The Smoking Gun

Dr Christopher Vertullo
A/Prof Griffith University

A 32-year-old entertainment industry technician presents to an Orthopaedic surgeon for a second opinion. He described an injury after a night of celebration where he fell and suffered a closed transverse fracture to his right patella 9 months prior. He was taken by ambulance to the emergency room of his local public hospital and on the following day open reduction and internal fixation of his fractured patella was undertaken with a tension band. Intraoperative imaging was then commenced and this confirmed that the surgeon had achieved an anatomic reduction of the fracture with a tension band wire. 

The patient was initially managed in a splint, touch weight-bearing on crutches and range of motion exercises were started two weeks later. Initial radiographs at 8 weeks suggested anatomic reduction was maintained. However, at 3 months a delayed union was diagnosed, and at 7 months a non-union was noted, with fixation wire breakage, and displacement of the fracture fragments. The patient also complained of severe pain and stated he is "extremely disappointed" with the care received at the hospital. 

The surgeon noted at the time that the patient was an active smoker consuming 1.5 packets per day since he was 16 years old. 

The outpatient notes from the public hospital contained multiple references to advice that was given to the patient in regards to not smoking peri-operatively, advice that was not followed by the patient.

The surgeon recommended revision fixation with bone grafting; however, only if the patient were to stop smoking. 

Due to recurrent failure to smoking in the past, the patient was referred to a psychologist, and once the smoking cessation was confirmed, the revision surgery was completed successfully.

Take home messages: 

1. Patient's and sometimes medical staff, have a cognitive bias to downplay the effects of smoking on postoperative complications.

2. Smoking increases infection risk, thromboembolism risk and non-union risk by 300-500%

3. Nicotine patches still increase the risk of complications, particularly non-union 

4. Elective surgery should not be undertaken until smoking has ceased

5. Patients who smoke are more at risk of musculoskeletal trauma, and hence complications

6. Many patients require psychological support to alter their behaviour.