Download PDF
J Knee Surg 2023; 36(09): 957-964
DOI: 10.1055/s-0042-1748819
Original Article

Trends in the Prevalence and Postoperative Surgical Complications for Smokers Who Underwent a Total Knee Arthroplasty from 2011 to 2019: An Analysis of 406,553 Patients

Hannah L. Simmons
1   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
,
Dan Grits
1   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
,
Melissa Orr
1   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
,
Trevor Murray
1   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
,
Alison K. Klika
1   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
,
Nicolas S. Piuzzi 
1   Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Smoking is a modifiable risk factor for complications following total knee arthroplasty (TKA). It is unclear if the declining prevalence of tobacco use in the U.S. population is reflected in patients undergoing elective TKA. This study aims to investigate (1) the incidence of 30-day complications following TKA in smokers and (2) trends in preoperative smoking status among TKA patients. In this study, patients undergoing primary elective TKA in the United States from 2011 to 2019 were identified in the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database. Our cohort included 406,553 cases, 8.13% of which had smoked cigarettes within 1 year of undergoing TKA. Smokers were propensity score-matched to a group of nonsmokers, with each n = 32,533. The incidences of 30-day complications, readmission, and non-home discharge were compared between groups. The rate of preoperative smoking among elective primary TKA patients remained stagnant from 2011 to 2019. Smokers had higher rates of superficial surgical site infections (SSIs; 1.1 vs. 0.5%, p < 0.001), deep SSI (0.3 vs. 0.2%, p = 0.012), wound disruption (0.4 vs. 0.2%, p < 0.001), pneumonia (0.5 vs. 0.3%, p < 0.001), and 30-day readmission (3.6 vs. 2.7%, p < 0.001) compared with nonsmokers. No significant trends in 30-day complications were noted between 2011 and 2019. This study supports the success of national efforts to reduce the prevalence of smoking and reports a modest effect within the TKA population. However, almost 1 in 10 patients undergoing elective TKA continues to smoke and maintains a higher risk of postoperative complications.

Keywords

smoking - surgical outcomes - total knee arthroplasty

Note

The current study was performed at the Cleveland Clinic Foundation's Department of Orthopaedic Surgery.




Publication History

Received: 05 October 2021

Accepted: 18 March 2022

Article published online:
07 July 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GAU.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health 2014: 1-36
    PubMedGoogle Scholar
  • 2 Luther T, Guthrie E, Stavrides A. et al. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. 1964 :1–386. Available at: https://www.pbs.org/newshour/health/first-surgeon-general-report-on-smokings-health-effects-marks-50-year-anniversary#:~:text=The%20U.S.%20Surgeon%20General's%20first,lung%20cancer%20and%20heart%20disease.
    PubMedGoogle Scholar
  • 3 Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco product use among adults - United States, 2019. MMWR Morb Mortal Wkly Rep 2020; 69 (46) 1736-1742
    CrossrefPubMedGoogle Scholar
  • 4 Bedard NA, DeMik DE, Owens JM, Glass NA, DeBerg J, Callaghan JJ. Tobacco use and risk of wound complications and periprosthetic joint infection: a systematic review and meta-analysis of primary total joint arthroplasty procedures. J Arthroplasty 2019; 34 (02) 385.e4-396.e4
    CrossrefPubMedGoogle Scholar
  • 5 Sahota S, Lovecchio F, Harold RE, Beal MD, Manning DW. The effect of smoking on thirty-day postoperative complications after total joint arthroplasty: a propensity score-matched analysis. J Arthroplasty 2018; 33 (01) 30-35
    CrossrefPubMedGoogle Scholar
  • 6 Singh JA. Smoking and outcomes after knee and hip arthroplasty: a systematic review. J Rheumatol 2011; 38 (09) 1824-1834
    CrossrefPubMedGoogle Scholar
  • 7 Siddiqi A, Warren JA, Manrique-Succar J, Molloy RM, Barsoum WK, Piuzzi NS. Temporal trends in revision total hip and knee arthroplasty from 2008 to 2018: gaps and opportunities. J Bone Joint Surg Am 2021; 103 (14) 1335-1354
    CrossrefPubMedGoogle Scholar
  • 8 Siddiqi A, Warren JA, McLaughlin J. et al. Demographic, comorbidity, and episode-of-care differences in primary total knee arthroplasty. J Bone Joint Surg Am 2021; 103 (03) 227-234
    CrossrefPubMedGoogle Scholar
  • 9 McConaghy K, Warren JA, Siddiqi A, Murray T, Molloy R, Piuzzi NS. Demographic, comorbidity, and episode of care trends in unicompartmental knee arthroplasty: 2008 to 2018. Eur J Orthop Surg Traumatol 2022; 32 (01) 121-128
    CrossrefPubMedGoogle Scholar
  • 10 Thomsen T, Tønnesen H, Møller AM. Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. Br J Surg 2009; 96 (05) 451-461
    CrossrefPubMedGoogle Scholar
  • 11 Warner DO. Preoperative smoking cessation: the role of the primary care provider. Mayo Clin Proc 2005; 80 (02) 252-258
    CrossrefPubMedGoogle Scholar
  • 12 Tischler EH, Matsen Ko L, Chen AF, Maltenfort MG, Schroeder J, Austin MS. Smoking increases the rate of reoperation for infection within 90 days after primary total joint arthroplasty. J Bone Joint Surg Am 2017; 99 (04) 295-304
    CrossrefPubMedGoogle Scholar
  • 13 Fuchshuber PR, Greif W, Tidwell CR. et al. The power of the National Surgical Quality Improvement Program–achieving a zero pneumonia rate in general surgery patients. Perm J 2012; 16 (01) 39-45
    CrossrefPubMedGoogle Scholar
  • 14 Molina CS, Thakore RV, Blumer A, Obremskey WT, Sethi MK. Use of the National Surgical Quality Improvement Program in orthopaedic surgery. Clin Orthop Relat Res 2015; 473 (05) 1574-1581
    CrossrefPubMedGoogle Scholar
  • 15 Neuman HB, Michelassi F, Turner JW, Bass BL. Surrounded by quality metrics: what do surgeons think of ACS-NSQIP?. Surgery 2009; 145 (01) 27-33
    CrossrefPubMedGoogle Scholar
  • 16 Schiller J, Lucas J, Peregoy J. Summary health statistics for U.S. adults: National Health Interview Survey, 2011. Vital Heal Stat 2012; (256) 1-218
    PubMedGoogle Scholar
  • 17 CDC. Quarterly Early Release tables. Accessed July 28, 2021 at: https://wwwn.cdc.gov/NHISDataQueryTool/ER_Quarterly/index_quarterly.html
    PubMedGoogle Scholar
  • 18 Trivedi A, Ezomo OT, Gronbeck C, Harrington MA, Halawi MJ. Time trends and risk factors for 30-day adverse events in black patients undergoing primary total knee arthroplasty. J Arthroplasty 2020; 35 (11) 3145-3149
    CrossrefPubMedGoogle Scholar
  • 19 Sheth M, Chambers M, Gronbeck C, Harrington MA, Halawi MJ. Total hip arthroplasty in black/african american patients: an updated nationwide analysis. J Racial Ethn Health Disparities 2021; 8 (03) 698-703
    CrossrefPubMedGoogle Scholar
  • 20 Rajaee SS, Debbi EM, Paiement GD, Spitzer AI. Increased prevalence, complications, and costs of smokers undergoing total knee arthroplasty. J Knee Surg 2022; 35 (01) 91-95
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Cobb N, Espey D, King J. Health behaviors and risk factors among American Indians and Alaska Natives, 2000-2010. Am J Public Health 2014; 104 (Suppl. 03) S481-S489
    CrossrefPubMedGoogle Scholar
  • 22 Odani S, Armour BS, Graffunder CM, Garrett BE, Agaku IT. Prevalence and disparities in tobacco product use among American Indians/Alaska Natives - United States, 2010-2015. Morb Mortal Wkly Rep 2017; 66 (50) 1374-1378
    CrossrefPubMedGoogle Scholar
  • 23 Azagba S, Shan L, Latham K, Qeadan F. Trends in cigarette smoking among American Indians and Alaska Natives in the USA: 1992-2015. Cancer Causes Control 2020; 31 (01) 73-82
    CrossrefPubMedGoogle Scholar
  • 24 Pruzansky JS, Bronson MJ, Grelsamer RP, Strauss E, Moucha CS. Prevalence of modifiable surgical site infection risk factors in hip and knee joint arthroplasty patients at an urban academic hospital. J Arthroplasty 2014; 29 (02) 272-276
    CrossrefPubMedGoogle Scholar
  • 25 Debbi EM, Rajaee SS, Spitzer AI, Paiement GD. Smoking and total hip arthroplasty: increased inpatient complications, costs, and length of stay. J Arthroplasty 2019; 34 (08) 1736-1739
    CrossrefPubMedGoogle Scholar
  • 26 Hart A, Rainer WG, Taunton MJ, Mabry TM, Berry DJ, Abdel MP. Smoking cessation before and after total joint arthroplasty-an uphill battle. J Arthroplasty 2019; 34 (7S): S140-S143
    CrossrefPubMedGoogle Scholar
  • 27 Singh JA, Houston TK, Ponce BA. et al. Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans. Arthritis Care Res (Hoboken) 2011; 63 (10) 1365-1374
    CrossrefPubMedGoogle Scholar
  • 28 Grønkjær M, Eliasen M, Skov-Ettrup LS. et al. Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. Ann Surg 2014; 259 (01) 52-71
    CrossrefPubMedGoogle Scholar
  • 29 Turan A, Mascha EJ, Roberman D. et al. Smoking and perioperative outcomes. Anesthesiology 2011; 114 (04) 837-846
    CrossrefPubMedGoogle Scholar
  • 30 Rodriguez-Merchan EC. The importance of smoking in orthopedic surgery. Hosp Pract (1995) 2018; 46 (04) 175-182
    CrossrefPubMedGoogle Scholar
  • 31 Ehnert S, Aspera-Werz RH, Ihle C. et al. Smoking dependent alterations in bone formation and inflammation represent major risk factors for complications following total joint arthroplasty. J Clin Med 2019; 8 (03) 406
    CrossrefPubMedGoogle Scholar
  • 32 Keswani A, Tasi MC, Fields A, Lovy AJ, Moucha CS, Bozic KJ. Discharge destination after total joint arthroplasty: an analysis of postdischarge outcomes, placement risk factors, and recent trends. J Arthroplasty 2016; 31 (06) 1155-1162
    CrossrefPubMedGoogle Scholar
  • 33 Piuzzi NS, Strnad GJ, Sakr Esa W. et al; Cleveland Clinic Orthopaedic Arthroplasty Group. The main predictors of length of stay after total knee arthroplasty: patient-related or procedure-related risk factors. J Bone Joint Surg Am 2019; 101 (12) 1093-1101
    CrossrefPubMedGoogle Scholar
  • 34 Zmistowski B, Restrepo C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors. J Bone Joint Surg Am 2013; 95 (20) 1869-1876
    CrossrefPubMedGoogle Scholar
  • 35 AAOS. Preoperative risk factors. Accessed July 28, 2021 at: https://aaos.org/quality/quality-programs/quality-toolkits/smoking/
    PubMedGoogle Scholar
  • 36 Hart A, Rainer WG, Taunton MJ, Mabry TM, Berry DJ, Abdel MP. Cotinine testing improves smoking cessation before total joint arthroplasty. J Arthroplasty 2019; 34 (7S): S148-S151
    CrossrefPubMedGoogle Scholar
  • 37 Ellis ST, Rao BM, Kohlrieser D, Kollmorgen RC, Sochacki KR. Validation of self-reported smoking status among orthopedic hip surgery patients. Cureus 2020; 12 (10) e10753
    PubMedGoogle Scholar