Search

BACKGROUND As indications for elective total hip arthroplasty (THA) expand to younger patients, we sought to (1) compare revision risk following primary elective THA in patients

Background With the heightened focus on lowering adverse postoperative events through preoperative patient optimization, malnutrition may be a modifiable risk factor that could be addressed and lead to improved postoperative outcomes. However, an understanding of the association between malnutrition status and adverse postoperative events following shoulder arthroplasty is lacking. We sought to evaluate the association between preoperative malnutrition status, identified via the total serum lymphocyte count, and adverse postoperative events following shoulder arthroplasty. Methods We conducted a cohort study using data from Kaiser Permanente's Shoulder Arthroplasty Registry. Patients who underwent elective primary shoulder arthroplasty were identified (2005-2016). Patients with a preoperative total lymphocyte count Results The final study cohort comprised 6956 shoulder arthroplasty patients, with 2133 (30.7%) identified as malnourished. No difference in septic or aseptic revision risks was observed when comparing patients with and without malnutrition; however, malnourished patients had a higher risk for death, regardless of age ( Conclusion Only a higher mortality risk was observed to be associated with total lymphocyte count-defined malnutrition in patients undergoing elective shoulder arthroplasty. When instead looking at total lymphocyte count continuously, an optimal threshold for discriminating risk of adverse postoperative events could not be identified. Further study is needed to identify an appropriate indicator of malnutrition in shoulder arthroplasty patients and if this indicator can be modified to improve patient status and quality of care. Level of Evidence Level III; Retrospective Cohort Comparative Study

Background The total joint literature has shown promising results of bisphosphonate use on decreasing early bone loss after hip and knee arthroplasty and reducing aseptic revision risk though a higher risk of periprosthetic fracture has also been reported. We sought to evaluate the association between bisphosphonate use and aseptic revision risk in patients undergoing shoulder arthroplasty. Methods A US integrated healthcare system's registry was used to identify 6204 patients who underwent primary elective shoulder arthroplasty for osteoarthritis (2005-2016). Preoperative bisphosphonate users (defined as having at ≥6-month supply and 80% adherence) were compared to nonbisphosphonate users. Multivariable Cox proportional hazard regression was used to evaluate aseptic revision risk according to bisphosphonate use while adjusting for confounders. Secondary analysis stratified by age (40-64, ≥65 years) and bone quality status (normal, osteopenia, osteoporosis, or unknown). Results At the time of index procedure, 564 (9.1%) were considered as bisphosphonate users. We failed to observe a difference in aseptic revision risk by bisphosphonate use (hazard ratio = 0.92, 95% confidence interval = 0.50-1.72). No association was observed even after stratifying by bone quality and age. No revisions for periprosthetic fracture occurred in the bisphosphonate user group during follow-up. Conclusions While prior studies in lower extremity joint arthroplasty cohorts have observed a differential risk for revision surgery with bisphosphonate use, we failed to observe any associations between bisphosphonate use and revision risk in a cohort of shoulder arthroplasty patients. Level of Evidence Level III; Retrospective Cohort Comparative Study

Background Recent case series have reported early failure with the use of high-viscosity cement (HVC) in total knee arthroplasty (TKA). We evaluated revision risk after TKA with HVC compared with medium-viscosity cement (MVC) in a large cohort. Methods We conducted a cohort study using data from Kaiser Permanente’s Total Joint Replacement Registry. Patients who underwent fully cemented primary TKA for osteoarthritis were identified (2001-2018). Only posterior-stabilized, fixed-mobility designs of the 3 highest-volume implant systems (DePuy PFC, Zimmer NexGen, and Zimmer Persona) were included to mitigate confounding from implant characteristics. Palacos (Zimmer/Heraeus) and Simplex (Stryker) cements comprised the HVC and MVC exposure groups, respectively. Propensity score–weighted Cox proportional hazards regression was used to evaluate risk for any revision during follow-up and risk for revision from aseptic loosening specifically. Results The final cohort comprised 76,052 TKAs, 41.1% using MVC. The crude 14-year cumulative revision probability was 4.55% and 5.12% for TKA with MVC and HVC, respectively. In propensity score–weighted Cox models, MVC compared with HVC had a lower risk of any revision (hazard ratio = 0.82, 95% confidence interval = 0.70-0.95) while no difference was observed for revision from aseptic loosening (hazard ratio = 0.80, 95% confidence interval = 0.56-1.13). Conclusion While we observed a lower risk for any revision with the use of Simplex MVC compared with Palacos HVC, we did not observe a difference in revision for aseptic loosening specifically. Given the widespread use of HVC, additional research to investigate other HVC and potential mechanisms for failure outside of loosening is warranted. Level of Evidence Level III.

Background Endologix issued important safety updates for the AFX Endovascular AAA System in 2016 and 2018 owing to the risk of type III endoleaks. Outcomes with these devices are limited to small case series with short-term follow-up. We describe the midterm outcomes for a large cohort of patients who received an Endologix AFX or AFX2 device. Study design Data from an integrated healthcare system's implant registry, which prospectively monitors all patients after endovascular aortic repair, was used for this descriptive study. Patients undergoing endovascular aortic repair with three AFX System variations (Strata [AFX-S], Duraply [AFX-D], and AFX2 with Duraply [AFX2]) were identified (2011-2017). Crude cumulative event probabilities for endoleak (types I and III), major reintervention, conversion to open, rupture, and mortality (aneurysm related and all cause) were estimated. Results Among 605 patients, 375 received AFX-S, 197 received AFX-D, and 33 received AFX2. Median follow-up for the cohort was 3.9 (interquartile range, 2.5-5.1) years. The crude 2-year incidence of overall endoleak, any subsequent reintervention or conversion, and mortality was 8.8% (95% confidence interval [CI], 6.3-12.3), 12.0% (95% CI, 9.1-15.9), and 8.8% (95% CI, 6.3-12.2) for AFX-S. Respective estimates for AFX-D were 7.9% (95% CI, 4.8-13.0), 10.6% (95% CI, 6.9-16.1), and 9.7% (95% CI, 6.3-14.7); for AFX2, they were 14.1% (95% CI, 4.7-38.2), 16.2% (95% CI, 6.4-37.7), and 21.2% (95% CI, 10.7-39.4). Conclusions The midterm outcomes of a large U.S. patient cohort with an Endologix AFX or AFX2 System demonstrate a concerning rate of adverse postoperative events. Patients with these devices should receive close clinical surveillance to prevent device-related adverse events.

Introduction Anatomic total shoulder arthroplasty (TSA) is a proven treatment for glenohumeral joint osteoarthritis, with superior results compared with hemiarthroplasty. However, glenoid component loosening remains a problem and is one of the most common causes of failure in TSA. Multiple component designs have been developed in an attempt to reduce loosening rates. The purpose of this study was to evaluate risk of revision after anatomic TSA according to the glenoid component design. Methods We conducted a cohort study including patients aged ≥18 years who underwent primary elective TSA for the diagnosis of osteoarthritis between 2010 and 2017. Patients with missing implant information, who received stemless humeral implants, or who received augmented glenoid implants, were excluded. Glenoid component designs used were categorized into 4 mutually exclusive treatment groups: polyethylene central-pegged ingrowth, polyethylene-metal hybrid, polyethylene all-cemented pegged, and polyethylene cemented keeled. Multivariable competing risk regression was used to evaluate the risk of glenoid loosening as a cause-specific revision by the glenoid component design. Results Of the 5566 TSA included in the final cohort, 39.2% of glenoid implants were polyethylene central-pegged ingrowth, 31.1% were polyethylene-metal hybrid, 26.0% were polyethylene all-cemented pegged, and 3.6% were polyethylene cemented keeled. At 6-year final follow-up, 4.1% of TSA were revised for any cause, and 1.4% for glenoid loosening. Compared with the polyethylene central-pegged ingrowth design, no difference in glenoid loosening revision risk was observed for the polyethylene-metal hybrid design (hazard ratio [HR] = 1.15, 95% confidence interval [CI] = 0.42-3.20). However, both the polyethylene all-cemented pegged (HR = 2.48, 95% CI = 1.08-5.66) and polyethylene cemented keeled (HR = 3.84, 95% CI = 1.13-13.00) designs had higher risks for revision due to glenoid loosening. Conclusions We observed glenoid component designs to be associated with differential risks in revision due to glenoid loosening with polyethylene all-cemented pegged glenoids and polyethylene cemented keeled glenoids having higher risks when compared with polyethylene central-pegged ingrowth glenoids. Surgeons may want to consider the glenoid component design when performing anatomic TSA.

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.

The opioid epidemic remains a serious issue in the United States with significant impact to the medical and socioeconomic welfare of communities. We sought to determine baseline opioid use in patients undergoing shoulder arthroplasty (SA) and identify patient characteristics, comorbidities, and surgical risk factors associated with postoperative opioid use.A Shoulder Arthroplasty Registry identified the number of dispensed opioid medication prescriptions (Rxs) in the first postoperative year in patients who underwent elective primary SA from 2008 to 2014. We used Poisson regression to study the effect of preoperative risks factors on number of dispensed opioid Rxs in the first postoperative year, evaluated quarterly (Q1: days 0-90, Q2: days 91-180, Q3: days 181-270, Q4: days 271-360).Included were 4243 SAs from 3996 patients, and 75% used opioids in the 1-year preoperative period. The factors associated with increased opioid use in all postoperative quarters (Q4 incident rate ratio [IRR] shown) were age60 years (IRR, 1.40; 95% confidence interval [CI], 1.29-1.51), preoperative opioid use (1-4 Rxs: IRR, 2.15; 95% CI, 1.85-2.51; ≥5 Rxs: IRR, 9.83; 95% CI , 8.53-11.32), anxiety (IRR, 1.11; 95% CI, 1.03-1.20), opioid dependence (IRR, 1.23; 95% CI, 1.05-1.43), substance abuse (IRR, 1.17; 95% CI, 1.07-1.28), and general chronic pain (IRR, 1.38; 95% CI, 1.28-1.50).Opioid usage in patients undergoing SA is widespread at 1 year, with three-fourths of patients having been dispensed at least one Rx. These findings emphasize the need for surgeon and patient awareness as well as education in the management of postoperative opioid usage associated with the indicated conditions. Surgeons may consider these risk factors for preoperative risk stratification and targeted deployment of preventative strategies.

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.

Background Previous studies evaluating reasons for 30-day readmissions following total joint arthroplasty (TJA) may underestimate hospital-based utilization of healthcare resources during a patient's episode-of-care. We sought to identify common reasons for 90-day emergency department (ED) visits and hospital readmissions following primary elective unilateral TJA. Methods Patients from July 1, 2012 through June 30, 2015 having primary elective TJA and at least one 90-day postoperative ED-only visit and/or readmission for any reason were identified using the Kaiser Permanente Total Joint Replacement Registry. Chart reviews for ED visits/readmissions included 13 surgical and 11 medical reasons. The 2344 total hips and 5520 total knees were analyzed separately. Results Incidence of at least one ED visit following total hip arthroplasty (THA) was 13.4% and 4.5% for readmissions. The most frequent reasons for ED visits were swelling (15.6%) and pain (12.8%); the most frequent reasons for readmissions were infection (12.5%) and unrelated elective procedures (9.0%). The incidence of at least one ED visit following total knee arthroplasty (TKA) was 13.8%, and the incidence of readmission was 5.5%. The most frequent reasons for ED visits were pain (15.8%) and swelling (15.6%); the most common readmission reasons were gastrointestinal (19.1%) and manipulation under anesthesia (9.4%). Conclusion Swelling and pain related to the procedure were the most frequent reasons for 90-day ED visits after both THA and TKA. Readmissions were most commonly due to infection or unrelated procedures for THA and gastrointestinal or manipulation under anesthesia for TKA. Modifications to discharge protocols may help prevent or alleviate these issues, avoiding unnecessary hospital returns.

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. Refereed/Peer-reviewed

This study compared the total joint arthroplasty (TJA) surgical outcomes of patients who had bariatric surgery prior to TJA to TJA patients who were candidates but did not have bariatric surgery. Patients were retrospectively grouped into: Group 1 (n = 69), those with bariatric surgery > 2 years prior to TJA, Group 2 (n = 102), those with surgery within 2 years of TJA, and Group 3 (n = 11,032), those without bariatric surgery. In Group 1, 2.9% (95% CI 0.0–6.9%) had complications within 1 year compared to 5.9% (95% CI 1.3%–10.4%) in Group 2, and 4.1% (95% CI 3.8%–4.5%) in Group 3. Ninety-day readmission (7.2%, 95% CI 1.1%–13.4%) and revision density (3.4/100 years of observation) was highest in Group 1. Bariatric surgery prior to TJA may not provide dramatic improvements in post-operative TJA surgical outcomes. Refereed/Peer-reviewed

There is a paucity of data on the effect of multimorbidity on early (≤ 1-year) mortality in older adults after permanent pacemaker placement (PPM) implantation. Observational retrospective study from 2008 to 2015, within an integrated healthcare delivery system to assess the association of the

Background Improved narcotic pain management after total joint arthroplasty (TJA) is necessary to help battle the opioid epidemic. The goal of this study was to determine the sources of prescriptions prescribed to TJA patients. Methods An evaluation of opioid use in patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) was performed between 2008 and 2012. Using a Total Joint Replacement Registry and pharmacy data, opioids dispensed to TJA patients were identified. The main outcome of interest was who prescribed opioids to patients in the year before and after surgery. Results Primary care (pre-TKA 31% TKA, post-TKA 38%, pre-THA 34%, post-THA 40%) and internal medicine (27% pre-TKA, post-TKA 37%, pre-THA 32%, post-THA 40%) were the highest prescribers in the year before, and after, TJA. For TKA patients, orthopedists prescribed 9% of the opioids in the year before surgery, 47% in days 1-90 after surgery, and 14% in days 271-360. Similarly, in THA patients, orthopedists prescribed 14% of the opioids in the year before surgery, 40% in days 1-90 after surgery, and 14% in days 271-360. Conclusion Patients receive opioid prescriptions from multiple physician types before, and after, TJA. The majority of preoperative, and late postoperative, narcotics were not provided by their surgeons. Orthopedic surgeons may not even know that their TJA patients continue to receive opioids. Coordination of opioid care with health-care providers and greater communication with patients on narcotic use expectations should be promoted.

The routine use of antibiotic-loaded bone cement (ALBC) in primary total knee arthroplasty (TKA) is controversial. Outcomes were recorded in patients who underwent primary TKA from May 2003 to March 2007 using a community-based total joint registry. Infection rates were compared in patients undergoing TKA with ALBC and regular cement. A total of 22 889 primary TKA were performed, with 2030 cases (8.9%) using ALBC. Two thousand four hundred forty-nine patients were diabetic (10.7%), with ALBC used in 295 cases (12%). The rate of deep infection was 1.4% for ALBC TKA (28 cases) and 0.7% (154 cases) with regular cement (P = .002). Among patients with diabetes, the infection rate was 1.7% (5 cases) with ALBC and 0.9% (19 cases) with regular cement (P = .199). In patients whom surgeons considered higher risk for infection, ALBC did not appear to reduce TKA infection rates. The routine use of antibiotic-laden cement warrants further investigation.

This prospective study documented patterns of scar formation after anterior cruciate ligament (ACL) rupture in order to test the hypothesis that ACL remnants can contribute to anterior knee passive motion limits tested with a ligament arthrometer.Prospective cohort study.Forty-eight consecutive patients undergoing ACL reconstructions had intra-operative ligament arthrometry testing before and immediately after preparation of the notch and debridement of the ACL remnant. Patterns of scar formation were compared with changes in knee laxity after debridement of the ACL remnant.Eighteen patients (38%) had ligament scarring to the posterior cruciate ligament (group 1). Four patients (8%) had scar tissue that appeared to extend from the ACL fibers to the roof of the notch (group 2). Six ACL remnants (12%) appeared to have healed to the lateral wall of the notch or the medial aspect of the lateral femoral condyle in a position anterior and distal to the ACL anatomic footprint (group 3). In 20 patients (42%), there was no identifiable ligament tissue remaining (group 4). Changes in anterior laxity were associated with the specific pattern of scar formation within the notch. The greatest increase in anterior laxity after debridement was observed in knees in which the injured ACL had an aberrant reattachment to the femur: group 1 (mean, -1.3 mm; P.01), group 2 (mean, -3.4 mm; P.05), and group 3 (mean, -4.3 mm; P.05). In group 4, the change in knee laxity was not significant (mean, 0.2 mm; 95% CI, -0.29 to 0.74 mm). Overall, 14 of 48 knees (29%) loosened more than 2 mm after ACL resection ( P.01).Resection of the ACL scar resulted in a measurable increase in passive anterior laxity in a subset of ACL-deficient knees. This increase in anterior laxity occurred in patients whose ligament healed to the femur, effectively crossing the joint. When performing arthroscopy without reconstruction in ACL-injured knees, we recommend caution in resecting the torn ACL or scar tissue because removal of this tissue contributed to increased anterior laxity in some ACL-deficient knees.Level II, diagnostic study of consecutive patients.

Purpose: The purpose of this investigation was to determine current views regarding lateral release among experienced knee surgeons with a specific interest in the patellofemoral joint. Type of Study: Scientific survey. Methods: A questionnaire was developed and mailed to all members of an international group with a specific interest in disorders of the patellofemoral joint. Frequencies and percentages of responses were calculated for each question to determine surgeon consensus. We measured agreement among responses using the kappa statistic. This provided an indication of consistency for each question as well as correlation among the responses to different questions. Results: The survey response rate was 60%. Isolated lateral release was estimated to account for only 1 to 5 surgical cases per respondent per year, or 2% of cases performed annually. In the setting of arthroscopy or exploration, 74% of respondents believed that lateral release calls for specific informed consent. Strong consensus was found that objective evidence is needed to justify lateral release, but agreement was poor as to what clinical evidence provides the most appropriate indication for the procedure. Conclusions: Even among experienced knee surgeons with a special interest in diseases of the patellofemoral articulation, isolated lateral release is rarely performed. Strong consensus was found that isolated lateral release should not be undertaken without prior planning in the form of objective clinical indications and preoperative informed consent. Level of Evidence: Level V.

Background: Rates of venous thromboembolism in contemporary studies of primary total knee arthroplasty (TKA) have been reported to be as high as 3.5%. Although drug prophylaxis is effective, the best option among these regimens is not well established. The purpose of this study was to evaluate the comparative effectiveness and safety of aspirin, low-molecular-weight heparin, synthetic pentasaccharide factor Xa inhibitors, and vitamin K antagonist. Methods: Data were from a US total joint replacement registry, with 30,499 patients receiving unilateral TKA from May 16, 2006, to December 31, 2013. Patients received either aspirin (324-325 mg daily), enoxaparin (40-60 mg daily), fondaparinux (2.5 mg daily), or warfarin (all doses) and were followed up 90 days postoperatively on several outcomes: deep vein thrombosis, pulmonary embolism, major bleeding, wound complications, infection, and death. Results: There was no evidence that fondaparinux, enoxaparin, or warfarin were superior to aspirin in the prevention of pulmonary embolism, deep vein thrombosis, or venous thromboembolism or that aspirin was safer than these alternatives. However, enoxaparin was found to be as safe as aspirin with respect to bleeding, and fondaparinux was as safe as aspirin for risk of wound complications. Conclusion: Among TKA patients, we did not find evidence for decreased effectiveness or increased safety with use of aspirin, but enoxaparin had comparable safety to aspirin for bleeding and fondaparinux had comparable safety to aspirin for wound complications. Refereed/Peer-reviewed

There is a paucity of data on cardiovascular outcomes in patients with end-stage renal disease (ESRD) after implantation of an implantable cardiac defibrillator (ICD) or cardiac resynchronization therapy (CRT). We enrolled 7,825 Kaiser Permanente members across 6 geographical regions of the United

Article-at-a-Glance Background In response to the increased volume, risk, and cost of medical devices, in 2001 Kaiser Permanente (KP) developed implant registries to enhance patient safety and quality, and to evaluate cost-effectiveness. Methods Using an integrated electronic health record system, administrative databases, and other institutional databases, orthopedic, cardiology, and vascular implant registries were developed in 2001, 2006, and 2011, respectively. These registries monitor patients, implants, clinical practices, and surgical outcomes for KP's 9 million members. Critical to registry success is surgeon leadership and engagement; each geographical region has a surgeon champion who provides feedback on registry initiatives and disseminates registry findings. Results The registries enhance patient safety by providing a variety of clinical decision tools such as risk calculators, quality reports, risk-adjusted medical center reports, summaries of surgeon data, and infection control reports to registry stakeholders. The registries are used to immediately identify patients with recalled devices, evaluate new and established device technology, and identify outlier implants. The registries contribute to cost-effectiveness initiatives through collaboration with sourcing and contracting groups and confirming adherence to device formulary guidelines. Research studies based on registry data have directly influenced clinical best practices. Conclusions Registries are important tools to evaluate longitudinal device performance and safety, study the clinical indications for and outcomes of device implantation, respond promptly to recalls and advisories, and contribute to the overall high quality of care of our patients.