Tobacco Smoking Independently Predicts Lower Patient-Reported Outcomes: New Insights on a Forgotten Epidemic

Influence of smoking on patient-reported outcome measures (PROMs) in patients undergoing surgery for adult spinal deformity: a propensity score-matched analysis

PURPOSE

The purpose of this study was to determine the isolated influence of smoking in patient-reported outcome measures (PROMs) for adult spinal deformity (ASD) surgery excluding known tobacco-related complications.

METHODS

Retrospective analysis of a prospective multicenter ASD database. Patients operated on ASD with 2 year post-operative follow-up were included. Former smokers (non-active smokers) and patients developing mechanical or infectious complications were excluded. Changes of PROMs over time were analyzed using mixed models for repeated measures (MMRM). Propensity score matching (PSM) (1:1 ratio, caliper 0.10) was performed without replacement using optimum algorithm, tolerance ≤ 0.001, and estimated with 95% confidence interval (CI). PROMS in both groups were compared by paired t test or Wilcoxon signed-rank test.

RESULTS

692 out of 1246 surgical patients met our inclusion criteria. 153 smokers were matched with 153 non-smokers according to age, BMI, number of fused levels, and global tilt. After PSM both groups were homogeneous regarding baseline parameters, surgical data, and complications (mechanical complications and infection excluded). Smokers had worse baseline results for SRS-total, SRS-pain COMI-back, and ODI; smokers also showed worse 2-year outcomes for SRS-total, SRS-function, SRS-pain, SRS-self-image, and ODI. However, no differences between the two groups were found in the improvement from baseline to 2-year follow-up or in the timing of this improvement (MMRM). The proportion of patients reaching the minimal clinically important difference (MCID) after surgery was similar in the two groups, but the proportion of patients reaching patient acceptable symptom state (PASS) was significantly lower in smokers for SRS-Subtotal, SRS-function, and SRS-image.

CONCLUSION

Even in the absence of smoking-related complications, smokers had worse PROMs at baseline and 2 years after surgery with less patients achieving PASS, but similar degrees on improvement compared to non-smokers. The proportion achieving MCID was also similar between the two cohorts.

Examining the Evidence Regarding Smoking and Patient Outcomes for Isolated Meniscus Pathology: A Comprehensive Systematic Review and Meta-Analysis

Smoking is a well-known cause of impairment in wound healing and postoperative outcomes; however, its effects on treating meniscus issues remain unclear. This study assesses the relationship between smoking and meniscus treatment outcomes. PubMed, Scopus, Cochrane, and CINAHL were searched from inception to 24 December 2023. Inclusion criteria encompassed studies examining smoking's impact on patient outcomes regarding meniscus pathology. A secondary PubMed search targeted randomized controlled trials (RCTs) in the top ten orthopedic journals focusing on meniscus pathology and smoking as a demographic variable. Meta-analysis of six studies (n = 528) assessed meniscus failure rate based on smoking status. Eighteen observational studies (n = 8353 patients; 53.25% male; mean age: 51.35 ± 11.53 years; follow-up: 184.11 ± 117.34 months) were analyzed, covering meniscus repair, meniscectomy, allograft transplant, conservative care, and arthroscopy. Results showed four studies (36.36%) linked smoking with worse meniscus repair outcomes, while seven studies (63.64%) did not find significant associations. Meta-analysis from six studies showed no significant impact of smoking on repair failure (p = 0.118). Regarding meniscectomy, one study (33.33%) identified a significant association with smoking, but two did not. Only one (3.8%) of the RCTs in leading orthopedic journals included smoking as a factor. The evidence on smoking's effect on meniscus treatment is mixed, necessitating further investigation.

Mental Health Effects on the Minimal Clinically Important Difference in Total Joint Arthroplasty

INTRODUCTION

The effect of mental health on patient-reported outcome measures is not fully understood in total joint arthroplasty (TJA). Thus, we investigated the relationship between mental health diagnoses (MHDs) and the Minimal Clinically Important Difference for Improvement (MCID-I) and Worsening (MCID-W) in primary TJA and revision TJA (rTJA).

METHODS

Retrospective data were collected using relevant Current Procedural Terminology and MHDs International Classification of Diseases, 10th Revision, codes with completed Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form, Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form, Patient-reported Outcomes Measurement Information System (PROMIS)-Physical Function Short Form 10a, PROMIS Global-Mental, or PROMIS Global-Physical questionnaires. Logistic regressions and statistical analyses were used to determine the effect of a MHD on MCID-I/MCID-W rates.

RESULTS

Data included 4,562 patients (4,190 primary TJAs/372 rTJAs). In primary total hip arthroplasty (pTHA), MHD-affected outcomes for Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (MCID-I: 81% versus 86%, P = 0.007; MCID-W: 6.0% versus 3.2%, P = 0.008), Physical Function Short Form 10a (MCID-I: 68% versus 77%, P < 0.001), PROMIS Global-Mental (MCID-I: 38% versus 44%, P = 0.009), and PROMIS Global-Physical (MCID-I: 61% versus 73%, P < 0.001; MCID-W: 14% versus 7.9%, P < 0.001) versus pTHA patients without MHD. A MHD led to lower rates of MCID-I for PROMIS Global-Physical (MCID-I: 56% versus 63%, P = 0.003) in primary total knee arthroplasty patients. No effects from a MHD were observed in rTJA patients.

DISCUSSION

The presence of a MHD had a prominent negative influence on pTHA patients. Patients who underwent rTJA had lower MCID-I rates, higher MCID-W rates, and lower patient-reported outcome measure scores despite less influence from a MHD.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Estimating County-Level Overdose Rates Using Opioid-Related Twitter Data: Interdisciplinary Infodemiology Study

BACKGROUND

There were an estimated 100,306 drug overdose deaths between April 2020 and April 2021, a three-quarter increase from the prior 12-month period. There is an approximate 6-month reporting lag for provisional counts of drug overdose deaths from the National Vital Statistics System, and the highest level of geospatial resolution is at the state level. By contrast, public social media data are available close to real-time and are often accessible with precise coordinates.

OBJECTIVE

The purpose of this study is to assess whether county-level overdose mortality burden could be estimated using opioid-related Twitter data.

METHODS

International Classification of Diseases (ICD) codes for poisoning or exposure to overdose at the county level were obtained from CDC WONDER. Demographics were collected from the American Community Survey. The Twitter Application Programming Interface was used to obtain tweets that contained any of the 36 terms with drug names. An unsupervised classification approach was used for clustering tweets. Population-normalized variables and polynomial population-normalized variables were produced. Furthermore, z scores of the Getis Ord Gi clustering statistic were produced, and both these scores and their polynomial counterparts were explored in regression modeling of county-level overdose mortality burden. A series of linear regression models were used for predictive modeling to explore the interpretability of the analytical output.

RESULTS

Modeling overdose mortality with normalized demographic variables alone explained only 7.4% of the variability in county-level overdose mortality, whereas this was approximately doubled by the use of specific demographic and Twitter data covariates based on a backward selection approach. The highest adjusted R² and lowest AIC (Akaike Info Criterion) were obtained for the model with normalized demographic variables, normalized z scores from geospatial analyses, and normalized topic counts (adjusted R²=0.133, AIC=8546.8). The z scores of the Getis Ord Gi statistic appeared to have improved utility over population-normalization alone. In this model, median age, female population, and tweets about web-based drug sales were positively associated with opioid mortality. Asian race and Hispanic ethnicity were significantly negatively associated with county-level burdens of overdose mortality.

CONCLUSIONS

Social media data, when transformed using certain statistical approaches, may add utility to the goal of producing closer to real-time county-level estimates of overdose mortality. Prediction of opioid-related outcomes can be advanced to inform prevention and treatment decisions. This interdisciplinary approach can facilitate evidence-based funding decisions for various substance use disorder prevention and treatment programs.

Changes in Patient Reported Outcome Measure Scores From Initial Presentation to Day-of-Surgery in Patients Undergoing Hip and Knee Arthroplasty

BACKGROUND

It is not well understood how patient reported outcome measures (PROMs) change from initial presentation to day-of-surgery (DOS). This study sought to quantify preoperative PROM changes for hip and knee arthroplasty patients.

METHODS

A retrospective review was performed on primary total hip, total knee, and partial knee arthroplasty patients from October 2020 through January 2021. Trends in preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) scores were compared using scores at initial presentation in the ambulatory clinic and at a time near the date-of-surgery. A total of 497 patients possessed 2 preoperative PROMIS-PF (497/497), HOOS-JR (152/497), or KOOS-JR (258/497) surveys.

RESULTS

There was no significant statistical difference in mean PROM scores between initial presentation and DOS PROMIS-PF or HOOS-JR scores. Only KOOS-JR demonstrated a significant statistical difference of 2 ± 14 (P = .002) when comparing initial versus preoperative scores. Partial knee arthroplasty patients saw a strong positive correlation (r = 0.77) between initial PROMIS-PF and DOS scores. However, mean absolute value changes on an individual level were 4 ± 4, 11 ± 39, and 11 ± 10 for PROMIS-PF, HOOS-JR, and KOOS-JR, respectively, indicating the presence of meaningful patient-level score changes as based on previously published anchor-based minimal clinically important differences.

CONCLUSION

PROMs collected during the preoperative period demonstrated wide variability at an individual level, but not at a population level. Collection at both time points may be necessary in order to understand the clinical impact of surgery on these patients.

The influence of obesity on functional outcomes and patient satisfaction 8 weeks after total knee arthroplasty: results of the prospective FInGK study

OBJECTIVES

To investigate obese versus non-obese subjects´ knee joint function, stiffness, pain, expectations, and outcome satisfaction before and two months after total knee arthroplasty (TKA).

METHODS

This study is a secondary analysis of data retrieved via a prospective single-centre cohort study investigating knee joint function and health care services utilization in patients undergoing TKA (FInGK Study). For the primary study, elective TKA patients were consecutively recruited between December 2019 and May 2021. Preoperative expectations, Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), surgery outcome satisfaction, and sociodemographic variables were assessed via self-reported questionnaires. In the current study, obese (Body Mass Index (BMI) ≥ 30 kg/m²) versus non-obese (BMI < 30 kg/m²) subjects' data were exploratively compared before and two months after TKA. Multivariable logistic regression assessed factors associated with TKA satisfaction two months postoperatively. Linear regression evaluated factors associated with higher WOMAC change two months postoperatively.

RESULTS

A total of 241 subjects participated (response: 85.2%). Eighty-seven were non-obese (mean age: 70.7 years, 63.2% female) and 154 were obese (mean age: 67.1 years, 57.8% female). Obese subjects reported inferior pre- and postoperative pain and knee joint function compared to non-obese subjects. Yet, WOMAC scores of obese and non-obese subjects significantly improved from preoperative means of 52.6 and 46.8 to 32.3 and 24.4 after surgery, respectively. The only significant TKA satisfaction predictor was subjects' smoking status. Non-obesity and worse preoperative WOMAC scores were predictive of higher WOMAC change scores after two months.

CONCLUSION

Both obese and non-obese subjects reported significant symptom improvements. However, as obese subjects' short-term outcomes were still inferior, more research on TKA rehabilitation measures adapted to the needs of this growing patient group is warranted to maximize their benefits from TKA.

Associations between smoking and clinical outcomes after total hip and knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Smoking increases risk of several complications after total hip or knee arthroplasty (THA/TKA), so we systematically reviewed and meta-analyzed the literature to take into account all relevant evidence, particularly studies published since 2010.

METHODS

The PubMed, Ovid Embase, Web of Science, and EBSCOHost databases were searched and studies were selected and analyzed according to MOOSE recommendations. Methodological quality of included studies was assessed using the Newcastle-Ottawa Scale. Data were qualitatively synthesized or meta-analyzed using a random-effects model.

RESULTS

A total of 40 studies involving 3,037,683 cases were included. Qualitative analysis suggested that smoking is associated with worse patient-reported outcomes within one year after surgery, and meta-analysis showed that smoking significantly increased risk of the following outcomes: total complications (OR 1.41, 95% CI 1.01-1.98), wound complications (OR 1.77, 95% CI 1.50-2.10), prosthetic joint infection (OR 1.84, 95% CI 1.52-2.24), aseptic loosening (OR 1.62, 95% CI 1.12-2.34), revision (OR 2.12, 95% CI 1.46-3.08), cardiac arrest (OR 4.90, 95% CI 2.26-10.60), cerebrovascular accident (OR 2.22, 95% CI 1.01-4.85), pneumonia (OR 2.35, 95% CI 1.17-4.74), acute renal insufficiency (OR 2.01, 95% CI 1.48-2.73), sepsis (OR 4.35, 95% CI 1.35-14.00), inpatient mortality (OR 12.37, 95% CI 4.46-34.28), and persistent opioid consumption (OR 1.64, 95% CI 1.39-1.92).

CONCLUSION

Smoking patients undergoing THA and TKA are at increased risk of numerous complications, inpatient mortality, persistent opioid consumption, and worse 1-year patient-reported outcomes. Pre-surgical protocols for these outcomes should give special consideration to smoking patients.

The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty

BACKGROUND

Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA.

METHODS

We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores.

RESULTS

Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS.

CONCLUSION

Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.

Comparison of Outcomes Between Nonsmokers and Patients Who Discontinued Smoking 1 Month Before Primary Hip Arthroscopy: A Propensity-Matched Study With Minimum 2-Year Follow-up

Background:

Cigarette smoking has been shown to negatively affect outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). The effect of cessation of cigarette smoking before surgery has not been well established.

Purposes:

(1) To report minimum 2-year patient-reported outcomes (PROs) of former smokers who underwent primary hip arthroscopy for FAIS and (2) to compare these results with those of a propensity-matched control group of nonsmokers.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data were collected for all patients who underwent primary hip arthroscopy for FAIS between December 2008 and November 2017. Patients were eligible if they indicated that they had previously smoked cigarettes but had quit smoking at least 1 month before surgery and had minimum 2-year postoperative outcomes for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and visual analog scale (VAS) for pain. The percentage of hips achieving the minimal clinically important difference (MCID) were recorded. The study group was then propensity matched in a 1:1 ratio by age, sex, and body mass index (BMI) to patients who had never smoked.

Results:

A total of 83 former-smoking patients (84 hips; age, 45.0 ± 13.5 years) were included at a median follow-up of 38.6 months (interquartile range, 27.5-48.2 months); all patients had stopped smoking at a mean ± standard deviation of 14.3 ± 24.5 months preoperatively. Former smokers demonstrated significant improvement from preoperatively to the minimum 2-year follow-up for all recorded PROs (P < .001 for all) and achieved the MCID for the mHHS, NAHS, and VAS at favorable rates (75.0%-81.6%). Logistic regression analysis did not identify a significant relationship between cessation time and rates of achieving MCID for mHHS, NAHS, or VAS. When compared with 84 never-smokers (84 hips), the former smokers demonstrated similar preoperative scores, postoperative scores, and improvement on all recorded PROs (P > .05 for all). Both groups achieved MCID for mHHS, NAHS, and VAS at similar rates and demonstrated similar rates of revision surgery.

Conclusion:

Former smokers who underwent primary hip arthroscopy for FAIS demonstrated significant improvement in PROs at minimum 2-year follow-up. When compared with a propensity-matched control group of never-smokers, they achieved similar postoperative PROs and rates of achieving psychometric thresholds.

Increased Risk of Short-Term Complications in Smokers Undergoing Primary Unicompartmental Knee Arthroplasty

The effects of smoking on unicompartmental knee arthroplasty (UKA) are unknown. The purpose of this study was to evaluate the effects of smoking on short-term outcomes following primary UKA. A query of the National Surgical Quality Improvement Project (NSQIP) database was used to identify cases of primary UKA performed during years 2006 to 2017. Patient demographics, operative times, and postoperative complications were compared between smoking and nonsmoking cohorts. Descriptive statistics, univariate analyses, and multivariate analyses were conducted to evaluate the effects of smoking on primary UKA. A total of 10,593 cases of UKA were identified; 1,046 of these patients were smokers. Univariate analysis demonstrated smokers to have higher rates of any complication (4.6 vs. 3.3%, p = 0.031), any wound complication (1.82 vs. 0.94%, p = 0.008), deep wound infection (0.57 vs. 0.13%, p = 0.006), and reoperation (1.34 vs. 0.68%, p = 0.018) relative to nonsmokers. Multivariate analysis demonstrated smokers to have higher rates of any wound complication (odds ratio [OR] = 1.79; 95% confidence interval [CI]: 1.06-2.95) and reoperation (OR = 2.11; 95% CI: 1.12-3.97). Smokers undergoing primary UKA are at higher risk for any wound complication and reoperation relative to nonsmokers in the first 30 days postoperatively. Further studies evaluating the long-term effects of smoking on outcome following UKA, as well as the impact of smoking cessation on outcomes following UKA, are needed.

Smoking cessation: health system challenges and opportunities

The systematic integration of evidence-based tobacco treatment has yet to be broadly viewed as a standard-of-care. The Framework Convention on Tobacco Control recommends the provision of support for tobacco cessation. We argue that the provision of smoking cessation services in clinical settings is a fundamental clinical responsibility and permits the opportunity to more effectively assist with cessation. The role of clinicians in prioritising smoking cessation is essential in all settings. Clinical benefits of implementing cessation services in hospital settings have been recognised for three decades-but have not been consistently provided. The Ottawa Model for Smoking Cessation has used an 'organisational change' approach to its introduction and has served as the basis for the introduction of cessation programmes in hospital and primary care settings in Canada and elsewhere. The significance of smoking cessation dwarfs that of many preventive interventions in primary care. Compelling evidence attests to the importance of providing cessation services as part of cancer treatment, but implementation of such programmes has been slow. We recognise that the provision of such services must reflect the realities and resources of a particular health system. In low-income and middle-income countries, access to treatment facilities pose unique challenges. The integration of cessation programmes with tuberculosis control services may offer opportunities; and standardisation of peri-operative care to include smoking cessation may not require additional resources. Mobile phones afford unique opportunities for interactive cessation programming. Health system change is fundamental to improving the provision of cessation services; clinicians can be powerful advocates for such change.

Health Conditions, Substance Use, Physical Activity, and Quality of Life in Current and Former Baseball Players

Background:

A comprehensive understanding of lifestyle (health conditions and substance use), health-related quality of life (HRQoL), flourishing (holistic representation of health), and physical activity can inform stakeholders (players, coaches, and clinicians) and help improve long-term health across the life span.

Purpose:

To describe health conditions (comorbidities or diagnoses), substance use, physical activity, HRQoL, and flourishing in current and former collegiate and professional baseball players and to assess the relationship between playing position and HRQoL/flourishing in former baseball players.

Study Design:

Descriptive epidemiology study.

Methods:

Eligible participants were those ≥18 years old with ≥1 season of collegiate or professional baseball experience. Participants completed a survey on health conditions (asthma, diabetes, hypertension, hypercholesterolemia, and depression), substance use (tobacco, alcohol, and energy drinks), physical activity (International Physical Activity Questionnaire–Short Form), HRQoL (Veterans Rand 12-Item Health Survey [VR-12] physical and mental component scores), and flourishing (Flourishing Scale). Adjusted multivariable regressions were performed for HRQoL and flourishing.

Results:

Overall, 260 baseball players opened the survey, and 214 (current players, 97; former players, 117) participated for an 82% response rate. Of the former players, 32% had hypertension or hypercholesterolemia. In addition, 26% of current players had used smokeless tobacco (median, 3 years; interquartile range [IQR], 1-5 years) as compared with 34% of former players (median, 15 years; IQR, 5-25 years). In addition, 14% of current players had used electronic cigarettes (median, 2 years; IQR, 0-4 years) as opposed to 3% of former (median, 3 years; IQR, 2-4 years). Energy drinks were consumed by 31% and 14%, respectively, of current and former players on at least a weekly basis. Current baseball players performed 8667 metabolic equivalents per week of physical activity as opposed to 3931 in former players. Pitching was associated with worse VR-12 Mental Component Scores (–5.0; 95% confidence interval, –9.0 to –1.0). Playing position was not related to VR-12 Physical Component Scores or flourishing in former baseball players.

Conclusion:

The similar smokeless tobacco prevalence between current and former baseball players suggests that they may start using tobacco products during baseball participation and continue after retirement. Similar reported HRQoL as compared with the general US population and high flourishing and physical activity levels suggest that baseball players may present with good musculoskeletal and psychological health.

Patient Outcomes and Satisfaction After Mohs Micrographic Surgery in Patients With Nonmelanoma Skin Cancer

BACKGROUND

Quality in medicine is increasingly being measured through patient-reported outcome measures. Given the rising incidence and costs for nonmelanoma skin cancer (NMSC) treatment, it is imperative to define quality measures specific to dermatologic surgery.

OBJECTIVE

This study aims to evaluate patient-reported outcomes and satisfaction with Mohs micrographic surgery (MMS) together with patient and tumor factors to better define their use in developing treatment strategies and quality measures.

METHODS AND MATERIALS

A prospective study was conducted among 226 patients undergoing MMS for treatment of NMSC. Patient demographics, quality of life, functional status, satisfaction, and prognostic factors were gathered. Postoperative outcomes were measured at 1 month and included patient-reported problems and provider-reported complications. Relationships between patient factors and outcomes were evaluated through statistical analysis.

RESULTS

Average patient satisfaction in the domain of general satisfaction of the Patient Satisfaction Questionnaire-18 was 4.34 of 5. General patient satisfaction did not differ across age, final defect size, sex, or prognostic scores. At 1-month postoperatively, 97 percent of patients expressed willingness to undergo future MMS if indicated.

CONCLUSION

Patients are generally satisfied with MMS for treatment of NMSC. Specific patient factors that may affect satisfaction include smoking status and anticoagulation use.

Three distinct recovery patterns following primary total knee arthroplasty: dutch arthroplasty register study of 809 patients

PURPOSE

Total knee arthroplasty (TKA) is usually effective, although not all patients have satisfactory outcomes. This assumes distinct recovery patterns might exist. Little attention has been paid to determine which patients have worse outcomes. This study attempts to distinguish specific recovery patterns using the Oxford knee score (OKS) during the first postoperative year. The secondary aim was to explore predictors of less favourable recovery patterns.

METHODS

Analysis of patients in the Dutch Arthroplasty Register (LROI) with unilateral primary TKA. Data collected up to one year postoperative was used. To identify subgroups of patients based on OKS, latent class growth modeling (LCGM) was used. Moreover, multivariable multinomial logistic regression analysis was used to explore predictors of class membership.

RESULTS

809 Patients completed three OKS during the first year postoperative and were included. LCGM identified 3 groups of patients; 'high risers' (most improvement during first 6-months, good 12-month scores 77%), 'gradual progressors' (continuous improvement during the first year 13%) and 'non responders' (initial improvement and subsequent deterioration to baseline score 10%). Predictors of least favourable class membership (OR, 95%CI) are EQ-5D items: VAS health score (0.83, 0.73-0.95), selfcare (2.22, 1.09-4.54) and anxiety/depression (2.45, 1.33-4.52).

CONCLUSION

Three recovery patterns after TKA were distinguished; 'high risers', 'gradual progressors' and 'non responders'. Worse score on EQ-5D items VAS health, selfcare, and anxiety/depression were correlated with the least favourable 'non responders' recovery pattern.

Smoking Negatively Effects Patient-Reported Outcomes Following Arthroscopic Partial Meniscectomy

Purpose

To determine whether active smokers have different patient-reported outcomes relative to nonsmokers for pain, function, and overall health at baseline and 1 or 2 years after an arthroscopic partial meniscectomy.

Methods

Patients who underwent arthroscopic partial meniscectomy were identified. Demographic data, including smoking status and patient-reported outcome measures (PROMs), were prospectively collected preoperatively and 3 months, 6 months, 1 year, and 2 years postoperatively. Statistical analysis was performed using the mixed-effects model to compare PROMs preoperatively and 1 or 2 years postoperatively between nonsmokers and active smokers.

Results

509 knees undergoing arthroscopic partial meniscectomy were divided into 2 cohorts: group I, nonsmokers (n = 470) and group II, active smokers (n = 39). There were statistically significant baseline differences in PROMs for nonsmokers versus smokers: visual analog scale (VAS), 5.0 ± 0.4 versus 6.3 ± 0.7, respectively (P = .001); Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain scale, 50.3 ± 3.2 versus 42.5± 5.5 (P = .005); KOOS Symptoms scale, 50.0 ± 3.2 versus 43.6 ± 5.4 (P = .019); and Western Ontario and McMaster Universities Arthritis Index (WOMAC) Pain scale, 57.5 ± 3.4 versus 48.2 ± 6.1 (P = .003). There were also statistically significant differences in nonsmokers versus smokers regarding knee function at baseline shown by the KOOS Activites of Daily Living (ADL) scale: (61.1 ± 3.3 versus 53.5 ± 6.1; P = .015). Baseline mental health, as assessed by the Veterans Rand 12-Item Health Survey (VR-12) Mental Health questionnaire, was also statistically different between nonsmokers (55.4 ± 0.8) and smokers (51.5 ± 3.3; P = .020). Importantly, PROMs for pain and function were lower at all time points for smokers.

Conclusion

Patients who were active smokers at the time of partial meniscectomy had significantly worse baseline and postoperative PROMs compared with nonsmokers. Changes from baseline for smokers and nonsmokers were relatively consistent between groups 1 and 2 years postoperatively. Smokers will improve a relatively similar amount as nonsmokers after partial meniscectomy, but their overall PROM scores are lower.

Level of Evidence

III, retrospective comparative study.

Outpatient vs. inpatient hip arthroplasty: a matched case-control study on a 90-day complication rate and 2-year patient-reported outcomes

BACKGROUND

The transition to outpatient-based surgery is a major development occurring in recent years in the field of total hip arthroplasty (THA). The effect of this transition on patient-reported outcomes (PROs) is still not well established. The purpose of the current study was to compare patients undergoing inpatient THA (iTHA) to patients undergoing outpatient THA (oTHA) regarding (1) perioperative variables including surgical time, blood loss, and length of stay (2) 90-day complication rates and unplanned emergency room or office visits (3) 2-year PROs including modified Harris hip score (mHHS), Harris hip score (HHS), forgotten joint score (FJS), pain, and satisfaction, as well as the quality of live measures.

METHODS

The American Hip Institute registry was analyzed for patients undergoing THA between July 2014 and April 2016. The first 100 patients undergoing oTHA were selected and matched to 100 patients undergoing iTHA via propensity matching based on the following variables: age, sex, body mass index (BMI), Charlson comorbidity index (CCI), and smoking status. The primary outcomes were PROs at 2 years post-operatively. The secondary outcomes were perioperative surgical variables, 90-day complication rates, and unplanned emergency and clinic visits.

RESULTS

After exclusions, 91 patients remained in each group and were compared. The oTHA group showed improved 2-year PROs with regard to mHHS (91.5 vs. 86.2; P = 0.02), HHS (92.3 vs. 87.4; P = 0.02), and pain (1.0 vs. 1.5; P = 0.04). The oTHA group had an average length of stay of 6.8 h compared to 43.2 h for the iTHA group (P < 0.001). There were no significant differences between the groups regarding readmissions, emergency room visits, and unplanned clinic visits. Complications and revision rates were similar in both groups.

CONCLUSION

In appropriately selected, younger patients, oTHA can achieve improved postoperative 2-year PROs compared to iTHA. We found no differences regarding postoperative short-term complications or 2-year revision rates, and no differences in unplanned office visits or readmissions.

LEVEL OF EVIDENCE

Prognostic level 3.

Which Preoperative Factors are Associated with Not Attaining Acceptable Levels of Pain and Function After TKA? Findings from an International Multicenter Study

BACKGROUND

Although TKA is a common and proven reliable procedure for treating end-stage knee osteoarthritis, a minority of patients still do not achieve satisfactory levels of pain relief and functional improvement. Even though several studies have attempted to identify patients at risk of having poor clinical outcomes, few have approached this issue by considering the outcome of the patient-acceptable symptom state (PASS), defined as the value on a patient-reported outcome measure scale above which the patient deems their current symptom state acceptable.

QUESTIONS/PURPOSES

(1) What is the proportion of patients who do not attain the PASS in pain and function at 1 year after TKA? (2) Which preoperative patient factors are associated with not achieving the PASS in pain at 1 year after TKA? (3) Which preoperative patient factors are associated with not achieving the PASS in function at 1 year after TKA?

METHODS

This retrospective study is a secondary analysis of the 1-year follow-up data from a prospective, international, multicenter study of a single TKA system. Inclusion criteria for that study were patients diagnosed with primary osteoarthritis or post-traumatic arthritis and who were able to return for follow-up for 10 years; exclusion criteria were infection, osteomyelitis, and failure of a previous joint replacement. Between 2011 and 2014, 449 patients underwent TKA at 10 centers in five countries. At 1 year, 13% (58 of 449) were lost to follow-up, 2% could not be analyzed (eight of 449; missing 1-year KOOS), leaving 85% (383 of 449) for analysis here. The primary outcomes were not surpassing evidence-derived PASS thresholds in the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain and Activities in Daily Living (ADL) sub-scores. Multivariate binary logistic regressions considering preoperative demographic, radiographic, and patient-reported outcome measure data were constructed using a forward stepwise elimination algorithm to reach the simplest best-fit regression models.

RESULTS

At 1 year after TKA, 38% of the patients (145 of 383) did not reach the PASS in KOOS Pain, 36% (139 of 383) did not reach the PASS in KOOS ADL, and 29% (110 of 383) did not achieve the PASS in either KOOS Pain or ADL. After controlling for potentially confounding variables such as gender, age, BMI, and comorbidity scores, we found that men (odds ratio 2.09; p = 0.01), and patients with less-than-advanced radiographic osteoarthritis (OR 2.09; p = 0.01) were strongly associated with not achieving the PASS in pain. After controlling for the same potentially confounding variables, we found that patients with less-than-advanced radiographic osteoarthritis (OR 2.09; p = 0.01) were also strongly associated with not achieving the PASS in function.

CONCLUSIONS

We found that patients with less severe osteoarthritis were much less likely to attain the PASS in pain and function at 1 year after TKA, and that men were much less likely to achieve the PASS in pain at 1 year after TKA. Based on these findings, surgeons should strongly consider delaying surgery in patients who present with less-than-severe osteoarthritis, with increased caution in men. Surgeons should counsel their patients on their expectations and their chances of achieving meaningful levels of pain and functional improvement. Future regional and national registry studies should assess the true proportion of patients attaining PASS in pain and function after TKA and confirm if the preoperative factors identified in this study remain significant in larger, more diverse patient populations.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Identifying Risk Factors Associated With Postoperative Infection Following Elective Lower-Extremity Total Joint Arthroplasty

This article addresses the importance of identifying risk factors associated with postoperative infection following elective lower-extremity total joint arthroplasty. Specifically, this review discusses risk factors recognized by the American Academy of Orthopaedic Surgeons that should be carefully considered and assessed by the orthopaedic team in collaboration with the primary care provider before proceeding with surgery.

Smoking Effects in Foot and Ankle Surgery: An Evidence-Based Review

BACKGROUND

The purpose of this article was to review the basic science pertaining to the harmful effects of cigarette smoke, summarize recent clinical outcome studies, and examine the benefits of smoking cessation and the efficacy of current smoking cessation strategies.

METHODS

The literature concerning basic science, clinical outcomes, and smoking cessation was reviewed; over half (56%) of the 52 articles reviewed were published in the last 5 years.

RESULTS

Smoking is associated with low bone mineral density, delayed fracture union, peri-implant bone loss, and implant failure. Orthopedic surgical patients who smoke have increased pain and lower overall patient satisfaction, along with significantly increased rates of wound healing complications.

DISCUSSION/CONCLUSION

Active smoking is a significant modifiable risk factor and should be discontinued before foot and ankle surgery whenever possible. Orthopedic surgeons play an important role in educating patients on the effects of smoking and facilitating access to smoking cessation resources.

LEVEL OF EVIDENCE

Level V, expert opinion.

Opioid use following shoulder stabilization surgery: risk factors for prolonged use

HYPOTHESIS

The purpose of this study was to determine the rate of opioid use before and after shoulder stabilization surgery for instability due to recurrent dislocation and assess patient factors associated with prolonged opioid use postoperatively.

METHODS

Patients undergoing primary shoulder stabilization procedures for shoulder instability due to recurrent dislocation were accessed from the Humana administrative claims database. Patients were categorized as those who filled 1 or more opioid prescriptions within 1 month, those who filled opioid prescriptions between 1 and 3 months, and those who never filled opioid prescriptions before surgery. Rates of opioid use were evaluated preoperatively and longitudinally tracked for each group. Multiple binomial logistic regression analysis was used to identify factors associated with opioid use at 3 months and 1 year after surgery.

RESULTS

Overall, 4802 patients (45.9% opioid naive) underwent shoulder stabilization surgery for shoulder instability during the study period. Rates of opioid use significantly declined after the first postoperative month; however, at 1 year, the rate of opioid use was significantly greater in patients who filled opioid prescriptions preoperatively (13.4% vs. 1.9%, P < .0001). Filling opioid prescriptions 1 to 3 months prior to surgery was the strongest risk factor for opioid use at 1 year after surgery.

CONCLUSIONS

Patients who were prescribed opioids 1 to 3 months before surgery had the highest risk of prolonged opioid use following surgery. Obesity, tobacco use, and a preoperative diagnosis of fibromyalgia were independently associated with prolonged opioid use following surgery.