SLR - May 2019 - Elena S. Manning

The Effect of Tobacco Use on Incision Healing in Total Ankle Arthroplasty: A Review of 114 Patients

Reference: Cottom JM, Douthett SM, McConnell KK, Plemmons BS. The Effect of Tobacco Use on Incision Healing in Total Ankle Arthroplasty: A Review of 114 Patients. Foot Ankle Spec. 2019 Feb 5.

Scientific Literature Review

Reviewed By: Elena S. Manning, DPM
Residency Program: Mount Auburn Hospital, Cambridge, MA

Podiatric Relevance: CDC reports an estimated 15.5 percent of Americans were active smokers in 2016. With the known long-term consequences of tobacco use, it remains a burden on our healthcare system. The literature has shown that tobacco use adversely affects wound healing outcomes. In the literature, it is stated that the risk of reoperation due to infection in active smokers who undergo hip and knee arthroplasty is 80 percent greater than that in nonsmokers. Yet there is limited literature stating the effect of tobacco use in total ankle replacements (TARs). This level III retrospective comparative study examined the outcomes of those undergoing TAR who were active, former and nontobacco users.

Methods: This is a level III retrospective comparative study. All patients who underwent TAR during a five-year period between March 2012 and July 2017 were considered. Patients were excluded if they had an arthrodesis takedown or revision arthroplasty, as well as those with a history of diabetes mellitus, peripheral vascular disease, poor soft-tissue envelope, history of deep extremity infection or morbid obesity. Patients included in the study were then divided into three groups. Group 1 were active tobacco users. These patients were instructed per surgeon’s protocol to stop usage, were tested using urine nicotine screening tests and were found to be negative for a period of three months. Group 2 included patients who were former tobacco users who had quit for a minimum of 24 months. Group 3 included patients who had never used tobacco. Outcomes included patient demographics, smoking status, implant used, concomitant procedures, postoperative complications and patient-reported outcome scores. 

Results: A total of 221 patients underwent TAR between March 2012 and July 2017. Group 1 included 11 active smokers, Group 2 included 38 former smokers and Group 3 included 65 never smokers. In those who were current tobacco users (Group 1), 45.5 percent (5/11) had wound complications. Group 2 had a 10.5 percent (4/38) wound complication rate, and Group 3 had a 12.3 percent (8/65) wound complication rate. Wound complications ranged from superficial infections needing incision and drainage and VAC therapy or flap closure to deeper infections causing implant failure resulting in a BKA, fusion or revision arthroplasty. The wound complication rate when comparing active smokers (Group 1) to never smokers (Group 3) was found to be statistically significant using the Fisher’s exact test (P=0.0223). Wound complication rate was not statistically significant when comparing former smokers (Group 2) to never smokers (Group 3). 

Conclusions: This study shows that active use of tobacco in patients undergoing TARs have a significantly higher wound complication rate compared to former smokers and nonsmokers. This data is similar to what has been reported in hip and knee arthroplasty literature. The study is limited by its retrospective design, as it relies on data, which had been collected. Thus, there is a possibility that some patients were active smokers who chose not to report it. In conclusion, this study shows the importance of smoking cessation prior to total joint replacement surgery and highlights the effects in TAR patients. It also raises the question on the effect of the length of smoking cessation on healing potential. 

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