The use of tobacco is a modifiable risk factor for poor outcomes and readmissions after shoulder arthroplasty.

AIMS: The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA. METHODS: Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors. RESULTS: A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively. CONCLUSION: Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA. Cite this article: Bone Joint J 2020;102-B(11):1549-1554.

The use of tobacco is a modifiable risk factor for poor outcomes and readmissions after shoulder arthroplasty.

AIMS: The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA. METHODS: Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors. RESULTS: A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively. CONCLUSION: Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA.

Rational Selection of Patient-Reported Outcomes Measures in Lumbar Spine Surgery Patients.

BACKGROUND: The Short Form-12 (SF-12) was developed as a shorter version of the SF-36, yet there has been limited validation of its reliability at measuring postoperative changes. The purpose of this study was to determine if the SF-12 could safely substitute for the SF-36 in measuring postoperative change in lumbar spine surgery patients and if the condition specific (Oswestry Disability Index [ODI]) or pain (visual analog scale [VAS]) instruments, provided additional utility. METHODS: A total of 972 patients from a single center who underwent lumbar spine surgery for a predominant symptom of radiating leg pain with (n = 237) or without (n = 735) fusion and prospectively completed both SF-36 and ODI instruments before and after surgery were included. The SF-12 score was calculated from the appropriate subset of SF-36 responses. The absolute sensitivity and the intraclass correlation coefficient were calculated. Reliability of each instrument to measure preoperative to postoperative change was calculated as the standardized response mean. RESULTS: The SF-12 and SF-36 demonstrated a strong correlation with each other ([0.97, P < .001] and [0.93, P < .001], respectively) preoperatively and postoperatively. The SF-12 and SF-36 scores were moderately to strongly inversely correlated with the ODI. The ODI showed greater reliability at measuring change than the SF-12 for both fusion (0.94 versus 0.72) and nonfusion (0.81 versus 0.33) lumbar surgery patients. CONCLUSIONS: The SF-12 was as effective as the SF-36 to measure general health status in lumbar spine surgery patients, and both were moderate to strong predictors of ODI preoperatively and postoperatively, but lack the reliability to detect change seen with the ODI or VAS after surgical intervention. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: These data suggest that the SF-12 is a valid substitute for the SF-36 to measure postoperative outcomes changes, but that the ODI should continue to be used to measure condition specific changes in function.

Defining the Volume-Outcome Relationship in Reverse Shoulder Arthroplasty: A Nationwide Analysis.

BACKGROUND: As the utilization of reverse total shoulder arthroplasty (RSA) grows, it is increasingly important to examine the relationship between hospital volume and RSA outcomes. We hypothesized that hospitals that perform a higher volume of RSAs would have improved outcomes. We also performed stratum-specific likelihood ratio (SSLR) analysis with the aim of delineating concrete definitions of hospital volume for RSA. METHODS: The Nationwide Readmissions Database was queried for patients who had undergone elective RSA from 2011 to 2015. Annual hospital volume and 90-day outcome data were collected, including readmission, revision, complications, hospital length of stay (LOS), supramedian cost, and discharge disposition. SSLR analysis was performed to determine hospital volume cutoffs associated with increased risks for adverse events. Cutoffs generated through SSLR analysis were confirmed via binomial logistic regression. RESULTS: The proportion of patients receiving care at high-volume centers increased from 2011 to 2015. SSLR analysis produced hospital volume cutoffs for each outcome, with higher-volume centers showing improved outcomes. The volume cutoffs associated with the best rates of 90-day outcomes ranged from 54 to 70 RSAs/year, whereas cost and resource utilization cutoffs were higher, with the best outcomes in hospitals performing >100 RSAs/year. SSLR analysis of 90-day readmission produced 3 hospital volume categories (1 to 16, 17 to 69, and ≥70 RSAs/year), each significantly different from each other. These were similar to the strata for 90-day revision (1 to 16, 17 to 53, and ≥54 RSAs/year) and 90-day complications (1 to 9, 10 to 68, and ≥69 RSAs/year). SSLR analysis produced 6 hospital volume categories for cost of care over the median value (1 to 5, 6 to 25, 26 to 47, 48 to 71, 72 to 105, and ≥106 RSAs/year), 5 categories for an extended LOS (1 to 10, 11 to 25, 26 to 59, 60 to 105, and ≥106 RSAs/year), and 4 categories for non-home discharge (1 to 31, 32 to 71, 72 to 105, and ≥106 RSAs/year). CONCLUSIONS: We have defined hospital surgical volumes that maximize outcomes after RSA, likely related to surgical experience, ancillary staff familiarity, and protocolized pathways. This information may be used in future policy decisions to consolidate complex procedures, such as RSA, at high-volume destinations, or to encourage lower-volume institutions to strategize an approach to function as a higher-volume center. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Avocado-related knife injuries: Describing an epidemic of hand injury.

INTRODUCTION: Recent media reports have described knife injuries sustained while preparing avocados; however, this rise has not been reported in the literature. The purpose of this study is to describe, quantify, and trend emergency department (ED) encounters associated with avocado-related knife injuries. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried for avocado-related knife injuries from 1998 to 2017. Patient demographic and injury data was collected and analyzed to describe trends in incidence, patient demographics, and injury patterns associated with an ED encounter for an avocado-related knife injury. RESULTS: There were an estimated 50,413 (95% Confidence Interval: 46,333-54,492) avocado-related knife injuries from 1998 to 2017. The incidence of avocado-related knife injuries increased over this time period (1998-2002 = 3143; 2013-2017 = 27,059). This increase correlated closely with a rise in avocado consumption in the U.S. (Pearson's Correlation: 0.934, p < 0.001) Women comprised 80.1% of injuries. The most common demographic injured were 23 to 39-year old females (32.7%), while the least common was males under the age of 17 (0.9%). Most ED presentations occurred on Saturdays (15.9%) or Sundays (19.9%) and the majority occurred during the months of April through July (45.6%). Injuries were much more common on the left (and likely non-dominant) hand. CONCLUSION: Avocado-related knife injuries are a preventable cause of hand injury. The incidence has risen significantly in recent years, possibly due to an increased consumption of avocados in the United States. Education on safe avocado preparation techniques and public safety initiatives, such as warning labels, could help prevent serious injuries in the future.