Abstract
Objectives:
Tobacco use is a known modifiable risk factor for postoperative complications and revision surgery after anterior cruciate ligament reconstruction (ACLR). Prior studies focus on “tobacco” as a broad categorization of traditional cigarette smoking, smokeless tobacco, and other forms of nicotine use. It is unclear if differences in the type of nicotine used lead to similar adverse outcomes after ACLR. Thus, the purpose of this study was to (1) assess the incidence of postoperative complications among ACLR patients who use smokeless tobacco, and (2) compare these outcomes with those of patients who do not use tobacco and those who smoke cigarettes.
Methods:
A retrospective cohort study utilizing a large insurance database was conducted. Patients undergoing primary ACLR without concomitant knee procedures with a minimum 2-year follow-up were included. Smokeless tobacco only users, cigarette only users, and non-tobacco users were matched based on demographic variables and comorbidities. Postoperative complications within 90 days of surgery and subsequent knee surgery within 2 years were compared among groups. Multivariable logistic regressions were employed to control for confounding variables.
Results:
After applying exclusion criteria, there were 241,194 ALCR patients eligible for analysis. Of these, there were 898 (0.37%) patients that used smokeless tobacco only, 22,062 (9.1%) patients that exclusively used cigarettes, and 207,462 (86%) patients that did not use any tobacco products. Compared to non-users, smokeless tobacco users demonstrated increased risk of emergency department (ED) utilization (20.4% vs 8.7%, OR: 6.29; 95% CI: 3.70-10.9, p<0.001), pneumonia (1.2% vs 0.5%, OR: 3.36; 95% CI: 1.41-7.90, p=0.005), and acute kidney injury (AKI) (1.2% vs 0.1%, OR:12.7; 95% CI: 3.77-52.8, p<0.001) within 90 days of surgery. Additionally, smokeless tobacco users had a markedly increased risk of subsequent ACLR (13.5% vs 3.2%, OR: 4.75; 95% CI: 3.60-6.26, p<0.001) and meniscus surgery (12.9% vs 4.9%, OR: 2.89; 95% CI: 2.23-3.73, p<0.001) within 2 years compared to controls. When compared to cigarette smokers, smokeless tobacco users showed increased risk of ED visits (20.6% vs 19.3%, OR: 1.55; 95% CI: 1.25-1.90, p<0.001), pneumonia (1.2% vs 0.6%, OR: 3.25; 95% CI: 1.33-7.78, p=0.008), and AKI (1.3% vs 0.3%, OR: 7.63; 95% CI: 2.72-22.5, p<0.001) within 90 days. They also demonstrated a significantly increased risk of subsequent ACLR (13.4% vs 4.1%, OR: 4.81; 95% CI: 3.58-6.47, p<0.001) and meniscus surgery (12.8% vs 5.5%, OR: 2.45; 95% CI: 2.45-4.26, p<0.001) within 2 years when compared to cigarette smokers.
Conclusions:
Smokeless tobacco use was associated with increased risk of medical complications, ED utilization, and subsequent procedures compared to non-user controls and traditional smokers. These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR.
