INTRODUCTION:Obesity is a known risk factor for complications and revision following total hip arthroplasty (THA). A triple-taper femoral stem design may improve metaphyseal engagement and rotational stability. This study investigated outcomes in obese patients undergoing cementless primary THA by stem design. METHODS:We conducted a retrospective cohort study of 25,112 obese patients undergoing unilateral, cementless THA for osteoarthritis between 2018 and 2024. Use of triple-taper increased over the study period (25.4% in 2018 versus 58.3% in 2024). Patients were categorized by stem type per the Khanuja-Mont 2011 classification: Type 1 (single taper), Type 2 (dual taper), and Type 3C (triple-taper) and stratified by obesity class (Class I: body mass index (BMI) 30.0 to 34.9; Classes II to IV: BMI ≥ 35.0). Multivariable Cox proportional hazard models assessed cause-specific revision risk, adjusting for confounders and surgeon clustering. RESULTS:At five years, cumulative aseptic revision probability was lowest for Type 3C stems. Among Class I obesity patients, Type 3C stems were associated with lower aseptic revision risk compared to Type 1 (hazard ratio (HR) = 0.47, 95% confidence interval (CI) = 0.31 to 0.71, P = 0.0004) and Type 2 stems (HR = 0.39, 95% CI = 0.17 to 0.91, P = 0.029). Similar findings were observed for Class II to IV obesity. Type 3C stems were also associated with lower periprosthetic fracture risk. CONCLUSIONS:The triple-taper stems are increasingly utilized in obese THA patients and are associated with a reduced aseptic revision and (periprosthetic fracture (PPF) risks compared to Type 1 and 2 stems, supporting the notion that these stems confer a clinically relevant biomechanical advantage.

STUDY DESIGN:Retrospective cohort study. OBJECTIVE:To evaluate the association between iliac fixation and long-term reoperation risk in patients undergoing multilevel lumbosacral fusion for degenerative pathology. SUMMARY OF BACKGROUND DATA:Spinopelvic fixation using iliac screws is commonly employed to improve construct stability in long lumbar fusions involving the sacrum. While biomechanical benefits are well established, clinical evidence regarding long-term reoperation risk and failure mechanisms in degenerative populations remains limited. METHODS:We identified adult patients undergoing primary elective multilevel lumbosacral fusion (>4 levels) between 2009 and 2023 from a large integrated healthcare spine registry by using iliac fixation. Primary outcome was all-cause reoperation. Secondary outcomes included reoperation for adjacent segment disease (ASD), nonunion, and hardware-related complications. We used Multivariable Cox proportional hazards regression models adjusted for patient and surgical factors to evaluate reoperation risk. Time-stratified analyses addressed nonproportional hazards. RESULTS:A total of 1,301 patients were included, including 483 with iliac fixation and 818 without. Mean follow-up was 6.3 years. At 10 years, crude all-cause reoperation incidence was 26.0% with iliac fixation versus 31.1% without. Iliac fixation was associated with reduced long-term all-cause reoperation risk (>1 y) (HR 0.63, 95% CI 0.43-0.92, P=0.018), but not early reoperation risk. Nonunion-related reoperation risk was significantly lower with iliac fixation (HR 0.30, 95% CI 0.13-0.67, P=0.004). No significant differences were observed in ASD-related reoperation risk. CONCLUSIONS:In patients undergoing multilevel lumbosacral fusion for degenerative pathology, iliac fixation was associated with significantly lower long-term reoperation risk, driven primarily by reduced nonunion-related reoperation. These findings support the role of iliac fixation in improving long-term construct durability. LEVEL OF EVIDENCE:III.

BACKGROUND:Uncemented modular acetabular components are commonly used in total hip arthroplasty. Liner wear is uncommon since the introduction of highly crosslinked polyethylene. Our study goal was to identify the incidence of liner dissociation and all-cause revision by manufacturer. METHODS:We included 117,051 patients aged 18 years and older who underwent primary total hip arthroplasty for osteoarthritis with a unipolar acetabular component and highly crosslinked polyethylene liner between 2009 and 2022. There were six acetabular component treatment groups categorized alphabetically by manufacturer: group one (n = 25,040), group two (n = 11,819), group three (reference group) (n = 72,221), group four (n = 3,233), group five (n = 2,021), and group six (n = 2,717). Revision during follow-up was modeled using Cox proportional hazard regression. RESULTS:In adjusted analysis, group one (hazard ratio [HR] = 1.51; 95% confidence interval [CI] = 1.30 to 1.75) and group four (HR = 1.35, 95% CI = 1.07 to 1.70) had higher all-cause revision risks. Liner dissociation incidence at 13 years was 0.25% for group three, 0.04% for group one, 0.00% for group four, 0.15% for group four, and 0.32% for group five. It was 0.01% for group one, which had a lower risk for revision due to liner dissociation (HR = 0.12; 95% CI = 0.04 to 0.33). The percentage of all failures attributable to liner dissociation was 0.4% for group one, 0.4% for group two, 4.0% for group three, 0% for group four, 1.2% for group five, and 0.9% for group six. CONCLUSIONS:In this large United States-registry-based study, the most utilized acetabular component showed a higher incidence of liner dissociations compared to the second most used cup/liner combination in this cohort.

Background: Hamstring autograft (HA) is a popular graft for anterior cruciate ligament reconstruction (ACLR). Although multiple studies have demonstrated that increasing the graft diameter decreases the risk of failure or revision surgery, the exact minimum graft diameter remains controversial, with the unofficial standard being 8 mm. Purpose: To evaluate the risk of aseptic revision after HA-ACLR in patients aged ≤25 years, comparing graft diameters of (1) <8 versus ≥8 mm and (2) ≤8 versus >8 mm. A secondary purpose was to determine whether there was a threshold for graft diameter that best identifies patients at a higher risk of aseptic revision. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 5972 primary HA-ACLRs were identified using data from the ACLR registry of Kaiser Permanente. Propensity score–weighted Cox regression was used to evaluate revision risk for HAs with <8 versus ≥8 mm diameter and with ≤8 versus >8 mm diameter. An effect plot and receiver operating characteristic curve and area under the curve (AUC) analysis were also created to model the probability of revision based on the HA diameter to determine whether there was a specific diameter threshold to minimize revision risk. Results: In the propensity score–weighted Cox model, <8 mm autografts had a higher risk of aseptic revision compared with ≥8 mm autografts (hazard ratio [HR], 1.32 [95% CI, 1.01-1.71]; P = .039); a higher risk was also observed when comparing ≤8 to >8 mm grafts (HR, 1.32 [95% CI, 1.06-1.66]; P = .015). In receiver operating characteristic analysis, an HA diameter that best identified patients at a higher risk for revision after ACLR could not be identified (AUC, 0.56). However, the adjusted effect plot showed a direct decrease in revision risk with each increasing increment in graft size. Conclusion: A 32% higher risk of revision was observed in smaller graft diameter groups (<8 or ≤8 mm) compared with larger graft sizes (≥8 or >8 mm), regardless of specific diameter cutoff. In a cohort of almost 6000 HA-ACLR, the authors were unable to determine a definitive minimum graft diameter threshold that should be used.

BACKGROUND:While some prior research has shown helical blades to have higher risks of fixation failure and cut-out than lag screws in the cephalomedullary nailing of intertrochanteric femoral fractures, other studies have not demonstrated any such differences. The purpose of this study was to compare the performance of helical blade and lag screw fixation among older patients with a hip fracture treated with cephalomedullary nailing and to determine whether the relative performance of these 2 fixation methods varies on the basis of patient characteristics. METHODS:This retrospective cohort study utilized the hip fracture registry of an integrated health-care system to identify patients ≥60 years old who underwent cephalomedullary nailing with a helical blade or lag screw from 2009 to 2023. Propensity score-weighted Cox proportional hazards regression was used to evaluate the risk of aseptic revision (the primary outcome measure) and the risks of revision for specific reasons (the secondary outcome measures), with mortality considered as a competing risk. RESULTS:The study sample included 22,308 cases (11,877 with a helical blade and 10,431 with a lag screw; mean patient age, 81.7 years; 71.5% female; 73.3% White; 71.8% with an American Society of Anesthesiologists [ASA] classification of ≥3). The 10-year cumulative incidence of aseptic revision was 1.69% (n = 194) in the helical blade group and 1.88% (n = 182) in the lag screw group (adjusted hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.69 to 1.11; p = 0.27). There was evidence of effect modification by ASA classification, with the helical blade outperforming the lag screw in patients with an ASA of 1 to 2 (aseptic revision incidence, 1.74% versus 2.56%; adjusted HR, 0.65; 95% CI, 0.43 to 0.98; p = 0.04) but not in those with an ASA of ≥3 (aseptic revision incidence, 1.72% versus 1.64%; adjusted HR, 1.03; 95% CI, 0.78 to 1.35; p = 0.85). There was no evidence of effect modification by age or sex. CONCLUSIONS:In this study of geriatric patients with a hip fracture treated with cephalomedullary nailing, helical blade and lag screw fixation performed similarly overall. Our finding that helical blade fixation may perform better in healthier (ASA 1 to 2) geriatric patients is interesting and deserves further investigation. LEVEL OF EVIDENCE:Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background Augmented glenoid implant usage in shoulder arthroplasty bone loss cases has increased over the past decade. While safe in the short term, there are insufficient studies on longer term survivorship data on the newer generation of implants. We sought to determine whether there was a difference in survivorship for patients treated with glenoid augmentation vs. those with traditional total shoulder arthroplasty (TSA). Method A retrospective cohort study was conducted using data from a US integrated health-care system's shoulder arthroplasty registry. Patients ≥18 years who underwent primary shoulder arthroplasty for arthritis, inflammatory arthritis, and rotator cuff tear were included (2018-2024). Augmented and nonaugmented glenoids were compared separately for anatomic (aTSA) and reverse (rTSA) TSA. All-cause, aseptic, and revision risk due to infection were evaluated through cause-specific Cox proportional hazard regression with confounder and operating surgeon adjustment. Reason for revision was recorded. Hazard ratios (HRs) and 95% confidence intervals (CIs) are presented, a P < .05 was considered statistically significant. Results Augmented glenoid implants were identified in 11.9% (n = 500) of aTSA and 55.8% (n = 2,641) of rTSA procedures. All-cause 5-year cumulative revision probability was 2.3% for rTSA and 2.6% aTSA. Average follow-up time for aTSA was 3.4 years (standard deviation [STD] = 2.0 years) and 2.6 years for rTSA (STD = 2.0 years). Mean time to first revision in aTSA was 2.1 years (STD = 1.8 years). The most common reason for aTSA revision was rotator cuff tear. We observed a 27% decreased risk of aseptic revision in aTSA patients with augmented glenoids (HR = 0.73, 95% CI = 0.56-0.93, P = .012) and no difference in all-cause or revision for infection (HR = 0.64, 95% CI = 0.32-1.29, P = .209 and HR = 0.79, 95% CI = 0.53-1.18, P = .253, respectively). The mean time to first revision in rTSA was 1.8 years (STD = 2.0 years). The most common reason for rTSA revision is chronic dislocation (instability). In rTSA, we failed to detect a difference in all-cause, aseptic, or revision for infection in augmented compared to nonaugmented glenoids (HR = 1.01, 95% CI = 0.80-1.28, P = .919, HR = 0.99, 95% CI = 0.78-1.26, P = .929, and HR = 0.98, 95% CI = 0.74-1.30, P = .885, respectively). Conclusions We found a lower 5-year risk of aseptic revision in aTSA and no-difference by augment status for rTSA. Augmented glenoid implants have several advantages when addressing glenoid wear, and our data support the use of these implants in the toolkit to address glenoid pathology.

In recent years, breast reconstruction following mastectomy has gained popularity. This study aimed to compare short-term unplanned return to the operating room (OR) for women undergoing breast reconstruction after mastectomy for malignancy by reconstruction timing, delayed compared to immediate (IBR). Subcategories of direct-to-implant and primarily autologous reconstruction were analyzed. Data from an integrated electronic medical record system identified patients undergoing breast reconstruction after mastectomy at Kaiser Permanente facilities between 2010–2022. Reconstruction timing was the exposure of interest, with stratification based on reconstructive techniques including tissue expander followed by either implant or autologous reconstruction, direct-to-implant, or primarily autologous reconstruction. Univariable and multivariable logistic regression models assessed the association between reconstruction timing and 90-day reoperations in direct-to-implant or primarily autologous reconstruction, using delayed reconstruction as the reference. A total of 23,272 cases were identified (immediate = 18,248, delayed = 5025). The IBR patients exhibited higher odds of reoperations [odds ratio (OR) = 1.96, 95% confidence interval (CI) = 1.65–2.33, P < 0.0001] compared to delayed reconstruction after covariate adjustment. Among patients with expanders, IBR increased reoperation odds (OR = 1.83, 95% CI = 1.43–2.33, P < 0.0001). Immediate direct-to-implant reconstruction had the highest reoperation odds (OR = 5.55, 95% CI = 2.08–4.67, P = 0.039). No significant differences were observed between immediate and delayed approaches in autologous reconstruction, regardless of whether it was conducted in a single- or 2-stage process. Immediate reconstruction, involving expanders or direct-to-implant reconstructions, showed increased 90-day reoperation risks compared to delayed reconstruction. Conversely, no significant differences were identified between IBR and delayed reconstruction with autologous reconstruction conducted in a single- or 2-stage process.

Background: Few studies have compared the risk of reoperation by timing in breast reconstruction surgery after mastectomy. We evaluated the first and total number of reoperations by reconstruction timing in women with breast cancer undergoing primary mastectomy. Methods: A cohort study of 23,301 primary mastectomies in women with breast cancer undergoing either immediate breast reconstruction (IBR) or delayed reconstruction was carried out within Kaiser Permanente between 2010 and 2022. The first reoperation rate was calculated using cause-specific Cox Proportional Hazards Models, while Multiplicative Cox Proportional Hazards Models were used to account for mortality and timing in reoperation. Patients were continuously monitored for death, outcome of interest, loss to follow-up through healthcare membership termination, or study end date (31 December 2022). Results: In total, 78.4% (n = 18,276) of the cohort underwent IBR. The average follow-up time was 5.9 years (±3.8). The following covariates were imbalanced (standardized mean difference [SMD] ≥ 0.20) between IBR and delayed groups: BMI, smoking status, year of mastectomy, bilateral procedures, and reconstruction type. The crude incidence of first reoperation was 33.04% vs. 31.72% in IBR vs. delayed patients and the risk of reoperation was 18% higher in IBR patients (HR = 1.18, 95% CI = 1.12–1.25). There was no difference in the risk of reoperation by timing (p > 0.05) when assessing multiple reoperations. The reoperation risk was the highest for IBR patients who did not complete reconstruction or single-stage reconstruction. In addition, the first reoperation rate of IBR patients was higher in those who underwent expander–implant-based reconstruction. Conclusions: The first reoperation rate was higher in IBR patients compared to those who delayed reconstruction, although we failed to detect a difference for multiple returns to surgery, except in certain subgroups. Assessing reoperation risk by timing among different reconstruction modalities can aid patients in making informed decisions about the type of breast reconstruction to undergo.

Background: The one-year mortality risk for elderly patients undergoing proximal femur fracture repair surgery is three to four times higher compared to the general population. Other than time to surgery, risk factors for postoperative morbidity and mortality following surgery are poorly understood in the elderly. We sought to identify risk factors associated with morbidity and mortality in geriatric patients by anticoagulation status undergoing hip fracture repair. Methods: Patients aged ≥65 years undergoing surgery for hip fracture repair were included (2009–2019) from a US-based hip fracture registry. Factors associated with 90-day mortality were determined using multivariable logistic regression and stratified by antithrombotic agent medication use prior to surgery. Direct oral anticoagulation (DOAC) medications were the largest group, and all antithrombotic agents were included in the delineation. Results: A total of 35,463 patients were identified, and 87.1% (N = 30,902) were DOAC-naïve. Risk factors for 90-day mortality in DOAC-naïve patients were an American Society of Anesthesiologist’s (ASA) classification ≥3 (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 2.24–2.93), preoperative myocardial infarction (OR = 1.87, 95% CI = 1.33–2.64), male gender (OR = 1.73, 95% CI = 1.59–1.88), congestive heart failure (CHF) (OR = 1.64, 95% CI = 1.50–1.80), psychoses (OR = 1.27, 95% CI = 1.15–1.42), renal failure (OR = 1.29, 95% CI = 1.19–1.40), smoking history (OR = 1.19, 95% CI = 1.09–1.29), chronic pulmonary disease (OR = 1.14, 95% CI = 1.05–1.25), increasing age (OR = 1.07, 95% CI = 1.06–1.07), and decreasing body mass index (BMI) (OR = 1.06, 95% CI = 1.05–1.08). Identified factors for mortality in the DOAC group also included ASA classification ≥3 (OR = 2.15, 95% CI = 1.44–3.20), male gender (OR = 1.68, 95% CI = 1.41–2.01), CHF (OR = 1.45, 95% CI = 1.22–1.73), chronic pulmonary disease (OR = 1.34, 95% CI = 1.12–1.61), decreasing BMI (OR = 1.04, 95% CI = 1.02–1.06), and increasing age (OR = 1.02, 95% CI = 1.01–1.03). Conclusions: Regardless of preoperative DOAC status, ASA classification, gender, CHF, chronic pulmonary disease, lower BMI, and higher age are associated with an increased risk of mortality. Some of these comorbidities can be utilized for risk stratification prior to surgery.

Background: In recent years, breast reconstruction following mastectomy has gained popularity. This study aimed to compare short-term unplanned return to the operating room (OR) for women undergoing breast reconstruction after mastectomy for malignancy by reconstruction timing, delayed compared to immediate (IBR). Subcategories of direct-to-implant and primarily autologous reconstruction were analyzed. Methods: Data from an integrated electronic medical record system identified patients undergoing breast reconstruction after mastectomy at Kaiser Permanente facilities between 2010-2022. Reconstruction timing was the exposure of interest, with stratification based on reconstructive techniques including tissue expander followed by either implant or autologous reconstruction, direct-to-implant, or primarily autologous reconstruction. Univariable and multivariable logistic regression models assessed the association between reconstruction timing and 90-day reoperations in direct-to-implant or primarily autologous reconstruction, using delayed reconstruction as the reference. Results: A total of 23,272 cases were identified (immediate = 18,248, delayed = 5025). The IBR patients exhibited higher odds of reoperations [odds ratio (OR) = 1.96, 95% confidence interval (CI) = 1.65-2.33, P < 0.0001] compared to delayed reconstruction after covariate adjustment. Among patients with expanders, IBR increased reoperation odds (OR = 1.83, 95% CI = 1.43-2.33, P < 0.0001). Immediate direct-to-implant reconstruction had the highest reoperation odds (OR = 5.55, 95% CI = 2.08-4.67, P = 0.039). No significant differences were observed between immediate and delayed approaches in autologous reconstruction, regardless of whether it was conducted in a single- or 2-stage process. Conclusions: Immediate reconstruction, involving expanders or direct-to-implant reconstructions, showed increased 90-day reoperation risks compared to delayed reconstruction. Conversely, no significant differences were identified between IBR and delayed reconstruction with autologous reconstruction conducted in a single- or 2-stage process.

Background: Radial head arthroplasty (RHA) is performed with increasing frequency for reconstruction of comminuted radial head fractures. Implants can be categorized by stem design, either loose fit or press fit. Currently, the RHA literature does not suggest one implant type is superior to another based on revision and reoperation rates, although most RHA outcome studies have small numbers of patients with few events to detect a difference. This study evaluated the association between stem design and risk of revision and reoperation after RHA. Methods: A total of 1575 patients aged >= 18 years who underwent primary RHA within a US-based health care system were identified (2009-2021). Revision following the index RHA was the primary outcome of interest; ipsilateral reoperation was a secondary outcome. Multivariable Cox proportional hazard regression was used to evaluate the risk of outcomes by loose vs. press fit with the adjustment for race and ethnicity, American Society of Anesthesiologists classification, region, surgeon RHA volume, and simultaneous ipsilateral extremity procedures. Results: Of the 1575 RHAs, 681 (43.2%) received a loose-fit stem. The cumulative revision probability was 2.6% for loose fit and 3.5% for press fit. In adjusted analysis, we did not observe a difference in risk of revision (hazard ratio [HR] = 0.78, 95% confidence interval [CI] = 0.41-1.46) or reoperation (HR = 0.73, 95% CI = 0.43-1.25). Additionally, there were no observed differences in risk of revision (HR = 0.62, 95% CI = 0.28-1.38) or reoperation (HR = 0.90, 95% CI = 0.48-1.71) in the patient subgroup who underwent additional procedures in the same extremity at the time of RHA. Conclusion: In this large multicenter cohort of 1575 primary RHAs, we did not observe a difference in risk of revision or reoperation following RHA based on stem design. The choice between using an implant with a loose- or press-fit stem may be based more on surgeon familiarity, implant availability, cost, and ease of use.

Background/Objective: The first-year postoperative mortality in elderly hip fracture patients is between 15 and 36%. Current scientific evidence indicates that morbidity and mortality are impacted by time of admission to surgery in hip fracture patients, although anticoagulation (AC) medication status specific optimization is unknown. Our objectives were to identify an ideal preoperative wait time by anticoagulation status in patients before hip fracture repair based on the incidence of postoperative morbidity and mortality. Methods: A total of 35,463 patients age ≥ 65 undergoing hip fracture repair were selected from a United States hip fracture registry (2009–2019). Patients were separated into strata (yes/no) based on whether they received anticoagulation (AC) medications ≤ 100 days prior to surgery. Multivariable logistic regression was adjusted for non-linear surgical wait time trends with prespecified percentiles using cubic splines. Results: A total of 87.1% (N = 30,902) of patients did not have AC preoperatively. Their median wait time was 20.3 h (IQR 13–27 h), and a positive linear trend was observed between surgical wait time and mortality. In patients with pre-operative AC, there was a “U”-shaped trend for all mortality time points although the breakpoint slopes were not significantly different from zero. Conclusions: In the study of more than 30,000 patients, short-term mortality was lowest for non-AC patients, undergoing surgery within the first 6–15 h of admission but remained uniform throughout the first 24 h of admission. These findings can be used to optimize patients prior to hip fracture surgery based on preoperative AC use and can positively affect resource planning and perioperative protocols.

BACKGROUND:Bone loss in revision total knee arthroplasty (rTKA) makes achieving a well-fixed construct challenging. Metaphyseal sleeves and porous cones were designed to enhance fixation during rTKA and are typically used in combination with modular stems. However, there are limited outcome data comparing rTKA constructs with stems and sleeves or cones to those with stems alone. Therefore, we sought to compare re-revision rates in patients undergoing rTKA with cones/sleeves + stems to those with just stems. METHODS:We conducted a cohort study from a United States health care system's arthroplasty registry. The study sample included 2,882 aseptic rTKAs that included a stemmed component only (N = 2,264) or a stem and a cone/sleeve (N = 618) (2008 to 2022). Propensity score-weighted Cox proportional hazard regression was used to evaluate the risk of aseptic re-revision and re-revision due to loosening specifically. RESULTS:At 8-year follow-up, after propensity score weighting, no difference was observed between stem + cone/sleeve compared with stem alone for aseptic re-revision (hazard ratio = 0.76, 95% confidence interval = 0.42 to 1.37) or aseptic loosening specifically (hazard ratio = 0.62, 95% confidence interval = 0.27 to 1.43). CONCLUSIONS:In a cohort of over 2,500 rTKAs, we found the addition of metaphyseal sleeves or porous cones did not change the risk of aseptic re-revision overall or re-revision due to loosening specifically. Further large-scale studies with long-term follow-up are warranted to confirm these results.

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.

BACKGROUND:Although the majority of intertrochanteric femoral fractures in the United States are now treated with cephalomedullary nailing, it remains uncertain whether differences in clinical performance by nail type exist. The purpose of this study was to compare the aseptic revision rates associated with the 3 most commonly utilized cephalomedullary nails in the United States today: the Gamma nail (Stryker), the INTERTAN (Smith+Nephew), and the Trochanteric Fixation Nail/Trochanteric Fixation Nail Advanced (TFN/TFNA; DePuy Synthes). METHODS:Using an integrated health-care system's hip fracture registry, patients ≥60 years of age who were treated with 1 of these 3 commonly used cephalomedullary nail devices were identified. Potential confounders were identified and controlled for, including age, gender, race or ethnicity, body mass index, smoking status, American Society of Anesthesiologists classification, anesthesia type, Elixhauser comorbidities, and the operating surgeon. Multivariable Cox proportional-hazards regression was used to evaluate the risk of aseptic revision (the primary outcome measure) by cephalomedullary nail type, with mortality and revisions unrelated to the index fracture considered as competing events. RESULTS:There were 19,215 patients included in the study sample (71.4% female, 77.0% White), including 4,421 in the Gamma nail group, 2,350 in the INTERTAN nail group, and 12,444 in the TFN/TFNA nail group. In the multivariable analysis involving nails of all lengths, the INTERTAN group was found to have a higher risk of aseptic revision compared with the TFN/TFNA group (8-year crude revision rate, 2.9% compared with 1.8%; hazard ratio [HR], 1.62 [95% confidence interval (CI), 1.15 to 2.27]; p = 0.006). The increased risk associated with the INTERTAN nail was primarily seen among the long nails (HR, 1.83 [95% CI, 1.16 to 2.87]; p = 0.009) rather than the short nails (HR, 1.36 [95% CI, 0.87 to 2.11]; p = 0.18). There were no differences in aseptic revision observed between the Gamma group and the TFN/TFNA group. CONCLUSIONS:In this study of 19,215 patients with a hip fracture treated with cephalomedullary nailing, the INTERTAN nail was found to have a significantly higher risk of aseptic revision. Further research is required to determine whether these results could be related to the unique design of this implant. LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE Biomechanical factors in lumbar fusions accelerate the development of adjacent -segment disease (ASD). Stiffness in the fused segment increases motion in the adjacent levels, resulting in ASD. The objective of this study was to determine if there are differences in the reoperation rates for symptomatic ASD (operative ASD) between anterior lumbar interbody fusion plus pedicle screws (ALIF+PS), posterior lumbar interbody fusion plus pedicle screws (PLIF+PS), transforaminal lumbar interbody fusion plus pedicle screws (TLIF+PS), and lateral lumbar interbody fusion plus pedicle screws (LLIF+PS). METHODS A retrospective study using data from the Kaiser Permanente Spine Registry identified an adult cohort (>= 18 years old) with degenerative disc disease who underwent primary lumbar interbody fusions with pedicle screws between L3 to S1. Demographic and operative data were obtained from the registry, and chart review was used to document operative ASD. Patients were followed until operative ASD, membership termination, the end of study (March 31, 2022), or death. Operative ASD was analyzed using Cox proportional hazards models. RESULTS The final study population included 5291 patients with a mean +/- SD age of 60.1 +/- 12.1 years and a followup of 6.3 +/- 3.8 years. There was a total of 443 operative ASD cases, with an overall incidence rate of reoperation for ASD of 8.37% (95% CI 7.6-9.2). The crude incidence of operative ASD at 5 years was the lowest in the ALIF+PS cohort (7.7%, 95% CI 6.3-9.4). In the adjusted models, the authors failed to detect a statistical difference in operative ASD between ALIF+PS (reference) versus PLIF+PS (HR 1.06 [0.79-1.44], p = 0.69) versus TLIF+PS (HR 1.03 [0.81-1.31], p = 0.83) versus LLIF+PS (HR 1.38 [0.77-2.46], p = 0.28). CONCLUSIONS In a large cohort of over 5000 patients with an average follow-up of > 6 years, the authors found no differences in the reoperation rates for symptomatic ASD (operative ASD) between ALIF+PS and PLIF+PS, TLIF+PS, or LLIF+PS.

BACKGROUND:Research has identified disparities in returns to care by race/ethnicity following primary total joint arthroplasty. We sought to identify risk factors for 90-day emergency department (ED) returns following primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) for these populations.METHODS:Black, Hispanic, and non-Hispanic White patients who underwent elective primary unilateral TKA and THA in an integrated US healthcare system were identified. Risk factors for 90-day postoperative ED visits including patient demographics, household income and education, comorbidities, preoperative healthcare utilization, and copay data were identified with multivariable logistic regression.RESULTS:Postoperative 90-day ED visits occurred in 13.3% of 79,565 TKA patients (17.2% Black; 14.9% Hispanic; 12.5% White) and 11.0% of THA patients (13.4% Black; 12.1% Hispanic; 10.7% White). Across racial/ethnic categories, patients who had an ED visit within 1 year of their TKA or THA date were more likely to have a 90-day ED return. Shared risk factors for TKA patients were chronic lung disease and outpatient utilization (25th and 75th percentile), while peripheral vascular disease was a shared risk factor for THA patients. Risk factors for multiple races of TKA and THA patients included depression, drug abuse, and psychosis. Prior copay for White (TKA) and Hispanic (TKA and THA) patients was protective, while preoperative primary care was protective for Black THA patients.CONCLUSION:Future strategies to reduce postoperative ED returns should include directed patient outreach for patients who had ED visits and mental health in the year prior to TKA and THA.LEVEL OF EVIDENCE:III.

Study Design. A retrospective cohort study. Objective. To determine if there is a difference in reoperation rates for symptomatic adjacent segment disease (operative ASD) and symptomatic nonunions (operative nonunions) in posterior cervical fusions (PCFs) stopping at C7 using either lateral mass screws (LMS) or cervical pedicle screws (CPS) at C7. Summary of Background Data. Stopping PCFs at C7 has been controversial because of the risks of adjacent segment disease or nonunions. The two commonly used fixation techniques at the C7 level are LMS and CPS. Materials and Methods. A retrospective analysis from the Kaiser Permanente Spine Registry identified a cohort of patients with cervical degenerative disk disease who underwent primary PCFs stopping at C7 with either LMS or CPS at C7. Demographic and operative data were extracted from the registry, and operative ASD and operative nonunions were adjudicated through chart review. Patients were followed until validated operative ASD or nonunion, membership termination, death, or end of study (March 31, 2022). Descriptive statistics and multivariable Cox proportional hazards models were calculated for operative ASDs and operative nonunions. Results. We found 481 patients with PCFs stopping at C7 with either LMS (n=347) or CPS (n=134) at C7 with an average follow-up time of 5.6 (±3.8) years, time to operative ASD of 3.0 (±2.8) years, and to operative nonunion of 1.2 (±0.7) years. There were 11 operative ASDs (LMS=8, CPS=3) and eight operative nonunions (LMS=4, CPS=4). There was no statistical difference between patients stopping at C7 with LMS versus CPS for operative ASDs (HR: 0.68, 95% CI=0.17–2.77, P=0.60) or operative nonunions (HR: 2.09, 95% CI=0.45–8.58, P=0.37). Conclusion. A large cohort of patients with PCFs stopping at C7 with an average follow-up of > 5 years found no statistical difference in reoperation rates for symptomatic ASD (operative ASD) or operative nonunion using either LMS or CPS at C7.

Background: 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.

BACKGROUND:With an increasing number of primary anterior cruciate ligament reconstructions (ACLRs), the burden of revision ACLR (rACLR) has also increased. Graft choice for rACLR is complicated by patient factors and the remaining available graft options.PURPOSE:To examine the association between graft type at the time of rACLR and the risk of repeat rACLR (rrACLR) in a large US integrated health care system registry while accounting for patient and surgical factors at the time of revision surgery.STUDY DESIGN:Cohort study; Level of evidence, 3.METHODS:Data from the Kaiser Permanente ACLR registry were used to identify patients who underwent a primary isolated ACLR between 2005 and 2020 and then went on to have rACLR. Graft type used at rACLR, classified as autograft versus allograft, was the exposure of interest. Multivariable Cox proportional hazard regression was used to evaluate the risk of rrACLR, with ipsilateral and contralateral reoperation as secondary outcomes. Models included factors at the time of the rACLR (age, sex, body mass index, smoking status, staged revision, femoral fixation, tibial fixation, femoral tunnel method, lateral meniscal injury, medial meniscal injury, and cartilage injury) and a factor from the primary ACLR (activity at injury) as covariates.RESULTS:A total of 1747 rACLR procedures were included. The crude cumulative rrACLR incidence at 8-year follow-up was 13.9% for allograft and 6.0% for autograft. Cumulative ipsilateral reoperation incidence at 8-year follow-up was 18.3% for allograft and 18.9% for autograft; contralateral reoperation cumulative incidence was 4.3% for allograft and 6.8% for autograft. With adjustment for covariates, a 70% lower risk for rrACLR was observed for autograft compared with allograft (hazard ratio [HR], 0.30; 95% CI, 0.18-0.50; P < .0001). No differences were observed for ipsilateral reoperation (HR, 1.05; 95% CI, 0.73-1.51; P = .78) or contralateral reoperation (HR, 1.33; 95% CI, 0.60-2.97; P = .48).CONCLUSION:The use of autograft at rACLR was associated with a 70% lower risk of rrACLR compared with allograft in this cohort from the Kaiser Permanente ACLR registry. When accounting for all reoperations outside of rrACLR after rACLR, the authors found no significant difference in risk between autograft and allograft. To minimize the risk of rrACLR, surgeons should consider using autograft for rACLR when possible.