The use of ultraporous metal in acetabular reconstruction during complex primary and revision THA has improved survivorship and shown few failures (Table 4) [3-5, 11-13, 15-18, 20, 23-29, 32, 33, 36-42, 48-50, 52, 54, 55, 57, 59, 62, 67-69, 72, 73, 75, 76]. Ultraporous components have been touted to possess optimized ingrowth surfaces that are truly three-dimensional, unlike beaded and plasma-sprayed surfaces. Therefore, one would intuitively believe that biological fixation into these surfaces would be superior. One would also intuitively believe that the percent of biological fixation required for stability of the component would be less than for devices with standard porous coatings. Smoking is a surgical risk factor for delayed wound healing, increased transfusions, infections, and cardiac complications [21, 46, 47, 58, 64-66, 70, 71] as well as increased complications in orthopaedic surgery, including THA [1, 22, 30, 34, 45, 53, 56, 60, 61]. Smoking also impairs fracture repair and osteointegration [2, 10, 14, 31, 43, 63]. The purpose of our study was to retrospectively review our use of ultraporous metal acetabular devices in patients undergoing complex primary and revision THA to determine the incidence and modes of failure and the influence, if any, of smoking status on risk for early failure.
We caution readers of the limitations of our study. First, this was a retrospective review rather than a prospective study with some missing data. In particular we had no smoking data on seven patients, but presume this would not affect the findings. Second, there were demographic differences between the smoking groups, which may have had an influence on implant survival with the current smoking group having more male patients, greater height, younger age, more need for constraint, and higher incidence of diabetes and cardiac disease. While none of these factors differed between failure and nonfailure groups we did not perform a multivariable analysis to control for these potentially confounding variables.
Newer ultraporous metals for acetabular construction in both primary and revision THA have been associated with few failures and survivorship of 86% to 100% at 1.5 to 10.2 years (Table 4). We found a higher risk of failure of ultraporous metal acetabulum reconstruction in current and prior smokers compared with nonsmokers. While smoking has not been reported as a risk factor for early failure in the use of newer ultraporous metal acetabular components, our findings are consistent with other contemporary research of ultraporous metal components and the impact of smoking on surgical outcomes including wound healing, osteointegration, rates of infection, and implant survival. Smoking has a negative impact on surgical outcomes both perioperatively as well as postoperatively [34, 45, 46]. Smoking is associated with decreased survivorship of implants as well as increased surgical complications, delayed wound healing, osteointegration and fracture repair, negatively impacted arthroplasty outcomes, and increased length of stay [1, 2, 10, 14, 21, 30, 34, 43, 45, 46, 53, 56, 60, 61, 63].
In a study of 202 patients undergoing THA or TKA comparing differences in resource consumption and short-term outcomes between current smokers (25 [12%]; average 28.3 pack-years) and nonsmokers (177 [88%]), Lavernia et al.  found that despite being younger and having fewer comorbidities, smokers had longer surgical and anesthesia times and higher charges adjusted for age and procedure. Previous smokers had better short-term outcomes than current smokers, indicating a benefit to smoking abstinence before joint replacement. In contrast, our data did not reveal a difference between current and previous smokers in terms of survival of the acetabular component. Møller et al. , in a study of the effects of smoking on early complications after elective orthopaedic surgery in 811 patients undergoing THA or TKA, found smoking was the single most important risk factor for development of postoperative complications resulting in delay of discharge, particularly wound-related, cardiopulmonary, and need for intensive care. There were 232 (29%) current smokers with 35 average pack-years (± 17; range, 1-101 pack-years). The 579 (71%) nonsmokers included 125 prior smokers and 454 who never smoked. For patients requiring prolonged hospitalization (> 15 days), there was a greater than twofold proportion of smokers versus nonsmokers with wound complications. Tobacco use reportedly increases the risk of postoperative complications: in a study of 3309 patients undergoing primary THA the risk of postoperative complications was increased by 43% for previous versus nonusers, by 56% for current versus nonusers, and by 121% for heavy users (> 40 pack-years) versus nonusers . AbdelSalam et al.  reviewed 22,343 primary and revision THA and TKA cases performed between 1999 through 2008 and examined predictors of intensive care unit (ICU) admission after total joint arthroplasty. One hundred thirty admissions were identified and matched to 260 (two times) control subjects for comparison. The greatest independent risk factor was having ever smoked with an incidence of 38% in those requiring ICU admission versus 5.4% in control subjects for an odds ratio of 65.13. Finally, a study of the effect of smoking on short-term outcomes in 33,336 veterans undergoing primary THA or TKA  found current smokers were more likely than nonsmokers to have surgical site infection (odd ratio, 1.41), pneumonia (odds ratio, 1.53), stroke (odds ratio, 2.61), and 1-year mortality (odds ratio, 1.63). Prior smokers were more likely than never smokers to have pneumonia (odds ratio, 1.34), stroke (odds ratio, 2.14), and urinary tract infection (odds ratio, 1.26). The primary author  also performed a meta-analysis of smoking and outcomes after hip and knee arthroplasty, reviewing 21 studies. Both current and former smokers had an increased risk of postoperative complications and perioperative death after arthroplasty.
Osteointegration of orthopaedic implants involves a coordinated, complex cascade of events similar to those that occur during fracture repair and likewise adversely affected by smoking [2, 10, 14, 63, 65]. One study specifically reported a link between smoking and increased risk for aseptic loosening after primary THA with uncemented porous cups in all cases and cemented stems in 61% . In 147 patients (165 hips), 21% were current smokers and 79% were nonsmokers. There were eight of 68 (12%) cups or stems revised for aseptic loosening in smokers compared with only five of 262 (2%) in nonsmokers for a 4.5-fold greater risk in smokers (p = 0.0012). In our study, a higher rate of aseptic loosening was observed in prior smokers (p = 0.015), whereas current smokers had a higher rate of failure secondary to infection (p = 0.003).
Several studies have reported that smoking leads to higher rates of wound infection after surgery [2, 22, 30, 64-66] with both transient and prolonged effects. The leading cause of failure in our study was SSI (3% overall) with an 8% incidence in current smokers compared with 4% in prior smokers and 2% in nonsmokers. Similarly, in a systematic review across surgical specialties to clarify evidence on smoking and postoperative healing complications, analysis of 140 studies involving 479,150 patients revealed an odds ratio of 1.8 for SSI for smokers compared with nonsmokers . The same study also reviewed four randomized controlled trials of smoking cessation intervention and observed a reduction in SSIs (odds ratio, 0.4) with cessation but not in other healing complications. We found the incidence of infection was lower for patients who never smoked compared with prior and current smokers but the difference between prior and current smokers was not significant with the numbers available.
Ultraporous metal technology offers the advantages of improved mechanical stability, enhanced fixation, osteoconductivity, and the ability to allow vascularized bone ingrowth [3, 6-8, 59, 72]. Despite these benefits, smoking, both current and prior, appears to be a risk factor for early failure in complex primary and revision THA using ultraporous metal acetabular components. Long-term followup is recommended in addition to well-documented radiographic evaluation of patient status. Quitting smoking can effectively reduce some inherent risks following THA but not eliminate them. While we continue to recommend preoperative discussion of smoking cessation to decrease incidence of complications and improve recovery and overall quality of life, we found no improvement in implant survival for prior smokers compared with current smokers. This suggests earlier efforts to further educate and discourage young people from taking up the harmful and addictive habit of smoking tobacco would be ideal.
We thank Tawnya L. Tucker, MT, for her assistance in gathering data for this study.
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