Increased Prevalence, Complications, and Costs of Smokers Undergoing Total Knee Arthroplasty

Trends in prevalence and complications for smokers who underwent total hip arthroplasty from 2011 to 2019: an analysis of 243,163 patients

BACKGROUND

Smoking is an established risk factor for postoperative complications after total hip arthroplasty (THA). It is unknown if the decreasing prevalence of adult smoking in the United States is reflected in the elective THA patient population. We aimed to investigate recent trends in: (1) the prevalence of smoking pre-THA, stratified by patient demographics; and (2) rates of 30-day complications and increased healthcare utilisation post-THA in smokers versus non-smokers.

METHODS

Patients who underwent primary elective THA (2011-2019) were identified using the National Surgical Quality Improvement Program database. A total of 243,163 cases (Smokers: n = 30,536; Non-smokers: n = 212,627) were included. Trends analyses were performed for smoking prevalence across the study period. Smokers were propensity score-matched (1:1) to a cohort of non-smokers (n = 29,628, each), and rates of 30-day complications, readmission, and non-home discharge were compared.

RESULTS

The rate of preoperative smoking significantly decreased from 14.0% in 2011 to 11.6% in 2019 (p-trend = 0.0286). When stratified, a significant decreasing trend in smoking was found for males and all races; within races, American-Indian/Alaska-Native race had the sharpest decline (2011:36.3% vs. 2019:23.2%). No significant change in 30-day complication rates among smokers or non-smokers was observed (p-trend > 0.05), but non-home discharge significantly decreased for both smokers (p-trend = 0.001) and non-smokers (p-trend < 0.001). After matching, higher rates of superficial surgical site infections (SSI) (0.9% vs. 0.5%; p < 0.001), deep SSI (0.5% vs. 0.3%; p < 0.001), wound disruption (0.2% vs. 0.1%; p = 0.006), and readmission (4.2% vs. 3.1%; p = <0.001) were found in smokers versus non-smokers.

CONCLUSIONS

The present study is encouraging that national efforts to reduce the prevalence of smoking may be successful within the THA population, but there is a persistently elevated risk of postoperative complications in smokers after THA.

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

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.