Do you have a ‘hard stop’ for active smokers scheduled for revision orthopedic surgery?
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‘Hard stop’ may enhance presurgical stress
Smoking is one of the most harmful factors for clinical outcomes in orthopedic surgery. Numerous studies have reported the negative effects of smoking on infection rate, cardiopulmonary complications and tendon healing.
In addition, smoking cessation can have a profound positive impact on the risk of postoperative complications. One could reasonably argue complete cessation of smoking should be required of any patient planning to undergo a revision procedure. However, smoking and other forms of nicotine delivery are highly addictive. Smoking cessation that leads to nicotine withdrawal can produce anxiety, depressed mood, irritability and restlessness. Firmly requiring patients to take on these symptoms at a time of injury, disability, pain and or loss of income may create an overwhelming burden of stress.
Considering all of these factors, an individualized, patient-centered approach to this issue is utilized in our practice. We do not implement a “hard stop” for smokers undergoing revision surgery to quit, but we do thoroughly discuss the detrimental effects of smoking and tobacco use on general health and the increased risks in the perioperative period. Smoking cessation is strongly recommended, and we have found many patients have attempted or considered quitting previously and are motivated by our discussion to resume or begin the process. We encourage patients to discuss a smoking cessation plan with their primary care doctor. A simple analysis of outcomes of those who underwent shoulder arthroplasty at our institution revealed no difference in smokers vs. nonsmokers postoperatively at 4 years.
At our institution, we have a strong academic interest in biological supplementation in the treatment of musculoskeletal injuries. We have developed a technique and have studied the augmentation of rotator cuff tendon repair with an autologous clot prepared from bursal tissue and whole blood. We believe smokers who have a high risk for repair failure, especially in the revision setting, could benefit from this therapy. Therefore, this population of patients routinely receives this specific treatment.
Augustus D. Mazzocca, MS, MD, FAAOS, a shoulder and elbow surgeon, is director of the UConn Musculoskeletal Institute and professor of orthopedic surgery at University of Connecticut. He is Orthopedics Today Section Editor, Basic Science & Technology.
Gregory M. Kanski, MD, is an orthopedic surgery sports medicine fellow at UConn Health Center in Farmington, Connecticut.
- References:
- Benowitz NL. N Engl J Med. 2010;doi:10.1056/NEJMra0809890.
- Hatta T, et al. J Shoulder Elbow Surg. 2017;doi:10.1016/j.jse.2016.09.011.
- Møller AM, et al. J Bone Joint Surg Br. 2003;doi:10.1302/0301-620x.85b2.13717.
- Morikawa D, et al. Arthroscopy. 2019;doi:10.1016/j.arthro.2019.05.024.
- Santiago-Torres J, et al. Am J Sports Med. 2015;doi:10.1177/0363546514533776.
- Sørensen LT. Arch Surg. 2012;doi:10.1001/archsurg.2012.5.
- Stephens BF, et al. J Bone Joint Surg Am. 2013;doi:10.2106/00004623-201312040-00010.
- Wong J, et al. Can J Anaesth. 2012;doi:10.1007/s12630-011-9652-x.
Mandatory cessation with revision spine surgery
Smoking is a significant risk factor for failure after spinal surgery. Perhaps the most widely understood detrimental effect of smoking and nicotine abuse on spinal surgery is the association with nonunion or pseudoarthrosis following fusion. Multiple studies have shown increased failure after cervical and lumbar fusion in smokers compared to nonsmokers. This effect on bony fusion has been demonstrated on a cellular level as nicotine has been shown to inhibit activity and recruitment of osteoblast cells.
Perhaps more concerning is smoking also appears to prevent neurologic healing after spinal decompression. Our group published several studies which demonstrated smoking and nicotine abuse prevented neurologic improvement in patients undergoing cervical and lumbar decompression surgery for radiculopathy or myelopathy.
G.D. Carlson and colleagues determined neurologic healing occurs as a result of reperfusion and revascularization after cord compression. These data would support the fact that improvement after spinal decompression surgery is contingent on revascularization of the affected nerve tissue which, in turn, ultimately leads to healing of the tissues and improvement of symptoms and deficits. As smoking inhibits revascularization and damages small vessels, it would stand to reason that nicotine abuse may prevent neurologic healing after surgery by inhibiting the blood supply to the healing nerve tissue.
Smoking can lead to complications after surgery, as well. Our group showed significantly higher rates of blood loss and dural tears in patients who were smokers compared to those who did not smoke. This is not to mention the intrinsic risk of pulmonary issues after surgery in smokers, as well. These complications are intrinsically more frequent and worrisome in patients undergoing revision spinal surgery, which makes nicotine abuse of even more concern in these patients.
Revision lumbar surgery is intrinsically associated with lower overall success and higher complication rates compared to primary surgery. Smoking and nicotine abuse serves to further diminish successful osseus and neurologic healing and increases complication rates. Aside from emergency circumstances, smoking cessation should be mandatory patients undergoing revisionin spine surgery.
Nicholas U. Ahn, MD, is an orthopedic surgeon and director of the UH Spine Fellowship Program at University Hospitals in Cleveland.
- References:
- Carlson GD, et al. J Neurotrauma. 1997;doi:10.1089/neu.1997.14.951.
- Kusin DJ, et al. Spine (Phila Pa 1976). 2015;doi:10.1097/BRS.0000000000001014.PMID: 26426709.
- Kusin DJ, et al Spine (Phila Pa 1976). 2016;doi:10.1097/BRS.0000000000001597.
- McCunniff PT, et al. Clin Orthop Relat Res. 2016;doi:10.1007/s11999-015-4650-x.
- Smith EJ, et al. Orthopedics. 2020;doi:10.3928/01477447-20200619-14.
‘Hard stop’ benefits patients
In my practice, all new patients are screened for smoking at the time of initial consultation. Those who disclose smoking of nicotine products are counseled to find a plan for smoking cessation. We require that surgical patients have been abstinent from smoking for 4 weeks prior to surgery, so most are scheduled for surgery at least 8 weeks out at a minimum. Additionally, patients and family members are informed that the patient will be tested for cotinine, a nicotine metabolite present in the blood, prior to surgery. Patients are also given a number of resources, including a same-day appointment at our smoking cessation clinic on-site.
As 15% of active smokers at our institution who reported abstinence have been shown to have positive screening studies, objective data is key. The cotinine test does take up to 48 hours to result, so occasionally a carbon monoxide breath test is utilized as a point-of-care test. If either of those tests are indicative of continued nicotine use, the surgery is canceled and not rescheduled until cessation is documented.
Our reasoning for withholding surgery for active smokers is the continued scientific evidence that smokers have a higher rate of morbidity and mortality after total joint arthroplasty than nonsmokers. Smoking decreases tissue oxygenation due to carbon monoxide bonding in red blood cells, the inflammatory healing response is blunted by a reduced responsiveness of inflammatory cells and the proliferation of fibroblasts is muted leading to reduced collagen deposition. Therefore, it stands to reason that smoking has been shown as an independent risk factor for delays in incisional healing, surgical site infection, revision and mortality. I believe we owe it to our patients to take the extra time and attention to address this important societal health risk.
Michael J. Taunton, MD, is an orthopedic surgeon at the Mayo Clinic in Rochester, Minnesota.
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- Benowitz NL. N Engl J Med. 2010;doi:10.1056/NEJMra0809890.
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