Non-Tobacco Nicotine Tied to Higher Complication Risk After Hip Arthroplasty

New research presented at the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting suggests that nicotine use, regardless of source—traditional tobacco products or newer non-tobacco forms like pouches and lozenges—carries similar risks for complications following total hip arthroplasty (THA). The findings highlight a potential blind spot in pre-operative risk assessment, as clinicians often focus on traditional tobacco use while overlooking the growing prevalence of alternative nicotine delivery systems.

The study, led by Neil P. Sheth, MD, FACS, FAAOS, and colleagues, analyzed data from over 7,400 patients undergoing elective primary THA using the TriNetX Research Network. Researchers categorized patients based on their nicotine dependence: non-tobacco nicotine dependent, tobacco nicotine dependent, and nicotine independent. The goal was to compare post-operative outcomes across these groups, specifically looking at surgical site infections, deep vein thrombosis, and revision rates.

Non-Tobacco Nicotine and Surgical Risks

The research revealed concerning trends for patients using non-tobacco nicotine products. Compared to nicotine-independent patients, those using non-tobacco nicotine faced a 32% increased risk of surgical site infection at 90 days, and a 39% increased risk of hospital readmission within the same timeframe. Looking further out to two years, the risks escalated: a 41% increase in prosthesis loosening, a 38% higher risk of periprosthetic joint infection (PJI), a 79% increased risk of dislocation, and a 40% higher risk of any revision surgery were all observed in the non-tobacco nicotine group.

Importantly, the study found no statistically significant differences in 90-day or 2-year post-operative outcomes between patients who used non-tobacco nicotine products and those who used traditional tobacco products. This suggests that the method of nicotine delivery may not be the primary driver of complications, but rather nicotine exposure itself.

“The conclusion from this study is that maybe we demand to be a little bit more vigilant in the office when we spot patients and actually ask them about nicotine use,” Dr. Sheth told Healio. “An additional question that we need to ask in the realm of questioning for the patient is to say, ‘Are you using any other devices with regards to vaping, e-cigarettes, pouches or lozenges?’ because we think that there’s a risk of it causing complications.”

Understanding the Mechanisms

While the study establishes a correlation, the underlying mechanisms linking nicotine use to these complications remain unclear. Nicotine is known to impair wound healing, potentially increasing the risk of infection. It can also affect blood flow, contributing to the risk of deep vein thrombosis and prosthesis loosening. Research on smoking cessation highlights the complex physiological effects of nicotine, which could plausibly contribute to these adverse outcomes.

The lack of difference between tobacco and non-tobacco nicotine users is particularly noteworthy. Non-tobacco products, such as nicotine pouches and lozenges, are often marketed as “safer” alternatives to smoking, and may be perceived as less harmful by both patients and clinicians. However, this study challenges that assumption, suggesting that the nicotine itself, rather than the combustion products of tobacco, may be the primary culprit.

Study Details and Limitations

The retrospective cohort study utilized data from the TriNetX Research Network, a large, real-world database of electronic health records. This allows for the analysis of large patient populations and provides insights into clinical practice patterns. However, it’s important to acknowledge the limitations inherent in retrospective studies. The data relies on accurate coding of nicotine use, which may be subject to reporting bias. The study cannot establish a causal relationship between nicotine use and post-operative complications; it can only demonstrate an association.

The researchers carefully matched the three cohorts—non-tobacco nicotine dependent, tobacco nicotine dependent, and nicotine independent—for similar comorbidity profiles, attempting to control for confounding factors. However, unmeasured confounders may still exist. For example, patients who use nicotine products may also have other lifestyle factors that contribute to poorer surgical outcomes.

Implications for Patient Care and Public Health

The findings have significant implications for pre-operative risk assessment and patient counseling. Clinicians should routinely inquire about all forms of nicotine use, not just traditional tobacco products, and educate patients about the potential risks associated with nicotine exposure before elective surgery. The Wyanoke Group, parent company of Healio, emphasizes delivering high-quality information to healthcare professionals, and studies like this contribute to that mission.

This research also underscores the need for comprehensive smoking and nicotine cessation programs. While integrated care, combining medication and intensive counseling, has shown promise in helping individuals quit smoking, as highlighted in a recent study, more research is needed to determine the most effective strategies for addressing non-tobacco nicotine dependence.

What Comes Next

Dr. Sheth emphasizes the importance of proactive risk mitigation. “Since we’re so conscientious of cost and value-based care, I think it’s important for us to attempt and alter any factors that put patients at risk for a postoperative complication before any elective surgery,” he stated. Future research should focus on identifying the specific mechanisms by which nicotine impairs wound healing and increases the risk of infection. Prospective studies, with more detailed data collection and control for confounding factors, are needed to confirm these findings and establish a causal link. Investigations into the long-term effects of non-tobacco nicotine products on surgical outcomes are warranted.

For more information, Neil P. Sheth, MD, FACS, FAAOS, can be contacted at [email protected].