BACKGROUND: Psychiatric comorbidities are associated with worse results after total knee arthroplasty (TKA), but outcomes in patients who have personality disorders (PD) remain poorly defined. This study evaluated complications and opioid-related outcomes after primary TKA in patients who have PD.
METHODS: Patients who underwent primary TKA from 2010 to 2022 were identified in a national all-payer claims database. Patients who had PD were identified by diagnosis codes and classified by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition cluster. Because they carried a greater baseline comorbidity burden, patients who had PD were matched 1:1 to patients who did not have PD on demographics, comorbidities, psychiatric conditions, and preoperative opioid abuse. Multivariable regressions evaluated medical, wound and infectious, orthopaedic, and opioid-related outcomes.
RESULTS: Of 698,040 patients, 2,961 (0.4%) had PD; 75.7% had Cluster B PD, of which 81.1% were borderline. After matching (n = 2,922 per group) and adjustment, PD was independently associated with opioid abuse at two years (odds ratio [OR] 1.26; 95% confidence interval [CI], 1.04 to 1.52) and five years (OR 1.36; CI, 1.15 to 1.60), and with lower odds of wound and infectious complications (OR 0.80; CI, 0.67 to 0.95); all P < 0.05. Total 90-day opioid exposure in morphine milligram equivalents did not differ. Only Cluster B PD remained associated with opioid abuse at two years (OR 1.39; CI, 1.19 to 1.63) and five years (OR 1.43; CI, 1.25 to 1.64; both P < 0.001).
CONCLUSIONS: The greater baseline comorbidity burden of patients who have PD accounts for most of the excess perioperative risk. However, Cluster B PD remains independently associated with opioid abuse at two and five years after TKA despite similar opioid exposure, supporting preoperative psychiatric screening and targeted opioid stewardship.
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