Cardiac Implantable Electronic Devices: Reoperations and the Competing Risk of Death.

BACKGROUND: The use of cardiac implantable electronic devices (CIED), which includes pacemakers, implantable cardioverter-defibrillators (ICD), cardiac resynchronisation therapy pacemakers (CRT-P) and cardiac resynchronisation therapy defibrillators (CRT-D) has increased over the past 20 years, but there is a lack of real world evidence on the longevity of these devices in the older population which is essential to inform health care delivery and support clinical decisions. METHODS AND RESULTS: We conducted a retrospective cohort study using data from the Australian Government Department of Veterans' Affairs database. The cohort consisted of people who had a CIED procedure between 2005 and 2015. The cumulative risk of generator replacement/reoperations was estimated accounting for the competing risk of death. A total of 16,662 patients were included. In pacemaker recipients with an average age of 85 years, the 5-year risk of reoperation ranged from 2.8% in single chamber, 3.6% in dual chamber to 7.6% in CRT-P recipients, while the 5-year risk of dying with the index pacemaker in situ was 63% in single chamber, 46% in dual chamber and 56% in CRT-P recipients. In defibrillator recipients with an average age of 80 years, the 5-year risk of reoperation ranged from 11% in single chamber, 13% in dual chamber to 24% in CRT-D recipients, while the 5-year risk of dying with the index defibrillator in situ was 46% in single chamber, 40% in dual chamber and 41% in CRT-D recipients. CONCLUSION: In this cohort of older patients the 5-year risk of generator reoperation was low in pacemaker recipients whereas up to one in four CRT-D recipients would have a reoperation within 5 years.

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.

Lumbar Spine Fusion Patients See Similar Improvements in Physical Activity Level to Non-Spine Fusion Patients Following Total Hip Arthroplasty.

BACKGROUND: The impact of prior lumbar spinal fusion on the change in physical activity level following total hip arthroplasty (THA) has not been thoroughly examined. Therefore, we sought to compare the change in physical activity level following THA for patients with and without a history of lumbar spine fusion. METHODS: Patients who underwent primary elective THA were identified using an integrated healthcare system's Total Joint Replacement Registry (2010-2013). Prior lumbar spine fusion was identified using the healthcare system's Spine Registry. Physical activity was self-reported by patients and measured in min/wk. Generalized linear models were used to evaluate the association between prior spine fusion and the change in physical activity from 1 year pre-THA to 1-2 years post-THA. RESULTS: Of 11,416 THAs, 90 (0.8%) had a history of lumbar spinal fusion. Patients with a prior lumbar fusion had a median physical activity level of 28 min/wk prior to THA compared to 45 min/wk in the patients with no history of lumbar spinal fusion. One year after THA, patients with a history of lumbar spinal fusion reported a median of 120 min/wk of physical activity compared to 150 min/wk for patients without a history of lumbar spinal fusion. The difference in physical activity level change between groups was not statistically significant (estimate = -23.1, 95% confidence interval -62.1 to 15.9, P = .246). CONCLUSION: Patients with prior lumbar fusion were found to have lower self-reported physical activity levels than patients without spine fusion both before and after THA surgery. However, both groups saw the same degree of improvement in physical activity level following THA. These findings may help in counseling patients who have had a prior lumbar spine fusion and in setting appropriate expectations prior to THA.

Preoperative Risk Factors for Opioid Utilization After Total Hip Arthroplasty.

BACKGROUND: Opioid prescriptions following orthopaedic procedures may contribute to the opioid epidemic in the United States. Risk factors for greater and prolonged opioid utilization following total hip arthroplasty have yet to be fully elucidated. We sought to determine the prevalence of preoperative and postoperative opioid utilization in a cohort of patients who underwent total hip arthroplasty and to identify preoperative risk factors for prolonged utilization of opioids following total hip arthroplasty. METHODS: A cohort study of patients who underwent primary elective total hip arthroplasty at Kaiser Permanente from January 2008 to December 2011 was conducted. The number of opioid prescriptions dispensed per 90-day period after total hip arthroplasty (up to 1 year) was the outcome of interest. The risk factors evaluated included preoperative analgesic medication use, patient demographic characteristics, comorbidities, and other history of chronic pain. Poisson regression models were used, and relative risks (RRs) and 95% confidence intervals (CIs) are presented. RESULTS: Of the 12,560 patients who underwent total hip arthroplasty and were identified, 58.5% were female and 78.6% were white. The median age was 67 years (interquartile range, 59 to 75 years). Sixty-three percent of patients filled at least 1 opioid prescription in the 1 year prior to the total hip arthroplasty. Postoperative opioid use went from 88.6% in days 1 to 90 to 24% in the last quarter. An increasing number of preoperative opioid prescriptions was associated with a greater number of prescriptions over the entire postoperative period, with an RR of 1.10 (95% CI, 1.10 to 1.11) at days 271 to 360. Additional factors associated with greater utilization over the entire year included black race, chronic pulmonary disease, anxiety, substance abuse, and back pain. Factors associated with greater utilization in days 91 to 360 (beyond the early recovery phase) included female sex, higher body mass index, acquired immunodeficiency syndrome, peripheral vascular disease, and history of non-specific chronic pain. CONCLUSIONS: We identified preoperative factors associated with greater and prolonged opioid utilization long after the early recovery period following total hip arthroplasty. Patients with these risk factors may benefit from targeted multidisciplinary interventions to mitigate the risk of prolonged opioid use. CLINICAL RELEVANCE: Opioid prescriptions following orthopaedic procedures are one of the leading causes of chronic opioid use; strategies to reduce the risk of misuse and abuse are needed. At 1 year postoperatively, almost one-quarter of patients who underwent total hip arthroplasty used opioids in the last 90 days of the first postoperative year, which makes understanding risk factors associated with postoperative opioid utilization imperative.

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

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

Rehospitalizations for complications and mortality following pacemaker implantation: A retrospective cohort study in an older population.

INTRODUCTION: A large number of older people receive pacemakers each year but broad population-based studies that describe complications following pacemaker implantation in this population are lacking. METHODS: We conducted a retrospective cohort study using data from the Australian Government Department of Veterans' Affairs database. The cohort consisted of patients who received a pacemaker from 2005 to 2014. The outcomes were subsequent rehospitalizations for infections, procedure-related complications, thromboembolism, cardiovascular events (heart failure, myocardial infarction, and atrial fibrillation), and reoperation of pacemaker, and mortality. RESULTS: There were 10 883 pacemakers recipients, the median age was 86 years (interquartile range 83-89), 61% were males, and 74% received a dual-chamber pacemaker. Within 90 days postdischarge, rehospitalizations were occasioned by pacemaker infection in 0.5%, device-related complications in 1.5%, cerebral infarction in 0.7%, and heart failure in 6% of single-chamber pacemaker recipients. In dual-chamber pacemaker recipients rehospitalizations were occasioned by pacemaker infection in 0.4%, septicemia in 0.4%, device-related complications in 1.2%, cerebral infarction in 0.3%, and heart failure in 3%. Rehospitalizations for pacemaker adjustment occurred in 1.5% of patients. The 90-day postdischarge mortality was 5% and 3% in patients with single- and dual-chamber pacemaker, respectively. CONCLUSION: Rehospitalizations for infection, procedure-related complications, or thromboembolism occurred in 1% to 2% of patients within 90 days postdischarge, while 10% of single chamber and 7% of dual-chamber recipients experienced a rehospitalization for a cardiovascular event.

Patient Factors Associated With Prolonged Postoperative Opioid Use After Total Knee Arthroplasty.

BACKGROUND: Pain persists in a moderate proportion of patients after total knee arthroplasty (TKA). Identifying patient factors that are associated with persistent pain may lead to improved care. PURPOSE: The purpose of the study was to identify preoperative factors associated with increased opioid prescriptions after TKA. METHODS: A retrospective cohort study of TKAs in an integrated health-care system (January 2008-December 2011) was conducted. The number of opioid prescriptions per 90-day period after TKA (up to 1 year), was the outcome of interest. Patient risk factors that were evaluated included demographics, pain prescriptions, comorbidities, and chronic pain conditions. Multivariable Poisson regression models were employed. RESULTS: The median age for 23,726 patients was 67 years. Before surgery, 60.0% used opioids. Three months after surgery, 41.2% of patients continued using opioids. Factors associated with greater opioid use included: younger age (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.82-0.84 per 10-year increase), liver disease (OR = 1.11, 95% CI 1.06-1.16), preoperative nonsteroidal anti-inflammatory drug use (OR = 1.09, 95% CI 1.07-1.10), anxiety (OR = 1.05, 95% CI 1.03-1.08), substance abuse (OR = 1.03, 95% CI 1.00-1.06), diabetes mellitus (OR = 1.03, 95% CI 1.01-1.05), preoperative opioid use (OR = 1.04, 95% CI 1.04-1.04), back pain (OR = 1.23, 95% CI 1.18-1.127), congestive heart failure (OR = 1.16, 95% CI 1.06-1.27), depression (OR = 1.14, 95% CI 1.09-1.18), fibromyalgia (OR = 1.10, 95% CI 1.02-1.18), hypertension (OR = 1.06, 95% CI 1.02-1.10), nonspecific chronic pain (OR = 1.06, 95% CI 1.02-1.10), black race (OR = 1.17, 95% CI 1.12-1.23), and chronic lung disease (OR = 1.05, 95% CI 1.01-1.10). CONCLUSION: Several preoperative factors were associated with prolonged opioid use after TKA, and their identification can assist providers guide pain management. Avoidance or weaning of preoperative opioids should be considered.

Body Mass Index Is Associated With All-cause Mortality After THA and TKA.

BACKGROUND: Both obesity and underweight are associated with a higher risk of mortality in adulthood, but the association between mortality after arthroplasty and extreme ranges of body mass index (BMI) have not been evaluated beyond the first year. QUESTIONS/PURPOSES: The purpose of this study was to investigate the association between BMI and all-cause mortality after TKA and THA. METHODS: Data from two arthroplasty registries, the St Vincent's Melbourne Arthroplasty (SMART) Registry from Australia and the Kaiser Permanente Total Joint Replacement Registry (KPTJRR) from the United States, were used to identify patients aged ≥ 18 years undergoing elective TKAs and THAs between January 1, 2002, and December 31, 2013. Same-day bilateral THA and hemiarthroplasties were excluded. All-cause mortality was recorded from the day of surgery to the end of the study (December 31, 2013). Data capture was complete for the SMART Registry. No patients were lost to followup in the KPTJRR cohort and 2959 (5%) THAs and 5251 (5%) TKAs had missing data. Cox proportional hazard regression was used to estimate the all-cause mortality associated with six BMI categories: underweight (< 18.5 kg/m), normal weight (18.5-24.9 kg/m), overweight (25.0-29.9 kg/m), obese class I (30.0-34.9 kg/m), obese class II (35.0-39.9 kg/m), and obese class III (> 40 kg/m). For TKA, the SMART cohort had a median followup of 5 years (range, 0-12 years) and the KPTJRR cohort had a median followup of 4 years (range, 0-12 years). For THA, the SMART cohort had a median followup of 5 years (range, 0-12 years) and the KPTJRR cohort had a median followup of 4 years (range, 0-12 years). RESULTS: In both the Australian and US cohorts, being underweight (Australia: hazard ratio [HR], 3.72; 95% confidence interval [CI], 1.94-7.08; p < 0.001 and United States: HR, 1.88; 95% CI, 1.33-2.64; p < 0.001) was associated with higher all-cause mortality after TKA, whereas obese class I (Australia: HR, 0.66; 95% CI, 0.47-0.92; p = 0.015; United States: HR, 0.71; 95% CI, 0.66-0.78; p < 0.001) or obese class II (Australia: HR, 0.54; 95% CI, 0.35-0.82; p = 0.004; United States: HR, 0.73; 95% CI, 0.66-0.81; p < 0.001) was associated with lower mortality when compared with normal-weight patients. In the US cohort, being overweight was also associated with a lower risk of mortality (HR, 0.76; 95% CI, 0.71-0.82; p < 0.001). In the US cohort, being underweight had a higher risk of mortality after THA (HR, 2.09; 95% CI, 1.65-2.64; p < 0.001), whereas those overweight (HR, 0.73; 95% CI, 0.67-0.80; p < 0.001), obese class I (HR, 0.68; 95% CI, 0.62-0.75; p < 0.001), or obese class II (HR, 0.71; 95% CI, 0.62-0.81; p < 0.001) were at a lower risk of mortality after THA when compared with normal-weight patients. In patients undergoing THA in the Australian cohort, we observed no association between BMI and risk of death. CONCLUSIONS: We found that even severe obesity is not associated with a higher risk of death after arthroplasty. Patients should be informed of this when considering surgery. Clinicians should be cautious when considering total joint arthroplasty in underweight patients without first considering their nutritional status. LEVEL OF EVIDENCE: Level III, therapeutic study.

Persistent Opioid Use Following Total Knee Arthroplasty: A Signal for Close Surveillance.

BACKGROUND: Prolonged opioid use following total knee arthroplasty (TKA) has not been extensively studied. METHODS: A cohort study of primary TKA for osteoarthritis using an integrated healthcare system and Total Joint Replacement Registry (January 2008-December 2011) was conducted. Opioid use during the first year after TKA was the exposure of interest and cumulative daily oral morphine equivalent (OME) amounts were calculated. Total postsurgical OME per 90-day exposure periods were categorized into quartiles. The end point was aseptic revision surgery. Survival analyses were conducted and hazard ratios (HRs) were adjusted for age, gender, prior analgesic use, opioid-related comorbidities, and chronic pain diagnoses. RESULTS: A total of 24,105 patients were studied. After the initial 90-day postoperative period, 41.5% (N = 9914) continued to use opioids. Also, 155 (0.6%) revisions occurred within 1 year and 377 (1.6%) within 5 years. Compared to patients not taking any opioids, patients using medium-low to high OME after the initial 90-day period had a higher adjusted risk of 1-year revision, ranging from HR = 2.4 (95% confidence interval, 1.3-4.5) to HR = 33 (95% confidence interval, 10-110) depending on the OME and time period. CONCLUSION: Patients who require opioids beyond 90 days after TKA warrant close follow-up.

Magnetic Resonance Imaging in People With Cardiac Implantable Electronic Devices: A Population Based Cohort Study.

Magnetic resonance imaging (MRI) is a widely used diagnostic tool with great benefits but has been considered contraindicated in people with cardiac implantable electronic devices (CIED). We investigated the occurrence of MRI in people with CIEDs and associated adverse events in a national cohort. Of 17,848 people included, 56 (0.3%) had at least one MRI; 16 of 16,102 (0.1%) with MRI non-compatible CIEDs and 40 of 1746 (2%) with MRI compatible CIEDs. Following MRI exposure, hospitalisations for potential serious adverse events were rare.

The Incidence of Subsequent Meniscal Surgery Is Higher in the Anterior Cruciate Ligament-Reconstructed Knee Than in the Contralateral Knee.

BACKGROUND: A goal of anterior cruciate ligament (ACL) reconstruction is to provide a meniscal protective effect for the knee. PURPOSE: (1) To evaluate whether there was a different likelihood of subsequent meniscal surgery in the ACL-reconstructed knee or in the normal contralateral knee and (2) to compare the risk factors associated with subsequent meniscal surgery in the ACL-reconstructed knee and contralateral knee. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Using an integrated health care system's ACL reconstruction registry, patients undergoing primary ACL reconstruction, with no meniscal injury at the time of index surgery and a normal contralateral knee, were evaluated. Subsequent meniscal tears associated with ACL graft revision were excluded. Subsequent meniscal surgery in either knee was the outcome of interest. Sex, age, and graft type were assessed as potential risk factors. Survival analysis was used to compare meniscal surgery-free survival rates and to assess risk factors of subsequent meniscal surgery. RESULTS: Of 4087 patients, there were 32 (0.78%) patients who underwent subsequent meniscal surgery in the index knee and 9 (0.22%) in the contralateral knee. The meniscal surgery-free survival rate at 4 years was 99.08% (95% CI, 98.64%-99.37%) in the index knee and 99.65% (95% CI, 99.31%-99.82%) in the contralateral knee. There was a 3.73 (95% CI, 1.73-8.04; P < .001) higher risk of subsequent meniscal surgery in the index knee compared with the contralateral knee, or a 0.57% absolute risk difference. After adjustments, allografts (hazard ratio [HR], 5.06; 95% CI, 1.80-14.23; P = .002) and hamstring autografts (HR, 3.11; 95% CI, 1.06-9.10; P = .038) were risk factors for subsequent meniscal surgery in the index knee compared with bone-patellar tendon-bone (BPTB) autografts. CONCLUSION: After ACL reconstruction, the overall risk of subsequent meniscal surgery was low. However, the relative risk of subsequent meniscal surgery in the ACL-reconstructed knee was higher compared with the contralateral knee. Only graft type was found to be a risk factor for subsequent meniscal surgery in the ACL-reconstructed knee, with a higher risk for allografts and hamstring autografts compared with BPTB autografts.

Mortality After Total Knee and Total Hip Arthroplasty in a Large Integrated Health Care System.

CONTEXT: The number of excess deaths associated with elective total joint arthroplasty in the US is not well understood. OBJECTIVE: To evaluate one-year postoperative mortality among patients with elective primary and revision arthroplasty procedures of the hip and knee. DESIGN: A retrospective analysis was conducted of hip and knee arthroplasties performed in 2010. Procedure type, procedure volume, patient age and sex, and mortality were obtained from an institutional total joint replacement registry. An integrated health care system population was the sampling frame for the study subjects and was the reference group for the study. MAIN OUTCOME MEASURES: Standardized 1-year mortality ratios (SMRs) and 95% confidence intervals (CIs) were calculated. RESULTS: A total of 10,163 primary total knee arthroplasties (TKAs), 4963 primary total hip arthroplasties (THAs), 606 revision TKAs, and 496 revision THAs were evaluated. Patients undergoing primary THA (SMR = 0.6, 95% CI = 0.4-0.7) and TKA (SMR = 0.4, 95% CI = 0.3-0.5) had lower odds of mortality than expected. Patients with revision TKA had higher-than-expected mortality odds (SMR = 1.8, 95% CI = 1.1-2.5), whereas patients with revision THA (SMR = 0.9, 95% CI = 0.4-1.5) did not have higher-than-expected odds of mortality. CONCLUSION: Understanding excess mortality after joint surgery allows clinicians to evaluate current practices and to determine whether certain groups are at higher-than-expected mortality risk after surgery.

Increase in Total Joint Arthroplasty Projected from 2014 to 2046 in Australia: A Conservative Local Model With International Implications.

BACKGROUND: The incidence of joint arthroplasty is increasing worldwide. International estimates of future demand for joint arthroplasty have used models that propose either an exponential future increase, despite obvious system constraints, or static increases, which do not account for past trends. Country-specific projection estimates that address limitations of past projections are necessary. In Australia, a high-income country with the 7th highest incidence of TKA and 15th highest incidence of THA of the Organization for Economic Cooperation and Development (OECD) countries, the volume of TKAs and THAs increased 198% between 1994 and 2014. QUESTIONS/PURPOSE: To determine the projected incidence and volume of primary TKAs and THAs from 2014 to 2046 in the Australian population older than 40 years. METHODS: Australian State and Territory Health Department data were used to identify TKAs and THAs performed between 1994 and 1995 and 2013 and 2014. The Australian Bureau of Statistics was the source of the population estimates for the same periods and population-projected estimates until 2046. The incidence rate (IR), 95% CI, and prediction interval (PI) of TKAs and THAs per 100,000 Australian citizens older than 40 years were calculated. Future IRs were estimated using a logistic model, and volume was calculated from projected IR and population. The logistic growth model assumes the existence of an upper limit of the TKA and THA incidences and a growth rate directly related to this incidence. At the beginning, when the observed incidence is much lower than the asymptote, the increase is exponential, but it decreases as it approaches the upper limit. RESULTS: A 66% increase in the IR of primary THAs between 2013 and 2046 is projected for Australia (2013: IR = 307 per 100,000, [95% CI, 262-329 per 100,000] compared with 2046: IR= 510 per 100,000, [95% PI, 98-567 per 100,000]), which translates to a 219% increase in the volume during this period. For TKAs the IR is expected to increase by 26% by 2046 (IR = 575 per 100,000; 95% PI, 402-717 per 100,000) compared with 2013 (IR = 437 per 100,000; 95% CI, 397-479 per 100,000) and the volume to increase by 142%. CONCLUSION: A large increase in the volume of arthroplasties is expected using a conservative projection model that accounts for past surgical trends and future population changes in Australia. These findings have international implications, as they show that using country- specific, conservative projection approaches, a substantial increase in the number of these procedures is expected. This increase in joint arthroplasty volume will require appropriate workforce planning, resource allocation, and budget planning so that demand can be met. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

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.

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

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

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.

An underlying diagnosis of osteonecrosis of bone is associated with worse outcomes than osteoarthritis after total hip arthroplasty.

BACKGROUND: Well-designed studies of complications and readmission rates in patients undergoing total hip arthroplasty (THA) with osteonecrosis are lacking. Our objective was to examine if a diagnosis of osteonecrosis was associated with complications, mortality and readmission rates after THA. METHODS: We analyzed prospectively collected data from an integrated healthcare system's Total Joint Replacement Registry of adults with osteonecrosis vs. osteoarthritis (OA) undergoing unilateral primary THA during 2001-2012, in an observational cohort study. We examined mortality (90-day), revision (ever), deep (1 year) and superficial (30-day) surgical site infection (SSI), venous thromboembolism (VTE, 90-day), and unplanned readmission (90-day). Age, gender, race, body mass index, American Society of Anesthesiologists class, and diabetes were evaluated as confounders. We used logistic or Cox regression to calculate odds or hazard ratios (OR, HR) with 95% confidence intervals (CI). RESULTS: Of the 47,523 primary THA cases, 45,252 (95.2%) had OA, and 2,271 (4.8%) had osteonecrosis. Compared to the OA, patients with osteonecrosis were younger (median age 55 vs. 67 years), and were less likely to be female (42.5% vs. 58.3%) or White (59.8% vs. 77.4%). Compared to the OA, the osteonecrosis cohort had higher crude incidence of 90-day mortality (0.7% vs. 0.3%), SSI (1.2% vs. 0.8%), unplanned readmission (9.6% vs. 5.2%) and revision (3.1% vs. 2.4%). After multivariable-adjustment, patients with osteonecrosis had a higher odds/hazard of mortality (OR: 2.48; 95% CI:1.31-4.72), SSI (OR: 1.67, 95%CI:1.11-2.51), unplanned 90-day readmissions (OR: 2.20; 95% CI:1.67-2.91) and a trend towards higher revision rate 1-year post-THA (HR: 1.32; 95% CI: 0.94-1.84), than OA patients. CONCLUSIONS: Compared to OA, a diagnosis of osteonecrosis was associated with worse outcomes post-THA. A detailed preoperative discussion including the risk of complications is needed for informed consent from patients with osteonecrosis.