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Objectives: To evaluate the risk of developing a new mental disorder diagnosis within 2 years of lower extremity fracture., Design: Retrospective cohort study., Setting: National insurance claims database., Patient Selection Criteria: Patients between 18 and 65 years with lower extremity, pelvis, and acetabular fractures without prior mental disorders as defined using International Classification of Diseases, 9th and 10th revision diagnosis codes were included. Mental disorders evaluated included alcohol use disorder, generalized anxiety disorder, bipolar disorder, major depressive disorder, drug use disorder, panic disorder, posttraumatic stress disorder, and suicide attempt., Outcome Measures and Comparisons: The individual lower extremity fracture cohorts were matched 1:4 with nonfracture controls. The specific groups of interest were pelvis fractures, acetabulum fractures, proximal femur fractures, femoral shaft fractures, distal femur fractures, patella fractures, tibia plateau fractures, tibia shaft fractures, ankle fractures, pilon fractures, calcaneus fractures, and Lisfranc fractures. Rates of mental disorders after primary lower extremity fractures within 2 years were compared using multivariable logistic regression., Results: Overall, the 263,988 patient-fracture group was 57.2% female with an average age of 46.6 years. Compared with controls with no fracture, patients who sustained pelvis, acetabulum, proximal femur, femoral shaft, distal femur, patella, tibia plateau, tibia shaft, pilon, calcaneus, or Lisfranc fracture had a statistically significantly increased risk of being diagnosed with a queried mental disorder within 2 years of fracture. When comparing all fracture patients by location, those suffering from fractures proximal to the knee joint, including pelvis fractures [OR: 1.51, 95% confidence interval (CI): 1.39-1.64] and proximal femur fractures [odds ratio (OR): 1.36, 95% CI: 1.26-1.47], demonstrated greater risk of developing any of the queried mental disorders compared with fractures distal to the knee, including ankle fractures (OR: 0.99, 95% CI: 0.95-1.03) and pilon fractures (OR: 1.05, 95% CI: 0.81-1.36). When comparing specific fracture patients with patients without fracture by mental disorder, patients demonstrated an increased risk of suicide attempt following fracture of the pelvis, acetabulum, femoral shaft, distal femur, and calcaneus, as well as patients sustaining a Lisfranc fracture., Conclusions: There is an increased risk of being diagnosed with a new mental disorder following lower extremity trauma in patients without prior mental disorder diagnosis compared with matched individuals without a lower extremity fracture. Among the fractures studied, those that were more proximal, such as pelvis and proximal femur fractures, carried greater risk compared with more distal fracture sites, including ankle and pilon fractures. Patients who experienced certain lower extremity fractures had a significantly higher rate of suicide attempt compared with patients without fracture. Physicians should consider increased mental health screening and potential referral for mental health evaluation for patients following lower extremity trauma., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: W.F. Sherman is a paid consultant for Stryker. K.C. Vemulapalli is a paid consultant for Skeletal Dynamics, Johnson & Johnson, and Smith & Nephew. All remaining authors have no conflicts of interest to declare., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective study., Objective: This study evaluated the impact of chewing tobacco on both medical and spine-related complication rates after spinal lumbar fusions in comparison to both a control cohort and a smoking cohort., Summary of Background Data: Smoking is a prevalent modifiable risk factor that has been demonstrated to be associated with increased complications after lumbar fusion. Although smoking rates have decreased in the United States, chewing tobacco use has not similarly reduced. Despite chewing tobacco delivering up to 4 times the dose of smoking, the impact of chewing tobacco is incompletely understood., Methods: A retrospective cohort study was conducted using the PearlDiver database. Patients who underwent lumbar spine fusion and used chewing tobacco were matched with a control cohort and a smoking cohort. Medical complications within 90 days after primary lumbar fusion were evaluated, including deep venous thrombosis, acute kidney injury, pulmonary embolism, transfusion, acute myocardial infarction, and inpatient readmission. Spine-related complications were evaluated at 2 years postoperatively, including pseudoarthrosis, incision and drainage (I&D), instrument failure, revision, and infection., Results: After primary lumbar fusion, the chewing tobacco cohort demonstrated significantly higher rates of pseudoarthrosis [odds ratio (OR): 1.41], revision (OR: 1.57), and any spine-related complication (OR: 1.32) compared with controls. The smoking cohort demonstrated significantly higher rates of pseudoarthrosis (OR: 1.88), I&D (OR: 1.27), instrument failure (OR: 1.39), revision (OR: 1.54), infection (OR: 1.34), and any spine-related complication (OR: 1.77) compared with controls. The chewing tobacco cohort demonstrated significantly lower rates of pseudoarthrosis (OR: 0.84), I&D (OR: 0.49), infection (OR: 0.70), and any spine-related complication (OR: 0.81) compared with the smoking cohort., Conclusions: This study demonstrated that chewing tobacco is associated with higher rates of both spine-related and medical complications after primary lumbar fusion. However, chewing tobacco use is associated with less risk of complications compared with smoking., Level of Evidence: Level III., Competing Interests: M.C. is a paid speaker for Medtronic, Stryker and ATEC. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: With the use of anterior cervical discectomy and fusion (ACDF) expected to rise by 13.3% from 2020 to 2040, the increased usage of interbody cages with integral anterior fixation prompted a Centers for Medicare & Medicaid Services (CMS) review, which resulted in coding changes affecting anterior instrumentation documentation. CMS determined that Current Procedural Terminology (CPT) code 22845 should not be used to report integrated instrumentation (plate) with an interbody device, and if additional anterior instrumentation (e.g., plates and screws) is placed with an integrated interbody device, then a 59 modifier should be used. There is sparse literature examining the trends of ACDF without and with additional anterior instrumentation after the 2015 CMS audit. Therefore, this study aimed to evaluate the trends of single-level subaxial ACDF utilization from 2011 to 2019 to determine whether the 2015 CMS audit influenced the documented usage of additional anterior instrumentation., Methods: A retrospective cohort study was performed using the commercially available database PearlDiver. Patient records were queried from 2011 to 2019 for single-level subaxial ACDF without (CPT code 22551) and with (CPT codes 22551 + 22845) instrumentation. Cochran-Armitage trend analyses were performed to evaluate the hypothesis that ACDF with additional anterior instrumentation decreased over the given time period., Results: Between 2011 and 2019, the total number of single-level ACDFs decreased from 6202 to 4402. From 2011 to 2015, an average of 6240 patients per year underwent single-level subaxial ACDF; of those, 950 patients (15.2%) had ACDF without instrumentation and 5290 patients (84.8%) had ACDF with instrumentation. In 2016, the total number of single-level subaxial ACDFs decreased to 5525, with 1006 patients (18.2%) receiving no instrumentation and 4519 patients (81.8%) receiving instrumentation. From 2017 to 2019, an average of 4283 patients per year underwent a single-level subaxial ACDF; of these, 1280 (29.9%) had no instrumentation and 3003 (70.1%) had instrumentation (all p < 0.0001)., Conclusions: From 2015 to 2019, single-level ACDF without instrumentation significantly increased by 91.5% and ACDF with anterior instrumentation significantly decreased by 18.1%. The 2015 CMS audit of interbody cages and anterior instrumentation coding (CPT code 22845) may account for the decreased documentation of anterior instrumentation in the 9-year period. Understanding CMS auditing could help surgeons perceive changes in practice patterns that may lead to a more thorough evaluation of patient outcomes, cost, and overall value.

Introduction: The United States is experiencing a national opioid epidemic. This study seeks to analyze recent trends in opioid claims after elective total joint arthroplasty and quantify the effect of preoperative opioid use on risk of prolonged postoperative claim rates., Methods: A retrospective cohort study was conducted using the PearlDiver database to track annual trends in opioid claims after elective total hip arthroplasty (THA), total knee arthroplasty (TKA), and total shoulder arthroplasty (TSA). Trend analysis of opioid claim rates was done with the Cochran-Armitage test. Rates of postoperative opioid claims were compared between opioid-naïve patients versus patients with opioid claims in the preoperative year through multivariable logistic regression., Results: In total, 105,860 procedures were included. For all procedures, the proportion of patients filing an opioid claim within 30 days postoperatively trended upward from 2011 to 2017 (all P < 0.001). Patients with one to three opioid claims in the year before arthroplasty were more likely to file an opioid claim within 30 days after arthroplasty (THA: odds ratio [OR], 2.61; TKA: OR, 3.04; and TSA: OR, 4.83), between 31 and 90 days (THA: OR, 2.76; TKA: OR, 2.87; and TSA: OR, 3.22), and between 91 days and 6 months (THA: OR, 4.83; TKA: OR, 4.07; and TSA: OR, 3.77). Patients with more than three prior opioid claims were more likely to file an opioid claim within 30 days (THA: OR, 6.15; TKA: OR, 6.79; and TSA: OR, 8.68), between 31 and 90 days (THA: OR, 20.99; TKA: OR, 14.00; and TSA: OR, 28.40), and between 91 days and 6 months (THA: OR, 46.31; TKA: OR, 33.93; and TSA: OR, 59.06)., Conclusion: Opioid claims in the preoperative year markedly increase risk of prolonged postoperative opioid claims after arthroplasty. Surgeons should look further before the acute preoperative period when evaluating opioid exposure and assessing risk of chronic opioid dependence after elective arthroplasty., Level of Evidence: Level III., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Background: In the past decade, the popularity of robot arm assistance in total joint arthroplasty has outpaced the reporting of long-term data. This study aimed to understand the motivations for use and perceptions of the technology among total joint surgeons., Methods: An online survey was distributed to the membership of the American Association of Hip and Knee Surgeons. The questions were asked for respondent's motivations for utilization of the technology, perceptions regarding outcomes and training, and personal characteristics that may have influenced responses., Results: Increased precision was the primary reason for users (73.1%) to utilize robot arm assistance in total joint procedures. Nonusers were just as likely to consider adopting the technology because of increase precision and marketing (P = .590). Nonclinical reasons such as marketing, administrative pressure, and peer pressure were primary motivators for 19.7% of users of the technology. Respondents regardless of financial interest and use of the technology felt that robot arm assistance increased operative time (76.5%) and was not more cost-effective than traditional methods (78.7%). Most American Association of Hip and Knee Surgeons members felt that 20-40 surgical cases were needed to become competent with the technique (54.1%). A unique finding of this study is that a larger proportion of orthopedic surgeons considered themselves "innovators" or "early adopters," based on Roger's diffusion of innovations, than was expected for the general population., Conclusion: This study demonstrates that the decision to adopt robot arm assistance in total joint arthroplasty is multifactorial and may have a significant contribution from nonclinical factors and inherent surgeon characteristics. Continued evaluation of surgeon perceptions will be valuable as new evidence emerges regarding long-term outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)