Holle, Alejandro M.

Purpose To evaluate the association between myocardial infarction (MI) timing within 2 years prior to arthroscopic rotator cuff repair (aRCR) and postoperative cardiac, medical, and surgical complications. Methods The PearlDiver Mariner Database (2010‐2022) was queried to identify patients undergoing aRCR (CPT‐29827). Patients with an MI within 2 years before surgery were propensity matched 1:4 to controls without MI based on demographics and comorbidities. Subgroup analyses evaluated MI timing (0‐6, 6‐12, 12‐18, and 18‐24 months), MI type (type 1 vs type 2, ST‐elevation MI vs non‐ST‐elevation MI), percutaneous coronary intervention (PCI) status, guideline‐directed medical therapy, and infarct location. Primary outcomes included 90‐day medical and 2‐year surgical complications. Odds ratios with 95% confidence intervals were calculated. Results A total of 2886 patients with prior MI were matched to 10,613 controls. Prior MI increased the odds of postoperative MI (odds ratio, 3.48; 95% confidence interval, 2.13, 8.32). The highest risk of postoperative MI occurred when aRCR was performed within 6 months of MI (odds ratio, 7.55; 95% confidence interval, 4.38, 13.01), with no significant elevation beyond this window. Type 1 MI was associated with postoperative MI and mortality, whereas type 2 MI was associated with acute kidney injury, pneumonia, and readmission. Both ST‐elevation MI and non‐ST‐elevation MI were linked to increased postoperative MI risk. Patients without PCI showed broader postoperative complications, including mortality, acute kidney injury, and stiffness, compared with those who underwent PCI. Conclusions Recent MI is associated with increased postoperative risk of MI after aRCR, particularly when surgery is performed within 6 months. Patients without PCI experience additional vulnerability. 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.

Background: Matching techniques such as direct covariate matching and propensity score matching (PSM) are increasingly used in anterior cruciate ligament reconstruction (ACLR) research to reduce bias in observational study designs. However, the rationale for covariate selection, consistency in methodological reporting, and patterns of matching practices remain unclear. Purpose: To systematically evaluate covariate matching practices in ACLR literature, including the types and number of covariates used, methodological transparency, and trends in matching strategies. Study Design: Systematic review. Methods: A systematic literature search of the PubMed, EMBASE, and Cochrane databases was conducted to evaluate covariate matching practices in the ACLR literature. A comprehensive search identified 798 unique studies, of which 97 met eligibility criteria. Data were extracted on study design, matching technique, covariate inclusion, reporting practices, and matching ratios. Descriptive and comparative statistics were used to summarize trends. Results: The 97 included studies encompassed 91,165 ACLRs. Most studies were retrospective (90.7%) and cohort in design (92.8%). PSM was used in 41 studies (42.3%), while 56 (57.7%) used direct matching. A total of 60 unique covariates were used across 76 different combinations. PSM studies used significantly more covariates than direct matching studies (6.17 ± 2.79 vs 3.75 ± 1.63; P < .0001), and database studies used more covariates than single-center studies (6.33 ± 2.89 vs 4.08 ± 1.96; P < .0001). The most commonly used covariates were age (96.9%), sex (84.5%), and body mass index (41.2%). Only 6 studies (6.2%) provided justification for covariate selection. The most frequent matching ratio was 1:1 (73.2%). While most studies reported descriptive statistics after matching (95.9%), only 10.3% did so before matching, and 13.4% failed to report prematching sample size. Conclusion: Matching practices in ACLR studies remain highly variable, with limited justification provided for covariate selection. PSM and database-based studies tend to incorporate a greater number of covariates, yet reporting of matching methodology is often inconsistent. To enhance the quality, reproducibility, and comparability of ACLR research, future studies should adopt standardized reporting practices for matching, including explicit descriptions of covariate selection, matching algorithms, balance diagnostics, and match ratios. These steps can serve as a foundation for a more unified research framework, enabling future studies to collectively generate higher quality, generalizable evidence for ACLR outcomes.

Background Long-term corticosteroid (LTC) use is a known risk factor for adverse outcomes after various surgical procedures. However, the impact of LTC use on surgical complications after TSA remains underexplored. This study aims to assess the influence of LTC use on 90-day and 5-year complications following TSA. Methods A retrospective cohort study utilizing the PearlDiver database was conducted. Patients undergoing primary TSA with a minimum 5-year follow-up were included. LTC users were propensity-matched 1:10 with controls based on demographic variables and comorbidities. Postoperative complications within 90 days of surgery and long-term complications within 5 years were compared between groups. Multivariable logistic regressions were used to compare complications controlling for demographic variables and comorbidities. Results In a matched cohort of 556 LTC users to 4942 controls, corticosteroid users exhibited a 2.91-fold higher risk of pneumonia (95% CI: 1.69–4.80, p < 0.001) and a 2.19-fold higher risk of venous thromboembolism (VTE) (95% CI: 1.30–3.51, p = 0.001) within 90 days following TSA. No significant differences in 5-year surgical outcomes were observed. Discussion LTC users are at a heightened risk for 90-day medical complications, including pneumonia and VTE following TSA. However, their 5-year risk of surgical complications was comparable to patients without LTC use.

Abstract Mohs Surgery from 2016 to 2022: Declining Medicaid Reimbursement and ACA Expansion Impact Mohs micrographic surgery (MMS) is the standard of care for many nonmelanoma skin cancers, yet access remains highly variable due to low reimbursement rates. Only 39.5% of Mohs surgeons nationally accept Medicaid. While the Affordable Care Act (ACA) Medicaid expansion improved coverage for low-income adults, its effects on dermatologic reimbursement remain unclear. This study provides the first comprehensive analysis of inflation-adjusted Medicaid reimbursement trends for MMS and determines whether ACA Medicaid expansion translated into improved payment rates. Average physician reimbursement per patient for MMS procedures (CPT codes 17311–17314) from 2016 to 2022 was extracted from a large insurance claims database and adjusted for inflation to 2022 U.S. dollars. States were categorized by Medicaid expansion status, and linear regression assessed reimbursement trends. Between 2016 and 2022, national weighted average reimbursement for MMS first stage (CPT 17311) declined 18.33%, while MMS additional stages (CPT 17312) decreased 25.52% (p = 0.0182). When stratified by expansion status, CPT 17311 reimbursement declined − 5.71% in expansion states versus increasing + 5.80% in non-expansion states (p = 0.00121). Reimbursement for non-high-risk anatomic areas declined 26.10% and 32.6%, respectively. Inflation-adjusted Medicaid payments for MMS declined substantially from 2016 to 2022, with greater reductions in Medicaid expansion states. While ACA expansion increased coverage, it introduced financial pressures through lower fee schedules, potentially threatening physician participation and access to essential dermatologic surgery for vulnerable populations.

Background: The impact of obesity on outcomes following total ankle arthroplasty (TAA) remains unclear, with existing literature reporting mixed results. Although some studies have identified obesity as a risk factor for perioperative complications and poor clinical outcomes, others have found no significant association. Thus, the purpose of this study was to evaluate the association between obesity, across a range of body mass index (BMI) classifications, and postoperative complications after TAA. Methods: Patients undergoing primary TAA were identified from a large national insurance database. Individuals with a BMI ≥30 were identified and matched 1:1 to nonobese controls using propensity score matching based on demographics and comorbidities. Obese patients were further stratified into BMI categories: 30-34.9, 35-39.9, 40-44.9, and ≥45. Ninety-day complications and 2-, 5-, and 10-year surgery-specific outcomes were assessed. Odds ratios (ORs) with 95% CIs and Kaplan-Meier survival analyses were used to evaluate complication risks. Results: After matching, 3364 patients were included in each cohort. No significant differences in 90-day complication rates were observed for patients with BMI 30-44.9 compared with controls. Patients with BMI ≥45 had increased risk of surgical site infection (OR 2.21, 95% CI 1.29-3.79, P = .003), emergency department visits (OR 1.43, 95% CI 1.04-1.96, P = .025), and readmissions (OR 2.31, 95% CI 1.47-3.63, P < .001). The pooled 90-day complication rate was significantly higher in this group as well (12.9% vs 7.6%, OR 1.77, 95% CI 1.26-2.48, P < .001). At 10-year follow-up, Kaplan-Meier analysis demonstrated that patients with a BMI ≥45 had a higher risk of periprosthetic joint infection (PJI compared with controls (hazard ratio 1.75, 95% CI 1.07-2.85, P = .03). Patients with BMI 30-34.9 had a significantly lower risk of aseptic loosening at both 5 years (OR 0.68, 95% CI 0.49-0.94, P = .019) and 10 years (OR 0.65, 95% CI 0.48-0.88, P = .005). Conclusion: BMI ≥45 was associated with higher all-cause health care utilization, including emergency department visits and hospital readmissions, as well as higher long-term risk of PJI following TAA. Level of Evidence: Level III, retrospective cohort study.

Purpose To assess the ability of artificial intelligence (AI) to identify common sports‐related pathologies using radiologic imaging and to compare ChatGPT 4.0 with 2 competitors, Grok 2 and Claude 3.5 Sonnet. Methods ChatGPT 4.0, Grok 2, and Claude 3.5 Sonnet were used. Five common orthopaedic sports pathologies were chosen: anterior cruciate ligament tears, posterior cruciate ligament tears, meniscal tears, chondral pathologies, and rotator cuff tears. Fifty images representing each pathology were collected from a radiologic imaging database when possible, which included radiographic images, computed tomography, and magnetic resonance imaging. Normal images were collected that corresponded to each diagnostic category. Receiver operator characteristic curves and area under the curve values were calculated to assess the accuracy of each AI platform. Results ChatGPT 4.0, Grok 2, and Claude 3.5 Sonnet accurately identified the pathology in 23.6%, 15.7%, and 17.1% of diseased images, respectively. ChatGPT and Grok were most accurate at identifying meniscus pathologies (ChatGPT: 48%, Grok: 42%), whereas Claude Sonnet was most accurate at identifying anterior cruciate ligament pathologies (30%). The area under the curve for ChatGPT, Grok, and Claude Sonnet was 0.21, 0.16, and 0.15, respectively (ChatGPT 4.0 vs Grok 2, P = .30; ChatGPT 4.0 vs Claude 3.5 Sonnet, P = .24; Grok 2 vs Claude 3.5 Sonnet, P > .99). There were no differences in performance between the 3 platforms overall or within any of the diagnostic categories. Conclusions ChatGPT 4.0, Grok 2, and Claude 3.5 Sonnet correctly identified the pathology in less than 25% of images of common sports‐related pathologies and showed area under the curve values well below 0.5, indicating poor accuracy. Based on these findings, we do not recommend the current use of these generative AI models for image‐based diagnosis in orthopaedics. Clinical Relevance As the use of AI becomes more popular within the general public, it becomes increasingly important to make aware the capabilities and limitations of popular AI platforms in regard to their current image‐based diagnostic capabilities.

Introduction Preoperative testosterone exposure has been associated with various health outcomes, but its impact on postoperative complications in patients undergoing total shoulder arthroplasty (TSA) has not been fully explored. This study aims to evaluate the association between preoperative testosterone exposure and postoperative medical and surgical complications in patients undergoing TSA. Methods A retrospective cohort study was conducted using the PearlDiver database. Patients who underwent TSA and used preoperative testosterone within 3 months of the index procedure were identified and matched 1:4 to controls without testosterone use using propensity score matching. Matching was performed based on age, gender, comorbidities, Charlson comorbidity index, obesity, tobacco use, and hypogonadism to balance the groups. Postoperative complications were assessed at 90 days and five years. Statistical comparisons were made using odds ratios (ORs) with 95% confidence intervals (CIs), and a p -value of <0.05 was considered statistically significant. Results The matched cohort included 677 testosterone users and 2554 controls. There were no statistically significant differences between the testosterone and control groups in 90-day complications such as myocardial infarction (OR 2.52, P = 0.31), pneumonia (OR 0.86, P = 0.70), and deep vein thrombosis (no cases in the testosterone group). Over five years, the testosterone group had a significantly higher risk of periprosthetic joint infection (4.1% vs. 2.4%, OR 1.76, 95% CI 1.10–2.75, P = 0.015), but no differences in revision rates, dislocation, aseptic loosening, or stiffness were observed. Conclusion Preoperative testosterone exposure was associated with a higher risk of periprosthetic joint infection following TSA, but no significant differences were found in major medical complications or revision rates.

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.