title: Cigarette smoking increases complication rate in forefoot surgery.
abstract: BACKGROUND
  Cigarette smoking is known to increase perioperative complication rates, but no study to date has examined its effect specifically in forefoot surgery. The purpose of this study was to determine whether cigarette smoking increased complications after forefoot surgery.
  
  
  METHODS
  The records of 602 patients who had forefoot surgery between 2008 and 2010, and for whom smoking status was known, were reviewed. Patients were categorized into 3 groups based on smoking status: active smoker, smoker in the past, or nonsmoker. Medical records were reviewed for occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain.
  
  
  RESULTS
  Active smokers were found to have a notably higher complication rate (36.4%) after forefoot surgery than patients who previously (16.5%) or never (8.5%) smoked. Patients who continued to smoke in the perioperative period had the highest percentage of delayed union (3.0%), infection (9.1%), delayed wound healing (10.6%), and persistent pain (15.2%). Active cigarette smokers were 4.3 times more likely to have a complication than nonsmokers. Patients who smoked at any point in the past but quit prior to surgery were 1.9 times more likely than nonsmokers to incur a complication. The average time of smoking cessation for patients who had smoked at any point in the past but had quit prior to surgery was 17 years. For active smokers, those with a complication smoked an average of 18 cigarettes daily, while those without a complication smoked 14 cigarettes daily.
  
  
  CONCLUSIONS
  Before forefoot surgery, surgeons should educate patients who smoke about their increased risk of complications and encourage smoking cessation.
  
  
  METHODS
  Level III, retrospective comparative study.
authors.affiliation: University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, Memphis, TN, USA clayton.bettin@gmail.com.
authors.forename: Clayton C
authors.initials: CC
authors.lastname: Bettin
authors.affiliation: University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, Memphis, TN, USA.
authors.forename: Kellen
authors.initials: K
authors.lastname: Gower
authors.affiliation: Hope Orthopaedics of Oregon, Salem, OR, USA.
authors.forename: Kelly
authors.initials: K
authors.lastname: McCormick
authors.affiliation: University of Tennessee Health Science Center, Department of Biostatistics & Epidemiology, Memphis, TN, USA.
authors.forename: Jim Y
authors.initials: JY
authors.lastname: Wan
authors.affiliation: University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, Memphis, TN, USA.
authors.forename: Susan N
authors.initials: SN
authors.lastname: Ishikawa
authors.affiliation: University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, Memphis, TN, USA.
authors.forename: David R
authors.initials: DR
authors.lastname: Richardson
authors.affiliation: University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, Memphis, TN, USA.
authors.forename: G Andrew
authors.initials: GA
authors.lastname: Murphy
mesh_terms: D001172:Arthritis, Rheumatoid / Q000453:epidemiology; D039702:Current Procedural Terminology; D003920:Diabetes Mellitus / Q000453:epidemiology; D005260:Female; D005545:Forefoot, Human / Q000601:surgery*; D006801:Humans; D016015:Logistic Models; D008297:Male; D019637:Orthopedic Procedures / Q000706:statistics & numerical data*; D010523:Peripheral Nervous System Diseases / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D012907:Smoking / Q000009:adverse effects*; D016540:Smoking Cessation; D013530:Surgical Wound Infection / Q000453:epidemiology; D016896:Treatment Outcome; D014945:Wound Healing
keywords: complications; forefoot surgery; smoking