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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.

BACKGROUND: Physician online ratings are ubiquitous and influential, but they also have their detractors. Given the lack of scientific survey methodology used in online ratings, some health systems have begun to publish their own internal patient-submitted ratings of physicians. OBJECTIVE: The purpose of this study was to compare online physician ratings with internal ratings from a large healthcare system. DESIGN: Retrospective cohort study comparing online ratings with internal ratings from a large healthcare system. SETTING: Kaiser Permanente, a large integrated healthcare delivery system. PARTICIPANTS: Physicians in the Southern California region of Kaiser Permanente, including all specialties with ambulatory clinic visits. MAIN MEASURES: The primary outcome measure was correlation between online physician ratings and internal ratings from the integrated healthcare delivery system. RESULTS: Of 5438 physicians who met inclusion and exclusion criteria, 4191 (77.1%) were rated both online and internally. The online ratings were based on a mean of 3.5 patient reviews, while the internal ratings were based on a mean of 119 survey returns. The overall correlation between the online and internal ratings was weak (Spearman’s rho .23), but increased with the number of reviews used to formulate each online rating. CONCLUSIONS: Physician online ratings did not correlate well with internal ratings from a large integrated healthcare delivery system, although the correlation increased with the number of reviews used to formulate each online rating. Given that many consumers are not aware of the statistical issues associated with small sample sizes, we would recommend that online rating websites refrain from displaying a physician’s rating until the sample size is sufficiently large (for example, at least 15 patient reviews). However, hospitals and health systems may be able to provide better information for patients by publishing the internal ratings of their physicians.

Newer fixation devices for hamstring (HS) autograft have been introduced over the years, yet the impact of these devices on ACLR outcomes requiring surgical intervention remains unclear. We sought to evaluate the risk of aseptic revision and reoperation after HS autograft ACLR according to various femoral-tibial fixation methods. A cohort study was conducted using the Kaiser Permanente ACLR Registry. Primary isolated unilateral ACLR patients who received a HS autograft were identified (2007–2014). Fixation devices were categorized as crosspin, interference, suspensory, or combination (defined as more than one fixation device used on the same side) and femoral-tibial fixation groups used in more than 500 ACLR were evaluated. Cox proportional-hazard regression was used to evaluate the association between femoral-tibial fixation method and outcomes while adjusting for confounders. 6,593 primary ACLR were included. Four femoral-tibial fixation groups had more than 500 ACLR: suspensory–interference (n = 3004, 45.6%), interference–interference (n = 1659, 25.2%), suspensory–combination (n = 1103, 16.7%), and crosspin–interference (n = 827, 12.5%). After adjusting for covariates, revision risk was lower for crosspin–interference (HR = 0.43, 95% CI 0.29–0.65) and interference–interference (HR = 0.63, 95% CI 0.41–0.95) methods compared to the suspensory–interference. In contrast, reoperation risk was higher for crosspin–interference (HR = 2.13, 95% CI 1.37–3.32) and suspensory–combination (HR = 1.68, 95% CI 1.04–2.69) methods compared to suspensory–interference. ACLR using HS autograft appears to have the lowest risk of aseptic revision when crosspin or interference fixation is used on the femoral side and is coupled with an interference screw on the tibial side. III.

ObjectiveFindings from individual anterior cruciate ligament reconstruction (ACLR) registry studies are impactful, but how various registries from different countries compare with different patient populations and surgical techniques has not been described. We sought to describe six ACLR registry cohorts to understand variation across countries.MethodsFive European registries and one US registry participated. For each registry, all primary ACLR registered between registry establishment through 31December 2014 were identified. Descriptive statistics included frequencies, proportions, medians and IQRs. Revision incidence rates following primary ACLR were computed.Results101 125 ACLR were included: 21 820 in Denmark, 300 in Luxembourg, 17 556 in Norway, 30 422 in Sweden, 2972 in the UK and 28 055 in the US. In all six cohorts, males (range: 56.8%–72.4%) and soccer injuries (range: 14.1%–42.3%) were most common. European countries mostly used autografts (range: 93.7%–99.7%); allograft was most common in the US (39.9%). Interference screw was the most frequent femoral fixation in Luxembourg and the US (84.8% and 42.9%), and suspensory fixation was more frequent in the other countries (range: 43.9%–75.5%). Interference was the most frequent tibial fixation type in all six cohorts (range: 64.8%–98.2%). Three-year cumulative revision probabilities ranged from 2.8% to 3.7%.ConclusionsSimilarities in patient demographics and injury activity were observed between all cohorts of ACLR. However, graft and fixation choices differed. Revision rates were low. This work, including >100 000 ACLR, is the most comprehensive international description of contemporary practice to date.

Background: Allograft tissue is frequently used in anterior cruciate ligament reconstruction (ACLR). It is often irradiated and/or chemically processed to decrease the risk of disease transmission, but some tissue is aseptically harvested without further processing. Irradiated and chemically processed allograft tissue appears to have a higher risk of revision, but whether this processing decreases the risk of infection is not clear. Purpose: To determine the incidence of deep surgical site infection after ACLR with allograft in a large community-based sample and to evaluate the association of allograft processing and the risk of deep infection. Study Design: Cohort study; Level of evidence, 3. Methods: The authors conducted a cohort study using the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry. Primary isolated unilateral ACLR with allograft were identified from February 1, 2005 to September 30, 2015. Ninety-day postoperative deep infections were identified via an electronic screening algorithm and then validated through chart review. Logistic regression was used to evaluate the likelihood of 90-day postoperative deep infection per allograft processing method: processed (graft treated chemically and/or irradiated) or nonprocessed (graft not irradiated or chemically processed). Results: Of 10,190 allograft cases, 8425 (82.7%) received a processed allograft, and 1765 (17.3%) received a nonprocessed allograft. There were 15 (0.15%) deep infections during the study period: 4 (26.7%) coagulase-negative Staphylococcus, 4 (26.7%) methicillin-sensitive Staphylococcus aureus, 1 (6.7%) Peptostreptococcus micros, and 6 (40.0%) with no growth. There was no difference in the likelihood for 90-day deep infection for processed versus nonprocessed allografts (odds ratio = 1.36, 95% CI = 0.31-6.04). Conclusion: The overall incidence of deep infection after ACLR with allograft tissue was very low (0.15%), suggesting that the methods currently employed by tissue banks to minimize the risk of infection are effective. In this cohort, no difference in the likelihood of infection between processed and nonprocessed allografts could be identified.

Background: Hamstring autograft anterior cruciate ligament reconstructions (ACLRs) have exhibited higher infection rates compared with bone–patellar tendon–bone (BPTB) autograft. The reason for this observed difference is unclear, warranting investigation. Purpose: To evaluate the association between tibial fixation, either with or without a sheath and screw construct, and the risk of deep infection after hamstring autograft ACLR, using BPTB autograft as a reference group for comparison. Study Design: Cohort study; Level of evidence, 3. Methods: Using the Kaiser Permanente ACLR Registry, we identified all primary isolated, unilateral, single-bundle ACLRs with a BPTB or hamstring autograft (January 1, 2008, to September 30, 2016). The exposure groups included the following: (1) BPTB ACLR, (2) hamstring ACLR using a screw and sheath construct for tibial fixation (HS with screw and sheath), and (3) hamstring ACLR using a method other than a screw and sheath construct for tibial fixation (HS without screw and sheath). We used logistic regression to evaluate the likelihood of 90-day postoperative deep infection using BPTB autograft as the reference group and adjusting for age, sex, and body mass index. The number needed to be exposed (NNE) was calculated. Results: Of 15,671 ACLRs, 6745 (43.0%) used a BPTB graft, 2852 (18.2%) used HS with screw and sheath tibial fixation, and 6074 (38.8%) used HS without screw and sheath tibial fixation. There were 38 (0.2%) 90-day deep infections: 11 (0.2%) for BPTB, 14 (0.5%) for HS with screw and sheath, and 13 (0.2%) for HS without screw and sheath. Staphylococcus aureus for the BPTB group and Staphylococcus epidermidis in both hamstring groups were the most common infecting organisms. HS with screw and sheath had a higher likelihood of 90-day deep infection compared with BPTB ACLR (odds ratio [OR], 2.87; 95% CI, 1.29-6.38). We failed to observe a difference for HS without screw and sheath compared with BPTB ACLR (OR, 1.23; 95% CI, 0.54-2.77). The NNE was 330 and 2701 for HS with and HS without screw and sheath, respectively. Conclusion: Although the overall infection rate after ACLR is low, the higher likelihood of infections when sheath and screw combined are used for tibial fixation of a hamstring autograft ACLR should be a consideration when this procedure is performed.

Background:There is evidence that tibial slope may play a role in revision risk after anterior cruciate ligament reconstruction (ACLR); however, prior studies are inconsistent.Purpose:To determine (1) whether there is a difference in lateral tibial posterior slope (LTPS) or medial tibial posterior slope (MTPS) between patients undergoing revised ACLR and those not requiring revision and (2) whether the medial-to-lateral slope difference is different between these 2 groups.Study Design:Case-control study; Level of evidence, 3.Methods:We conducted a matched case-control study (2006-2015). Cases were patients aged ≤21 years who underwent revision surgery after primary unilateral ACLR; controls were patients aged ≤21 years without revision who were identified from the same source population. Controls were matched to cases by age, sex, body mass index, race, graft type, femoral fixation device, and post-ACLR follow-up time. Tibial slope measurements were made by a single blinded reviewer using magnetic resonance imaging. The Wilcoxon signed rank test and McNemar test were used for continuous and categorical variables, respectively.Results:No difference was observed between revised and nonrevised ACLR groups for LTPS (median: 6° vs 6°, P = .973) or MTPS (median: 4° vs 5°, P = .281). Furthermore, no difference was found for medial-to-lateral slope difference (median: −1 vs −1, P = .289). A greater proportion of patients with revised ACLR had an LTPS ≥12° (7.6% vs 3.8%) and ≥13° (4.7% vs 1.3%); however, this was not statistically significant after accounting for multiple testing.Conclusion:We failed to observe an association between revision ACLR surgery and LTPS, MTPS, or medial-to-lateral slope difference. However, there was a greater proportion of patients in the revision ACLR group with an LTPS ≥12°, suggesting that a minority of patients who have more extreme values of LTPS have a higher revision risk after primary ACLR. A future cohort study evaluating the angle that best differentiates patients at highest risk for revision is needed.

Background: The misuse of opioid medications has contributed to a significant national crisis affecting public health as well as patient morbidity and medical costs. After orthopaedic surgical procedures, patients may require prescription (Rx) opioid medication, which can fuel the opioid epidemic. Opioid Rx usage after anterior cruciate ligament reconstruction (ACLR) is not well characterized. Purpose: To determine baseline utilization of Rx opioids in patients undergoing ACLR and examine demographic, patient, and surgical factors associated with greater and prolonged postoperative opioid utilization. Study Design: Cohort study; Level of evidence, 3. Methods: Primary elective ACLRs were identified using Kaiser Permanente’s ACLR registry (2005-2015). We studied the association of perioperative risk factors on the number of dispensed opioid Rx in the early (0-90 days) and late (91-360 days) postoperative recovery periods using logistic regression. Results: Of 21,202 ACLRs, 25.5% used at least 1 opioid Rx in the 1-year preoperative period; 17.7% and 2.7% used ≥2 opioid Rx in the early and late recovery periods, respectively. Risk factors associated with greater opioid Rx in both the early and the late periods included the following: ≥2 preoperative opioid Rx, age ≥20 years, American Society of Anesthesiologists classification ≥3, other activity at the time of injury, chondroplasty, chronic pulmonary disease, and substance abuse. Risk factors associated with opioid Rx use during the early period only included the following: other race, acute injury, meniscal injury repair, multiligament injury, and dementia/psychosis. Risk factors associated with greater opioid Rx during the late period only included the following: 1 preoperative opioid Rx, female sex, body mass index ≥25 kg/m2, motor vehicle accident as the mechanism of injury, and hypertension. Conclusion: A quarter of ACLR patients had at least 1 opioid Rx before the procedure, but usage dropped to 2.7% toward the end of the postoperative year. We identified several perioperative risk factors for greater and prolonged opioid usage after ACLR.

Objectives: The misuse of opioid medication has contributed to a significant national crisis affecting public health, as well as patient morbidity and medical costs. We sought to determine baseline opioid utilization in patients undergoing ACLR and examine demographic, patient characteristics, and medical factors associated with postoperative opioid utilization. Methods: Primary elective ACLR were identified using an integrated healthcare system’s ACLR registry (January 2005-January 2015). Patients with cancer or those who had other knee surgery in the preceding year were excluded. We studied the effect of preoperative and intraoperative risks factors on number of dispensed opioid medication prescriptions (Rx) in the early (0-90 days) and late (91-360 days) postoperative periods using logit regression. Risk factors studied included: number of opioid Rx in preceding year, age, gender, race, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), activity at the time of injury, time from injury to ACLR, concomitant procedure or injury, medical comorbidities, and opioid-use comorbidities. Results: Of 21202 ACLR from 20813 patients, 25.5% used at least 1 opioid Rx in the one-year preoperative period. 17.7% and 2.7% used ≥2 opioid Rx in the early and late recovery periods, respectively. The risk factors associated with greater opioid Rx in both the early and late periods included: preoperative opioid use, age >20 years, ASA classification of ≥3, other activity at the time of injury, repaired cartilage injury, chronic pulmonary disease, and substance abuse. Risk factors associated with opioid Rx use during the early period only included: other race, acute ACL injury, repaired meniscal injury, multi-ligament injury, and dementia/psychoses. Risk factors associated with greater opioid Rx during the late period included: female gender, BMI >25 kg/m2, motor vehicle accident as the mechanism of injury, and hypertension. Conclusion: We identified several risk factors for postoperative opioid usage after ACLR. The strongest predictors of postoperative prescription opioid usage after ACLR included preoperative opioid use, increasing age, ASA classification of 3 or more, other activity at the time of injury, repaired meniscal injury, cartilage repair, chronic pulmonary disease, and substance abuse. Awareness of risk factors for postoperative opioid usage may encourage more targeted utilization of opioids in pain management. Surgeons may consider additional support or referral to a pain specialist for patients with these risk factors. [Figure: see text]

Introduction The global pandemic has raised awareness of the need for alternative ways to deliver care, notably telehealth. Prior to this study, research has been mixed on its effectiveness and impact on downstream utilization, especially for seniors. Our multi-institution study of more than 300,000 telehealth visits for seniors evaluates the clinical outcomes and healthcare utilization for urgent and non-emergent symptoms. Methods We conducted a retrospective cohort study from November 2015 to March 2019, leveraging different models of telehealth from three health systems, comparing them to in-person visits for urgent and non-emergent needs of seniors based on International Classification of Diseases, 10th edition diagnoses. The study population was adults aged 60 years or older who had access to telehealth and were affiliated with and resided in the geographic region of the healthcare organization providing telehealth. The primary outcomes of interest were visit resolution and episodes of care for those that required follow-up. Results In total, 313,516 telehealth visits were analysed across three healthcare organizations. Telehealth encounters were successful in resolving urgent and non-emergent needs in 84.0–86.7% of cases. When visits required follow-up, over 95% were resolved in less than three visits for both telehealth and in-person cohorts. Discussion While in-person visits have traditionally been the gold standard, our results suggest that when deployed within the confines of a patient’s existing primary care and health system provider, telehealth can be an effective alternative to in-person care for urgent and non-emergent needs of seniors without increasing downstream utilization.

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, 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 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.

Anterior cruciate ligament reconstructions (ACLRs) in skeletally immature patients are increasing. The purpose of this study is to describe the demographics, graft usage, revision, and re-operation rates in skeletally immature ACLRs in the Kaiser Permanente healthcare system. Skeletally immature patients (

Background:Allograft tissue is a common graft choice for anterior cruciate ligament reconstruction (ACLR). Allograft sterilization methods vary widely across numerous commercial tissue vendors. Multiple studies, despite being limited in sample size, have suggested a higher rate of clinical failure associated with the use of allograft tissue in ACLR when compared with autograft.Purpose:To examine the association of graft processing techniques, patient characteristics, and graft type with risk of revision surgery after allograft ACLR.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective cohort study was conducted that used an integrated United States health care system’s ACLR registry to identify primary unilateral cases in which allografts were used. Aseptic revision was the endpoint of the study. Allograft type, processing methods (irradiation dose, AlloWash, AlloTrue, BioCleanse), and graft donor age were assessed as potential risk factors for revision, with adjustment for patient age, sex, and body mass index (BMI) by use of survival analysis. Hazard ratios (HR) and 95% confidence intervals (CIs) were calculated.Results:A total of 5968 primary ACLR cases with allograft were included in the study, of which 3688 (61.8%) were male patients. The median age of the cohort at the time of surgery was 34.1 years (interquartile range, 24.1-42.9 years). The mean time to follow-up (±SD) was 2.1 ± 1.5 years. There were 3751 (62.9%) allograft ACLRs using soft tissue, 1188 (19.9%) with Achilles tendon, and 1029 (17.2%) with bone–patellar tendon–bone (BPTB). Graft processing groups included BioCleanse (n = 367), AlloTrue or AlloWash (n = 2278), irradiation greater than 1.8 Mrad (n = 1146), irradiation up to 1.8 Mrad (n = 3637), and no irradiation (n = 1185). There were 156 (2.6%) aseptic revisions. After adjustment for patient age, sex, and BMI, the use of BioCleanse (HR = 2.45; 95% CI, 1.36-4.40) and irradiation greater than 1.8 Mrad (HR = 1.64; 95% CI, 1.08-2.49) were associated with a higher risk of revision when compared with all other methods of processing. BPTB allografts were at higher risk of revision (HR = 1.79; 95% CI, 1.20-2.66) when compared with soft tissue allografts. Conversely, with every 5-year increase in age, the risk of revision was 0.67 (95% CI, 0.61-0.73) times lower. Male patients were found to be at higher risk of revision when compared with females (HR = 1.47; 95% CI, 1.04-2.07). The use of AlloWash or AlloTrue processing, patient BMI, and graft donor age did not affect revision rate significantly.Conclusion:In the largest known study of its kind examining outcome after primary allograft ACLR, graft irradiation greater than 1.8 Mrad, BioCleanse graft processing, younger patient age, male patients, and BPTB allograft were all associated with a higher risk of clinical failure and subsequent revision surgery.

Objectives: Risk factors for anterior cruciate ligament reconstruction (ACLR) revision have included graft type, as well as fixation methods. Newer fixation techniques and devices for hamstring (HS) autograft have been introduced over the years. The purpose of this study was to compare the risk of aseptic revision after HS autograft ACLR between various femoral and tibial fixation methods/devices. Methods: Patients who underwent primary ACLR using a HS autograft from 2007-2014 were identified through a community-based registry for this retrospective cohort study. Bilateral, double bundle, and multiligament ACLRs were excluded. Patients were categorized (crosspin, interference, suspensory, or combination [more than one fixation]) based on the type of fixation utilized for the femur and tibia. Femoral/tibial fixation groupings with more than 500 patients were evaluated as a risk factor for aseptic revision, with adjustment for age, sex, body mass index, and race/ethnicity, using a multivariable Cox proportional-hazards regression model. Results: 6,716 primary ACLR patients were included, of whom 2,894 (38.8%) were younger than 22 years old, 4,111 (61.2%) were male, 2,956 (44.0%) had a BMI < 25 kg/m2, and 3,163 (47.1%) were caucasian. Five femoral/tibial groupings had more than 500 patients: suspensory/interference (n=2,176, 32.4%), suspensory/combination (n=1,940, 28.9%), interference/combination (n=1,025, 15.3%), interference/interference (n=845, 12.6%), and crosspin/combination (n=730, 10.9%). The cumulative failure probability at 5 years was highest for the suspensory/interference group (9.0%, 95% CI 7.2-11.2), followed by suspensory/combination (6.7%, 95% CI 5.4-8.4), interference/interference (5.1%, 95% CI 3.7-7.2), interference/combination (4.3%, 95% CI 2.9-6.3), and crosspin/combination (3.1%, 95% CI 2.0-4.9). After adjusting for the other covariates, the hazard ratio for aseptic revision was 2.9 (95% CI 1.9-4.7) for the suspensory/interference group, 2.7 (95% CI 1.7-4.5) for the suspensory/combination group, 1.6 (95% CI 0.9-3.0) for the interference/combination group, and 2.1 (95% CI 1.2-3.7) for the interference/interference group when compared to the crosspin/combination group. Conclusion: ACLR using HS autograft appears to have the highest risk of aseptic revision when suspensory fixation is used on the femoral side and is coupled with either an interference screw or combination fixation on the tibial side. Understanding the device-related risk of aseptic revision after HS autograft ACLR will help guide surgeons regarding which devices may negatively influence surgical outcomes.

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.

Background: Patients generally choose to undergo anterior cruciate ligament reconstruction (ACLR) to return to their active lifestyles. However, returning to their previous activity level may result in a retear of their reconstructed knee or an injury to their contralateral anterior cruciate ligament (CACL). Purpose: To determine the risk factors associated with revision ACLR and contralateral ACLR (CACLR), compare the survival of the reconstructed ACL with the CACL, and determine how the risk factors associated with revision ACLR compare with those for CACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study of prospectively collected data from the Kaiser Permanente ACLR registry between February 1, 2005, and September 30, 2012, was conducted. Primary ACLR cases without history of contralateral knee ACL injury were included. The study endpoints included revision ACLR and CACLR. Graft type (bone–patellar tendon–bone [BPTB] autograft, hamstring autograft, and allograft) was the main exposure of interest, and patient characteristics were evaluated as risk factors for revision ACLR and CACLR. Survival analyses were conducted. Results: A total of 17,436 ACLRs were evaluated. The median age was 27.2 years (interquartile range, 18.7-37.7 years), and 64% were males. The 5-year survival for index ACLR was 95.1% (95% CI, 94.5%-95.6%), and for CACL it was 95.8% (95% CI, 95.2%-96.3%). Overall, the cohort had a mean of 2.4 ± 1.7 years of follow-up; 18.2% were lost to follow-up. There were fewer CACLRs per 100 years of observation (0.83) than there were revision ACLRs (1.05) during the study period ( P < .001). There was a statistically significant difference in the density of revision ACLR and CACL in BPTB autografts (0.74 vs 1.06, respectively; P = .010), hamstring autografts (1.07 vs 0.81; P = .042), and allografts (1.26 vs 0.67; P < .001). The risk factors for revision ACLR and contralateral surgery were different ( P < .05). After adjusting for covariates, factors associated with higher risk of revision ACLR were as follows: allografts, hamstring autografts, male sex, younger age, lower body mass index (BMI), and being white as opposed to black. Factors associated with higher risk of CACLR were as follows: younger age, female sex, and lower BMI. Conclusion: The 5-year revision-free and CACLR-free survival rate in this study was 95.1% and 95.8%, respectively. Allografts and hamstring autografts had a higher risk of revision ACLR surgery, and BPTB autografts had a higher risk of CACLR. Males were found to have a higher risk of revision ACLR, and females had a higher risk of CACLR. Increasing age and increasing BMI decreased the risk of both revision and CACLR.

Objectives: There is evidence the slope of the tibial plateau may play a role in need for revision following ACL reconstruction (ACLR), however, previous studies are limited by small sample sizes, radiographic measurement, single surgeon experience, lateral tibial posterior slope (LTPS) only, or a lack of confounder adjustment. Further, the role of the medial posterior tibial slope (MTPS) on revision risk has yet to be evaluated. We sought to (1) determine the relationship of revision status following ACLR and LTPS, (2) determine the relationship of revision status and MTPS, and (3) determine the relationship of revision status and the difference between MTPS and LTPS. Methods: We conducted a nested case-control study of 317 matched pairs using an integrated U.S. healthcare system’s ACLR registry (2006- 2014). Cases were defined as patients who underwent a revision following primary unilateral ACLR; controls were defined from the same cohort as non-revised patients during the same time frame. Controls were matched to cases according to age, gender, body mass index, race, graft type, femoral fixation device, and follow-up time. Magnetic resonance imaging (MRI) images were used by a single blinded reviewer to measure tibial slopes. Wilcoxon signed rank test was applied to compare the slopes between revised and non-revised groups continuously and McNemar test to compare slopes of ≥12° between groups. Results: No difference was observed between revised and non-revised patients in LTPS (mean: 6.1 vs. 6.1, p=0.972) or MTPS (mean: 4.6 vs. 4.9, p=0.281) measurement. When comparing revised ACLR to non-revised ACLR, a greater proportion of revised ACLR had a LTPS of ≥12° (7.6% vs. 3.8%, P=0.034), while no difference was found in the proportion of ACLR with a MTPS ≥12° (1.6% vs. 2.5%, P=0.405). No difference was found when evaluating the medial-to-lateral slope difference (-1.5 vs. -1.2, p=0.289). Conclusion: In our nested case-control study of over 300 revised ACLR patients matched to non-revised patients, we did not find an association between the slope of the lateral and medial tibial plateaus and revision. [Figure: see text][Table: see text]

Background: Orthopaedic registries have shown value in tracking and surveillance of patients, implants, and outcomes associated with procedures. No current anterior cruciate ligament reconstruction registry (ACLRR) exists in the United States. Purpose: To describe the current cohort captured by an institutional ACLRR and describe the outcomes observed in the registered patients and how findings from the ACLRR are disseminated. Study Design: Cohort study; Level of evidence, 2. Methods: The anterior cruciate ligament reconstructions (ACLRs) registered between February 2005 and September 2011 by 244 surgeons in 48 medical centers were evaluated. The ACLRR collected data intra- and postoperatively using paper forms and electronic medical records. The ACLRR cohort was longitudinally followed and outcomes were prospectively ascertained. Outcomes (ie, revisions, subsequent operations, venous thromboembolism, and surgical site infections) were adjudicated via chart review. Descriptive statistics are used to describe the cohort and Kaplan-Meier curves to evaluate survival. Results: During the study period, 16,192 ACLRs (15,101 primary and 1091 revisions) with a median follow-up of 1.6 years (interquartile range, 0.7-2.8 years) were registered. Male patients received 64% of both primary and revision ACLRs. The mean age at surgery was 29.5 years (SD, 11.4 years) for primary and revision reconstructions. Cartilage injuries were noted in 25.2% of primary and 37.5% of revision ACLRs, and meniscal injuries were identified in 60.8% and 53.2%, respectively. Autografts were used in 57.6% of primary ACLRs and 20.9% of revisions. Allografts were used in 42.4% of primaries and 78.8% of revisions. In primary ACLR, the most common femoral and tibial fixation types were interference screws (42.2% and 79.7%, respectively). Fixation type distribution was nearly identical in primaries and revisions. Of the primary ACLRs, 3.7% had subsequent operations on the same knee and 1.7% on the contralateral knee. Deep surgical site infection developed in 0.3% of primaries and 0.8% of revisions. Symptomatic deep vein thromboses were seen in 0.2% of both primaries and revisions. The overall revision rate was 1.7%. Lower rates of graft survival were identified in younger patients and those with allografts. Conclusion: Large, community-based ACLRRs are useful in informing participating surgeons of current treatment practices, prevalence of concurrent injuries, and outcomes associated with the procedures. Information from the ACLRR can be used to develop interactive patient and surgeon tools that can be used to optimize patient care.

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, 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; 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.

Background: The surgical technique for anterior cruciate ligament (ACL) reconstruction has evolved as a result of improved understanding of ligament biomechanics, anatomy, device development, and failed reconstructions. Studies on surgical technique preferences have been limited to surgeon surveys, which are subject to selection and recall bias.The purpose of this study was to evaluate ACL reconstruction surgical technique and yearly revision rate trends in a community-based setting. Methods: A population-based epidemiological study was conducted using data on primary ACL reconstruction procedures registered in an ACL reconstruction registry from 2007 to 2014. Changes in the incidence rates of different types of femoral tunnel drilling methods, different types of grafts and graft fixation, and revisions were studied. Adjusted incidence rate ratios (IRRs) are provided. Results: Of the 21,686 ACL reconstructions studied, 72.4% were performed by sports medicine fellowship-trained surgeons. The incidence rate of femoral tunnel drilling via a tibial tunnel decreased at an adjusted rate of 26% per year (IRR = 0.74, 95% confidence interval [CI] = 0.71 to 0.78), from 56.4% to 17.6% during the study period. The incidence rate of medial portal drilling increased from 41.3% to 65.1% at an adjusted rate of 11% per year (IRR = 1.11, 95% CI = 1.09 to1.13), and the incidence rate of drilling through a lateral approach increased from 2.3% to 17.3% at an adjusted rate of53% per year (IRR = 1.53, 95% CI = 1.39 to 1.67). There was no change in the use of hamstring autograft, bone-patellar tendon-bone autograft, or tibial tendon allograft. Use of first-generation bioabsorbable femoral and tibial fixation decreased for all graft types. For soft-tissue grafts, usage of suspensory metal femoral fixation increased 12% to 13% per year (IRR = 1.12, 95% CI = 1.09 to 1.15 for tibial tendon grafts; IRR = 1.13, 95% CI = 1.10 to 1.15 for hamstring grafts). For bone-patellar tendon-bone autografts, the use of femoral fixation with interference biocomposite screws increased 7%per year (IRR = 1.07, 95% CI = 1.04 to 1.10). On the tibial side, utilization of biocomposite screws increased for all grafttypes. No association was found between revision rate and the year of the primary operation. Conclusions: Surgeons changed their femoral tunnel drilling technique over the study period, whereas the incidence rates of specific graft utilization remained stable. There has been a shift away from first-generation bioabsorbable fixation and increasing use of biocomposite fixation across all graft types. Early cumulative revision rates remained stable. Refereed/Peer-reviewed

Background: Knee arthroscopy is the most commonly performed orthopaedic procedure in the United States and is usually considered to be a low-risk procedure. The purposes of this study were to describe the incidence of symptomatic deep venous thrombosis, symptomatic pulmonary embolism, and mortality after elective knee arthroscopy performed without thromboembolic prophylaxis, as well as to investigate the association of age, sex, procedure type, and oral contraceptive use with the odds of developing a venous thromboembolism. Conclusions: The ninety-day incidence of symptomatic venous thromboembolism after elective knee arthroscopy was relatively low, with a 0.25% incidence of deep venous thrombosis and a 0.17% incidence of pulmonary embolism. The overall ninety-day mortality after arthroscopic knee surgery was 0.04%. Methods: A retrospective cohort study of elective arthroscopic knee procedures during a twenty-seven-month period (January 1, 2006, through March 31, 2008) was performed with use of the administrative database of a large health maintenance organization. Use of ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) procedure codes for arthroscopic surgery identified 21,794 arthroscopic knee procedures. The occurrence of a symptomatic deep venous thrombosis or pulmonary embolism within ninety days after surgery was identified by reviewing administrative and electronic medical record data for inpatient, outpatient, urgent care, and emergency encounters. Mortality and the cause of death were captured with use of electronic medical records, Social Security Administration Death Master Files, and county death certificates. Patient charts were reviewed for confirmation of the deep venous thrombosis, pulmonary embolism, or death. Patients who had a history of a venous thromboembolism or who had received anticoagulation therapy within fourteen days prior to the index surgery were excluded. Results: The study cohort comprised 20,770 patients who met the inclusion criteria. Fifty-one patients (0.25%; 95% confidence interval, 0.18% to 0.31%) developed a deep venous thrombosis, and thirty-five (0.17%; 95% confidence interval, 0.11% to 0.22%) developed a pulmonary embolism. The incidence of venous thromboembolism was higher in patients who were fifty years of age or older (0.51% compared with 0.34% in younger patients), and the incidence in female patients was higher if they had been prescribed oral contraceptive medication (0.63% compared with 0.30% in female patients with no such prescription). No differences in the incidence of deep venous thrombosis or pulmonary embolism on the basis of sex or arthroscopic procedure code were noted. Nine patients (0.04%) died within ninety days of surgery, although only one death was confirmed to have resulted from a pulmonary embolism. Refereed/Peer-reviewed

Hip fractures are a large public health problem with significant negative impact on an individual’s overall health and survival. But while the total numbers of persons affected by hip fractures may be anticipated to increase, incidence rates appear to be declining. To describe annual hip fracture incidence rate trends in an integrated health-care organization over 1997–2006, during which a proactive bone health program was initiated program-wide and other secular trends occurred in the population. For this ecologic trend study, we identified all men and women ≥45 years old as of January 1 of each year. Incident fractures for each year were identified using ICD-9 diagnosis codes 820–820.9, excluding all subjects who had fractures in prior years. Annual person-time at risk for hip fracture was determined from enrollment data. Sex- and age-specific and adjusted annual incidence rates were calculated. The overall annual hip fracture incidence rate for men declined from 1.52/1,000 person-years in 1997 to 1.29/1,000 person-years in 2006, a 15.3% (95% confidence interval [CI]=6.2–24.5) decrease. For women, incidence declined from 2.65/1,000 person-years in 1997 to 2.24/1,000 person-years in 2006, a 15.3% (95% CI=8.7–21.9) decrease. Among subjects aged 85 years or older, incidence rates for men declined from 27.0/1,000 to 18.9/1,000 person-years, and for women they declined from 32.7/1,000 to 27.1/1,000 person-years. Hip fracture incidence has been declining in all age groups over the past 10 years. While many factors may contribute to this decline, the results are consistent with a potential benefit of the active bone health intervention.

Ethnic disparities in care have been documented with a number of musculoskeletal disorders including osteoporosis. We suggest a systems approach for ensuring osteoporosis care can minimize potential ethnic disparities in care.We evaluated variations in osteoporosis treatment by age, sex, and race/ethnicity by (1) measuring the rates of patients after a fragility fracture who had been evaluated by dual-energy xray absorptiometry and/or in whom antiosteoporosis treatment had been initiated and (2) determining the rates of osteoporosis treatment in patients who subsequently had a hip fracture.We implemented an integrated osteoporosis prevention program in a large health plan. Continuous screening of electronic medical records identified patients who met the criteria for screening for osteoporosis, were diagnosed with osteoporosis, or sustained a fragility fracture. At-risk patients were referred to care managers and providers to complete practice guidelines to close care gaps. Race/ethnicity was self-reported. Treatment rates after fragility fracture or osteoporosis treatment failures with later hip fracture were calculated. Data for the years 2008 to 2009 were stratified by age, sex, and race/ethnicity.Women (92.1%) were treated more often than men (75.2%) after index fragility fracture. The treatment rate after fragility fracture was similar among race/ethnic groups in either sex (women 87.4%-93.4% and men 69.3%-76.7%). Osteoporotic treatment before hip fracture was more likely in white men and women and Hispanic men than other race/ethnic and gender groups.Racial variation in osteoporosis care after fragility fracture in race/ethnic groups in this healthcare system was low when using the electronic medical record identifying care gaps, with continued reminders to osteoporosis disease management care managers and providers until those care gaps were closed.

Objectives: One purpose of a registry is to identify procedures or devices that have either good or poor outcomes and improve treatment outcomes through feedback to surgeons. In 2010 we initially reported the influence of graft choice on the risk of early revision after ACL Reconstruction (ACLR). In 2012 we reported a three times higher risk of revision if allograft was used rather than bone-patellar tendon-bone (BPTB) autograft. In subsequent studies of allografts, we have identified poorer results with BPTB allografts compared to soft tissue allografts and with soft tissue allografts irradiated with > 1.8 Mrads or processed with chemical methods. Patients < 21 years of age were also identified to be at particularly high-risk for revision if allograft tissue was employed. These registry findings were disseminated to surgeons within and outside our integrated healthcare system. The purpose of this study was to evaluate the impact of registry feedback on surgeon graft type selection. Methods: Feedback to surgeons on graft performance was presented through a variety of mechanisms including (1) peer-reviewed publications, (2) internal and external meetings and conferences (3) newsletters of study findings, (4) Risk calculators and (5) confidential individualized reports of surgeon’s outcomes. In addition, surgeon champions set a quality improvement goal to reduce allograft usage overall and specifically to decrease the use of high risk grafts and usage in high-risk patient groups. Allograft usage was monitored on a quarterly basis to determine if the target was achieved. Annual graft utilization from 2008-2015 is reported here as proportions, for the overall cohort and for high-risk subgroups. Results: Our integrated healthcare system’s ACLR registry currently includes over 35,000 patients. Beginning in 2008, the annual proportion of ACLR cases using an allograft increased with a peak of 45% in 2010. Allograft use has decreased in the ensuing years and was 33% in 2015, a decrease of 27%. High-risk graft usage decreased from 8% in 2011 to 5% in 2015 which is a 38% decrease. Allograft use in patients < 21 years of age decreased 68% from a high of 28% in 2009 to 9% in 2015. (see Figure) Conclusion: Translating registry findings into evidence-based clinical practice is the goal of a registry. In this study, we found that information derived from an ACL Registry and disseminated to the participants can directly influence the use of specific procedures or implants that are associated with poor outcomes. Registries can provide useful information that may ultimately be used to improve patient care.

Background Several challenges are associated with collecting clinically meaningful post-operative outcomes. The widespread implementation of electronic medical records (EMR) offers a new opportunity to evaluate surgical outcomes using routinely collected data in these systems. This study evaluated whether surgical outcomes can be ascertained from EMR’s hospital and outpatient encounters. Specifically, we evaluated anterior cruciate ligament reconstructions (ACLR) outcomes. Methods A retrospective cohort study of 6985 ACLRs performed between 2/2005-9/2012 was conducted. Patient encounters during days 1–90 and days 91–180 after ACLR surgery were the exposures of interest. Nine hospital and eight outpatient encounter types were evaluated. The main endpoint of the study was revision surgery six months after ACLR. Results The cohort was 66.7% male, the mean age was 28 (standard deviation = 11) years-old, and the incidence of revision was 1.5% (n = 105). After adjustments, in days 1–90 post-ACLR, compared to patients with 0–4 orthopedic office visits, patients with 5–9 (hazard ratio (HR) = 9.9, 95% confidence interval(CI), 4.3–23.2) and those with 10 or more (HR = 13.8, 95%CI, 5.6–33.8) visits had a higher risk of revision. In days 91–180, patients with any outpatient hospital encounters (HR = 2.5, 95%CI 1.4–4.5) had a higher risk of revision than patients without visits. Additionally, patients with 4–5 regular office visits (HR = 3.8 times, 95%CI, 2.0–7.0) had a higher risk of revision surgery than those with 0–1 visits. Discussion The number of post-operative outpatient visits was associated with ACLR revision surgery. Using EMR encounters to assess surgical outcomes is a viable option for monitoring ACLR patients. The simple assessment of visit types and number of encounters alone can provide valuable information regarding the normal course of rehabilitation of a surgical patient and possible deviation from this normal course. In large cohorts of patients, this type of patient surveillance can assist surgeons with monitoring their patients.

The cases of renal osteodystrophy-associated slipped capital femoral epiphysis in 11 consecutive patients were reviewed. Nine patients had bilateral involvement, totaling 20 hips. The mean age at presentation was 10.6 years. Slip location was physeal in 13 and metaphyseal in seven hips. All patients had prompt medical treatment of their bone disease, and nine patients underwent surgical stabilization. Fixation consisted of multiple custom-machined Steinmann pins that were smoothed distally but threaded proximally, allowing continued proximal femoral growth. The mean radiographic and clinical follow-up was 5.7 years and 9.1 years, respectively. Slips stabilized in 14 of 16 operated hips (88%), whereas one patient with inadequate renal disease control had slip progression requiring subsequent subtotal parathyroidectomy and repeat fixation. Combined medical management and surgery with custom-machined pins prevented slip progression while allowing continued physeal growth.

Considering the cost and risk associated with revision Total knee arthroplasty (TKAs) and Total hip arthroplasty (THAs), steps to prevent these operations will help patients and reduce healthcare costs. Revision risk calculators for patients may reduce revision surgery by supporting clinical decision-making at the point of care.We sought to develop a TKA and THA revision risk calculator using data from a large health-maintenance organization's arthroplasty registry and determine the best set of predictors for the revision risk calculator.Revision risk calculators for THAs and TKAs were developed using a patient cohort from a total joint replacement registry and data from a large US integrated healthcare system. The cohort included all patients who had primary procedures performed in our healthcare system between April 2001 and July 2008 and were followed until January 2014 (TKAs, n = 41,750; THAs, n = 22,721), During the study period, 9% of patients (TKA = 3066/34,686; THA=1898/20,285) were lost to followup and 7% died (TKA= 2350/41,750; THA=1419/20,285). The outcome of interest was revision surgery and was defined as replacement of any component for any reason within 5 years postoperatively. Candidate predictors for the revision risk calculator were limited to preoperative patient demographics, comorbidities, and procedure diagnoses. Logistic regression models were used to identify predictors and the Hosmer-Lemeshow goodness-of-fit test and c-statistic were used to choose final models for the revision risk calculator.The best predictors for the TKA revision risk calculator were age (odds ratio [OR], 0.96; 95% CI, 0.95-0.97; p0.001), sex (OR, 0.84; 95% CI, 0.75-0.95; p = 0.004), square-root BMI (OR, 1.05; 95% CI, 0.99-1.11; p = 0.140), diabetes (OR, 1.32; 95% CI, 1.17-1.48; p0.001), osteoarthritis (OR, 1.16; 95% CI, 0.84-1.62; p = 0.368), posttraumatic arthritis (OR, 1.66; 95% CI, 1.07-2.56; p = 0.022), and osteonecrosis (OR, 2.54; 95% CI, 1.31-4.92; p = 0.006). The best predictors for the THA revision risk calculator were sex (OR, 1.24; 95% CI, 1.05-1.46; p = 0.010), age (OR, 0.98; 95% CI, 0.98-0.99; p0.001), square-root BMI (OR, 1.07; 95% CI, 1.00-1.15; p = 0.066), and osteoarthritis (OR, 0.85; 95% CI, 0.66-1.09; p = 0.190).Study model parameters can be used to create web-based calculators. Surgeons can enter personalized patient data in the risk calculators for identification of risk of revision which can be used for clinical decision making at the point of care. Future prospective studies will be needed to validate these calculators and to refine them with time.Level III, prognostic study.

Hypothesis and background Proximal humeral fractures comprise 10% of fractures in the Medicare population. The effect, if any, of treating osteoporosis to prevent these fractures has not been determined. The primary objective is to determine the effectiveness of a systematic osteoporosis screening and treatment program on the hazard of developing a fracture over the treatment period. The secondary aim is to determine demographic risk factors. Methods This is a retrospective cohort study in a health care organization serving 3.3 million members. Individuals selected for dual-energy x-ray absorptiometry screening were (1) women aged 65 years or older; (2) men aged 70 years or older; and (3) individuals aged 50 years or older who have a history of fragility fracture, use glucocorticoids, have a parental history of hip fracture, have rheumatoid arthritis, use alcohol at a high rate, or are cigarette smokers. Treatment consisted primarily of pharmacologic intervention with bisphosphonates. Results Individuals diagnosed with osteoporosis had a hazard ratio of 7.43 for sustaining a fracture over the study period. Patients screened with dual-energy x-ray absorptiometry had a hazard ratio of 0.17 whereas those treated medically had a hazard ratio of 0.55 versus untreated controls. Risk factors that significantly increased the risk of a fracture developing included age, female gender, white race, diabetes mellitus, and history of a distal radius fracture. Discussion and conclusion Over the study period, screening and treatment for osteoporosis significantly decreased the hazard ratio for proximal humeral fracture. This information broadens the impact of such programs because current best practices are primarily based on prevention of spine and hip fractures.

Background: The incidence of nonrevision reoperations after anterior cruciate ligament reconstruction (ACLR) is less commonly studied and quantified. Purpose: To describe the incidence of short-term reoperations after primary ACLR for the 4 most common procedures and to evaluate the risk factors associated with these reoperations. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent ACLRs and were enrolled in an ACLR registry between February 2005 and September 2011 were evaluated. First reoperations after primary ACLR performed for the 4 most common procedures (meniscal procedures, cartilage procedures, hardware removal procedures, and arthrofibrosis procedures) were the primary end points of the study. Patient, surgical, surgeon, and hospital risk factors associated with reoperations were evaluated, and Cox regression models were employed. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. Results: A total of 14,522 ACLRs were identified. The patients had a mean age of 29.4 ± 11.5 years and were mostly male (63.3%) and white (48.3%). The mean follow-up was 1.9 ± 1.5 years (range, 0-6.7 years), and the median time to reoperation was 301 days (interquartile range, 172-515 days). The reoperation rate per 100 person-years of follow-up was 1.1 for meniscal reoperations, 0.3 for cartilage reoperations, 0.4 for hardware removal reoperations, and 0.4 for arthrofibrosis reoperations. Meniscal repair at the index ACLR was a significant risk factor for subsequent meniscal procedures (HR, 4.19; 95% CI, 3.10-5.67). Sports medicine fellowship training of the surgeon (HR, 2.17; 95% CI, 1.01-4.62) and older patient age (≤17 vs ≥26 years) (HR, 0.32; 95% CI, 0.12-0.81) were significant risk factors for cartilage reoperations. Use of allografts (HR, 1.90; 95% CI, 1.10-3.30) and female sex (HR, 1.75; 95% CI, 1.16-2.64) were risk factors for hardware removal reoperations. Female sex (HR, 2.48; 95% CI, 1.66-3.71) and prior surgery (HR, 3.02; 95% CI, 1.39-6.53) were risk factors for subsequent surgery for arthrofibrosis. Conclusion: Overall short-term reoperation rates after ACLR are relatively low. Risk factors for subsequent surgery vary depending on the type of surgery evaluated. Some of the risk factors observed for reoperations include previous meniscal repair, female sex, allografts, prior surgery, older patient age, and being operated on by a sports medicine fellowship–trained surgeon.

Background: Anterior cruciate ligament (ACL) injuries are more commonly seen with certain cutting and pivoting sports. However, injury patterns associated with these sports have not been well described. Purpose: (1) To describe the patient demographics and injury pattern at the time of ACL reconstruction (ACLR) by activities that lead to ACL injuries and (2) to estimate the association of activities at the time of injury with the odds of isolated ACL injuries as well as with meniscus, cartilage, and multiligament injuries diagnosed at the time of ACLR. Study Design: Cross-sectional study; Level of evidence, 3. Methods: This study combined 2 ACLR registry cohorts, from Norway and the United States, from 2004 to 2011. A cohort of 10,958 primary ACLRs was included. The most prevalent sports activities at the time of injury were the following: soccer, skiing, American football, basketball, and team handball. The end points were the concurrent injury patterns at the time of ACLR: isolated ACL, meniscus, cartilage, and multiligament injuries. Results: All sports were compared with the most prevalent injury mechanism: soccer. Skiing injuries were 1.13 (95% confidence interval [CI], 1.01-1.27) times more likely to result in isolated ACL tears, 2.05 (95% CI, 1.01-4.16) times more likely to result in posterior cruciate ligament tears, 1.94 (95% CI, 1.51-2.49) times more likely to result in medial collateral ligament (MCL) tears, and 1.73 (95% CI, 1.38-2.17) times more likely to result in multiligament injuries. Athletes playing American football were 2.72 (95% CI, 1.32-5.62) times more likely to have MCL tears. Those injured playing basketball were 1.28 (95% CI, 1.06-1.54) times more likely to have lateral meniscus tears, 1.23 (95% CI, 1.01-1.51) times more likely to have cartilage damage, and 1.38 (95% CI, 1.11-1.72) times more likely to have meniscus and cartilage injuries. Athletes injured playing team handball were less likely to have MCL tears (odds ratio [OR], 0.68; 95% CI, 0.46-0.99) and more likely to have lateral meniscus injuries (OR, 1.27; 95% CI, 1.10-1.48). Conclusion: Injury patterns were associated with certain sports. Compared with soccer, American football has a higher likelihood of resulting in multiligament injuries, whereas basketball has a higher likelihood of resulting in cartilage and lateral meniscus injuries. Injury patterns seen at the time of surgery may reflect the forces applied to the knee by the specific sports performed. Refereed/Peer-reviewed

Background: Infections after anterior cruciate ligament reconstruction (ACLR) can be devastating. Hamstring tendon autografts may be more susceptible to infections than other graft types. Purpose: To determine the incidence of surgical site infections (SSIs) in a large sample of patients who underwent ACLR and to evaluate the risk of superficial and deep SSIs associated with grafts used for ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: All primary ACLRs performed between February 2005 and September 2010 registered in the Kaiser Permanente ACLR registry were included in the study. The graft types evaluated included the bone–patellar tendon–bone (BPTB) autograft, hamstring tendon autograft, and allograft (all types). The main end point of the study, SSIs (deep and superficial), was prospectively ascertained using an electronic screening algorithm and adjudicated by the principal investigator. Descriptive statistics were used to describe the cohort, and logistic regression models were used to evaluate the likelihood of an infection. Results: There were 10,626 cases that fit the study criteria. The overall cohort was 64% male, mean age was 29 ± 11 years, and mean body mass index (BMI) was 27 ± 5 kg/m2. The overall incidence of SSIs was 0.48% (n = 51), with 17 (0.16%) superficial infections and 34 (0.32%) deep infections. Hamstring tendon autografts (n = 20; 0.61%) had the highest incidence of deep SSIs of the graft types (BPTB autograft, n = 2 [0.07%]; allograft, n = 12 [0.27%]; P < .001). After adjusting for age, sex, and BMI, the likelihood of a patient with a hamstring autograft having a deep SSI was 8.24 times higher (95% CI, 1.91-35.55; P = .005) than someone receiving a BPTB autograft. The risk of infections in allografts was not statistically significantly higher than BPTB autografts. Conclusion: The overall SSI rate after ACLR was 0.48%. Deep SSIs were identified in 0.32% of the ACLR cases and superficial SSIs in 0.16%. An 8.2-times higher risk of SSIs was observed in hamstring tendon autografts compared with BPTB autografts. No difference in SSI incidence was identified between allografts and BPTB autografts. Surgeons should bear in mind that although the overall infection rates after ACLR are low, there is an increased risk of deep infections with hamstring tendon autografts.

Both nonoperative and operative treatments for anterior cruciate ligament (ACL) deficient knees in skeletally immature patients have reported potentially negative outcomes. This study describes primary ACL reconstruction patients with open physes and their concurrent injuries and evaluates whether these patients are at a higher early risk of revision and reoperation than closed physes patients. A retrospective analysis of prospectively collected data was performed. Patients were identified using an ACL Reconstruction Registry. Summary statistics comparing open and closed physes patients of similar ages in regard to patient characteristics and incidence of early revision and reoperation are provided. Adjusted Cox regression models assessed risk of early revision and reoperation for open physes patients. Of 1,867 patients identified, 232 (12.4%) patients had open physes and 1,635 (87.6%) patients had closed physes. Patients with open physes were younger, less likely to be women, and had less medial meniscal injuries than closed physes patients. No significant differences were observed in cartilage injury, overall menisci injury and repair, and early revision and reoperation rate. According to the our results, no significant differences in risk of early revision or early reoperation in open physes compared with closed physes patients when adjusting for age were observed, nor were there any reoperations for physeal closure. Refereed/Peer-reviewed

Patient registries are defined as “organized systems that use observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes” [8]. While randomized clinical trials (RCTs) provide a high level of scientific evidence, patient registries provide a unique opportunity to study devices and outcomes in a real-world environment when RCTs are not feasible, practical, or ethical. Registries are ideal when longitudinal follow-up is necessary, when large sample sizes are required to detect rare events, and when examining outcomes in patients with various comorbidities and in different practice settings [8].

Bisphosphonates reduce the rate of osteoporotic fractures in clinical trials and community practice. “Atypical” nontraumatic fractures of the diaphyseal (subtrochanteric or shaft) part of the femur have been observed in patients taking bisphosphonates. We calculated the incidence of these fractures within a defined population and examined the incidence rates according to duration of bisphosphonate use. We identified all femur fractures from January 1, 2007 until December 31, 2011 in 1,835,116 patients older than 45 years who were enrolled in the Healthy Bones Program at Kaiser Southern California, an integrated health care provider. Potential atypical fractures were identified by diagnostic or procedure codes and adjudicated by examination of radiographs. Bisphosphonate exposure was derived from internal pharmacy records. The results showed that 142 patients had atypical fractures; of these, 128 had bisphosphonate exposure. There was no significant correlation between duration of use (5.5 ± 3.4 years) and age (69.3 ± 8.6 years) or bone density (T-score −2.1 ± 1.0). There were 188,814 patients who had used bisphosphonates. The age-adjusted incidence rates for an atypical fracture were 1.78/100,000/year (95% confidence interval [CI], 1.5–2.0) with exposure from 0.1 to 1.9 years, and increased to 113.1/100,000/year (95% CI, 69.3–156.8) with exposure from 8 to 9.9 years. We conclude that the incidence of atypical fractures of the femur increases with longer duration of bisphosphonate use. The rate is much lower than the expected rate of devastating hip fractures in elderly osteoporotic patients. Patients at risk for osteoporotic fractures should not be discouraged from initiating bisphosphonates, because clinical trials have documented that these medicines can substantially reduce the incidence of typical hip fractures. The increased risk of atypical fractures should be taken into consideration when continuing bisphosphonates beyond 5 years. © 2012 American Society for Bone and Mineral Research.

Background and purpose:Patient and implant registries are important clinical tools in monitoring and benchmarking quality of care. For comparisons amongst registries to be valid, a common data set with comparable definitions is necessary. In this study we compared the patients in the Norwegian Knee Ligament Registry (NKLR) and the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry (KP ACLRR) with regard to intraarticular findings, procedures, and graft fixation characteristics reported by the operating surgeon for both primary and revision anterior cruciate ligament reconstructions (ACLRs). Conclusions:Baseline findings between the NKLR and the KP ACLRR were congruent regarding patient characteristics and most injury patterns, adding to the evidence that comparisons and collaborations between these registries will provide generalizable information to the international orthopedic community. The variation in the treatment, including graft and implant selection and meniscus procedures, between the 2 registries provides opportunities to explore the impact of treatment choices on the outcomes of ACLRs. Methods:We performed a cross-sectional comparison of the NKLR and KP ACLRR cohorts registered between 2005 and 2010. Aggregate-level data including patient characteristics (age, sex, and laterality), meniscal and cartilage injury patterns and corresponding treatment procedures, choice of graft, and fixation characteristics (type and component material) were shared between registries. Descriptive analyses were then conducted. Results:During the study period, 11,217 ACLRs were registered in the NKLR and 11,050 were registered in the KP ACLRR. In the NKLR, hamstring autograft was used more (68% vs. 30 %) for primary ACLRs and allograft was used less (0.2% vs. 41%) than in the KP ACLRR. The KP ACLRR reports more meniscal tears among both primary and revision ACLRs (63% and 50 % vs. 49% and 36 %). The NKLR reports less use of biodegradable fixation devices. Refereed/Peer-reviewed

Purpose To study risk factors associated with osteoporotic distal radius fractures and evaluate the effectiveness of the screening and treatment components of a comprehensive osteoporosis program. Methods We retrospectively identified a cohort of patients aged 60 years or older from a large health maintenance organization. For the period 2002 to 2008, information on age, race, sex, diabetes status, osteoporosis diagnosis, osteoporosis screening activity, medications dispensed, and fracture events, including distal radius, proximal humerus, and hip fractures were recorded. We compared demographic and clinical characteristics for patients with and without distal radius fractures. We estimated multivariable estimates of the associations between pharmacologic treatment, and osteoporosis screening and distal radius fracture risk using Cox proportional hazards methods, and adjusted them for age, sex, race, diabetes status, and prior history of hip or proximal humerus fractures. Results Overall, 1.7% of the cohort (n = 8,658) of the study population (N = 524,612) sustained a new distal radius fracture during 2002 to 2008. In the multivariable model, we found that patients who received pharmacological intervention were 48% less likely to sustain a distal radius fracture. Similarly, patients who were screened for osteoporosis were 83% less likely to sustain a distal radius fracture. Patients with osteoporosis were 8.9 times more likely to have a distal radius fracture than patients without osteoporosis. White subjects had a 1.6 times higher risk of distal radius fracture than non-whites, and women had a 3.8 times higher risk than men. Conclusions White race, female sex, and a diagnosis of osteoporosis are high risks for distal radius fracture. Screening for and pharmacologic management of osteoporosis using a multidisciplinary team approach in a comprehensive osteoporosis management program resulted in a statistically significant decrease in the risk of distal radius fracture. Type of study/level of evidence Therapeutic III.

Introduction: Joint registries have demonstrated value as a resource for the study of large numbers of patients, providing the opportunity to study rare occurrences and identify early failures of surgical procedures. Anterior cruciate ligament (ACL) reconstruction registries have been established in Norway and the U.S. In this study, we compared the preoperative characteristics of the Norwegian National Knee Ligament Registry (NKLR) and the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry (KP ACLRR) cohorts. Conclusions: Baseline findings are so congruent between the NKLR and the KP ACLRR cohorts that comparisons between these two registries will likely provide information to the orthopaedic community that can be generalized. Methods: A cross-sectional comparison of the NKLR and KP ACLRR cohorts registered between 2005 and 2010 was performed. Aggregate level data including preoperative patient characteristics, mechanisms of injury, preoperative Knee Injury and Osteoarthritis Outcome Score (KOOS), intraoperative findings, and adjusted revision rates were shared between the two registries, and a descriptive analysis was conducted. Results: During the study period, 10,468 primary ACL reconstructions were entered in the NKLR and 10,394, in the KP ACLRR. The age at the time of surgery was similar between the two cohorts (twenty-seven years in the NKLR versus twentyeight years in the KP ACLRR), although the KP ACLRR had a higher proportion of males (65% versus 58%, p < 0.001). The revision rate per follow-up year was 0.9% in the NKLR and 1.5% in the KP ACLRR. Soccer was the most common mechanism of injury in both registries (40.0% in the NKLR and 26.6% in the KP ACLRR). The preoperative KOOS was statistically different, but the difference was not clinically relevant (defined as a change of >10 points). A higher prevalence of meniscal tears was seen in the KP ACLRR (61% versus 49%, p < 0.001). Refereed/Peer-reviewed

Background: It has been suggested that a surgeon’s experience and training are the most important factors associated with graft selection, but no studies have qualified this association. Graft usage prevalence has not been described for large anterior cruciate ligament reconstruction (ACLR) populations in the United States. Purpose: To describe the prevalence of graft usage in a large community-based practice and evaluate the association of patient, surgeon, and site characteristics with choice of primary ACLR graft. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Primary ACLRs performed between February 2005 and June 2010 were selected for the study. A community-based ligament registry was used to identify cases and variables used for analysis. Graft choice (any allograft, hamstring autograft, and bone–patellar tendon–bone [BPTB] autograft) was compared by patient characteristics and surgeon and site characteristics. Associations between independent variables and graft choice were evaluated using a polychotomous regression model. Results: Of the 9849 patients included in the study, 64% were male, and overall median age was 28 years. Of these, 2796 (28.4%) received BPTB autografts, 3013 (30.6%) received hamstring autografts, and 4040 (41.0%) received allografts. The prevalence of graft source by patients’ gender, race, age, body mass index (BMI), as well as surgeons’ fellowship training status, average volume, and site volume were significantly different (all P < .001). Adjusted models showed that patients’ gender ( P < .001), race ( P = .018), age ( P < .001), BMI ( P < .001), as well as surgeons’ fellowship training status ( P < .001), average volume ( P < .001), and site volume ( P < .001) are associated with graft selection. Older and female patients with lower BMI were more likely to receive allografts and hamstring autografts than BPTB autografts. Cases performed by non–fellowship-trained surgeons, lower volume sites, and/or lower volume surgeons were also more likely to be performed with allografts or hamstring autografts than BPTB autografts. Conclusion: Gender, age, race, as well as facility and surgeon characteristics such as volume and location are associated with ACL graft choices.

Background: Functional instability after anterior cruciate ligament injury can be successfully treated with ligament reconstruction. However, the associated meniscus and cartilage lesions often cannot be repaired and may have long-term detrimental effects on knee function. Purpose: The authors used the large database within the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry to evaluate time to surgery, age, and gender as risk factors for meniscus and cartilage injury and associations with meniscus repair rates in patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review of the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry was performed. The associations between time to surgery, age, and gender with meniscus and cartilage lesions and meniscus repair were analyzed using binary logistic regression modeling to calculate odds ratios (ORs) while adjusting for potential confounding variables. Results: A total of 1252 patients met the inclusion criteria. The risk of medial meniscus injury increased only with time to surgery (6–12 months: OR = 1.81, 95% confidence internal [CI] 1.29-2.54, P = .001; and >12 months: OR = 2.19, 95% CI 1.58-3.02, P < .001). The risk of lateral meniscus injury decreased only with female gender (OR = 0.65, 95% CI 0.51-0.83, P = .001). The risk of cartilage injury increased with age (OR = 1.05 per year, 95% CI 1.04-1.07, P < .001) and time to surgery >12 months (OR = 1.57, 95% CI 1.12-2.20, P = .009), but decreased with female gender (OR = 0.71, 95% CI 0.54-0.92, P = .009). Medial meniscus repairs relative to medial meniscus injury decreased with increasing time to surgery (3-6 months: OR = 0.61, 95% CI 0.37-1.00, P = .050; and >12 months: OR = 0.41, 95% CI 0.25-0.67, P < .001) and increasing age (OR = 0.96 per year, 95% CI 0.94-0.98, P < .001). Conclusion: Increased risk of medial meniscus injury and decreased repair rate were strongly associated with increasing time to surgery. Increased risk of cartilage injury was associated with increasing age, increasing time to surgery, and male gender.

Context: Anterior cruciate ligament (ACL) reconstructions are among the most common sports medicine procedures performed in the US each year. Differences have been reported in the incidence rates (IRs) of ACL tears among male and female national elite athletes. However, there is little information in the published literature that assesses IRs for ACL reconstructions done in the Health Maintenance Organization (HMO) setting specifically. Different populations may show variation in ACL reconstruction IRs. Objective: This study reports on the IR of ACL reconstructions in a predefined population and compares the differences in age and sex over time. Design: A retrospective analysis of 4485 ACL reconstructions performed within Kaiser Permanente Southern California between 2001 and 2005 was completed by a query of an administrative database. Trends in IRs per 100,000 members were calculated and compared across age, sex, and the five-year study period. Main Outcome Measures: Linear regression was used to test trends in IR. Sex distribution was compared using the χ 2 test. Analysis of variance was used to compare the mean age from year to year in males and females. The independent sample t-test was used to compare mean age between males and females for each independent year. Results: The IR of ACL reconstructions in females rose significantly (p = 0.010) from 14.4 in 2001 (95% confidence interval [CI], 12.6–16.3) to 19.3 in 2005 (95% CI, 17.2–21.5). Within specific age groups, IR increased significantly for females age 14 to 17 (p = 0.013), 18 to 21 (p = 0.017), and 45 to 49 years (p = 0.014). The most dramatic change was seen in the female age category of 14 to 17 years, which increased at a rate of 8.14 cases/100,000 members per year. Conclusion: Identifying the sex and age groups with most rapidly increasing rates of ACL reconstructions is important in implementing ACL injury-prevention programs.

Objectives: The use of allograft tissue for anterior cruciate ligament reconstruction (ACLR) remains controversial. Numerous meta-analysis and systematic reviews of small clinical studies have not found differences between autograft and allograft outcomes but large registry studies have shown an increased risk of revision with allografts. The purpose of this study was to compare the risk of aseptic revision between bone-patellar tendon-bone (BPTB) autografts, hamstring tendon autografts and soft tissue allografts.

references: 1. McClung MR et. Al. Effect of Risedronate on the Risk of Hip Fracture in Elderly Women. Michael R. N Engl J Med (2001) 344:333-340. 2. Kelsey JL, Browner WS, Seeley DG, Nevitt MC, Cummings SR and for the Study of Osteoporotic Fractures Research Group. Risk Factors for Fractures of the Distal Forearm and Proximal Humerus. Am. J. Epidemiol. (1992) 135 (5): 477-489. 3. Nguyen TV, Center JR, Sambrook PN, and Eisman JA. Risk Factors for Proximal Humerus, Forearm, and Wrist Fractures in Elderly Men and Women: The Dubbo Osteoporosis Epidemiology Study. Am. J. Epidemiol. (2001) 153 (6): 587-595. please address all quesTions and commenTs To: Ronald Navrro, MD • Department of Orthopedics • Kaiser Permanente South Bay 25825, Harbor City, CA 90710 • Ronald.A.Navarro@kp.org Anshu Singh, MD • Richard Dell, MD • Tadashi Funahashi, MD • Annette Adams, PhD • Ronald Navarro, MD • Kaiser Permanente Medical Group, Southern California

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.