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Postoperative Anterior Cruciate Ligament Reconstruction Quadricep and Patella Tendon Rupture, Infection, and Lysis of Adhesions Decreased Despite Changing Graft Trends Over the Past Decade

Open AccessPublished:June 23, 2022DOI:https://doi.org/10.1016/j.asmr.2022.04.033

      Purpose

      To investigate recent trends in postoperative complications following anterior cruciate ligament (ACL) reconstruction.

      Methods

      Patients who underwent ACL reconstruction surgery were identified in a national insurance database and separated into 2 cohorts based on the date of their initial surgery comprising the years 2010 to 2012 and 2016 to 2018, respectively. Patients were matched 1:1 based on comorbidities and Elixhauser Comorbidity Index. All patients were assessed for postoperative complications within 18 months of surgery. Rate of complication was compared between cohorts.

      Results

      Overall, the all-cause complication rate was 2%. There were significantly more quadriceps tendon rupture, patella tendon rupture, lysis of adhesion, and infection in the early cohort. There were significantly more instances of deep vein thrombosis in the late cohort. We found no significant difference in manipulations under anesthesia between the 2 cohorts.

      Conclusions

      Patients who underwent surgery in the late cohort had lower rates of postoperative complications, except for deep vein thrombosis. The rate of postoperative quadriceps tendon rupture decreased despite considerable increase in the use of quadriceps tendon autograft.

      Clinical Relevance

      As there has been an increased use of quadriceps tendon autografts, but little is known about the postoperative complications after ACL reconstruction with these grafts. This information has the potential to improve patient outcomes.
      Anterior cruciate ligament (ACL) tears are one of the most common orthopaedic injuries sustained in the United States, with an annual incidence of 68.6 per 100,000 person-years.
      • Sanders T.L.
      • Maradit Kremers H.
      • Bryan A.J.
      • et al.
      Incidence of anterior cruciate ligament tears and reconstruction: A 21-year population-based study.
      ACL reconstruction is most commonly performed using either bone–patellar tendon–bone (BPTB) or hamstring tendon (HT) autograft; however, use of quadriceps tendon (QT) autograft has increased over the past decade.
      • Hurley E.T.
      • Calvo-Gurry M.
      • Withers D.
      • Farrington S.K.
      • Moran R.
      • Moran C.J.
      Quadriceps tendon autograft in anterior cruciate ligament reconstruction: A systematic review.
      ,
      • Middleton K.K.
      • Hamilton T.
      • Irrgang J.J.
      • Karlsson J.
      • Harner C.D.
      • Fu F.H.
      Anatomic anterior cruciate ligament (ACL) reconstruction: A global perspective. Part 1.
      Reported advantages of QT autograft include ease of harvest, large cross-sectional area, and relatively low donor-site morbidity.
      • Lavender C.
      • Fravel W.
      • Patel T.
      • Singh V.
      Minimally invasive quad harvest featuring endoscopic closure and preparation with adjustable suspensory fixation device incorporated with braided suture.
      ,
      • Mouarbes D.
      • Menetrey J.
      • Marot V.
      • Courtot L.
      • Berard E.
      • Cavaignac E.
      Anterior cruciate ligament reconstruction: A systematic review and meta-analysis of outcomes for quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring-tendon autografts.
      In less than 5 years, the rate of QT autograft use increased 4-fold from 2.5% in 2010 to 11% in 2014.
      • Widner M.
      • Dunleavy M.
      • Lynch S.
      Outcomes following ACL reconstruction based on graft type: Are all grafts equivalent?.
      A recent survey of the ACL study group demonstrated that the popularity of QT autograft has continued to increase from 2014 to present.
      • Arnold M.P.
      • Calcei J.G.
      • Vogel N.
      • et al.
      ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades.
      It is also known that QT autograft is becoming increasingly used in revision ACL reconstruction, possibly due to decreased failure rates relative to HT autograft.
      • Winkler P.W.
      • Vivacqua T.
      • Thomassen S.
      • et al.
      Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction.
      As QT use has increased since 2010, so too has its inclusion in orthopaedic literature. A systematic review by Heffron et al.
      • Heffron W.M.
      • Hunnicutt J.L.
      • Xerogeanes J.W.
      • Woolf S.K.
      • Slone H.S.
      Systematic review of publications regarding quadriceps tendon autograft use in anterior cruciate ligament reconstruction.
      showed that since its introduction to orthopaedic literature in 1979, 30% of all publications on QT for ACL reconstruction were published between 2016 and 2019.
      BPTB and HT are traditionally thought to be the standard choices for ACL reconstruction autograft; however, recent data have shown that outcomes for QT versus BPTB and HT are, at least, equivocal. Cavaignac et al.
      • Cavaignac E.
      • Coulin B.
      • Tscholl P.
      • Nik Mohd Fatmy N.
      • Duthon V.
      • Menetrey J.
      Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years.
      found that Lysholm, Knee Injury and Osteoarthritis Outcome Score, and Knee Injury and Osteoarthritis Outcome Score Sport scores were significantly improved in patients grafted with QT versus HT. In the same study, indices of stability such as side-to-side difference and presence of negative Lachman test were improved in the QT group.
      • Cavaignac E.
      • Coulin B.
      • Tscholl P.
      • Nik Mohd Fatmy N.
      • Duthon V.
      • Menetrey J.
      Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years.
      Recent systematic reviews have gone on to demonstrate no significant differences in patient-reported outcomes, stability indices, and graft failure rates in patients treated with QT compared with both BPTB and HT. In fact, QT was shown to have lower rates of anterior knee pain and donor-site pain than BPTB.
      • Hurley E.T.
      • Calvo-Gurry M.
      • Withers D.
      • Farrington S.K.
      • Moran R.
      • Moran C.J.
      Quadriceps tendon autograft in anterior cruciate ligament reconstruction: A systematic review.
      ,
      • Mouarbes D.
      • Menetrey J.
      • Marot V.
      • Courtot L.
      • Berard E.
      • Cavaignac E.
      Anterior cruciate ligament reconstruction: A systematic review and meta-analysis of outcomes for quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring-tendon autografts.
      The purpose of this study was to investigate recent trends in postoperative complications following ACL reconstruction. Our null hypothesis was that there would be no significant difference in the rate of postoperative complications between the 2 cohorts despite a significant increase in QT use for ACL reconstruction since 2010.

      Methods

      Database

      This retrospective study was conducted using PearlDiver, a national insurance claims database widely used in orthopaedic literature. PearlDiver comprises more than 93 million individual patient records spanning 2010 to 2020. These records are searchable using physician billing codes including International Classification of Diseases, Revisions 9 and 10 (ICD-9/ICD-10) diagnostic codes, Current Procedural Terminology (CPT) procedural codes, and drug codes.

      Patient Selection

      All patients who underwent an ACL reconstruction were identified in the database via CPT 29888 and sorted based on the date of their surgery into 2 cohorts: an early cohort comprising the years of 2010 to 2012 and a late cohort from 2016 to 2018. As we were interested in comparing their postoperative complications, all patients were required to be continuously active for 18 months in the database following the initial date of surgery.
      We matched patient comorbidities 1:1 based on age, sex, tobacco use, obesity, diabetes, and Elixhauser Comorbidity Index between the 2 cohorts. Postoperative surgical complications included QT rupture, patellar tendon rupture, manipulation under anesthesia, return to the operating room for lysis of adhesions, infection, and deep vein thrombosis (DVT). The surgical complications rates were defined using CPT and ICD-9 codes.

      Statistical Analysis

      We used Pearson χ2 analysis to assess the univariate difference in rates of surgical complications between the early and late cohorts. The Student t-test was used to compare continuous variables. All tests were conducted at an alpha level of 0.05. For complication outcomes that were statistically significant, a multivariate logistic regression was used to account for potential confounding from the comorbidities and demographic factors of age, sex, tobacco use, obesity, and diabetes. The adjusted odds ratios (ORs) and confidence intervals (CIs) were determined from the multivariate analysis. Statistical analysis was done using the R statistical package available through PearlDiver.

      Results

      A total of 80,376 patients who underwent ACL reconstruction were identified, 46,024 of whom underwent surgery in the years 2010 to 2012, and 34,352 of whom underwent surgery in the years 2016 to 2018 with 18 months of follow-up. After matching patient comorbidities and Elixhauser Comorbidity Index 1:1, 27,057 patients remained in each cohort (Table 1). Overall, the all-cause complication rate was 2%. There was significantly more QT rupture, patella tendon rupture, lysis of adhesion, and infection in the early cohort (Table 2). However, there was significantly more DVTs in the late cohort. We found no significant difference in manipulations under anesthesia (MUA) between the 2 cohorts.
      Table 1Patient Demographics
      DemographicsEarly Cohort (n = 27,057)Late Cohort (n = 27,057)P Value
      Obesity5,356 (19.8%)5,356 (19.8%)1
      Diabetes2,163 (7.9%)2,163 (7.9%)1
      Tobacco5,761 (21.3%)5,761 (21.3%)1
      >60 years old518 (1.9%)518 (1.9%)1
      Female14,254 (52.7%)14,254 (52.7%)1
      NOTE. n = 54,114. Patient demographics showing the percentage of patients with diagnosis of obesity, history of diabetes, history of tobacco use, age older than 60 years, and female sex in both the early (2010-2012) and late (2016-2018) cohorts.
      Table 2Complication Rates
      OutcomesEarly Cohort (n = 27,057)Late Cohort (n = 27,057)P Value
      Quadriceps rupture15 (0.1%)1 (0.003%)<.001
      Patella tendon rupture12 (0.04%)1 (0.003%).003
      Manipulation198 (0.7%)221 (0.8%).178
      Adhesion lysis22 (0.08%8 (0.03%).013
      Infection344 (1.3%)191 (0.7%)<.001
      DVT3 (0.01%)89 (0.3%)<.001
      NOTE. P values in bold indicate statistical significance.
      DVT, deep vein thrombosis.
      The univariate and multivariate logistic regression results are listed in Appendix Table 1, Appendix Table 2, Appendix Table 3, Appendix Table 4, Appendix Table 5, Appendix Table 6, Appendix Table 7, Appendix Table 8, available at www.arthroscopyjournal.org. Univariate analysis demonstrated QT rupture to be independently associated with diabetes (OR 5.24; 95% CI 1.65-14.4). MUA was found to be independently associated with female sex (OR 2.3; 95% CI 1.86-2.85). Patella tendon rupture and lysis of adhesions were not found to be associated with any patient comorbidities. Infection was found to be associated with female sex, obesity, and tobacco use on multivariate analysis, whereas DVT was found to associated with diabetes and obesity.

      Discussion

      The most important finding of our study was that patients who underwent ACLR in the late cohort had lower rates of postoperative complications, except for DVT. Counterintuitively, there was a significantly lower number of postoperative QT ruptures in patients who underwent ACL reconstruction in the late cohort despite increasing popularity of QT autograft over the past decade. The rate of patella tendon rupture also significantly decreased in the late cohort; however, this observation may be secondary to the decreasing popularity of BPTB autograft for ACL reconstruction over the past 2 decades (preferred graft for 90% of surgeons in 1990 to under 40% in 2021).
      • Arnold M.P.
      • Calcei J.G.
      • Vogel N.
      • et al.
      ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades.
      ,
      • Yucens M.
      • Aydemir A.N.
      Trends in anterior cruciate ligament reconstruction in the last decade: A web-based analysis.
      There was a significant increase in the rate of DVTs in the late cohort. At our institution pharmacologic thromboprophylaxis is not routinely prescribed for patients following ACL reconstruction. A recent national insurance database study reported that only 3.5% of the more than 14,000 patients included in the study received pharmacologic thromboprophylaxis following ACL reconstruction.
      • Qin C.
      • Qin M.M.
      • Baker H.
      • Shi L.L.
      • Strelzow J.
      • Athiviraham A.
      Pharmacologic thromboprophylaxis other than aspirin is associated with increased risk for procedural intervention for arthrofibrosis after anterior cruciate ligament reconstruction.
      Interestingly, pharmacologic thromboprophylaxis other than aspirin (acetylsalicylic acid) was associated with increased risk of procedural intervention for arthrofibrosis after ACL reconstruction.
      • Qin C.
      • Qin M.M.
      • Baker H.
      • Shi L.L.
      • Strelzow J.
      • Athiviraham A.
      Pharmacologic thromboprophylaxis other than aspirin is associated with increased risk for procedural intervention for arthrofibrosis after anterior cruciate ligament reconstruction.
      In our study, DVT was associated with diabetes and obesity. Not using a tourniquet has also previously been reported to decrease the incidence of DVT after ACL reconstruction.
      • Nagashima M.
      • Takeshima K.
      • Origuchi N.
      • et al.
      Not using a tourniquet may reduce the incidence of asymptomatic deep venous thrombosis after ACL reconstruction: An observational study.
      Surgeons should consider forgoing or limiting the use of tourniquet in patients who are high risk for postoperative DVT (those with obesity, diabetes, or those who are smokers).
      • Forlenza E.M.
      • Parvaresh K.C.
      • Cohn M.R.
      • et al.
      Incidence and risk factors for symptomatic venous thromboembolism following anterior cruciate ligament reconstruction.
      ,
      • Gaskill T.
      • Pullen M.
      • Bryant B.
      • Sicignano N.
      • Evans A.M.
      • DeMaio M.
      The prevalence of symptomatic deep venous thrombosis and pulmonary embolism after anterior cruciate ligament reconstruction.
      The overall infection rate was low between the 2 cohorts, approximately 1%. Infection, not surprisingly, was associated with obesity and tobacco use, which has previously been reported.
      • Novikov D.A.
      • Swensen S.J.
      • Buza 3rd, J.A.
      • Gidumal R.H.
      • Strauss E.J.
      The effect of smoking on ACL reconstruction: A systematic review.
      Baron et al.
      • Baron J.E.
      • Shamrock A.G.
      • Cates W.T.
      • et al.
      Graft preparation with intraoperative vancomycin decreases infection after ACL reconstruction: A review of 1,640 cases.
      previously demonstrated that ACL graft preparation with vancomycin-soaked grafts were associated with a 10-fold reduction in infection rate after ACL reconstruction (0.1 vs 1.2%). Graft preparation with vancomycin-soaked gauze for high-risk patients (those with obesity or those who are smokers) should be considered.
      The rate of return to the operating room for postoperative lysis of adhesion was found to be significantly lower in the late cohort. These findings may be secondary to the continued emphasis on the importance of prehabilitation before ACL reconstruction.
      • Carter H.M.
      • Littlewood C.
      • Webster K.E.
      • Smith B.E.
      The effectiveness of preoperative rehabilitation programmes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction: a systematic review.
      • Cunha J.
      • Solomon D.J.
      ACL prehabilitation improves postoperative strength and motion and return to sport in athletes.
      • Giesche F.
      • Niederer D.
      • Banzer W.
      • Vogt L.
      Evidence for the effects of prehabilitation before ACL-reconstruction on return to sport-related and self-reported knee function: A systematic review.
      Female sex was found to be associated with MUA; this risk factor has been previously described with similar ORs to our results.
      • Sanders T.L.
      • Kremers H.M.
      • Bryan A.J.
      • Kremers W.K.
      • Stuart M.J.
      • Krych A.J.
      Procedural intervention for arthrofibrosis after ACL reconstruction: Trends over two decades.
      Interestingly there was no difference in MUA between the cohorts, despite the significant difference in lysis of adhesions.
      Given the increasing popularity of QT autograft for ACL reconstruction, several studies have been published recently comparing the outcomes of QT autograft with BPTB and NT autografts. Two recently published systematic reviews demonstrated QT autograft has comparable clinical and functional outcomes and graft survival rate with BPTB and HT autografts.
      • Hurley E.T.
      • Calvo-Gurry M.
      • Withers D.
      • Farrington S.K.
      • Moran R.
      • Moran C.J.
      Quadriceps tendon autograft in anterior cruciate ligament reconstruction: A systematic review.
      ,
      • Mouarbes D.
      • Menetrey J.
      • Marot V.
      • Courtot L.
      • Berard E.
      • Cavaignac E.
      Anterior cruciate ligament reconstruction: A systematic review and meta-analysis of outcomes for quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring-tendon autografts.
      Several studies have demonstrated significantly less harvest-site pain in patients who underwent ACL reconstruction with QT autograft compared with BPTB autograft.
      • Geib T.M.
      • Shelton W.R.
      • Phelps R.A.
      • Clark L.
      Anterior cruciate ligament reconstruction using quadriceps tendon autograft: Intermediate-term outcome.
      • Gorschewsky O.
      • Stapf R.
      • Geiser L.
      • Geitner U.
      • Neumann W.
      Clinical comparison of fixation methods for patellar bone quadriceps tendon autografts in anterior cruciate ligament reconstruction: Absorbable cross-pins versus absorbable screws.
      • Han H.S.
      • Seong S.C.
      • Lee S.
      • Lee M.C.
      Anterior cruciate ligament reconstruction: Quadriceps versus patellar autograft.
      • Kim S.J.
      • Jo S.B.
      • Kumar P.
      • Oh K.S.
      Comparison of single- and double-bundle anterior cruciate ligament reconstruction using quadriceps tendon-bone autografts.
      • Kim S.J.
      • Kumar P.
      • Oh K.S.
      Anterior cruciate ligament reconstruction: Autogenous quadriceps tendon-bone compared with bone-patellar tendon-bone grafts at 2-year follow-up.
      However, three studies demonstrated no significant difference in donor-site pain when comparing HT autograft to QT autograft.
      • Cavaignac E.
      • Coulin B.
      • Tscholl P.
      • Nik Mohd Fatmy N.
      • Duthon V.
      • Menetrey J.
      Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years.
      ,
      • Haner M.
      • Bierke S.
      • Petersen W.
      Anterior cruciate ligament revision surgery: Ipsilateral quadriceps versus contralateral semitendinosus-gracilis autografts.
      ,
      • Runer A.
      • Wierer G.
      • Herbst E.
      • et al.
      There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: A 2-year patient-reported outcome study.
      Biomechanically QT autograft has properties similar to those of the native ACL.
      • Duquin T.R.
      • Wind W.M.
      • Fineberg M.S.
      • Smolinski R.J.
      • Buyea C.M.
      Current trends in anterior cruciate ligament reconstruction.
      ,
      • Mohtadi N.G.
      • Chan D.S.
      • Dainty K.N.
      • Whelan D.B.
      Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults.
      The cross-sectional area and load to failure of the native ACL is 44 mm2 and 1725 to 2160 N, respectively.
      • Noyes F.R.
      • Butler D.L.
      • Grood E.S.
      • Zernicke R.F.
      • Hefzy M.S.
      Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions.
      While the tensile strength of the QT autograft is 2352 N, which exceeds the load to failure of the native ACL, and is similar to the tensile strength of BPTB(2977 N) and quadriceps autograft (2422 to 4090 N).
      • Noyes F.R.
      • Butler D.L.
      • Grood E.S.
      • Zernicke R.F.
      • Hefzy M.S.
      Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions.
      However, in comparison, the cross-sectional area of QT autograft is larger (62 mm2) than HT (53 mm2) and BPTB (35 mm2) autografts.
      • Noyes F.R.
      • Butler D.L.
      • Grood E.S.
      • Zernicke R.F.
      • Hefzy M.S.
      Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions.
      ,
      • Harris N.L.
      • Smith D.A.
      • Lamoreaux L.
      • Purnell M.
      Central quadriceps tendon for anterior cruciate ligament reconstruction. Part I: Morphometric and biomechanical evaluation.
      Thus, QT autograft provides a thicker graft, compared with HT and BPTB autograft, with acceptable load to failure strength and similar clinical and functional outcomes.
      Both QT and BPTB autograft are harvested from the extensor mechanism; thus, potential donor-site morbidity theoretically is similar between the 2 graft choices. However, BPTB carries a greater incidence of morbidity in terms of anterior knee pain, patella fracture, patella tendon rupture, patellofemoral arthritis, kneeling pain, and infrapatellar nerve injury.
      • Mohtadi N.G.
      • Chan D.S.
      • Dainty K.N.
      • Whelan D.B.
      Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults.
      ,
      • Benner R.W.
      • Shelbourne K.D.
      • Urch S.E.
      • Lazarus D.
      Tear patterns, surgical repair, and clinical outcomes of patellar tendon ruptures after anterior cruciate ligament reconstruction with a bone–patellar tendon–bone autograft.
      • Ejerhed L.
      • Kartus J.
      • Sernert N.
      • Kohler K.
      • Karlsson J.
      Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction? A prospective randomized study with a two-year follow-up.
      • Ferrer G.A.
      • Miller R.M.
      • Murawski C.D.
      • et al.
      Quantitative analysis of the patella following the harvest of a quadriceps tendon autograft with a bone block.
      • Kartus J.
      • Movin T.
      • Karlsson J.
      Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts.
      • Liden M.
      • Ejerhed L.
      • Sernert N.
      • Laxdal G.
      • Kartus J.
      Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction: A prospective, randomized study with a 7-year follow-up.
      In their series of 5364 ACL reconstructions with BPTB autograft, Benner at al.
      • Benner R.W.
      • Shelbourne K.D.
      • Urch S.E.
      • Lazarus D.
      Tear patterns, surgical repair, and clinical outcomes of patellar tendon ruptures after anterior cruciate ligament reconstruction with a bone–patellar tendon–bone autograft.
      reported an incidence of patella tendon rupture of 0.24%. In comparison with our findings, the rate of patella tendon rupture after ACL reconstruction with BPTB autograft reported by Benner et al. is approximately 1,000 times that of QT rupture following ACL reconstruction. Thus, all-soft tissue QT auto graft demonstrates a lower rate of extensor mechanism disruption when compared BPTB autograft.

      Limitations

      This paper has a number of limitations consistent with those of any database study. The power of this paper rests on the validity of physician billing and coding, which at times can be imprecise. Although previous studies have reported the error rate of coding to be roughly 1.3%, it is important nonetheless to acknowledge that we are unable to report the accuracy of the coding in this dataset. Unfortunately, there is only one CPT code for ACL reconstruction (29888), and it does not further specify between ACL repair, ACL reconstruction, and if reconstruction was performed whether autograft or allograft was used and the technique performed. Further, the PearlDiver database does not code for laterality, thus we were unable to confirm whether the 20 cases of QT rupture were on the ipsilateral side of the ACL reconstruction. Thus, it is likely that our findings overestimated the number of QT ruptures following ACL reconstructions, and our findings should be interpreted with this in mind.

      Conclusions

      Patients who underwent surgery in the late cohort had lower rates of postoperative complications, except for DVT. The rate of postoperative QT rupture decreased despite considerable increase in the use of QT autograft.

      .Supplementary Material

      Appendix Table 1Quadriceps Rupture Univariate Analysis
      CharacteristicQuadriceps Rupture OR (95% CI)P Value
      Late Cohort0.07 (0.01-0.33)<.001
      Age >60 y3.42 (0.45-25.99).234
      Sex (female)0.08 (0.01-0.64).477
      Diabetes5.24 (1.65-14.4).002
      Obesity1.36 (0.38-3.88).603
      Tobacco0.85 (0.20-2.65).804
      NOTE. P values in bold indicate statistical significance.
      CI, confidence interval; OR, odds ratio.
      Appendix Table 2Patella Rupture Univariate Analysis
      CharacteristicPatella Rupture OR (95% CI)P Value
      Late cohort0.08 (0.01-0.64).017
      Age >60 y1.76 (0.99-2.27).988
      Sex (female)0.40 (0.13-1.30).126
      Diabetes0.96 (0.12-7.38).968
      Obesity0.74 (0.16-3.32).691
      Tobacco2.31 (0.76-7.07).142
      NOTE. P values in bold indicate statistical significance.
      CI, confidence interval; OR, odds ratio.
      Appendix Table 3Manipulation Univariate Analysis
      CharacteristicManipulation OR (95% CI)P Value
      Late cohort1.12 (0.92-1.35).260
      Age >60 y0.62 (0.26-1.49).284
      Sex (female)2.30 (1.86-2.85)<.001
      Diabetes1.02 (0.70-1.42).927
      Obesity1.14 (0.90-1.44).265
      Tobacco1.19 (0.95-1.49).126
      NOTE. P values in bold indicate statistical significance.
      CI, confidence interval; OR, odds ratio.
      Appendix Table 4Adhesion Lysis Univariate Analysis
      CharacteristicAdhesion Lysis OR (95% CI)P Value
      Late cohort0.36 (0.15-0.78).014
      Age >60 y2.07 (0.34-4.38).981
      Sex (female)0.69 (0.33-1.41).308
      Diabetes2.26 (0.29-4.33).984
      Obesity1.23 (0.49-2.73).627
      Tobacco1.58 (0.69-3.36).248
      NOTE. P values in bold indicate statistical significance.
      CI, confidence interval; OR, odds ratio.
      Appendix Table 5Infection Univariate Analysis
      CharacteristicInfection OR (95% CI)P Value
      Late cohort0.55 (0.46-0.66)<.001
      Age >60 y0.58 (0.23.-1.18).184
      Sex (female)0.66 (0.55-0.78)<.001
      Diabetes1.40 (1.07-1.85).015
      Obesity1.59 (1.23-1.81)<.001
      Tobacco1.66 (1.38-1.99)<.001
      NOTE. P values in bold indicate statistical significance.
      CI, confidence interval; OR, odds ratio.
      Appendix Table 6Infection Multivariate Analysis
      CharacteristicInfection OR (95% CI)P Value
      Late cohort0.49 (0.43-0.55)<.001
      Sex (female)0.63 (0.56-0.71)<.001
      Diabetes1.14 (0.92-1.39).213
      Obesity1.34 (1.15-1.54)<.001
      Tobacco1.36 (1.19-1.56)<.001
      NOTE. P values in bold indicate statistical significance.
      CI, confidence interval; OR, odds ratio.
      Appendix Table 7DVT Univariate Analysis
      CharacteristicDVT OR (95% CI)P Value
      Late cohort29.77 (9.42-94.02)<.001
      Age >60 y1.14 (0.28-4.63).856
      Sex (female)0.98 (0.65-1.48).922
      Diabetes2.43 (1.42-4.17)<.001
      Obesity2.73 (1.79-4.13)<0.001
      Tobacco1.46 (0.93-2.30).104
      NOTE. P values in bold indicate statistical significance.
      CI, confidence interval; DVT, deep vein thrombosis; OR, odds ratio.
      Appendix Table 8DVT Multivariate Analysis
      CharacteristicDVT OR (95% CI)P Value
      Late cohort14.05 (8.18-26.68)<.001
      Diabetes1.59 (1.02-2.39).031
      Obesity2.15 (1.56-2.95)<.001
      NOTE. P values in bold indicate statistical significance.
      CI, confidence interval; DVT, deep vein thrombosis; OR, odds ratio.

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