Patients who underwent rotator cuff repair had a higher incidence of suicide death than matched controls in a South Korean nationwide cohort study, with the association emerging more than 1 year following surgery.
Researchers analyzed National Health Insurance Service Sample cohort data collected from 2007 to 2018, including 3,992 patients aged older than 40 years who underwent rotator cuff repair (RCR) and 3,992 matched controls without rotator cuff tear. Suicide death was identified through national death-certificate records using International Classification of Diseases, 10th Revision intentional self-harm codes.
During a mean follow-up of about 5.75 years, 17 suicide deaths occurred: 13 among patients who underwent RCR and 4 among matched controls. Across the full follow-up period, suicide incidence was 56 per 100,000 person-years among patients who underwent surgery compared with 18 per 100,000 person-years among controls. Patients who underwent RCR had a 3.19-fold higher hazard of suicide death over the full follow-up period, although the wide confidence interval suggested substantial statistical uncertainty.
The association was concentrated beyond the first postoperative year. Within the first year following surgery, suicide risk did not differ statistically between groups. Beyond 1 year, however, 12 suicide deaths occurred among patients who underwent RCR compared with 2 among matched controls, corresponding to incidence rates of 63 vs 11 per 100,000 person-years. Patients who underwent RCR had a 5.86-fold higher hazard of suicide death during this later period.
Researchers used time-dependent propensity-score matching and adjusted for demographic characteristics, comorbidities, medication history, opioid prescription exposure, and prior medical conditions. Competing-risk sensitivity analyses that accounted for non-suicide deaths yielded similar findings.
The findings should be interpreted cautiously because suicide events were rare, and the study could not establish causality. A difference of 10 suicide deaths between groups drove the elevated late-period hazard ratio, meaning the estimate should be interpreted with particular caution.
The researchers noted that persistent pain, rehabilitation burden, sleep disturbance, functional limitations, retear, and dissatisfaction with recovery may contribute to psychological distress following surgery. The study also referenced prior evidence linking chronic pain and opioid exposure with suicide risk.
Notably, psychiatric diagnoses such as depression and psychosis could not be analyzed because the National Health Insurance Service masked sensitive psychiatric diagnostic codes for privacy reasons. Although propensity matching achieved acceptable balance between groups, patients who underwent RCR had slightly higher baseline antidepressant use (4.3% vs 3.4%) and benzodiazepine use (13.7% vs 12.5%) compared with controls.
The cohort also represented a surgical subset of patients with symptomatic rotator cuff tears requiring hospital admission and operative management, limiting generalizability to patients treated conservatively or those with asymptomatic tears. In addition, the Korean health care system and sociocultural attitudes toward psychiatric care and opioid use may affect applicability to other populations.
The researchers noted that the suicide incidence observed among patients who underwent RCR was lower than rates previously reported following hip fracture or spinal fracture, but appeared higher than rates reported following total knee or total hip arthroplasty.
“Patients who underwent RCR demonstrated no association with suicide within the first postoperative year, but a noticeable trend of increased suicide incidence emerged after this period,” wrote lead study author Hyojune Kim, MD, of Chung-Ang University Hospital in Seoul, South Korea, and colleagues.
The researchers suggested that orthopedic surgeons consider routine mental health screening during long-term postoperative follow-up, particularly among patients with persistent pain, prolonged rehabilitation difficulty, or dissatisfaction with surgical outcomes.
Disclosures: The researchers reported no relevant conflicts of interest.
Source: Clinics in Orthopedic Surgery
