Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're highlighting the effect of smoking on outcomes after total shoulder arthroplasty. Joining me is Dr. Jonathan Wright. He's the acting Chief of Orthopedic Surgery at the North Florida South Georgia Veterans Health System, and an Assistant Professor in the Department of Orthopedic Surgery and Sports Medicine at the University of Florida College of Medicine.

Dr. Wright, thank you so much for being with us today. I'd like you to tell us about smoking as a risk factor for poor outcomes after shoulder replacement. Tell us about the studies and how that came about.

Jonathan Wright, MD: Thanks for having me. We've been doing shoulder arthroplasty here at the University of Florida and the VA for a long time. We have a large database of patients. So when we're looking at ways we can optimize patient outcome, there are a lot of different things we look at. Obviously, as surgeons, we look at surgical factors and the implant factors, but there's also a patient factor that's really important, right? Where the patient's preoperative status is affects their outcome.

And one of those things that has gotten a lot of attention recently in like the overall arthroplasty literature is smoking status. So, there have been a lot of studies looking at the effect smoking has on outcomes, and there have been a large database studies that showed smokers tend to have more complications, not just pulmonary complications, which what the lay people think about, right? Smoking hurts your lungs, right? Well, it also hurts a lot of other things. Smokers have a lot, poor healing, all sorts of other problems that go along with smoking. And the database studies have showed that, that they have higher complication rates, higher infection rates, and higher rates of loosening.

However, not a lot of people have looked about how that actually affects their overall satisfaction and function long term for those people that, say, didn't have complications. Like, do they still do as well as non-smokers? Because a lot of surgeons are wondering whether or not to ask everyone to quit smoking before doing an elective arthroplasty and some surgeons actually require patients to not smoke. While the others don't always make people quit smoking, just tell them it's a risk factor. So, that's one thing we want to look at here. In the hip and knee literature, it actually shows that a smoking status has an effect on your outcomes, your pain scores, and your long-term function. But very little has looked at that in shoulder replacement, only one other small study, which is why we decided to look at our database and look at how do our patients, how have they done? The smokers versus former smokers versus non-smokers.

Melanie Cole, MS: This is a really interesting topic when we think about bone and soft tissue and healing post-surgery. What do we know now, maybe that we didn't know, as you mentioned, hip and knee, these things have been looked at, but now when we're talking about shoulders, which is such a complex joint to begin with, what's known about what's changed? What do we know now that we maybe didn't know about the effect on bone and soft tissue healing?

Jonathan Wright, MD: You know, I think studies have been coming out looking at that more and more, like even rotator cuff repairs, that smokers tend to not heal as well. Their soft tissue healing is delayed and when you're looking at these implants, yes, we need bony ingrowth and that's what you think about with the joint replacement, but all the soft tissue healing is very important. For an anatomic total shoulder arthroplasty to work well, you have to have a rotator cuff healed and functioning well. The reverse maybe not quite as much, but still the soft tissue healing to some extent plays into that and we know smoking hurts that. Just to be able to quantify how much it may affect that, well, that's why we decided to do the study.

Melanie Cole, MS: So, as we're talking about this, Dr. Wright, and we're looking at the key differences in surgical outcomes between smokers and non-smokers after TSA, I want you to tell us the complications that you've seen, not only in your study, but in your practice, and is there a noticeable difference in the rate of revision surgeries between smokers and non-smokers post-TSA?

Jonathan Wright, MD: I can tell you anecdotally, I do worry about smokers, and I don't force everyone to completely quit smoking, but we have a long counseling session. I encourage them to cut back significantly. I have had several smokers with fractures. So, these weren't elective shoulder replacements, but they are in people who smoked a lot. They didn't heal a fracture probably because they were smoking. And when we did the shoulder replacement, although two of them did well, initially, both of them eventually got infections and needed more surgery. I think the literature overall shows that trend. While some people still do well and do okay, they don't have problems. When you do have like an infection postoperatively, that's catastrophic. It affects their lives for years to come and they never get as good of an outcome. And the data does show smokers definitely have higher rates of infections postoperatively and needing revisions. So, just that in and of itself is a good enough reason to not smoke, I think, before you go to through an elective joint replacement.

Melanie Cole, MS: Well, and certainly with joints as we know smoking has a deleterious effect on bone density. So, it's going to be harder for any of those replacements to really stay where they're put and so I can see what you're saying now. What role do you see, Dr. Wright, for smoking cessation programs in that preoperative planning for TSA, but really for any joint replacement. Do you recommend? You said that you don't always recommend it, but if you do recommend it for certain people, this is a very hard thing to do.

Jonathan Wright, MD: While I might have misspoke, I recommend it for everyone. Some of my partners say, "No, I won't even do your joint replacement if you smoke at all." Like in the case of a fracture, someone who hasn't quit smoking but they need a joint replacement, I'll still offer it, but we have a very frank discussion, like quitting smoking's going to be in your best interest for your good. If you can quit now or cut back dramatically, there's a much better outcome you can have long term. And I'll refer them for smoking cessation programs, and those types of things before surgery. I just don't draw quite as hard of a line in the sand. If they have a fracture that needs surgery and they just can't quit smoking, I'll still go ahead and do it if they realize they're at a higher risk of complications and are willing to take that risk.

Melanie Cole, MS: Are there smoking cessation programs that you can refer them to?

Jonathan Wright, MD: I think my PAs have seen some. And often, we rely on the primary care doctors who will prescribe medications for that.

Melanie Cole, MS: But that's an important distinction that primary care then, because that really hits home to the multidisciplinary factor to this. And if someone's going in for TSA, then primary care can help work with them before this happens.

Jonathan Wright, MD: Oh, for sure. The primary care doc's huge, because even when I interact with these people, I'll see them a couple times before surgery, then after surgery. We see them for three months regularly, then the visits stretch out from there. The primary care doc is going to be with that patient for a long time. So, sometimes I've used the joint replacement as the impetus to get them to quit smoking. But then, hopefully, they can continue that for a long time. The primary care doc is integral in that. They'll have that continuity of care with smoking that I just won't have with these patients.

Melanie Cole, MS: Dr. Wright, this is really an interesting topic and very eye-opening for Orthopedic Medicine. I'd like you to just kind of summarize the results of your study. What did you learn and want to pass on to listeners about the fact that smoking is not only associated with early postoperative complications, but also has this effect on long-term functional outcomes and possibly survivorship of the implants? Give us a good summary and key takeaways.

Jonathan Wright, MD: The key thing because when I counsel patients, I tell them if you have one of these complications, it's devastating and smokers are more likely to have them. But if you look at the overall complication rate of an infection, it's less than 5% even for smokers. So, that honestly wasn't enough for some of my patients to get them to quit smoking. And they often tell me, "Oh, I'm a good healer. I won't be one of those 5%." And, I mean, there's a good chance they won't be, right?

So in this study, we actually took out those people that had early complications and looked at the people that did well between two to four years after surgery and followed up. And we compared the smokers to the former smokers to the current smokers, and not looking at their complications, but also their functional outcomes. We have a lot of patient-reported outcome measures, functional scores, pain measures, and we measure a range of motion in these patients too, to see how everyone's doing. And we compared those three cohorts. We actually noticed that between two to four years, the current smokers did worse. Fewer of them achieved what we call the minimal clinically important difference to see improvement after in these outcome measures that include pain and function, but also in the actual range of motion measurements.

So across the board, some of these scores, the smokers did worse. The former smokers also did worse than the non-smokers for a lot of these. So, our data definitely showed when I talk with patients now, I'm not just saying, "You're at a higher risk of complications." I also tell them, "Hey, look, if you continue to smoke, your outcomes won't be able to be as good. You'll have more pain and not as good function two to four years after the surgery as if you had quit smoking compared to if you'd quit smoking. So, getting people knowing that, "Hey, the shoulder pain that's bugging you so much that you want surgery for, it's going to still be worse if you don't quit smoking." That really gives people an impetus, I think, to quit smoking because they're here, they're seeing me because their shoulder hurts so bad. And knowing that quitting smoking is an important part to make their shoulders stop hurting. I think counseling patient, it gives them more of a desire to want to quit smoking before surgery. And so, I think that's huge to getting them to know that, "Hey, your long-term outcomes are affected."

Melanie Cole, MS: Well, that's certainly great advice for physicians listening to be able to counsel their patients who are candidates for shoulder replacement and regarding those benefits of smoking cessation and the risks of continuing to smoke when you are going in for these types of surgeries.

Jonathan Wright, MD: One other thing I wanted to add, on the anatomic side at least, interestingly, we found that former smokers still did a little worse than the non-smokers, but if you compared it to people who had quit smoking more than 10 years ago, their outcomes were very similar to non-smokers. So, it's a time-dependent thing. And while someone currently smoking, getting them to quit six weeks before surgery probably still helps. Even in younger people, talking to them, you know, we can counsel that it's not just your lungs and other things, smoking has dramatic effects on all soft tissue healing that can affect you years down the road. So, it behooves anyone to quit smoking as early as possible, even for outcomes such as your joint pain. It'll be better in the long term if you can quit smoking now.

Melanie Cole, MS: That's a good point, and thank you so much for really hitting home on that. So important. And to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.