Patients who smoke have a higher risk for nonunion, non-healing wounds and other complications. Offering insights from the literature and their experience, these authors discuss the impact of smoking on surgical outcomes, timing issues with smoking cessation and pertinent pearls for improving surgical results in patients who continue to smoke.
Cigarette smoking is a major health and economic concern. Smoking is well known to have destructive effects on the respiratory, cardiovascular, endocrine and immune systems.1 The adverse health effects from cigarette smoking account for an estimated 443,000 deaths or nearly one of every five deaths each year in the United States.2,3 Smoking is the most preventable cause of premature death.
Smoking also has adverse effects on bone, decreasing calcium absorption and increasing bone resorption.4 It is a risk factor for the development of osteoporosis and fractures.4 Smoking has a negative effect on surgical outcomes. Multiple studies have shown that smoking has negative effects on bone, skin and wound healing as well as fusion procedures.5-9
Smoking contains over 4,000 chemicals of which only 109 are known chemicals, including nicotine, benzene, arsenic, hydrogen cyanide and tar. Nicotine negatively impacts fracture healing and bone fusion processes. Nicotine causes the release of catecholamines, which results in peripheral vasoconstriction that causes decreased blood flow, tissue ischemia and oxygen tension as well as depressed osteoblastic activity in bone.10-14 Cigarette smoke contains carbon monoxide, which causes tissue hypoxia by binding to hemoglobin to form carboxyhemoglobin. Carbon monoxide has a high affinity for oxygen and decreases the delivery of oxygen at a cellular level.15 Hydrogen cyanide inhibits the cellular respiratory enzymes.
Various authors have reported the adverse effects of cigarette smoking on wound and bone healing. Looking at the effects of smoking on lumbar fusions, Brown and colleagues found a 40 percent pseudarthrosis rate in smokers versus 8 percent in non-smokers.5 Ishikawa and co-workers found a 18.6 percent nonunion rate in smokers versus 7.1 percent in non-smokers receiving hindfoot fusion.6 Krannitz and coworkers found the healing time after Austin bunionectomy was delayed in smokers and even in secondhand smokers in comparison to non-smokers.7 The authors determined there was a 42 percent increase in the time to bone healing in the smoking group in comparison to the non-smoking group. Studies have shown that nicotine has detrimental effects on tendon to bone healing in a rat rotator cuff animal model.8 Daftari and colleagues showed that nicotine reduced the revascularization of cancellous bone grafts.9
Law and Hackham reported that postmenopausal bone loss is greater in smokers than in non-smokers and that tobacco smoking increases the lifetime risk of hip fracture in women by about 50 percent.15
In addition to its adverse effect on bone healing, smoking can result in an increased risk for infection after surgery. Smoking decreases cutaneous blood flow, which interferes with the natural process of wound healing and leads to an increased complication rate. The Lower Extremity Assessment Project (LEAP) study group showed that current smokers were more than twice as likely to develop an infection and 3.7 times as likely to develop osteomyelitis at the site of open tibial fractures.16
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.
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.
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.
The risks and complications associated with cigarette smoking are well documented. Ideally, the patient will start a smoking cessation program prior to elective surgery. The surgeon must be aware of the complications and make an effort to educate the patient of these risks.
Dr. Fallat is the Program Director of the Podiatric Surgery Residency at the Oakwood Annapolis Hospital within the Oakwood Healthcare System in Wayne, Mich. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Chahal is a second-year podiatric surgery resident with the Oakwood Annapolis Hospital within the Oakwood Healthcare System in Wayne, Mich.
1. Barendregt JJ, Bonneux L, van der Maas PJ. The health care costs of smoking. N Engl J Med. 1997; 337(15):1052-7.
2. Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 2000–2004. MMWR Morb Mortal Wkly Rep. 2008; 57(45):1226–8.
3. Centers for Disease Control and Prevention. Health, United States. Available at http://www.cdc.gov/nchs/hus/previous.htm .
4. Lucas TS, Einhorn TA. Osteoporosis: the role of the orthopaedist. J Am Acad Orthop Surg. 1993; 1(1):48-56.
5. Brown CW, Orme TJ, Richardson HD. The rate of pseudarthrosis (surgical nonunion) in patients who are smokers and patients who are nonsmokers: a comparison study. Spine. 1986; 11(9):942-943.
6. Ishikawa S, Murphy A, Richardson G. The effect of cigarette smoking on hindfoot fusions. Foot Ankle Int. 2002; 23(11):996–8.
7. 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):525-527.
8. Galatz LM, Silva MJ, Rothermich SY, Zaegel MA, Havlioglu N, Thomopoulos S. Nicotine delays tendon-to-bone healing in a rat shoulder model. Bone Joint Surg Am. 2006; 88(9):2027-34.
9. Daftari TK, Whitesides TE Jr, Heller JG, Goodrich AC, McCarey BE, Hutton WC. Nicotine on the revascularization of bone graft. An experimental study in rabbits. Spine. 1994; 19(8):904–911.
10. Hollinger JO, Schmitt JM, Hwang K, Soleymani P, Buck D. Impact of nicotine on bone healing. J Biomed Mat Res 1999; 46(3):438-9.
11. Benowitz NL. Clinical pharmacology of nicotine. Annu Rev Med. 1986; 37:21-32.
12. Forrest CR, Pang CY, Lindsay WK. Pathogenesis of ischemic necrosis in random-pattern skin flaps induced by long-term low-dose nicotine treatment in the rat. Plast Reconstr Surg. 1991; 87(3):518-28.
13. Sørensen LT, Jørgensen S, Petersen LJ, Hemmingsen U, B¨ulow J, Loft S, Gottrup F. Acute effects of nicotine and smoking on blood flow, tissue oxygen, and aerobe metabolism of the skin and subcutis. J Surg Res. 2009; 152(2):224-30.
14. Heliövaara M, Karvonen MJ, Vilhunen R, Punsar S. Smoking, carbon monoxide, and atherosclerotic diseases. Br Med J. 1978; 1(6108):268-70.
15. Law MR, Hackham AK. A meta-analysis of cigarette smoking, bone density and risk of hip fracture: recognition of a major effect. Br Med J. 1997; 315(7112):841-6.
16. Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BM, LEAP Study Group. Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. J Orthop Trauma. 2005;19:151-7.
17. Capen DA, Calderone RR, Green A. Preoperative risk factors for wound infections after low back pain fusions. Orthop Clin North Am. 1996;27:83-86.
18. Kayvanfar JF, Capen DA, Thomas JC, et al. Wound infections after instrumented posterolateral adult lumbar spine fusions. Abstract presented at the Annual Meeting of the American Academy of Orthopedic Surgeons, February 1995, Orlando, FL.
19. Thalgot JS, Cotler HB, Sasso RC, et al. Postoperative infections in spinal implants. Classifications and analysis – a multicenter study. Spine. 1991; 16(8):981-984.
20. Lindström D, Sadr Azodi O, Wladis A, Tønnesen H, Linder S, Nåsell H, Ponzer S, Adami J. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg. 2008; 248(5):739-45.
21. Livingston EH, Arterburn D, Schifftner TL, Henderson WG, DePalma RG. National Surgical Quality Improvement Program analysis of bariatric operations: modifiable risk factors contribute to bariatric surgical adverse outcomes. J Am Coll Surg. 2006; 203(5):625-33.
22. Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002; 359(9301):114-7.
23. Nasell H, Adami J, Samnegard E, Tonnesen H, Ponzer S. Effect of smoking cessation intervention on results of acute fracture surgery. J Bone Joint Surg. 2010; 92(6):1335-42.
24. Moller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg [Br] 2003; 85(2):178-81.
25. Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg 1994; 73(6):911-915.
26. Lind J, Kramhoft M, Bodtker S. The influence of smoking on complications after primary amputations of the lower extremity. Clin Orthop Rel Res. 1991; 267:211-7.
27. Mosley LH, Finseth F. Goody M. Nicotine and its effect on wound healing. Plast Reconstr Surg. 1978; 61(4):570-575.
28. Donley BG, Ward DM. Implantable electrical stimulation in high-risk hindfoot fusions. Foot Ankle Int. 2002; 23(1):13-18.
29. Frey C, Halikus N, Vu-Rose T. A review of ankle arthrodesis: Predisposing factors to nonunion. Foot Ankle Int. 1994; 15(11):581-584.
30. Cobb TK, Gabrielsen TA, Campbell DC II, et al. Cigarette smoking and nonunion after ankle arthrodesis. Foot Ankle 1994; 15(2):64-67.
31. Holt E, Hansen S, Mayo K, Sangeorzan B. Ankle arthrodesis using internal screw fixation. Clin Orthop Rel Res. 1991; 286:21-28.
Editor’s note: For further reading, see “Study Examines Effect Of Smoking On Elective Foot Surgery” in the November 2009 issue of Podiatry Today or“Does Secondhand Smoke Contribute To Delayed Post-Op Wound Healing?” in the May 2007 issue. For other related articles, visit the archives at www.podiatrytoday.com .