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36 (); 99-105
doi:
10.1016/j.jor.2023.01.002

The impact of tobacco use on clinical outcomes and long-term survivorship after anatomic total shoulder arthroplasty

, , , , , ,
Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, USA

∗Corresponding author: Christopher A. White. christopher.white@icahn.mssm.edu

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Postoperative outcomes following total shoulder arthroplasty can be affected by preoperative health factors such as tobacco usage.

The charts of patients who underwent anatomic total shoulder arthroplasty were retrospectively analyzed and stratified based on smoking status. The primary data included range of motion and patient reported outcomes. Additionally, demographic, radiographic, and survivorship analyses were conducted. All data were analyzed using statistical inference.

There were 78, 49, and 16 non-smoker, former smoker, and current smoker shoulders respectively with no significant differences in sex, American Society of Anesthesiologists status, body mass index, or mean follow-up time (average: 10.7 yrs). Smokers (51.5 ± 10.4 years) were younger than both non-smokers (64.9 ± 8.1 years; p < 0.01) and former smokers (65.1 ± 9.1years; p < 0.01) at the time of surgery. For non-smokers and former smokers, all range of motion and patient reported outcome scores significantly improved. Smokers reported significant improvements in all patient reported outcomes and external and internal rotation. Visual Analog Scale, American Shoulder and Elbow, and Simple Shoulder Test scores were lower for smokers comparatively, but these differences did not reach significance. Forward elevation was higher postoperatively for non-smokers (149.7o ± 17.2o) and former smokers (147.1o ± 26.0o) compared to current smokers (130.9o ± 41.2o; p = 0.017). No differences between the cohorts were found in the radiographic analysis. Revision rates were lower in the non-smoking cohort (7.7%) compared to both former (20.4%; p = 0.036) and current smokers (37.5%; p < 0.01). Survival curves showed that non-smoker implants lasted longer than those of current smokers.

After a decade, patients generally had improved shoulder range of motion, functionality, and pain regardless of smoking status. However, current smokers required shoulder replacements sooner and revision surgery more frequently.

Keywords

Shoulder replacement
Smoking
Patient reported outcomes
Revision
Long-term
Implant survival
1

1 Introduction

The volume of orthopedic operations continues to grow annually alongside a growing and aging national population.1,2 To this end, the number of anatomic total shoulder arthroplasty (aTSA) cases have seen persistent growth over the last three decades.3–5 Current advancements in aTSA management have led to reductions to perioperative and postoperative complications following surgery as noted in consecutively updated reviews.6–8

Multiple patient specific health factors, including but not limited to body mass index (BMI), diabetes, and opioid use have been shown to influence postoperative outcomes across various orthopedic disciplines.9,10 Further, there has been a particular emphasis on patient's smoking status throughout the literature as it has been shown to significantly influence operative results. Presently, tobacco smoking is cited as one of the top modifiable risk factors for health-related issues in the United States.11–13 Previous literature has demonstrated that across orthopedic subspecialties, tobacco smokers are more likely to develop postoperative infections, complications (e.g., urinary tract infections, myocardial infarcts, mortality), and to experience longer hospitalizations as compared to non-smokers.14–16 Multiple studies have also analyzed patient smoking status for TSA outcomes at the national and institutional levels. In two national analyses of patients who underwent aTSA or reverse TSA (rTSA), it was shown that smokers were significantly more likely to develop surgical site infections.17,18 Moreover, patients who smoked were found to have significantly higher 30-day and 90-day readmission rates in a national study of 116,991 aTSA and 93,795 rTSA patients; smokers also had higher rates of surgical revisions following aTSA than non-smokers.17–19 In terms of shoulder range of motion (ROM), smokers have been shown to achieve similar improvements as non-smokers while reporting significantly worse scores on patient reported outcome (PROs) indexes at short-term follow-up.20,21 The impact of smoking on long-term outcomes after shoulder arthroplasty is less clear.

Indeed, the longest clinical follow-up analyzing the impact smoking status has on aTSA outcomes (i.e., ROM and PROs) is four years.22 This current study investigates the impact of smoking status on aTSA outcomes at long term follow-up (mean follow-up >10 years). We hypothesized that aTSA would provide non-smokers and former smokers greater shoulder functionality and survivorship as compared to current smokers.

2

2 Material and methods

2.1

2.1 Patient cohort

This was a retrospective study approved by the institutional review board within our health system. Surgical records were queried for patients who underwent aTSA surgery (Current Procedural Code: 23472) by a single fellowship-trained orthopedic surgeon between 1994 and 2018. Patients were excluded if they had either a hemi-arthroplasty or rTSA, shorter than two-year follow-up, were missing both preoperative and postoperative range of motion and patient reported outcome scores, and/or they had an ambiguous smoking status at the time of surgery. Operative notes were screened for concomitant procedures (i.e., procedures done simultaneously with the aTSA) which are noted in the results section. Demographic variables (i.e., sex, age, BMI, packs/day (ppd), smoking quit year, American Society of Anesthesiologist (ASA) scores) were collected at the time of surgery. Patients were stratified into three cohorts based on their smoking status on the date of their operation: 1) non-smokers 2) former smokers 3) current smokers. Non-smokers were defined as individuals who had never smoked tobacco. Former smokers were defined as individuals who quit smoking tobacco at least one year prior to their index procedure23; these individuals had previously smoked at least 0.25 packs per day (ppd). Former smokers were further stratified by the amount of time between their surgery and quit dates (0–15 years, 15–30 years, >30 years). Current smokers were defined as individuals who started smoking at least one year prior to surgery and continued to smoke within one year of their surgery.23 Smoking, in general, was defined as the consumption of at least 0.25 packs per day (ppd) for one year; the 0.25 ppd mark was used as this is the lowest ppd reported in our electronic health record system.

2.2

2.2 Surgical technique and rehabilitation

All procedures were performed by a single operating surgeon through a deltopectoral incision using a pegged or keeled Bigliani/Flatow Complete Shoulder Solution TSA implant (Zimmer Incorporated - Warsaw, In.) or Zimmer Trabecular Metal Shoulder System. The subscapularis muscle was taken down via a subscapularis peel or lesser tuberosity osteotomy and the tendon was later repaired prior to closure. The subscapularis management was completed through a bone tunnel approach as described by Cagle et al.24 Postoperatively, patients were allowed to engage in immediate passive range of motion, with 40o of external rotation and 140o of forward elevation. Six weeks postoperatively, active range of motion was started and sling use was stopped. Strengthening programs for the rotator cuff, periscapular, and deltoid muscles was begun at postoperative week ten. Rehabilitation was uniform across the cohorts.

2.3

2.3 Clinical evaluation

Shoulder range of motion scores were obtained preoperatively and postoperatively by the operative surgeon. For this study, forward flexion (i.e., forward elevation), external rotation, and internal rotation were assessed; internal rotation was measured quantitatively as defined by Amroodi et al.25 Measures of preoperative and postoperative shoulder pain and shoulder function were evaluated using patient reported outcome indexes. The Visual Analog Scale (VAS) questionnaire was used to assess overall shoulder pain while both the American Shoulder and Elbow Surgeon (ASES) and Simple Shoulder Test (SST) scores were used to evaluate shoulder functionality. Kaplan-Meier survival analysis was conducted to compare implant survival time in subjects who were smokers, former smokers, or non-smokers; failure was defined as implant revision or removal. A log rank test was used to determine any differences in survival distributions between cohorts.

2.4

2.4 Radiographic review

Measurements of humeral bone lucency, lateral humeral offset (LHO), and acromiohumeral interval (AHI) were captured. Humeral lucency was assessed on follow-up anterior-posterior, scapular-Y, and axillary radiographs based upon the technique described by Sanchez-Sotelo et al.26 The presence of a radiolucent line (>2 mm) in any of the eight implant radiographic zones were defined as having humeral lucency. LHO was defined as the distance in millimeters (mm) found between the lateral aspect of both the greater humeral tuberosity and the acromion.27 The distance (mm) from caudal acromion to the articular cortex of the humeral head was used to determine the AHI.28 Glenoid loosening was defined as radiographic loosening or migration of the glenoid component as previously discussed by Walch et al.28 Glenoid implants were identified radiographically and confirmed by reviewing patient charts. All radiographic analysis was performed by two fellowship trained orthopedic shoulder and elbow surgeons. Radiographic parameters were analyzed using immediate postoperative images and most recent postoperative follow-up images. The majority of measures were identical between the reviewing surgeons and when needed an average of the measures was used. Implant survivorship was collected and defined as arthroplasties procedures that require no form of revision surgery for any reasons.

2.5

2.5 Statistical analysis

Data were compared individually and simultaneously between the three smoking cohorts. Preoperative and postoperative differences in continuous variables were analyzed using a student's t-test or Mann Whitney U tested dependent on normality. Normality was determined using a Kolmogorov-Smirnov test and variables were represented as mean ± standard deviation. A one-way analysis of variance (ANOVA) test was used to compare postoperative measurements between cohorts for continuous variables. A Pearson's coefficient was used to determine the association between two continuous variables. Categorical data were compared using χ2 or a Fisher's Exact test when appropriate. Dispersion data for each clinical outcome will be noted as minimum value - maximum value. Kaplan-Meier estimates were used to define implant survival at a 95% confidence interval. All p-values <0.05 were marked as statistically significant.

3

3 Results

3.1

3.1 Patient demographics

A total of 185 patient shoulders were identified for this study. Forty-two shoulders were excluded as the patient's smoking status at the time of their surgery was deemed ambiguous. One hundred and forty-three patients were included in the final analysis representing 78 non-smokers, 49 former smokers, and 16 current everyday smokers who had undergone aTSA for osteoarthritis (n = 134), rheumatoid arthritis (n = 8), avascular necrosis (n = 5), and post-traumatic arthritis (n = 2). Current smokers required shoulder replacement at a significantly younger age (52.4 ± 10.7 years (35.5–66.3 years)) than both non-smokers (64.5 ± 8.8 years (33.7–82.6 years); p < 0.01) and former smokers (65.1 ± 9.1 years (45–84.6 years); p < 0.01). There was no difference in age at surgery for those who never smoked and former smokers (p = 0.89). Former smokers quit smoking on average 25.0 ± 15.4 years (3.8–51.7 years) before their shoulder replacement surgery. Former smokers who quit smoking 0 to 15 (n = 14), 15 to 30 (n = 14), and greater than 30 (n = 17) years prior to surgery were 61.7 ± 10.9, 63.0 ± 5.5, and 70.9 ± 6.1 years old at the time of surgery respectively (p < 0.01). There was a positive correlation between number of years without smoking and age at surgery for former smokers (p < 0.01, r = 0.51) (Fig. 1); smoking quit dates were not available for four former smokers. The average follow-up time for our entire cohort was 10.7 ± 5.2 years (2.0–26.1 years) with no difference in follow-up time between groups. There was no difference between the three cohorts with respect to sex, BMI, or American Society of Anesthesiologist (ASA) status. No differences were seen between the cohorts when comparing the number or types of concomitant procedures, indications for surgery, implant type (keeled, pegged, metal backed), or the number of patients whose first procedure at our institution was a revision arthroplasty (Table 1).

Quit Date vs. Age At Surgery: Age at surgery (years) is on the x-axis and number of years without smoking cigarettes prior to surgery is on the y-axis. There was a positive correlation between the number of years quit before undergoing aTSA and a patient's age at surgery for former smokers (n = 45; r = 0.51; p˂0.01).
Fig. 1 Quit Date vs. Age At Surgery: Age at surgery (years) is on the x-axis and number of years without smoking cigarettes prior to surgery is on the y-axis. There was a positive correlation between the number of years quit before undergoing aTSA and a patient's age at surgery for former smokers (n = 45; r = 0.51; p˂0.01).
Table 1 Patient Information. NS = Non-smoker, FS = Former-smoker, S = Current Smoker, ORIF = Open Reduction Internal Fixation. † Indicates overall comparison for total concatenate procedures performed. All significant p-values are bolded.
Characteristic Non-Smoker (n = 78) Former Smoker (n = 49) Current Smoker (n = 16) NS v. FSp-value NS v. S p-value FS v. S p-value
Sex (% Female) 58% 43% 31% 0.23 0.089 0.38
Age at Surgery (years) 64.5 ± 8.7 65.1 ± 9.1 52.4 ± 10.7 0.89 <0.01 <0.01
Mean Follow-up Time (years) 10.2 ± 4.7 11.0 ± 6.0 12.0 ± 5.0 0.35 0.17 0.54
BMI 27.8 ± 5.4 27.0 ± 4.2 27.5 ± 5.2 0.39 0.83 0.72
Secondary Procedure (% yes) 13% 20% 38% 0.24 0.12 0.50
ASA Scores (1, 2, 3, 4) (3, 46, 22, 1) (1, 28, 16, 1) (1, 11, 3, 0) 0.89 0.67 0.48
Implant (% keeled, pegged, metal backed) (23%, 69%, 9%) (33%, 63%, 4%) (17%, 67%, 17%) 0.46 0.70 0.23
Revision TSA Following Study Case (%) 7.7% 20.4% 37.5% 0.036 <0.01 0.17
Characteristic Non-Smoker (n=78) Former Smoker (n=49) Current Smoker (n=16) Overall Comparison (p-value)
Prior Shoulder Replacement (same shoulder) 6 1 3 0.068
Concomitant Procedures (n) † 0.74
ORIF 0 1 0 0.45
Anterior Acromioplasty 1 0 0 0.99
Posterior Capsulorrhaphy 1 1 0 0.99
Latissimus Dorsi Transfer 0 1 0 0.45
Pectoralis Major Transfer 2 0 0 0.63
Distal Clavicle Excision 2 3 1 0.38
Prior Arthroplasty 8 2 3 0.15
Indications for Surgery (n)
Avascular Necrosis 4 1 0 0.81
Osteoarthritis 73 46 15 0.99
Rheumatoid Arthritis 3 3 2 0.30
Post-traumatic Arthritis 1 1 0 0.99
3.2

3.2 Clinical outcomes

All three cohorts saw significant improvements in VAS, ASES, and SST scores from their preoperative to final postoperative visits. There were no significant differences for changes in patient reported outcomes scores when comparing the three cohorts. VAS scores decreased from 6.4 (1.0–10.0) to 2.4 (0.0–10.0), 6.6 (0.0–10.0) to 2.4 (0.0–10.0), and 7.3 (2.0–10.0) to 4.2 (0.0–9.0) in the non-smoking, former smoking, and current smoking cohorts respectively (preoperative: p = 0.49, postoperative: p = 0.081). ASES scores improved from 34.6 (0.0–73.3) to 73.1 (10.0–100.0), 33.9 (0.0–83.3) to 74.1 (6.7–100.0), and 26.5 (0.0–63.3) to 60.3 (11.6–100.0) respectively in the non-smoking, former smoking, and current smoking groups (preoperative: p = 0.36, postoperative: p = 0.16). SST scores additionally improved from 3.6 (0.0–11.0) to 8.1 (0.0–12.0), 3.2 (0.0–10.0) to 8.3 (0.0–12.0), and 2.8 (0.0–9.0) to 6.9 (0.0–11.0) for the non-smoking, former smoking, and current smoking groups, respectively (preoperative: p = 0.53, postoperative: p = 0.36).

Both the non-smoking (preoperative: 117.6o ± 27.5o (20.0o-170.0o), postoperative: 149.7o ± 17.2o (90.0o-180.0o); p < 0.01) and former smoking (preoperative: 124.8o ± 21.6o (80.0o-160.0o), postoperative: 147.1o ± 26.0o (20.0o-180.0o); p < 0.01) cohorts saw significant improvements in forward elevation. The current smoking cohort did not see significant postoperative improvements in forward elevation (preoperative: 124.3o ± 20.3o (80.0o-150.0o); postoperative: 130.9o ± 41.2o (30.0o-165.0o); p = 0.58), and their postoperative scores were significantly lower than the non-smoking and former smoking patients (p = 0.017). All three cohorts saw significant improvements in external and internal rotation postoperatively (p < 0.01). External rotation improved from 22.0o (−30.0o-80.0o) to 52.3o (20.0o-80.0o), 22.7o (−30.0o-80.0o) to 54.0o (30.0o-80.0o), and 16.9o (−30.0o-50.0o) to 47.8o (0.0o-70.0o) for the non-smoking, former smoking, and current smoking cohorts respectively with comparable improvements between cohorts (p = 0.88). Internal rotation for the non-smoking, former smoking, and current smoking cohorts improved preoperatively to postoperatively by five, four, and six vertebral levels respectively (p = 0.70). For a complete report on clinical outcomes see Table 2.

Table 2 Patient ROM and PRO scores. VAS = Visual Analog Score, ASES = American Shoulder and Elbow Scores, SST = Simple Shoulder Test. All significant p-values (p < 0.05) are bolded.
Range of Motion Non-Smoker (n = 78) Former Smoker (n = 49) Current Smoker (n = 16) p-value
Forward Elevation
Preoperative 117.6o ± 27.5o 124.8o ± 21.6o 124.3o ± 20.3o 0.11
Postoperative 149.7o ± 17.2o 147.1o ± 26.0o 130.9o ± 41.2o 0.017
Change pre- to post-op. p-value <0.01 <0.01 0.58
External Rotation
Preoperative 22.0o ± 23.3o 22.7o ± 23.6o 16.9o ± 27.4o 0.69
Postoperative 52.3o ± 14.0o 54.0o ± 13.2o 47.8o ± 18.7o 0.34
Change pre- to post-op. p-value <0.01 <0.01 0.042
Internal Rotation
Preoperative L5 L4 Sacrum 0.39
Postoperative T12 T12 T12 0.70
Change pre- to post-op. p-value <0.01 <0.01 <0.01
Patient Reported Outcomes Non-Smoker (n = 78) Former Smoker (n = 49) Current Smoker (n = 16) p-value
VAS
Preoperative 6.4 ± 2.4 6.6 ± 2.7 7.3 ± 2.1 0.49
Postoperative 2.4 ± 2.9 2.4 ± 2.7 4.2 ± 3.6 0.081
Change pre- to post-op. p-value <0.01 <0.01 0.039
ASES
Preoperative 34.6 ± 18.3 33.9 ± 18.7 26.5 ± 20.3 0.36
Postoperative 73.1 ± 25.1 74.1 ± 23.8 60.3 ± 31.0 0.16
Change pre- to post-op. p-value <0.01 <0.01 <0.01
SST
Preoperative 3.6 ± 2.7 3.2 ± 3.0 2.8 ± 2.5 0.53
Postoperative 8.1 ± 3.1 8.3 ± 4.1 6.9 ± 3.6 0.36
Change pre- to post-op. p-value <0.01 <0.01 <0.01

Additionally, 13%, 20%, and 38% of the non-smoker, former smoker, and current smoker cohorts required a secondary procedure on the same shoulder; these rates did not differ significantly between cohorts (p = 0.058). In the non-smoking cohort, patients presented for secondary surgery due to glenoid component loosening (n = 6), subscapular nerve neurolysis (n = 1), acromioclavicular arthrosis (n = 1), and chronic pain (n = 2) on average 9.5 years after their original replacement. At an average of 10.4 years, all of the former smoking cohort who required a secondary procedure presented with glenoid component loosening. Current smokers presented with glenoid implant loosening (n = 4) and rotator cuff failure (n = 2) around 7.5 years (0.50–14.1 years) after their initial surgery. Of the non-smokers (n = 10), former smokers (n = 10), and current smokers (n = 6) who required a second operation on the same shoulder, 6, 10, and 6 required a revision arthroplasty respectively (p < 0.01). The four non-smokers who required non-revision secondary surgery underwent arthroscopic subacromial decompression with distal clavicle resection, arthroscopic debridement with subacromial decompression (n = 2), and right suprascapular nerve neurolysis.

Non-smokers required a revision surgery less often than both former smokers (7.7% vs. 20.4%; p = 0.036) and current smokers (7.7% vs. 37.5%; p < 0.01). No difference in revision surgery rates were seen between former smokers and current smoker (p = 0.17); these findings refer to revision surgeries done after the study date surgery. It was noted that the non-smoker group showed 5-year, 10-year, and 15-year implant survival of 98.5%, 96.9%, and 85.5%, respectively. The former smoker group noted 5-year, 10-year, and 15-year survival of 95.7%, 87.0%, and 73.5%, respectively. The current smoker group demonstrated 5-year, 10-year, and 15-year survival of 93.8%, 69.9%, and 49.0%, respectively. The pairwise log rank test demonstrated a p-value of 0.11 between non-smokers and former smokers, <0.01 between non-smokers and current smokers, and 0.11 between former and current smokers suggesting a significant difference in implant survival curves between non-smokers and current smokers. Overall, there was a significant difference in survival curves between groups (p = 0.015). Estimated mean implant survival time was 20.3 years for non-smokers, 19.0 years for former smokers, and 12.5 years for current smokers (Fig. 2).

Kaplan-Meier curve for implant failure-free survival stratified by smoking status.
Fig. 2 Kaplan-Meier curve for implant failure-free survival stratified by smoking status.
3.3

3.3 Radiographic outcomes

There were no significant differences between the three cohorts with respect to immediate postoperative and final postoperative LHO or AHI. LHO changed on average by 2.2 mm (p = 0.061) and 2.6 mm (p = 0.17) for the non-smoking and current smoking cohorts respectively. There was a significant reduction in LHO for former smokers by 3.9 mm (p = 0.021). There were no differences in final postoperative LHO between the three cohorts (p = 0.77). The non-smoking, former smoking, and current smokers saw a 1.8 mm, 2.3 mm, and 2.3 mm reduction in AHI with no differences in final postoperative AHI (p = 0.21). These reductions in AHI were significant for the non-smoking (p = 0.013) and former smoking (p < 0.01) cohorts. Humeral radiolucency was present in 0%, 5%, and 0% of non-smokers, former smokers, and current smokers (p = 0.19). Glenoid types were comparable between the three cohorts (p = 0.47) (Table 3).

Table 3 Patient Radiographic Outcomes. All significant p-values (p < 0.05) are bolded.
Radiographic Measurements Non-Smoker (n = 78) Former Smoker (n = 49) Current Smoker (n = 16) p-value
Lateral Humeral Offset (mm)
Immediate Postoperative 12.7 ± 6.2 15.1 ± 5.9 14.8 ± 3.3 0.10
Final Postoperative 10.5 ± 7.9 11.2 ± 9.4 12.2 ± 5.5 0.77
p-value for change 0.061 0.021 0.17
Acromiohumeral Interval (mm)
Immediate Postoperative 11.3 ± 4.4 10.5 ± 3.9 11.3 ± 4.4 0.63
Final Postoperative 9.5 ± 3.9 8.2 ± 3.4 9.0 ± 4.9 0.21
p-value for change 0.013 <0.01 0.24
Humeral Radiolucency 0.19
Yes 0% 5% 0%
No 100% 95% 100%
Glenoid Component 0.47
Keeled 23% 33% 17%
Pegged 69% 63% 67%
Trabecular Metal Backed 9% 4% 17%
4

4 Discussion

There is limited literature to date evaluating the effect of tobacco use on outcomes following shoulder arthroplasty. Previous literature in hip, knee, and ankle arthroplasty has demonstrated that tobacco use leads to earlier revision surgery, higher complication rates, and worse outcomes.23,30,31 The available literature on shoulder arthroplasty offers short-to mid-term outcomes suggesting that smoking status leads to increased 30- and 90-day readmission, infection, and revision rates.18,22,32,33 At 10.7 years follow-up, our study found that patients achieved favorable results regardless of their smoking status as it pertains to patient reported outcome and range of motion measures. However, current smokers were significantly younger at the time of surgery (average: 52.4 years), required more revision surgeries (6/16 patients), and their implants last shorter durations (12.5 years) compared to both non-smokers (20.3 years) and former smokers (19.0 years).

Tobacco users have decreased bone density and more advanced glenohumeral arthritis compared to non-users.34–36 Unsurprisingly, these results coincide with tobacco users requiring shoulder arthroplasty at a younger age than their non-smoking peers. For individuals necessitating shoulder replacement, Walters et al. showed that smokers (n = 14) were 8.6 years younger than non-smokers (n = 59) and 8.7 years younger than former smokers (n = 29).20 In a National Readmissions Database analysis of 196,325 non-smokers and 14,461 smokers who underwent TSA, Schwartz et al. showed that the majority of non-smokers were between 65 and 74 years old while smokers were more likely to be between 55 and 64 years of age at the time of surgery.18 Our findings are consistent with what has been reported previously with tobacco users being significantly younger (52.4 years) than both non-smokers (64.5 years; p < 0.01) and former smokers (65.1 years; p < 0.01). Despite this, the rate of glenohumeral arthritis within each cohort was the same (p = 0.99). This demonstrates that smokers developed advanced glenohumeral arthritis a decade before their peers, necessitating shoulder replacement surgery at a younger age. Furthermore, within the former smoking cohort, individuals who quit smoking relatively recently were closer in age to current smokers than individuals who quit decades prior. With multiple studies showing that the cessation of smoking prior to arthroplasty procedures can result in more favorable postoperative outcomes, it should be a worthwhile point of consideration for surgeons to consult prospective patients on in order to potentially negate increased healthcare costs or the need for potential revision procedures.37,38 This is especially prudent, as smoking cessation has been shown to result in recovery of tissue metabolism, oxygenation, and healing with repression of inflammatory responses in as little as one month post cessation intervention.38,39

Tobacco usage has also been shown to impact implant survivorship. Hatta et al. showed that smokers had significantly lower estimations for 10-year implant survival free of complications compared to non-smokers (smokers: 78.4%, non-smokers: 90.2%; p < 0.01), but no differences in predicted 10-year survival rates (smokers: 86.3%, non-smokers: 92.2%; p = 0.45) following shoulder arthroplasty.32 Alternatively, our investigation did note a significantly different long-term implant survival rate between current smokers and non-smokers. However, this difference could be partially explained by the differences in age at time of index procedure. While there have been limited reports on the influence of smoking on long-term survivorship after total shoulder arthroplasty, an investigation evaluating patients undergoing TSA for osteoarthritis at age 55 years or younger demonstrated 98% 5-year survival but only 62.5% 10-year survival for the implants.40 Similar concerns have been raised by other investigations, with younger patients more likely to demonstrate glenoid loosening after TSA necessitating revision surgery.41 While our finding of decreased long-term survival in current smokers provides a significant contribution to the literature, future propensity-matched cohort studies can further delineate the contribution of age versus smoking status on long-term survivorship and outcomes. Although young age at time of arthroplasty may be a contributing factor to decreased survivorship, the compromised bone stock and healing potential of current smokers also is likely to negatively impact long-term implant survivorship.

An expected outcome following shoulder replacement surgery is restoration of range of motion. In general, the literature to date suggests improvements of 40o, 25o, and four vertebral levels can be expected in forward elevation, external rotation, and internal rotation for patients who underwent aTSA.42–45 However, restrictions in range of motion improvements have been indicated for patients based on factors such as suboptimal preoperative range of motion, higher BMI, diabetes, and hypertension.22,29,46 To our knowledge, this is only the second study to report on the range of motion outcomes in aTSA patients stratified by smoking status. At three years follow-up, Walters et al. found that postoperative forward elevation (non-smoker: 142o vs. smoker: 124o), external rotation (non-smoker: 49o vs. smoker: 46o), and internal rotation (non-smoker: 56o vs. smoker: 52o) for smokers (n = 14) was lower than the scores seen for non-smokers (n = 59), but not significantly.47 Regardless of smoking status, each of our cohorts had approximately the same degree of external (47.8o-54.0o; p = 0.88) and internal rotation (T12; p = 0.70) at final follow-up. However, we do report that postoperative forward elevation was significantly lower for current smokers (130.9o ± 41.2o; p = 0.017) compared to both the non-smoking (149.7o ± 17.2o) and former smoking (147.1o ± 26.0o) patients, despite no differences preoperatively. We believe this is a result of our sample size and the high proportion of smokers who required revision surgery ultimately leading to shoulder dysfunction. Alternatively, it has been characterized that cigarette smoking activates the innate inflammatory response while reducing muscle contraction and oxygen delivery.48,49 Thus, forward elevation at long-term follow-up may be hindered by prolonged skeletal muscle damage at the shoulder flexors (e.g., anterior deltoid, pectoralis major). Nevertheless, as each of our cohorts, on average, achieved acceptable range of motion scores at upwards of a decade postoperatively, our study suggests that aTSA can provide favorable outcomes regardless of smoking status.

Patient reported outcomes are of keen interest in improving shoulder functionality following arthroplasty. In a previous study, Tashjian et al. reported on the minimal clinically important differences (MCID) for shoulder arthroplasty patients. They found that the MCID for VAS, ASES, and SST were 1.4, 20.9, and 2.4 points respectively.50 In the one study that analyzed patient reported outcomes following aTSA to date for tobacco users, Wells et al. demonstrated that patient VAS scores improved significantly less for smokers (n = 28, △VAS = 2.8) compared to both non-smokers (n = 88, △VAS = 4.0) and former smokers (n = 47, △VAS = 4.3) (p < 0.01) at twelve weeks follow-up.21 In our study, each cohort had improvements that exceeded the MCID as reported previously for VAS, ASES, and SST scores. However, while not significantly, we do report that postoperative VAS scores were the highest while ASES and SST scores were the lowest for current smokers compared to both non-smokers and former smokers. Moreover, the VAS (p = 0.73), ASES (p = 0.95), and SST (p = 0.21) scores were nearly identical between non-smokers and former smokers at final follow-up. This suggests that these two groups have similar shoulder utility in activities of daily living at long-term intervals following surgery, further emphasizing the clinical importance of preoperative cessation programs. Overall, our long-term study agrees with the previously published short-term research showing that patient reported outcomes are lower for current smokers following aTSA. However, given that all three cohorts saw improvements preoperatively to postoperatively for each index, aTSA proves to still provide significant relief for patients with shoulder dysfunction regardless of smoking status.

At an average follow-up time of over a decade, this study represents the longest clinical report that addresses the impact a patient's smoking status has on outcomes following aTSA. However, this study is not without its limitations. The retrospective nature of the study resulted in the smoking statuses of 42 patients being unknown and thus not included. Additionally, range of motion and patient reported outcome scores were not consistently available for preoperative or postoperative visits prior to the year 2000 and radiographs were not obtainable for patients whose files were not within the electronic medical records database at our institution. Further, our geographic location may have acted to limit the number of current smokers available for inclusion in our analysis. Lastly, the unblinded postoperative assessment, allocation of outcome measurements, and retrospective nature of this study provides space for inherent biases. Future studies analyzing the impact that smoking tobacco has on long-term outcomes following shoulder replacement should seek to understand long-term results in larger patient populations and stratified by replacement type (i.e., aTSA, rTSA, and hemi-arthroplasty).

5

5 Conclusion

Following aTSA, we saw significant improvements in range of motion and patient reported outcomes regardless of smoking status. However, current smokers were more than ten years younger when presenting for surgery, had higher revision rates, and their implants failed sooner compared to non-smokers and former smokers. This study should encourage surgeons to continue to incorporate discussions surrounding modifiable risk factors into their preoperative consultations in order to establish realistic long-term outcome expectations with patients.

Author contributions

Christopher White – conceptualization, data curation, formal analysis, investigation, methodology, writing original draft, review & editing. Akshar Patel – conceptualization, data curation, investigation, methodology, writing original draft. Kevin Wang – data curation, formal analysis, investigation, methodology, review & editing. Carl Cirino – data curation, formal analysis, investigation, methodology, review & editing. Bradford Parsons – Investigation, methodology, project administration, resources, review & editing. Evan Flatow – Investigation, methodology, project administration, resources, review & editing. Paul Cagle – conceptualization, investigation, methodology, project administration, resources, review & editing, validation, visualization.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Informed consent

n/a.

Institutional ethical committee approval

The Institutional Review Board at our institution reviewed and approved this study prior to the investigation.

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