Description of the condition
Total knee and hip arthroplasty (TKA and THA) are very common surgeries performed in patients who suffer from pain and functional limitation due to symptomatic arthritis, when medical management has failed. These surgeries are usually elective, and are associated with excellent outcomes including significant improvement in function, quality of life and reduction in pain severity (Ethgen 2004; Kane 2005). Some people fail to improve dramatically after THA/TKA; this may be related to the presence of several non-modifiable and modifiable risk factors, such as obesity, comorbidity and depression (Brander 2003; Brander 2007; Santaguida 2008; Singh 2008; Singh 2009; Singh 2010a; Singh 2010b). One common risk factor in this arena that is receiving increasing attention is smoking (Singh 2011a), which is a modifiable risk factor.
Description of the intervention
Smoking is a modifiable risk factor. A variety of smoking cessation interventions that include behavioral and pharmacological components have been examined for improving the quit rates in smokers (Annonymous 1996; Carmody 2008; Prochazka 1992; Prochazka 1998; Prochazka 2004; Simon 2003). Smoking cessation programs have been implemented in surgical populations (Quraishi 2006, Sorenson 2007, Villebro 2008, Wolfenden 2008). Although challenges to smoking cessation exist (CDC 1990), these programs can be implemented. Smoking cessation can have a positive impact on postoperative complications (Yamashita 2004).
How the intervention might work
Smoking cessation interventions include behavioral modification or pharmacological interventions (including nicotine replacement therapy), or both. These interventions help to reduce the symptoms of nicotine withdrawal, and thus improve the quit rates in people attempting to quit smoking. Decreasing the exposure to nicotine decreases the detrimental effect of current smoking on intra- and postoperative complications. Several short-term post-arthroplasty complications have been linked to current smoking, such as surgical site infections, pneumonia, stroke and one-year mortality (Singh 2011a). In addition, a systematic review showed that current smokers were significantly more likely to have postoperative complications and death compared to nonsmokers (Singh 2011b). Smoking cessation in the perioperative period is likely to decrease the risk of some of these complications compared to active smoking in the perioperative period.
Why it is important to do this review
Smoking is a modifiable risk factor for these elective surgeries. Knee and hip replacements are very common surgeries worldwide; in the USA alone, one-million procedures are performed per year (Kurtz 2007). If evidence supports the hypothesis that perioperative smoking cessation decreases post-operative complications, interventions to modify this risk in the pre- or post-operative period can be implemented. Although a Cochrane review on preoperative smoking cessation in surgical patients exists (Thomsen 2010), that review included all surgeries in its analyses. Since THA and TKA are almost always elective surgeries, and the recovery period - as well as complications - after THA or TKA are different from several other surgeries, it is prudent to perform a Cochrane review to assess smoking cessation interventions that is limited to this population.