What is the effect of smoking on postoperative outcomes after ankle-fracture surgery? A retrospective cohort study

Abstract

Background: Smoking is a primary modifiable factor associated with postoperative complications after ankle-fracture fixation. Although most literature concludes that smoking is detrimental to wound healing and tissue oxygenation, there remains disparity in studies reporting on outcomes after ankle-fracture surgery. Therefore, our purpose was to evaluate the differences in (1) infection; (2) malunion and nonunion rates; (3) return to the operating room; and (4) overall complication rates between smokers and nonsmokers who underwent ankle-fracture fixation. Methods: Patients who had ankle-fracture surgery at our institution between July 2012 and April 2014 were retrospectively identified. Information was collected on demographics, injury data, and smoking status. The incidences of infection, malunion or nonunion, and postoperative complications and revision surgery were determined. A P value of 0.05 was used to determine statistical significance. There were 263 patients included in this study, 112 smokers and 151 nonsmokers. Results: The overall infection rate in the smoker cohort was 29.4% compared with 9.9% in the nonsmoker cohort, and there was a four-fold higher rate of malunions and nonunions in the smoker compared with the nonsmoker cohort (8.7% vs. 2%). The overall rate of return to the operating room was higher in the smoker compared to nonsmoker group (67.8 vs. 43.7%), as well as complication rates (8.9% vs. 2.6%; odds ratio [OR] 3.6, 95% confidence interval [CI] 1.1 to 11.8). Conclusions: This study showed that tobacco smoking had a direct adverse effect on infection rates, union, and return to the operating room in patients who underwent ankle-fracture fixation. These findings reiterated the importance of advocating for smoking cessation to improve postoperative clinical outcomes. Level of Evidence: Level III.