Smoking and joint replacement: resource consumption and short-term outcome

Smoking has been shown to increase morbidity and mortality in surgical procedures. Microvascular and trauma surgeons have documented the adverse effect of smoking in the healing of skin flaps and increased complication rates in the treatment of nonunions. In addition, spine surgeons have shown the adverse effects of smoking in fusion rates. The objective of this study was to assess the effects of smoking on the incidence of short term complications, resource consumption, and length of hospital stay of patients undergoing arthroplasty of the hip and knee. Two hundred two patients who underwent joint replacement surgery were evaluated. A smoking history was assessed for all patients. The number of packs multiplied by the number of years as a smoker were calculated. Operative and anesthesia time and medical severity of illness were documented on all patients. Short term outcome was assessed using hospital charges, length of stay, inhospital consults, and the presence and number of complications during the acute hospitalization. One hundred forty-one primary and 61 revision procedures were done. The mean age of the patients was 66.07 years. Sixty-one percent of the patients had osteoarthritis, 3.9% had rheumatoid arthritis, 4.9% had osteonecrosis, 28% had a failed total knee or hip arthroplasty and 2% had a periprosthetic fracture. There were 25 patients who smoked and 177 patients who did not smoke. For patients who currently smoke, the mean number of packs of cigarettes smoked per day multiplied by the number of years as a smoker was 28.3. The average length of stay in the hospital was 5.1 days and the average hospital charges were $31,315. Patients who smoked were younger and had fewer comorbidities than patients who did not smoke. However, patients who smoked were found to have statistically longer surgical time and higher charges adjusted for age, procedure, and surgeon than patients who did not smoke. Patients who smoked also had longer anesthesia times. A history of smoking is obtained easily on all patients. Preoperative screening for nicotine use can predict operative time and health resource consumption. The exact reasons why patients who smoked had higher hospital charges remain elusive. Probable reasons include higher degree of operative complexity (orthopaedic severity of illness). In addition patients who smoked previously also had better short term outcome than patients who currently smoke. This indicates the importance of smoking abstinence before joint replacement surgery and other surgical procedures. Regardless of the exact causes, it is more expensive to treat patients who smoke. Contracting for orthopaedic care should include a history of smoking.