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Smoking as a risk factor for complications following arthroscopic rotator cuff repair

Open AccessPublished:November 19, 2020DOI:https://doi.org/10.1016/j.jseint.2020.10.002

      Background

      The purpose of this study was to investigate the association between smoking status and postoperative complications within 30 days of arthroscopic rotator cuff repair (ARCR).

      Methods

      The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients who underwent ARCR from 2015 to 2017. Smokers were defined as patients who reported smoking cigarettes in the year prior to rotator cuff repair. Patients who used chewing tobacco, cigars, or electronic cigarettes were not included in the smoking cohort. Postoperative complications were reported within 30 days of the procedure. Multivariate logistic regression was performed to investigate the relationship between smoking status and postoperative complications.

      Results

      There were 18,594 patients included in this study. Of these patients, 2834 (15.2%) were current smokers. Smokers were more likely to be men, to be aged < 65 years, and to have a body mass index < 30. Smokers were also more likely to have chronic obstructive pulmonary disease, to be functionally dependent, and to have an American Society of Anesthesiologists (ASA) class ≥ 3. After adjustment for all significantly associated patient demographic characteristics and comorbidities, smoking was identified as a significant predictor of surgical complications (odds ratio [OR], 1.955; P = .022), return to the operating room (OR, 2.547; P = .003), readmission (OR, 1.570; P = .014), and sepsis or septic shock (OR, 4.737; P = .021). Smoking was not a significant predictor of medical complications (OR, 1.105; P = .687) or surgical-site infections (OR, 1.216; P = .713).

      Conclusion

      Smoking may be a risk factor for surgical complications, readmission, and sepsis or septic shock within 30 days of ARCR.

      Level of evidence

      Keywords

      A recent analysis of the 2016 National Health Interview Survey has identified 37.8 million adults in the United States as tobacco smokers.
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      Smoking tobacco has also been associated with an increased risk of the development of rotator cuff tears
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      The impact of preoperative smoking habits on the results of rotator cuff repair.
      The purpose of this study was to use a large national database to investigate the association between smoking status and postoperative complications within 30 days of ARCR. A secondary objective of this study was to identify patient demographic characteristics and comorbidities that are associated with preoperative smoking status.

      Materials and methods

      The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who underwent ARCR from 2015 to 2017. The NSQIP database includes patient data from >600 community and academic hospitals. Data in the NSQIP database are collected by certified surgical clinical reviewers, and the database is episodically audited for accuracy.
      • Sebastian A.S.
      • Polites S.F.
      • Glasgow A.E.
      • Habermann E.B.
      • Cima R.R.
      • Kakar S.
      Current quality measurement tools are insufficient to assess complications in orthopedic surgery.
      Variables collected in this study included cigarette smoking status, patient demographic characteristics, comorbidities, postoperative complications, readmission rates, reoperation rates, and discharge information.
      Patients who underwent ARCR were identified by Current Procedural Terminology code 29827. Patients were grouped into 2 cohorts based on their preoperative smoking status. Smokers were defined as patients who reported smoking cigarettes in the year prior to rotator cuff repair. Patients who used chewing tobacco, cigars, or electronic cigarettes were included in the nonsmoking cohort as the use of these alternative forms of tobacco is not a variable collected in the NSQIP database. Patient demographic characteristics including age, sex, body mass index, and American Society of Anesthesiologists (ASA) physical status classification were collected. Patient comorbidities including congestive heart failure, diabetes mellitus, hypertension (HTN), and chronic obstructive pulmonary disease (COPD) were also collected. Moreover, patients' functional status and preoperative use of steroids for a chronic condition were included in the analysis. Cases were excluded if any of the following variables had missing information: age, height, weight, functional health status, ASA class, or discharge destination.
      Postoperative complications were reported within 30 days of the procedure. Surgical complications included wound dehiscence, deep surgical-site infection (SSI), superficial SSI, organ/space SSI, and return to the operating room. Medical complications included cardiac arrest or myocardial infarction, pulmonary complications, renal complications, urinary tract infection (UTI), deep vein thrombosis or pulmonary embolism, and sepsis or septic shock. Pulmonary complications included postoperative pneumonia, unplanned reintubation, and requirement of mechanical ventilation for >48 hours. Renal complications included acute renal failure and progressive renal insufficiency. Readmissions and reoperations within 30 days after ARCR were also reported.
      All statistical analyses were conducted using SPSS Software (version 26.0; IBM, Armonk, NY, USA). Patient demographic characteristics, comorbidities, and procedural characteristics were compared between cohorts using bivariate analysis. Multivariate logistic regression, adjusted for all significantly associated patient demographic characteristics and comorbidities, was performed to investigate the relationship between preoperative smoking status and postoperative complications. Odds ratios (ORs) were reported in relation to 95% confidence intervals. The level of significance was set at P < .05.

      Results

      After application of the exclusion criteria, 18,594 patients were included in this study. Of these patients, 2834 (15.2%) were identified as current smokers (within 1 year of surgery) and 15,760 (84.8%) were identified as nonsmokers (Table I). In comparison to nonsmokers, smokers undergoing ARCR were more likely to be men (63.2% vs. 57.8%, P < .001), to be aged < 65 years, and to have a body mass index < 30 (Table I). Smokers were also more likely to have COPD (7.7% vs. 2.1%, P < .001), to be functionally dependent (0.6% vs. 0.3%, P = .036), and to have an ASA class ≥ 3 (38.4% vs. 32.3%, P < .001) (Table I). In comparison to smokers, nonsmokers were more likely to have diabetes (16.9% vs. 15.1%, P = .025), to have a diagnosis of HTN (46.0% vs. 42.3%, P < .001), and to use steroids preoperatively (2.1% vs. 1.5%, P = .039) (Table I). Smoking status was not associated with a diagnosis of congestive heart failure (0.2% vs. 0.2%, P = .414; Table I).
      Table IComparison of patient demographic characteristics and comorbidities between smokers and nonsmokers
      NonsmokerSmokerP value
      n (%)n (%)
      Overall15,7602834
      Sex<.001
      Statistically significant (P < .05).
       Male9109 (57.8)1791 (63.2)
       Female6651 (42.2)1043 (36.8)
      Age
       18-39 yr743 (4.7)245 (8.6)<.001
      Statistically significant (P < .05).
       40-64 yr10,023 (63.6)2193 (77.4)<.001
      Statistically significant (P < .05).
       65-74 yr4030 (25.6)357 (12.6)<.001
      Statistically significant (P < .05).
       ≥75 yr964 (6.1)39 (1.4)<.001
      Statistically significant (P < .05).
      BMI
       <18.541 (0.3)32 (1.1)<.001
      Statistically significant (P < .05).
       18.5-29.97996 (50.7)1552 (54.8)<.001
      Statistically significant (P < .05).
       30-34.94312 (27.4)732 (25.8).094
       35-39.92085 (13.2)309 (10.9).001
      Statistically significant (P < .05).
       ≥401326 (8.4)209 (7.4).071
      Comorbidities
       CHF24 (0.2)2 (0.2).414
       Diabetes mellitus2656 (16.9)429 (15.1).025
      Statistically significant (P < .05).
       HTN7256 (46.0)1199 (42.3)<.001
      Statistically significant (P < .05).
       COPD334 (2.1)217 (7.7)<.001
      Statistically significant (P < .05).
      Functional status.036
      Statistically significant (P < .05).
       Dependent48 (0.3)16 (0.6)
       Independent15,712 (99.7)2818 (99.4)
      Steroid use.039
      Statistically significant (P < .05).
       Yes336 (2.1)43 (1.5)
       No15,424 (97.9)2791 (98.5)
      ASA class<.001
      Statistically significant (P < .05).
       ≤210,664 (67.7)1747 (61.6)
       ≥35096 (32.3)1087 (38.4)
      BMI, body mass index; CHF, congestive heart failure; HTN, hypertension; COPD, chronic obstructive pulmonary disease; ASA, American Society of Anesthesiologists.
      Statistically significant (P < .05).
      The overall rate of complications in our study was 1.1%. In comparison to nonsmokers, smokers had higher rates of surgical complications (0.6% vs. 0.3%, P = .009), return to the operating room (0.6% vs. 0.2%, P = .001), and readmission (1.5% vs. 1.0%, P = .027) (Table II). There was no significant difference in the rate of overall medical complications (0.7% vs. 0.8%, P = .897) or SSIs (Table II). Unadjusted bivariate logistic regression identified smoking as a significant predictor of surgical complications (OR, 2.137; P = .006), return to the operating room (OR, 2.791; P = .001), and readmission (OR, 1.476; P = .026) (Table III). After adjustment for all significantly associated patient demographic characteristics and comorbidities, smoking was identified as a significant predictor of surgical complications (OR, 1.955; P = .022), return to the operating room (OR, 2.547; P = .003), readmission (OR, 1.570; P = .014), and sepsis or septic shock (OR, 4.737; P = .021) (Table IV). Smoking was not a significant predictor of medical complications (OR, 1.105; P = .687) or SSIs (OR, 1.216; P = .713).
      Table IIComparison of postoperative complication rates between smokers and nonsmokers
      NonsmokerSmokerP value
      n (%)n (%)
      Medical complication124 (0.8)21 (0.7).897
       Cardiac arrest or MI20 (0.1)2 (0.1).563
       Pulmonary complication30 (0.2)6 (0.2).816
       Renal complication5 (0.0)2 (0.1).290
       UTI28 (0.2)5 (0.2)>.999
       DVT or PE51 (0.3)7 (0.2).587
       Sepsis or septic shock8 (0.1)4 (0.1).097
      Surgical complication47 (0.3)18 (0.6).009
      Statistically significant (P < .05).
       Wound dehiscence2 (0.0)0 (0.0)>.999
       Superficial SSI9 (0.1)2 (0.1).679
       Deep SSI6 (0.0)2 (0.1).350
       Organ/space SSI4 (0.0)2 (0.1).229
       Return to operating room34 (0.2)17 (0.6).001
      Statistically significant (P < .05).
      Any complication164 (1.0)36 (1.3).277
      Readmission159 (1.0)42 (1.5).027
      Statistically significant (P < .05).
      Non-home discharge89 (0.6)9 (0.3).126
      MI, myocardial infarction; UTI, urinary tract infection; DVT, deep vein thrombosis; PE, pulmonary embolism; SSI, surgical-site infection.
      Statistically significant (P < .05).
      Table IIIUnivariate analysis of impact of smoking status on complications following arthroscopic rotator cuff repair
      Smoking unadjusted OR (95% CI)P value
      Medical complication0.941 (0.592-1.498).799
       Cardiac arrest or MI0.556 (0.130-2.379).429
       Pulmonary complication1.112 (0.463-2.675).812
       Renal complication2.225 (0.432-11.475).339
       UTI0.993 (0.383-2.574).989
       DVT or PE0.763 (0.346-1.682).502
       Sepsis or septic shock2.783 (0.837-9.248).095
      Surgical complication2.137 (1.239-3.685).006
      Statistically significant (P < .05).
       Wound dehiscence
       Superficial SSI1.236 (0.267-5.723).786
       Deep SSI1.854 (0.374-9.192).450
       Organ/space SSI2.782 (0.509-15.195).238
       Return to operating room2.791 (1.557-5.003).001
      Statistically significant (P < .05).
      Any complication1.224 (0.851-1.759).276
      Readmission1.476 (1.048-2.079).026
      Statistically significant (P < .05).
      Non-home discharge0.561 (0.282-1.115).099
      OR, odds ratio; CI, confidence interval; MI, myocardial infarction; UTI, urinary tract infection; DVT, deep vein thrombosis; PE, pulmonary embolism; SSI, surgical-site infection.
      Statistically significant (P < .05).
      Table IVMultivariate analysis of impact of smoking status on complications following arthroscopic rotator cuff repair
      Smoking adjusted OR (95% CI)P value
      Surgical complication1.955 (1.104-3.462).022
      Statistically significant (P < .05).
      Return to operating room2.547 (1.386-4.678).003
      Statistically significant (P < .05).
      Readmission1.570 (1.095-2.253).014
      Statistically significant (P < .05).
      Sepsis or septic shock4.737 (1.262-17.782).021
      Statistically significant (P < .05).
      OR, odds ratio; CI, confidence interval.
      Statistically significant (P < .05).

      Discussion

      In this study, we used a large national database to identify smoking as an independent predictor of readmission, surgical complications, return to the operating room, and sepsis or septic shock following ARCR. Furthermore, smokers undergoing ARCR were more likely to have COPD, be functionally dependent, and be aged < 65 years.
      Many patient- and procedure-specific variables, including male sex, older age, HTN, COPD, diabetes, dialysis, steroid use, ASA class 3 or 4, and increased operative time, have been identified as risk factors for complications after ARCR.
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      Previous studies have identified smoking as a risk factor for complications following total shoulder arthroplasty, shoulder arthroscopy, and open rotator cuff repair.
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      Smoking is associated with increased surgical complications following total shoulder arthroplasty: an analysis of 14,465 patients.
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      Many studies have also suggested that in comparison to nonsmokers, smokers may have decreased functional improvements, earlier recovery plateau points, lower postoperative outcome scores, and lower postoperative patient satisfaction scores after rotator cuff repair.
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      Do patients who smoke tobacco have success with primary arthroscopic rotator cuff repair? A comparison with nonsmokers.
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      The impact of preoperative smoking habits on the results of rotator cuff repair.
      ,
      • Naimark M.
      • Robbins C.B.
      • Gagnier J.J.
      • Landfair G.
      • Carpenter J.
      • Bedi A.
      • et al.
      Impact of smoking on patient outcomes after arthroscopic rotator cuff repair.
      ,
      • Santiago-Torres J.
      • Flanigan D.C.
      • Butler R.B.
      • Bishop J.Y.
      The effect of smoking on rotator cuff and glenoid labrum surgery: a systematic review.
      However, to our knowledge, no study has identified an association between preoperative smoking status and readmission rates, individual postoperative complications, and reoperation rates specifically after ARCR.
      Previous studies have identified numerous risk factors for readmission following arthroscopic shoulder surgery and rotator cuff repair; however, our study is the first to identify smoking as a risk factor for readmission after ARCR. Kosinski et al
      • Kosinski L.R.
      • Gil J.A.
      • Durand W.M.
      • DeFroda S.F.
      • Owens B.D.
      • Daniels A.H.
      30-Day readmission following outpatient rotator cuff repair: an analysis of 18,061 cases.
      identified older age, COPD, HTN, dialysis, and ASA class 3 or 4 as predictors of readmission following outpatient rotator cuff repair. Hill et al
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      identified operative time > 1.5 hours, age > 40 years, ASA class 3 or 4, COPD, and chronic steroid use as independent predictors of readmission after elective arthroscopic shoulder surgery. Smoking has also been identified as a risk factor for readmission following all-arthroscopic surgery including knee, shoulder, and hip procedures.
      • Johnson D.J.
      • Castle J.P.
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      • Baker H.
      • Selley R.S.
      • Nicolay R.W.
      • et al.
      Smoking as a risk factor for readmission in arthroscopic surgery: a propensity matched analysis.
      Our study identified preoperative smoking status as a significant predictor of short-term readmission, further expanding our understanding of risk factors for readmission after ARCR. Our findings reiterate the importance of counseling patients to stop smoking preoperatively as this may reduce their likelihood of readmission following ARCR.
      This study also identified smoking as a risk factor for overall surgical complications after ARCR. Surgical complications included wound dehiscence, SSI, and return to the operating room within 30 days. Regarding the individual surgical complications, we found the greatest association between smoking status and the likelihood of reoperation. Our results suggest that in comparison to nonsmokers, smokers are more than 2 times as likely to undergo a reoperation within 30 days of ARCR. Previous studies have identified an association between smoking and impaired wound healing and tissue regeneration. These studies have suggested that smoking hinders the synthesis of collagen and modifies the balance of extracellular matrix turnover, leading to a detriment in wound healing.
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      Less collagen production in smokers.
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      Although our study identified smoking as a significant risk factor for overall surgical complications, we did not find an association between smoking and rates of wound dehiscence or SSI. Our results suggest that smoking status may not play a role in predicting individual wound disruptions or SSIs after ARCR. As smoking has been associated with an increased risk of SSIs and wound disruptions after other open procedures on the shoulder, such as total shoulder arthroplasty,
      • Althoff A.D.
      • Reeves R.A.
      • Traven S.A.
      • Wilson J.M.
      • Woolf S.K.
      • Slone H.S.
      Smoking is associated with increased surgical complications following total shoulder arthroplasty: an analysis of 14,465 patients.
      ,
      • Hatta T.
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      this difference may be explained by the minimally invasive nature of arthroscopic shoulder surgery. These findings may also be ascribed to the relatively low infection rate of ARCR. A cohort study of 903 patients comparing infection rates between open rotator cuff repair and ARCR found that a postoperative infection was 5.6 times more likely to develop in the open group than in the arthroscopic group.
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      Infection rates in arthroscopic versus open rotator cuff repair.
      Nonetheless, the results of our study demonstrate that smoking status is a significant predictor of overall surgical complications following ARCR.
      In this study, we found smokers and nonsmokers to have similar rates of overall medical complications. Our analysis did not identify smoking status as a significant predictor of overall medical complications after ARCR. Padaki et al
      • Padaki A.S.
      • Boddapati V.
      • Mathew J.
      • Ahmad C.S.
      • Jobin C.M.
      • Levine W.N.
      The effect of age on short-term postoperative complications following arthroscopic rotator cuff repair.
      suggested that patients aged > 65 years have an increased likelihood of postoperative respiratory complications and UTIs developing after ARCR. Agarwalla et al
      • Agarwalla A.
      • Gowd A.K.
      • Yao K.
      • Bohl D.D.
      • Amin N.H.
      • Verma N.N.
      • et al.
      A 15-minute incremental increase in operative duration is associated with an additional risk of complications within 30 days after arthroscopic rotator cuff repair.
      identified that an increased operative time is associated with increased rates of postoperative anemia requiring transfusion, venous thromboembolism, SSI, and an extended length of hospital stay following ARCR. In particular, smoking has been identified as an independent risk factor for venous thromboembolic events after open rotator cuff repair.
      • Best M.J.
      • Aziz K.T.
      • Nayar S.K.
      • Patten I.S.
      • Bansal A.
      • Huish E.
      • et al.
      Smoking is an independent risk factor for complications following open rotator cuff repair.
      The results of our study suggest that preoperative smoking status may not increase the risk of thromboembolic events, UTIs, pulmonary complications, or overall medical complications after ARCR. However, this lack of association may also be attributed to the low rates of these complications in our study population. Nonetheless, our results identify an association between smoking and an increased likelihood of postoperative sepsis or septic shock, a finding consistent with the results of a meta-analysis of large cohort studies and systematic reviews.
      • Pierre S.
      • Rivera C.
      • Le Maître B.
      • Ruppert A.-M.
      • Bouaziz H.
      • Wirth N.
      • et al.
      Guidelines on smoking management during the perioperative period.
      Current trends in the operative management of rotator cuff tears include a continuing shift toward arthroscopy, which allows for preservation of the deltoid muscle, improved visualization of intra-articular pathology, and decreased early postoperative pain. In addition, open arthroscopic repair has been associated with deltoid detachment or atrophy and increased immediate postoperative pain and stiffness.
      • Buess E.
      • Steuber K.-U.
      • Waibl B.
      Open versus arthroscopic rotator cuff repair: a comparative view of 96 cases.
      ,
      • Colvin A.C.
      • Egorova N.
      • Harrison A.K.
      • Moskowitz A.
      • Flatow E.L.
      National trends in rotator cuff repair.
      Complications following ARCR are relatively infrequent. Current estimates of complication rates after ARCR fall between 0.88% and 2%.
      • Agarwalla A.
      • Gowd A.K.
      • Yao K.
      • Bohl D.D.
      • Amin N.H.
      • Verma N.N.
      • et al.
      A 15-minute incremental increase in operative duration is associated with an additional risk of complications within 30 days after arthroscopic rotator cuff repair.
      ,
      • Day M.
      • Westermann R.
      • Duchman K.
      • Gao Y.
      • Pugely A.
      • Bollier M.
      • et al.
      Comparison of short-term complications after rotator cuff repair: open versus arthroscopic.
      ,
      • Hill J.R.
      • McKnight B.
      • Pannell W.C.
      • Heckmann N.
      • Sivasundaram L.
      • Mostofi A.
      • et al.
      Risk factors for 30-day readmission following shoulder arthroscopy.
      ,
      • Johnson D.J.
      • Castle J.P.
      • Hartwell M.H.
      • Baker H.
      • Selley R.S.
      • Nicolay R.W.
      • et al.
      Smoking as a risk factor for readmission in arthroscopic surgery: a propensity matched analysis.
      ,
      • Padaki A.S.
      • Boddapati V.
      • Mathew J.
      • Ahmad C.S.
      • Jobin C.M.
      • Levine W.N.
      The effect of age on short-term postoperative complications following arthroscopic rotator cuff repair.
      ,
      • Schairer W.W.
      • Nwachukwu B.U.
      • Fu M.C.
      • Warren R.F.
      Risk factors for short-term complications after rotator cuff repair in the United States.
      ,
      • Shields E.
      • Thirukumaran C.
      • Thorsness R.
      • Noyes K.
      • Voloshin I.
      An analysis of adult patient risk factors and complications within 30 days after arthroscopic shoulder surgery.
      Our study demonstrated an overall complication rate of 1.1%, which is consistent with these literature reports. Although rare, these complications may increase patient morbidity and health care expenditures. Recognizing modifiable risk factors such as smoking is important to improve surgical outcomes and reduce complication rates. Additionally, an increasing number of arthroscopic procedures are being performed at many physician-owned outpatient surgical centers,
      • Iyengar J.J.
      • Samagh S.P.
      • Schairer W.
      • Singh G.
      • Valone F.H.
      • Feeley B.T.
      Current trends in rotator cuff repair: surgical technique, setting, and cost.
      ,
      • Mitchell J.M.
      Effect of physician ownership of specialty hospitals and ambulatory surgery centers on frequency of use of outpatient orthopedic surgery.
      thereby increasing orthopedic surgeons' accountability for complications after these procedures.
      • Agarwalla A.
      • Gowd A.K.
      • Yao K.
      • Bohl D.D.
      • Amin N.H.
      • Verma N.N.
      • et al.
      A 15-minute incremental increase in operative duration is associated with an additional risk of complications within 30 days after arthroscopic rotator cuff repair.
      Therefore, knowledge of modifiable risk factors for readmissions, complications, and reoperations following ARCR is becoming increasingly valuable. Our findings emphasize the importance of counseling patients to stop smoking prior to ARCR, a recommendation that has been supported by many studies.
      • Galatz L.M.
      Nicotine delays tendon-to-bone healing in a rat shoulder model.
      ,
      • Jorgensen L.N.
      • Kallehave F.
      • Christensen E.
      • Siana J.E.
      • Gottrup F.
      Less collagen production in smokers.
      ,
      • Lundgreen K.
      • Lian Ø.B.
      • Scott A.
      • Nassab P.
      • Fearon A.
      • Engebretsen L.
      Rotator cuff tear degeneration and cell apoptosis in smokers versus nonsmokers.
      ,
      • Neyton L.
      • Godenèche A.
      • Nové-Josserand L.
      • Carrillon Y.
      • Cléchet J.
      • Hardy M.B.
      Arthroscopic suture-bridge repair for small to medium size supraspinatus tear: healing rate and retear pattern.
      ,
      • Santiago-Torres J.
      • Flanigan D.C.
      • Butler R.B.
      • Bishop J.Y.
      The effect of smoking on rotator cuff and glenoid labrum surgery: a systematic review.
      Additionally, orthopedic surgeons may use patients' smoking status for preoperative risk stratification prior to ARCR.
      Although this study identified an association between smoking status and specific postoperative complications following ARCR, there are several limitations that warrant further discussion. Patients were placed in the smoking cohort if they had reported smoking cigarettes within 1 year prior to ARCR. This introduces an aspect of reporting bias as patients may not accurately report their smoking history. Moreover, the duration and extent of a patient's smoking history are unavailable in the NSQIP database. Additional studies are needed to evaluate whether there is a relationship between the extent of patients' smoking history and complication rates after ARCR. This study found significant differences in demographic characteristics between smokers and nonsmokers; this represents a limitation that is likely unavoidable owing to underlying differences between smokers and the general population. Furthermore, patients who used electronic cigarettes, cigars, or chewing tobacco were included in the nonsmoking cohort as the use of these alternative forms of tobacco is not a variable collected in the NSQIP database. Rates of electronic cigarette use in the United States have seen considerable growth in the past decade.
      • Al Rifai M.
      • Merchant A.T.
      • Nambi V.
      • Jia X.
      • Gulati M.
      • Valero-Elizondo J.
      • et al.
      Temporal trends in E-cigarette use among U.S. adults: Behavioral Risk Factor Surveillance System, 2016 to 2018.
      A recent analysis has suggested that approximately 14% of current cigarette smokers in the United States concurrently use electronic cigarettes
      • Al Rifai M.
      • Merchant A.T.
      • Nambi V.
      • Jia X.
      • Gulati M.
      • Valero-Elizondo J.
      • et al.
      Temporal trends in E-cigarette use among U.S. adults: Behavioral Risk Factor Surveillance System, 2016 to 2018.
      ; thus, an association between electronic cigarette use and adverse outcomes following ARCR has yet to be elucidated. Additional studies with the ability to identify electronic cigarette users, chewing tobacco users, and cigar smokers are also needed to investigate whether these alternative forms of tobacco are risk factors for complications after ARCR. This study identified smoking as an independent risk factor for complications following ARCR. However, smoking may potentiate other patient comorbidities to increase patients' risk of complications. Future research is needed to identify how patients' smoking status modifies concomitant comorbidities as risk factors for complications after ARCR. Additionally, future research identifying risk factors specific to smokers undergoing ARCR would improve physicians' ability to stratify smokers' preoperative risk. Finally, the American College of Surgeons NSQIP database only records complications occurring within 30 days of the principal procedure. As intended, the findings of this study are limited to the immediate 30-day postoperative period.

      Conclusion

      Complications following ARCR are relatively infrequent. Smoking was identified as an independent predictor of readmission, surgical complications, return to the operating room, and sepsis or septic shock within 30 days of ARCR. Smokers undergoing ARCR were more likely to have COPD, to be functionally dependent, and to be aged < 65 years. Patients undergoing ARCR should be counseled to stop smoking preoperatively as smoking cessation may reduce their likelihood of surgical complications, readmission, reoperation, and sepsis or septic shock. Additionally, knowledge of smoking as a risk factor for complications following ARCR may assist orthopedic surgeons in preoperative risk stratification.

      Disclaimer

      The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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