RISK FACTORS: SMOKING
Smoking cessation should be attempted before total knee arthroplasty, as a history of smoking may result in higher complications, lower functional scores, higher pain scores, and SSIs.

Rationale

This recommendation has been downgraded for imprecision. There is one low quality study (An, 2021) assessing female patients who are heavy smokers compared to no smoking and mild smokers and their outcomes after total knee arthroplasty. The study reports lower HSS, ROM and SF-Physical. The study also demonstrated higher SSIs and higher pain scores in the heavy smoking group. Even though, our total knee arthroplasty specific inclusion criteria led to limited evidence, it is a widely accepted in the total knee arthroplasty literature that smoking is an independent risk factor.

Benefits/ Harms of Implementation

The risks associated with performing total knee arthroplasty on patients with heavy smoking history may include lower functional scores and higher SSIs which may increase the financial resources needed to manage some of these issues.

Outcome Importance

Patients who smoke have higher rates of complications after total knee arthroplasty.

Cost Effectiveness / Resource Utilization

Smoking has been shown to increase complications such as SSIs which would increase use of resources such as antibiotics and the need for consulting services which may increase the cost.

Acceptability

The recommendation comes with high acceptability.

Feasibility

Since smoking may increase complications in patients after total knee arthroplasty, it is reasonable to achieve smoking cessation before surgery.

Future Research

There were no high quality and three low quality studies (Naylor 2017, McLawhorn 2017, Padgett 2018) evaluating whether discharge to an acute rehabilitation facility or skilled nursing facility improve outcomes and/ or decrease complications compared with discharge to home, with or without home services.

McLawhorn (2017) showed fewer adverse events and readmissions with home discharge. Padgett (2018) demonstrated a higher length of stay with home discharge, but no difference in adverse events. Naylor (2017) showed significantly better functional scores with home discharge. In the absence of reliable, comparative studies a consensus recommendation was made by the workgroup.

It is worth noting that literature comparing costs associated with discharge disposition was not included for analysis.

Benefits/ Harms of Implementation

There are no known harms associated with implementing this recommendation. The decision to discharge a patient to home versus post-acute care facility should be made with consideration of patient’s medical complexity and postoperative function. The practitioner should be aware of the advantages and disadvantages of specific discharge disposition.

Future Research

Higher-quality studies are needed to compare outcomes associated with discharge disposition following total knee arthroplasty.