Smoking-related complications in foot and ankle surgery: a systematic review

The detrimental effects of cigarette smoking on overall health are well-documented, with nicotine and carbon monoxide contributing to peripheral vasoconstriction and impaired oxygen delivery to tissues. This study reviews the impact of smoking on wound and bone healing, specifically in foot and ankle surgery, given its significant role as a modifiable risk factor for complications in orthopedic procedures.

A systematic literature review was conducted in May 2024 following PRISMA guidelines. An electronic search of PubMed was performed using keywords related to smoking and wound complications in foot and ankle surgery. Inclusion criteria were studies published in English from 1993 to May 2024 focusing on orthopedic procedures. After screening 28 studies, six relevant articles were selected, comprising literature reviews, retrospective studies, and comparative series.

The review highlights that smoking, including smokeless tobacco, significantly increases the risk of complications in foot and ankle surgeries. Smokers show markedly higher rates of non-union, wound infections, and delayed bone healing compared to non-smokers. For instance, smokers exhibit a 14.8% wound infection rate and higher rates of malunion and non-union, with 14.5% vs. 6.7% in non-smokers. Elective procedures such as total ankle replacement (TAR) also show worse outcomes for smokers, including increased infection rates and poorer functional scores. Conversely, smoking's impact on amputation procedures is less pronounced, although complications remain significant in patients with comorbid conditions.

This review underscores the severe impact of smoking on surgical outcomes in foot and ankle procedures. Smoking cessation before surgery has demonstrated substantial benefits, including reduced infection rates and improved healing. Preoperative counseling and smoking cessation programs are crucial for optimizing patient outcomes, and a multidisciplinary approach should be considered to enhance therapeutic strategies. Future studies should focus on refining smoking cessation guidelines and exploring new tobacco alternatives.