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 Obesity is a risk factor for complications after total shoulder arthroplasty (TSA). GLP-1 receptor agonists (GLP-1 RAs) and bariatric surgery (BS) are common weight-loss strategies, but their impact on TSA outcomes is unclear. Methods Using a national database, we identified obese patients undergoing anatomic TSA in three groups: GLP-1 RA use, BS, or no intervention. Three separate pairwise 1:1 propensity-matched comparisons balanced demographics, BMI, serum albumin, and Charlson Comorbidity Index components. Outcomes were compared at 90 days, 2 years, and 5 years, and by achievement of a non-obese state (BMI < 30 kg/m2). Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Results After matching, 14,124 patients were analyzed across three pairwise comparisons: 4,972 GLP-1 RA users, 3,167 BS patients, and 5,985 controls. Compared with no intervention, GLP-1 RA users had higher rates of all-cause revision, the primary outcome, at 90 days (OR 1.56, 95% CI 1.07-2.28, p=0.019), 2 years (OR 1.41, 95% CI 1.11-1.79, p=0.005), and 5 years (OR 1.43, 95% CI 1.15-1.77, p=0.001), all of which remained significant after correction for multiple comparisons, while BS patients had higher odds of dislocation at 2 years (OR 1.73, 95% CI 1.25-2.40, p<0.001) and 5 years (OR 1.53, 95% CI 1.15-2.05, p=0.004). In exploratory analyses stratified by achieved BMI, GLP-1 RA responders had fewer 5-year periprosthetic fractures than BS responders (OR 0.38, p=0.007); no other stratified difference persisted after correction for multiple comparisons. Among BS patients, mechanical complication rates did not differ by whether a non-obese state was achieved. Conclusion GLP-1 RA use was associated with a modest increase in revision, and BS with a small increase in dislocation, which must be weighed against the systemic benefits of weight loss. These associations are hypothesis-generating rather than causal. Level of Evidence Level III, Retrospective Cohort Comparison using Large Database, Prognosis Study

BACKGROUND:The purpose of this study was to evaluate national- and state-level trends in inflation-adjusted Medicaid physician reimbursement for total knee arthroplasty (TKA) and total hip arthroplasty (THA) from 2014 to 2022 and to assess whether these trends differ based on Medicaid expansion status. METHODS:Average physician reimbursement per patient for TKA and THA from 2014 to 2022 was extracted from a large insurance claims database. All monetary values were adjusted for inflation using the Consumer Price Index and reported in 2022 United States dollars. For each procedure, the total percentage change in reimbursement over the study period as well as the average annual percentage change was calculated. Data were then broken down by state, and states were categorized based on Medicaid expansion status (expanded versus nonexpanded). RESULTS:Between 2014 and 2022, the national weighted average reimbursement for TKA declined from $2,024 to $1,579, representing an overall decrease of 22.0%. The annual percentage change for TKA reimbursement was -3.0% per year (P = 0.003). For THA, reimbursement decreased from $2,050 to $1,395, an overall reduction of 31.9%, with an annual percentage change of -4.7% per year (P = 0.048). When stratified by Medicaid expansion status, TKA reimbursement declined at similar rates in expansion states (-2.4%) and non-expansion states (-2.7%) (P > 0.05). Similarly, THA reimbursement declined with a percentage change of -3.2% in expansion states and -5.4% in nonexpansion states (P > 0.05). CONCLUSIONS:Medicaid reimbursement for TKA and THA procedures declined significantly from 2014 to 2022, with similar drops in both Medicaid expansion and nonexpansion states.

Abstract Distal radius fracture (DRF) open reduction and internal fixation (ORIF) is a common procedure performed across inpatient and outpatient settings. This study compared postoperative complications and healthcare utilization between these settings using a large national claims database. Patients aged 18 years and older who underwent DRF ORIF were identified in the PearlDiver Mariner database using International Classification of Diseases and Current Procedural Terminology codes. Service location determined surgical setting. Patients with pathological fractures, malignancy, or polytrauma were excluded. Cohorts were propensity matched 1:1 based on age, sex, Charlson and Elixhauser comorbidity indices, and relevant comorbidities. The matched cohort included 9,697 inpatient and 9,697 outpatient DRF ORIF cases. Serious postoperative complications occurred in 16.8% of inpatient procedures versus 5.0% of outpatient procedures. Inpatient surgery was associated with higher odds of surgical site infection (OR 2.23, 95% CI: 1.78–2.79), wound dehiscence (OR 2.57, 95% CI: 1.07–6.17), and deep vein thrombosis (OR 7.75, 95% CI: 3.53–17.04). Inpatients also had greater odds of emergency department visits (OR 1.17, 95% CI: 1.05–1.31), readmissions (OR 3.64, 95% CI: 2.91–4.54), reoperations (OR 2.15, 95% CI: 1.70–2.73), and higher 90-day reimbursements. Inpatient DRF ORIF was associated with significantly higher complication rates and increased postoperative healthcare utilization compared with outpatient procedures, with the largest absolute differences seen in readmissions, reoperations, and 90-day reimbursements. These associations are unlikely to be causal, as inpatient admission typically reflects greater medical necessity and clinical complexity not fully captured by administrative data. Nonetheless, because admission status is readily available at the point of care, it may serve as a practical flag to identify patients who warrant closer post-discharge surveillance and individualized follow-up planning. III.

Background:The menisci provide mechanical stability and shock absorption in the knee joint, distributing stress across the tibial plateau. Root tears to the menisci are functionally equivalent to a total meniscectomy, frequently leading to rapidly progressive degenerative osteoarthritis within the knee joint. The majority of medial meniscal bony avulsions have been reported in younger, skeletally immature patients. Cases of bony avulsions in older patients have sparsely documented. Care Presentation:In this case report, we highlight the case of a 45-year-old male with a history of osteoporosis who sustained a twisting injury to the right knee which subsequently resulted in a bony avulsion injury of his medial meniscal root. MRI imaging was acquired, showing injury to the medial meniscus concurrent with an avulsion of the posterior root. A transtibial pullout repair was performed, anchoring the bony avulsion into its insertion site to allow for direct bone-to-bone healing. Conclusion:This case presents a unique mechanism of injury, as most medial meniscal root injuries in older patients involve a tear of the root rather than avulsion of the bone. Additionally, meniscal bony avulsions have been reported to mainly be a consequence of acute traumatic injury. We hypothesize that this patient's history of osteoporosis contributed to his bony avulsion, especially because of his age and his relatively nontraumatic mechanism of injury.

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 Little research exists regarding geographic comparisons within the United States for Medicaid reimbursement. We compared Medicaid reimbursement for a broad range of orthopedic surgery codes from each state on a geographic and state level. Methods We obtained Medicaid reimbursement rates in each state for 211 orthopedic procedure codes along with corresponding work Relative Value Units (wRVUs). Rates were divided by wRVUs to control for differences between procedures and subspecialties. States were designated as either West, Midwest, South, or Northeast. Kruskal-Wallis tests with Dunn’s post-hoc analyses ascertained differences between regions and each orthopedic subspecialty by state. Coefficient of variation (CoV) values were calculated to measure the amount of variability in rates. A Kruskall-Wallis with Dunn’s post-hoc test assessed differences in quartiles for reimbursement compared to a square miles per orthopedic surgeon ratio. Results The West region reimbursed the highest at $72.92/wRVU and the Northeast reimbursed the lowest at $51.78. Hand surgery was the highest reimbursing subspecialty ($94.58/wRVU) and Oncology the lowest ($62.89/wRVU). The CoV ranged from 0.15–0.77 by state and 0.27–0.50 by subspecialty. A linear regression model between wRVU-adjusted Medicaid reimbursement and square miles per surgeon yielded an R2 value of 0.453. States with the most land area relative to orthopedic surgeons reimbursed significantly higher. Conclusion The West geographic region is associated with the highest Medicaid reimbursement for orthopedic procedures, and the Northeast the lowest. Wide variability was seen in rates, both between states and within states. Large, sparsely-populated states may increase Medicaid reimbursement as a tactic to attract physicians. Level of Evidence: IV; Economic Analysis

Platelet-rich plasma (PRP) continues to generate both excitement and skepticism within orthopaedics and sports medicine. As a biologic derived from autologous blood, PRP offers an appealing, minimally invasive option for treating musculoskeletal pathology through the delivery of concentrated growth factors and cytokines. Evidence across orthopaedic subspecialties remains mixed, however, with studies showing variable efficacy and inconsistent methodologies. Recent data on PRP use for extra-articular hip pathology, particularly greater trochanteric pain syndrome, hamstring injuries, and piriformis syndrome show encouraging improvements in pain and function, including faster return to sport and favorable patient-reported outcomes. Yet, significant heterogeneity in study design, PRP preparation, and control interventions limits generalizability and hinders clear clinical guidance. These inconsistencies mirror similar challenges in PRP research for a variety of other orthopaedic pathologies, underscoring the need for standardized preparation protocols and consistent reporting frameworks. Despite these limitations, a signal of efficacy persists within the data, suggesting PRP may indeed provide meaningful benefit for select extra-articular hip conditions. As surgical alternatives for these pathologies often carry substantial morbidity, continued refinement of PRP formulations and methodology represents a promising step toward establishing biologics as reliable, evidence-based tools in orthopaedic care.

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.

PURPOSE:To evaluate retear rates, clinical outcomes, and complications of a consecutive series of full-thickness rotator cuff repair cases augmented with an autograft biceps patch. METHODS:A retrospective review was performed of patients undergoing rotator cuff repair with autograft biceps patch augmentation. Patients underwent either magnetic resonance imaging or ultrasound to evaluate rotator cuff repair integrity at a minimum of 6 months postoperatively. Patient-reported outcomes including the American Shoulder and Elbow Surgeons Score and Single Assessment Numeric Evaluation score were also collected and evaluated for clinical significance at a minimum of 12 months postoperatively. Analysis of retear rates was performed by comparing observed retear rates to expected retear rates using the modified Rotator Cuff Healing Index score. RESULTS:The final cohort included 25 rotator cuff repair cases. Postoperative imaging was obtained by magnetic resonance imaging in 22 patients at a mean of 9 months postoperatively (range, 6.0-15.3 months) and ultrasound in 3 patients at a mean of 30.4 months (range, 28.8-32.2 months). The expected retear rate using the modified Rotator Cuff Healing Index score was 21.5% for the entire cohort. There was 1 retear, resulting in an actual retear rate of 4% at an average of 23.5-month follow-up (P = .0196). The average Single Assessment Numeric Evaluation score was 93 (standard deviation 9), and the average American Shoulder and Elbow Surgeons Score was 96 (standard deviation 6.3) at an average of 23.5-month follow-up (range 14-32). Patient acceptable symptomatic state was achieved by 96% of the cohort for the American Shoulder and Elbow Surgeons Score and 88% of the cohort for the Single Assessment Numeric Evaluation score. There were no cases of reoperation or complications. CONCLUSIONS:In this consecutive series, the biceps autograft "smash" patch for rotator cuff augmentation resulted in a low rate of retears, favorable patient-reported outcomes, and no complications. This augmentation option has the potential to be safe and effective for improving rotator cuff repair healing rates. LEVEL OF EVIDENCE:Level IV, retrospective case series.

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:Carpal tunnel release (CTR) is one of the most frequently performed procedures in the United States, with both open (OCTR) and endoscopic (ECTR) techniques widely used. As surgical practices evolve and outpatient care expands, understanding future utilization trends across care settings is increasingly important. This study projects the use of OCTR and ECTR through 2040 to inform shifting surgical preferences and healthcare demands. METHODS:This study analyzed procedural data from 2010 to 2019 using the PearlDiver Mariner all-payer claims database. Cases of OCTR and ECTR were identified using Current Procedural Terminology codes. Procedures were further stratified by inpatient or outpatient status based on the documented site of service field within the database. Log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average (ARIMA) models were applied to procedural volumes to project trends through 2040. The ARIMA model was selected based on the lowest normalized root mean square error and overall model performance. RESULTS:In 2019, there were 31,190 outpatient ECTR, 155 inpatient ECTR, 101,334 outpatient OCTR, and 1359 inpatient OCTR procedures. By 2040, outpatient ECTR is projected to grow to 65,072 cases (95% CI, 62,471-67,781) at 3.79% annually. Inpatient ECTR is projected to reach 181 cases (95% CI, 97-340) with 2.13% annual growth. Outpatient OCTR is expected to decline to 77,834 cases (95% CI, 76,287-79,413), and inpatient OCTR to 962 cases (95% CI, 809-1143), with annual decreases of 1.19% and 1.48%, respectively. CONCLUSIONS:By 2040, demand for outpatient ECTR is projected to increase by 110.31% compared to 2019, whereas outpatient OCTR is expected to decline by 20.31%. Although inpatient utilization remains limited, the adoption of endoscopic techniques is anticipated to rise across all care settings, in contrast to the continued decline of open procedures. These trends highlight the ongoing shift toward minimally invasive, ambulatory surgical care. Strategic planning in surgical training, healthcare infrastructure, and reimbursement models will be critical to meet changing demands. Further research is needed to validate these projections in broader populations and across diverse healthcare systems.

BACKGROUND:Shoulder arthroplasty utilization has grown significantly in the United States, driven by an aging population and the success of reverse total shoulder arthroplasty procedures. Despite this, Medicare (MCR) reimbursement for these procedures sharply declined over the past several decades. Medicaid (MCD) reimbursement is more difficult to ascertain due to the decentralized nature of state fee schedules. This study aimed to compare current MCD rates to 2024 MCR rates for primary and revision shoulder arthroplasty procedures. METHODS:We analyzed 4 Current Procedural Terminology codes representing primary and revision shoulder arthroplasty. MCD rates were obtained from state fee schedules online and adjusted using the Medicare Wage Index to study the effect of wage differences throughout the country. MCR rates were collected from the Centers for Medicare & Medicaid Services Physician Fee Schedule. These rates were compared to each other using national and state averages, dollar differences with and without adjustment for work Relative Value Units, and coefficient of variability values. Two primary shoulder arthroplasty codes were compared to a 2020 study using unadjusted and inflation-adjusted percentage differences. RESULTS:Current MCD reimbursement for shoulder arthroplasty procedures was 13.1% lower than MCR on average. This difference increased to 24.6% when adjusting for wage differences. Reimbursement varied between 46% and 135% of MCR by state. The coefficient of variation ranged from 0.25 to 028 for unadjusted MCD data and from 0.34 to 0.37 for Medicare Wage Index-adjusted MCD data. From 2020 to 2024, the shoulder hemiarthroplasty code fell 32.2% when unadjusted and 43.3% when adjusted for inflation. Total shoulder arthroplasty rose by 1.1% but fell by 15.4% when adjusted for inflation. CONCLUSIONS:MCD reimbursement for shoulder arthroplasty procedures is substantially lower than MCR on average but highly variable among states. The percentage difference between MCD and MCR for shoulder arthroplasty codes is greater than the percentage difference for total hip and knee arthroplasty. Compared to 2020, primary shoulder arthroplasty reimbursement is decreasing when adjusted for inflation.

Background:Medicare reimbursement for spine procedures has been decreasing, and it is well-established that Medicaid reimburses physicians even less than Medicare. This study seeks to provide an updated analysis of Medicaid reimbursement using 24 common spine procedure codes. Methods:Medicaid rates were obtained from state online fee schedules, and Medicare rates from the Centers for Medicare and Medicaid online fee database. Rates were compared directly to each other by state and averaged to reflect national differences. The Medicare Wage Index was used to control for variability in wages between states and was used to adjust Medicaid data for comparison. Variability between states and codes was quantified using coefficient of variation values. Results:Medicaid reimbursement was lower than Medicare for all 24 included Current Procedural Terminology codes. Nationally, Medicaid rates were 13% less than Medicare, and this difference increased to 25% when adjusting for wage differences. Average cost differences were -$118 per code. Substantial variability between states and codes was also found for Medicaid, while little variability in Medicare rates existed. Conclusions:We found that Medicaid reimbursement to surgeons for 24 common spine surgeons was 13% less than Medicare on average. This difference increased to 25% when adjusting for wage differences. For Medicaid, wide variability existed between states and between different codes, indicating that some state payment systems may lack objective metrics when determining rates.

Introduction Preoperative post-traumatic stress disorder (PTSD) has previously been associated with increased rates of complications following various orthopedic procedures. However, there is a paucity in the literature regarding the association of PTSD with complications in the context of total shoulder arthroplasty (TSA). Thus, the purpose of this study was to compare postoperative medical and surgical complications among patients with and without PTSD. Methods A retrospective cohort study was conducted using the PearlDiver database. Patients who underwent TSA with a diagnosis code for PTSD within six months of TSA were matched 1:4 to controls without PTSD using propensity score matching. Matching was performed based on age, gender, Charlson Comorbidity Index (CCI), and other comorbidities. Multivariable logistic regressions accounting for age, gender, CCI, alcohol abuse, and substance abuse, were employed to compare complications between groups. Postoperative complications were assessed at 90 days, one year, and two years. Complications assessed included myocardial infarction, deep vein thrombosis, wound dehiscence, acute kidney injury, sepsis, readmission, revision, periprosthetic joint infection, aseptic loosening, fracture, among others. Statistical comparisons were made using odds ratios (OR) with 95% confidence intervals (CI), and a p-value of <0.05 was considered statistically significant. Bonferroni correction was applied that determined a p-value = 0.0029 as the threshold for significance. Results The query resulted in a total of 4,137 patients (3,092 control and 1,045 PTSD) who underwent TSA. The PTSD cohort displayed elevated prevalence of ED visits (OR 1.68) and acute kidney injury (OR 2.13) within 90 days of surgery compared to controls.At one- and two- year following TSA, the PTSD cohort displayed similar rates of revision, periprosthetic joint infection (PJI), dislocation, aseptic loosening, periprosthetic fracture, and postoperative stiffness compared to controls. Conclusion This study suggests that PTSD is associated with a higher incidence of ED visits and acute kidney injury within 90-days following TSA. No increase in the incidence of other major or minor complications was noted.

Background: The Latarjet and other bony augmentation procedures are commonly used to treat anterior shoulder instability in the setting of significant glenoid bone loss. Although several fixation strategies have been reported, the biomechanical strength of these techniques remains poorly understood. Purpose: To perform a systematic review of the biomechanical strength of glenoid bony augmentation procedures for anterior shoulder instability. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic search of the Medline, Embase, Web of Science, and Cochrane Library databases was performed to identify biomechanical studies evaluating various fixation strategies for coracoid and other bone transfer procedures for anterior shoulder instability. Biomechanical results included load to failure with both compression and traction forces, stiffness, and cyclic displacement. The quality of included articles was assessed based on the Quality Appraisal for Cadaveric Studies (QUACS) scale. Results: A total of 21 biomechanical studies comprising 486 specimens were included. The number of screws used and the addition of washers were found to significantly increase rigidity and load to failure. The comparison of fixation techniques demonstrated mixed results in load to failure between screw and alternative constructs including suture buttons and suture anchors. However, studies that tested graft displacement consistently found more graft displacement in buttons compared with screws. The median and mean of the QUACS scale were both 12, with a range of 10-13. Conclusion: Biomechanical studies consistently demonstrated that when glenoid bone grafts were fixed with screws, the number of screws and use of washers significantly increased construct rigidity and load to failure. Different metal screw materials and sizes did not consistently demonstrate a significant difference in biomechanical strength. There are mixed results when comparing suture buttons to screw fixation. The evaluated studies revealed that all double metal screw constructs and the majority of suture button and anchor constructs were able to withstand the glenohumeral load reflective of activities of daily living using a 150-N threshold.

PURPOSE:The purpose of the study was to compare the Medicaid and Medicare professional service reimbursement rates for a select group of hand surgery procedures. METHODS:Medicare rates for 26 common hand procedures were obtained from the Center for Medicare & Medicaid fee schedule database using Medicare Administrative Contractor localities to approximate state lines. Medicaid rates were found at each state Medicaid online fee schedule website. State rates were compared with corresponding Medicare rates using mean values and dollar differences. Each state's reimbursement values were also adjusted using the Medicare Wage Index, a relative scale comparing state wages with the national average, to account for regional wage differences. Variability between states and between procedures was analyzed using the coefficient of variation values. RESULTS:Medicaid reimbursement was lower than that of Medicare for 22 of the 26 procedures included in the analysis. On average, Medicaid reimbursement rates were 18% lower than Medicare for the same procedure, a difference that increased to 29% when accounting for wage differences via the Medicare Wage Index. The coefficient of variation values were low across Medicare procedures, indicating low variability between states. The coefficient of variation values were much higher for Medicaid rates and increased when adjusted for state wage differences, indicating high variability between state Medicaid rates. CONCLUSIONS:Professional fee reimbursement for select hand surgery procedures is substantially lower with Medicaid compared with Medicare, and there is a high degree of variability between states. Wage differences do not explain differences in state pricing. CLINICAL RELEVANCE:Low Medicaid reimbursement for hand surgery procedures may have negative implications for health care access in some states. The wide variability in reimbursement between states is concerning, given that Medicaid is supported mostly by federal funding.

OBJECTIVES:This study seeks to evaluate the variability of Medicaid reimbursement and compare it with Medicare reimbursement using the 20 most commonly billed orthopaedic trauma Current Procedural Terminology (CPT) codes nationwide. The authors anticipate significant variability between states and hypothesize that Medicaid payment will be significantly less than Medicare payment.METHODS:The top 20 most common orthopaedic trauma surgery procedural codes were identified from a previous analysis performed by Haglin et al. The Centers for Medicare and Medicaid Services Physician Fee Schedule was used to determine reimbursement rates from Medicare, and state Medicaid fee schedules were used to determine reimbursement rates for Medicaid. State Medicaid rates were compared with their corresponding Medicare rates to determine a dollar difference. In addition, the dollar difference for each CPT code was divided by its respective physician relative value unit. This was used to acknowledge the possible variability in the complexity of orthopaedic procedures and the related physician effort. The Medicare Wage Index was used to adjust Medicaid rates based on the cost of living for the state as well. Coefficients of variation were calculated to represent overall variability in Medicaid and Medicare reimbursement rates.RESULTS:The mean reimbursement rates for Medicaid were lower for all 20 procedures compared with Medicare. On average, Medicaid reimbursed 16.0% less than Medicare and 29.6% less when adjusting for cost of living. MCD reimbursed at a higher rate than MCR for all procedures in only 9 states (Alaska, Arizona, Arkansas, Montana, Nebraska, New Jersey, New Mexico, North Dakota, and South Dakota) while 38 states reimbursed at a lower rate than MCR, on average. The coefficient of variation ranged from 0.24 to 0.34 for the Medicaid unadjusted group and from 0.35 to 0.46 for the Medicare Wage Index-adjusted group. By contrast, the Medicare group was consistent at 0.06 for all 20 procedures. The average dollar difference across the 20 CPT codes for Medicaid reimbursement compared with Medicare reimbursement ranged from -$76.89 to -$225.17, and the dollar difference per relative value unit ranged from -$5.96 to -$15.16.CONCLUSIONS:This study found a high amount of variation between state Medicaid reimbursement rates and average rates that were significantly lower than Medicare reimbursement rates for the top 20 most used orthopaedic trauma CPT codes as identified by Haglin et al. The discrepancy in reimbursement was increased when Medicaid rates were adjusted for state cost of living.LEVEL OF EVIDENCE:Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose: To evaluate the superior to inferior glenoid height as a reliable reference in best -fit circle creation for glenoid anatomy. Methods: The morphology of the native glenoid was evaluated using magnetic resonance imaging (MRI) in patients without shoulder instability. Using T1 sagittal MRI images, 2 reviewers independently estimated glenoid size using the two-thirds technique and the "best -fit circle" technique at 2 different times. A Student t -test was used to determine significant difference between the two methodologies. Inter- and intra-rater reliability were calculated using interclass and intraclass coefficients. Results: This study included 112 patients. Using the results of glenoid height and "best -fit circle" diameter, the diameter of the "best -fit circle" was found to intersect the glenoid line at 67.8% of the glenoid height on average. We found no significant difference between the 2 measures of glenoid diameter (27.6 vs 27.9, P 1/4 .456). The interclass and intraclass coefficients for the two -third method were 0.85 and 0.88, respectively. The interclass and intraclass coefficients for the perfect circle methods were 0.84 and 0.73, respectively. Conclusions: We determined that the diameter of a circle placed on the inferior glenoid using the "best -fit circle" technique corresponds to 67.8% of the glenoid height. Additionally, we found that constructing a perfect circle using a diameter equal to two-thirds the height of the glenoid may improve intraclass reliability. Level of Evidence: Level IV, retrospective cohort study.