NYU: Smoking Cessation Program Improves TJR Outcomes

New research from New York University Langone Medical Center has found that smokers who quit before total hip or knee replacement fared better than those did not quit. Specifically, according to the March 16, 2017 news release, patients “…who needed a hip or knee replacement experienced better surgical outcomes and fewer adverse events including hospital readmissions, surgical site infections and blood clots if they were enrolled in a smoking cessation program prior to surgery…”

The researchers created a voluntary smoking cessation program with four pre-operative telephone counseling sessions, nicotine replacement therapy, and two post-operative follow-up sessions. They reviewed the medical records of 539 smokers who underwent total joint replacements at NYU Langone’s Hospital for Joint Diseases between October 2013 (after the smoking cessation program was implemented) through March 2016.

“By delaying surgery in high-risk patients until they enroll in a program to quit smoking, we are not only improving how the patient will do after surgery, but eliminating some of the burden on the healthcare system caused by poor outcomes and increases in costly reoperations,” says Richard Iorio, M.D., the Dr. William and Susan Jaffe Professor of Orthopaedic Surgery and chief of the Division of Adult Reconstructive Surgery at NYU Langone. “Our study adds that telling patients to stop smoking likely is not enough, and an established smoking cessation program may be most beneficial.”

Lead study author Amy Wasterlain, M.D., a fourth-year resident in the Department of Orthopaedic Surgery at NYU Langone, told OTW, “Bundled payment initiatives and healthcare reform have inspired hospitals and physicians to identify modifiable risk factors and address them prior to surgery. Smokers undergoing total joint arthroplasty experience 50% more complications and incur $5,000 incremental hospital costs relative to non-smokers. Data from 7,000 total joint arthroplasty patients at our hospital revealed that smokers are 2.1 times more likely to develop a deep surgical site infection after total joint arthroplasty. These findings, combined with the numerous overall health benefits of smoking cessation, led us to develop a pilot tobacco cessation program in the hopes of improving perioperative outcomes for smokers undergoing total joint arthroplasty.”

“Patients who completed the program were 4.3 times more likely to quit before surgery than those who tried to quit on their own. We were also surprised to see that patients undergoing total knee arthroplasty appeared to benefit the most from smoking cessation. For patients undergoing total knee arthroplasty, patients who completed the program experienced about 24% fewer complications than active smokers. However, we did not find a difference in complication rates for patients undergoing total hip arthroplasty. It is possible that the thicker soft tissue envelope and improved vascularity surrounding the hip make total hip arthroplasties less susceptible to the negative effects of tobacco and nicotine.”

“Although the current pilot study shows encouraging early results, we will need to continue to enroll more patients to ensure we have adequate power to detect statistically significant differences in outcomes. Currently we have relied on patients’ self-reported tobacco use and quit status. In the next phase of this study, we plan to initiate urine testing for nicotine metabolites to confirm patients’ self-reported tobacco cessation.”