The Impact of Smoking on Clinical Results Following the Rotator Cuff and Biceps Tendon Complex Arthroscopic Surgery

Abstract

The purpose of this study was to investigate the association of smoking and functional outcomes after arthroscopic treatment of complex shoulder injuries: rotator cuff tears (RCTs) with biceps tendon (LHBT) tears. This retrospective case-control study has been conducted on a cohort of patients who underwent shoulder arthroscopy between 2015 and 2017 due to complex injury treatment. The outcomes were assessed using the American Shoulder and Elbow Surgeons Score (ASES), the University of California at Los Angeles (UCLA) Shoulder Score, need for non-steroid anti-inflammatory drugs (NSAIDs) consumption and the visual analog scale (VAS). Complications and changes in smoking status were also noted. A cohort of 59 patients underwent shoulder arthroscopy, due to complex LHBT pathology and RCTs, and were enrolled in the final follow-up examination; with mean duration of 26.03 months. According to smoking status, 27 of patients were classified as smokers, and the remaining 32 were non-smokers. In the examined cohort, 36 patients underwent the LHBT tenotomy and 23 tenodesis. We observed a relationship between smoking status and distribution of various RCTs (p < 0.0001). The mean postoperative ASES and UCLA scores were 80.81 and 30.18 in the smoker's group and 84.06 and 30.93 in the non-smoker's group, respectively. There were no statistically significant differences in pre/postoperative ASES and postoperative UCLA scores between smokers and non-smokers (p > 0.05). The VAS was significantly lower in the non-smokers' group (p = 0.0021). Multi-tendon injuries of the shoulder are a serious challenge for surgeons, and to obtain an excellent functional outcome, we need to limit the negative risk factors, including smoking. Furthermore, there is a significant association between smoking and the occurrence of massive rotator cuff tears, and the pain level measured by the VAS. Simultaneous surgical treatment of RC and LHBT lesions in the smoker population allowed us to obtain the functional outcomes approximated to non-smokers in the long-term follow-up. Of course, we cannot assert that smoking is the real cause of all complications, however, we may assume that this is a very important, negative factor in shoulder arthroscopy.

Keywords: LHBT; arthroscopy; biceps; massive rotator cuff tears; rotator cuff; shoulder; smoking; tendinopathy; tenodesis; tenotomy.

Figure 1

Arthroscopic slides obtained during the shoulder arthroscopy presenting biceps tendon pathology with abundant vascularization in (A,D); partial rotator cuff tears, articular side in (E) and bursal side in (F); and also, complete rotator cuff tears in (B,C).

Figure 2

Summarized statistical analysis depending on age, the smoking status, rotator cuff tears morphology, pre/postoperative ASES and postoperative UCLA. (A) Comparison of age in tenotomy/tenodesis groups. (B) Heat map of distribution of RCTs morphology according to smoking status. (C) Comparison of preoperative ASES and postoperative ASES in general population. (D) Comparison of preoperative ASES and postoperative ASES in non-smoking population. (E) Comparison of preoperative ASES and postoperative ASES in smoking population. (F) Comparison of preoperative ASES in non-smoking and smoking population. (G) Comparison of postoperative ASES in non-smoking and smoking population. (H) Comparison of postoperative UCLA in non-smoking and smoking population; ns, p > 0.05; ** p > 0.0001; *** p < 0.0001.

Figure 3

(A,B) Heat map of distribution of Popeye deformity and night pain according to smoking status; (C) Comparison of VAS in non-smoking and smoking population; (D,E,F) Correlation between the VAS and pack-years index, cigarettes per day, smoking years.

Figure 4

(A) Heat map of correlation matrix, according to Spearman rho; (B) Heat map of correlation matrix, according to p-value.