Saturday, October 15, 2016

Tobacco use increases risk of infection and revision surgery

Tobacco use is associated with increased rates of infection and revision surgery after primary superior labrum anterior and posterior repair.

These authors used a national database (PearlDiver) to investigate the relationship between tobacco use and rates of superior labrum anterior and posterior (SLAP) repair failure and postoperative infection after primary SLAP repair compared with matched controls.

The database was queried using CPT code 29807 to identify patients who underwent arthroscopic SLAP repair. This cohort of primary SLAP repairs was then divided into tobacco use and non–tobacco use cohorts using ICD-9 code 305.1 (tobacco use disorder). The non– tobacco use patients were matched to patients with a coded tobacco use disorder to achieve asimilar distribution of age, sex, obesity, concomitant rotator cuff repair, and concomitant instability repair.

Both cohorts were assessed for postoperative infection within 90 days and subsequent ipsilateral revision SLAP repair or biceps tenodesis within up to 7 years postoperatively.

The incidences of revision SLAP repair or revision to a biceps tenodesis (P = .023) and postoperative infection (P = .034) were significantly higher in patients who used tobacco versus matched controls.

They concluded that SLAP repair in patients who use tobacco is associated with significantly increased rates of postoperative infection and revision SLAP repair or conversion to a biceps tenodesis.

Comment: While these results concern athroscopic SLAP repair, it seems quite likely that similar effects of smoking occur with other surgeries: tobacco use is a treatable co-morbidity.

The authors provide a nice summary of some of the effects of tobacco:

"On a cellular level, tobacco use reduces cutaneous blood flow, impairing softtissue oxygenation, resulting in increased anaerobic metabolism in healing tissues. Simultaneously, thrombi are generated as a result of increased platelet aggregation, which compounds an already hypoxic environment, leading to decreased healing potential. This reduced perfusion impairs the delivery of critical lymphocytes to areas undergoing healing or prone to infection. Furthermore, systemic nicotine has been shown to have a negative immunomodulatory effect on T-cell function, resulting in cells that are more susceptible to in- fectious pathogens. Finally, and perhaps most specific to tendon healing required for a successful SLAP repair, the synthesis of collagen has been shown to be greatly impeded in smokers, leading to impaired wound and soft-tissue healing."

There is another aspect to tobacco use: while the dangers of tobacco are widely known, certain individuals continue to use it. Thus one can surmise that tobacco use is a marker for the user's disregard for his or her health and safety - features that of themselves would seem to increase the risk of surgical failure.