Primary shoulder arthroplasty in tobacco users: a systematic review of patient-reported outcomes and complications in 338,117 cases

Abstract

Background

The purpose of this systematic review was to characterize the association between tobacco use and postoperative outcomes, complications, and revision rates following shoulder arthroplasty through a systematic review of the literature.

Methods

The PubMed/MEDLINE and Embase databases were queried for studies published between January 1, 1985, and April 18, 2023, comparing outcomes following both anatomic and reverse total shoulder arthroplasty (TSA) between tobacco users and nontobacco users. Studies with a level of evidence IV or greater were included, while case reports, systematic reviews, basic science studies, and studies including revision arthroplasty were excluded. American Shoulder and Elbow Surgeons scores, simple shoulder test scores, visual analog scale for pain, complications, readmissions, and reoperations were reported.

Results

A total of 20 unique studies including 338,117 shoulder arthroplasties (38,225 [11.3%] performed on tobacco users) were included in this review. Patient-reported outcome measures, including American Shoulder and Elbow Surgeons, simple shoulder test, and visual analog scale, were overall superior in nontobacco users compared to tobacco users. Similarly, tobacco users had lower patient acceptable symptomatic state achievement, worse Single Assessment Numeric Evaluation scores (odds ratio 0.647; 95% confidence interval, 0.324-1.293; P = .0221), and worse constant scores (odds ratio, 0.478; 95% confidence interval, 0.251-0.909; P = .027). Tobacco users demonstrated a higher rate of complications in four of the eight included studies. Two included studies found higher rates of readmission in tobacco users (15.3% vs. 13.6%, P = .007 and 7.8% vs. 7.1%, P = .001), though six included studies found no significant difference in readmissions. Nine of 11 studies that included reoperation as a variable found higher rates of reoperation in tobacco users, with three reaching statistical significance (P < .05). Tobacco users experienced higher rates of gastrointestinal complications (0.07% vs. 0.01%, P = .021), acute renal failure (2.5% vs. 1.9%, P = .005), acute respiratory distress (1.3% vs. 0.9%, P = .002), need for ventilator assistance (1.2% vs. 0.7%, P < .001), instability of the prosthesis (P < .001), pneumonia (P < .001), sepsis (P = .001), and myocardial infarction (P < .001). Smokers also demonstrated increased postoperative opioid use (2643 mg oral morphine equivalents) compared to nonsmokers (2121 mg) and former smokers (2015 mg; P = .04).

Conclusion

Tobacco use is associated with inferior outcomes after TSA, including lower patient-reported outcome measures, increased complications, and higher reoperation rates. Further high-level, prospective studies with long-term follow-up are required to further elucidate the impact of tobacco use on long-term postoperative outcomes following TSA.