Smoking and Bone Healing – A Risky Surgical Combination

Imagine being on crutches for weeks following foot or ankle surgery. Imagine the inconvenience and potential loss of income. Then, imagine learning that the bone is not mending. In a study comparing the bone healing rates of smokers and non-smokers, the findings revealed that smokers took nearly 50 percent longer to heal after surgery than non-smokers and the bones of some failed to heal. Foot and ankle surgeons are assessing ways to decrease the dangers posed to smokers during and after surgery and improve their bone health.

Smokers are a high-risk group under any circumstances, but particularly so during and after surgery.  According to foot and ankle surgeons, there are ways to reduce the risks to appropriately treat these patients for the best outcomes possible.

In addition to longer healing times, blood clots, wounds that break open and greater risk of infection are other dangers facing smokers. Perhaps the most serious threat to smokers who have foot and ankle surgery, however, is non-union or failure of the bone to mend. Smokers are four times more likely to experience non-union than non-smokers.

The implications for non-union are serious; they can be costly and time-consuming. In some cases, bones that fail to mend can be treated with a non-surgical bone stimulating device, while some patients require additional surgery. Options include internal fixation using screws or plates to stabilize the bone, external fixation or bone grafts. Bone grafts involve harvesting small sections of bone from the patient or a cadaver and implanting them in the non-healing bone.

What do foot and ankle surgeons recommend for smokers facing surgery? It goes without saying that they'd prefer patients to quit smoking. There hasn't been a great deal of research on the topic, but some preliminary findings indicate quitting smoking for even a few weeks has a significant impact on bone healing. Surgeons who request that patients stop smoking before surgery sometimes conduct pre-operative tests to look for nicotine in the patient's system. If nicotine is present, surgery is delayed.  

Several studies cited in The Journal of Foot & Ankle Surgery, published by the ACFAS, reveal the high incidence of bone healing complications in patients who smoke; the Journal articles stress the importance of smoking cessation prior to surgery and the critical role of foot and ankle surgeons play in pre-operative patient education. Surgeons are urged to inform their patients of the dangers posed by smoking and warn them that a choice to continue smoking can result in delayed bone healing, bone non-union and possibly more surgery. With wide access to smoking cessation counseling and assistive methods, educated and motivated patients are able to better position themselves for optimal bone healing.

While education is appropriate and possible in the case of scheduled surgeries, many foot and ankle surgeries result from accidents or injuries that require an immediate response. In those cases, surgeons recommend quitting smoking at least during the recovery period. While no definitive studies currently exist that suggest the best time to quit smoking before surgery, growing interest in the topic will likely lead to more answers. In the meantime, foot and ankle surgeons will continue to strategize on how to help their patients who smoke obtain the best surgical outcomes.  

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  • Founded in 1942, the American College of Foot and Ankle Surgeons is a specialty medical society of more than 6,000 foot and ankle surgeons. All Fellows of the College are board certified by the American Board of Podiatric Surgery. OUR VISION IS CLEAR: To serve society as the preeminent source of knowledge for foot and ankle surgery. OUR MISSION IS SOLID: To advance the competency of our members and the care of our patients.
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