Performing Surgery On Smokers: What You Should Know

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

   In a study of high-risk hindfoot fusions, Donley and Ward used electrical bone stimulation to supplement rigid internal fixation.28 At a minimum of one year postoperatively, fusion occurred in 12 of 13 patients even though 11 of the 13 patients were smokers.

   One can also consider minimally invasive procedures with percutaneous fixation. This has the advantage of smaller incisions with less vascular and periosteum disruption. Surgeons can perform many foot and ankle procedures in this manner. This includes surgery for calcaneal fractures, LisFranc fractures, metatarsal fractures and many elective forefoot procedures. Surgeons can even close, reduce and fixate some ankle fractures with a bone plate and screws percutaneously.

   Alternate or supplemental fixation that provides greater strength and stability to the osteotomy or fracture can offset non-adherence and a lot of comorbidities such as smoking, osteoporosis and diabetes. Holt suggested that fixation with cancellous screws encourages revascularization by not interfering with the contact of bone to soft tissue as plates do.31 Frey and coworkers also indicated that surgeons can keep the nonunion to a minimum by understanding the predisposing factors and using good compression techniques.29

   Authors have demonstrated that the Austin osteotomy takes longer to heal in a smoker.7 Instead of just using one bone screw for fixation, one may use two screws to provide a more stable osteotomy site.

   Recently, we have been using a low profile bone plate on the Austin osteotomy in high-risk patients like smokers. This type of fixation provides excellent stability in osteoporotic bone, cystic areas in the distal portion of the metatarsal head and greater protection against displacement in a non-adherent patient or a patient who does not have the ability to stay off the extremity.

   Surgeons can even strengthen fixation for the Akin osteotomy when operating on the smoker. Instead of using just an interosseous wire, one can stabilize the osteotomy with a staple or K-wire. Many times, the senior author will combine a staple with insertion of a K-wire from the distal aspect of the toe across the osteotomy site to resist axial loading. Using bicortical fixation with a small, two-hole bone plate also offers very strong fixation.

   It can be difficult to obtain fusion at the talonavicular joint either as a solitary procedure or as part of a double or triple arthrodesis in any patient, let alone the smoker. Good preparation of the joint is essential for union. One must remove all cartilage and there must be bleeding bone with good alignment of the bone surfaces. In the patient who is at a higher risk for nonunion at the talonavicular joint, the senior author will consider intramedullary beaming, primarily using it in Charcot reconstruction. We will insert a large diameter cancellous screw in the medial column through the talonavicular joint, anchoring it into the talar body.

   Insert another screw through the lateral column to stabilize the calcaneocuboid joint. If fusing the subtalar joint, insert one or two large diameter screws from the posterior aspect of the calcaneus into the body of the talus. The combination of large diameter cancellous bone screws, good joint preparation and minimal dissection can provide very acceptable fusion rates, even in the patient with comorbidities.

   Surgeons can use supplemental fixation in ankle fractures in patients at risk for prolonged healing. In addition to conventional forms of fixation, one can stabilize the fractures with hook plates for both malleoli and locking plates, or bicortical fixation for the medial malleolar fractures. The surgeon can create a fibular cage to add greater strength to the fibula by inserting one or two K-wires.


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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