Holle, Alejandro M

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.