Performing Surgery On Smokers: What You Should Know

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

Case Study One: When There Is A Nonunion Following An Avulsion Fracture In An Active Smoker

A 52-year-old female sustained an injury to her right foot after stepping off a curb, twisting her right foot. Her medical history was positive for hyperlipidemia, arthritic changes in the lumbosacral spine and fibromyalgia. She was taking amitriptyline (Elavil, Pfizer), ropinirole (Requip, GlaxoSmithKline), diazepam (Valium, Roche USA) and simvastatin (Zocor, Merck). The patient had a 30-year history of smoking. She had a hysterectomy and multiple surgeries for endometriosis.

   Radiographic examination showed a non-displaced avulsion fracture of the fifth metatarsal in the right foot (see left of photo above). We educated the patient on the adverse effects of smoking regarding the inhibition of bone healing. She wore a non-weightbearing, below-the-knee fiberglass cast for six weeks. Radiographs showed some consolidation at the fracture site but not complete healing.

   After six weeks, she started wearing a controlled ankle motion (CAM) walker. The patient had follow up every four weeks in our clinic and X-rays showed no further healing of the fracture site. The patient reported that she had reduced smoking from one pack of cigarettes a day to one-half pack a day. However, she continued to smoke despite knowing it would delay bone healing and could result in nonunion. The patient continued to have pain at the fracture site.

   At five months after the injury, it became obvious that she had a painful nonunion. She declined the option for surgery. We then utilized a bone growth stimulator. After 12 months, the fracture healed radiographically and pain had resolved even though she continued to smoke (see right of photo above).

Case Study Two: How Additional Fixation Helped Facilitate Healing Of A Fifth Metatarsal Fracture In A 20-Year Smoker

A 59-year-old male sustained an injury to his left foot when he slid off the stairs and fell. The patient’s medical history was positive for chronic low back pain secondary to trauma resulting in multiple back surgeries. The patient has been smoking cigarettes for about 20 years. The patient was on hydromorphone (Dilaudid, Purdue Pharma) for chronic back pain. At times when his back pain was so severe that he could not walk, he would use a wheelchair.

   Radiographs showed a displaced oblique diaphyseal fracture of the fifth metatarsal. We immobilized the patient with a multilayer compressive dressing and scheduled him for surgery. His surgery consisted of open reduction and internal fixation of the fifth metatarsal. We fixated the diaphyseal oblique fracture of the fifth metatarsal with two one-quarter tubular plates. We applied the first tubular plate laterally and fixated it with 2.7 mm cortical screws. We applied the second one-quarter plate dorsally and fixated it with 2.7 mm cortical screws. Additionally, a 0.062 K-wire supplemented the fixation to provide greater strength and stability at the fracture site (see photo at left).

   Postoperatively, the patient wore a non-weightbearing slipper cast after three weeks and a partial weightbearing cast for an additional three weeks. Radiographs revealed early consolidation at six weeks and the patient wore a surgical shoe. The patient transitioned to shoe gear after eight weeks postoperatively and he returned to full activity after 12 weeks.

   The additional fixation helped achieve greater stability of the fracture and offset the detrimental effects of smoking. This resulted in fracture consolidation within a reasonable time and early weightbearing without complications.


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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