The Smoking Gun

A cognitive bias backfires in the worst possible way......

A 32-year-old entertainment industry technician presents to an Orthopaedic Surgeon for a second opinion. He describes 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 department of his local public hospital and the next day open reduction and internal fixation of his fractured patella was undertaken with a tension band. Intraoperative imaging was undertaken 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 then range of motion exercises were started after two weeks. 

Initial radiographs at 8 weeks suggested anatomic reduction was maintained. By 3 months a delayed union was diagnosed, and by 7 months a non-union was noted, with fixation wire breakage, and displacement of the fracture fragments. 

The patient complains of severe pain and states he is "extremely disappointed" with the care received at the hospital. 

The surgeon notes that the patient is an active smoker consuming 1.5 packets per day since he was 16 years old. The outpatient notes from the public hospital contain multiple references to advice given to the patient to not smoke peri-operatively, advice which was not followed.

The surgeon recommends revision fixation with bone grafting, but only if the patient stops 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 300-500%

4 Nicotine patches still increase risk of complications, particularly non-union 

5 Elective surgery should not be undertaken until smoking has ceased

6 Patients who smoke are more at risk of musculoskeletal trauma, and hence complication with accidental bony injury

7 Many patients require psychological support to alter behaviour.