How To Address Smoking In The Podiatric Patient

Allen Jacobs DPM FACFAS

Last year, I acted as a moderator for an American College of Foot and Ankle Surgeons (ACFAS) podcast on the subject of complications. The panel consisted of rather well-known and accomplished podiatric surgeons. The subject of smoking came up and interestingly, no panel members stated that they would interdict the performance of surgery in someone who is smoking.

In fact, one panel member stated that if he were to refuse to perform surgery on a patient who smoked that he literally would have no one to do surgery on.

That response in particular, as well as the response of the panel in general, was somewhat surprising to me. Increasingly, I have noticed that the failure to interdict smoking has appeared in malpractice cases in which complications such as postoperative infection or delayed union have been attributed to smoking.

Smoking is associated with an increased risk of problematic soft tissue healing, postoperative infection, delayed union and nonunion.1,2 In addition, research has shown smoking to be associated with an increased risk of thrombosis due to increased risk of platelet adhesion, vasoconstriction and tissue ischemia.1,2

Krannitz and colleagues demonstrated in a study of 46 patients that the healing time for an Austin bunionectomy in smokers was 120 days in comparison to 69 days for a non-smoker.3 In addition, the authors demonstrated that people exposed to secondhand smoke also had a longer duration to heal following the Austin bunionectomy and that the healing time of the Austin bunionectomy in smokers generally resulted in a 42 percent increased healing time in comparison to non-smokers.

In a review of delayed healing of ankle fractures, Dodson and coworkers found cigarette smoking, obesity and diabetes as the major risk factors contributing to delayed healing.4

Research has also demonstrated tobacco use to be associated with increased pain following surgery. Steinmiller and colleagues demonstrated that smokers had more demand for patient controlled analgesia use following surgery in comparison to non-smokers.5 The authors also found that discontinuation of smoking the day of surgery and following surgery resulted in increased demand for opioid analgesics in smokers.

Nicotine utilization results in decreased bone strength, reduced cancellous graft incorporation and decreased vascular ingrowth to bone.6 These effects are reversible after two weeks of smoking cessation. Research has also shown smoking to be associated with the presence of decreased growth factors in bone as well as decreased vascularity. In a study of 85 patients with tibial shaft fractures, smokers had a three to 18 times higher risk of abnormal bone healing.7

Smoking is also associated with a higher postoperative infection rate, higher surgical failure rate and a greater need for revision surgery.3,8 In order to maximize postoperative healing, patients should discontinue tobacco use in the perioperative period, ideally at least two weeks preceding surgery.

As one would expect, smoking is particularly deleterious in those with diabetes or peripheral arterial disease (PAD). In a study of 21 failed transmetatarsal amputations versus 21 successful transmetatarsal amputations, the major risk factors for failure included smoking, as well as hemoglobin A1c greater than 8, the need for postoperative debridement and lengthy duration of ulcerations.9

Cigarette smoke contains over 4,000 chemicals, the most important being nicotine, hydrogen cyanide and carbon monoxide. Nicotine is a strong vasoconstrictor, increases platelet adhesion, impairs fibroblast activity and impairs macrophage activity. Hydrogen cyanide can inhibit oxidative metabolism while carbon monoxide decreases oxygen transport.

In addition to the direct effects of smoking on wound healing, it is well established that smoking is associated with an increased risk of pulmonary pathology and cardiovascular disease. Research has suggested that smoking is an increased risk factor for deep vein thrombosis (DVT) and pulmonary embolism.10 Interestingly, however, one study suggested that smoking may be associated with a small, decreased incidence of postoperative DVT.11

Keys To Effective Documentation Of Smoking Cessation Discussions With Patients

I recall one case in which I was acting as a defense expert for a family physician. The plaintiff was suing for amputation of a leg secondary to PAD. The patient was a smoker and claimed that his primary care physician never informed him that smoking could cause vascular problems. Indeed, there was no evidence in the chart suggesting that the patient was aware of the possible vascular problems associated with smoking. As I had mentioned earlier, patients with complications who pursue litigation against their surgeon or treating doctor for pathology such as ulceration increasingly include in their lawsuits the failure of the treating healthcare provider to interdict smoking.

In general, I believe it is important to recommend that patients stop smoking. One should advise patients that smoking is associated with an increased risk of complications, including delayed union, nonunion, impaired soft tissue healing, poor cosmetic outcome and infection. The medical record should indicate that the healthcare provider has advised the patient of the risks of smoking and the importance of smoking cessation. Include the patient’s agreement to discontinue smoking in the medical record.

When a smoker has surgery, I believe the medical record should show a stronger indication for the need for surgery, knowing that smoking is associated with increased risks of surgical complications. One should include a recommendation for consultation with the patient's primary care physician for smoking discontinuation and, in general, should undergo a documented vascular evaluation appropriate to the individual patient.

A survey of British Orthopaedic Foot & Ankle Society members with regard to smoking demonstrated that while 99 percent of the foot surgeons were "aware" of the effects of smoking, only 84 percent of society members documented smoking in the medical record.12 Furthermore, the survey says only 9 percent of physicians included this in the consent form for surgery. However, 23 percent of those surveyed acknowledged that they had altered their surgical approach due to the potential effects of smoking.

In a study of patients undergoing orthopedic surgery, researchers noted that the majority of patients who smoked continued to smoke up to the day of surgery.13 Smokers had a 3.6 percent wound infection rate in comparison to a 0.6 percent wound infection rate in non-smokers. Ex-smokers had the same complication rate as smokers with double the healing problems following foot surgery.

It is important to document a discussion with the patient regarding the complications associated with smoking. Frequently, patients deny any recollection of a preoperative discussion regarding surgical complications. In a study of foot and ankle surgical patients, physicians discussed 11 risks in a consent form.14 In general, the average risk recollection of patients following such discussions in the postoperative period was one out of 11. The authors included that in general, patients have poor or no recollection of surgical risks discussed prior to surgery.

Documentation for former smokers should include when the patients quit as well as how long and how much they had previously smoked.

In my opinion, the operative note should include any noted abnormalities that could have been attributed to the effects of smoking. The discharge summary as well as discharge instructions should clearly state that the patient received instructions to discontinue smoking in the preoperative period.

Following surgery, the postoperative visit documentation should include, in my opinion, whether or not the patient did or did not stop smoking. If the patient did not stop smoking, give repeated warnings to the patient and document the warnings.

In my experience, the worst case scenario is when a less than optimal surgical outcome, poor wound healing, occurs. Then when there is a recognition of postoperative infection or delayed wound healing, the documenting healthcare provider attributes the poor result to smoking. However, if the medical record indicates no prior warning by the healthcare provider that smoking could indeed inhibit postoperative wound healing, I believe this makes the healthcare provider quite vulnerable in litigation. On the one hand, the healthcare provider is attributing poor outcome to the effects of smoking, acknowledging that smoking can interfere with healing. On the other hand, there is no indication in the chart that the provider indeed recommended smoking discontinuation.

There are several aspects to smoking discontinuation. All of us try for the best outcome in our treatment of patients. Therefore, a recommendation for smoking discontinuation would help to optimize conditions for healing. There is also the issue of medical negligence action as plaintiff attorneys are increasingly pointing to the failure to recommend smoking discontinuation as negligence on the part of the treating healthcare provider.

In Summary

Smoking is associated with an increased risk of poor outcome following surgery or in the treatment of wounds and ulceration. It is my opinion that the patient and healthcare provider are best served by a documented recommendation for smoking discontinuation prior to surgical treatment and during wound care treatment, and postoperatively. One should document the failure of a patient to comply with this request, and also document the repeated recommendation for smoking discontinuation.

References 

1. Lind J, Kramhoft M, Bodtker S. The influence of smoking on complications after primary amputations of the lower extremity. Clin Orthop. 1991; 267:211-17.

2. Silverstein P. Smoking and wound healing. Am J Medicine. 1992; 93(1A):22S-24S.

3. Krannitz KW, Fong HW, Fallat LM, Kish J. The effect of cigarette smoking on radiographic bone healing after elective foot surgery. J Foot Ankle Surg. 2009; 48(5):525-7.

4. Dodson NB, Ross AJ, Mendicino RW, Catanzariti AR. Factors affecting healing of ankle fractures. J Foot Ankle Surg. 2013; 52(1):2-5.

5. Steinmiller CL, Diederichs C, Roehrs T, et al. Post-surgical patient-controlled opioid self-administration is greater in hospitalized abstinent smokers than nonsmokers. J Opioid Manage. 2012; 8(4):227-35.

6. Riebel GD, Boden SD, Whitesides TE, Hutton WC. The effect of nicotine on incorporation of cancellous bone graft in an animal model. Spine. 1995; 20(20):2198-2020.

7. Moghaddam A, Zimmermann G, Hammer K, et al. Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury. 2011; 42(12):1435-42.

8. Capen DA, Calderone RR, Green A. Preoperative risk factors for wound infections after low back pain fusions. Orthop Clin N Am. 1996; 27:83-86.

9. Younger SE, Awwad MA, Kalla TP, de Vries G. Risk factors for failure of transmetatarsal amputation in diabetic patients: a cohort study. Foot Ankle Int. 2009; 30(12):1177-82.

10. National Heart, Lung and Blood Institute. How does smoking affect the heart and blood vessels? Available at http://www.nhlbi.nih.gov/health/health-topics/topics/smo/ . Published Dec. 20, 2011. Accessed Aug. 29, 2013.

11. Edmonds M, Crichton TJ, Runciman WB, Pradhan N. Evidence-based risk factors for postoperative deep vein thrombosis. ANZ J Surg. 2004; 74(12):1082-97.

12. Bhargava A, Greiss M. Effects of smoking in foot and ankle surgery – An awareness survey of members of the British Orthopaedic Foot & Ankle Society. Foot. 2007; 17(3):132-5.

13. Moller A, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg. 2003; 85(2):178-81.

14. Shurnas PS, Coughlin MJ. Recall of the risks of forefoot surgery after informed consent. Foot and Ankle Int. 2003; 24(12):904-8.

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