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Reoperation Risk due to Post-Surgery Infection Increase for Smokers

Feb 17, 2017
Reoperation Risk due to Post-Surgery Infection Increase

According to a study in The February 15, 2017 issue of The Journal of Bone & Joint Surgery, smoking is linked to an increased risk of infectious (septic) complications requiring repeat surgery for individuals undergoing total knee or hip replacement.

"Our results found that current smokers had a significantly higher rate of septic reoperation compared with nonsmokers," remarked senior author Dr. Matthew S. Austin of the Rothman Institute at Thomas Jefferson University, Philadelphia. "Furthermore, each additional pack-year significantly contributed to total reoperations."

Risk Increase of 80 Percent for Smokers for Reoperation due to Infection

Patients undergoing total joint replacement, either hip or knee replacement, were examined by researchers to see how their smoking history affected their risk of hospital readmissions. Patients were excluded from the cohort if smoking status was not recorded or if they were cigar or pipe smokers.

Between 2000 and 2014, data was studied on 15,264 patients who underwent a total of 17,394 total joint replacements: 8.917 hip and 8,477 knee replacements.

Nine percent of patients were current smokers, 34 percent were former smokers, and 57 percent were nonsmokers, at the time of surgery. Current smokers were younger than nonsmokers with the average age about 58 versus 63 years. Overall, former smokers reported a median of 22.2 years (range, 0.2 to 60 years) of abstaining from smoking prior to the surgical procedure. Smokers also had increased rates of certain major respiratory and cardiovascular diseases.

For infectious complications, the risk of reoperation within 90 days was low at 0.71 percent. But, this risk was significantly higher for current smokers at 1.2 percent, compared to 0.56 percent for nonsmokers.

Patient demographic characteristics such as age, sex, body mass index (BMI), race, joint (hip or knee), type of surgical procedure (simultaneous bilateral, staged bilateral, or unilateral), smoking status (including packs per decade), and years of abstinence for former smokers was evaluated.

After adjustment for other components, current smokers stayed at significantly increased risk of reoperation for infectious complications. The relative risk was 80 percent higher, compared to nonsmokers. Former smokers as a group, were not at increased risk.

Risk Increase of 80 Percent for Smokers

For current and former smokers alike, however, the risk of 90-day nonoperative readmission increased with the amount of "pack-years" smoked. Smoking an extra pack per day for ten years was linked to a 12 percent increase in that relative risk. Smoking overall, however, was not related to the risk of readmission without surgery, or for reoperation for reasons beside infections.

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An effective treatment for advanced degenerative joint disease is arthroplasty (total joint replacement). Almost one million total joint replacements, most typically of the knee and hip, were performed in the United States in 2011. Over the next ten years, the demand for these procedures is expected to increase.

The relationship between smoking and complications after total hip or knee replacement has been unclear, even though some important risk factors for complications have been identified. A major focus of efforts to improve the quality and value of healthcare is minimizing unplanned hospital readmissions.

The new results suggest that current smokers are at substantially higher risk of reoperation for septic complications, even though there's no difference in the total readmission rate. Also at an increased risk are patients with a history of heavier smoking, even if they have since quit since.

Centers for Medicare & Medical Services (CMS) has placed a strong emphasis on minimizing unplanned readmissions. Readmission rates are determined by access, regulatory policies, age-related comorbidities, and social determinants. As tobacco use remains the single largest preventable cause of death and disease in the United States, it is vital to identify the true effect of cigarette smoking on postoperative total joint arthroplasty complications and to counsel patients on potential risks after a surgical procedure.

"If smoking is associated with elevated perioperative risk of readmission and/or reoperation, then it may be reasonable to engage the patient in a smoking cessation program prior to total joint arthroplasty," Dr. Austin and coauthors write. Nevertheless, further studies would be needed to determine if quitting smoking before joint replacement surgery can reduce the risk of complications.

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