Smokeless tobacco use may increase risk of complications after THA
Key takeaways:
- Smokeless tobacco use had an association with complications after total hip arthroplasty.
- Surgeons may consider making a distinction between smoking and smokeless tobacco use during the preoperative period.
Results published in the Journal of Arthroplasty showed smokeless tobacco users had “significantly higher” rates of complications after primary total hip arthroplasty compared with non-users.
In a retrospective cohort study of patients who underwent THA, researchers compared rates of joint complications within 2 years and medical complications within 90 days postoperatively among patients who used smokeless tobacco (n=950) and patients who smoked (n=21,585) with matched control groups of patients who did not use tobacco (n=3,800 and 86,340, respectively). Researchers also matched patients who used smokeless tobacco (n=922) with people who smoked (n=3,688). Among the 250,026 total patients identified in the study, researchers identified 0.59% (n=1,481) as smokeless tobacco users.
Results showed smokeless tobacco users had significantly higher rates of wound disruption, pneumonia, deep vein thrombosis, acute kidney injury, cardiac arrest, transfusion, readmission and increased length of stay compared with non-users 90 days after surgery. Researchers also noted smokeless tobacco users had significantly higher rates of prosthetic joint dislocation compared with non-users at 2 years after surgery. Patients who used smokeless tobacco had higher rates of overall joint complications, according to results. Researchers found both men and women significantly under-reported smokeless tobacco use.
“Smokeless tobacco use may be under-diagnosed in patients undergoing elective THA,” the researchers wrote in the study. “Surgeons may consider delineating between smoking and smokeless tobacco use during preoperative medical optimization,” they concluded.
Perspective
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In the past 2 decades, the collective body of joint replacement literature has attempted to establish relationships between patient health — including social habits — and surgical outcomes. Reported associations between active tobacco use (eg, cigarette smoking) and early postoperative complications have contributed to growing calls for smoking cessation for a minimum of 4 weeks before and after joint replacement surgery. Some patients and physicians may consider the use of nicotine replacement therapies as a pathway to smoking cessation, but there have been conflicting reports on either a reduction or an increase in perioperative complications with nicotine replacement therapies.
Smokeless tobacco product use is less common than cigarette smoking and its impact on arthroplasty outcomes has not been extensively studied. Timothy L. Waters, BA, and colleagues provide important observations on potential associations between smokeless tobacco and adverse short- and long-term hip arthroplasty outcomes in their study titled “Smokeless tobacco use is associated with worse medical and surgical outcomes following total hip arthroplasty.” The major advantage of their research approach using a commercial payer administrative claims database (PearlDiver) is the amplification of observations that cannot be obtained through individual institutions. The major weakness includes an inability to clearly define whether associations are related to specific interactions or whether other concurrent factors — not included within the dataset — press smokeless tobacco use into a surrogate status. Regardless, the information is important to help us consider whether pulmonary-circulatory entrance of tobacco products into the body is the primary mechanism for adverse effects. And while the specific mechanism for interactions between smokeless tobacco use and adverse outcomes needs refinement (eg, what is the relationship between smokeless tobacco use and increased hip dislocation risk), the study raises sufficient questions to exclude smokeless tobacco as a substitute for cigarettes in a preoperative smoking cessation program.
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