Tobacco Use Is Associated with More Severe Adverse Outcomes Than Morbid Obesity after Aseptic Revision TKA

Abstract

The association of morbid obesity with increased revision total knee arthroplasty (rTKA) complications is potentially confounded by concurrent risk factors. This study was performed to evaluate whether morbid obesity was more strongly associated with adverse aseptic rTKA outcomes than diabetes or tobacco use history—when present as a solitary major risk factor. Demographic characteristics, surgical indications, and adverse outcomes (reoperation, revision, infection, and amputation) were compared between 270 index aseptic rTKA performed for patients with morbid obesity (n = 73), diabetes (n = 72), or tobacco use (n = 125) and 239 “healthy” controls without these risk factors at a mean 75.7 (range: 24–111) months. There was no difference in 2-year reoperation rate (17.8 vs. 17.6%, p = 1.0) or component revision rate (8.2 vs. 8.4%) between morbidly obese and healthy patients. However, higher reoperation rates were noted in patients with diabetes (p = 0.02) and tobacco use history (p < 0.01), including higher infection (p < 0.05) and above knee amputation (p < 0.01) rates in patients with tobacco use history. Multivariate analysis retained an independent association between smoking history and amputation risk (odds ratio: 7.4, 95% confidence interval: 1.7–55.2, p < 0.01). Morbid obesity was not associated with an increased risk of reoperation or component revision compared with healthy patients undergoing aseptic revision. Tobacco use was associated with increased reoperation and above knee amputation. Additional study will be beneficial to determine whether risk reduction efforts are effective in mitigating postoperative complication risks.

Keywords

revision total knee arthroplasty - tobacco use - diabetes - morbid obesity - complications

Publikationsverlauf

Eingereicht: 19. Januar 2021

Angenommen: 01. Mai 2021

Artikel online veröffentlicht:
05. Juli 2021

• References

• 1 Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am 2005; 87 (07) 1487-1497
• 2 Kurtz SM, Ong KL, Lau E. et al. International survey of primary and revision total knee replacement. Int Orthop 2011; 35 (12) 1783-1789
• 3 Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am 2014; 96 (08) 624-630
• 4 Fehring TK, Odum SM, Griffin WL, Mason JB, McCoy TH. The obesity epidemic: its effect on total joint arthroplasty. J Arthroplasty 2007; 22 (06, Suppl 2): 71-76
• 5 Mohamed NS, Wilkie WA, Remily EA. et al. The rise of obesity among total knee arthroplasty patients. J Knee Surg 2020;
• 6 Odum SM, Springer BD, Dennos AC, Fehring TK. National obesity trends in total knee arthroplasty. J Arthroplasty 2013; 28 (08) 148-151
• 7 Odum SM, Van Doren BA, Springer BD. National obesity trends in revision total knee arthroplasty. J Arthroplasty 2016; 31 (09) 136-139
• 8 Boyce L, Prasad A, Barrett M. et al. The outcomes of total knee arthroplasty in morbidly obese patients: a systematic review of the literature. Arch Orthop Trauma Surg 2019; 139 (04) 553-560
• 9 D'Apuzzo MR, Novicoff WM, Browne JA. The John Insall Award: morbid obesity independently impacts complications, mortality, and resource use after TKA. Clin Orthop Relat Res 2015; 473 (01) 57-63
• 10 George J, Klika AK, Navale SM, Newman JM, Barsoum WK, Higuera CA. Obesity epidemic: is its impact on total joint arthroplasty underestimated? An analysis of national trends. Clin Orthop Relat Res 2017; 475 (07) 1798-1806
• 11 Jämsen E, Nevalainen P, Eskelinen A, Huotari K, Kalliovalkama J, Moilanen T. Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Joint Surg Am 2012; 94 (14) e101
• 12 Kee JR, Mears SC, Edwards PK, Barnes CL. Modifiable risk factors are common in early revision hip and knee arthroplasty. J Arthroplasty 2017; 32 (12) 3689-3692
• 13 Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty 2009; 24 (06) 84-88
• 14 Meller MM, Toossi N, Johanson NA, Gonzalez MH, Son MS, Lau EC. Risk and cost of 90-day complications in morbidly and superobese patients after total knee arthroplasty. J Arthroplasty 2016; 31 (10) 2091-2098
• 15 Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty 2005; 20 (07, Suppl 3): 46-50
• 16 Sisko ZW, Vasarhelyi EM, Somerville LE, Naudie DD, MacDonald SJ, McCalden RW. Morbid obesity in revision total knee arthroplasty: a significant risk factor for re-operation. J Arthroplasty 2019; 34 (05) 932-938
• 17 Watts CD, Wagner ER, Houdek MT, Lewallen DG, Mabry TM. Morbid obesity: increased risk of failure after aseptic revision TKA. Clin Orthop Relat Res 2015; 473 (08) 2621-2627
• 18 Bedard NA, DeMik DE, Owens JM, Glass NA, DeBerg J, Callaghan JJ. Tobacco use and risk of wound complications and periprosthetic joint infection: a systematic review and meta-analysis of primary total joint arthroplasty procedures. J Arthroplasty 2019; 34 (02) 385-396.e4
• 19 Bedard NA, Dowdle SB, Wilkinson BG, Duchman KR, Gao Y, Callaghan JJ. What is the impact of smoking on revision total knee arthroplasty?. J Arthroplasty 2018; 33 (7S) S172-S176
• 20 Duchman KR, Gao Y, Pugely AJ, Martin CT, Noiseux NO, Callaghan JJ. The effect of smoking on short-term complications following total hip and knee arthroplasty. J Bone Joint Surg Am 2015; 97 (13) 1049-1058
• 21 Gu A, Wei C, Robinson HN. et al. Postoperative complications and impact of diabetes mellitus severity on revision total knee arthroplasty. J Knee Surg 2020; 33 (03) 228-234
• 22 Kapadia BH, Johnson AJ, Naziri Q, Mont MA, Delanois RE, Bonutti PM. Increased revision rates after total knee arthroplasty in patients who smoke. J Arthroplasty 2012; 27 (09) 1690-1695
• 23 Lee D, Lee R, Gowda NB. et al. Impact of diabetes mellitus on surgical complications in patients undergoing revision total knee arthroplasty: insulin dependence makes a difference. J Clin Orthop Trauma 2020; 11 (01) 140-146
• 24 Lim CT, Goodman SB, Huddleston III JI. et al. Smoking is associated with earlier time to revision of total knee arthroplasty. Knee 2017; 24 (05) 1182-1186
• 25 López-de-Andrés A, Hernández-Barrera V, Martínez-Huedo MA, Villanueva-Martinez M, Jiménez-Trujillo I, Jiménez-García R. Type 2 diabetes and in-hospital complications after revision of total hip and knee arthroplasty. PLoS One 2017; 12 (08) e0183796
• 26 Singh JA, Schleck C, Harmsen WS, Jacob AK, Warner DO, Lewallen DG. Current tobacco use is associated with higher rates of implant revision and deep infection after total hip or knee arthroplasty: a prospective cohort study. BMC Med 2015; 13: 283
• 27 Bass AR, McHugh K, Fields K, Goto R, Parks ML, Goodman SM. Higher total knee arthroplasty revision rates among United States blacks than whites: a systematic literature review and meta-analysis. J Bone Joint Surg Am 2016; 98 (24) 2103-2108
• 28 Dy CJ, Marx RG, Bozic KJ, Pan TJ, Padgett DE, Lyman S. Risk factors for revision within 10 years of total knee arthroplasty. Clin Orthop Relat Res 2014; 472 (04) 1198-1207
• 29 Ong KL, Lau E, Suggs J, Kurtz SM, Manley MT. Risk of subsequent revision after primary and revision total joint arthroplasty. Clin Orthop Relat Res 2010; 468 (11) 3070-3076
• 30 Sodhi N, Anis HK, Vakharia RM. et al. What are risk factors for infection after primary or revision total joint arthroplasty in patients older than 80 years?. Clin Orthop Relat Res 2020; 478 (08) 1741-1751
• 31 Kamath AF, Nelson CL, Elkassabany N, Guo Z, Liu J. Low albumin is a risk factor for complications after revision total knee arthroplasty. J Knee Surg 2017; 30 (03) 269-275
• 32 Springer BD, Roberts KM, Bossi KL, Odum SM, Voellinger DC. What are the implications of withholding total joint arthroplasty in the morbidly obese? A prospective, observational study. Bone Joint J 2019; 101-B (7_supple_C): 28-32
• 33 Maradit Kremers H, Schleck CD, Lewallen EA, Larson DR, Van Wijnen AJ, Lewallen DG. Diabetes mellitus and hyperglycemia and the risk of aseptic loosening in total joint arthroplasty. J Arthroplasty 2017; 32 (9S) S251-S253
• 34 Argintar E, Triantafillou K, Delahay J, Wiesel B. The musculoskeletal effects of perioperative smoking. J Am Acad Orthop Surg 2012; 20 (06) 359-363
• 35 Sahota S, Lovecchio F, Harold RE, Beal MD, Manning DW. The effect of smoking on thirty-day postoperative complications after total joint arthroplasty: a propensity score-matched analysis. J Arthroplasty 2018; 33 (01) 30-35
• 36 Springer BD. Modifying risk factors for total joint arthroplasty: strategies that work nicotine. J Arthroplasty 2016; 31 (08) 1628-1630