Lin, Eugenia

Purpose To compare lower extremity soft tissue injury and revision surgery rates for patients with anorexia nervosa (AN) and bulimia nervosa (BN) compared with matched controls. Methods This retrospective cohort study used a deidentified claims database. Patients were included if they carried an International Classification of Diseases code for AN or BN. Respective matched cohorts for AN and BN were created using propensity score matching. Primary and revision surgeries for anterior cruciate ligament (ACL) reconstruction, posterior cruciate ligament reconstruction, knee collateral ligament reconstruction, meniscus repair or meniscectomy, and any ankle ligament reconstruction were identified by their CPT codes. Patients over the age of 40 and without a minimum 2‐year follow‐up after primary surgery were excluded. Differences in prevalence and revision rates were analyzed. Results A total of 56,146 patients with AN and 42,630 patients with BN were included in this study with equal numbers in respective matched cohorts. Patients with BN showed an increased risk of ACL injury (relative risk = 1.32, P = .019), medial collateral ligament injury (1.17, 0.04), calcaneofibular sprain (1.92, <0.001), deltoid sprain (1.41, 0.004), and unspecified ankle sprain (1.44, <0.001). Patients with AN showed an increased risk for calcaneofibular sprain (1.25, 0.007), deltoid sprain (1.28, 0.015), and unspecified ankle sprain (1.17, <0.001). Patients with BN were more likely to have revision ACL repair (1.89, 0.02), partial meniscus revision (3.44, <0.001) and any meniscus revision (4.74, <0.001) while patients with AN were more likely to have an ACL revision (2.81, <0.001), partial meniscus (4.37, <0.001), and any meniscus (4.52, <0.001). Conclusions In this study, patients with AN and BN had a significantly increased risk for various knee and ankle injuries and revision surgeries compared with matched controls. Additionally, patients with AN and BN who sustained these injuries were more likely to undergo a revision surgical procedure within the first 5 years of the primary procedure. Level of Evidence Level III, retrospective comparative study.

Background: Tobacco use is a known risk factor for poor healing after rotator cuff repair (RCR), but the effects of nontobacco nicotine products remain unclear. Purpose: To compare postoperative complications among nontobacco nicotine users, tobacco users, and nonusers undergoing RCR. Study Design: Cohort study; Level of evidence, 3. Methods: Using the PearlDiver database, the authors identified patients who underwent arthroscopic RCR with ≥2 years of follow-up. Three 1:1 propensity-matched comparisons were conducted: nontobacco nicotine users versus nonusers (n = 4844), tobacco users versus nonusers (n = 19,182), and nontobacco nicotine users vs tobacco users (n = 4882). Outcomes included 90-day complications and 2-year revision surgeries. Results: Nontobacco nicotine users had mildly higher rates of lysis of adhesions than controls (0.7% vs 0.4%; OR, 1.95; P = .033) but no other significant differences. Tobacco users showed increased rates of acute kidney injury (AKI), pneumonia, infections, emergency department (ED) visits, readmissions, and revision surgery compared to controls. Compared to tobacco users, nontobacco nicotine users had moderately strong lower risks of pneumonia (0.6% vs 1.2%; OR, 0.46), ED visits (8.8% vs 13.6%; OR, 0.62), and readmissions (0.8% vs 1.5%; OR, 0.54) (all P < .01). Conclusion: While nontobacco nicotine use was associated with a modestly increased risk of lysis of adhesions after RCR, it did not significantly elevate the risk of major medical complications, infections, or revision surgery when compared to nonnicotine users. In contrast, tobacco users demonstrated consistently worse postoperative outcomes across multiple domains, including higher rates of AKI, pneumonia, surgical site infection, ED visits, readmissions, and revision procedures. Notably, when compared directly to tobacco users, nontobacco nicotine users had significantly lower rates of pneumonia, ED utilization, and readmissions. These findings suggest that although nontobacco nicotine products may not be entirely benign, their perioperative risk profile appears to be less severe than that of traditional tobacco use.

Purpose To project the future utilization of open and arthroscopic rotator cuff repair (RCR) in the Medicare population through 2050, incorporating post‐COVID recovery data to provide insight into evolving surgical preferences, economic pressures, and implications for health care delivery. Methods We analyzed 2003‐2024 data from the Centers for Medicare and Medicaid Services Medicare Part‐B National Summary, which captures all Medicare beneficiaries undergoing open or arthroscopic RCR as identified by Current Procedural Terminology codes. Projections were based on 2003‐2019 and 2023‐2024 data, reflecting post‐COVID‐19 recovery and avoiding distortions from 2020 to 2022 pandemic‐related disruptions. Statistical models evaluated included log‐linear, Poisson, negative binomial, and autoregressive integrated moving average. Autoregressive integrated moving average was selected based on the lowest normalized root mean square error, reflecting superior predictive accuracy and its ability to capture time‐dependent trends, and was used to forecast RCR volumes through 2050. Results In 2024, there were 23,154 open and 188,700 arthroscopic RCR procedures, which served as the baseline for modeling. Open RCR is projected to decline on average by 5.91% annually, while arthroscopic RCR is projected to grow by 2.88% annually. By 2050, arthroscopic RCR volume is expected to reach 394,434 procedures (95% forecast interval: 363,424‐425,321), whereas open RCR is expected to decline to 4748 procedures (95% forecast interval: 1243‐43,747). Conclusions Autoregressive integrated moving average modeling projects that by 2050 arthroscopic RCR utilization will increase by 2‐fold and open RCR will decline to one‐fifth compared with 2024 baseline volumes. Level of Evidence Level III, retrospective cohort study.

Background: To our knowledge, there are no studies assessing associations between patients on preoperative estrogen replacement therapy (ERT) undergoing distal radius open reduction and internal fixation (DRORIF) and postoperative outcomes. Thus, the purpose of this study was to compare surgical and medical complications in patients on ERT undergoing DR-ORIF with a matched control cohort. Materials and Methods: The PearlDiver Mariner database was searched for female patients who took ERT within 3 months of the index procedure. Patients were matched 1:4 with non-ERT controls using propensity score matching. Complications were assessed at 90 days, 2 years, and 5 years. Statistical analyses were conducted using odds ratios (OR) with 95% confidence intervals (CI). Statistical significance was determined at a P value of <.05. Results: The ERT cohort consisted of 1,815 ERT users, and the control cohort consisted of 7,247 patients. At 2 years, the ERT cohort was associated with a slightly greater incidence of malunion/nonunion (OR, 1.57; 95% CI, 1.13–2.18) but with no increased risk of revision surgery (OR, 1.10; 95% CI, 0.50–2.10). Similarly, at 5 years, the ERT cohort was associated with a slightly higher likelihood of a malunion/nonunion diagnosis (OR, 1.69; 95% CI, 1.24–2.30). Conclusion: The current study suggests that patients on preoperative ERT had a slightly increased risk of malunion/nonunion at 2 years and 5 years after DR-ORIF. We did not find associations between increases in the risk of any other major or minor complications and the cohort of patients on preoperative ERT within 5 years postoperatively.

Background: Postoperative emergency department (ED) utilization significantly reduces patient satisfaction and increases health care spending. Purpose: To identify the incidence, risk factors, and reasons for ED visits within 90 days of Achilles tendon repair (ATR). Study Design: Case-control study; Level of evidence, 3 Methods: This study utilized the PearlDiver database to identify all instances of primary ATR. Patient age, sex, Elixhauser comorbidity index (ECI), region, and insurance coverage were extracted. The incidence, timing, and primary diagnoses for those with an ED visit 90 days post-ATR were extracted. Also, the 90-day total cost was determined and compared for those with and without a postoperative ED visit. Welch t test and Pearson chi-square test were used to determine significant differences between groups. Multivariable logistic regressions were used to determine risk factors associated with ED utilization after ATR. Results: Of the 82,604 patients with an ATR identified in the database, 6939 (8.4%) had ≥1 ED visit. Of ED visits, 1506 (21.7%) occurred in the first week after ATR and 3587 (51.7%) occurred in the first 4 weeks after ATR. The mean 90-day cost for those with an ED visit was significantly greater than those without an ED visit ($7330 ± $13,383 vs $3515 ± $5787; P < .001). Independent risk factors associated with ED utilization within 90 days were younger age (odds ratio [OR], 1.02; P < .001), female sex (OR, 1.26; P < .001), higher ECI (OR, 1.17; P < .001), a history of tobacco use (OR, 1.57; P < .001), and having Medicaid insurance (OR, 1.73; P < .001). Most ED visits within the first 2 weeks after ATR were for surgical-site pain (53.6%), with 62.4% of diagnoses being directly related to the surgical site. After 2 weeks following ATR, pain persisted as the most common reason for ED utilization (20.9%). Conclusion: More than 8% of patients had ≥1 ED visit within 90 days of ATR, with over half occurring in the first 4 weeks. This markedly increased health care spending. Addressing regional disparities, improving Medicaid acceptance policies, and enhancing perioperative care plans, such as multimodal pain management and addressing the psychological aspects of pain, may reduce the incidence and economic burden of postoperative ED visits.

Background: Knee injuries are among the most common injuries in female basketball players. Despite the growing popularity of professional women's basketball, particularly the Women's National Basketball Association (WNBA), there are limited recent data evaluating the incidence of and risk factors for knee injuries in WNBA athletes. Hypothesis: Older age, minutes played per game, number of games played, and player usage rate would be significantly associated with having a knee injury in WNBA players from the 2017 to 2022 seasons. Study Design: Descriptive epidemiology study. Methods: Publicly available data on the injury history and player records of active WNBA players between the 2017 and 2022 seasons were reviewed to identify players with a knee injury resulting in ≥1 games missed. The primary outcome was the incidence of knee injuries reported per 1000 minutes-exposures (MEs). Player demographics, statistics, and injury characteristics were recorded. Secondary analysis was conducted using bivariate and multivariable logistic regression to investigate risk factors associated with having a knee injury. Results: A total of 87 players (10.8% of all players) sustained a combined 104 knee injuries between the 2017 and 2022 seasons, indicating a rate of 6.03 knee injuries per 1000 MEs. Accounting for potential confounders, having a knee injury was significantly associated with older age (OR, 1.11; 95% CI, 1.05-1.18; P = .0002) and higher usage rate (OR, 1.06; 95% CI, 1.02-1.11; P = .02). Conclusion: This study showed that knee injuries occurred in 10.8% of players, with an overall rate of 6.03 injuries per 1000 MEs. The most significant risk factors associated with having a knee injury in WNBA athletes were older age and higher player usage rate. Implementing targeted load management strategies for players with higher usage rates or advanced age may help reduce the incidence of knee injuries among female basketball athletes.

Background: Patellofemoral dislocations are often associated with chondral injuries. In adults, diagnostic arthroscopy (DA) has identified chondral injuries in up to one-third of cases where magnetic resonance imaging (MRI) was negative. However, the value of DA in detecting cartilage injuries in pediatric patients undergoing medial patellofemoral ligament reconstruction (MPFLR) has not been well studied. Purposes: To evaluate the utility of DA in diagnosing cartilaginous injuries in pediatric patients undergoing MPFLR with negative preoperative MRI findings and to compare postoperative outcomes between patients with and without chondral injury findings on DA. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A retrospective review was conducted on patients aged 0 to 18 years who underwent combined MPFLR and DA procedures from 2015 to 2023 at a single institution. The exclusion criteria were as follows: revision MPFLR; tibial tubercle osteotomy; multiligament reconstructions; and previous meniscal injury. MRI and DA reports were reviewed for chondral findings. Patients were classified into 3 groups: +MRI/+DA, –MRI/+DA, and –MRI/–DA. Subgroup analysis was performed within the –MRI/+DA group to compare outcomes in the immediate postoperative recovery period between those who underwent a chondroplasty versus those who did not. Results: Of the 155 patients included, follow-up averaged 7.8 months (median, 5 months [range, 0-41 months]). Among 89 patients with negative MRI findings, 39 (43.8%) had chondral injuries detected on DA. Targeted treatment was performed in 22 (56.4%) of these patients, a lower rate than in those with positive MRI findings (80.3%; P = .02). No significant differences were observed in knee flexion at 2 weeks postoperatively: +MRI/+DA (77.9°± 23°), –MRI/+DA (66.5°± 30.2°), and –MRI/–DA (73.3°± 30°) ( P = .14). Similarly, no significant differences were found at 12 weeks: +MRI/+DA (135.3°± 13°), –MRI/+DA (127.8°± 21°), and –MRI/–DA (134.1°± 13.4°) ( P = .10). Range of motion and complication rates were comparable across all groups ( P > .05). A subgroup analysis in the –MRI/+DA cohort comparing patients who underwent an arthroscopic procedure (n = 22) with those who did not (n = 17) showed no significant differences in range of motion or complication rates ( P > .05). Conclusion: Diagnostic arthroscopy detected cartilaginous injuries in 43.8% of pediatric patients with negative preoperative MRI undergoing MPFLR. This highlights the diagnostic value of DA in identifying injuries that would otherwise remain undetected.

Background: The Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) has undergone numerous changes to promote care for patients at high social risk. However, the effect of these changes on surgeon MIPS performance and caseload selection remains unclear. Thus, the purpose of this study was to evaluate how orthopaedic surgeon MIPS scores, demographics, practice characteristics, and patient populations varied on the basis of patient social risk in 2017 compared with 2021. Methods: CMS data were utilized to examine U.S. orthopaedic surgeons. Surgeons were placed into social-risk quintiles on the basis of the proportion of their patients who were dually eligible for Medicare and Medicaid, with the highest quintile representing the highest social risk. Demographics, practice location characteristics, patient data, and MIPS performance were assessed for the years 2017 and 2021. Differences between social-risk quintiles were assessed utilizing chi-square, Student t, and Wilcoxon signed-rank tests and multivariable logistic regression. Results: In 2017, surgeons with caseloads at the highest, compared with the lowest, social risk had lower MIPS performance scores (mean [and standard deviation], 66.0 ± 37.6 versus 70.1 ± 33.5; p < 0.001). However, in 2021, orthopaedic surgeons with caseloads at the highest, compared with the lowest, social risk had significantly higher MIPS performance scores (mean, 88.7 ± 16.9 versus 81.5 ± 18.3; p < 0.001). In terms of demographics, in 2021, orthopaedic surgeons with caseloads at the highest, compared with the lowest, social risk were more often women (9.2% versus 3.6%; p < 0.001), more often had a DO degree (11.2% versus 6.6%; p < 0.001), more recently graduated from medical school (mean, 23.0 ± 12.9 versus 25.7 ± 10.9 years; p < 0.001), and worked in areas with higher Distressed Communities Index (DCI) distress scores (mean, 56.9 ± 27.3 versus 35.1 ± 25.2; p < 0.001). Similar findings were present in 2017. Conclusions: The addition of the Complex Patient Bonus to the MIPS in 2020 may have reduced performance inequities in MIPS scoring for surgeons with caseloads at high social risk. However, the demographics and practice patterns of the orthopaedic surgeons caring for populations at the highest social risk remained consistent between years. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background Value-based care payment and delivery models such as the recently implemented Merit-based Incentive Payment System (MIPS) aim to both provide better care for patients and reduce costs of care. Gender disparities across orthopaedic surgery, encompassing reimbursement, industry payments, referrals, and patient perception, have been thoroughly studied over the years, with numerous disparities identified. However, differences in MIPS performance based on orthopaedic surgeon gender have not been comprehensively evaluated. Questions/purposes After controlling for potentially confounding variables such as experience, geography, group size, and Medicare beneficiary characteristics, does MIPS performance differ between men and women orthopaedic surgeons? Methods The Medicare Physician and Other Practitioners and the Physician Compare databases were queried for years 2017, the first year MIPS was incorporated, and 2021, the most recent year with MIPS data published, to identify all physicians with a self-reported specialty of orthopaedic surgery. Together, these databases include all physicians who submitted at least 11 Medicare claims each year. Physician gender, US census region, years in practice, group practice size, billing practices, and patient demographic characteristics were collected for each surgeon. The MIPS Performance database was used to extract an overall MIPS performance score for each surgeon for each year. Payment adjustments, which are determined based on overall MIPS performance score, were derived for each surgeon based on the thresholds published by the Centers for Medicare & Medicaid Services. Payment adjustments include a negative adjustment, neutral adjustment, positive adjustment, or exceptional performance bonus and are associated with different thresholds each year. Statistical differences based on surgeon gender were assessed utilizing chi-square tests for categorical data, Student t-test for parametric continuous data, and Wilcoxon signed-rank test for nonparametric continuous data. Univariable and multivariable analyses were performed to analyze the relationship between surgeon gender and MIPS performance. Results After controlling for other patient and surgeon variables, woman gender was associated with a slightly increased MIPS performance score in 2021 (β 1.5 [95% confidence interval (CI) 0.02 to 3.00]; p = 0.047). However, this finding was statistically fragile, with the lower bound 95% CI being very close to the line of no difference. No association between surgeon gender and MIPS performance score was found in 2017 (β 2.2 [95% CI -0.5 to 4.9]; p = 0.11). Additionally, no relationship was found between gender and receiving either an exceptional performance MIPS bonus or a MIPS penalty in either year. Conclusion Women orthopaedic surgeons scored slightly higher on the MIPS in 2021, after controlling for surgeon and patient variables, despite providing care for a higher percentage of dual Medicare-Medicaid eligible patients and more medically complex patients. However, this finding was statistically fragile, with a small effect size, a 95% CI close to 0, and no consistent association in MIPS performance in 2017. Additionally, with no differences in MIPS performance bonuses or penalties, the clinical monetary impact of this difference may be minimal. Clinical Relevance The observed association between surgeon gender and MIPS performance scores in 2021, with women orthopaedic surgeons achieving slightly higher scores, raises interesting questions about potential differences in practice behaviors, communication styles, care quality, or other unmeasured variables. These findings may reflect true differences in how care is delivered or documented as scored by the MIPS. However, given the small effect size, statistical fragility, and inconsistency across years, there is a chance that this finding may be spurious. That being so, future research should aim to validate or refute these findings by examining a broader range of variables including documentation practices, practice behaviors, institutional differences, potential systemic biases in scoring methodologies, and patient outcomes. Understanding whether these differences are true is important to ensure that performance metrics like MIPS accurately and equitably reflect care quality.

Purpose To assess surgeon reimbursement for common arthroscopic procedures, including arthroscopic meniscal debridement and arthroscopic rotator cuff repair, in patients with differing risk profiles within the Medicare population. Methods A publicly available Medicare database was used to identify all cases of arthroscopic meniscal debridement and arthroscopic rotator cuff repair procedures billed to Medicare from 2013 to 2020. The surgeon reimbursement from Medicare was collected and adjusted for inflation. All procedure episodes were split into 2 cohorts; those with a hierarchical condition category (HCC) risk score ≥1.5, and those with patient HCC risk scores <1.5. Reimbursement rates were compared between groups. Results From 2013 to 2020, a total of 624,077 meniscal debridement procedures and 567,794 arthroscopic rotator cuff repairs were billed to Medicare Part B. During this time, the mean adjusted surgeon reimbursement for arthroscopic rotator cuff repair decreased by 9.2% from 2013 to 2020. During the same time period, the adjusted mean surgeon reimbursement for arthroscopic both compartment meniscal debridement and single compartment meniscal debridement decreased by 7.9% and 9.9%, respectively. Throughout the study period, the mean HCC risk score increased from 1.19 in 2013 to 1.31 in 2020 ( P < .001). Across all years in the study, the sicker cohort had a significantly greater rate of all comorbidities and a greater mean body mass index ( P < .001 for all variables). The mean reimbursement across this cohort was lower for both rotator cuff repair ( P = .037) and meniscal debridement procedures ( P < .001) compared with the healthier cohort. Conclusions This study demonstrates that from 2013 to 2020, inflation‐adjusted surgeon reimbursement for arthroscopic rotator cuff repair and meniscal debridement decreased while patient complexity increased. Further, mean surgeon reimbursement was lower among patients with more complexity in comparison with their healthier counterparts for such procedures. Level of Evidence Level III, retrospective cohort study.