Patel, Karan A.

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: 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: Tendinopathies are common in middle-aged women. While estrogen regulates tendon remodeling, the influence of systemic hormone replacement therapy (HRT) on the risk of tendon degeneration remains unclear. Hypothesis/Purpose: The purpose of this study was to investigate the association between systemic HRT use and tendon injuries/repair in perimenopausal women. It was hypothesized that systemic HRT would be associated with an increased incidence of tendon injuries and repair. Study Design: Cohort study; Level of evidence, 4. Methods: Using the TriNetX Research Network, we identified female patients aged ≥45 years diagnosed with major tendon abnormalities, including rotator cuff tears, bicipital tendinitis, lateral or medial epicondylitis, Achilles tendinopathy, patellar tendinitis, or quadriceps strain, from January 2004 to July 2025. HRT exposure was defined as systemic estrogen and/or progestin use within 1 year before a diagnosis. Patients with contraindications to HRT were excluded. After 1:1 propensity score matching, 2 groups of 63,836 patients each were generated. Primary outcomes included diagnosis rates of specific tendon conditions; secondary outcomes were lifetime rates of corresponding tendon repair procedures. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The independent t test and chi-square test were used for analysis. Results: HRT users had significantly higher rates of several tendon abnormalities compared to matched controls, including rotator cuff tears (39.2% vs 37.9%, respectively; P < .001), bicipital tendinitis (13.3% vs 11.0%, respectively; P < .001), lateral epicondylitis (27.8% vs 22.7%, respectively; P < .001), and medial epicondylitis (6.8% vs 5.3%, respectively; P < .001). Achilles tendinopathy had similar rates between the 2 groups (14.6% vs 14.5%, respectively; P = .387). Surgical repair was more common in the HRT group, including biceps tendon repair/tenodesis (3.9% vs 3.3%, respectively; OR, 1.16 [95% CI, 1.10-1.23]; P < .001), rotator cuff repair (6.6% vs 6.2%, respectively; OR, 1.06 [95% CI, 1.01-1.11]; P = .013), and Achilles tendon repair (0.7% vs 0.6%, respectively; OR, 1.23 [95% CI, 1.06-1.41]; P = .005). Conclusion: Our study showed that systemic HRT use in women aged ≥45 years was associated with an increased risk of tendon injuries and a greater likelihood of surgical repair, although the absolute risk differences were modest. These findings underscore the need for awareness of the possible musculoskeletal effects of hormone therapy and highlight an underexplored area in women's orthopaedic health.

OBJECTIVES: To evaluate and compare the ability of three popular open-source artificial intelligence platforms to diagnose common trauma-related fractures using radiologic imaging. METHODS: Design: Retrospective diagnostic performance comparison study. Setting: Publicly accessible online radiologic imaging databases. Patient Selection Criteria: Five common orthopedic trauma fractures were assessed: ankle, tibial plateau, intertrochanteric, femoral neck, and humerus. Radiographs and computed tomography (CT) images were collected. Images were randomly selected from confirmed diagnoses on Radiopaedia.org. Outcome Measures and Comparisons: ChatGPT 5, Grok 3, and Claude 4.5 Sonnet were queried with each image. Diagnostic accuracy, sensitivity, specificity, positive and negative predictive values, and performance by modality (X-ray vs. CT) were assessed. The reference standard was the expert-verified diagnosis provided by Radiopaedia.org, limited to cases labeled with a “diagnosis certain” tag. RESULTS: Each model was provided with 30 radiographs and 20 CT images whenever possible. ChatGPT 5, Grok 3, and Claude 4.5 Sonnet accurately diagnosed diseased images in 26.8%, 18.8%, and 22.4% of cases, respectively. By fracture type, ChatGPT 5 demonstrated the highest correct classification rates for ankle (10%), femoral neck (38%), humerus (40%), and tibial plateau (44%) fractures. Grok 3 demonstrated the highest correct classification rate for intertrochanteric fractures (6%). Overall sensitivities were 0.267, 0.187, and 0.223 for ChatGPT 5, Grok 3, and Claude 4.5 Sonnet, respectively. ChatGPT 5 and Grok 3 outperformed Claude 4.5 Sonnet (both P < 0.001). No modality-based performance differences were observed for any model. CONCLUSIONS: Among the publicly available large language models evaluated for radiologic interpretation of orthopedic trauma imaging, ChatGPT 5 demonstrated the highest overall diagnostic accuracy, followed by Claude 4.5 Sonnet and Grok 3. Despite relative variation between the models, overall diagnostic accuracy for fracture detection was low across all platforms (<27%). In their baseline forms, these publicly accessible large language models are not recommended for radiologic imaging interpretation. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

» Affordable Care Act Medicaid expansion increased orthopaedic surgery access and utilization among Medicaid patients, including for racial and ethnic minorities. » Despite improved coverage, Medicaid patients continue to face significant real-world barriers to orthopaedic care, including lower appointment success and longer wait times compared with privately insured patients. » Evidence on cost and quality impacts remains limited, with early signals of increased reimbursements, higher charges, and some quality improvements postexpansion.

Background: Medicaid reimbursement to physicians is often perceived to be lower than Medicare, but little is known about orthopaedic foot and ankle reimbursement. This study sought to compare Medicare and Medicaid reimbursement for the 20 most common foot and ankle procedures. Methods: Medicare reimbursement rates for common foot and ankle codes were obtained from the online Centers for Medicare & Medicaid fee schedule, while Medicaid rates were found from individual state fee schedule websites. Medicaid rates were compared by state and pooled to obtain national differences. The Medicare Wage Index was used to adjust Medicaid rates by state wages to ensure a more accurate comparison. Variability between states was measured using state percentages of Medicare and coefficient of variation values. Results: Medicaid reimbursed physicians higher than Medicare in 31 states overall, with average reimbursement ranging from 37% to 324% of Medicare. Nationally, Medicaid reimbursed 8.8% higher than Medicare, but Medicare reimbursed 3.7% higher when adjusted for the Medicare Wage Index. The Current Procedural Terminology ( CPT ) codes with the highest ratio of Medicaid to Medicare reimbursement were CPT 28002 for incision and drainage of the foot (176.6%) and CPT 28820 for toe amputation (167.6%). Five codes had lower relative Medicaid reimbursement on average: CPT 27687 for repair procedures on the leg and ankle joint, CPT 28810 for amputation procedures on the foot and toes, CPT 28010 for toe tenotomy, CPT 28005 for incision procedures on the foot and toes, and CPT 28470 for closed treatment of a metatarsal fracture. The coefficient of variation values ranged from 0.34 to 0.84 in the Medicaid group and 0.40 to 0.78 in the adjusted group, indicating high variability between states and between procedures. Conclusion: Medicaid reimbursement is highly inconsistent between states, ranging from 37% to 324% of Medicare. Medicaid reimbursed more than Medicare overall, which is in contrast with most published findings that tend to show higher reimbursement for Medicare when compared to Medicaid. When adjusting for wage differences between states, Medicare reimbursed slightly higher than Medicaid. Level of Evidence: Level IV, economic analysis.

Background: Concussions have previously been shown to have persistent neurological changes represented by altered reaction time and postural stability in high-level athletes. The effects of concussions on professional basketball players’ performance and subsequent injuries during the 90 days after return to play (RTP) have not been investigated. Purpose/Hypothesis: the purpose of this study was to evaluate player statistical performance and risk of musculoskeletal (MSK) injury within 90 days of RTP from a diagnosed concussion. It was hypothesized that within the 90 days after RTP from a concussion, players would be at a greater risk for MSK injury with an associated decrease in player statistical performance. Study Design: Descriptive epidemiology study. Methods: Concussions sustained by National Basketball Association (NBA) players between the 2015-2016 and 2021-2022 seasons, excluding the 2019-2020 season, were evaluated using a publicly available database. The database was queried to identify any MSK injury in the 90-day post-RTP period after a concussion, along with time loss after subsequent injury. Performance statistics were obtained from each player’s preindex season and postindex season, as well as defined time points within the 90-day post-RTP period. Each concussed player was matched 1 to 1 with a nonconcussed control using position, win shares, player efficiency rating, and points per game. MSK injury incidence and player statistics in the concussion group were compared with controls using unpaired Student t tests. Results: A total of 70 concussions were identified in 70 professional basketball players and included in this analysis. A total of 49 players sustained an MSK injury in the 90-day post-RTP period (70%). Compared with controls, the odds of sustaining an MSK injury in the concussed cohort were 11.3 times greater (95% CI, 5.04-25.2; P < .001). Games missed after subsequent MSK injury were similar between the concussed and control groups ( P = .687). Comparisons over the 90-day post-RTP period did not reveal any significant changes in points per game, minutes per game, or true shooting percentage ( P > .05). When compared with controls, no changes in performance statistics were significantly different ( P > .05). Conclusion: Our analysis demonstrates that basketball players who sustain concussions are at a significantly increased risk for subsequent MSK injury within the 90-day post-RTP period but not player performance. Knowledge of this increased risk of MSK injury in concussed athletes can help guide concussion management for proper RTP and targeted rehabilitation in professional basketball players.

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.