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The Foot 17 (2007) 132–135

Effects of smoking in foot and ankle surgery—An awarenesssurvey of members of the British Orthopaedic

Foot & Ankle Society

Amit Bhargava ∗, M.E. GreissDepartment of Orthopaedics & Trauma, West Cumberland Hospital, Hensingham, Whitehaven,

Cumbria CA28 8JG, United Kingdom

Received 22 May 2006; received in revised form 22 November 2006; accepted 5 December 2006

bstract

A survey of members of the British Orthopaedic Foot & Ankle Society (BOFAS) was undertaken to document surgeons’ awareness of theetrimental effects of smoking in patients undergoing elective foot and ankle surgery and the measures they take to prevent these problems.he survey was returned by 104 of the 225 surgeons (47%). One hundred and two (99%) surgeons were aware of the damaging effects ofmoking in foot and ankle surgery. Eighty-nine (84%) of these recorded the smoking habits of their patients in their dictated notes. However,nly 9% of respondents recorded the smoking habits of their patients in the consent forms and warned them about potential risks andomplications at the time of consenting. Twenty-four surgeons (23%) used eleven different protocols in an attempt to reduce smoking related

perative complications. When asked, if there should be a unified policy amongst Foot & Ankle Society members to deal with smoking relatedroblems, 64% agreed to it. The remaining 34% were against this idea. However, 33% of those who were against the idea of a unified policyere interested in having evidence based information and recommendations to improve awareness amongst themselves and their patients.2007 Elsevier Ltd. All rights reserved.

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eywords: Awareness survey; Smoking; Foot Society

. Introduction

Every 10 s, somewhere in the world, someone dies ofobacco-related causes. The adverse effects of smoking onhe cardiovascular, respiratory, endocrine, and immune sys-ems have been well documented, and the medical cost to theociety has recently been assessed [1,2]. Smoking has alsoeen found to have major effects on the musculoskeletal sys-em and is considered a risk factor for the development ofsteoporosis and senile fractures [3].

Several studies have shown that the results of lower limb

rthroplasty, tibial shaft fracture healing, spine and hind footrthrodesis are also adversely affected by cigarette-smoking.t accounts for poorer clinical outcomes, lower rates of

∗ Corresponding author at: 15, Princes Meadow, Gosforth, Newcastlepon Tyne, Newcastle Upon Tyne NE3 4RZ, United Kingdom.el.: +44 191 2846463.

E-mail address: amitb03@aol.com (A. Bhargava).

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958-2592/$ – see front matter © 2007 Elsevier Ltd. All rights reserved.oi:10.1016/j.foot.2006.12.001

racture union, bony fusion and higher rates of postoperativenfection and wound breakdown in smokers [4,5]. Initially,t was postulated that the lower rate of consolidation ofrthrodesis among smokers was due to a lower oxygen-arrying capacity of the bloodstream [4]. However, it wasecently demonstrated in an animal model that nicotinetself has a direct negative impact on bone and graft healing6,7]. Smoking is also shown to be detrimental to superficialound healing.Data on surgeon’s awareness and their practices to over-

ome the adverse effects of smoking in elective foot surgerys limited. The purpose of this study is to report the resultsf a survey of foot and ankle surgeons assessing their aware-ess of the detrimental effects of smoking and the measureshey take in their practice to prevent them. We specifically

ddressed the issues of explaining smoking related risks tohe patient and mentioning them on the consent form. Addi-ionally surgeons were asked whether they would consideraving a unified BOFAS policy on this issue.

A. Bhargava, M.E. Greiss / The Foot 17 (2007) 132–135 133

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astaof these, 33% surgeons were interested in having evidencebased information and recommendations to improve aware-ness amongst themselves and their patients (Fig. 3).

Table 1

No. of surgeons Protocol they are practicing to combat deleteriouseffects of smoking in their practice

2 We do not operate for hind foot fusion until patientstops smoking

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. Material and methods

All the members of the British Orthopaedic Foot & Ankleociety (BOFAS) were sent a survey (Fig. 1) on a single A4heet assessing their awareness of adverse effects of smokingn elective foot and ankle surgery.

They were asked if they recorded the smoking habits ofheir patients in the dictated notes. Surgeons were also askedf they warn smokers about higher rates of operative compli-ations and if they recorded this information on the consentorm. Additionally they were asked about the measures theyake to prevent smoking related peri-operative complicationsnd if they would like to have a unified policy amongst theociety members to tackle this issue.

. Results

The survey was returned by 104 of the 225 surgeons. Oneundred and two (99%) surgeons were aware of the damagingffects of smoking in foot and ankle surgery. Eighty-nine88%) were of the view that smoking affects the results ofoot and ankle surgery by a moderate to severe degree. Onhe contrary eight (7%) thought that the effect of smoking

as only mild. Two (1.5%)surgeons said that smoking has no

ffect on the results of surgery and five (3.5%) were unsuref this (Fig. 2).

Fig. 2. Results.

222

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421

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Eighty-six (84%) surgeons recorded the smoking habitsf their patients in their dictated notes. However, only 9% ofhe respondents recorded the smoking habits of their patientsn the consent forms and warned them of the risk of com-lications. Interestingly only 24 surgeons (23%) reportedaking any preventive measures. They took various measuresased on their information and beliefs. Eleven different proto-ols were being followed by different surgeons are tabulatedelow (Table 1).

Sixty-four percent of the surgeons were keen on havingunified policy amongst BOFAS members to deal with the

moking related problems. The remaining 34% were againsthis idea and thought it should be left to individual patientsnd surgeons to decide between themselves. However out

Protocol varies with type of surgeryStop smoking 2 weeks before surgeryStop smoking 2 weeks preoperatively and until 6weeks postoperativelyStop smoking 2 weeks preoperatively and untilwound healing/fusionStop smoking 3 weeks pre- and postoperativelyStop smoking 4 weeks preoperatively and untilwound healing or fusionStop smoking 6 weeks preoperativelyStop smoking 6 weeks pre- and postoperativelyStop smoking 6 weeks preoperatively and untilfusion/wound healingReduce as much smoking as possible preoperativelyand intranasal oxygen during recovery from surgery

134 A. Bhargava, M.E. Greiss / The

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Fig. 3. How to combat smoking related problems in practice?

. Discussion

A literature review gives conflicting reports about theffects of smoking on general orthopaedic and foot and ankleurgery. Some studies clearly indicate the increased rate oferi-operative complications in smokers [8–11] but othersail to prove any strong correlation [12,13]. However, closernalysis of studies denying a link between smoking and peri-perative complications reveal that they are few in numbernd show a small sample size, from which it may be difficulto draw conclusions. In a recent Cochrane review by Mollert al. [14] it was concluded that there is clear evidence thatmokers are at increased risk of complications after surgeryut there was limited direct evidence that stopping smokingefore surgery reduces wound and bone healing complica-ions. This was mainly because of the paucity of randomisedtudies looking at the effects of smoking cessation on theseeri-operative complications.

About a third of all the patients who undergo surgery aremokers. Smoking has repeatedly been shown to be an impor-ant risk factor for intra and postoperative complications [15].mokers have an increased frequency of pulmonary, circu-

atory, infectious complications, impaired wound and boneealing [16,17] and postoperative admittance to the intensiveare unit [19].

Tobacco combustion in cigarettes releases tissue-amaging oxygen free radicals [20], in addition to tar,mmonia, formaldehyde, lead, and many other unidentifiedrganic particulates [21]. Inhaled carbon monoxide reducesissue oxygenation and impairs the microcirculation withinealing soft tissue and bone [18,19]. Nicotine is also a potentasoconstrictor [22] and impairs the revascularization ofealing bone [18].

Findings of physiological studies have shown that most ofhe smoking induced changes are reversible to some degree,nd that the period needed for a substantial improvement isbout 6–8 weeks [23]. Warner et al. [24] showed that patientsho stopped smoking 8 weeks before cardiac surgery had

ewer pulmonary complications than smokers. Moller et al.19] have shown that 6–8 weeks preoperative smoking ces-ation leads to significant reduction in postoperative woundelated and cardiovascular complications in patients undergo-ng arthroplasty. The mechanism probably involves recovery

f the amount or the structure of collagen, and of the immuneapacity, improved oxygenation of peripheral tissues, andeduced vasoconstriction induced by nicotine [19]. It washown in a study by Cobb and his colleagues that smokers

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Foot 17 (2007) 132–135

ave a 16-fold risk of nonunion of fracture as compared toatients without any risk factors [25].

Smokers make up a considerable proportion of the totalumber of patients with postoperative complications. If pre-perative smoking cessation can reduce these complications,he morbidity and financial savings would be substantial [1].n effective smoking intervention programme applied 6–8eeks before surgery could halve the frequency of postoper-

tive complications, with the greatest effect on wound-relatednd cardiovascular complications [19].

Shannon-Cain [26] found that patients were not routinelynformed of the risk of tobacco use or the potential of ben-fit of abstinence before surgery, and concluded that thereoperative period might be an opportunity for smokingntervention.

As seen from the results of our survey most of the Britishrthopaedic Foot & Ankle Society members were very well

ware of the harmful effects of smoking. However some wereess aware of the extent of the problem and means to addresshese. Our survey also shows that surgeons tend to put thisssue aside in the absence of proper information and guide-ines. Lack of information and the absence of a clear strategy

ay be one of the potential causes for not discussing thesessues with the patient and recording them in the case notes.his may also be a cause of not replying to our survey.

Although 23% of the surgeons who replied to our surveyad a protocol for preventing smoking related operative com-lications, we noticed 11 different protocols being practicedy 24 surgeons. There was considerable variation among theurgeons regarding actual measures taken to prevent smokingelated complications in foot surgery. Wright et al. [27] haveroposed three potential sources of clinical disagreementmong surgeons. They include lack of evidence, contro-ersy about existing evidence and lack of awareness and/orcceptance of existing evidence. The clinical disagreementsescribed in the current study probably reflect all three ofhese explanations.

Our study has several limitations. Firstly, the responseate of 47% in our survey was lower than other comparableeported studies. This is known to happen in voluntary sur-eys without any monetary incentive. The sensitive naturef this survey and confusion created by lack of substantivevidence based information in the literature, could also be aontributing factor. This is reflected in the varying preventiverotocols suggested by the surgeons. Secondly, our samplingrame was limited to members of BOFAS, but some generalrthopaedic surgeons undertake foot surgery and we couldot know their views on these issues. However, such limita-ions are unlikely to have any influence on the validity of the

ain conclusion of this study.The majority of foot and ankle surgeons would like the

ociety to work on common evidence based guidelines. Even

hose who do not like this idea agree that it would be useful toave information leaflets for patients explaining the benefitsf smoking cessation. Especially useful would be a aide-meoire giving information regarding smoking and its effects on

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A. Bhargava, M.E. Greis

urgery in general and foot surgery. This initiative we think,ould not only help patients, but also increase awareness

mongst surgeons.Although there is substantial evidence to inform patients

bout the deleterious effects of smoking on surgery includingoot surgery [8–11,19], we do not have sufficient evidence tout a strict time frame on smoking abstinence before and afterurgery. Based on the present evidence, patients should bedvised to stop smoking 6 weeks before surgery until woundr bone healing. This should be highlighted to all at riskatients and final decisions should be left to the individual’shoice and understanding.

There is no doubt that further randomised controlled stud-es especially to measure the direct effects of preoperativemoking cessation on foot and ankle surgery patients woulde helpful.

In summary it is clear from our survey that more needso be done to increase awareness amongst surgeons of smok-ng related problems in foot and ankle surgery. It would beeneficial to have whatever evidence-based information isvailable, in order to increase awareness amongst patientsnd to take appropriate measures for reducing the effects ofmoking and related complications in foot surgery practice.

onflict of interest statement

This is to certify that no financial help was received byny of the authors for planning or conducting this study. Its also not in conflict with any previously published materialnd does not affect the personal or financial interest of anyne.

eferences

[1] Barendregt JJ, Bonneux L, van der Maas PJ. The health care costs ofsmoking. N Engl J Med 1997;337:1052–7.

[2] Kessler DA, Witt AM, Barnett PS, Zeller MR, Natanblut SL, WilkenfeldJP, et al. The Food and Drug Administration’s regulation of tobaccoproducts. N Engl J Med 1996;335:988–94.

[3] Lucas TS, Einhorn TA. Osteoporosis: the role of the orthopaedist. J AmAcad Orthop Surg 1993;1:48–56.

[4] Capen DA, Calderone RR, Green A. Perioperative risk factors forwound infections after lower back fusions. Orthop Clin North Am1996;27:83–6.

[5] Carpenter CT, Dietz JW, Leung KY, Hanscom DA, Wagner TA. Repair

of a pseudarthrosis of the lumbar spine. A functional outcome study. JBone Joint Surg Am 1996;78:712–20.

[6] Daftari TK, Whitesides TE, Heller JG, Goodrich AC, McCarey BE,Hutton WC. Nicotine on the revascularization of bone graft. An exper-imental study in rabbits. Spine 1994;19:904–11.

[

Foot 17 (2007) 132–135 135

[7] Silcox DH, Daftari T, Boden SD, Schimandle JH, Hutton WC, White-sides TE. The effect of nicotine on spinal fusion. Spine 1995;20:1549–53.

[8] Conti SF, Wong YS. Osteolysis of structural autograft after calca-neocuboid distraction arthrodesis for stage II posterior tibial tendondysfunction. Foot Ankle Int 2002;23(6):521–9.

[9] Easley ME, Trnka HJ, Schon LC, Myerson MS. Isolated subtalararthrodesis. J Bone Joint Surg Am 2000;82(5):613–24.

10] Ishikawa SN, Murphy GA, Richardson EG. The effect of cigarettesmoking on hindfoot fusions. Foot Ankle Int 2002;23(11):996–8.

11] Reuben SS, Ablett D, Kaye R. High dose nonsteroidal anti-inflammatory drugs compromise spinal fusion. Can J Anaesth 2005;52(5):506–12.

12] Monroe MT, Beals TC, Manoli II A. Clinical outcome of arthrodesisof the ankle using rigid internal fixation with cancellous screws. FootAnkle Int 1999;20(4):227–31.

13] Suchomel P, Barsa P, Buchvald P, Svobodnik A, Vanickova E. Autol-ogous versus allogenic bone grafts in instrumented anterior cervicaldiscectomy and fusion: a prospective study with respect to bone unionpattern. Eur Spine J 2004;13(6):510–5 [Epub March 20, 2004].

14] Moller A, Villebro N. Interventions for preoperative smoking cessation.Cochrane Database Syst Rev 2005;20(3). CD002294.

15] Schwilk B, Bodmer U, Schraag S, Georgieff M. Perioperative respira-tory events in smokers and nonsmokers undergoing general anaesthesia.Acta Anaesthesiol Scand 1997;41:348–55.

16] Wetterslev J, Hansen EG, Kamp-Jensen M, Roikjaer O, Kanstrup IL.PaO, during anaesthesia and years of smoking predict late postoper-ative hypoxaemia and complications after upper abdominal surgeryin patients without preoperative cardiopulmonary dysfunction. ActaAnaesthesiol Scand 2000;44:9–16.

17] Frick WG, Seals Jr RR. Smoking and wound healing: a review. TexDenty 1994;111:21–3.

18] Gullihorn L, Karpman R, Lippiello L. Differential effects of nicotineand smoke condensate on bone cell metabolic activity. J Orthop Trauma2005;19:17–22.

19] Moller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smokingon early complications after elective orthopaedic surgery. J Bone JointSurg Br 2003 Mar;85(2):178–81.

20] Huang MF, Lin WL, Ma YC. A study of reactive oxygen species inmainstream of cigarette. Indoor Air 2005;15:135–40.

21] Baker RR, Pereira da Silva JR, Smith G. The effect of tobacco ingredi-ents on smoke chemistry. Part I. flavourings and additives. Food ChemToxicol 2004;42(Suppl):3–37.

22] Misery L. Nicotine effects on skin: are they positive or negative? ExpDermatol 2004;13:665–70.

23] Beckers S, Camu F. The anesthetic risk of tobacco smoking. ActaAnaesthesiol Belg 1991;42:45–56.

24] Warner MA, Divertie MB, Tinker JH. Preoperative cessation of smok-ing and pulmonary complications in coronary artery bypass patients.Anesthesiology 1984;60:380–3.

25] Cobb TK, Gabrielsen TA, Campbell II DC, Wallrichs SL, Ilstrup DM.Cigarette smoking and nonunion after ankle arthrodesis. Foot AnkleInt 1994;15(2):64–7.

26] Shannon-Cain J, Webster SF, Cain BS. Prevalence of and rea-

sons for preoperative tobacco use. Am Assoc Nurse Anesthetists J2002;70:33–40.

27] Wright JG, Coyte P, Hawker G, Bombardier C, Cooke D, Heck D, etal. Variation in orthopedic surgeons’ perceptions of the indications forand outcomes of knee replacement. CMAJ 1995;152:687–97.