Performing Surgery On Smokers: What You Should Know

Lawrence Fallat, DPM, FACFAS, and Ruby Chahal, DPM

   Smoking has also been implicated in postoperative infections.17 In a study of wound infections after adult posterolateral lumbar spine fusions, Kayvanfar and co-workers discovered a significant incidence of infections in smokers as well as obese patients.18 Thalgot and colleagues also found that 90 percent of postoperative infections in elective surgery occurred in smokers.19

What Is The Ideal Timing For Surgery After Smoking Cessation?

Studies have shown that smoking cessation four to six weeks prior to elective surgery decreases the postoperative complications, especially in wound healing.20-23 Møller and colleagues determined that smokers were not only at an increased risk for wound complications but they stayed in the hospital longer than the non-smokers.24 The authors concluded that smoking was the single most important risk factor for the development of postoperative complications, especially those related to wound healing, cardiopulmonary complications and the need for postoperative intensive care with hip and knee arthroplasties.

   The results of experimental laboratory studies and clinical outcomes following surgery clearly indicate the detrimental effects of cigarette smoking and postoperative complications. As a result, many surgeons will not perform elective surgery until the patient has stopped smoking.

   Currently, there are no specific criteria to suggest how long the surgeon should wait after smoking cessation before performing surgery. Rees and colleagues suggest waiting a minimum of 12 hours based on the time it takes to clear carbon monoxide from the blood and return the carboxyhemoglobin to normal.25 Lind and colleagues have suggested waiting one week to operate based on the half-life of free radicals and thrombotic components in tobacco.26

   Following surgery, Mosley and coworkers recommended smoking cessation for at least one week because their data indicates that nicotine can impair the wound healing of incisions for up to 10 days.27 Nasell and co-workers also reported that smoking cessation intervention programs initiated during the first six weeks after acute fracture surgery decrease the risk of postoperative complications.20

   Some foot and ankle elective procedures are considered high risk because of the likelihood of delayed union, nonunion and possibly pseudarthrosis. This would include tibial and fibular osteotomies with allogenic bone grafts, repair of large osteochondral defects with bone grafts, ankle arthrodesis, solitary talonavicular fusions and double and triple arthrodesis.11,28-30 In our experience, it can be difficult to achieve union in first metatarsophalangeal arthrodesis procedures as well as diaphyseal metatarsal fractures, pilon and comminuted Weber C fibular fractures in patients who are smokers.

   In cases like these, the foot and ankle surgeon has the option of not performing elective surgery until the patient stops smoking. Many hospitals, communities and even health insurance companies sponsor smoking cessation programs that educate the patient in the many adverse risks of smoking. The program should include a discussion of the risks of surgery associated with smoking.

   Trauma of the foot and ankle usually does not give patients time to enroll in a program preoperatively but if they are hospitalized, a smoking cessation program can start in the hospital or they can enroll in a program after discharge.

Pertinent Pearls For Performing Surgery In Smokers

If you decide to operate on the nicotine addict who cannot stop smoking, there are several options that can minimize the risks of delayed union and nonunion.


I believe a few years ago I read in one of the major journals that you never do elective surgery on a smoker. I've abided by that rule for over 20 years. If they were in enough pain that they needed to consider foot surgery, they were referred back to their primary care doctor to get help to stop smoking before the surgery was scheduled. If there were ever doubts they had quit, a nicotine level was run a day or so before the case was to be scheduled.

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