Foot surgery and smoking

[mandrew]

What are the thoughts on doing elective foot surgery on smokers?

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[HardRoadPaved]

Same thought as sex with a hooker. Might feel great in the moment but you dont know what fresh hell awaits you afterwards.

 

[Feli]

Dude, it's obvious you're fresh outta residency and looking to cut, but you know these answers. Tons of literature...

Smokers heal worse.
More nonunion.
More infections.
More CRPS.
More lawsuits.
More stinking up your exam rooms.
More stinking up waiting room.
Some payers won't auth elective surg for smokers.
Some PCPs won't say smokers are medically optimized.
More VTE events.
More anesthesia complications.
More pain med dependence.
Etc etc etc

....find better ppl to operate on. Smokers (beyond party years) are psychologically weak and feeble people. Tell them all the worst complications that can happen with surgery, and get them a wonderful pad or insole. When a 55yo smokes or dresses crazy or needs a support animal just to leave the house, see 99 red flags.

Let the loser associate down the street get the weekend call from ER for infection or 10/10 pain because they operated on dingbats.

Yes, we are saturated... no, you don't have to operate on literally anyone. Abfas qual lasts 7 years.

 

[Hybrocure]

normal smokers don’t go to the doctor, only the crazy ones do.


Use this information how you will

 

[Retrograde_Nail]

I just did an achilles debridement/repair with partial excision of calcaneus and gastrocnemius recession for calcific achilles tendinosis on a patient who smokes 8 cigarettes a day. Patient incisions healed fine. As long as their perfusion is adequate and they have palpable pulses it really does not matter.

Yes smoking can cause delayed soft tissue and bone healing. Explain it to the patient. Document it. But it should not prevent you from offering surgery when all conservative modalities have failed and the patient needs the procedure.

This is another reason to learn and embrace MIS surgery. More and more of the traditional procedures you were taught can now be done MIS.

You are a podiatrist. You get all the patients nobody will see or treat. Time to walk the walk. Or sit in the corner and clip toenails trying to bill level 4 visits because you spent 45 minutes talking to an old lady about her crusty nails.

 

[josebiwasabi]

for me, smoking is not simply a binary yes/no. the amount of smoking matters. how long does a pack last them? whatever answer they give you, they probably smoke about 2x that amount.

i usually refer to the PCP for smoking cessation with the patch, etc. i make the patient jump through a bunch of hoops until they are down to <1/4 PPD. i have had some patients successfully quit smoking entirely because they were so motivated to have their surgery done.

i forget what the paper is, but it showed that if a smoker stops for 6-8 weeks prior to surgery until the end of acute postop they have similar wound and bone healing issues to a non smoker.

the more concerning patients are the meth or crack users who say that they quit drugs because it's been 3 weeks since they last used.

 

[msion]

Do them after you get board certified.

Otherwise getting a case like this audited for boards is not fun, speaking from experience.
Mine was a Lapidus with an asymptomatic nonunion in a smoker.
I documented a heck of this. I refused surgery. Patient really wanted it. Made the patient sign an extensive informed consent form. Got 3 months of lab work prior to the surgery. Then documented patient immediately went back on smoking right after the surgery.

The smokers simply won't quit smoking just for a foot surgery. They may quit after getting a MI or lung nodules.

 

[Feli]

Do them after you get board certified.

...

Yes.
You'll get grilled on ABFAS doing surgery on psych pts, smokers, high HbA1c, etc.

It's a funny paradox that inexperienced podiatrists badly want cases and will "find" them - yet they dont want to fail boards. Meanwhile, experienced cert docs are usually smart enough to avoid bad candidates. So really, neither group should do elective on smokers.

...After cert, up to the pod. It's a issue of ethics, patient safety, how many headaches and legal risks the doc wants. It is also typically an issue of employment/malpractice situ... private group/solo vs hospital/govt situation work.

I agree the smokers don't quit. The party/social smokers are under 30ish. The heavily addicted daily adult smokers don't quit. They lie and minimize their tobacco use. They have major health effects from years and years of it and sadly view a cigarette as "the answer" to any bad day, pain, anxiety... they will smoke immediately at the slightest stress (ie pre and post op).

 

[MortonExtension]

I will never do an elective case on a smoker. Don’t even like doing nail avulsions on them

 

[Sweatshirt]

I don't do it unless it's something small like a ganglion. No bone work. Don't be so eager to cut on people, the headaches aren't worth it. I've had several smokers get pissy at me after I told them no surgery. Imagine their attitude after they have a dehisced incision or non-union and blame me

 

[DYK343]

I don't do it unless it's something small like a ganglion. No bone work.

This.

I just did an achilles debridement/repair with partial excision of calcaneus and gastrocnemius recession for calcific achilles tendinosis on a patient who smokes 8 cigarettes a day. Patient incisions healed fine.

For me too risky. If it didnt heal fine staring at the achilles really sucks.

 

[Retrograde_Nail]

This.


For me too risky. If it didnt heal fine staring at the achilles really sucks.

When 50% of your practice is revising stuff from other people and some of your own cases plus you are confident in doing wound care and muscle flaps and frames nothing really bothers me these days.

 

[MicroPod]

Took out a lipoma on a smoker last week. Was kinda conflicted about it but they are young and had good circulation.

I have had to tell a few patients already that I won’t do any surgery (bone involved) on them unless they are able to quit smoking for a long period of time.

 

[air bud]

I will never do an elective case on a smoker. Don’t even like doing nail avulsions on them

This

 

[Flip-flop-flerpity]

I do take time to explain to smokers why I'm hesitant to operate- my experience is they're less likely to feel discriminated against or drop a negative review if they understand the risks. They still really want the procedure? Fine, show me you can quit for 6 weeks pre-op and 6 weeks post-op- Ive yet to be burned by these rules. I tell them that if they want to go back to smoking after 3 months without- fine by me. But be prepared to have a pre-op cotinine the week prior- and elective surgery cancelled if positive. The motivated patients will abide, and those that won't will find the next DPM to do it.

 

[deleted285117]

I do take time to explain to smokers why I'm hesitant to operate- my experience is they're less likely to feel discriminated against or drop a negative review if they understand the risks. They still really want the procedure? Fine, show me you can quit for 6 weeks pre-op and 6 weeks post-op- Ive yet to be burned by these rules. I tell them that if they want to go back to smoking after 3 months without- fine by me. But be prepared to have a pre-op cotinine the week prior- and elective surgery cancelled if positive. The motivated patients will abide, and those that won't will find the next DPM to do it.

Not gonna lie just had to look up cotinine.

I like it though. I think that's a good method you got goin'.

 

[Feli]

I do take time to explain to smokers why I'm hesitant to operate- my experience is they're less likely to feel discriminated against or drop a negative review if they understand the risks. They still really want the procedure? Fine, show me you can quit for 6 weeks pre-op and 6 weeks post-op- Ive yet to be burned by these rules. I tell them that if they want to go back to smoking after 3 months without- fine by me. But be prepared to have a pre-op cotinine the week prior- and elective surgery cancelled if positive. The motivated patients will abide, and those that won't will find the next DPM to do it.

Lol, say you're hospital employed (or even straight salary VA) without saying you're hospital employed.

 

[Flip-flop-flerpity]

Lol, say you're hospital employed (or even straight salary VA) without saying you're hospital employed.

TBH I made that my policy before I was hospital employed. I'm sure it cost me some cases but I still got abfas cert

 

[Feli]

TBH I made that my policy before I was hospital employed. I'm sure it cost me some cases but I still got abfas cert

No, I was just saying most ppl in normal eat-what-you-kill situations can't babysit patients like that.
It's good you have policy that works for you.

Non-elective and on-call, sure... we have to take what we get sometimes. But I just don't have time for it with elective pts. If there is any shred of non-compliance or substance/psych concern, they are not good elective sx candidates imo... just time wastes and post-op problems waiting to happen (drama, complications, Rx dependence, etc). I will let those ppl be another doc/group's problem.

 

[Flip-flop-flerpity]

No, I was just saying most ppl in normal eat-what-you-kill situations can't babysit patients like that.
It's good you have policy that works for you.

Non-elective and on-call, sure... we have to take what we get sometimes. But I just don't have time for it with elective pts. If there is any shred of non-compliance or substance/psych concern, they are not good elective sx candidates imo... just time wastes and post-op problems waiting to happen (drama, complications, Rx dependence, etc). I will let those ppl be another doc/group's problem.

Also I can probably count on one hand the smokers that actually followed through. Of interesting note I attended a lecture once where a well-regarded member of our profession claimed they never ever operate on anyone with a psych dx in their chart. Even depression.

 

[Feli]

Also I can probably count on one hand the smokers that actually followed through. Of interesting note I attended a lecture once where a well-regarded member of our profession claimed they never ever operate on anyone with a psych dx in their chart. Even depression.

It's good policy on the psych/depression. There is just no reason on elective.
I have even been burned by some who have no bona fide psych diagnosis or Rx... they are just going through a divorce/breakup or have family grief issue or drama with their work or their kids or whatever. They can be terrible with pain tolerance and neediness, tough time with transportation for post-op, etc. That is something to be on the watch for pre-op also (I had no detrimental complications, but far too many re-schedules, annoying messages for me, my staff). I strongly encourage those people to delay surgery or pretend my surgery schedule has nothing open right now. I blame myself for the one or two of those I miss and do elective surg on yearly, and I even enlist the help of my staff on help identifying them (sometimes they see the crazy or catch smell the cigarettes on new or pre-op pts when I do not).

Beyond the teen or young adult party smokers, I honestly view the middle age and older adults smoking same light (mental malfunction, highly dangerous and elective sx to be avoided). With everything we know now, if ppl regularly do a habit universally known to be harmful to health in 100 ways, they are not exactly stoic and well-equipped for a surgery. Smoking for the addicted smoker is a weird psychology... but they view smoking as the answer for anxiety, partying, relax, fear, pain, boredom, lonely and everything else.

 

[Flip-flop-flerpity]

I do take time to explain to smokers why I'm hesitant to operate- my experience is they're less likely to feel discriminated against or drop a negative review if they understand the risks. They still really want the procedure? Fine, show me you can quit for 6 weeks pre-op and 6 weeks post-op- Ive yet to be burned by these rules. I tell them that if they want to go back to smoking after 3 months without- fine by me. But be prepared to have a pre-op cotinine the week prior- and elective surgery cancelled if positive. The motivated patients will abide, and those that won't will find the next DPM to do it.

Interesting note- coding department at my hospital recently sent a letter from insurance company regarding authorization for a bunionectomy. They stipulate as part of authorization that "patient must be a non-smoker, has never been a smoker, or has stopped smoking minimum 6 weeks prior to procedure"

 

[Feli]

Interesting note- coding department at my hospital recently sent a letter from insurance company regarding authorization for a bunionectomy. They stipulate as part of authorization that "patient must be a non-smoker, has never been a smoker, or has stopped smoking minimum 6 weeks prior to procedure"

This is common. Huw mannah has always done this... others following suit. That's what I was getting at in post #3 above.