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Where There Is Smoke, There Is Fire!

Commentary on an article by Kyle R. Duchman, MD, et al.: “The Effect of Smoking on Short-Term Complications Following Total Hip and Knee Arthroplasty”

Cherian, Jeffrey J. DO; Mont, Michael A. MD*

doi: 10.2106/JBJS.O.00481
Commentary and Perspective

Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland

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Where there is smoke, there is often a fire. This phrase eloquently depicts the outcomes of tobacco users undergoing total joint arthroplasty, with “smoke” referring to the tobacco use and “fire” alluding to the complications and poor outcomes that are most likely lurking in this patient population. We read with great interest the article by Duchman et al., which evaluated the rate of short-term complications following total knee and total hip arthroplasty among nonsmokers, former smokers, and current smokers with use of the American College of Surgeons National Surgical Quality Improvement Program database.

We commend the authors for their efforts on this article and their work in highlighting the detrimental consequences of smoking on patient outcomes following lower-extremity joint arthroplasty. The authors demonstrated that the current smokers had a higher rate of wound complications compared with both nonsmokers and former smokers, while the former smokers had a higher rate of complications overall. More specifically, multivariate analysis demonstrated that current smokers were at increased risk of wound complications, and both current and former smokers were at increased risk of total complications, which was associated with increasing pack-year history. The findings of this study closely align with those of two studies from our institution by Kapadia et al.1,2, which demonstrated decreased survivorship as well as increased medical and surgical complications among smokers undergoing lower-extremity total joint arthroplasty. Our studies also demonstrated that patients undergoing total knee arthroplasty had greater complications with increasing pack-year history. Although the total hip arthroplasty study demonstrated no difference in complications with increasing pack-year history, this analysis may have been underpowered because of small patient sample size. Fortunately, the larger study by Duchman et al. is able to delineate this increased complication risk.

Despite the positive awareness that this report brings to the field of joint arthroplasty, it raises several concerns about the need for additional studies on this topic. Some of our major concerns with this database study are that it assigns only general definitions of “present” and “former” smoker and is unable to adequately define a time point at which smoking should be stopped prior to surgery or the duration of time needed between smoking cessation and surgery to decrease the risk of adverse outcomes. Specifically, this study is not granular in its definition of smoking, and we cannot assume that patients who smoke one to two cigarettes per day are comparable with those who smoke one to two packs per day, and therefore, trials are needed that stratify patients by more strict tobacco usage. Furthermore, to combine patients who, for example, quit smoking one year ago with those who stopped twenty years prior may be inaccurate. We appreciate that the authors subanalyzed per pack-year history, which we think helps to give us more detailed information about these patients’ risks, but as per our previous comment, a twenty-pack-year smoking history is completely different for someone who quit last year than for one who quit twenty years ago. Additionally, smoking status is based on patient reporting, and thus we believe that tobacco use may be underreported. Nevertheless, the rates of current smokers (10.3%) and former smokers (7.9%) in the present study are similar to rates reported by the Centers for Disease Control and Prevention for the current U.S. population3.

The above concerns are particularly important and have been greatly debated over the past several years. Currently, as surgeons, we have no concrete evidence to follow regarding when to advise smoking cessation prior to a joint replacement procedure. Møller et al.4 evaluated the effects of smoking intervention, consisting of counseling and nicotine-replacement measures, six to eight weeks prior to total knee or hip arthroplasty compared with no intervention. They demonstrated that there was a significantly decreased overall complication rate in the smoking-cessation intervention group (18% versus 52%). Another study has shown that even smoking intervention up to four weeks preoperatively can reduce short-term complication risk5. The use of nicotine replacement has been advocated, but this yields potential complications of continued vasoconstriction, which may also negatively impact wound-healing. Currently, there is a dearth of literature on the effects of smoking cessation on outcomes of lower-extremity joint arthroplasty.

We thank the authors of the present article for highlighting the potential negative outcomes of total joint arthroplasty in patients who smoke. However, this report further demonstrates the need for higher-quality studies that evaluate the optimal time point for smoking cessation as well as the best programs and options for nicotine replacement.

*None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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1. Kapadia BH, Issa K, Pivec R, Bonutti PM, Mont MA. Tobacco use may be associated with increased revision and complication rates following total hip arthroplasty. J Arthroplasty. 2014 Apr;29(4):777-80. Epub 2013 Oct 3.
2. Kapadia BH, Johnson AJ, Naziri Q, Mont MA, Delanois RE, Bonutti PM. Increased revision rates after total knee arthroplasty in patients who smoke. J Arthroplasty. 2012 Oct;27(9):1690-1695.e1. Epub 2012 May 23.
3. Centers for Disease Control and Prevention. Current cigarette smoking among adults in the United States. Accessed 2015 May 1.
4. Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7.
5. Lindström D, Sadr Azodi O, Wladis A, Tønnesen H, Linder S, Nåsell H, Ponzer S, Adami J. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg. 2008 Nov;248(5):739-45.
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