Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data.

INTRODUCTION: Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty. METHODS: Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes. RESULTS: A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time (P < 0.001). DISCUSSION: TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued. LEVEL OF EVIDENCE: Level III, therapeutic retrospective cohort study.

The Effect of Concomitant Biceps Tenodesis on Revision Surgery Rates After Primary Rotator Cuff Repair.

INTRODUCTION: We aimed to use a national database to compare the 4-year revision surgery rates after rotator cuff repair (RCR) in patients with concomitant biceps tenodesis (BT) versus those without BT. METHODS: A retrospective cohort analysis was conducted using the PearlDiver database from 2015 to 2017. Patients undergoing primary open and arthroscopic RCR with and without BT were identified. Demographic variables, 90-day complications, and 2- and 4-year revision surgery rates were analyzed, and a multivariable logistic regression was conducted. RESULTS: Of the 131,155 patients undergoing RCR, 24,487 (18.7%) underwent concomitant BT and 106,668 (81.3%) did not. After controlling for comorbidities and demographics, patients with concomitant BT were associated with lower odds of all-cause revision (OR; P-value [0.77; P < 0.001]), revision BT (0.65; P < 0.001), revision RCR (0.72; P < 0.001), and shoulder arthroplasty (0.81; P = 0.001) within 4 years when compared with those without concomitant BT. DISCUSSION: In our analysis, patients undergoing primary RCR with concomitant BT had 35% reduced odds of revision BT and 23% reduced odds of any all-cause revision within 4 years when compared with those without concomitant BT. This suggests that tenodesis at the time of primary RCR may be associated with a reduction in the utilization of ipsilateral shoulder revision surgery rates.

The cumulative incidence and risk factors associated with 5-year conversion to knee arthroplasty following primary meniscus repair or primary meniscectomy.

Background: This study aimed to observe the 5-year knee arthroplasty conversion incidence rate and associated risk factors in patients who underwent meniscus procedures. Methods: Using a national database, we analyzed patients who had undergone primary meniscus repair or meniscectomy without prior knee surgeries. The cumulative knee arthroplasty conversion incidence was determined via Kaplan Meier analysis. Risk factors for conversion within 5 years were assessed using a Cox proportional hazard ratio model, with results as hazard ratios (HR). Results: 8125 patients had meniscus repair, while 240,209 had meniscectomy. 5-year conversion rates: repair 1.7%, meniscectomy 8.4%. Arthroplasty likelihood decreased as age decreased for repair (70+ [HR: 162.20]; 60-69 [HR: 81.64]; 50-59 [HR: 49.85]; 40-49 [HR: 17.79]; p < 0.001 all). Additional risk factors included male sex (HR: 0.35; p < 0.001) and higher Charlson Comorbidity Index (CCI) (CCI1 [HR: 1.28; p = 0.012]). For meniscectomy, arthroplasty likelihood also decreased with age (70+ [HR: 99.41]; 60-69 [HR: 84.57]; 50-59 [HR: 66.60]; 40-49 [HR: 36.15]; 30-39 [HR: 10.18]; p < 0.001 all). Additional risk factors included male sex (HR: 0.68; p < 0.001), obesity (HR: 1.18; p < 0.001), smoking (HR: 0.1.12; p = 0.010), and higher CCI (CCI1 [HR: 1.25]; CCI2 [HR 1.39]; CCI3+ [HR 1.46]; p < 0.001 all). Conclusion: This study revealed the national 5-year conversion incidence following primary meniscus repair (1.7%) and meniscectomy (8.4%). It also enhanced understanding of age, sex, obesity, smoking, comorbidities (CCI), and knee arthroplasty likelihood after meniscus procedures.

Social determinants of health disparities impact postoperative complications in patients undergoing total shoulder arthroplasty.

BACKGROUND: Understanding the role of social determinants of health disparities (SDHDs) in surgical outcomes can better prepare providers to improve postoperative care. In this study, we use International Classification of Diseases (ICD) codes to identify SDHDs and investigate the risk of postoperative complication rates among patients undergoing total shoulder arthroplasty (TSA). METHODS: A retrospective cohort analysis was conducted using a national insurance claims database. Using ICD and Current Procedural Terminology (CPT) codes, patients who underwent primary TSA with at least 2 years of follow-up in the database were identified. Patients with a history of SDHDs were identified using appropriate ICD-9 and ICD-10 codes. Patients were grouped in one of 2 cohorts: (1) patients with no history of SDHDs (control) and (2) patients with a history of SDHDs (SDHD group) prior to TSA. The SDHD and control groups were matched 1:1 for comorbidities and demographics prior to conducting multivariable analysis for 90-day medical complications and 2-year surgical complications. RESULTS: After matching, there were 8023 patients in the SDHD group and 8023 patients in the control group. The SDHD group had significantly higher odds for 90-day medical complications including heart failure, cerebrovascular accident, renal failure, deep vein thrombosis, pneumonia, sepsis, and urinary tract infection. Additionally, the SDHD group had significantly higher odds for revision surgery within 2 years following TSA. Patients in the SDHD group also had a significantly longer length of hospital stay following TSA. DISCUSSION: This study highlights the association between SDHDs and postoperative complications following TSA. Quantifying the risk of complications and differences in length of stay for TSA patients with a history of SDHDs is important in determining value-based payment models and risk stratifying to optimize patient care.

Trends in utilization of meniscal allograft transplantation between 2010 and 2019.

OBJECTIVES: The aim of this study was to observe the trends in (1) utilization of meniscus allograft transplantation (MAT), (2) demographics and comorbidities of patients undergoing transplants and (3) reimbursements for this procedure between the years of 2010 and 2019. METHODS: Using a national database, patients who underwent MAT were observed. Incidence of MAT, percentage of female patients, average age, and average Charlson comorbidity index (CCI) were analyzed between 2010 and 2019. Average reimbursement during the index and postoperative 90-day bundle period were also calculated from 2010 to 2019. Compound annual growth rate (CAGR) of change in incidence, demographic and reimbursement was calculated, and linear regressionwas conducted for each trends analysis. RESULTS: In total, 744 patients underwent a MAT between the years of 2010 and 2019. The incidence of MAT increased from 0.12 per 100,000 to 0.15 per 100,000 during this period but was not statistically significant (p=0.345). There was no significant difference in age (p=0.462) and gender (p=0.831) among the patients, but the average CCI significantly increased from 2010 to 2019 (CAGR: +15.30; p=0.001). The total reimbursement in the index (p=0.451) and 90-day bundle period (p=0.191) did not significantly change from 2010 to 2019. CONCLUSIONS: Although MAT has been shown to be a safe and reliable surgery for the treatment of meniscus deficient knees, the incidence of MAT as well as the population undergoing MAT has minimally increased from 2010 to 2019. Future studies should seek to identify why the utilization of this efficacious surgery has not increased. LEVEL OF EVIDENCE: IV; Descriptive Epidemiology Study.

The Persistent Backlog of Knee and Shoulder Orthopedic Sport Surgery Case Volume Following the COVID-19 Pandemic.

Objectives: As COVID-19 will not be the last pandemic, understanding our historical response allows us to predict and improve our current practices in preparation for the next pandemic. Following the removal of the elective surgery suspension at the onset of the COVID-19 pandemic, it is unclear whether sports medicine surgery volume has returned to pre-pandemic levels as well as whether the backlog from the original suspension was addressed. The purpose of this study to observe the monthly changes in volume and backlog of knee and shoulder sports surgery one year since the original suspension. Methods: National all-payer data was utilized to identify patients undergoing knee and shoulder sports procedures from January 2017 to April 2021. Descriptive analysis was utilized to report the monthly changes in surgeries. A linear forecast analysis using historical data was utilized to determine the expected volume. This was compared to the observed case volume. The difference in expected and observed volume was utilized to calculate the estimated change in backlog. Results: From March to May 2020, there was a persistent decrease in the observed shoulder and knee sports volume when compared to the expected volume. By June 2020, all knee and shoulder sports volume reached the expected volume. By April 2021, the estimated backlog for shoulder and knee procedures had increased by 49.8% (26,412 total cases) and 19.0% (26,412 total cases), respectively, with respect to the original calculated backlog from March to May 2020. Conclusion: Within four months, the sudden decrease in volume for knee and shoulder sports procedures had returned to pre-pandemic levels; however, the original backlog in cases has continually increased one year following the suspension. Additionally, the backlog is significantly higher for knee when compared to shoulder surgeries.

Use of custom glenoid components for reverse total shoulder arthroplasty.

BACKGROUND: Our purpose was to evaluate a custom reverse total shoulder arthroplasty glenoid baseplate for severe glenoid deficiency, emphasizing the challenges with this approach, including short-term clinical and radiographic outcomes and complications. METHODS: This was a single-institution, retrospective series of 29 patients between January 2017 and December 2022 for whom a custom glenoid component was created for extensive glenoid bone loss. Patients were evaluated preoperatively and at intervals for up to 5 years. All received preoperative physical examinations, plain radiographs, and computed tomography (CT). Intra- and postoperative complications are reported. RESULTS: Of 29 patients, delays resulted in only undergoing surgery, and in three of those, the implant did not match the glenoid. For those three, the time from CT scan to implantation averaged 7.6 months (range, 6.1-10.7 months), compared with 5.5 months (range, 2-8.6 months) for those whose implants fit. In patients with at least 2-year follow-up (n=9), no failures occurred. Significant improvements were observed in all patient-reported outcome measures in those nine patients (American Shoulder and Elbow Score, P<0.01; Simple Shoulder Test, P=0.02; Single Assessment Numeric Evaluation, P<0.01; Western Ontario Osteoarthritis of the Shoulder Index, P<0.01). Range of motion improved for forward flexion and abduction (P=0.03 for both) and internal rotation up the back (P=0.02). Pain and satisfaction also improved (P<0.01 for both). CONCLUSIONS: Prolonged time (>6 months) from CT scan to device implantation resulted in bone loss that rendered the implants unusable. Satisfactory short-term radiographic and clinical follow-up can be achieved with a well-fitting device. Level of evidence: III.

Outpatient Versus Inpatient Total Shoulder Arthroplasty: A Matched Cohort Analysis of Postoperative Complications, Surgical Outcomes, and Reimbursements.

INTRODUCTION: There has been a trend toward performing arthroplasty in the ambulatory setting. The primary purpose of this study was to compare outpatient and inpatient total shoulder arthroplasties (TSAs) for postoperative medical complications, healthcare utilization outcomes, and surgical outcomes. METHODS: Patients who underwent outpatient TSA or inpatient TSA with a minimum 5-year follow-up were identified in the PearlDiver database. These cohorts were propensity-matched based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index > 30). All outcomes were analyzed using chi square and Student t-tests where appropriate. RESULTS: Outpatient TSA patients had markedly lower rates of various 90-day medical complications. Outpatient TSA patients had lower risk of aseptic loosening at 2 years postoperation and lower risk of periprosthetic joint infection at 5 years postoperation relative to inpatient TSA patients. Outpatient TSA reimbursements were markedly lower than inpatient TSA reimbursements at the 30-day, 90-day, and 1-year postoperative intervals. CONCLUSION: This study found patients undergoing outpatient TSA to be at lowers odds for both postoperative medical and surgical complications compared with those undergoing inpatient TSA. Despite increased risk of postoperative healthcare utilization for readmissions and emergency department visits, outpatient TSA was markedly less expensive at every postoperative time point assessed.

Epidemiologic trends in hand injuries in the National Football League from 2009-2010 to 2019-2020.

OBJECTIVES: In American football, hand injuries have been shown to negatively impact performance. The purpose of this study is to characterize the prevalence and severity of hand injuries in National Football League (NFL) players. METHODS: A public online database was utilized to identify hand injuries in NFL players from 2009-2010 to 2019-2020. The primary outcome was to analyze the overall incidence of hand injuries (including wrist, metacarpus, finger, and thumb), injury type by each aforementioned anatomic location, and player position. Injury severity was evaluated based on percentage of injuries in which players returned to play (RTP), number of games missed before RTP, and the percentage of injuries resulting in the player being placed on injured reserve (IR). RESULTS: Of the 6,127 players included, 847 (13.8%) players sustained a hand injury, of which 24.8%, 34.3%, 17.9%, and 22.9% occurred at the wrist, metacarpus, finger, and thumb, respectively. Of the injured players, 97.4% returned to play following their injury, 14.8% were put on IR, and an average of 1.7 (SD 3.3) games were missed. Quarterbacks were the most likely to sustain hand injuries at all anatomic locations. Wrist injuries were associated with the lowest RTP rate (93.3%), the most players placed on injured reserve (28.6%), and the greatest number of games missed (mean 2.5, SD 4.2). CONCLUSION: Hand injuries decreased in prevalence by 65.6% over the 11 NFL seasons evaluated. This trend coincides with the implementation of several safety rules that relate to components of play involving the hands. Quarterbacks experienced the greatest prevalence and severity for all hand injuries. Wrist injuries represent the anatomic location associated with the greatest severity. These findings may be able to inform tailored injury prevention practices by position, and advocate for the further adoption of safety rules to protect players from further injury.

Graft failure within 2 years of isolated anterior cruciate ligament reconstruction is associated with increased risk of secondary meniscus tears.

PURPOSE: A debilitating complication following anterior cruciate ligament reconstruction is a secondary meniscus tear. Currently, the literature is mixed regarding the risk factors associated with the incidence of secondary meniscus tears. The aim of this study was to investigate risk factors associated with meniscus tears following an isolated primary anterior cruciate ligament reconstruction. ACL graft failure was hypothesized to be the strongest risk factor for secondary meniscal injury occurrence. METHODS: A retrospective cohort analysis was performed using the PearlDiver Database. Patients with a primary anterior cruciate ligament reconstruction were identified in the database. Patients with concomitant knee ligament injury or meniscus injury present at the time the index procedure were excluded. Patients were grouped to those who had a secondary meniscus tear within 2 years following anterior cruciate ligament reconstruction and those who did not. Univariate analysis and multivariable regression analysis was conducted to identify significant risk factors for a secondary meniscus tear. RESULTS: There were 25,622 patients meeting criteria for inclusion in this study. Within 2 years from the primary anterior cruciate ligament reconstruction, there were 1,781 patients (7.0%) that experienced a meniscus tear. Graft failure had the highest odds of having a postoperative meniscus tear within 2 years (OR: 4.1; CI 3.5-4.8; p < 0.002). Additional significant risk factors included tobacco use (OR: 2.0; CI 1.0-3.1; p < 0.001), increased Charlson Comorbidity Index (OR: 1.2; CI 1.1-1.4), male gender (OR: 1.1; CI 1.1-1.2; p < 0.001), obesity (OR: 1.1; CI 1.1-1.2; p < 0.001), delayed surgery (OR:1.1; CI 1.1-1.2; p < 0.002), and patients age 30 and older (OR: 1.0; CI 1.0-1.0; p < 0.001). CONCLUSIONS: This study found that anterior cruciate ligament graft failure is the strongest predictor of post-operative meniscus tears. Other risk factors, including tobacco use, increased CCI, male gender, obesity, delayed surgery, and age 30 and older, were established, with several being modifiable. Therefore, targeted preoperative optimization of modifiable risk factors and postoperative protocols may reduce the risk of secondary meniscus tears. LEVEL OF EVIDENCE: Level III, prognostic trial.

The influence of elevated international normalized ratio on complications following total shoulder arthroplasty.

Background: Identifying preoperative risk factors for complications following total shoulder arthroplasty (TSA) has both clinical and financial implications. The purpose of this study was to determine the influence of different degrees of preoperative INR elevation on complications following TSA. Methods: Patients undergoing primary TSA from 2007 to 2018 were identified in a national database. Patients were stratified into 4 cohorts: INR of <1.0, INR of >1.0 to 1.25, INR of >1.25 to 1.5, and INR of >1.5. Postoperative complications were assessed. Multivariate logistic regressions were performed to adjust for differences in demographics and comorbidities among the INR groups. Results: Following adjustment and relative to patients with an INR of <1.0, those with INR of >1.0-1.25, >1.25-1.5, and >1.5 had 1.6-times, 2.4-times, and 2.8-times higher odds of having postoperative bleeding requiring transfusion, respectively (p < 0.05 for all). Relative to patients with INR <1.0, those with INR of > 1.25-1.5 and INR of >1.5 had 7.8-times and 7.0-times higher odds of having pulmonary complications, respectively (p < 0.05 for both). Discussion: With increasing INR levels, there is an independent and step-wise increase in odd ratios for postoperative complications. Current guidelines for preoperative INR thresholds may need to be adjusted for more predictive risk-stratification for TSA. Level of Evidence: III.

Impact of preoperative urinary tract infection on postoperative outcomes following total shoulder arthroplasty for osteoarthritis.

Introduction: As the utilization of total shoulder arthroplasty (TSA) increases, it is essential to identify risk factors associated with postoperative complications. Urinary tract infection (UTI) is one such example. Our objective is to identify whether UTI is associated with increased rates of prosthetic joint infection (PJI) and determine whether its treatment reduces PJI rates. Methods: Patients who underwent primary TSA for glenohumeral osteoarthritis between 2010 and 2019 with minimum two-year follow-up were identified in a national database (PearlDiver Technologies) using Current Procedural Terminology and International Classification of Diseases codes. These patients were stratified into two cohorts: those with preoperative UTI within two weeks of TSA and those without. The preoperative UTI cohort was stratified into those treated and those untreated prior to TSA. Univariate and multivariable analyses were performed. Results: Following multivariable analysis, there were significantly higher odds of postoperative anemia, pulmonary embolism, and death in the UTI cohort. Comparing treated to untreated UTI, there were no significant differences in multivariable analysis for any 90-day medical or two-year surgical complications. Discussion: This study showed that UTI was not associated with increased rates of PJI. UTI was, however, associated with postoperative medical complications that surgeons should be aware of.

Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs.

Background: Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. This retrospective epidemiology study was performed to report 90-day postoperative complications and costs of Latarjet, anterior bone block reconstruction, arthroscopic, and open Bankart repair for shoulder instability. Methods: Patients 18 years and older who underwent four primary shoulder surgeries from 2010 to 2019 were identified using national claims data. Patient demographics, comorbidities, and 90-day postoperative complications were analyzed using univariate analysis and multivariable logistic regression. Total and itemized 90-day reimbursements were determined for each procedure. Results: The 90-day medical and surgery-specific complication rates were highest for anterior bone block reconstruction, followed by Latarjet. Arthroscopic Bankart repair had the highest 90-day costs and primary procedure costs compared to other procedures. Conclusion: Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day medical and surgery-specific complications, while arthroscopic Bankart repair was associated with the highest costs.

Trends and outcomes of outpatient total shoulder arthroplasty after its removal from CMS's inpatient-only list.

BACKGROUND: In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality. METHODS: Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics. RESULTS: Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P < .001), readmissions (3.7 vs 6.1%, P < .001), and mortality (0.2 vs 0.4%, P = .024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P < .001). CONCLUSIONS: There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.

Increased prevalence of lower extremity soft tissue injuries and surgeries in patients with anorexia nervosa and bulimia nervosa.

PURPOSE: An abundance of literature exists linking eating disorders and fracture risk. However, no studies, to our knowledge, have investigated the impact of eating disorders on lower extremity soft tissue injury or surgery risk. The purpose of this study was to determine if anorexia nervosa and bulimia nervosa are associated with prevalence of lower extremity soft tissue injuries and surgeries. METHODS: Patients with anorexia nervosa or bulimia nervosa over 2010-2020 were identified through the International Classification of Diseases (ICD) codes in the PearlDiver Claims Database. Patients were matched by age, gender, comorbidities, record dates, and region to control groups without anorexia or bulimia. Soft tissue injuries were identified through ICD codes, and surgeries were identified through Current Procedural Terminology codes. Differences in relative prevalence were analyzed using chi-square analysis. RESULTS: Patients with anorexia had a significantly increased prevalence of meniscus tears (RR = 1.57, CI 1.22-2.03, p = 0.001) or deltoid ligament sprains (RR = 1.83, CI 1.10-3.03, p = 0.025), and patients with bulimia had a significantly increased prevalence of meniscus tears (RR = 1.98, CI 1.56-2.51, p < 0.001), medial collateral ligament sprains (RR = 3.07, CI 1.72-5.48, p < 0.001), any cruciate ligament tears (RR = 2.14, CI 1.29-3.53, p = 0.004), unspecified ankle sprains (RR = 1.56, CI 1.22-1.99, p < 0.001), or any ankle ligament sprains (RR = 1.27, CI 1.07-1.52, p = 0.008). Patients with anorexia had a significantly increased prevalence of anterior cruciate ligament reconstructions (RR = 2.83, CI 1.12-7.17, p = 0.037) or any meniscus surgeries (RR = 1.54, CI 1.03-2.29, p = 0.042), and patients with bulimia had a significantly increased prevalence of partial meniscectomies (RR = 1.80, CI 1.26-2.58, p = 0.002) or any meniscus surgeries (RR = 1.83, CI 1.29-2.60, p < 0.001). CONCLUSIONS: Anorexia and bulimia are associated with increased prevalence of soft tissue injuries and surgeries. Orthopedic surgeons should be aware of this risk, and patients presenting to clinics should be informed of the risks associated with these diagnoses and provided with resources promoting recovery to help prevent further injury or surgery.

Increased Incidence of Upper Extremity Soft Tissue Injuries and Orthopaedic Surgeries in Patients with Eating Disorders.

Background: Despite an established increased fracture risk in eating disorder patients, no studies, to our knowledge, have investigated the association between eating disorders and upper extremity soft tissue injury or surgery incidence. Given the association of eating disorders with nutritional deficiency and musculoskeletal sequelae, we hypothesized that patients with eating disorders would have an increased risk of soft tissue injury and surgery. The aim of this study was to elucidate this link and investigate if these incidences are increased in patients with eating disorders. Methods: Cohorts of patients with anorexia ner-vosa or bulimia nervosa, identified using International Classification of Diseases (ICD) -9 and -10 codes, were identified in a large national claims database over 2010-2021. Control groups without these respective diagnoses were constructed, matched by age, sex, Charlson Comorbidity Index, record date, and geographical region. Upper extremity soft tissue injuries were identified using ICD-9 and -10 codes and surgeries using Current Procedural Terminology codes. Differences in incidence were analyzed using chi-square tests. Results: Patients with anorexia and bulimia were significantly more likely to sustain a shoulder sprain (RR=1.77; RR=2.01, respectively), rotator cuff tear (RR=1.39; RR=1.62), elbow sprain (RR=1.85; RR=1.95), hand/wrist sprain (RR=1.73; RR=16.0), hand/wrist ligament rupture (RR=3.33; RR=1.85), any upper extremity sprain (RR=1.72; RR=1.85), or any upper extremity tendon rupture (RR=1.41; RR=1.65). Patients with bulimia were also more likely to sustain any upper extremity ligament rupture (RR=2.88). Patients with anorexia and bulimia were significantly more likely to undergo SLAP repair (RR=2.37; RR=2.03, respectively), rotator cuff repair (RR=1.77; RR=2.10), biceps tenodesis (RR=2.73; RR=2.58), any shoulder surgery (RR=2.02; RR=2.25), hand tendon repair (RR=2.09; RR=2.12), any hand surgery (RR=2.14; RR=2.22), or any hand/wrist surgery (RR=1.87; RR=2.06). Conclusion: Eating disorders are associated with an increased incidence of numerous upper extremity soft tissue injuries and orthopaedic surgeries. Further work should be undertaken to elucidate the drivers of this increased risk. Level of Evidence: III.

Publication Trends in Research on Mental Health and Mental Illness in Orthopaedic Surgery: A Systematic Review.

BACKGROUND: Mental health conditions affect tens of millions of Americans. In recent years, particularly with the advent of the coronavirus disease 2019 pandemic, there has been a burst of interest in mental health and mental illness among orthopaedic surgical patients. The mental health of orthopaedic surgeons themselves has also come into focus, with high reported rates of burnout and depression. The aim of this article was to evaluate trends in publication on mental health and mental illness in orthopaedic surgery. METHODS: Web of Science and PubMed were queried to conduct a systematic review. Studies that discussed orthopaedic surgery and mental illnesses or mental health topics over 2001 to 2022 were included. Publications were analyzed by article-, author-, and topic-level characteristics. RESULTS: A total of 416 studies were analyzed after application of inclusion and exclusion criteria. Publication volume increased dramatically, demonstrating quadratic growth over 2001 to 2022 (p < 0.001). Eighty-eight percent of studies focused on patients and 10% on surgeons, with studies about patients more likely to focus on mental illness and those about surgeons more likely to focus on mental health (p < 0.001). Twenty percent of publications had a female senior author, and 5 authors collectively accounted for 10% of all publications. Eight journals published more than 10 publications, accounting for 35% of all publications. The most productive subspecialties were arthroplasty (135, 30%), general orthopaedics (87, 21%), and spine (69, 17%). Mental illnesses that were least represented included schizophrenia, bipolar disorder, eating disorders, attention-deficit/hyperactivity disorder, and personality disorders (1% or less of total publications each). CONCLUSION: This analysis showed a dramatically increasing trend in publications on mental health and mental illness in orthopaedic surgery. A high concentration of publications came from a subset of journals and senior authors, and women were overrepresented as senior authors relative to their representation in the field. The results of this analysis identified gaps in the literature, including underrepresented subspecialties, understudied mental illnesses, and study of orthopaedic surgeon mental health, and thus highlighted areas for future investigation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Trends in total elbow arthroplasty in patients with rheumatoid arthritis receiving disease-modifying antirheumatic drug therapy based on payer status.

INTRODUCTION: Total elbow arthroplasty (TEA) is often used to manage advanced arthropathies of the elbow caused by inflammatory conditions such as rheumatoid arthritis (RA). Recent literature has shown that use of TEA is decreasing in patients with RA, part of which can be attributed to early medical management involving disease-modifying antirheumatic drugs (DMARDs). However, there is a significant economic barrier to accessing DMARD therapy. The purpose of this study was to compare the use of TEA between patients with and without DMARD therapy from 2010 to 2020. METHODS: A retrospective cohort analysis was performed using a national insurance claim database to investigate the trends of patients with RA undergoing TEA from 2010-2020. Patients who underwent TEA and had a diagnosis of RA were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)-9 and ICD-10 codes between 2010 and 2020. These patients were then stratified into 2 cohorts: those with DMARD prescription claims and those without. A linear regression, compound annual growth rate (CAGR) analysis, and χ2 analysis were conducted to compare trends and demographic variables, including insurance type, between cohorts. Additionally, a multivariable logistic regression was subsequently performed to observe odds ratios (ORs) and 95% confidence intervals. RESULTS: From 2010 to 2020, there has been no significant change in the incidence of TEA in RA patients without DMARD prescriptions, whereas there has been a statistically significantly decreasing rate of TEA observed in RA patients with DMARD prescription claims. The analysis showed that there was a CAGR of -4%. For patients with a diagnosis of RA and DMARD prescription claims, the highest incidence of undergoing TEA was seen in the age group of 60-69 years, whereas patients with a diagnosis of RA and no DMARD prescription claims had the highest incidence of undergoing TEA in the age group of 70-79 years. CONCLUSION: The incidence of patients undergoing TEA with a diagnosis of RA and DMARD prescription claims has shown a statistically significant decrease from 2010 to 2020, whereas no significant difference was observed for patients without DMARD prescription claims. There were no statistically significant differences in the insurance plans between cohorts.

A Comparison of Complications and Survivorship after Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture compared with Cuff Tear Arthropathy.

Objectives: Traditionally used to treat rotator cuff tear arthropathy (CTA), reverse total shoulder arthroplasty (RTSA) is becoming increasingly utilized for the treatment of proximal humeral fractures (PHF). The purpose of this study was to use a matched cohort analysis to assess differences in 90-day complications as well as 2-year and 5-year implant survival between patients undergoing RTSA for CTA and patients undergoing RTSA for PHF. Methods: Patients with at least a 5-year follow-up who underwent primary RTSA for either PHF or CTA were identified in a national database (PearlDiver Technologies) using current procedural terminology (CPT) and international classification of diseases (ICD) 9 and 10 codes. Patients with a surgical indication of PHF were matched with patients with a surgical indication of CTA based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index (BMI)>30). All-cause revision at the 2-year and 5-year postoperative time intervals were assessed. Reimbursements for the surgical care episode up to the 30-day, 90-day, and 1-year postoperative intervals were also assessed. Bivariate analysis was performed with a significance set at P<0.05. Results: In total, 802 PHF patients were matched with 802 CTA patients. Compared to CTA patients, PHF patients undergoing RTSA were significantly at increased risk of atrial fibrillation, anemia, and heart failure within 90 days of surgery. Notably, there was no significant difference in all-cause revision surgery at 2-year and 5-year postoperative intervals or hospital reimbursements at the 30-day, 90-day, and 1-year postoperative intervals. Conclusion: Preoperative indication appears to be an important driver of healthcare utilization for RTSA, as PHF patients undergoing RTSA have a higher risk of short-term postoperative complications compared to CTA patients. However, there is no difference in hospital reimbursement for the two indications of RTSA, suggesting that current payment modalities may not appropriately adjust for risk based on the surgical indication.