Background: Prior reports of the DePuy Synthes Trochanteric Fixation Nail Advanced (TFNA) revealed a potential mode of fatigue failure at the proximal screw aperture following fixation of extracapsular hip fractures. We sought to compare the revision risk between the TFNA and its prior-generation forebear, the Trochanteric Fixation Nail (TFN). Methods: A retrospective cohort study was performed using data from a U.S. integrated health-care system’s hip fracture registry. The study sample comprised patients who underwent cephalomedullary nail fixation for hip fracture with a TFN (n = 4,007) or TFNA (n = 3,972) from 2014 to 2019. We evaluated the charts and radiographs for patients who underwent any revision. Multivariable Cox regression was used to evaluate the risk of revision related to the index fracture. Results: At the 3-year follow-up, the cumulative probability of revision related to the index fracture was 1.8% for the TFN and 1.9% for the TFNA. After adjustment for covariates, no difference was observed in revision risk (hazard ratio [HR], 1.18 [95% confidence interval (CI), 0.80 to 1.75]; p = 0.40) for the TFNA compared with the TFN. The TFNA was associated with a higher risk of revision for nonunion than the TFN (HR, 1.86 [95% CI, 1.11 to 3.12]; p = 0.018). At the 3-year follow-up, implant breakage was 0.06% for the TFN and 0.2% for the TFNA; with regard to aperture failures related to the index fracture, there were 1 failure for the TFN group and 3 failures for the TFNA group. Conclusions: In a large cohort from a U.S. hip fracture registry, the TFNA had an overall revision rate that was similar to that of the earlier TFN, with implant breakage being a rare revision reason for both groups. Chart and radiographic review found that the TFNA was associated with a higher risk of revision for nonunion. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: With an increasing number of primary anterior cruciate ligament reconstructions (ACLRs), the burden of revision ACLR (rACLR) has also increased. Graft choice for rACLR is complicated by patient factors and the remaining available graft options. Purpose: To examine the association between graft type at the time of rACLR and the risk of repeat rACLR (rrACLR) in a large US integrated health care system registry while accounting for patient and surgical factors at the time of revision surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Data from the Kaiser Permanente ACLR registry were used to identify patients who underwent a primary isolated ACLR between 2005 and 2020 and then went on to have rACLR. Graft type used at rACLR, classified as autograft versus allograft, was the exposure of interest. Multivariable Cox proportional hazard regression was used to evaluate the risk of rrACLR, with ipsilateral and contralateral reoperation as secondary outcomes. Models included factors at the time of the rACLR (age, sex, body mass index, smoking status, staged revision, femoral fixation, tibial fixation, femoral tunnel method, lateral meniscal injury, medial meniscal injury, and cartilage injury) and a factor from the primary ACLR (activity at injury) as covariates. Results: A total of 1747 rACLR procedures were included. The crude cumulative rrACLR incidence at 8-year follow-up was 13.9% for allograft and 6.0% for autograft. Cumulative ipsilateral reoperation incidence at 8-year follow-up was 18.3% for allograft and 18.9% for autograft; contralateral reoperation cumulative incidence was 4.3% for allograft and 6.8% for autograft. With adjustment for covariates, a 70% lower risk for rrACLR was observed for autograft compared with allograft (hazard ratio [HR], 0.30; 95% CI, 0.18-0.50; P < .0001). No differences were observed for ipsilateral reoperation (HR, 1.05; 95% CI, 0.73-1.51; P = .78) or contralateral reoperation (HR, 1.33; 95% CI, 0.60-2.97; P = .48). Conclusion: The use of autograft at rACLR was associated with a 70% lower risk of rrACLR compared with allograft in this cohort from the Kaiser Permanente ACLR registry. When accounting for all reoperations outside of rrACLR after rACLR, the authors found no significant difference in risk between autograft and allograft. To minimize the risk of rrACLR, surgeons should consider using autograft for rACLR when possible.

Objective To determine the association of age at index birth with postpartum contraceptive use and optimal interpregnancy interval (IPI, defined as delivery to next pregnancy >18 months), controlling for provider type and client demographics among adolescent mothers who have repeat pregnancies. Methods California’s 2008 birth records were linked to California’s Medi-Cal and Family PACT claims data to identify 26,393 women with repeat births between 2002 and 2008, whose index birth occurred as an adolescent, and who received publicly-funded services within 18 months after the index birth. Multivariable regression analyses were conducted to examine the relationship between timing of contraception provision and interpregnancy intervals, adjusting for socio-demographic factors. Results Seventy-eight percent of adolescent women did not receive contraception at their first postpartum visit, and twenty-eight percent of adolescent women never received contraception from a Family PACT or Medi-Cal provider. Adolescents who were older at their index birth had lower rates of optimal IPIs. Native American, Asian-Pacific Islander and Latina women had lower rates of optimal IPIs compared to white women. Compared to those using only barrier methods, adolescent women receiving highly effective contraceptive methods had a 4.25 times higher odds of having an optimal IPI than those receiving hormonal methods (OR 2.10), or using no method (OR 0.70). Conclusion Effective postpartum contraceptive use and being a Family PACT provider were associated with optimal birth spacing among adolescent mothers, yet racial and ethnic disparities persisted. A missed opportunity was the provision of contraception at the first postpartum visit. Providers should aim to remove barriers to initiation of contraception at this visit.

Background: Use of cementless TKA has grown after encouraging data from contemporary implants. Yet registry studies have shown inferior survivorship of cementless fixation when treated as a monolithic class aggregating contemporary and historic designs. Two contemporary cementless TKA designs with distantly different fixation strategies have emerged in the last 2 decades, mostly focused on tibial fixation: porous tantalum and twin-peg tibia and, more recently, porous titanium and a spikes-and-keel tibia. However, their survivorship in comparison with cemented options and between each other remains to be thoroughly delineated. Questions/purposes: (1) Is there a difference in aseptic survivorship between cementless twin-peg TKA constructs compared with cemented options? (2) Is there a difference in aseptic survivorship between cementless spikes-and-keel TKA constructs compared with cemented options? (3) Is there a difference in aseptic survivorship between cementless twin-peg TKA constructs compared with cementless spikes-and-keel TKA constructs? Methods: We conducted a cohort study using data from the Kaiser Permanente Total Joint Replacement Registry (TJRR). The TJRR prospectively collects patient, perioperative, and implant details on all patients who undergo TKA in a multiregional organization with 12 million members; patients included in the TJRR are longitudinally monitored for outcomes after TKA, and identified outcomes are manually validated through chart review. Patients who underwent primary TKA for osteoarthritis from 2009 to 2023 with a fully cementless construct of either twin-peg or spikes-and-keel, and their fully cemented options, were included (n = 136,443). TKA with hybrid or unknown fixation (2.6% [3571]), rotating or unknown mobility (0.8% [1081]), or fully constrained or unknown stability (1.1% [1549]) were excluded. The final study sample included 130,242 primary TKAs performed by 388 surgeons at 60 hospitals. Of the 125,414 patients receiving twin-peg TKAs, 9.2% who received cemented and 12.3% who received cementless were lost to follow-up. Of the 4828 patients receiving spikes-and-keel TKAs, 11.3% who received cemented versus 11.2% who received cementless were lost to follow-up. Those who terminated membership during the study period tended to be younger than those who did not (65 versus 68 years for both groups). A comparison between cementless (575 twin-peg and 1574 spikes-and-keel) versus cemented (124,839 twin-peg and 3254 spikes-and-keel) fixation was performed for each pair of analogous implants. For the twin-peg comparison, when comparing the cementless group to the cemented group, the cementless group was younger (61 versus 68 years), included more male patients (77% versus 39%), and more patients who self-reported White race (76% versus 66%). For the spikes-and-keel comparison, when comparing the cementless group to the cemented group, the cementless group was younger (65 versus 70 years), had a higher BMI (32 versus 31 kg/m²), included more male patients (47% versus 29%), and had a higher proportion of minimally stabilized implants (57% versus 33%). A secondary comparison was performed between the two fully cementless fixation constructs. When comparing the twin-peg to spikes-and-keel cementless groups, the twin-peg group was younger (61 versus 65 years), included more male patients (76% versus 47%), had a higher proportion of those with an American Society of Anesthesiologist (ASA) classification of 1 to 2 (70% versus 44%), and had a higher proportion of posterior stabilized implants (56% versus 43%). Before outcome evaluation, propensity score weights were calculated using multivariable logistic regression models that included patient age, gender, BMI, race, smoking status, ASA classification, implant stability, and operative year as predictors of treatment assignment. After the application of propensity score weighting, all factors were balanced between the comparison groups except for male gender for the cementless versus cemented twin-peg comparison and twin-peg versus spikes-and-keel cementless comparison. Propensity score–weighted Cox proportional hazards regression was used to evaluate aseptic revision risk of the TKA construct during follow-up for all comparisons. A secondary adjustment was applied in the regression model for male gender as balance was not achieved after propensity score weighting alone. Results: In the adjusted analysis for the twin-peg group, cementless fixation had a higher risk of aseptic revision compared with cemented fixation (HR 2.13 [95% confidence interval (CI) 1.30 to 3.50]; p = 0.003). In the adjusted analysis for the spikes-and-keel group, no difference in aseptic revision risk was observed between cementless and cemented fixation (HR 0.94 [95% CI 0.56 to 1.58]; p = 0.82). When directly comparing cementless twin-peg to spikes-and-keel, twin-peg was associated with a higher risk of aseptic revision compared with spikes-and-keel (HR 2.56 [95% CI 1.13 to 5.79]; p = 0.02). Conclusion: In this large registry-based cohort study, no cementless TKA construct was associated with better implant survivorship compared with their cemented counterpart options. Cementless fixation may continue to evolve and improve, as cementless spikes-and-keel performed better than twin-peg. But given that reliable results have been observed over longer periods with established cemented TKA, at present, the prudent choice remains cemented TKA. Future recommendations may change but require a demonstrable advantage in implant survivorship and outcomes of future cementless constructs over cemented fixation in carefully designed studies. Level of Evidence: Level III, therapeutic study.

Background: Hamstring autograft (HA) is a popular graft for anterior cruciate ligament reconstruction (ACLR). Although multiple studies have demonstrated that increasing the graft diameter decreases the risk of failure or revision surgery, the exact minimum graft diameter remains controversial, with the unofficial standard being 8 mm. Purpose: To evaluate the risk of aseptic revision after HA-ACLR in patients aged ≤25 years, comparing graft diameters of (1) 8 mm. A secondary purpose was to determine whether there was a threshold for graft diameter that best identifies patients at a higher risk of aseptic revision. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 5972 primary HA-ACLRs were identified using data from the ACLR registry of Kaiser Permanente. Propensity score–weighted Cox regression was used to evaluate revision risk for HAs with 8 mm diameter. An effect plot and receiver operating characteristic curve and area under the curve (AUC) analysis were also created to model the probability of revision based on the HA diameter to determine whether there was a specific diameter threshold to minimize revision risk. Results: In the propensity score–weighted Cox model, 8 mm grafts (HR, 1.32 [95% CI, 1.06-1.66]; P = .015). In receiver operating characteristic analysis, an HA diameter that best identified patients at a higher risk for revision after ACLR could not be identified (AUC, 0.56). However, the adjusted effect plot showed a direct decrease in revision risk with each increasing increment in graft size. Conclusion: A 32% higher risk of revision was observed in smaller graft diameter groups (8 mm), regardless of specific diameter cutoff. In a cohort of almost 6000 HA-ACLR, the authors were unable to determine a definitive minimum graft diameter threshold that should be used.