10-year Revision Rate Research Articles

Hospital Network Centralization of Primary Total Joint Arthroplasty Is Associated With Reduced Early Complication Rates But Not Reduced Readmission or Reoperation Rates: A Retrospective Database Study

Background: Hospital networks centralize primary total joint arthroplasty (TJA) within their existing systems to develop specialized service lines with higher surgical volumes to reduce adverse events. It is not known what role hospital network centralization has had on primary TJA outcomes. Purpose: We sought to determine whether the degree of hospital network centralization for primary TJA is associated with (1) 90-day postoperative complication rates, (2) 90-day hospital readmission rates, or (3) 1-year revision rates. Methods: We conducted a retrospective database study of Medicare Part A beneficiaries who underwent inpatient primary TJA for osteoarthritis in 2016 and 2017 ( n = 523,142 patients); individual hospital-level characteristics and hospital networks were also identified ( n = 360 unique networks, n = 3339 hospitals). Patients having surgery at a hospital that was not a member of a health care network were excluded ( n = 163,998 patients) because we wanted to examine only the role of network structures on outcomes; this resulted in a cohort of 359,144 patients. Hospital network centralization, which was defined as the percentage of total network cases performed at the highest volume hospital and categorized into quartiles (eg, lowest 25% of networks by concentration, 26%–50% of networks by concentration, etc). Primary outcomes included postoperative 90-day complications, 90-day readmissions, and 1-year revisions. Multivariable logistic and linear regressions evaluated associations of hospital network centralization with outcomes and controlled for relevant patient-level and hospital-level covariates, including hospital network volumes. Results: Odds of 90-day complications were lower in the most centralized hospital networks than in least centralized networks (odds ratio [OR] = 0.85; 95% confidence interval [CI]: 0.75, 0.95). Degree of centralization was not associated with readmissions or 1-year revision rates. Non-modifiable patient and individual hospital characteristics appeared to have a greater association with complications, readmissions, and early revision rates than hospital network centralization or volume. Conclusion: This retrospective database study found that increased centralization of primary TJA within a hospital network was associated with lower 90-day complication rates but not with 90-day readmission or 1-year revision rates. This suggests that structural changes within hospital networks may be beneficial to reduce early complications in this patient population. In addition, our findings suggest that risk adjustment in assessing non-modifiable patient and hospital risk factors may be important when assessing TJA outcomes.

NO DIFFERENCE IN SHORT-TERM REVISION RATE AND EARLY MORTALITY IN UNCEMENTED VERSUS CEMENTED TOTAL HIP ARTHROPLASTY: A REGRESSION DISCONTINUITY ANALYSIS IN THE DUTCH ARTHROPLASTY REGISTER DATA

Controversy persists over whether cemented or uncemented fixation is more effective in reducing revision and mortality risks following primary total hip arthroplasty (THA). Despite a shift towards uncemented THA in Europe, Australia, and the US, no consensus exists on superior outcomes. This ambiguity in evidence from randomized controlled trials (RCTs) and observational studies necessitates advanced research methodologies to derive more definitive conclusions.This study investigates the causal impact of THA fixation type on 2-year and 5-year revision rates, along with 90-day mortality, utilizing a regression discontinuity (RD) design in scenarios where fixation choice is guided by patient age.Employing data from the Dutch Arthroplasty Register, we conducted a cohort study on primary THAs for osteoarthritis from 2007 to 2019. A “fuzzy” RD design was executed to compute the Local Average Treatment Effect for subjects around the age-based selection threshold for fixation type. The main outcome of interest was the revision rate at 2 years post-operation.Analysis for the 2-year revision endpoint, covering any cause, included 2,344 females and 1,671 males across 5 hospitals each, with no significant variation in revision rates observed. For the 5-year mark, 1,058 females in 3 hospitals and 214 males in 1 hospital were examined, similarly showing no significant differences. Mortality within 90 days post-operation was also investigated in 5 female and 7 male cohorts, with 2,180 and 2,145 surgeries respectively, yielding no substantial disparities.In conclusion, the RD analysis revealed no notable differences in revision rates at 2 and 5 years or in early mortality based on the fixation method used in THA. These outcomes suggest that the age-based preference for THA fixation may not influence the revision or mortality risk, underscoring the value of RD design in deriving causal insights from observational data.

The Impact of Surgeon Volume on Unicompartmental Knee Arthroplasty Survivorship: A Michigan Arthroplasty Registry Collaborative Quality Initiative Database Analysis

BackgroundThe utilization of unicompartmental knee arthroplasty (UKA) has remained low when compared to total knee arthroplasty (TKA), possibly due to higher rates of revision and reoperation. This study aimed to quantify surgeon UKA case-volumes and measure the effect of surgeon volume on early revision. We hypothesized that surgeons who have high case volumes would have lower revision rates compared to medium- and low-volume surgeons. MethodsPrimary UKAs were performed between February 2012 and November 2021, and associated revisions were identified utilizing the Michigan Arthroplasty Registry Collaborative Quality Initiative. Surgeon information, including total cases and annual UKA volume, was collected. Case volume per year was stratified as High (≥ 35 cases per year), Medium (15 to 34 cases per year), and low (< 15 cases per year). ResultsThere were a total of 15,542 UKAs performed. Of these, 701 (4.5%) were revised, and 412 (58.8%) revisions occurred within 2 years. Of the 287 surgeons who performed an UKA in the registry, 237 (82.6%) were low-volume surgeons, 36 (12.5%) were medium-volume, and 14 (4.9%) were high-volume. High-volume surgeons were more likely to operate on older patients (P < 0.01), Medicare patients (P < 0.01), and patients who had American Society of Anesthesiologists scores of III and IV (P < 0.01). High-volume surgeons had significantly lower 5-year revision rates compared to medium and low-volume surgeons (high: 4.3% (95% confidence interval: 3.7 to 4.9), medium: 5.2% (4.4 to 6.1), low: 7.2% (6.4 to 8.0); P < 0.001). In comparison, the 5-year revision rate for TKA in Michigan was 3.0% (95% confidence interval: 2.9 to 3.1). ConclusionsWhen UKAs were performed by high-volume surgeons in the state of Michigan, there was better survivorship when compared to low-and medium-volume surgeons. High-volume surgeons were more likely to perform UKA on older patients, Medicare patients, and patients who had American Society of Anesthesiologists scores of III and IV. The revision rate for the high-volume surgeons still exceeded the 5-year revision rate for TKA in Michigan.

Best timing of bilateral total hip arthroplasty – an analysis of revision and mortality rates from the German Arthroplasty Registry (EPRD)

BackgroundThe burden of osteoarthritis (OA) in multiple joints is high and for patients with bilateral OA of the hip there is no clear recommendation about the indication for simultaneous (one-stage) bilateral total hip arthroplasty (THA) versus two-staged procedures. The purpose of this study was therefore to compare revision and mortality rates after different strategies of surgical timing in bilateral hip OA from the German Arthroplasty Registry (EPRD).MethodsSince 2012 22,500 patients with bilateral THA (including 767 patients with one-staged bilateral surgery and 11,796 patients with another separate procedures within one year after first THA) are documented in the registry. The patients who underwent simultaneous bilateral THA were matched with a cohort of 767 patients who underwent the second THA between 1 and 90 days postoperatively (short interval) and another cohort of 4,602 patients with THA between 91 and 365 days postoperatively (intermediate interval). Revision for all reasons and mortality rates were recorded. Cox regression was performed to evaluate the influence of different patient characteristics.ResultsThe cumulative 5-year revision rate for patients with simultaneous bilateral THA was 1.8% (95% CI 0.9–2.6), for patients with two-staged THA 2.3% (95% CI 1.0-3.6) in the short interval and 2.5% (95% CI 2.1–2.9) in the intermediate interval, respectively. In all three groups, patients who underwent THA in a high-volume center (≥ 500 THA per year) had a significant lower risk for revision (HR 0.687; 95% CI 0.501–0.942) compared to surgeries in a low-volume center (< 250 THA per year). There was no significant difference regarding cumulative mortality rates in the three cohorts. Higher age (HR 1.060; 95% CI 1.042–1.078) and severe comorbidities as reflected in the Elixhauser Score (HR 1.046; 95% CI 1.014–1.079) were associated with higher mortality rates after simultaneous THA.ConclusionSimultaneous bilateral THA seems to be a safe procedure for younger patients with limited comorbidities who have bilateral end-stage hip OA, especially if performed in high-volume centers.Level of evidenceIII.

Increased 1-Year Revision Rates Among Left-Sided Intertrochanteric Femur Fractures.

To compare 1-year revision rates among left-sided and right-sided intertrochanteric femur fractures. Retrospective. 120+ contributing centers to multicentered database. Patients who sustained intertrochanteric femur fracture (ITFF) and had a cephalomedullary nail (CMN) from 2015 to 2022 were identified. Patients were then stratified based on left-sided or right-sided fracture. Patients were excluded if younger than 18 years with <1-year follow-up. The intervention investigated was CMN on left or right side. One-year revision surgery, comparing CMN performed on left or right side for ITFFs. In total, 113,626 patients met inclusion criteria, with 55,295 in the right-sided cohort and 58,331 in the left-sided cohort. There was no difference between cohorts with respect to age, gender, diabetes, osteoporosis, chronic kidney disease, or congestive heart failure (P > 0.05 for all). Patients who sustained a left ITFF and treated with a CMN were more likely to have revision surgery at 1 year (Left: 1.24%, Right: 0.90%; OR: 1.24; 95% confidence interval [CI], 1.15-1.1.33) or develop a nonunion or malunion (Left: 1.30%, Right: 0.98%; OR: 1.31; 95% CI, 1.14-1.52). The most common revision surgery conducted for both cohorts was conversion total hip arthroplasty (Left: 70.4% and Right: 70.0%). Patients who sustained a left intertrochanteric femur fracture and were treated with a CMN were more likely to undergo revision at 1 year due to nonunion. There were no differences in demographics and comorbidities between cohorts. Though left-sided versus right-sided confounding variables may exist, the difference in nonunion rate may be explained by clockwise torque of the lag screw used in most implants. Increased awareness, implant design, and improved technique during fracture reduction and fixation may help lower this disproportionate nonunion rate and its associated morbidity and financial impact. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Social Determinants of Health Disparities Increase 5-Year Revision Rates but Not Postoperative Complications After Primary Hip Arthroscopy

To investigate the impact of social determinants of health (SDOH) disparities on 30-day emergency department (ED) visits, 90-day postoperative complications, and five-year secondary surgery rates after primary hip arthroscopy using a large national database. A national administrative claims database was used to identify patients who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2022. Patients were queried for whether they experienced any SDOH disparities, including economic, educational, environmental, or social disparities; those experiencing SDOH within 1 year prior to primary hip arthroscopy were matched 1:1 by age, sex, Elixhauser Comorbidity Index score, diabetes, obesity, and tobacco use to patients not experiencing any lifetime SDOH disparities. Odds of 90-day complications and 30-day ED visits were compared using multivariable logistic regression. Rates of five-year revision hip arthroscopy and of any secondary surgery (revision hip arthroscopy or total hip arthroplasty) were compared by Kaplan-Meier analysis. A total of 3,383 primary hip arthroscopy patients who experienced SDOH disparities were matched 1:1 to a control cohort of 3,383 patients who had not experienced SDOH (age, 41.0 years, 79.6% female, for both cohorts). Odds of adverse events following arthroscopy were low and not different between cohorts (SDOH: 1.51%, vs. No SDOH: 1.57%; P=0.09). Additionally, there was no difference in odds of 30-day ED visits (SDOH: 5.65%, vs. No SDOH: 4.79%; P=0.10). The rate of five-year revision hip arthroscopy was significantly greater among patients experiencing SDOH disparities (5.4% vs. 4.1%; P=0.02); however, there was no difference in rates of any secondary surgery between cohorts (11.8% vs. 10.4%; P=0.10). Patients experiencing SDOH disparities had similar odds of postoperative complications and ED visits after primary hip arthroscopy but greater rates of five-year revision hip arthroscopy compared to a matched-control cohort of patients not experiencing SDOH disparities. 3; retrospective case-control study.

How Has the Total Hip Arthroplasty Patient Population Changed? A Ten-Year Analysis of Total Hip Arthroplasty Patients From 2013 to 2022: A Retrospective, Single-Center Study

BackgroundOver the past decades, utilization of total hip arthroplasty (THA) has steadily increased. Understanding the demographic trends of THA patients can assist in projecting access to care. This study sought to assess the temporal trends in THA patient baseline characteristics and socioeconomic factors. MethodsWe retrospectively analyzed 16,296 patients who underwent primary elective THA from January 1, 2013, to December 31, 2022. Demographic data, including age, sex, race, body mass index (BMI), Charlson comorbidity index, insurance, and socioeconomic status, as determined by median income by patients’ zip code, were collected. The trends of these data were analyzed using the Mann-Kendall test. ResultsOver the past decade at our institution, patient age (2013: 62.1 years to 2022: 65.1 years, P = .001), BMI (2013: 29.0 to 2022: 29.5, P = .020), and mean Charlson comorbidity index (2013: 2.4 to 2022: 3.1, P = .001) increased. The proportion of Medicare patients increased from 48.4% in 2013 to 54.9% in 2022 (P = .001). The proportion of African American patients among the THA population increased from 11.3% in 2013 to 13.0% in 2022 (P = .012). Over this period, 90-day readmission and 1-year revision rates did not significantly change (2013: 4.8 and 3.0% to 2022: 3.4 and 1.4%, P = .107 and P = .136, respectively). The proportion of operations using robotic devices also significantly increased (2013: 0% to 2022: 19.1%; P < .001). ConclusionsIn the past decade, the average age, BMI, and comorbidity burden of THA patients have significantly increased, suggesting improved access to care for these populations. Similarly, there have been improvements in access to care for African American patients. Along with these changes in patient demographics, we found no change in 90-day readmission or 1-year revision rates. Continued characterization of the THA patient population is vital to understanding this demographic shift and educating future strategies and improvements in patient care.

Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement

Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient. To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement. This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023. Primary TKA with ALBC vs plain bone cement. The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes. Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement. In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.

Critically Evaluating the Role for Postoperative Antibiotics in Patients Undergoing Urethroplasty With Buccal Mucosa Graft: A Claims Database Analysis

ObjectivesTo compare outcomes among patients undergoing first-time urethroplasty with buccal mucosa graft (BMG) who receive post-operative antibiotics versus those who do not. MethodsA retrospective cohort study was conducted using the TriNetX claims database between 2008-2022. Using CPT, ICD10, and LOINC codes, patients >18 years old undergoing primary urethroplasty with BMG who received an outpatient prescription for antibiotics between post-operative day 0-30 or did not were queried. Patients with positive pre-operative urine culture or urinary tract infection (UTI) within 30 days pre-operatively were excluded. Surgical outcomes included 5-year revision rates and revision-free survival. Safety outcomes included new UTI within 30 days, surgical site infection (SSI) within 90 days, or Clostridium difficile infection within 30 days of urethroplasty. ResultsWe identified 884 patients (81% antibiotic cohort, 19% non-antibiotic cohort) that met inclusion criteria. Age at time of urethroplasty, suprapubic tube presence, and pre-existing medical comorbidities were comparable between cohorts (Table 1A). There was no difference in 5-year rates and revision-free survival for endoscopic revision (11.5% vs. 9.5%, RR 1.2, 95% CI [0.7, 2.0], RFS log-rank p=0.6), re-do urethroplasty (12.9% vs. 13.7%, RR 0.9, 95% CI [0.6, 1.5], RFS log-rank p=0.7), or all-cause revision (19.8% vs. 17.7%, RR 1.1, 95% CI [0.8, 1.6], p=0.5) between groups. Post-operative rates of UTI, SSI, and Clostridium difficile infection were similar between groups. ConclusionsIn this large retrospective cohort study of patients undergoing urethroplasty with BMG, we observed no significant benefit from use of post-operative antibiotics on long-term revision rates or perioperative infectious complications.

AIDS but not asymptomatic HIV is associated with lower 2–10-year implant survivorship following total knee arthroplasty

IntroductionPrior studies have demonstrated HIV does not increase the risk of 2-year complications following TKA; however, the literature is sparse regarding the impact of HIV and AIDS on long-term implant survivorship. The purpose of this study was to compare the 10-year cumulative incidence and risk of revision TKA in patients with and without asymptomatic HIV, and with and without AIDS. MethodsPatients with HIV who underwent elective TKA were identified using a national database and divided into subgroups of asymptomatic HIV (AHIV) and acquired immunodeficiency syndrome (AIDS). These patients with HIV were propensity matched based on age, sex, and Charlson Comorbidity Index (CCI) to a control group of elective TKA patients without HIV in a 1:2 ratio. Patients were also compared to an unmatched control group. ResultsThe 10-year risk for all-cause revision TKA was higher in the HIV group compared to unmatched controls (HR 1.40, 95% CI 1.02–1.93, p = 0.038) but not matched controls (HR 1.13, 95% CI 0.77–1.63, p = 0.594). When compared to both control groups (unmatched; matched), the AIDS group had a higher risk of 10-year all-cause revision (HR 2.74, 95% CI 1.51–4.99, p < 0.001; HR 2.19, 95% CI 1.17–4.11, p = 0.014), dislocation/instability (HR 4.89, 95% CI 1.54–15.51, p = 0.007; HR 3.86, 95% CI 1.12–13.34, p = 0.033), and periprosthetic fracture [PPF] (HR 0.67, 95% CI 0.16–2.74, p = 0.002; HR 3.82, 95% CI 1.08–13.45, p = 0.037). However, patients with AIDS were not at increased risk of PJI or mechanical loosening compared to unmatched controls or matched controls. DiscussionThis study expands on current literature by following a nationwide cohort of HIV/AIDS patients for 10 years after TKA. Although a diagnosis of asymptomatic HIV was not associated with increased risk of 10-year revision rates following TKA, a diagnosis of AIDS was. Surgeons should ensure patients’ serum CD4 level is sufficient, ideally in the normal range of 500–1500 cells per mm3, before undergoing TKA.

Total shoulder arthroplasty in patients with factor V Leiden

BackgroundAnatomic and reverse total shoulder arthroplasty (TSA) are effective treatment options for end-stage glenohumeral osteoarthritis. However, consideration for pre-existing conditions must be taken into account. Factor V Leiden (FVL), the most common inherited thrombophilia, is one such condition that predisposes to a prothrombotic state and may affect perioperative and longer-term outcomes following TSA. MethodsAdult patients undergoing primary TSA for osteoarthritis indication were identified in the 2010 through October 2021 PearlDiver M157 database. Patients with or without FVL were matched at a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events and five-year revision rates were assessed and compared with multivariable logistic regression and rank-log tests, respectively. Finally, the relative use and bleeding/clotting outcomes were assessed based on venous thromboembolic (VTE) prophylactic agents utilized, with categories defined as (1) warfarin, heparin, or direct oral anticoagulant (DOAC) or (2) aspirin/no prescriptions found. ResultsOf 104,258 TSA patients, FVL was identified for 283 (0.27%). Based on matching, 1,081 patients without FVL and 272 patients with FVL were selected. Multivariable analyses demonstrated that those with FVL displayed independently greater odds ratios (ORs) of deep vein thrombosis (DVT, OR=9.50, p<0.0001), pulmonary embolism (PE, OR = 10.10, p<0.0001), and pneumonia (OR=2.43, p=0.0019). Further, these events contributed to the increased odds of aggregated minor (OR = 1.95, p=0.0001), serious (OR=6.38, p<0.0001), and all (OR=3.51, p<0.0001) adverse events. All other individual 90-day adverse events, as well as 5-year revision rates, were not different between the study groups. When compared to matched patients without FVL on the same anticoagulant agents, FVL patients on warfarin/heparin/DOAC agents demonstrated lesser odds of 90-day DVT and PE (OR=4.25, p<0.0001 and OR=2.54, p=0.0065) than those on aspirin/no prescriptions found (OR=7.64 and OR=21.95, p<0.0001 for both). Interestingly, those on VTE prophylactic agents were not at greater odds of bleeding complications (hematoma or transfusion). Discussion and ConclusionsTSA patients with FVL present a difficult challenge to shoulder reconstruction surgeons. The current study highlights the strong risk of VTE that was reduced but still significantly elevated for those with stronger classes of VTE chemoprophylaxis. Acknowledging this risk is important for surgical planning and patient counseling, but also noted was the reassurance of similar 5-year revision rates for those with versus without FVL.

No Difference in Revision Rates up to 10 years Following Total Hip Arthroplasty in Patients Who Had Prior Bariatric Surgery When Compared to Patients Who Had Class III Obesity: A Propensity Matched Analysis

BackgroundThere is no clear research showcasing bariatric surgery’s (BS’s) impact on long-term surgical complications following total hip arthroplasty (THA). Therefore, this study compared the 10-year cumulative incidence and risk of revision following THA in patients who underwent BS when compared to the general population and class III obesity patients who did not undergo BS. MethodsPatients who underwent elective THA from 2010 to 2021 were identified using an all-payer claims database. Patients who underwent BS prior to THA were separately matched to a control of the general population and those who had class III obesity (body mass index ≥40) by age, sex, Charlson Comorbidity Index, and diabetes using a 1:4 ratio. Kaplan-Meier analyses generated 10-year cumulative incidence rates, and a Cox proportional hazard ratio (HR) model generated HRs and 95% confidence intervals (CIs). ResultsWhen compared to the general control, patients who have a history of BS had an elevated 10-year risk of all-cause revision (HR 1.31, 95% CI: 1.16 to 1.47, P < .001), prosthetic joint infection (HR: 1.62, CI: 1.30 to 2.04; P < .001), mechanical loosening (HR: 1.20, CI: 1.01 to 1.44; P = .040), and dislocation/instability (HR: 1.35, CI: 1.09 to 1.68; P = .007). There was no difference in the 10-year risk of all-cause revision or other indications for revision in the BS cohort compared to the matched class III obesity cohort (P = .142). ConclusionsThose who underwent BS before THA had comparable 10-year revision rates when compared to those who had class III obesity and higher rates compared to the general population. This suggests BS may not reduce the 10-year surgical risks associated with obesity when compared to a class III obese surgical population.

Promoting cemented fixation of the femoral stem in elderly female hip arthroplasty patients and elderly hip fracture patients: a retrospective cohort study from the Norwegian Arthroplasty Register and the Norwegian Hip Fracture Register.

Uncemented stems increase the risk of revision in elderly patients. In 2018, we initiated a national quality improvement project aiming to increase the proportion of cemented stems in elderly female total hip arthroplasty (THA) and hip fracture hemiarthroplasty (HA) patients. We aimed to evaluate the association of this project on the frequency of cemented stems and the risk of secondary procedures in the targeted population. 10,815 THAs in female patients ≥ 75 years in the Norwegian Arthroplasty Register and 19,017 HAs in hip fracture patients ≥ 70 years in the Norwegian Hip Fracture Register performed in 2015-2017 and 2019-2021 at all Norwegian hospitals were included in this retrospective cohort study. The quality improvement project was implemented at 19 hospitals (8,443 patients). 1-year revision risk (THAs) and reoperation risk (HAs) were calculated for uncemented and cemented stems by Kaplan-Meier and Cox adjusted hazard rate ratios (aHRRs) with all-cause revision/reoperation as main endpoint. The use of cemented stem fixation in the targeted population increased from 26% to 80% for THAs and from 27% to 91% for HAs. For THAs, the 1-year revision rate decreased from 3.7% in 2015-2017 to 2.1% in 2019-2021 (aHRR 0.7, 95% confidence interval [CI] 0.5-0.9) at the intervention hospitals. For HAs, the reoperation rate decreased from 5.9% in 2015-2017 to 3.3% in 2019-2021 (aHRR 0.6, CI 0.4-0.8) at the intervention hospitals. The quality improvement project resulted in a significant increase in the proportion of cemented stems and reduced risk of secondary procedures for both THAs and HAs.

The Impact of Hypogonadism on Surgical Outcomes Following Primary Urethroplasty: Analysis of a Large Multi-institutional Database

ObjectivesTo compare surgical outcomes among a cohort of eugonadal and hypogonadal patients undergoing primary urethroplasty (UP). MethodsA retrospective cohort study was conducted using TriNetX between 2008-2023. Patients that were eugonadal and hypogonadal (symptoms plus testosterone <300ng/dL) prior to UP were compared. A subgroup analysis of hypogonadal patients was performed to compare those with testosterone replacement therapy (TRT) vs. TRT-naïve prior to UP. Propensity-score matching was used to adjust for differences in comorbidities. Outcomes were 5-year revision rates and revision-free survival (RFS) for endoscopic revision and redo UP following primary UP. ResultsWe identified 12,556 eugonadal and 488 hypogonadal patients (153 TRT+, 335 TRT-) undergoing UP. Median age at UP and follow-up was 55 years and 5 years, respectively. After propensity-score matching, we compared 477 eugonadal and 477 hypogonadal patients. Hypogonadal patients had a statistically significantly higher 5-year redo UP rate (11% vs. 6%, RR 1.5 [95%CI, 1.2-2.2];p=0.01) when compared to eugonadal patients however there was no difference in 5-year rates of endoscopic revision (11% vs. 11%, RR 1.0 [95%CI, 0.7-1.5];p=1.0). We observed no difference in 5-year RFS time for endoscopic revision or redo UP between groups. Hypogonadal patients treated with TRT had a significantly higher 5-year redo UP rate (15% vs. 7%, RR 1.8 [95%CI, 1.1-3.3];p=0.02) compared to hypogonadal patients that were TRT-naïve prior to UP. There was no difference in rates of endoscopic revision (14% vs. 10%, RR 1.3 [95%CI, 0.7-2.4];p=0.2) between subgroups. ConclusionsPre-existing hypogonadism may modestly adversely affect surgical outcomes following primary urethroplasty based on data from a large, retrospective cohort study.

The impact of robotic assistance for lumbar fusion surgery on 90-day surgical outcomes and 1-year revisions.

To evaluate the (1) 90-day surgical outcomes and (2) 1-year revision rate of robotic versus nonrobotic lumbar fusion surgery. Patients >18 years of age who underwent primary lumbar fusion surgery at our institution were identified and propensity-matched in a 1:1 fashion based on robotic assistance during surgery. Patient demographics, surgical characteristics, and surgical outcomes, including 90-day surgical complications and 1-year revisions, were collected. Multivariable regression analysis was performed. Significance was set to P < 0.05. Four hundred and fifteen patients were identified as having robotic lumbar fusion and were matched to a control group. Bivariant analysis revealed no significant difference in total 90-day surgical complications (P = 0.193) or 1-year revisions (P = 0.178). The operative duration was longer in robotic surgery (287 + 123 vs. 205 + 88.3, P ≤ 0.001). Multivariable analysis revealed that robotic fusion was not a significant predictor of 90-day surgical complications (odds ratio [OR] = 0.76 [0.32-1.67], P = 0.499) or 1-year revisions (OR = 0.58 [0.28-1.18], P = 0.142). Other variables identified as the positive predictors of 1-year revisions included levels fused (OR = 1.26 [1.08-1.48], P = 0.004) and current smokers (OR = 3.51 [1.46-8.15], P = 0.004). Our study suggests that robotic-assisted and nonrobotic-assisted lumbar fusions are associated with a similar risk of 90-day surgical complications and 1-year revision rates; however, robotic surgery does increase time under anesthesia.

Increased risk of aseptic loosening for posterior stabilized compared with posterior cruciate-retaining uncemented total knee replacements: a cohort study of 13,667 knees from the Dutch Arthroplasty Registry.

While registry studies have suggested a higher risk of revision for posterior-stabilized (PS) compared with posterior cruciate-retaining (CR) total knee replacements (TKR) using cement, it is unknown whether this is also the case for uncemented TKR. We aimed to compare the revision rates of PS and CR designs in patients receiving primary uncemented TKR. Data from the Dutch arthroplasty register (LROI) was analyzed, comprising 12,226 uncemented primary CR TKRs and 750 uncemented PS TKRs registered between 2007 and 2022. Competing risk and multivariable Cox regression analyses were used to compare revision rates, risks of revision, and reasons for revision between groups. Sensitivity analyses were performed to analyze the risk, concerning the 5 most commonly used implants and performing hospitals for each group. Uncemented PS TKRs had higher 10-year revision rates for any reason and aseptic loosening (6.5%, 95% confidence interval [CI] 4.6-9.2 and 3.9%, CI 2.6-6.7) compared with uncemented CR TKRs (4.2%, CI 3.8-4.7 and 1.4%, CI 1.2-1.7). PS TKRs were 1.4 and 2.5 times more likely to be revised for any reason and aseptic loosening, respectively. These results remained consistent after adjustment for age, sex, BMI, previous surgeries, bearing mobility, and surface modification, with sensitivity analyses. We found that uncemented PS implants have a higher rate of revision than uncemented CR implants, mainly due to a higher risk of aseptic loosening.

1276. Mechanical, Microbiological, and Inflammatory Factors May Impact 1-Year Revision Rates after Arthroplasty Resection for Periprosthetic Joint Infection

Abstract Background Periprosthetic joint infection (PJI) is often managed using a combination of medical and surgical treatments, including irrigation and debridement or joint resection, spacer placement, and then revision to reimplant the arthroplasty components. The timing between surgical stages may vary, and little information exists about the clinical and microbiological factors impacting these temporal relationships. Methods A single center cohort study was conducted. The cohort included all cases of PJI for which resection was performed at the University of Iowa Health Care (UIHCs) between January 1, 2009, and December 31, 2016. Using a 1-year follow-up period, we constructed Kaplan-Meier estimates of the time to revision after resection—overall and then stratified by joint location (knee vs. hip), organism identification (known vs unknown), and C-reactive protein level (CRP &amp;gt;10 mg/L vs. CRP ≤10 mg/L). We then used Cox proportional hazard modeling to identify factors associated with revision within 1 year. Results Among a total of 109 cases of prosthetic joint resections (n = 67 knee, n = 42 hip), 56.9% underwent revision surgery during the follow-up period (n = 46 knee, n= 16 hip). Most revisions occurred between 2.5 and 3.0 months after resection. Knee arthroplasties were significantly more likely to undergo revision during the study period (hazard ratio, HR = 2.53, 95% confidence interval, CI: 1.38, 4.94) compared to hip arthroplasties. Identification of one or more organism involved in the PJI was also associated with revision during the study window (HR = 3.56, 95% CI: 1.94, 6.47), whereas elevated CRP was associated with lower rates of revision during the study period (HR = 0.21, 95% CI: 0.09, 0.46 for CRP &amp;gt;10 mg/L compared to CRP ≤10 mg/L). Figure 1. Kaplan-Meier curves for revision within 1-year after resection for the (A) cohort overall and then stratified by (B) joint location (hip vs knee), (C) organism identification (known vs unknown), and (D) C-reactive protein level (CRP &amp;gt;10 mg/L vs. CRP ≤10 mg/L). Conclusion For patients with surgically managed PJIs, joint location, organism identification, and lower CRP level were all associated with revision procedures within 1-year after resection. These findings may reflect mechanical and microbiological factors influencing the decision to proceed with revision. The variable length between stages—and thus, the variable time during which a spacer is retained—may be important to measure in future observational and clinical studies examining PJI outcomes. Disclosures All Authors: No reported disclosures

Total Hip Arthroplasty in Patients Who Have Marfan Syndrome: Adverse Events and 5-Year Revision Rates

BackgroundMarfan syndrome is a rare inherited connective tissue disease, which may be present in patients who have advanced hip pathologies that may require total hip arthroplasty (THA). The postoperative course of patients who have Marfan syndrome following THA has not yet been defined. MethodsAdult patients who have and do not have Marfan syndrome and underwent THA were identified in a national database. Patients diagnosed who had infection, trauma, or neoplasms within the 90 days prior to surgery were excluded. Those who have versus those who did not have Marfan syndrome were matched 1:10 based on age, sex, and a comorbidity index. After matching, 144 patients who have Marfan syndrome and 1,440 who do not have Marfan syndrome were identified. The 90-day postoperative adverse events and 5-year revisions were assessed and compared with multivariable analyses and log rank tests, respectively. ResultsMultivariable analyses demonstrated that Marfan syndrome was independently associated with greater odds of 90-day adverse events: venous thromboembolic events (odds ratio [OR]: 2.9, P = .001), cardiac events (OR: 4.5, P = .034), pneumonia (OR: 3.5, P < .001), and urinary tract infections (OR: 5.2, P < .001). There was no significant difference in 5-year rates of revision. ConclusionsFollowing THA, Marfan syndrome was independently associated with greater rates of several 90-day adverse events, but not higher 5-year rates of revision. The identified at-risk adverse events may help guide surgeons to improve perioperative care pathways, while having confidence regarding joint survival of THA in this rare disease population.

Beach-Chair Versus Lateral Decubitus Positioning for Primary Arthroscopic Anterior Shoulder Stabilization: A Consecutive Series of 641 Shoulders

Background: There are limited data comparing the beach-chair (BC) versus lateral decubitus (LD) position for arthroscopic anterior shoulder stabilization. Purpose: To identify predictors of instability recurrence and revision after anterior shoulder stabilization and evaluate surgical position and glenoid bone loss as independent predictors of recurrence and revision at short- and midterm follow-ups. Study Design: Cohort study; Level of evidence, 3. Methods: A consecutive series of 641 arthroscopic anterior stabilization procedures were performed from 2005 to 2019. All shoulders were evaluated for glenohumeral bone loss on magnetic resonance imaging. The primary outcomes of interest were recurrence and revision. Multivariable logistic regression models were used to assess the relationships of outcomes with age, position, glenoid bone loss group, and track. Results: A total of 641 shoulders with a mean age of 22.3 years (SD, 4.45 years) underwent stabilization and were followed for a mean of 6 years. The overall 1-year recurrent instability rate was 3.3% (21/641) and the revision rate was 2.8% (18/641). At 1 year, recurrence was observed in 2.3% (11/487) and 6.5% (10/154) of BC and LD shoulders, respectively. The 5-year recurrence and revision rates were 15.7% (60/383) and 12.8% (49/383), respectively. At 5 years, recurrence was observed in 16.4% (48/293) and 13.3% (12/90) of BC and LD shoulders, respectively. Multivariable modeling demonstrated that surgical position was not associated with a risk of recurrence after 1 year (odds ratio [OR] for LD vs BC, 1.39; P = .56) and 5 years (OR for LD vs BC, 1.32; P = .43), although younger age at index surgery was associated with a higher risk of instability recurrence (OR, 1.73 per SD [4.1 years] decrease in age; P < .03). After 1 and 5 years, surgical position results were similar in a separate multivariable logistic regression model of revision surgery as the dependent variable, when adjusted for age, surgical position, bone loss group, and track. At 5 years, younger age was an independent risk factor for revision: OR 1.68 per SD (4.1 years) decrease in age (P < .05). Conclusion: Among fellowship-trained orthopaedic surgeons, there was no difference in rates of recurrence and revision surgery after performing arthroscopic anterior stabilization in either the BC or the LD position at 1- and 5-year follow-ups. In multivariable analysis, younger age, but not surgical position, was an independent risk factor for recurrence.

Short-stem hip arthroplasty in Australia and the Netherlands: a comparison of 12,680 cases between the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Dutch Arthroplasty Register (LROI).

We compared the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Dutch Arthroplasty Register (LROI) regarding patient, prosthesis, and procedure characteristics as well as revision rates for uncemented short-stem total hip arthroplasties (THAs). All THAs with an uncemented short-stemmed femoral component performed between 2009 and 2021 were included from the AOANJRR (n = 9,328) and the LROI (n = 3,352). Kaplan-Meier survival analyses and multivariable Schemper's weighted Cox regression analyses with data from 2009-2021 and 2015-2021 were performed with overall revision as endpoint. In Australia, the proportion of male patients (51% vs. 40%), patients with ASA III-IV score (30% vs. 3.7%), BMI ≥ 30.0 (39% vs. 19%), and femoral heads of 36 mm (58% vs. 20%) were higher than in the Netherlands. Short-stem THAs in Australia and the Netherlands had comparable 10-year revision rates (3.4%, 95% confidence interval [CI] 2.9-4.0 vs. 4.8%, CI 3.7-6.3). Multivariable Cox regression analyses with data from 2009-2021 showed a higher risk for revision of short-stem THAs performed in the Netherlands (HR 1.8, CI 1.1-2.8), whereas the risk for revision was comparable (HR 0.9, CI 0.5-1.7) when adjusted for more potential confounders using data from 2015-2021. Short-stem THAs in Australia and the Netherlands have similar crude and adjusted revision rates, which are acceptable at 10 years of follow-up.