hemiarthroplasty), and anxiety. Prolonged opioid usage was less common among patients who were Asian or had a history of dementia. CONCLUSIONS: While prior research on the hazards of opioids in the elderly has focused on short-term risks such as oversedation and delirium, these findings suggest that prolonged opioid usage may be a risk for this older population as well. As initial prescription amounts have decreased, declines in prolonged opioid medication usage have also been observed.

Comparison of 90-Day Adverse Events Associated With Aspirin and Potent Anticoagulation Use for Venous Thromboembolism Prophylaxis: A Cohort Study of 72,288 Total Knee and 35,142 Total Hip Arthroplasty Patients.

BACKGROUND: While aspirin is acceptable for venous thromboembolism (VTE) prophylaxis following total joint arthroplasty in most patients, more potent agents are used in patients considered higher risk for VTE. We evaluated the efficacy and safety of aspirin versus potent anticoagulation agents following total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: A cohort study of 72,288 TKA and 35,142 THA from the Kaiser Permanente Total Joint Replacement Registry was performed (2009 to 2019). Identified medications were aspirin, factor Xa inhibitors, low-molecular-weight heparin (LMWH), and warfarin. A validated VTE risk score was assigned to each patient. Propensity score-weighted logistic regressions were used to evaluate 90-day VTEs. Noninferiority testing was performed with a margin of 1.25 using the upper bound (UB) of the 1-sided 95% CI. RESULTS: For TKA, aspirin was not inferior to LMWH (odds ratio [OR] = 0.77, UB = 1.09) and warfarin (OR = 0.64, UB = 0.90); there was no evidence to support noninferiority of aspirin compared to factor Xa inhibitors. Findings were consistent for THA (LMWH: OR = 0.59, UB = 0.75; warfarin: OR = 0.69, UB = 0.89). TKA was considered higher risk for VTE, whereas aspirin use demonstrated noninferiority compared to warfarin (OR = 0.54, UB = 0.81), we lacked evidence of noninferiority when compared to LMWH and factor Xa inhibitors. We lacked evidence of noninferiority of aspirin versus any potent anticoagulation in higher-risk THA. CONCLUSION: Aspirin was found to be effective and safe for VTE prevention in primary total joint arthroplasty, including in patients considered higher risk for VTE. LEVEL OF EVIDENCE: III.

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.

Single Wedge Femoral Stem Designs are Associated With a Higher Risk for Revision After Cementless Primary Total Hip Arthroplasty.

BACKGROUND: Cementless total hip arthroplasty (THA) femoral stems are the most commonly selected prostheses in the United States. Optimal stem geometry remains controversial with excellent survivorship reported for many designs. We compared cause-specific stem revision of single-wedge versus double-wedge designs from a multicenter US cohort. METHODS: Data from an integrated healthcare network's total joint replacement registry were used to conduct a cohort study. Primary elective cementless THAs were identified (2001 to 2018). Implant exposure groups were classified by design geometry using the system proposed by Khanuja et al. Type 1 single-wedge (n = 11,082) and type 2 double-wedge (n = 32,380) designs were compared, and other design types were excluded; the final study cohort comprised 43,462 THAs. Cause-specific multivariable Cox regressions were used to evaluate risk for revision due to infection or aseptic reasons, including loosening, instability, periprosthetic fracture, or other reasons. RESULTS: After adjustment for covariates, a higher aseptic revision risk was observed for type 1 when compared to type 2 designs (hazard ratio = 1.91, 95% confidence interval = 1.33-2.75). When looking at specific revision reasons, revision for aseptic loosening (hazard ratio = 3.46, 95% confidence interval = 2.24-5.34) was higher for type 1 versus type 2 designs. No differences were found for septic revision, instability, periprosthetic fracture, or revisions for other reasons. CONCLUSIONS: Type 1 single-wedge designs were found to have a higher risk of revision due to aseptic loosening relative to type 2 double-wedge designs. Femoral stem geometry should be considered when selecting a cementless femoral implant. LEVEL OF EVIDENCE: Level III.

Does Aseptic Revision Risk Differ for Primary Total Knee Arthroplasty Patients Who Have and Do not Have a Prior Primary or Revision Arthroplasty?

BACKGROUND: We sought to evaluate the risk of aseptic revision in total knee arthroplasty (TKA) patients who have and do not have a history of primary or revision arthroplasty of a different major joint. METHODS: We conducted a matched cohort study using data from Kaiser Permanente's arthroplasty registries. Patients who underwent primary unilateral TKA (index knee) were identified (2009-2018). Two matches based on exposure history were performed: (1) 33,714 TKAs with a history of primary arthroplasty of a different joint (contralateral knee, either hip, and/or either shoulder) were matched to 67,121 TKAs without an arthroplasty history and (2) 597 TKAs with a history of aseptic revision in a different joint were matched to 1,190 TKAs with a history of a prior arthroplasty in a different joint, but without any revision. After the matches were performed, Cox regressions were used to evaluate aseptic revision risk of the index knee using the no history groups as the reference in regression models. RESULTS: No difference in aseptic revision risk for the index knee was observed when comparing patients who had a prior primary arthroplasty in a different joint to those who did not have an arthroplasty history (hazard ratio = 0.95, 95% CI = 0.86-1.06). Those patients who did not have any prior aseptic revision history in a different joint had higher risk of aseptic revision in the index knee (hazard ratio = 2.06, 95% CI = 1.17-3.63). CONCLUSION: Patients who had a prior revision history had over a 2-fold higher risk of aseptic revision in the index knee, warranting close surveillance of these patients. LEVEL OF EVIDENCE: Level III.

Tranexamic acid is not associated with decreased infection risk after primary shoulder arthroplasty: a cohort study of 9276 patients.

BACKGROUND: The use of tranexamic acid (TXA) is associated with less blood loss and reduced transfusion risk after shoulder arthroplasty surgery. Recent studies have shown lower odds of postoperative infection after hip or knee arthroplasty with its use. The purpose of this study was to determine whether TXA use reduces the risk of infection after primary elective shoulder arthroplasty. METHODS: A retrospective cohort study was conducted using data from a US integrated health care system's shoulder arthroplasty registry. Patients aged 18 years who underwent primary elective anatomic total shoulder arthroplasty for osteoarthritis or primary reverse shoulder arthroplasty for rotator cuff arthropathy were included (2013-2020). We compared patients who received preoperative intravenous TXA to those who did not receive TXA by assessing the risk for revision due to deep infection within 5 years' follow-up using multivariable Cox proportional hazard regression. Interaction between TXA and diabetes status was analyzed separately. RESULTS: The study sample included 9276 shoulder arthroplasties performed by 153 surgeons at 43 hospitals. The mean age was 70.0 years and 48% were male. The 5-year probability of revision for deep infection was 0.8% and 0.7% for patients with and without TXA, respectively. We failed to observe a difference in infection risk after adjustment for confounders and surgeon differences (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.56-1.80, P = .998). Further, no differences were observed in patients with (HR 1.64, 95% CI 0.42-6.44, P = .481) or without diabetes (HR 0.79, 95% CI 0.40-1.55, P = .488). CONCLUSION: In a multicenter cohort of more than 9000 primary shoulder arthroplasty procedures, the use of preoperative TXA was not associated with a decrease in the 5-year probability of revision for deep infection.

Procedure Cost Comparison of Outpatient and Inpatient Shoulder Arthroplasty and Lower-Extremity Arthroplasty Within a Managed-Care Organization.

Introduction The authors sought to evaluate cost differences between shoulder arthroplasties and lower-extremity joint replacements in the outpatient and inpatient setting within a large health-maintenance organization. Methods A cross-sectional study of 100 total hip arthroplasties (THA), 100 total knee arthroplasties (TKA), and 100 shoulder arthroplasties (50 anatomical total shoulder arthroplasties and 50 reverse shoulder arthroplasties [RTSA]) was performed at a single regional health care center within an integrated health care maintenance organization. A time-driven activity-based costing methodology was used to obtain total cost of each episode for outpatient (vs) inpatient surgery. Results are presented by procedure type. Results Compared to their respective inpatient procedure, outpatient surgery was less expensive by 20% for RTSA, 22% for total shoulder arthroplasties, 29% for THA, and 30% for TKA. The cost of implants was the highest proportion of cost for all joint procedures across inpatient and outpatient settings, ranging from 28% of the total cost for inpatient THA to 63% of the cost for outpatient RTSA. Discussion Although many factors influence the total cost for arthroplasty surgery, including rate of hospitalization, duration of stay, operative time, complexity of cases, patient factors, equipment, and resource utilization, the implant cost remains the most expensive factor, with hospital bed admission status being the second costliest contribution. Conclusion Outpatient total arthroplasty substantially reduced procedure expenses in a managed-care setting by 20%-30%, although savings for outpatient shoulder arthroplasty was lower than savings for THA or TKA. Implant costs remain the largest portion of shoulder arthroplasty procedure expenses.