Cath Lab Digest

Study Examines Effect Of Smoking On Elective Foot Surgery

By Brian McCurdy, Senior Editor

   Although studies have previously shown a link between smoking cigarettes and delayed bone healing, research has until now been scarce on the effects of smoking on elective foot surgery. A recent study in the Journal of Foot and Ankle Surgery finds that bone healing can take as much as 42 percent longer in patients who smoke.

   Researchers analyzed 46 patients who had undergone Austin bunionectomies and separated the patients into three groups according to nicotine use. Seventeen patients were smokers, 12 were secondhand smokers and 17 did not smoke as measured by the standardized modified Fagerstrom test and a urine test. The study determined bone healing with the use of post-op radiographs.

   The healing time after the Austin bunionectomy was 69 days in non-smokers, 78 days in secondhand smokers and 120 days in smokers, according to the study. Researchers found that in smokers, the osteotomy took 1.73 times longer to achieve radiographic bone consolidation in comparison to non-smokers.

   Lawrence Fallat, DPM, a co-author of the study, says many of his patients smoke. When he discusses elective surgery, Dr. Fallat will educate smokers on the consequences of lighting up and why it delays healing. When undergoing Austin bunionectomies or any osteotomy of the foot or ankle, smokers should expect to take several weeks longer to heal, according to Dr. Fallat.

    “Many will tell me they are going to ‘cut down’ on smoking and that is good, but if they inhale one time, the vasoconstrictive effects of nicotine can last 12 hours. Less blood flow to the osteotomy results in longer healing,” notes Dr. Fallat, a Fellow of the American College of Foot and Ankle Surgeons.

   If smokers still choose to have elective surgery after being educated on the possible risks with delayed healing, Dr. Fallat will use extra fixation to achieve better stability and will keep patients non-weightbearing. Using those measures, he can usually overcome the disadvantages of smoking. Dr. Fallat also uses heparin postoperatively on all smokers.

   However, he will not perform ankle fusions, malleolar osteotomies or triple arthrodeses on smokers given the high risk of nonunion in this patient population.

   William Fishco, DPM, has encountered delayed union, nonunion and wound healing problems with patients who smoke. He also says wound dehiscence is a “real problem” and says the larger joint fusion cases are more prone to delayed healing. If patients smoke and need a fusion, Dr. Fishco will not refuse them.

    “I personally believe that although everyone knows that tobacco kills, it is an addiction that is hard to overcome. These are real people having real problems (with their foot/feet) that oftentimes need surgery to get better,” says Dr. Fishco, a Fellow of the American College of Foot and Ankle Surgeons.

   As Dr. Fishco notes, depression can sometimes go hand in hand with chronic pain, contributing to the need to smoke. He will have a candid conversation with potential surgery patients who will not quit smoking before surgery. Dr. Fishco conveys the real risk of the bone(s) not healing and notes that subsequent surgery may be required if that should happen. He uses a bone growth stimulator immediately after the surgery instead of waiting six to eight weeks when there are not enough radiographic signs of bone healing.

Online Poll Questions Lasers For Onychomycosis

By Lauren Grant, Editorial Assistant

   While lasers may provide emerging treatment options for onychomycosis, will DPMs be receptive to the technology? A majority of those who responded to a recent poll on the Podiatry Today Web site feel lasers would not be effective.

   With a total of 228 responses, 63 percent (144 votes) of DPMs responding to the poll feel that laser care is not a viable option for treating onychomycosis while 37 percent (84 votes) believe it is a viable option.