RED FLAG #2: “I Love My Camel Cigarettes, I’m 82-Years-Old & I’m Healthier Than You”
Peter K. Sculco, M.D.: A patient who comes in for total joint arthroplasty may have some non-modifiable risk factors. We can’t change an 82-year-old male patient’s age or gender. Smoking is probably one of the easiest, best, targeted modifiable risk factors.
The overall the rate of smoking has decreased. In 2018, the number is 16%. About 10% of your practice—1 out of 10 patients who come to you for joint replacement will be active smokers.
Smoking causes vasoconstriction, decreased oxygenation, and several cellular problems in regards to inflammatory response in the healing process, delayed wound healing issues because we can’t produce collagen. Every part of the body is affected. Creates free radicals that cause cellular damage.
What happens when you stop? If you stop, your blood flow and tissue oxygenation improves within a few hours. But it takes four weeks for your wound healing response to repair. There are issues with endothelial vasculature, with airway repair, and healing processes that can go on for decades, so really there is some permanent damage in these patients that we can’t control.
One study looked at 33,000 patients in the VA who are current smokers and former smokers. Current smokers had a number of medical complications, surgical site infections, pneumonia, stroke, and increase in one-year mortality. Former smokers also had an increase. Prior smoking is an underlying risk factor that actually becomes non-modifiable.
If a patient is going to do joint replacement, they have to stop smoking. We’re all talking to our patients, but really not doing much about it. Only 20% of us actually use a smoking-cessation program and very few of us actually test our patients for nicotine.
Intensive interventions where you go to a course eight weeks prior to surgery and put them on a nicotine patch are effective. Patients who completely stop smoking had a marked reduction of complications. If you just reduce smoking, really no difference, so really you can’t do it half-assed.
Testing is a powerful method. Do a cotinine test, which is urine, saliva, or blood test. Test them in the office with carbon monoxide exhalation. The carbon dioxide actually tests just the last 24 hours. The cotinine is about two weeks.
If you give a one-page handout on why they should stop smoking and test them prior to surgery, 70% pass the test, 13 stopped cold turkey and 64% continued to abstain from smoking, showing I think we have an opportunity change patients’ lives.
So, current smoking is bad: increase risk of revision and overall complications. Former smokers have increased risk. You should stop four weeks prior to surgery. It’s cost-effective and you have to stop you can’t just reduce it.
And we need to do a better job because only 6% of surgeons are currently testing patients.
Moderator: One other thing to mention is that cigars have about 10 times the amount of nicotine as cigarettes so be aware of that.
Another challenge is those who are culture negative and you’re really concerned about that knee and what to do after the patient may or may not have been on some antibiotics. Ed McPherson is going to talk to us about that issue.
