Saturday, May 4, 2013

Cigarette smoking affects bone, cuff repair, surgical risk and more

The Musculoskeletal Effects of Cigarette Smoking

The summary of this article says much of it:

* Cigarette smoking decreases bone mineral density and increases the risk of sustaining a fracture or tendon injury, with partial reversibility of these risks with long-term cessation of smoking.

* Cigarette smoking increases the risk for perioperative complications, nonunion and delayed union of fractures, infection, and soft-tissue and wound-healing complications.

* Brief preoperative cessation of smoking may mitigate these perioperative risks.

* Informed-consent discussions should include notification of the higher risk of perioperative complications with cigarette smoking and the benefits of temporary cessation of smoking

The authors of this most informative review point to the specific effects of smoking: diminution of tissue perfusion and oxygenation, increase in platelet aggregation, vascular damage, increase in blood clotting, interference with oxidative metabolism, and decreased immunity to infection (affecting both the antibody response and the cellular response).

From an orthopaedic standpoint, smoking reduces bone blood flow and can lead to osteonecrosis (bone death) and can reduce osteoblast function and osteogenesis and can interfere with fracture healing.  Interestingly, not all the effects of smoking are due to nicotine; other tobacco extracts can also impair bone healing and the strength of healing fractures.

Calcium absorption is decreased in smokers and increased rates of fracture of the hip, spine, and distal forearm. Smoking may increase the rate of bone loss related to menopause and aging. It was found to be an independent indicator of unintentional injuries.

Of course of particular relevance to shoulder surgery is the effect of smoking on soft tissues. The authors report that tendon-healing and ligament-healing appear to be negatively affected by cigarette smoking. In a rat rotator cuff tear model, nicotine delayed tendon-to-bone healing. In comparison with nonsmokers, smokers had lower increases in the University of California at Los Angeles (UCLA) scores with either open or arthroscopic rotator cuff repair for degenerative tears and were found to have larger tears with a dose-dependent relationship.  In a survey of 402 patients who had a primary anterior cruciate ligament reconstruction, smokers had 0.36 times the odds of success as nonsmokers. A higher prevalence of degenerative rotator cuff tears in smokers with a dose-and time-dependent relationship has been reported. A history of smoking was a risk factor for rotator cuff tear. The total number of cigarettes smoked in life differed significantly (p = 0.032) between patients who had a small rotator cuff tear and those who had medium or larger rotator cuff tears. Smokers also had a 7.5 times higher risk of distal biceps tendon rupture.

The authors conclude, "Tobacco smoking has important negative effects on multiple organ systems, including the musculoskeletal system, which increases the risk of injury, illness, and perioperative complications. The musculoskeletal effects include decreased BMD, fracture-healing complications, and wound complications. Perioperative cardiopulmonary complications are increased with smokers. Orthopaedic surgeons should encourage all patients who are contemplating elective procedures to quit smoking four to six weeks in advance of the proposed procedure and should advise them of the serious negative outcomes associated with active smoking in the perioperative period. Abstinence from smoking can be monitored with a urine cotinine test. By reducing smoking, a major burden of economic and emotional costs for the patient will be lessened."

We take it further: we question the value of elective orthopaedic surgery in the presence of active use of nicotine - the evidence suggests that rotator cuff repairs, bone grafting, and the subscapularis repair after shoulder arthroplasty all have an increased risk of failure in addition to the overall perioperative risk to the patient's health (The most common perioperative complications associated with smoking are wound-healing, infection, and cardiopulmonary complications). When with thing of the four "P"s (the problem, the patient, the procedure and the performing surgeon) this is a great example of the importance of the 'second P'. Beyond the direct effects of smoking, we consider that active use of nicotine suggests a suboptimal patient dedication to optimizing health - this dedication is important to achieving the best result from elective surgery.

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