Deep infection is a devastating complication of total knee arthroplasty (TKA). This study aimed to determine if there was a relationship between surgeon volume and the incidence of revision for infection after primary TKA. Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 1 September 1999 to 31 December 2020 for primary TKA for osteoarthritis that were revised for infection. Surgeon volume was defined by the number of primary TKA procedures performed by the surgeon in the year the primary TKA was performed and grouped as <25, 25-49, 50-74, 75-99, >100 primary TKA procedures per year. Kaplan Meir estimates for cumulative percent revision (CPR) and Cox Proportional Hazard Ratios were performed to compare rates of revision for infection by surgeon volume, with sub-analyses for patella and polyethylene use, age <65 years and male gender. 5295 of 602,919 primary TKA for osteoarthritis were revised for infection. High volume surgeons (>100 TKA/year) had a significantly lower rate of revision for infection with a CPR at 1 and 17 years of 0.4% (95% CI 0.3, 0.4) and 1.5% (95% CI 1.2, 2.0), respectively, compared with 0.6% (95% CI 0.5, 0.7) and 2.1% (95% CI 1.8, 2.3), respectively, for low volume surgeons (<25 TKR/year). Differences between the high-volume group and the remaining groups remained when sub-analysis for age, gender, ASA, BMI, patella resurfacing and the use of cross-linked polyethylene (XLPE). High volume surgeons have lower rates of revision for infection in primary TKA

Recent registry data from around the world has strongly suggested that using cemented hip hemiarthroplasty has lower revision rates compared to cementless hip hemiarthroplasty for acute femoral neck hip fractures. The adoption of using cemented hemiarthroplasty for hip fracture has been slow as many surgeons continue to use uncemented stems. One of the reasons is that surgeons feel more comfortable with uncemented hemiarthroplasty as they have used it routinely. The purpose of this study is to compare the difference in revision rates of cemented and cementless hemiarthroplasty and stratify the risk by surgeon experience. By using a surgeons annual volume of Total Hip Replacements performed as an indicator for surgeon experience. The Canadian Joint Replacement Registry Database was used to collect and compare the outcomes to report on the revision rates based on surgeon volume. This is a large Canadian Registry Study where 68447 patients were identified for having a hip hemiarthroplasty from 2012-2020. This is a retrospective cohort study, identifying patients that had cementless or cemented hip hemiarthroplasty. The surgeons who performed the procedures were linked to the procedure Total Hip Replacement. Individuals were categorized as experienced hip surgeons or not based on whether they performed 50 hip replacements a year. Identifying high volume surgeon (>50 cases/year) and low volume (<50 cases/year) surgeons. Hazard ratios adjusted for age and sex were performed for risk of revision over this 8-year span. A p-value <0.05 was deemed significant. For high volume surgeons, cementless fixation had a higher revision risk than cemented fixation, HR 1.29 (1.05-1.56), p=0.017. This pattern was similar for low volume surgeons, with cementless fixation having a higher revision risk than cemented fixation, HR 1.37 (1.11-1.70) p=0.004 We could not detect a difference in revision risk for cemented fixation between low volume and high volume surgeons; at 0-1.5 years the HR was 0.96 (0.72-1.28) p=0.786, and at 1.5+ years the HR was 1.61 (0.83-3.11) p=0.159. Similarly, we could not detect a difference in revision risk for cementless fixation between low volume and high volume surgeons, HR 1.11 (0.96-1.29) p=0.161. Using large registry data, cemented hip hemiarthroplasty has a significant lower revision rate than the use of cementless stems even when surgeons are stratified to high and low volume. Low volume surgeons who use uncemented prostheses have the highest rate of revision. The low volume hip surgeon who cements has a lower revision rate than the high volume cementless surgeon. The results of this study should help to guide surgeons that no matter the level of experience, using a cemented hip hemiarthroplasty for acute femoral neck fracture is the safest option. That high volume surgeons who perform cementless hemiarthroplasty are not immune to having revisions due to their technique. Increased training and education should be offered to surgeons to improve comfort when using this technique

Recent registry data from around the world has strongly suggested that using cemented hip hemiarthroplasty has lower revision rates compared to cementless hip hemiarthroplasty for acute femoral neck hip fractures. The adoption of using cemented hemiarthroplasty for hip fracture has been slow as many surgeons continue to use uncemented stems. One of the reasons is that surgeons feel more comfortable with uncemented hemiarthroplasty as they have used it routinely. The purpose of this study is to compare the difference in revision rates of cemented and cementless hemiarthroplasty and stratify the risk by surgeon experience. By using a surgeons annual volume of Total Hip Replacements performed as an indicator for surgeon experience. The Canadian Joint Replacement Registry Database was used to collect and compare the outcomes to report on the revision rates based on surgeon volume. This is a large Canadian Registry Study where 68447 patients were identified for having a hip hemiarthroplasty from 2012-2020. This is a retrospective cohort study, identifying patients that had cementless or cemented hip hemiarthroplasty. The surgeons who performed the procedures were linked to the procedure Total Hip Replacement. Individuals were categorized as experienced hip surgeons or not based on whether they performed 50 hip replacements a year. Identifying high volume surgeon (>50 cases/year) and low volume (<50 cases/year) surgeons. Hazard ratios adjusted for age and sex were performed for risk of revision over this 8-year span. A p-value <0.05 was deemed significant. For high volume surgeons, cementless fixation had a higher revision risk than cemented fixation, HR 1.29 (1.05-1.56), p=0.017. This pattern was similar for low volume surgeons, with cementless fixation having a higher revision risk than cemented fixation, HR 1.37 (1.11-1.70) p=0.004 We could not detect a difference in revision risk for cemented fixation between low volume and high volume surgeons; at 0-1.5 years the HR was 0.96 (0.72-1.28) p=0.786, and at 1.5+ years the HR was 1.61 (0.83-3.11) p=0.159. Similarly, we could not detect a difference in revision risk for cementless fixation between low volume and high volume surgeons, HR 1.11 (0.96-1.29) p=0.161. Using large registry data, cemented hip hemiarthroplasty has a significant lower revision rate than the use of cementless stems even when surgeons are stratified to high and low volume. Low volume surgeons who use uncemented prostheses have the highest rate of revision. The low volume hip surgeon who cements has a lower revision rate than the high volume cementless surgeon. The results of this study should help to guide surgeons that no matter the level of experience, using a cemented hip hemiarthroplasty for acute femoral neck fracture is the safest option. That high volume surgeons who perform cementless hemiarthroplasty are not immune to having revisions due to their technique. Increased training and education should be offered to surgeons to improve comfort when using this technique

Strategy regarding patella resurfacing in total knee replacement (TKR) remains controversial. TKR revision rates are reportedly influenced by surgeon procedure volume. The study aim was to compare revision outcomes of TKR with and without patella resurfacing in different surgeon volume groups using data from the AOANJRR. The study population included 571,149 primary TKRs for osteoarthritis. Surgeons were classified as low, medium, or high-volume based on the quartiles of mean primary TKR volume between 2011 and 2020. Cumulative percent revision (CPR) using Kaplan-Meier estimates of survivorship were calculated for the three surgeon volume groups with and without patella resurfacing. Cox proportional hazards models, adjusted for age and sex, were used to compare revision risks. High-volume surgeons who did not resurface the patella had the highest all-cause CPR (20-year CPR 10.9%, 95% CI [10.0%, 12.0%]). When the patella was resurfaced, high-volume surgeons had the lowest revision rate (7.3%, 95% CI [6.4%, 8.4%]). When the high-volume groups were compared there was a higher rate of revision for the non-resurfaced group after 6 months. When the medium-volume surgeon groups were compared, not resurfacing the patella also was associated with a higher rate of revision after 3 months. The low-volume comparisons showed an initial higher rate of revision with patella resurfacing, but there was no difference after 3 months. When only patella revisions were considered, there were higher rates of revision in all three volume groups where the patella was not resurfaced. TKR performed by high and medium-volume surgeons without patella resurfacing had higher revision rates compared to when the patella was resurfaced. Resurfacing the patella in the primary procedure protected against revision for patella reasons in all surgeon volume groups. Level of evidence: III (National registry analysis)

We compared the rate of revision of two classes of primary anatomic shoulder arthroplasty, stemmed (aTSA) and stemless (sTSA) undertaken with cemented all polyethylene glenoid components. A large national arthroplasty registry identified two cohort groups for comparison, aTSA and sTSA between 1. st. January 2011 and 31. st. December 2020. A sub-analysis from 1 January 2017 captured additional patient demographics. The cumulative percentage revision (CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HR) from Cox proportional hazard models adjusted for age and gender. Of the 7,533 aTSA procedures, the CPR at 8 years was 5.3% and for 2,567 sTSA procedures was 4.0%. There was no difference in the risk of revision between study groups (p=0.128). There was an increased risk of revision for aTSA and sTSA undertaken with humeral head sizes <44mm (p=0.006 and p=0.002 respectively). Low mean surgeon volume (MSV) (<10 cases per annum) was a revision risk for aTSA (p=0.033) but not sTSA (p=0.926). For primary diagnosis osteoarthritis since 2017, low MSV was associated with an increased revision risk for aTSA vs sTSA in the first year (p=0.048). Conversely, low MSV was associated with a decreased revision risk for sTSA in the first 6 months (p<0.001). Predominantly aTSA was revised for loosening (28.8%) and sTSA for instability/dislocation (40.6%). Revision risk of aTSA and sTSA was associated with humeral head size and mean surgeon volume but not patient characteristics. Inexperienced shoulder arthroplasty surgeons experience lower early revision rates with sTSA in the setting of osteoarthritis. Revision of aTSA and sTSA occurred for differing reasons

Background. Anterior cruciate ligament (ACL) reconstruction with concomitant meniscal injury occurs frequently. Meniscal repair is associated with improved long-term outcomes compared to resection but is also associated with a higher reoperation rate. Knowledge of the risk factors for repair failure may be important in optimizing patient outcomes. Purpose. This study aimed to identify the patient and surgical risk factors for meniscal repair failure, defined as a subsequent meniscectomy, following concurrent primary ACL reconstruction. Methods. Data recorded by the New Zealand ACL Registry and the Accident Compensation Corporation, the New Zealand Government's sole funder of ACL reconstructions and any subsequent surgery, was reviewed. Meniscal repairs performed with concurrent primary ACL reconstruction was included. Root repairs were excluded. Univariate and multivariate survival analysis was performed to identify the patient and surgical risk factors for meniscal repair failure. Results. Between 2014 and 2020, a total of 3,024 meniscal repairs were performed during concurrent primary ACL reconstruction (medial repair = 1,814 and lateral repair = 1,210). The overall failure rate was 6.6% (n = 201) at a mean follow-up of 2.9 years, with a failure occurring in 7.8% of medial meniscal repairs (142 out of 1,814) and 4.9% of lateral meniscal repairs (59 out of 1,210). The risk of medial failure was higher in patients with a hamstring tendon autograft (adjusted HR = 2.20, p = 0.001), patients aged 21–30 years (adjusted HR = 1.60, p = 0.037) and in those with cartilage injury in the medial compartment (adjusted HR = 1.75, p = 0.002). The risk of lateral failure was higher in patients aged ≤ 20 years (adjusted HR = 2.79, p = 0.021) and when the procedure was performed by a surgeon with an annual ACL reconstruction case volume of less than 30 (adjusted HR = 1.84, p = 0.026). Conclusion. When performing meniscal repair during a primary ACL reconstruction, the use of a hamstring tendon autograft, younger age and the presence of concomitant cartilage injury in the medial compartment increases the risk of medial meniscal repair failure, whereas younger age and low surgeon volume increases the risk of lateral meniscal repair failure

The primary objective is to compare revision rates for lumbar disc replacement (LDR) and fusion at the same or adjacent levels in Ontario, Canada. The secondary objectives include acute complications during hospitalization and in 30 days, and length of hospital stay. A population-based cohort study was conducted using health administrative databases including patients undergoing LDR or single level fusion between October 2005 to March 2018. Patients receiving LDR or fusion were identified using physician claims recorded in the Ontario Health Insurance Program database. Additional details of surgical procedure were obtained from the Canadian Institute for Health Information hospital discharge abstract. Primary outcome measured was presence of revision surgery in the lumbar spine defined as operation greater than 30 days from index procedure. Secondary outcomes were immediate/ acute complications within the first 30 days of index operation. A total of 42,024 patients were included. Mean follow up in the LDR and fusion groups were 2943 and 2301 days, respectively. The rates of revision surgery at the same or adjacent levels were 4.7% in the LDR group and 11.1% in the fusion group (P=.003). Multivariate analysis identified risk factors for revision surgery as being female, hypertension, and lower surgeon volume. More patients in the fusion group had dural tears (p<.001), while the LDR group had more “other” complications (p=.037). The LDR group had a longer mean hospital stay (p=.018). In this study population, the LDR group had lower rates of revision compared to the fusion group. Caution is needed in concluding its significance due to lack of clinical variables and possible differences in indications between LDR and posterior decompression and fusion

The aim of this study was to determine the incidence, annual trend, perioperative outcomes, and identify risk factors of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis. Risk factors for early-onset deep SSI were assessed. We performed a retrospective population-based cohort study using prospectively collected patient-level data from several provincial administrative data repositories between January 2013, and March 2020. The diagnosis of early-onset deep SSI was based on published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definitions. The Mann-Kendall Trend Test was used to detect monotonic trends in early-onset deep SSI rates over time. The effects of various patient and surgical risk factors for early-onset deep SSI were analyzed using multiple logistic regression. Secondary outcomes were 90-day mortality and 90-day readmission. A total of 20,580 patients underwent primary TKA for osteoarthritis. Forty patients had a confirmed deep SSI within 90-days of surgery representing a cumulative incidence of 0.19%. The annual infection rate did not change over the 7-year study period (p = 0.879). Risk factors associated with early-onset deep SSI included blood transfusions (OR, 3.93 [95% CI 1.34-9.20]; p=0.004), drug or alcohol abuse (OR, 4.91 [95% CI 1.85-10.93]; p<0.001), and surgeon volume less than 30 TKA per year (OR, 4.45 [1.07-12.43]; p=0.013). Early-onset deep SSI was not associated with 90-days mortality (OR, 11.68 [0.09-90-58]; p=0.217), but was associated with an increased chance of 90-day readmission (OR, 50.78 [26.47-102.02]; p<0.001). This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable or can be optimized prior to surgery and be effective in reducing the incidence of early-onset SSI. This could guide the formulation of provincial screening programs and identify patients at high risk for SSI

Revision is a key negative outcome of joint replacements. The purpose of this abstract is to present revision risk curves for hip and knee replacements based on the most recently available national data sources. Having a better understanding of determinants of revision risk can help inform clinical and health care system improvements. We explored revision risk of primary joint replacement stratified by key clinical, prosthesis, and surgeon-level factors using data from three databases managed by CIHI: the Canadian Joint Replacement Registry (CJRR), the Discharge Abstract Database, and the National Ambulatory Care Reporting System. To investigate early revisions, we used Kaplan-Meier analysis stratified by demographic factors to determine the risk of revision within up to five years of primary surgery. This analysis identified the primary cohort from the CJRR from April 1, 2012 to March 31, 2017 and was limited to mandatory reporting provinces (British Columbia, Manitoba and Ontario) to ensure maximal coverage of prosthesis information. Bearing surface was obtained from the International Prosthesis Library maintained by the International Consortium of Orthopaedic Registries (ICOR) and the International Society of Arthroplasty Registers (ISAR). The total revision risk cohort contained 283,620 primary surgeries, of which 5,765 (2%) had at least one revision. For total hip arthroplasties, revision risk at the end of the follow-up period did not differ by age, by sex or across bearing surface (metal on cross-linked polyethylene [XLPE], ceramic on XLPE, ceramic on ceramic, metal on non-cross-linked polyethylene). For hemiarthroplasties in hip fracture patients, cement fixation was significantly associated with decreased revision risk. Surgeon volume had a positive effect on survivorship with cementless fixation (2.7% at one year [95% CI 2.3%, 3.1%] for high-volume vs 3.2% [2.7%, 3.7%] for low-volume). However, surgeon volume did not have an effect on survivorship with cemented fixation (2% at one year [95% CI 1.3%, 2.6%] for high-volume vs. 2% [1.4%, 2.6%] for low-volume). For total knee replacements, revision risk increased with decreasing age and male sex. For patients aged 75 and older, four-year revision risks were 1.5% (95% CI 1.3%, 1.7%) for women and 2.0% (1.7%, 2.3%) for men, but for patients under 55 years old, they were 4.3% (3.7%, 5%) for women and 5.9% (4.9%, 6.9%) for men. Additional results from the upcoming 2019 CJRR annual report, including data up to March 31, 2018, will be presented. Revisions represent a key failure of the primary replacement, they are costly to the health care system and negatively affect patients' quality of life. CJRR's coverage is currently 72%, increased coverage and follow-up time will allow increasingly comprehensive reporting on hip and knee prostheses in Canada. Future work in this area involves exploring additional prosthesis attributes for stratification of revision risk curves and calculation of hazards ratios adjusted by age and sex

Meniscal repairs are commonly performed during anterior cruciate ligament (ACL) reconstruction. This study aimed to identify the risk factors for meniscal repair failure following concurrent primary ACL reconstruction. Primary ACL reconstructions with a concurrent repair of a meniscal tear recorded in the New Zealand ACL Registry between April 2014 and December 2018 were analyzed. Meniscal repair failure was defined as a patient who underwent subsequent meniscectomy, and was identified after cross-referencing data from the ACL Registry with the national database of the Accident Compensation Corporation (ACC). Multivariate Cox regression was performed to produce hazard ratios (HR) with 95% confidence intervals (CI) to identify the patient and surgical risk factors for meniscal repair failure. 2041 meniscal repairs were analyzed (medial = 1235 and lateral = 806). The overall failure rate was 9.4% (n = 192). Failure occurred in 11.1% of medial (137/1235) and 6.8% of lateral (55/806) meniscal repairs. The risk of medial failure was higher with hamstring tendon autografts (adjusted HR = 2.00, 95% CI 1.23 – 3.26, p = 0.006) and in patients with cartilage injury in the medial compartment (adjusted HR = 1.56, 95% CI 1.09 – 2.23, p = 0.015). The risk of lateral failure was higher when the procedure was performed by a surgeon with an annual case volume of less than 30 ACL reconstructions (adjusted HR = 1.92, 95% CI 1.10 – 3.33, p = 0.021). Age, gender, time from injury-to-surgery and femoral tunnel drilling technique did not influence the risk of meniscal repair failure. When repairing a meniscal tear during ACL reconstruction, the use of a hamstring tendon autograft or the presence of cartilage injury in the medial compartment increases the risk of medial meniscal repair failure. Lower surgeon case volume increases the risk of lateral meniscal repair failure

Background. The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardisation of care on short-term post-operative outcomes and resource utilisation in lower-extremity total joint arthroplasty. Methods. An analysis of 182,146 consecutive patients who underwent primary total joint arthroplasty was performed with use of data entered into the Perspective database by 3421 physicians from 312 hospitals over a two-year period. Adherence to evidence-based processes of care was defined by administration of appropriate perioperative antibiotic prophylaxis, beta blockade, and venous thromboembolism prophylaxis. Patient outcomes included mortality, length of hospital stay, discharge disposition, surgical complications, readmissions, and reoperations within the first 30 days after discharge. Hierarchical models were used to estimate effects of hospital and surgeon procedure volume and standardisation on individual and combined surgical outcomes and length of stay. Results. After adjustment in multivariate models, higher surgeon volume was associated with lower risk of complications, lower rates of readmission and reoperation, shorter length of stay, and higher likelihood of being discharged home. Higher hospital volume was associated with lower risk of mortality and lower risk of readmission and higher likelihood of being discharged home. The impact of process standardisation was substantial; maximising adherence to evidence-based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of hospital or surgeon procedure volume. Conclusion. Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty, process standardisation is also strongly associated with improved quality and efficiency of care. The exact relationship between individual processes of care and patient outcomes has not been established. However, our findings suggest that process standardisation could help providers optimise quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume

Purpose. Factors that contribute to early and late re-operation after cruciate reconstruction (CR) have not been evaluated on a population level in a public health system. After surgery patients are at risk for knee stiffness, infection or early graft failure prompting revision. Long-term, ipsilateral revision CR, contralateral CR and potentially even joint replacement may occur. Population research in total joint replacement surgery has demonstrated an inverse relationship between complication/failure rates and surgeon procedural volume. We hypothesized that in Ontario, younger patient age and lower surgeon volume would increase the risk of short and long-term re-operation after CR. Method. Billing, procedural and diagnostic coding from administrative databases (Ontario Health Insurance Plan, Canadian Institutes of Health Research) were accessed through the Institute for Clinical Evaluative Sciences to develop the cohort of all Ontario residents aged 14 to 60 who underwent anterior or posterior CR from July 1992 to April 2008. Logistic regression analysis was used to calculate the odds ratio for patient (age, gender, comorbidity, income, concurrent knee surgery) and provider (surgeon volume, teaching hospital status) factors for having a surgical washout of the knee, manipulation for stiffness or repeat of the index event within six months. A cox proportional hazards survivorship model was used to calculate the hazard ratio of the same covariates for repeat CR and partial/total knee arthroplasty from inception until end of 2009. Results. The cohort identified 34,735 CR patients with a median age 28 yrs (IQR 20–36) and 65% male. Re-operation for infection was 0.2% and stiffness 0.5%. The long-term rate of any repeat CR was 7.7% after a mean 4.23.4 years. Female gender (OR=2.8, p<0.0001), overnight hospital stay (OR=2.1, p=0.0005), meniscal repair with CR (OR=1.9, p=0.008) and surgeon volume of 0–12 CR/yr (OR=4.0, p=0.0006), significantly increased the odds of re-operation for stiffness. The odds of re-operation for infection were significantly increased for surgeons performing 0–12 CR/yr (OR=3.8, p=0.007), and for CR performed at a teaching hospital (OR=2.3, p=0.002). Repeat CR was not influenced by surgeon volume at any time-point. Survival analysis demonstrated a long-term repeat CR rate of 13% (HR=1.8, p<0.0001) for age 14–19 yrs compared to the mean cohort age. Late partial or total knee replacement occurred in 0.75% of patients, with increased risk found for patients >30 years (HR=2.5, p=0.002), or who had concurrent surgery for an osteochondral lesion at the index CR (HR=2.3, p=0.001). Conclusion. Although this data is limited by the ability to distinguish between anterior or posterior and revision or contralateral CR, we have demonstrated that lower volume surgeons have higher complication rates (stiffness, infection) after CR surgery. We have also identified at-risk groups, such as females for stiffness post-CR and osteochondral injury + CR for eventual knee replacement

Purpose. Our hypothesis was that closed tibia fractures treated with intramedullary nails are impacted by surgeon and center volumes. Method. Data from 813 patients with closed tibia fractures were obtained from the SPRINT study. Using multiple regression, we examined the effect of center and surgeon volume (categorized as high, moderate, or low), and geographic differences by country (Canada, USA, and the Netherlands) on health-related quality-of-life and revision surgeries to gain union at one year. Our measures of quality-of-life were the Short-Form 36 Health Survey Questionnaire (SF-36 PCS) and the Short Musculoskeletal Function Assessment (SMFA). Results. Patients treated by moderate volume surgeons had a reduced risk of reoperation versus patients treated by low volume surgeons (odds ratio =0.54, 95% CI = 0.33 to 0.89, p=0.02). No effects of surgeon volume were seen for the other outcomes. Patients treated at moderate volume centers had poorer quality of life at one year than patients treated at low volume centers, based on the SMFA Bother score (difference = 7.33, 95% CI = 2.65 to 12.01). This effect was not seen with the other outcomes. Patients with isolated fractures have better quality-of-life at one year, based on all three measures, p<0.001. Older patients have poorer SMFA scores at one year than younger patients, p<0.001. There were no significant differences by country. Conclusion. The traditional volume versus outcome relationship for closed tibial fractures within intramedullary nailing does not hold. Further analyses in other areas of orthopaedic trauma surgery are advisable

There is limited evidence in the literature suggesting that ceramic-on-ceramic (CoC) THA is associated with lower risk of revision for prosthetic joint infection (PJI) than other bearing combinations especially metal-on-polyethylene (MoP) and metal-on-metal (MoM). Pitto and Sedel reported hazard ratios of 1.3 – 2.1 for other bearing surfaces vs. CoC. Of interest, the PJI rate was not significantly lower in the first 6 months, when most infections occur, but only became significant in the long term. While factors such as patient age, fixation, mode, O.R. type, use of body exhaust suits, and surgeon volume were considered in the multivariate analysis, BMI, medical comorbidities, and ASA class were not. This is a major weakness that casts doubt on the conclusion, since those three factors are MAJOR risk factors for PJI AND all three factors are more likely to be unevenly distributed, much more likely present in groups other than CoC. The data was also limited by the fact that it was drawn from a retrospective review of National Registry data, The New Zealand Joint Registry. While similar findings have recently been reported from the Australian Joint Registry, the danger in attributing differences in outcomes to implants alone is possibly the single greatest danger in interpreting registry results. While device design can impact implant survival, other factors such as surgical technique, surgeon, hospital, and especially patient factors have a far greater likelihood of explaining differences in observed results. A recent report from the same New Zealand joint registry reported that obesity, ASA class, surgical approach, and trainee operations all were associated with higher PJI and all would be more likely in non-CoC THAs. Accuracy of diagnosis is also a major concern. Revision for trunnionosis is more common in non-CoC THA and is frequently misdiagnosed as PJI. Numerous non-registry studies and reviews have compared PJI in CoC vs. other bearing and none have concluded than the incidence of PJI differed significantly

Purpose. Elective ACLR is indicated for symptomatic instability of the knee. Despite being a common procedure, there are numerous surgical techniques, graft and fixation choices. Many have been directly compared in randomized trials and meta-analyses. The typical operation is arthroscopic-assisted, uses autograft tendon and screw fixation. Research in elective joint replacement surgery has demonstrated an inverse relationship between surgeon volume and revision and complication rates. How patient demographics, provider characteristics and graft/fixation choices influence ACLR revision rates has not been reported on a population level. We hypothesized that ACLR using tendon autograft and screw fixation performed by high volume surgeons will have the lowest rate of revision. In contrast, the risk of contralateral ACLR in the same cohort will be influenced only by patient factors. Method. All ACLR performed in Ontario from July 2003 to March 2008 on Ontario residents aged 14 to 60 were identified using physician billing, procedural and diagnostic codes from administrative databases. Data was accessed through the Institute for Clinical Evaluative Sciences. The main outcomes were revision and contralateral ACLR sought from inception until end of 2009. Patient factors (age, gender, income, co-morbidity), surgical choices (allograft or autograft tendon; screw, biodegradable or endobutton/staple fixation) and associated procedures (meniscal repair, collateral ligament surgery) were entered as covariates in a cox proportional hazards survivorship model. Mean cohort patient characteristics were chosen as reference groups. Surgical options and associated procedures were analyzed in a binary fashion (yes/no). Results. We identified 13,997 primary ACLR with a mean follow up of 3.2 years. The rate of revision ACLR was 1.8% (mean 1.9 years), and primary contralateral ACLR 2.0% (mean 2.0 years). In the cox model, younger age (14–19 yrs; HR 2.9, p<0.001), teaching hospital (HR 2.1, p<0.001) and the use of endobutton/staple fixation (HR 4.4, p=0.01) conferred a higher risk of revision. No effect of graft type or surgeon volume was found. Only younger age (14–19 yrs; HR 1.9, p=0.0005) and not any provider or surgical covariates conferred a significant risk of contralateral ACLR. Conclusion. Our results confirm that young age confers a higher risk of both revision and contralateral ACLR and these patients should be counseled accordingly pre-operatively. The use of endobutton or a staple for fixation was an independent risk for revision ACLR. This finding needs to be explored further in a direct fashion. Finally, we report that the mean time to revision ACLR was almost two years a fact that should impact future randomized controlled trial design and prompt re-evaluation of those already published which typically use only 1–2 years as the endpoint of data collection

There is limited evidence in the literature suggesting that ceramic-on-ceramic (CoC) THA is associated with lower risk of revision for prosthetic joint infection (PJI) than other bearing combinations especially metal-on-poly (MoP) and metal-on-metal (MoM). Pitto and Sedel reported hazard ratios of 1.3 – 2.1 for other bearing surfaces versus CoC. Of interest, the PJI rate was not significantly lower in the first 6 months, when most infections occur, but only became significant in the long term. While factors such as patient age, fixation, mode, OR type, use of body exhaust suits, and surgeon volume were considered in the multivariate analysis, BMI, medical comorbidities, and ASA class were not. This is a major weakness that casts doubt on the conclusion, since those three factors are MAJOR risk factors for PJI AND all three factors are more likely to be unevenly distributed, and much more likely present in groups other than CoC. The data was also limited by the fact that it was drawn from a retrospective review of National Registry data, The New Zealand Joint Registry. While similar findings have recently been reported from the Australian Joint Registry, the danger in attributing differences in outcomes to implants alone is possibly the single greatest danger in interpreting registry results. While device design can impact implant survival, other factors such as surgical technique, surgeon, hospital, and especially patient factors have a far greater likelihood of explaining differences in observed results. A recent report from the same New Zealand joint registry reported that obesity, ASA class, surgical approach, and trainee operations all were associated with higher PJI and all would be more likely in non-CoC THAs. Accuracy of diagnosis is also a major concern. Revision for trunnionosis is more common in non-CoC THA and is frequently misdiagnosed as PJI. Numerous non-registry studies and reviews have compared PJI in CoC vs. other bearings and none have concluded than the incidence of PJI differed significantly

Introduction. Satisfaction and survival rates after total knee arthroplasty were high according to literatures. However, around 8% of revision surgeries were still noted and almost half of them were early failures, which were most seen in 2 years after primary surgery. This study aimed to find out the factors lead to early failures after total knee arthroplasty. Materials and Methods. Data were collected based on the National Health Insurance Research Data Base of Taiwan from 1996 to 2010. Primary total knee arthroplasty surgeries were included. Revisional total knee arthroplasty, removal of total knee implant and arthrotomy surgeries registered after primary total knee surgeries are seen as failures. Results. 1. Overall prevalence. Total failure rate is 3.67% (4820 in 131441) and 44.46% of them are early failures in two years after primary surgery (2143 in 4820). 2. Characters of patient. Higher early failure rates were found in patients who accepted primary surgery under 56 years old, compared to 56∼64 years old and <65 years old groups (>65years/old compared to <56years/old, HR:0.51 [95% CI 0.44–0.58]; 56–64 years/old compared to <56years old, HR:0.61 [95% CI 0.52–0.72]). Male patients were found to have higher early failure rates compared to female group (compared to female, HR:1.55, [95% CI 1.41–1.69]). 3. Character of disease. Diagnosis of Osteoarthritis or rheumatoid arthritis would have no difference in failure rates, but gouty arthritis and other reasons would lead to higher early failure rates (compared to osteoarthritis, HR:1.94, [95% CI 1.55- 2.42]). 4. Influences of comorbidity. Diabetes Mellitus would lead to higher early failure rate (compared to non-DM, HR:1.28, [95% CI 1.13–1.46]). No significant differences were found in Renal disease and higher Charlson Comorbidity Index. 5. Character of Health Care Provider. 41.50% surgeries were performed in Medical Centers(>500 beds), 27.20% in Metropolitan Hospitals(>250 beds) and 31.20% in Local Community Hospitals(>20 beds). Surgeries performed in Metropolitan and Local Community Hospitals would have higher early failure rates (Local compared to center H, HR:1.42 [95% CI 1.28 −1.57]; Metropolitan compared to center H, HR:1.23 [95% CI 1.11 −1.37]). 83.40% surgeries were performed by high volume surgeons. High volume surgeons would have lower early failure rates (compared to low volume, HR:0.62, [95% CI 0.52–0.75]). 87.20% surgeries were performed in high volume hospitals. High volume hospitals would have lower early failure rates (compared to low volume, HR:0.51, [95% CI 0.41- 0.63]). Conclusion and Discussion. Early failure rate (<2 years after primary surgery) in Taiwan is compatible to global data. Younger patients accepted total knee arthroplasty would have more failures, which might be a result of higher activity demand. Reasons other than osteoarthritis and rheumatoid arthritis such as gouty arthritis, hemophilia, post-traumatic arthritis and osteonecrosis can complicate the surgery and lead to higher failure rates. Patients with diabetes mellitus would have more infection risks and therefore lead to higher failures. High volume surgeons, high volume hospitals and even non-local hospitals could provide better trainings and facilities to patients, which can therefore lead to lower failures

The evidence to help the surgeon decide on the merits of which type of replacement to offer their patients is steadily mounting and comes from large datasets such as joint registries. There are many advantages of UKR vs TKR such as satisfaction, function, recovery, morbidity, mortality and cost but there is one major disadvantage. All registries show a higher failure rate with UKRs. Registries show that there are more excellent and fewer poor Patient Reported Outcome Measure Scores (PROMS) with UKR compared to TKR and the higher revision rate is in major part due to the threshold of revision. For instance, 60% of UKR are revised vs 10% of TKR with an Oxford score that is worse post-operation than pre-operation. Ease of revision with UKR is a major determinant of the higher revision rate. The real issue with UKR relates to usage. Most surgeons perform very few UKR on young patients with early arthritis viewing the procedure as a pre-TKR. Low surgeon volume equates to high revision rate in the national registries. Surgeons should either abandon UKR or do an adequate number to ensure success. Surgeons can improve their results by increasing their usage of UKR. The Unicompartmental Knee National Joint Registry (UKNJR) data shows that the optimal usage of the mobile UKR is between 20 and 50% of replacements. Fixed bearing usage is optimal at 20% but not higher. The other major advantage concerns the lower mortality rate with UKR. At 90 days it is less than half that of TKR and even at 8 years it is 10% less. For every 10 UKRs performed rather than TKR then one life is saved at 8 years. There is very little evidence suggesting that bi-UKR is necessary certainly with the mobile UKR. There is evidence, however that patellofemoral joint problems are a problem with fixed bearing UKR in the second decade

BACKGROUND. High-volume surgeons and hospital systems have been shown to deliver higher value care in several studies. However, no evidence-based volume thresholds for cost currently exist in total hip arthroplasty (THA). The objective of this study was to establish clinically meaningful volume thresholds based on cost for surgeons and hospitals performing THA. A secondary objective was to analyze the relative market share of THAs among the newly defined surgeon and hospital volume strata. METHODS. Using 136,501 patients from the New York State Department of Health's SPARCS database undergoing total hip arthroplasty, we used stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve to generate volume thresholds predictive of increased costs for both surgeons and hospitals. Additionally, we examined the relative proportion of annual THA cases performed by each of these surgeon and hospital volume strata we had established. RESULTS. SSLR analysis of cost by annual surgeon THA volume produced stratifications at: 0–73 (low), 74–123 (medium), and 124 or more (high) (Figure 1). Analysis by annual hospital THA volume produced stratifications at: 0–121 (low), 122–309 (medium), and 310 or more (high) (Figure 2). Hospital costs decreased significantly (P < .05) in progressively higher volume stratifications. The largest proportion of THA cases are performed at high-volume hospitals (48.6%); however, low-volume surgeons perform the greatest share of these cases (44.6%) (Figure 3). CONCLUSIONS. Our study establishes economies of scale in total hip arthroplasty by demonstrating a direct relationship between volume and cost reduction. High volume hospitals are performing the greatest proportion of total hip arthroplasties; however, low volume, surgeons perform the largest share of these cases, which highlights a potential area for enhanced value in the care of patients undergoing total hip arthroplasty