No Smoking Allowed: Is the Operating Room the Next Place That Smoking Patients Undergoing Total Joint Arthroplasty Will Be Banned?: Commentary on an article by Eric H. Tischler, BA, et al.: “Smoking Increases the Rate of Reoperation for Infection within 90 Days After Primary Total Joint Arthroplasty” : JBJS

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No Smoking Allowed: Is the Operating Room the Next Place That Smoking Patients Undergoing Total Joint Arthroplasty Will Be Banned?

Commentary on an article by Eric H. Tischler, BA, et al.: “Smoking Increases the Rate of Reoperation for Infection within 90 Days After Primary Total Joint Arthroplasty”

Hamilton, William G. MD*

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The Journal of Bone and Joint Surgery: February 15, 2017 - Volume 99 - Issue 4 - p e17
doi: 10.2106/JBJS.16.01249
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In the current era of cost containment, bundled payments, and maximizing value to our patients and hospitals, total joint surgeons are on the hunt for strategies to reduce complications following hip and knee total joint arthroplasty. There have been studies that have identified factors that increase the total joint arthroplasty complication rate, including age1, obesity2,3, medical conditions4,5, and socioeconomic status6. Smoking has been previously identified as a substantial health risk, so the natural question would be: how does smoking influence the outcomes of total joint arthroplasty?

In this study, Tischler et al. attempt to answer that question. Using an institutional database, 15,264 patients who underwent 17,394 total joint arthroplasties were retrospectively studied, and the authors analyzed the association between their status as current smokers, former smokers, or nonsmokers and postoperative complications including infection, aseptic reoperations, and readmissions. Smokers were nearly twice as likely to undergo reoperation for infection, one of the most costly complications that joint replacement surgeons incur.

The study is subject to the weaknesses of any institutional database study. My main concern in calculating complications using an institutional database is the potential for losing patients to follow-up, especially in a city such as Philadelphia where there are many hospitals in which patients could have their complications treated. The massive size of the patient cohort along with the expected equal distribution of loss to follow-up between groups should overcome those concerns. Another concern is the possibility that the differences found between groups may have not been solely due to smoking status, but rather to a condition or behavior that is associated with smoking. The authors explain how they addressed these concerns, by performing a series of regression analyses to isolate the effects of smoking. The authors and their institution should be commended for not only prospectively collecting such a massive quantity of data, but then also assembling the data in a well-performed study.

Prior studies have examined the relationship between smoking and orthopaedic procedures. Cancienne et al. documented an increased rate of infection and venous thromboembolism following anterior cruciate ligament reconstruction7. Duchman et al. queried the National Surgical Quality Improvement Program (NSQIP) database of nearly 80,000 total joint arthroplasties and reported that both former and current smokers had increased total complication risk and current smokers had increased rates of wound complications8. Surprisingly, Tischler et al. did not find an association with increased wound complications.

There is a difference between modifiable and non-modifiable risk factors in total joint arthroplasty. Maoz et al. discussed the effect of modifiable risk factors such as tobacco use, obesity, operative time, and Staphylococcus aureus colonization, each of which increased the risk of infection after total hip arthroplasty9. The question remains to what extent we should attempt to reduce these factors prior to the surgical procedure in our patients undergoing total joint arthroplasty. The questions that we need to pose include: Is a patient’s access to a total joint replacement a right or a privilege? Do we have the resources to perform these procedures in higher-risk patients, especially when their own modifiable behaviors are contributing to these risks? Obviously, we would not intentionally limit access to care on the basis of socioeconomic status6, even with suboptimal outcomes, so should we limit the access for smokers or for obese patients? The answers to these questions can be emotionally charged and complex and will require thought and discussion.

I think it is safe to suggest that, as physicians, we should work cooperatively with our patients to enhance outcomes by attempting to reduce these modifiable risk factors. We can educate patients and can suggest smoking cessation programs and weight loss regimens that may not only improve the risk profile during the surgical episode, but also improve the patients’ overall health. Further research will need to be performed to determine if these efforts are warranted and effective.

*The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (


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7. Cancienne JM, Gwathmey FW, Miller MD, Werner BC. Tobacco use is associated with increased complications after anterior cruciate ligament reconstruction. Am J Sports Med. 2016 Jan;44(1):99-104. Epub 2015 Nov 2.
8. Duchman KR, Gao Y, Pugely AJ, Martin CT, Noiseux NO, Callaghan JJ. The effect of smoking on short-term complications following total hip and knee arthroplasty. J Bone Joint Surg Am. 2015 Jul 1;97(13):1049-58.
9. Maoz G, Phillips M, Bosco J, Slover J, Stachel A, Inneh I, Iorio R. The Otto Aufranc Award: Modifiable versus nonmodifiable risk factors for infection after hip arthroplasty. Clin Orthop Relat Res. 2015 Feb;473(2):453-9.

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