The effects of nutritional deficiencies, smoking, and systemic disease on orthopaedic outcomes

Heated Tobacco Products Have Detrimental Effects on Rotator Cuff Healing, Similar to Conventional Cigarettes

BACKGROUND

Cigarette smoking impairs rotator cuff healing, but no study, to our knowledge, has focused on the association between heated tobacco products and rotator cuff tears.

METHODS

This study retrospectively investigated 1,133 patients who underwent arthroscopic repair of symptomatic rotator cuff tears between March 2011 and April 2021. Patients were grouped on the basis of their smoking patterns as nonsmokers, cigarette smokers, and heated tobacco smokers. Propensity score matching was used to reduce selection bias, and 45 subjects were selected from each group via 1:1:1 matching. Functional scores and active range of motion were compared among the 3 groups preoperatively and at a 2-year follow-up. Postoperative magnetic resonance imaging was performed 6 months after the surgical procedure to assess structural integrity.

RESULTS

Except for sex, similar baseline characteristics were achieved after propensity score matching. There were no differences in the clinical scores or range of motion between the matched groups either preoperatively or at the 2-year follow-up. However, the retear rate for the matched nonsmoker group was significantly lower (8.9%) than those for the matched cigarette smoker group (31.1%) and the heated tobacco smoker group (28.9%) (p = 0.022). Multivariable logistic regression analysis revealed that the retear rates were 3.403 times higher for the cigarette smoker group and 3.397 times higher for the heated tobacco smoker group than that for the nonsmoker group.

CONCLUSIONS

Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. Regardless of the type of cigarette, abstinence from smoking is necessary for patients undergoing rotator cuff repair surgery.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Nutritional Laboratory Studies Prior to Total Knee Arthroplasty: Practice Versus Publication

BACKGROUND

Recent emphasis has been placed on nutritional status assessment prior to total knee arthroplasty (TKA), including multiple American Academy of Orthopaedic Surgeons publications recommending specific laboratory studies; however, the frequency with which surgeons obtain these laboratory studies remains unclear. We sought to assess the incidence of ordering nutritional laboratory studies in the 90 days prior to TKA, utilizing data from a large administrative claims database.

METHODS

With use of the PearlDiver database, we identified 557,670 patients undergoing primary TKA from 2011 to 2020 with a metabolic panel or blood cell count claim within 90 days prior to TKA. We then determined the incidence of prealbumin, transferrin, vitamin D, and zinc laboratory tests claimed 90 days prior to TKA. Associations between claims and the year of surgery, patient demographics, and clinical characteristics were assessed by comparing proportions and chi-square testing.

RESULTS

Nutritional laboratory studies were infrequently claimed within 90 days prior to TKA, with studies for prealbumin being performed in 2.2% of patients; transferrin, 1.9%; vitamin D, 10.2%; and zinc, 0.2%. From 2011 to 2020, there was a moderate but steady increase in the proportion of patients with claims for prealbumin (change from 0.8% in 2011 to 3.4% in 2020; p < 0.001), transferrin (0.8% to 2.7%; p < 0.001), and vitamin D (7.6% to 9.4%; p < 0.001) laboratory tests but there was less of a change for zinc (0.1% to 0.2%; p < 0.001). There were weak-to-absent associations of age, gender, obesity, diabetes, and anemia with laboratory claims.

CONCLUSIONS

Despite multiple publications and recommendations, nutritional laboratory studies are infrequently ordered prior to TKA. Although there has been a slight increase in the use of nutritional laboratory studies over the past decade, patient factors such as gender and obesity were not associated with this increase. Understanding current practice patterns may help target future areas for improvement.

LEVEL OF EVIDENCE

Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Salvage of Failed Lisfranc/Midfoot Injuries

Salvage of Lisfranc, or tarsometatarsal injuries, may be necessary because of a variety of clinical scenarios. Although rare, these injuries represent a broad spectrum of injury to the midfoot ranging from low-energy ligamentous injuries to high-energy injuries with significant displacement and associated fractures. Poor outcomes and complications may occur including posttraumatic arthritis, instability, pain, infection, and loss of function. Strategies and technical considerations for salvage of these complex injuries are provided.

Can You Believe Your Patients If They Say They Have Quit Smoking?

OBJECTIVES

To determine the reliability of self-reported smoking status in the orthopaedic trauma population and determine if certain patient factors might predispose inaccurate self-reported smoking cessation.

DESIGN

Prospective.

SETTING

Level I trauma center.

PATIENTS

Two hundred forty-seven orthopaedic trauma patients were included in the study.

INTERVENTION

In-office measurement of exhaled carbon monoxide (CO).

MAIN OUTCOME MEASUREMENTS

Self-reported smoking cessation with exhaled CO measurements.

RESULTS

A total of 906 self-reported surveys were completed over 4 follow-up visits. Of the responses indicating smoking cessation (n = 174), 12.6% [95% confidence interval (CI), 0.081-0.185] reported smoking cessation with positive CO readings, suggesting inaccurate self-reporting of smoking status. Over 20% of those patients inaccurately reporting abstinence did so more than once. The odds of inaccurate self-reporting was 3 times higher in patients with no insurance or government insurance [odds ratio (OR), 3.5; 95% CI, 1.1-11.0; P = 0.043] and in the unemployed (OR, 3.3; 95% CI, 0.97-8.57; P = 0.049).

CONCLUSIONS

Self-reported smoking status in the orthopaedic population is fairly reliable, with 13% of patient's inaccurately self-reporting smoking cessation despite knowing their smoking status was being measured. Clinicians should be aware of the potential for inaccuracy in self-reported smoking cessation, particularly in patients with the identified socioeconomic factors. Point-of-care testing before elective trauma procedures to confirm smoking status might have a role if the procedure outcome is highly dependent on smoking status.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The use of tobacco is a modifiable risk factor for poor outcomes and readmissions after shoulder arthroplasty

Aims

The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA.

Methods

Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors.

Results

A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively.

Conclusion

Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA. Cite this article: Bone Joint J 2020;102-B(11):1549–1554.

The use of tobacco is a modifiable risk factor for poor outcomes and readmissions after shoulder arthroplasty

AIMS

The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA.

METHODS

Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors.

RESULTS

A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively.

CONCLUSION

Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA.

Malnutrition in Orthopaedic Sports Medicine: A Review of the Current Literature

CONTEXT

Malnutrition is well-studied in various aspects of the orthopaedic literature, most commonly in relation to arthroplasty, spine surgery, and trauma. However, the management of nutritional deficiencies is commonly overlooked among orthopaedic sports medicine providers. The purpose of this article is to analyze the available sports medicine literature to review the associations between malnutrition and the management of orthopaedic sports medicine patients from a treatment and performance standpoint.

EVIDENCE ACQUISITION

PubMed was searched for relevant articles published from 1979 to 2019.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Few studies exist on the implications of macronutrient deficiencies specific to orthopaedic sports medicine procedures. Interestingly, micronutrient disorders-namely, hypovitaminosis D and iron deficiency-have been well studied and may lead to worse postoperative outcomes, injury rates, and athletic performance. Nutritional supplementation to correct such deficiencies has been shown to mitigate these effects, though further study is required.

CONCLUSION

Nutritional deficiencies are highly prevalent in orthopaedic sports medicine patients, and practitioners should be aware of their potential effects on treatment and performance outcomes. Management of such deficiencies and their effect on surgical patients remain an area of potential future research. Future studies are warranted in order to explore the potential therapeutic role of nutritional supplementation to prevent complications after common orthopaedic sports medicine procedures, improve athletic performance, and reduce injury rates.

Influence of Cigarette Smoking at the Time of Surgery on Postoperative Outcomes in Patients With Femoroacetabular Impingement: A Matched-Pair Cohort Analysis

BACKGROUND

There is literature on the association between smoking in patients undergoing orthopaedic procedures and poor short-term outcomes. However, there are few data on smoking as an independent predictor of midterm outcomes in patients undergoing hip arthroscopic surgery for femoroacetabular impingement (FAI).

PURPOSE

To evaluate 2-year postoperative outcomes in patients undergoing hip arthroscopic surgery for FAI in current smokers compared with an age- and body mass index (BMI)-matched group with no smoking history.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Consecutive patients undergoing primary hip arthroscopic surgery for FAI between June 2012 and January 2016 were screened for smoking habits. Exclusion criteria included revision or bilateral surgery, dysplasia, and less than 2-year follow-up. Forty current smokers at the time of surgery were matched 1:2 by age and BMI to patients with no smoking history. Outcome measures included the Hip Outcome Score (HOS)-Activities of Daily Living (ADL), HOS-Sports-Specific Subscale (SSS), modified Harris Hip Score (mHHS), and visual analog scale (VAS) for pain and satisfaction. Minimal clinically important difference (MCID) and patient acceptable symptom state rates were calculated for all patients.

RESULTS

All patients demonstrated significant improvements in all outcome measures ( P < .001). Current smokers experienced inferior postoperative HOS-ADL (80.4 vs 89.1, respectively; P = .013) and HOS-SSS (65.8 vs 75.6, respectively; P = .046) scores and greater VAS pain scores (3.2 vs 1.8, respectively; P = .011) than nonsmokers. Current smoking was correlated with inferior HOS-ADL ( r = -0.27, P = .003) and HOS-SSS ( r = -0.18, P = .046) scores and greater VAS pain scores ( r = 0.26, P = .005). Controlling for age, sex, and BMI, smoking was a significant independent predictor of postoperative HOS-ADL (β = -8.7 [95% CI, -14.3 to -3.0]; P = .003), HOS-SSS (β = -9.8 [95% CI, -19.5 to -0.2]; P = .046), and VAS pain (β = 14.6 [95% CI, 4.4 to 23.7]; P = .005) scores. Current smokers had lower odds of achieving the MCID for the HOS-ADL (odds ratio, 0.31 [95% CI, 0.12-0.83]; P = .019) and mHHS (odds ratio, 0.31 [95% CI, 0.10-0.88]; P = .028).

CONCLUSION

Current smokers had inferior postoperative HOS-ADL and HOS-SSS scores, increased pain, and lower odds of achieving the MCID for the HOS-ADL and mHHS at 2 years postoperatively than patients without any smoking history.

Hypoalbuminemia Is a Better Predictor than Obesity of Complications After Total Knee Arthroplasty: a Propensity Score-Adjusted Observational Analysis

BACKGROUND

Obesity is an established risk factor for complications after total knee arthroplasty (TKA) and is often associated with malnutrition.

QUESTIONS/PURPOSES

1. What is the prevalence of hypoalbuminemia in obese patients undergoing TKA? 2. What is the independent morbidity risk of malnutrition relative to obesity?

METHODS

TKA cases were identified from the National Surgical Quality Improvement Program from 2005 to 2013. Propensity scores for having preoperative albumin measurements were calculated using demographics, BMI, and modified Charlson Comorbidity Index (CCI). Malnutrition was defined as hypoalbuminemia (<3.5 g/dL). Patients were classified by BMI as follows: non-obese (18.5-29.9), obese I (30-34.9), obese II (35-39.9), or obese III (≥40). Postoperative complications were compared across obesity and nutritional statuses. Multivariable propensity-adjusted logistic regressions were performed to determine associations between malnutrition, obesity, and 30-day outcomes.

RESULTS

There were 71,599 cases identified, with 34,800 (48.6%) having albumin measurements. Propensity score adjustment adequately accounted for selection bias, with adjusted p > 0.05 for observable characteristics. Malnutrition prevalence increased with BMI (6.1% in obese III vs. 3.7% in non-obese). With propensity-adjusted multivariable analysis, obese III was the only obesity class associated with any complication, wound complication, and reoperation. Hypoalbuminemia was a stronger and more consistent independent risk factor, for any complication, wound, cardiac, or respiratory complications, and death.

CONCLUSIONS

Hypoalbuminemia is a more consistent independent predictor of complications after TKA than obesity. Strategies for medical optimization of these conditions should be investigated.

Effect of smoking on complications following primary shoulder arthroplasty

BACKGROUND

The purpose of this study was to examine the effect of smoking on the incidence of complications after primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA).

METHODS

All patients who underwent primary TSA or RSA at our institution between 2002 and 2011 and had a minimum 2-year follow-up were included. Smoking status was assessed at the time of surgery. Current smokers, former smokers, and nonsmokers were compared for periprosthetic infection, fractures (intraoperative and postoperative), and loosening after surgery.

RESULTS

The cohort included 1834 shoulders in 1614 patients (814 in smokers and 1020 in nonsmokers). Complications occurred in 73 patients (75 shoulders; 44 in smokers and 31 in nonsmokers). There were 20 periprosthetic infections (16 in smokers and 4 in nonsmokers), 27 periprosthetic fractures (14 in smokers and 13 in nonsmokers), and 28 loosenings (14 in smokers and 14 in nonsmokers). Smokers had lower periprosthetic infection-free survival rates (95.3%-99.4% at 10 years; P = .001) and overall complication-free survival rates (78.4%-90.2%; P = .012) than nonsmokers. Multivariable analyses showed that both current and former smokers had significantly higher risk of periprosthetic infection in comparison with nonsmokers (hazard ratio [HR], 7.27 and 4.56, respectively). In addition, current smokers showed a higher risk of postoperative fractures than both former smokers (HR, 3.63) and nonsmokers (HR, 6.99).

CONCLUSIONS

This study demonstrates that smoking is a significant risk factor of complications after TSA and RSA. These findings emphasize the need for preoperative collaborative interventions, including smoking cessation programs.

Orthopaedic trauma patients and smoking: Knowledge deficits and interest in quitting

BACKGROUND

Smoking is associated with increased complications in fracture care. Smoking cessation has a positive impact on outcomes. It is unknown whether orthopaedic trauma patients understand the ill effects of smoking on fracture care and whether knowledge can improve cessation interest. We hypothesized that (1) smokers less fully understand the negative effects of smoking than do nonsmokers, (2) an increased proportion of orthopaedic trauma patients are further in the process of change to quit smoking, (3) increased knowledge predicts increased readiness to quit, and (4) minimal education through a survey can improve interest in smoking cessation.

METHODS

Single-centre cross-sectional cohort survey study. Patients were approached consecutively for participation. Patients 18 years or older with a new fracture in our clinic for follow-up were eligible. Smokers and nonsmokers were included and surveyed regarding demographics. Smokers were asked questions about fractures and general knowledge questions regarding the effects of smoking on health. Smokers' interest in smoking cessation was assessed with direct questions, and transtheoretical model stage of change was queried before and after survey administration.

RESULTS

One hundred twelve patients participated (44 smokers, 68 nonsmokers; 75 male patients, 37 female patients). Forty-eight percent of smokers stated that the fracture made them more likely to quit. Smokers answered more questions incorrectly than did nonsmokers (p=0.003). An increased percentage of smokers were in favourable stages of change compared with a population-based tobacco survey (68% versus 54%, p=0.008). Survey administration increased interest in quitting in 48%, and 11% modified their stage of change towards quitting. Smokers scoring higher on knowledge questions had more than 2-fold increased odds of being in a favourable stage of change (p=0.013; odds ratio, 2.13; 95% confidence interval, 1.744-3.855).

CONCLUSIONS

Compared with nonsmokers, smokers less fully understand the negative effects of smoking on fracture care and general health. A large proportion of orthopaedic trauma patients who smoke are interested in smoking cessation and are possibly further along the pathway to change than expected. Brief education through a survey can increase interest in quitting. Formal education intervention may improve cessation rates and fracture outcomes.

Cigarette smoking increases complication rate in forefoot surgery

BACKGROUND

Cigarette smoking is known to increase perioperative complication rates, but no study to date has examined its effect specifically in forefoot surgery. The purpose of this study was to determine whether cigarette smoking increased complications after forefoot surgery.

METHODS

The records of 602 patients who had forefoot surgery between 2008 and 2010, and for whom smoking status was known, were reviewed. Patients were categorized into 3 groups based on smoking status: active smoker, smoker in the past, or nonsmoker. Medical records were reviewed for occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain.

RESULTS

Active smokers were found to have a notably higher complication rate (36.4%) after forefoot surgery than patients who previously (16.5%) or never (8.5%) smoked. Patients who continued to smoke in the perioperative period had the highest percentage of delayed union (3.0%), infection (9.1%), delayed wound healing (10.6%), and persistent pain (15.2%). Active cigarette smokers were 4.3 times more likely to have a complication than nonsmokers. Patients who smoked at any point in the past but quit prior to surgery were 1.9 times more likely than nonsmokers to incur a complication. The average time of smoking cessation for patients who had smoked at any point in the past but had quit prior to surgery was 17 years. For active smokers, those with a complication smoked an average of 18 cigarettes daily, while those without a complication smoked 14 cigarettes daily.

CONCLUSIONS

Before forefoot surgery, surgeons should educate patients who smoke about their increased risk of complications and encourage smoking cessation.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A multifactoral analysis of 1452 patients for smoking sensation. An outpatient lab experience

Smoking habit is held responsible for several respiratory and metabolic diseases. Data from 1452 patients were recorded from our outpatient laboratory. The following parameters were recorded within several follow ups of our patients; smoking habit, respiratory functions, smoking cessation questionnaires, and administered drugs. The treatment administered to smokers throughout the period of inspection seems to also have a significant effect on dependence. In fact, varelicline causes a 50% reduction in smoking dependence in regards to nicotine substitutes (odds ratio: 0.48 (0.31-0,74), p=0.001) so displaying a substantial preponderance on the choice to fight smoking dependence.