Smoking and Primary Total Shoulder Arthroplasty: an Important and Modifiable Risk Factor
Kevin Xavier Farley, BS1, Susanne Boden, BA2, Andrew Schwartz, MD2, Charles A Daly, MD1, Michael Brandon Gottschalk, MD1 and Eric R Wagner, MD, MS2, (1)Emory University, Atlanta, GA, (2)Emory University, Department of Orthopaedics, Atlanta, GA
INTRODUCTION: There remains a paucity of literature evaluating its role in primary total shoulder arthroplasty (TSA). We aimed to characterize the risk of 90-day readmissions, revisions, and prosthetic joint infections (PJI) in this patient population. We hypothesized that active tobacco smokers will be at an increased risk of detrimental postoperative outcomes in the subacute post-operative period after elective anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty.
METHODS: The National Readmission Database was queried for all primary shoulder arthroplasty procedures performed between 2011-2015. Active smokers were identified. 90-day readmissions and complications were documented. Multivariate regression was performed to quantify the risk profile of smoking status on postoperative and 90-day outcomes after elective aTSA and rTSA.
RESULTS: A total of 196,325 non-smokers (93.1%) and 14,461 current smokers (6.9%) underwent 210,786 shoulder arthroplasties between 2011 and 2015, including 116,991 aTSA and 93,795 rTSA. Smokers were not only at an increased risk for 30- day readmission (OR 1.13, p=0.025), but also 90-day readmission (OR 1.12, p =0.001) compared to non-smokers (Table 1). Compared to non-smokers, smokers had significantly increased risk for any 90-day revision (OR 1.54, p<0.001), surgical site or prosthetic joint infection (OR 1.58, p<0.001), and non-infectious wound complication (OR 1.54, p<0.001). Smoking had the most significant impact on dislocation rates, affecting 1.6% of smokers compared to 0.9% of non- smokers (OR 1.62, p<0.001). Smokers were at a significantly increased risk of infectious complications compared to non- smokers, with significantly higher risks for pneumonia (OR 1.67, p<0.001) and sepsis (OR 1.33, p=0.001) (Table 2). Smoking was found to more than double the risk of myocardial infarction, affecting 0.7% of smokers compared to 0.3% of non-smokers (OR 2.79, p<0.001) (Table 2). Smokers had a nondifferent risk of non-home discharge (OR 0.91, p = 0.014) and a decreased risk of an extended length of stay over 2 days (LOS) (OR 0.89, p<0.001).
CONCLUSION: Smokers have an increased risk of PJI, readmission and revision, prosthetic instability, pneumonia, sepsis, and myocardial infarction after primary total shoulder arthroplasty. These risks are similar to lower extremity arthroplasty, where many surgeons have chosen to avoid these elective procedures in smokers given the increased risks. While non- home discharge and LOS were not worsened in smokers, this may reflect a selection bias for otherwise healthy, young, and active current smokers. Given the increased risks, the potentially modifiable risk factor of active smoking she be seriously considered prior to undergoing a TSA.
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