Hypothyroidism Increases Risk of 90-Day and 1-Year Complications After Primary Rotator Cuff Repair: A Retrospective Cohort Study

Hypothyroidism Increases Risk of 90-Day and 1-Year Complications After Primary Rotator Cuff Repair: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Hypothyroidism Increases Risk of 90-Day and 1-Year Complications After Primary Rotator Cuff Repair: A Retrospective Cohort Study Yoli Meydan, Kenny Ling, Phoebe Lawrence, Edward D Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6649886/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Rotator cuff repair (RCR) is a commonly performed orthopedic procedure with generally favorable outcomes. However, the influence of systemic conditions such as hypothyroidism on postoperative complications remains underexplored. This study aimed to evaluate the impact of hypothyroidism on short- and long-term outcomes following primary RCR. Methods: A retrospective cohort study was conducted using data from the TriNetX Research Network, comprising over 100 healthcare organizations. Patients undergoing primary RCR between April 2005 and April 2024 were included. Hypothyroid patients were identified by a documented diagnosis within one week before surgery and matched 1:1 to euthyroid controls using propensity score matching based on demographics and comorbidities. Postoperative complications were assessed at 90 days and 1 year. Results: The final matched cohort included 7,647 patients in both cases and controls. At 90 days, hypothyroid patients had significantly higher rates of pulmonary embolism, deep vein thrombosis, acute kidney injury, urinary tract infections, fracture, shoulder stiffness, and postoperative pain. At 1 year, increased risks persisted for pulmonary embolism, deep vein thrombosis, acute kidney injury, urinary tract infections, fracture, shoulder stiffness, postoperative pain, sepsis, and shoulder replacement. Conclusion: Hypothyroidism is associated with increased postoperative complications following RCR, including higher rates of thromboembolic, renal, and musculoskeletal issues, as well as a greater likelihood of shoulder replacement. Preoperative identification and management of hypothyroidism may be crucial in optimizing surgical outcomes in this population. INTRODUCTION Rotator cuff tears are one of the most common orthopedic conditions, with an estimated prevalence around 20% in the general population 1 . In symptomatic patients, rotator cuff repair (RCR) often leads to excellent outcomes with high levels of patient satisfaction 2 – 4 . Given its effectiveness and increasing demand, RCR has become one of the most frequently performed orthopedic surgeries over the past two decades 5 , 6 . Between 2007 and 2016, over 300,000 RCR procedures were performed among insured adults under 65 living in the United States, with rates increasing by more than 1.5% annually 7 . Among increasing rates, patients undergoing RCR today are more likely to have additional comorbidities, including hypertension, diabetes, and vascular disease 7 . Therefore, as both surgical techniques and access to outpatient care improve, understanding patient-level risk factors that influence RCR outcomes becomes increasingly important. Hypothyroidism is one of the most common endocrine disorders, affecting over 11% of adults in the United States, with rates steadily rising over the past decade 8 . Growing evidence suggests that thyroid hormones play an important role in musculoskeletal health, influencing tenocyte function during tendon healing 9 , 10 . This hormonal influence has also been linked to adverse outcomes in orthopedic surgery. Patients with hypothyroidism have been shown to experience higher complication rates following total hip and knee arthroplasty 11 , 12 . A retrospective study by Lawand et al. also found that hypothyroid patients undergoing total shoulder arthroplasty had significantly higher rates of both short- and long-term complications, including infection, pulmonary embolism, periprosthetic fractures, prosthetic joint infection, and revision surgeries 13 . While the impact of hypothyroidism has been well documented in joint replacement procedures, its role in soft-tissue surgeries like rotator cuff repair remains underexplored. This is notable given that tendon-to-bone healing is critical to RCR success 14 . The purpose of our study was to use a large national database to identify postoperative complications associated with hypothyroidism following primary RCR. We hypothesized that patients with hypothyroidism would experience higher rates of complications compared to matched controls. METHODS Study Design This study was a retrospective cohort study conducted using de-identified electronic health record data from the TriNetX Research Network, a global database composed of over 100 academic medical centers and healthcare organizations. The study aimed to compare postoperative outcomes following primary rotator cuff repair between hypothyroid and euthyroid patients at 90 days and 1-year post-surgery. The TriNetX research network does not require IRB approval as no patient identifiable information is received. Cohort Selection Patients who underwent primary rotator cuff repair between April 1st, 2005, and April 1st, 2024, were identified using relevant CPT and ICD procedural codes (Supplemental Table 1). Patients were divided into two groups based on thyroid status: those with a documented diagnosis of hypothyroidism within 1 week prior to surgery (cases), and those without (controls). To reduce confounding, patients were excluded if they had a prior history of rotator cuff repair, shoulder arthroplasty, shoulder fracture, or the presence of a prosthetic shoulder joint. Individuals with a diagnosis of other thyroid pathologies (e.g., thyroiditis, hyperthyroidism) were also excluded to avoid overlapping endocrine influences. 1:1 Propensity Matching To minimize baseline differences between cohorts and reduce selection bias, the TriNetX platform was used to run 1:1 propensity score matching using logistic regression with a maximum allowable difference between propensity scores of ≤ 0.1. Matching variables included demographic factors (age, sex, race, ethnicity), body mass index (BMI), smoking status, and relevant comorbidities (e.g., diabetes, hypertension, chronic kidney disease, and coronary artery disease). We also matched for shoulder-specific diagnoses including complete vs partial rotator cuff tear, shoulder impingement, and tendinitis of the shoulder. A full list of matched variables and their corresponding standardized mean differences (SMDs) is provided in Table 1 , with detailed statistical values available in Supplementary Table 3. Before matching, the cohort consisted of 7,648 hypothyroid patients and 141,141 euthyroid controls. After 1:1 matching, 7,647 matched pairs remained for analysis. Prior to matching, multiple covariates demonstrated significant imbalance. These included current age (SMD = 0.402), age at index procedure (SMD = 0.462), sex (female: SMD = 0.573; male: SMD = 0.617), hypertension (SMD = 0.258), osteoarthritis (SMD = 0.250), and diabetes mellitus (SMD = 0.188). Following matching, all covariates were successfully reduced to below the 0.1 threshold, indicating successful balancing. Outcomes Both short-term and longer-term outcomes were analyzed at 90-days and 1-year postoperatively after rotator cuff repair. Short-term outcomes included thromboembolic disease, wound and systemic infections, heart attack, kidney injury, and wound disruption. Longer-term outcomes included ongoing pain, shoulder stiffness, joint infections, fractures, shoulder aspiration, shoulder replacement, removal of hardware, or revision surgery. A full list of outcomes and their associated codes is provided in Supplementary Table 2. RESULTS Table 2 demonstrates the postoperative complications within 90 days between hypothyroid and euthyroid patients. At 90 days postoperatively, hypothyroid patients had significantly higher rates of thromboembolic events, including pulmonary embolism (0.75% vs. 0.30%, RR [relative risk] 2.48, 95% CI [confidence interval] 1.53–4.02, p < 0.001) and deep vein thrombosis (0.64% vs. 0.33%, RR 1.96, 95% CI 1.21–3.17, p = 0.005). Hypothyroid patients also had higher rates of musculoskeletal complications including fracture of the upper arm and shoulder (2.86% vs. 1.86%, RR 1.54, 95% CI 1.25–1.90, p < 0.001), shoulder stiffness (8.13% vs. 6.41%, RR 1.27, 95% CI 1.13–1.42, p < 0.001), and postoperative pain (4.18% vs. 3.06%, RR 1.37, 95% CI 1.16–1.61, p < 0.001). Renal complications, including acute kidney injury (0.80% vs. 0.52%, RR 1.52, 95% CI 1.02–2.27, p = 0.036) and urinary tract infections (1.65% vs. 1.12%, RR 1.47, 95% CI 1.12–1.92, p = 0.006), were also significantly elevated in hypothyroid patients compared to controls. Table 3 demonstrates the postoperative complications within 1 year between hypothyroid and euthyroid patients. At 1-year, hypothyroid patients continued to show significantly elevated rates of pulmonary embolism, deep vein thrombosis, fracture of the upper arm and shoulder, shoulder stiffness, postoperative pain, acute kidney injury, and urinary tract infections. Notably, the rate of shoulder replacement was significantly higher in the hypothyroid group compared to controls (1.31% vs. 0.88%, RR 1.49, 95% CI 1.10–2.03, p = 0.010). Rates of revision, hardware removal, infection, and shoulder aspiration were not significantly elevated in either group at both 90 days and 1 year. Although sepsis was significant at the 1-year mark (0.98% vs. 0.68%, RR 1.44, 95% CI 1.01–2.05, p = 0.04), it was not elevated at 90 days. DISCUSSION The thyroid hormones triiodothyronine (T3) and thyroxine (T4) play critical roles in central metabolism 15 , bleeding 16 , and tissue repair 17 , all of which are essential for effective healing. In recent years, they have also been shown to play an important role in musculoskeletal health. Despite this, the impact of thyroid dysfunction on outcomes after soft-tissue orthopedic procedures remains poorly understood. In this large, multicenter retrospective cohort study, we found that hypothyroidism was associated with a significantly increased risk of postoperative complications following primary rotator cuff repair. Compared to matched euthyroid controls, hypothyroid patients experienced higher rates of thromboembolic events, kidney problems, and musculoskeletal issues such as shoulder stiffness, fractures, and persistent postoperative pain at both 90 days and 1 year. At 1 year, hypothyroidism was also associated with significantly higher rate of shoulder replacement, suggesting a greater likelihood of long-term surgical failure or unresolved symptoms. These findings support our hypothesis that thyroid dysfunction may negatively influence both short- and long-term recovery following RCR and highlight the effect of systemic metabolic conditions on outcomes in soft-tissue orthopedic procedures. Our finding that hypothyroid patients experienced significantly higher rates of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), aligns with prior literature in both orthopedic 11 , 13 , 18 and non-orthopedic 19 , 20 populations. Most notably, a 2024 retrospective study showed that patients with hypothyroidism who underwent total shoulder arthroplasty exhibited an elevated risk of pulmonary embolism, deep vein thrombosis, and myocardial infarction 13 . While the biological mechanisms underlying this observation are not fully established, hypothyroidism has been associated with increased levels of von Willebrand factor 16 , platelet dysfunction 21 , impaired fibrinolysis 16 , and increased blood viscosity 22 , all of which may contribute to a hypercoagulable state. This is further supported by a study by Huang et al., which found that hypertension was associated with an increased risk of DVT following orthopedic surgery 23 . Unlike Lawand et al., our study did not find a statistically significant difference in rates of myocardial infarction between hypothyroid and euthyroid patients following rotator cuff repair. This may be due to differences in cardiac strain from shoulder arthroplasty compared to RCR. We also found that hypothyroid patients had higher rates acute kidney injury (AKI) and urinary tract infections (UTIs) after rotator cuff repair. This finding is consistent with previous studies showing that thyroid hormone deficiency can impair kidney function 24 , 25 . Other studies have also shown increased rates of kidney injury in hypothyroid patients following total joint arthroplasty 11 , 13 , 26 . The relationship between thyroid hormones and renal function is well recognized. Hypothyroidism has been associated with decreased glomerular filtration rate (GFR), electrolyte abnormalities 27 , 28 , and elevated serum creatinine, urea, and uric acid levels relative to controls 29 . The relationship between hypothyroidism and increased risk for UTIs is less clear. Previous studies have shown that hypothyroid patients exhibit reduced micturition frequency compared to euthyroid controls 30 . This observation can also be secondary to the renal dysfunction associated with hypothyroidism, including impaired sodium and water handling and decreased renal perfusion 27 – 29 . Therefore, the combined influence of electrolytes imbalances, changes in urinary concentration, as well as delayed bladder emptying and urinary stasis, may all help explain the elevated risk of UTIs observed in our cohort 31 . Hypothyroid patients exhibited significantly higher rates of soft tissue complications at both 90-days and 1-year following rotator cuff repair, including postoperative pain and shoulder stiffness. These findings are consistent with the growing recognition of thyroid hormone signaling in rotator cuff tendon growth and repair. One clinical study by Oliva et al. examined 441 patients undergoing RCR and found a significantly higher prevalence of thyroid disease—particularly among women aged 60 to 80—suggesting a potential link between thyroid disease and tendon degeneration 32 . An earlier in-vitro study by the same group compared the expression of thyroid hormone receptors TRα and TRβ on tenocytes isolated from three patient groups: those with rotator cuff tears and thyroid disease, those with rotator cuff tears without thyroid disease, and those with healthy rotator cuff tendons. The presence of these receptors was comparable across all groups, and exposure to T3 and T4 was shown to enhance tenocyte proliferation and reduce apoptosis in a dose- and time-dependent manner 10 . These findings suggest that tenocytes remain responsive to thyroid hormone regardless of tendon health or disease status. A subsequent in-vitro study demonstrated that T3 and T4 signaling also increased tenocyte expression of ECM proteins such as collagen I, biglycan, and COMP (Cartilage Oligomeric Matrix Protein) 9 . Interestingly, the prevalence of hypothyroidism was also found to be significantly higher in patients with frozen shoulder compared to controls 33 . While thyroid hormones are not traditionally implicated in tendinopathies or soft tissue repair, these studies support our findings that disruptions in thyroid hormone signaling may compromise tendon-to-bone healing and increase the risk of musculoskeletal complications such as stiffness and pain following rotator cuff repair. In addition to soft tissue complications, hypothyroid patients in our cohort also experienced significantly higher rates of upper arm and shoulder fractures, as well as a higher likelihood of undergoing shoulder replacement within 1 year of surgery. These findings raise concern about both the structural integrity of bone and the long-term durability of tendon repair in this population. Thyroid hormones play a key role in regulating bone turnover, and hypothyroidism has been associated with decreased bone mineral density and impaired bone remodeling 34 , both of which may increase fracture risk. While the exact reasons for arthroplasty in our cohort are unknown, the increased rate of joint replacement within one year likely reflects a higher burden of complications such as re-tear, structural failure, or persistent pain. These complications are likely multifactorial, but may very well be rooted in the underlying effects of thyroid hormone deficiency on tenocyte function and extracellular matrix remodeling discussed above. A 2020 study found that the majority of patients undergoing shoulder arthroplasty following rotator cuff repair had a greater number of associated comorbidities such as hypertension, hyperlipidemia, and obesity 35 , all three of which are risk factors highly associated with hypothyroidism 36 – 38 . This study had several limitations, many of which are inherent to retrospective database research. TriNetX relies on ICD and CPT coding for diagnosis and procedure identification, which are naturally subject to errors in entry, variability across institutions, and potential underreporting. Due to the nonspecific nature of these codes, we were unable to assess the severity, duration, or treatment status of hypothyroidism, nor could we track laboratory values such as thyroid stimulating hormone, T3, or T4 levels over time. As a result, patients with well-controlled hypothyroidism may have been grouped with controls, or vice versa. Another limitation is the retrospective design, which prevents us from establishing causal relationships between hypothyroidism and postoperative complications. While propensity score matching was used to reduce confounding, unmeasured variables may still influence the results. Finally, TriNetX data is drawn from participating institutions, which may skew the sample toward larger, academic centers. Future studies should incorporate prospective designs with clinical data on thyroid function and treatment status to better clarify the relationship between hypothyroidism and postoperative outcomes following rotator cuff repair. CONCLUSION This study found that hypothyroid patients experienced significantly higher rates of thromboembolic, renal, and musculoskeletal complications, including higher rates of shoulder replacement within one year. These findings highlight the importance of recognizing hypothyroidism as a risk factor in surgical planning and postoperative care for rotator cuff repair. Preoperative screening and optimization of thyroid function may help to reduce complications and improve both short- and long-term outcomes following rotator cuff repair. Declarations Funding The authors did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study. No funds, grants, or other support was received. Competing Interests The authors have no relevant financial or non-financial interests to disclose. The authors have no competing interests to declare that are relevant to the content of this article. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. The authors have no financial or proprietary interests in any material discussed in this article. Ethics Approval This study used de-identified data from the TriNetX Research Network and was exempt from IRB approval. Consent to Participate Not applicable. Consent for Publication Not applicable. References Yamamoto A, Takagishi K, Osawa T, et al. Prevalence and risk factors of a rotator cuff tear in the general population. 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Indian J Endocrinol Metab. 2016;20(4):554–557. doi: 10.4103/2230-8210.183454 Tables Table 1 Standard mean difference (SMD) of baseline demographic and clinical characteristics before and after propensity score matching. Characteristic Name (Code) Before Matching SDM After Matching SDM Current Age (Age) 0.402 0.034 Age at Index (AI) 0.462 0.031 White (2106-3) 0.191 0.012 Not Hispanic or Latino (2186-5) 0.04 0.012 Female (F) 0.573 0.012 Male (M) 0.617 0.018 Unknown Ethnicity (UN) 0.005 0.018 Unknown Race (UNK) 0.02 0.01 Unknown Gender (UN) 0.071 0.01 Black or African American (2054-5) 0.198 0.019 Hispanic or Latino (2135-2) 0.093 0.01 Asian (2028-9) 0.09 0.018 Other Race (2131-1) 0.049 0.002 Native Hawaiian or Other Pacific Islander (2076-8) 0.017 0.006 American Indian or Alaska Native (1002-5) 0.018 0.002 Hypertensive diseases (I10-I1A) 0.258 0.004 Osteoarthritis (M15-M19) 0.25 0.024 Overweight and obesity (E66) 0.216 0.014 Diabetes mellitus (E08-E13) 0.188 0.004 Unspecified rotator cuff tear or rupture, not specified as traumatic (M75.10) 0.048 0.033 Impingement syndrome of shoulder (M75.4) 0.06 0.02 Other shoulder lesions (M75.8) 0.051 0.027 Bursitis of shoulder (M75.5) 0.032 0.033 Diseases of liver (K70-K77) 0.118 0.015 Nicotine dependence (F17) 0.041 0.042 Complete rotator cuff tear or rupture not specified as traumatic (M75.12) 0.032 0.037 Osteoporosis without current pathological fracture (M81) 0.205 0.029 Calcific tendinitis of shoulder (M75.3) 0.025 0.008 Bicipital tendinitis (M75.2) 0.063 0.022 Incomplete rotator cuff tear or rupture not specified as traumatic (M75.11) 0.063 0.016 Chronic kidney disease (CKD) (N18) 0.125 0.032 Heart failure (I50) 0.103 0.024 Other rheumatoid arthritis (M06) 0.119 0.031 Gout (M10) 0.034 0.027 Adhesive capsulitis of shoulder (M75.0) 0.021 0.028 Tobacco use (Z72.0) 0.043 0.026 Other arthritis (M13) 0.052 0.001 Shoulder lesion, unspecified (M75.9) 0.034 0.026 Osteoporosis with current pathological fracture (M80) 0.042 0.013 Rheumatoid arthritis with rheumatoid factor (M05) 0.024 0.006 Table 2 90-day postoperative complications in hypothyroid vs. euthyroid patients undergoing rotator cuff repair. Risk Complication Hypothyroid Euthyroid Risk Ratio 95% CI p-value Pulmonary Embolism 57.0 (0.75%) 23.0 (0.30%) 2.48 (1.53, 4.02) < 0.001* Deep Vein Thrombosis 49.0 (0.64%) 25.0 (0.33%) 1.96 (1.21, 3.17) 0.005* Sepsis 24.0 (0.31%) 15.0 (0.20%) 1.60 (0.84, 3.05) 0.149 Wound Disruption 19.0 (0.25%) 12.0 (0.16%) 1.58 (0.77, 3.26) 0.208 Fracture of Upper Arm/Shoulder 219.0 (2.86%) 142.0 (1.86%) 1.54 (1.25, 1.90) < 0.001* Myocardial Infarction 20.0 (0.26%) 13.0 (0.17%) 1.54 (0.77, 3.09) 0.223 Acute Kidney Injury 61.0 (0.80%) 40.0 (0.52%) 1.52 (1.02, 2.27) 0.036* Urinary Tract Infection 126.0 (1.65%) 86.0 (1.12%) 1.47 (1.12, 1.92) 0.006* Postoperative Pain 320.0 (4.18%) 234.0 (3.06%) 1.37 (1.16, 1.61) < 0.001* Shoulder Stiffness 622.0 (8.13%) 490.0 (6.41%) 1.27 (1.13, 1.42) < 0.001* Infection 33.0 (0.43%) 27.0 (0.35%) 1.22 (0.74, 2.03) 0.438 Shoulder Arthrocentesis 238.0 (3.11%) 234.0 (3.06%) 1.02 (0.85, 1.21) 0.852 Removal of Hardware 10.0 (0.13%) 10.0 (0.13%) 1.00 (0.42, 2.40) 1.000 Shoulder Replacement 10.0 (0.13%) 10.0 (0.13%) 1.00 (0.42, 2.40) 1.000 Revision 0.0 (0.00%) 0.0 (0.00%) 0.00 (0.00, 0.00) 1.000 Table 3 1-year postoperative complications in hypothyroid vs. euthyroid patients undergoing rotator cuff repair. Risk Complication Hypothyroid Euthyroid Risk Ratio 95% CI p-value Pulmonary Embolism 96.0 (1.26%) 44.0 (0.58%) 2.18 (1.53, 3.11) < 0.001* Deep Vein Thrombosis 96.0 (1.26%) 52.0 (0.68%) 1.85 (1.32, 2.58) < 0.001* Fracture of Upper Arm/Shoulder 281.0 (3.67%) 182.0 (2.38%) 1.54 (1.28, 1.86) < 0.001* Shoulder Replacement 100.0 (1.31%) 67.0 (0.88%) 1.49 (1.10, 2.03) 0.01* Sepsis 75.0 (0.98%) 52.0 (0.68%) 1.44 (1.01, 2.05) 0.04* Acute Kidney Injury 151.0 (1.97%) 108.0 (1.41%) 1.40 (1.09, 1.79) 0.007* Removal of Hardware 36.0 (0.47%) 26.0 (0.34%) 1.38 (0.84, 2.29) 0.203 Wound Disruption 35.0 (0.46%) 26.0 (0.34%) 1.35 (0.81, 2.23) 0.248 Urinary Tract Infection 343.0 (4.49%) 261.0 (3.41%) 1.31 (1.12, 1.54) < 0.001* Postoperative Pain 510.0 (6.67%) 399.0 (5.22%) 1.28 (1.13, 1.45) < 0.001* Shoulder Stiffness 746.0 (9.76%) 599.0 (7.83%) 1.25 (1.12, 1.38) < 0.001* Infection 64.0 (0.84%) 55.0 (0.72%) 1.16 (0.81, 1.67) 0.408 Myocardial Infarction 49.0 (0.64%) 45.0 (0.59%) 1.09 (0.73, 1.63) 0.679 Shoulder Arthrocentesis 988.0 (12.92%) 976.0 (12.76%) 1.01 (0.93, 1.10) 0.772 Revision 12.0 (0.16%) 12.0 (0.16%) 1.00 (0.45, 2.22) 1.000 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6649886","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":455692345,"identity":"05e6cb36-f6b0-48aa-97a2-f26fc81ee5b0","order_by":0,"name":"Yoli Meydan","email":"data:image/png;base64,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","orcid":"","institution":"Renaissance School of Medicine at Stony Brook University","correspondingAuthor":true,"prefix":"","firstName":"Yoli","middleName":"","lastName":"Meydan","suffix":""},{"id":455692346,"identity":"b246e415-eec1-4025-811d-a3a6c0bd7a6a","order_by":1,"name":"Kenny Ling","email":"","orcid":"","institution":"Stony Brook Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kenny","middleName":"","lastName":"Ling","suffix":""},{"id":455692347,"identity":"0b6527a8-acf5-426f-b9de-3ac923c9d822","order_by":2,"name":"Phoebe Lawrence","email":"","orcid":"","institution":"Renaissance School of Medicine at Stony Brook University","correspondingAuthor":false,"prefix":"","firstName":"Phoebe","middleName":"","lastName":"Lawrence","suffix":""},{"id":455692348,"identity":"52981b1f-ef2b-4fa3-83f6-2a946510aae5","order_by":3,"name":"Edward D Wang","email":"","orcid":"","institution":"Stony Brook Medicine","correspondingAuthor":false,"prefix":"","firstName":"Edward","middleName":"D","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-05-12 22:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6649886/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6649886/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83417290,"identity":"c2019b73-7184-45d2-a541-6a702e64f27c","added_by":"auto","created_at":"2025-05-25 21:46:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":726680,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6649886/v1/aab48bb0-5bc5-4737-8e31-b1df760b3eaa.pdf"},{"id":83262832,"identity":"05a1451f-c1be-48dc-8ee6-9141aafaa4b9","added_by":"auto","created_at":"2025-05-22 04:32:26","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27113,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6649886/v1/718b46d241c13fe3e343fdd8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hypothyroidism Increases Risk of 90-Day and 1-Year Complications After Primary Rotator Cuff Repair: A Retrospective Cohort Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eRotator cuff tears are one of the most common orthopedic conditions, with an estimated prevalence around 20% in the general population\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. In symptomatic patients, rotator cuff repair (RCR) often leads to excellent outcomes with high levels of patient satisfaction\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Given its effectiveness and increasing demand, RCR has become one of the most frequently performed orthopedic surgeries over the past two decades \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Between 2007 and 2016, over 300,000 RCR procedures were performed among insured adults under 65 living in the United States, with rates increasing by more than 1.5% annually\u003csup\u003e7\u003c/sup\u003e. Among increasing rates, patients undergoing RCR today are more likely to have additional comorbidities, including hypertension, diabetes, and vascular disease\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Therefore, as both surgical techniques and access to outpatient care improve, understanding patient-level risk factors that influence RCR outcomes becomes increasingly important.\u003c/p\u003e \u003cp\u003eHypothyroidism is one of the most common endocrine disorders, affecting over 11% of adults in the United States, with rates steadily rising over the past decade\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Growing evidence suggests that thyroid hormones play an important role in musculoskeletal health, influencing tenocyte function during tendon healing\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. This hormonal influence has also been linked to adverse outcomes in orthopedic surgery. Patients with hypothyroidism have been shown to experience higher complication rates following total hip and knee arthroplasty\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. A retrospective study by Lawand et al. also found that hypothyroid patients undergoing total shoulder arthroplasty had significantly higher rates of both short- and long-term complications, including infection, pulmonary embolism, periprosthetic fractures, prosthetic joint infection, and revision surgeries\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhile the impact of hypothyroidism has been well documented in joint replacement procedures, its role in soft-tissue surgeries like rotator cuff repair remains underexplored. This is notable given that tendon-to-bone healing is critical to RCR success\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The purpose of our study was to use a large national database to identify postoperative complications associated with hypothyroidism following primary RCR. We hypothesized that patients with hypothyroidism would experience higher rates of complications compared to matched controls.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study was a retrospective cohort study conducted using de-identified electronic health record data from the TriNetX Research Network, a global database composed of over 100 academic medical centers and healthcare organizations. The study aimed to compare postoperative outcomes following primary rotator cuff repair between hypothyroid and euthyroid patients at 90 days and 1-year post-surgery. The TriNetX research network does not require IRB approval as no patient identifiable information is received.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCohort Selection\u003c/h3\u003e\n\u003cp\u003ePatients who underwent primary rotator cuff repair between April 1st, 2005, and April 1st, 2024, were identified using relevant CPT and ICD procedural codes (Supplemental Table\u0026nbsp;1). Patients were divided into two groups based on thyroid status: those with a documented diagnosis of hypothyroidism within 1 week prior to surgery (cases), and those without (controls). To reduce confounding, patients were excluded if they had a prior history of rotator cuff repair, shoulder arthroplasty, shoulder fracture, or the presence of a prosthetic shoulder joint. Individuals with a diagnosis of other thyroid pathologies (e.g., thyroiditis, hyperthyroidism) were also excluded to avoid overlapping endocrine influences.\u003c/p\u003e\n\u003ch3\u003e1:1 Propensity Matching\u003c/h3\u003e\n\u003cp\u003eTo minimize baseline differences between cohorts and reduce selection bias, the TriNetX platform was used to run 1:1 propensity score matching using logistic regression with a maximum allowable difference between propensity scores of \u0026le;\u0026thinsp;0.1. Matching variables included demographic factors (age, sex, race, ethnicity), body mass index (BMI), smoking status, and relevant comorbidities (e.g., diabetes, hypertension, chronic kidney disease, and coronary artery disease). We also matched for shoulder-specific diagnoses including complete vs partial rotator cuff tear, shoulder impingement, and tendinitis of the shoulder. A full list of matched variables and their corresponding standardized mean differences (SMDs) is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, with detailed statistical values available in Supplementary Table\u0026nbsp;3.\u003c/p\u003e \u003cp\u003eBefore matching, the cohort consisted of 7,648 hypothyroid patients and 141,141 euthyroid controls. After 1:1 matching, 7,647 matched pairs remained for analysis. Prior to matching, multiple covariates demonstrated significant imbalance. These included current age (SMD\u0026thinsp;=\u0026thinsp;0.402), age at index procedure (SMD\u0026thinsp;=\u0026thinsp;0.462), sex (female: SMD\u0026thinsp;=\u0026thinsp;0.573; male: SMD\u0026thinsp;=\u0026thinsp;0.617), hypertension (SMD\u0026thinsp;=\u0026thinsp;0.258), osteoarthritis (SMD\u0026thinsp;=\u0026thinsp;0.250), and diabetes mellitus (SMD\u0026thinsp;=\u0026thinsp;0.188). Following matching, all covariates were successfully reduced to below the 0.1 threshold, indicating successful balancing.\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eBoth short-term and longer-term outcomes were analyzed at 90-days and 1-year postoperatively after rotator cuff repair. Short-term outcomes included thromboembolic disease, wound and systemic infections, heart attack, kidney injury, and wound disruption. Longer-term outcomes included ongoing pain, shoulder stiffness, joint infections, fractures, shoulder aspiration, shoulder replacement, removal of hardware, or revision surgery. A full list of outcomes and their associated codes is provided in Supplementary Table\u0026nbsp;2.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates the postoperative complications within 90 days between hypothyroid and euthyroid patients. At 90 days postoperatively, hypothyroid patients had significantly higher rates of thromboembolic events, including pulmonary embolism (0.75% vs. 0.30%, RR [relative risk] 2.48, 95% CI [confidence interval] 1.53\u0026ndash;4.02, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and deep vein thrombosis (0.64% vs. 0.33%, RR 1.96, 95% CI 1.21\u0026ndash;3.17, p\u0026thinsp;=\u0026thinsp;0.005). Hypothyroid patients also had higher rates of musculoskeletal complications including fracture of the upper arm and shoulder (2.86% vs. 1.86%, RR 1.54, 95% CI 1.25\u0026ndash;1.90, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), shoulder stiffness (8.13% vs. 6.41%, RR 1.27, 95% CI 1.13\u0026ndash;1.42, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and postoperative pain (4.18% vs. 3.06%, RR 1.37, 95% CI 1.16\u0026ndash;1.61, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Renal complications, including acute kidney injury (0.80% vs. 0.52%, RR 1.52, 95% CI 1.02\u0026ndash;2.27, p\u0026thinsp;=\u0026thinsp;0.036) and urinary tract infections (1.65% vs. 1.12%, RR 1.47, 95% CI 1.12\u0026ndash;1.92, p\u0026thinsp;=\u0026thinsp;0.006), were also significantly elevated in hypothyroid patients compared to controls.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e demonstrates the postoperative complications within 1 year between hypothyroid and euthyroid patients. At 1-year, hypothyroid patients continued to show significantly elevated rates of pulmonary embolism, deep vein thrombosis, fracture of the upper arm and shoulder, shoulder stiffness, postoperative pain, acute kidney injury, and urinary tract infections. Notably, the rate of shoulder replacement was significantly higher in the hypothyroid group compared to controls (1.31% vs. 0.88%, RR 1.49, 95% CI 1.10\u0026ndash;2.03, p\u0026thinsp;=\u0026thinsp;0.010). Rates of revision, hardware removal, infection, and shoulder aspiration were not significantly elevated in either group at both 90 days and 1 year. Although sepsis was significant at the 1-year mark (0.98% vs. 0.68%, RR 1.44, 95% CI 1.01\u0026ndash;2.05, p\u0026thinsp;=\u0026thinsp;0.04), it was not elevated at 90 days.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe thyroid hormones triiodothyronine (T3) and thyroxine (T4) play critical roles in central metabolism\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, bleeding\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, and tissue repair\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, all of which are essential for effective healing. In recent years, they have also been shown to play an important role in musculoskeletal health. Despite this, the impact of thyroid dysfunction on outcomes after soft-tissue orthopedic procedures remains poorly understood.\u003c/p\u003e \u003cp\u003eIn this large, multicenter retrospective cohort study, we found that hypothyroidism was associated with a significantly increased risk of postoperative complications following primary rotator cuff repair. Compared to matched euthyroid controls, hypothyroid patients experienced higher rates of thromboembolic events, kidney problems, and musculoskeletal issues such as shoulder stiffness, fractures, and persistent postoperative pain at both 90 days and 1 year. At 1 year, hypothyroidism was also associated with significantly higher rate of shoulder replacement, suggesting a greater likelihood of long-term surgical failure or unresolved symptoms. These findings support our hypothesis that thyroid dysfunction may negatively influence both short- and long-term recovery following RCR and highlight the effect of systemic metabolic conditions on outcomes in soft-tissue orthopedic procedures.\u003c/p\u003e \u003cp\u003eOur finding that hypothyroid patients experienced significantly higher rates of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), aligns with prior literature in both orthopedic\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e and non-orthopedic\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e populations. Most notably, a 2024 retrospective study showed that patients with hypothyroidism who underwent total shoulder arthroplasty exhibited an elevated risk of pulmonary embolism, deep vein thrombosis, and myocardial infarction\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. While the biological mechanisms underlying this observation are not fully established, hypothyroidism has been associated with increased levels of von Willebrand factor\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, platelet dysfunction\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, impaired fibrinolysis\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, and increased blood viscosity\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, all of which may contribute to a hypercoagulable state. This is further supported by a study by Huang et al., which found that hypertension was associated with an increased risk of DVT following orthopedic surgery\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Unlike Lawand et al., our study did not find a statistically significant difference in rates of myocardial infarction between hypothyroid and euthyroid patients following rotator cuff repair. This may be due to differences in cardiac strain from shoulder arthroplasty compared to RCR.\u003c/p\u003e \u003cp\u003eWe also found that hypothyroid patients had higher rates acute kidney injury (AKI) and urinary tract infections (UTIs) after rotator cuff repair. This finding is consistent with previous studies showing that thyroid hormone deficiency can impair kidney function\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Other studies have also shown increased rates of kidney injury in hypothyroid patients following total joint arthroplasty\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The relationship between thyroid hormones and renal function is well recognized. Hypothyroidism has been associated with decreased glomerular filtration rate (GFR), electrolyte abnormalities\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e, and elevated serum creatinine, urea, and uric acid levels relative to controls\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. The relationship between hypothyroidism and increased risk for UTIs is less clear. Previous studies have shown that hypothyroid patients exhibit reduced micturition frequency compared to euthyroid controls\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. This observation can also be secondary to the renal dysfunction associated with hypothyroidism, including impaired sodium and water handling and decreased renal perfusion\u003csup\u003e\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Therefore, the combined influence of electrolytes imbalances, changes in urinary concentration, as well as delayed bladder emptying and urinary stasis, may all help explain the elevated risk of UTIs observed in our cohort\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHypothyroid patients exhibited significantly higher rates of soft tissue complications at both 90-days and 1-year following rotator cuff repair, including postoperative pain and shoulder stiffness. These findings are consistent with the growing recognition of thyroid hormone signaling in rotator cuff tendon growth and repair. One clinical study by Oliva et al. examined 441 patients undergoing RCR and found a significantly higher prevalence of thyroid disease\u0026mdash;particularly among women aged 60 to 80\u0026mdash;suggesting a potential link between thyroid disease and tendon degeneration\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. An earlier in-vitro study by the same group compared the expression of thyroid hormone receptors TRα and TRβ on tenocytes isolated from three patient groups: those with rotator cuff tears and thyroid disease, those with rotator cuff tears without thyroid disease, and those with healthy rotator cuff tendons. The presence of these receptors was comparable across all groups, and exposure to T3 and T4 was shown to enhance tenocyte proliferation and reduce apoptosis in a dose- and time-dependent manner\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. These findings suggest that tenocytes remain responsive to thyroid hormone regardless of tendon health or disease status. A subsequent in-vitro study demonstrated that T3 and T4 signaling also increased tenocyte expression of ECM proteins such as collagen I, biglycan, and COMP (Cartilage Oligomeric Matrix Protein)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Interestingly, the prevalence of hypothyroidism was also found to be significantly higher in patients with frozen shoulder compared to controls\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. While thyroid hormones are not traditionally implicated in tendinopathies or soft tissue repair, these studies support our findings that disruptions in thyroid hormone signaling may compromise tendon-to-bone healing and increase the risk of musculoskeletal complications such as stiffness and pain following rotator cuff repair.\u003c/p\u003e \u003cp\u003eIn addition to soft tissue complications, hypothyroid patients in our cohort also experienced significantly higher rates of upper arm and shoulder fractures, as well as a higher likelihood of undergoing shoulder replacement within 1 year of surgery. These findings raise concern about both the structural integrity of bone and the long-term durability of tendon repair in this population. Thyroid hormones play a key role in regulating bone turnover, and hypothyroidism has been associated with decreased bone mineral density and impaired bone remodeling\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, both of which may increase fracture risk. While the exact reasons for arthroplasty in our cohort are unknown, the increased rate of joint replacement within one year likely reflects a higher burden of complications such as re-tear, structural failure, or persistent pain. These complications are likely multifactorial, but may very well be rooted in the underlying effects of thyroid hormone deficiency on tenocyte function and extracellular matrix remodeling discussed above. A 2020 study found that the majority of patients undergoing shoulder arthroplasty following rotator cuff repair had a greater number of associated comorbidities such as hypertension, hyperlipidemia, and obesity\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, all three of which are risk factors highly associated with hypothyroidism\u003csup\u003e\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study had several limitations, many of which are inherent to retrospective database research. TriNetX relies on ICD and CPT coding for diagnosis and procedure identification, which are naturally subject to errors in entry, variability across institutions, and potential underreporting. Due to the nonspecific nature of these codes, we were unable to assess the severity, duration, or treatment status of hypothyroidism, nor could we track laboratory values such as thyroid stimulating hormone, T3, or T4 levels over time. As a result, patients with well-controlled hypothyroidism may have been grouped with controls, or vice versa. Another limitation is the retrospective design, which prevents us from establishing causal relationships between hypothyroidism and postoperative complications. While propensity score matching was used to reduce confounding, unmeasured variables may still influence the results. Finally, TriNetX data is drawn from participating institutions, which may skew the sample toward larger, academic centers. Future studies should incorporate prospective designs with clinical data on thyroid function and treatment status to better clarify the relationship between hypothyroidism and postoperative outcomes following rotator cuff repair.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study found that hypothyroid patients experienced significantly higher rates of thromboembolic, renal, and musculoskeletal complications, including higher rates of shoulder replacement within one year. These findings highlight the importance of recognizing hypothyroidism as a risk factor in surgical planning and postoperative care for rotator cuff repair. Preoperative screening and optimization of thyroid function may help to reduce complications and improve both short- and long-term outcomes following rotator cuff repair.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003eNo funding was received to assist with the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003eNo funds, grants, or other support was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003eAll authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\n\u003cp\u003eThe authors have no financial or proprietary interests in any material discussed in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study used de-identified data from the TriNetX Research Network and was exempt from IRB approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYamamoto A, Takagishi K, Osawa T, et al. 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Published online February 1, 2023. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1530/EOR-22-0085\u003c/span\u003e\u003cspan address=\"10.1530/EOR-22-0085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlqahtani HA, Almagsoodi AA, Alshamrani ND, Almalki TJ, Sumaili AM. Common Electrolyte and Metabolic Abnormalities Among Thyroid Patients. Cureus. 13(5):e15338. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.15338\u003c/span\u003e\u003cspan address=\"10.7759/cureus.15338\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiamis G, Filippatos TD, Liontos A, Elisaf MS. MANAGEMENT OF ENDOCRINE DISEASE: Hypothyroidism-associated hyponatremia: mechanisms, implications and treatment. Eur J Endocrinol. 2017;176(1):R15-R20. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1530/EJE-16-0493\u003c/span\u003e\u003cspan address=\"10.1530/EJE-16-0493\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaini V, Yadav A, Arora MK, Arora S, Singh R, Bhattacharjee J. Correlation of creatinine with TSH levels in overt hypothyroidism \u0026mdash; A requirement for monitoring of renal function in hypothyroid patients? Clin Biochem. 2012;45(3):212\u0026ndash;214. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.clinbiochem.2011.10.012\u003c/span\u003e\u003cspan address=\"10.1016/j.clinbiochem.2011.10.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndersen LF, Walter S, Agner T, Hansen JM. 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J Clin Med. 2020;9(4):1034. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/jcm9041034\u003c/span\u003e\u003cspan address=\"10.3390/jcm9041034\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eApfel A, Lin CC, Burfeind W, Dillon MT, Navarro RA. Characteristics of Rotator Cuff Repairs Revised to Shoulder Arthroplasty. Arch Bone Jt Surg. 2020;8(5):575\u0026ndash;580. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.22038/abjs.2020.39006.2042\u003c/span\u003e\u003cspan address=\"10.22038/abjs.2020.39006.2042\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerta E, Lengyel I, Halmi S, et al. Hypertension in Thyroid Disorders. Front Endocrinol. 2019;10:482. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fendo.2019.00482\u003c/span\u003e\u003cspan address=\"10.3389/fendo.2019.00482\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMavromati M, Jornayvaz FR. Hypothyroidism-Associated Dyslipidemia: Potential Molecular Mechanisms Leading to NAFLD. Int J Mol Sci. 2021;22(23):12797. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijms222312797\u003c/span\u003e\u003cspan address=\"10.3390/ijms222312797\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanyal D, Raychaudhuri M. Hypothyroidism and obesity: An intriguing link. Indian J Endocrinol Metab. 2016;20(4):554\u0026ndash;557. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/2230-8210.183454\u003c/span\u003e\u003cspan address=\"10.4103/2230-8210.183454\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eStandard mean difference (SMD) of baseline demographic and clinical characteristics before and after propensity score matching.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristic Name (Code)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBefore Matching SDM\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAfter Matching SDM\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCurrent Age (Age)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.402\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge at Index (AI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.462\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite (2106-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot Hispanic or Latino (2186-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale (F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.573\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale (M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.617\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnknown Ethnicity (UN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnknown Race (UNK)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnknown Gender (UN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlack or African American (2054-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic or Latino (2135-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsian (2028-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther Race (2131-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNative Hawaiian or Other Pacific Islander (2076-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmerican Indian or Alaska Native (1002-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertensive diseases (I10-I1A)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.258\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteoarthritis (M15-M19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOverweight and obesity (E66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes mellitus (E08-E13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnspecified rotator cuff tear or rupture, not specified as traumatic (M75.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImpingement syndrome of shoulder (M75.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther shoulder lesions (M75.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBursitis of shoulder (M75.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiseases of liver (K70-K77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNicotine dependence (F17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplete rotator cuff tear or rupture not specified as traumatic (M75.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteoporosis without current pathological fracture (M81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalcific tendinitis of shoulder (M75.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBicipital tendinitis (M75.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncomplete rotator cuff tear or rupture not specified as traumatic (M75.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChronic kidney disease (CKD) (N18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeart failure (I50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther rheumatoid arthritis (M06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGout (M10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdhesive capsulitis of shoulder (M75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTobacco use (Z72.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther arthritis (M13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShoulder lesion, unspecified (M75.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteoporosis with current pathological fracture (M80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRheumatoid arthritis with rheumatoid factor (M05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e90-day postoperative complications in hypothyroid vs. euthyroid patients undergoing rotator cuff repair.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eRisk\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComplication\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHypothyroid\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEuthyroid\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRisk Ratio\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePulmonary Embolism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57.0 (0.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.0 (0.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.53, 4.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeep Vein Thrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49.0 (0.64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.0 (0.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.21, 3.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.005*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSepsis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24.0 (0.31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.0 (0.20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.84, 3.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWound Disruption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.0 (0.25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.0 (0.16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.77, 3.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.208\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFracture of Upper Arm/Shoulder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e219.0 (2.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e142.0 (1.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.25, 1.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMyocardial Infarction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.0 (0.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.0 (0.17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.77, 3.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.223\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute Kidney Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e61.0 (0.80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.0 (0.52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.02, 2.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.036*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrinary Tract Infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e126.0 (1.65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e86.0 (1.12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.12, 1.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.006*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e320.0 (4.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e234.0 (3.06%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.16, 1.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShoulder Stiffness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e622.0 (8.13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e490.0 (6.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.13, 1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.0 (0.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.0 (0.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.74, 2.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.438\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShoulder Arthrocentesis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e238.0 (3.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e234.0 (3.06%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.85, 1.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.852\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRemoval of Hardware\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.0 (0.13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.0 (0.13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.42, 2.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShoulder Replacement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.0 (0.13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.0 (0.13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.42, 2.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRevision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.00, 0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e1-year postoperative complications in hypothyroid vs. euthyroid patients undergoing rotator cuff repair.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eRisk\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComplication\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHypothyroid\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEuthyroid\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRisk Ratio\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePulmonary Embolism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e96.0 (1.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44.0 (0.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.53, 3.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeep Vein Thrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e96.0 (1.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52.0 (0.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.32, 2.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFracture of Upper Arm/Shoulder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e281.0 (3.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e182.0 (2.38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.28, 1.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShoulder Replacement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e100.0 (1.31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.0 (0.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.10, 2.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSepsis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e75.0 (0.98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52.0 (0.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.01, 2.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.04*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute Kidney Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e151.0 (1.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e108.0 (1.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.09, 1.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.007*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRemoval of Hardware\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36.0 (0.47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.0 (0.34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.84, 2.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.203\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWound Disruption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35.0 (0.46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.0 (0.34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.81, 2.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrinary Tract Infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e343.0 (4.49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e261.0 (3.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.12, 1.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e510.0 (6.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e399.0 (5.22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.13, 1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShoulder Stiffness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e746.0 (9.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e599.0 (7.83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(1.12, 1.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.0 (0.84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55.0 (0.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.81, 1.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.408\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMyocardial Infarction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49.0 (0.64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45.0 (0.59%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.73, 1.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.679\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShoulder Arthrocentesis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e988.0 (12.92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e976.0 (12.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.93, 1.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.772\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRevision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.0 (0.16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.0 (0.16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e(0.45, 2.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6649886/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6649886/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRotator cuff repair (RCR) is a commonly performed orthopedic procedure with generally favorable outcomes. However, the influence of systemic conditions such as hypothyroidism on postoperative complications remains underexplored. This study aimed to evaluate the impact of hypothyroidism on short- and long-term outcomes following primary RCR.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA retrospective cohort study was conducted using data from the TriNetX Research Network, comprising over 100 healthcare organizations. Patients undergoing primary RCR between April 2005 and April 2024 were included. Hypothyroid patients were identified by a documented diagnosis within one week before surgery and matched 1:1 to euthyroid controls using propensity score matching based on demographics and comorbidities. Postoperative complications were assessed at 90 days and 1 year.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe final matched cohort included 7,647 patients in both cases and controls. At 90 days, hypothyroid patients had significantly higher rates of pulmonary embolism, deep vein thrombosis, acute kidney injury, urinary tract infections, fracture, shoulder stiffness, and postoperative pain. At 1 year, increased risks persisted for pulmonary embolism, deep vein thrombosis, acute kidney injury, urinary tract infections, fracture, shoulder stiffness, postoperative pain, sepsis, and shoulder replacement.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eHypothyroidism is associated with increased postoperative complications following RCR, including higher rates of thromboembolic, renal, and musculoskeletal issues, as well as a greater likelihood of shoulder replacement. Preoperative identification and management of hypothyroidism may be crucial in optimizing surgical outcomes in this population.\u003c/p\u003e","manuscriptTitle":"Hypothyroidism Increases Risk of 90-Day and 1-Year Complications After Primary Rotator Cuff Repair: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-22 04:32:21","doi":"10.21203/rs.3.rs-6649886/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf245565-ff0c-46be-8492-5da9bf28b1fa","owner":[],"postedDate":"May 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-25T21:38:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-22 04:32:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6649886","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6649886","identity":"rs-6649886","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}