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.

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Shoulder surgery and the Marlboro Man

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

These authors used the PearlDiver Patient Records Database, a for-fee insurance-based database of patient records, to explore the relationship between tobacco use and the adverse outcomes of arthroscopic superior labrum anterior and posterior (SLAP) repairs. The 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). It is not known how accurate this coding is and how it reflects the different uses of tobacco (inhaled, chewed, etc).

They found that 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 suggest that tobacco’s negative effects on poor wound healing and the development of postoperative infection may results from a combination of factors. "On a cellular level, tobacco use reduces cutaneous blood flow, impairing soft tissue 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 infectious 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."

Comment: The same factors that impair success in SLAP repairs must apply to the healing of rotator cuff repairs, Bankart repairs and subscapularis healing in In addition to its effect on healing (see this link), tobacco use is also associated with increased pain (another cause of 'surgical failure')  as shown here and here .

The prior post also emphasizes the risk.

There is another association of importance than may account for some of the surgical failures in smokers, and that is the observation that smokers tend to take more risks than non-smokers (see this post). Here is a compelling quote from that article.

"The fact that smoking is bad for people’s health has become common knowledge, yet a substantial amount of people still smoke. Previous studies that sought to better understand this phenomenon have found that smoking is associated with the tendency to take risk in other areas of life as well. The current paper explores factors that may underlie this tendency. An experimental analysis shows that smokers are more easily tempted by immediate high rewards compared to nonsmokers. Thus the salience of risky alternatives that produce large rewards most of the time can direct smokers to make bad choices even in an abstract situation such as the Iowa Gambling Task. These findings suggest that the risk taking behavior associated with smoking is not related to the mere pursuit of rewards but rather reflects a tendency to yield to immediate temptation."

Now here's a quiz. This paper comes from Virginia. Can you name the top five tobacco producing states in order? The answer can be found here.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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