The members of the International Society of Arthroplasty Registries (ISAR) have a shared purpose of improving outcomes for individuals receiving hip and knee replacement surgeries worldwide. The focus of the society is to motivate worldwide cooperation to share medical device information. These collective efforts will assist in enhancing the quality of local registries and expanding the capacity of data-use related projects. The society is involved in the development of frameworks to encourage collaborative activities and provide a support network for established and developing registries. The AAOS American Joint Replacement Registry (AJRR) is a member of ISAR and participates at the Annual International Congress of Arthroplasty Registries each year.
The following AJRR data-based abstracts were accepted at the 10th Annual Virtual International Congress of Arthroplasty Registries in 2021. Additionally, this was the first year that an AAOS staff member presented at the congress regarding the progress of the International Prosthesis Library.
Racial Disparities in Rates of Revision and Use of Premium Surgical Features in Total Knee Arthroplasty, A National Registry Study
Alex Upfill-Brown1, Noah Paisner1,2, Patrick C Donnelly3, Ayushmita De3, Adam Sassoon1
1Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA 2Pacific Northwest University School of Health Sciences, Yakima, WA, USA
3American Joint Replacement Registry, American Academy of Orthopaedic Surgery, Rosemont, IL, USA
Presenter: Noah Paisner
We investigated the association of race with rates of premium surgical feature use and post-operative outcomes in total knee arthroplasty (TKA) using the AAOS American Joint Replacement Registry (AJRR).
Adult TKAs from 2012-2020 were queried from the AJRR. Mixed-effects multivariable logistic regression models were used to examine the association of race with each individual premium surgical feature (unicodylar knee arthroplasty (UKA), robotic assisted TKA (RA-TKA), and vitamin E polyethylene liner usage), 30- and 90-day readmission. A proportional subdistribution hazard model was used to model risk of revision TKA.
1,121,457 patients were available for analysis for surgical features and 1,068,210 patients for analysis of outcomes. Average length of follow up was 43.7 months. On multivariate analysis, compared to white patients, Black (OR 0.52 p<0.0001), Hispanic (OR 0.84 p=0.0003) and American Indian (OR 0.69 p=.0011) patients had lower rates of UKA, while only Black patients had lower rates of RA-TKA (OR 0.76 p<0.0001). Whites (HR=0.8, p<.0001), Asians (HR=0.51, p<.0001), and White-Hispanics (HR=0.73, p=0.001) had a lower risk of revision TKA than Black patients. Asians had a lower revision risk than Whites (HR=0.64, p<.0001) and White-Hispanics (HR=0.69, p=0.011). No significant differences existed between groups for vitamin E polyethylene use or 30- or 90-day readmissions.
Black patients had lower rates of premium TKA surgical features, including UKA and RA-TKA, compared to white patients. Furthermore, Black patients had a higher risk of revision TKA comparted to white and Asian patients. These results may highlight underlying differences in intra-operative and post-operative care.
Use of Cementless Metaphyseal Fixation in Revision Total Knee Arthroplasty in the United States
Christopher N. Carender1, Qiang An1, Mathew W. Tetreault2, Ayushmita De3, Timothy S. Brown1, Nicholas A. Bedard1
1University of Iowa Healthcare, Iowa City, Iowa, USA
2The Bone and Joint Center, Albany, NY, USA
3American Academy of Orthopaedic Surgeons (AAOS), Rosemont, IL, USA
Presenter: Christopher Carrender
Fixation options for revision total knee arthroplasty (revTKA) now include cementless metaphyseal fixation. However, utilization of these implants in the US are not well known. The purpose of this study is to analyze trends in cementless metaphyseal fixation for revTKA within the American Joint Replacement Registry (AJRR).
AJRR was queried to identify all revTKA from 2015-2019 with implant data. Trends in utilization of cementless metaphyseal sleeves, cones, and any metaphyseal fixation (sleeves + cones) were examined using logistic regression analysis.
20,280 revTKA cases were analyzed. Cementless metaphyseal fixation was used for 16% of revTKA and significantly increased during 2015-2019 (14% to 19%, p< 0.0001). Cementless metaphyseal fixation was more likely utilized during revision for aseptic loosening than other diagnoses (OR 1.014, 95%CI 1.001-1.027). Cementless sleeve utilization decreased over time (11% to 9%, p=0.004), driven by decreased femur use (4% to 2%, p<0.0001). Use of cones increased significantly over time (3% to 9%, p< 0.0001), driven by increased tibia use (2% to 9%, p< 0.0001). Cones were 22 times more likely utilized on the tibia versus the femur (p< 0.0001) and were more likely used in revisions for infection (OR 1.103, 95%CI 1.089-1.117) and aseptic loosening (OR 1.764, 95%CI1.728-1.800).
Use of cementless metaphyseal fixation in the US remains relatively rare (16%). However, utilization is increasing. This increase is mostly due to increased utilization of tibial metaphyseal cones. Additional research is required to determine if increased use of these implants decreases occurrences of implant loosening following revTKA.
Lower Rates of Ceramic Femoral Head Use in Non-white Patients, A National Registry Study
Noah Paisner1,2, Alex Upfill-Brown1, Patrick C. Donnell3, Ayushmita De3, Adam Sassoon1
1Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
2Pacific Northwest University School of Health Sciences, Yakima, WA
3American Joint Replacement Registry, American Academy of Orthopaedic Surgery, Rosemont, IL
Presenter: Noah Paisner
The purpose of our study was to investigate the association of race with rates of ceramic femoral head use and post-operative outcomes in total hip arthroplasty (THA) using the AAOS American Joint Replacement Registry (AJRR).
Adult THA procedures were queried from the AJRR from 2012 to 2020. A mixed-effects multivariate regression model was used to evaluate the association of race with ceramic femoral head usage, 30- and 90-day readmission. A proportional subdistribution hazard model was used to model risk of revision THA.
There were 85,188 THAs with complete data for analysis of outcomes, and 103,218 for analysis of ceramic head usage. Average length of follow up was 41 months. In multivariate models, compared to white non-Hispanic patients, Black (OR 0.79 p<0.001), Hispanic (OR 0.76 p=0.037), Asian (OR 0.74 p=0.045) and American Indian (OR 0.52 p=0.004) patients all had significantly lower rates of ceramic head use in THA. Compared to white non-Hispanic patients, Asian (HR 0.39 p=0.008) and Hispanic (HR 0.43, p=0.043) patients had significantly lower rates of revision. No differences in 30- or 90-day readmission rates were seen between groups.
Black, Hispanic, American Indian and Asian patients had lower rates of ceramic head use in THA when compared to white patients. These differences did not translate into worse clinical outcomes on short-term follow-up. Additional study is necessary to evaluate the long-term consequence of lower ceramic head use in non-white patients in the US.
Metal Backed Tibial Components Provide Minimal Mid-term Survivorship Benefits Despite Increased Cost and Frequency of Use: A Retrospective Review of the AJRR Database
Benjamin Kelley1, Kyle Mullen2, Ayushmita De2, Adam Anton Sassoon1
1UCLA Department of Orthopaedic Surgery
2American Joint Replacement Registry
Presenter: Ayushmita De
Previous studies have demonstrated equivalent survivorship of modular metal-backed
(MBT) and all-polyethylene tibial (APT) components. The purpose was to compare utilization and outcomes of APT and MBT components in a large US database.
The American Joint Replacement Registry (AJRR) was queried to identify all patients undergoing primary TKA from 2012-2019. These patients were divided into cohorts based on tibial components. Cohort demographics were reported with descriptive statistics. Overall reoperation rates, revisions for infection, aseptic loosening, periprosthetic fracture, manipulation under anesthesia, and other reasons were compared across the two cohorts. Categorical variables were compared using Chi-square statistics, adjusting for age sex, hospital type, and CCI.
703,007 TKAs were reported, with 97.8% utilizing MBT and 2.2% utilizing APT components. Demographics of the two cohorts were similar except for a higher proportion of female patients in the AP cohort (72.8% vs 60.6%). Survival of APT and MBT TKA were similar: 99.1% vs 99.5% at 1 year, 98.9% vs 99.2% at 2 years, 98.7% vs 98.9% at 4 years, 98.4% vs 98.7% at 6 years, and 98.1% vs 98.6% at 8 years. Rate of reoperation for all-cause was higher for APT compared to MBT (1.36% vs 1.00%, OR 1.52, p<0.0001). Rates of reoperation for infection, aseptic loosening, and other reasons were also higher for APT compared to MBT.
Healthcare incentives may not influence the utilization of AP tibial components. Despite low implantation, dated instrumentation, and cheaper materials, APT remained within a 0.4% margin of survivorship when compared to MBT implants.
Debridement, Antibiotics and Implant Retention (DAIR) and its Utilization to Treat Periprosthetic Joint Infections
Jeffrey B Stambough1, Bryan D. Springer2, Ayushmita De3, Heena Jaffri3, James A. Browne4, and David G. Lewallen5
1University of Arkansas for Medical Sciences; Little Rock, AR, USA
2OrthoCarolina Hip and Knee Center; Charlotte, North Carolina, USA
3American Academy of Orthopaedic Surgeons; Rosemont, IL, USA
4University of Virginia Health System; Charlottesville, VA, USA
5Mayo Clinic; Rochester, Minnesota, USA
Débridement, Antibiotics, and Implant Retention (DAIR) is utilized to manage acute periprosthetic joint infections (PJI) after total joint arthroplasty (TJA). The aim of this study is to evaluate the utilization of DAIR for total hip and knee arthroplasty and subsequent events identified on the same joint as reported in the American Joint Replacement Registry (AJRR).
DAIR procedures to treat PJI, defined by ICD-9/10 codes, reported to the AJRR from 2012-2020 were merged with Centers for Medicare and Medicaid Services (CMS) data from 2012-2020 to determine the incidence of patients who endured further PJI related procedures on the same joint. These procedures and conditions were queried as outcomes: sepsis, cellulitis, post-operative infection, endocarditis, amputation, knee fusion, resection, drainage, arthrotomy, and debridement.
There were 1,470 total DAIR procedures reported to both CMS and AJRR: 97% had a single DAIR and 3% had multiple DAIR attempts. After the first DAIR, 2.9% of subjects died, 18.9% progressed to subsequent revisions, 19.8% endured further TJA related procedures, and the remaining (55.4%) were not found to incur further surgery or infectious outcome. Frequencies after multiple DAIR attempts were queried: 2.3%, 34.1%, 34.1%, and 29.5% in the respective outcome order above.
Of the TJA population that had a DAIR procedure, 39.6% were identified with an additional PJI related event and 55.6% were not found to incur procedures, experience death, or an infectious endpoint in the linked CMS-AJRR dataset. Further investigation is required on this population to determine the fate of joints that undergo DAIR for PJI.
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