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AAOS Now

Published 6/1/2015
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Amber Blake

Smoking Increases Wound Complications After TJA

Should surgeons advise patients to quit smoking before undergoing total joint arthroplasty (TJA)? It’s a well-known fact that smoking is bad for overall health, increasing the chances of lung cancer, heart attack, and stroke. In a study presented at the 2015 Orthopaedic Research Society (ORS) annual meeting, Kyle Duchman, MD, and his team took a closer look at how smoking can lead to complications following TJA.

“TJA has a proven track record, with consistently excellent results reported throughout the orthopaedic literature,” explained Dr. Duchman. “However, patient factors have previously been identified that consistently produce results that are less than excellent.”

Some factors that can affect TJA outcomes are beyond a surgeon’s—or a patient’s—control. These include the patient’s age and gender. But others, including weight and smoking status, are modifiable.

Although smoking has been recognized as a risk factor, the impact of smoking cessation has not been previously quantified. Dr. Duchman and colleagues sought to compare the short-term complication rates among three groups of TJA patients: those who never smoked, those who quit smoking at least a year prior to surgery, and those who continued to smoke.

Using data from the American College of Surgeons National Surgical Quality Improvement Project, researchers identified 78,191 adult patients who underwent either total knee or total hip arthroplasty from 2006 to 2012. They analyzed risk-adjusted 30-day outcomes (any 30-day complication, wound complications, and mortality) and identified the independent effects of smoking cessation on those outcomes. They also evaluated the effect of total patient pack years, or lifetime amount smoked.

Of the total number of patients, 81.8 percent (63,971) had never smoked, 7.9 percent (6,158) were ex-smokers, and 10.3 percent (8,062) were current smokers. The mean age of current smokers was dramatically lower than the other two cohorts (58.9 years vs 68 years, P < 0.001). Unadjusted overall and wound-related complication rates were higher among smokers (P < 0.001), but mortality rates did not differ among groups.

Researchers found that smokers had the highest risk of wound complications. Compared with those who never smoked, both current smokers and ex-smokers had higher risk of any complication—and that risk increased with each successive pack-year smoked.

Quitting smoking for a minimum of 1 year prior to TJA was associated with a lower short-term wound complication risk, similar to those who have never smoked. “These results support the importance of smoking cessation protocols prior to elective arthroplasty,” said Dr. Duchman.

“Our findings are not only useful for the orthopaedic surgeon who counsels patients prior to surgery on patient-specific risks, they also establish a baseline for future smoking cessation programs to compare as we aim to change this modifiable risk factor to improve results and decrease complications following TJA.”

Dr. Duchman’s coauthors of “Total Joint Arthroplasty in Smokers: Should We Wait for Patients to Quit Before Operating?” include Andrew Pugely, MD; Christopher H. Martin, MD; Yubo Gao, PhD; Melissa Willenborg, MD; and John Callaghan, MD. One or more of the authors report potential conflicts of interest; for disclosure information, see www.aaos.org/disclosure

Amber Blake is the ORS communications manager; she can be reached at blake@ors.org