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Comparative Study
. 2019 Dec;90(6):559-567.
doi: 10.1080/17453674.2019.1649510. Epub 2019 Aug 2.

The effect of smoking on outcomes following primary total hip and knee arthroplasty: a population-based cohort study of 117,024 patients

Gulraj S Matharu  1   2 , Sofia Mouchti  2 , Sarah Twigg  3   4 , Antonella Delmestri  1 , David W Murray  1 , Andrew Judge  1   2   5 , Hemant G Pandit  1   4
Affiliations
Comparative Study

The effect of smoking on outcomes following primary total hip and knee arthroplasty: a population-based cohort study of 117,024 patients

Gulraj S Matharu et al. Acta Orthop. 2019 Dec.

Abstract

Background and purpose - Smoking is a modifiable risk factor that may adversely affect postoperative outcomes. Healthcare providers are increasingly denying smokers access to total hip and knee arthroplasty (THA and TKA) until they stop smoking. Evidence supporting this is unclear. We assessed the effect of smoking on outcomes following arthroplasty.Patients and methods - We identified THAs and TKAs from the Clinical Practice Research Datalink, which were linked with datasets from Hospital Episode Statistics and the Office for National Statistics to identify outcomes. The effect of smoking on postoperative outcomes (complications, medications, revision, mortality, patient-reported outcome measures [PROMs]) was assessed using adjusted regression models.Results - We studied 60,812 THAs and 56,212 TKAs (11% smokers, 33% ex-smokers, 57% non-smokers). Following THA, smokers had an increased risk of lower respiratory tract infection (LRTI) and myocardial infarction compared with non-smokers and ex-smokers. Following TKA, smokers had an increased risk of LRTI compared with non-smokers. Compared with non-smokers (THA relative risk ratio [RRR] = 0.65; 95% CI = 0.61-0.69; TKA RRR = 0.82; CI = 0.78-0.86) and ex-smokers (THR RRR = 0.90; CI = 0.84-0.95), smokers had increased opioid usage 1-year postoperatively. Similar patterns were observed for weak opioids, paracetamol, and gabapentinoids. 1-year mortality rates were higher in smokers compared with non-smokers (THA hazard ratio [HR] = 0.37, CI = 0.29-0.49; TKA HR = 0.52, CI = 0.34-0.81) and ex-smokers (THA HR = 0.53, CI = 0.40-0.70). Long-term revision rates were not increased in smokers. Smokers had improvement in PROMs compared with preoperatively, with no clinically important difference in postoperative PROMs between smokers, non-smokers, and ex-smokers.Interpretation - Smoking is associated with more medical complications, higher analgesia usage, and increased mortality following arthroplasty. Most adverse outcomes were reduced in ex-smokers, therefore smoking cessation should be encouraged before arthroplasty.

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Figures

Figure 1.
Figure 1.
Forest plot for complications and medication usage following total hip arthroplasty by smoking status. The respective relative risk ratios and 95% confidence intervals are provided in Appendix 3.
Figure 2.
Figure 2.
Forest plot for complications and medication usage following total knee arthroplasty by smoking status. The respective relative risk ratios and 95% confidence intervals are provided in Appendix 3.
Figure 3.
Figure 3.
Cumulative probability of mortality up to 1 year following total hip arthroplasty.
Figure 4.
Figure 4.
Cumulative probability of mortality up to 1 year following total knee arthroplasty.
Figure 5.
Figure 5.
Estimation of the mean predicted preoperative (0 months) and postoperative (6 months) Oxford Hip Score by smoking status for patients receiving total hip arthroplasty.
Figure 6.
Figure 6.
Estimation of the mean predicted preoperative (0 months) and postoperative (6 months) Oxford Knee Score by smoking status for patients receiving total knee arthroplasty.
See this image and copyright information in PMC

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