Does smoking mean that a total joint replacement (TJR) patient is more likely to be readmitted to the hospital or undergo a reoperation? Researchers from Rothman Institute at Thomas Jefferson University wanted definitive answers. Their work, “Smoking Increases the Rate of Reoperation for Infection within 90 Days After Primary Total Joint Arthroplasty,” was published February 15, 2017 in The Journal of Bone and Joint Surgery.
More Packs Per Decade=Higher Reoperation Rates
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Matthew Austin, M.D. is director of Joint Replacement Services at Rothman Institute in Philadelphia. Dr. Austin, a co-author on the study, told OTW, “We noticed a trend toward smokers having an increased risk of wound healing complications, so we looked at the literature. We discovered weaknesses in the prior data in that the studies involved small cohorts or specific cohorts that may not have been generalizable to the public at large.”
“We identified over 17,000 joint replacements in the Rothman database who underwent TJA [total joint arthroplasty] between 2000 and 2014. We then divided them into three groups: current smokers (9%), former smokers (34%), and patients who had never smoked (57%). Regarding the former smokers, the median time since they had stopped smoking was 22 years.”
“We found that current smokers have a higher rate of reoperation for sepsis than nonsmokers and, in addition, it was fascinating that whether someone is a current or former smoker, the more packs smoked per decade, the higher the risk of hospital readmission and complications as compared to those who have never smoked. Unfortunately, we were not able to tease out the difference between former smokers and nonsmokers in terms of complication risk. This could be because the damage from smoking may already be done. We really want to know, ‘If someone comes into the office and you get them to stop smoking, will that reduce the risk of complications?’ We are currently conducting a study to test this hypothesis.”
“And what do you do with patients who decide not to stop smoking when indeed they likely have a higher risk of sepsis? It is critical to know how smoking cessation changes the patient’s risk of a complication. This may have public policy implications.”
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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