FAI July 2024 Podcast: Association of Smokeless Tobacco and Complications Following Ankle and Hindfoot Arthrodesis

Summary

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Episode Overview

This episode of the Foot & Ankle International podcast, hosted by Dr. Charlie Saltzman, spotlights the July 2024 lead paper, "Association of Smokeless Tobacco and Complications Following Ankle and Hindfoot Arthrodesis." Special guests Dr. Adam Schiff (Associate Professor, Loyola University Medical Center) and Jacob Boudin (4th-year medical student, Tulane) discuss their collaborative research. The episode dives into how smokeless tobacco use—often overlooked in orthopedic outcomes—relates to postoperative complications after ankle and hindfoot fusion, and unpacks the study’s broader clinical implications.

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Key Discussion Points & Insights

1. Background and Study Motivation

• Research Inspiration:
  The project stems from similar investigations by Dr. Bill Sherman at Tulane, who previously explored tobacco’s impact on hip and knee replacements. The team applied this perspective to foot and ankle surgery due to known risks in smokers.
• Aim:
  To assess whether smokeless tobacco (chewing tobacco, etc.) poses similar postoperative dangers as traditional smoking in ankle and hindfoot arthrodesis patients.

2. Main Findings & Implications

• Core Findings:
  Users of smokeless tobacco face significantly increased risks for:
  • Nonunion and malunion of fusions
  • Medical complications (respiratory, cardiac, infections)
  • Similar overall risk profile as smokers
    (05:02) “It really seems that if we want to give our patients the best outcomes possible, we have to eliminate all forms of tobacco or tobacco byproducts.” —Dr. Adam Schiff
• Clinical Impact:
  These findings suggest preoperative risk counseling must include smokeless tobacco use—not just smoking. Patients using any nicotine or tobacco product should be advised of heightened complication risks.

3. Research Collaboration Story

• How the Team Formed:
  A unique cross-institutional partnership arose from a shared medical student’s connections at Tulane and Loyola. This mentorship evolved into a larger research collaboration, illustrating academic medicine’s potential for nationwide teamwork.
  (02:46) “It kind of started out of nowhere and now has turned into a really fun opportunity where we’re teaching medical students, we’re mentoring medical students and residents, and now hopefully having a long lasting collaboration on research.” —Dr. Adam Schiff

4. Study Limitations & Definitions

• Defining “Smokeless Tobacco”:
  The study used large patient databases, relying on diagnostic codes for “nicotine dependence other than smoking” or “smokeless tobacco use (chewing tobacco, etc.).”
  (03:32) “In this we used smokeless tobacco as essentially chewing tobacco or other codes… it actually has to be coded in a chart for that to pick up.” —Dr. Adam Schiff
• Vaping Not Tracked Directly:
  Vaping wasn’t specifically identified due to coding limitations, though investigators suspect similar risks may exist.

5. Mechanisms and Unanswered Questions

• Nicotine or Tobacco Byproducts?
  The team remains uncertain whether risks are driven mainly by nicotine, tobacco byproducts, or product-related lifestyle factors.
  (05:02) “We have so many patients who try to quit smoking cigarettes by using other types of nicotine products… I don’t think that’s actually reducing their risk factors at all.” —Dr. Adam Schiff

6. Changing Clinical Practice

• Future Preoperative Assessment:
  Both Dr. Saltzman and Dr. Schiff state they will change their approaches—screening all patients not just for smoking, but for all forms of tobacco or nicotine use before surgery.
• Patient Counseling:
  The hosts stress the need for candid discussions with patients about the risks of any tobacco or nicotine product prior to elective fusions.
  (07:10) “I think now I’m going to ask about their risk factors and try to control for risk factors as best we can… stopping smoking is not necessarily enough.” —Dr. Adam Schiff

7. Future Research Directions

• Distinguishing Nicotine vs. Tobacco:
  Jacob Boudin highlights the next research step: parsing out whether nicotine itself (e.g., in NRT) or other tobacco constituents are primarily responsible.
  (08:26) “Something we could definitely look into going forward is… maybe looking not specifically at tobacco use, but even just nicotine replacement therapy and seeing how much of an impact that might have.” —Jacob Boudin

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Notable Quotes & Memorable Moments

• On the Importance of Recognizing Smokeless Tobacco Risks:
  (04:48) “Isn’t that interesting that just chewing tobacco can change your whole risk profile? It’s just fascinating to me and I would never personally have imagined that.” —Dr. Charlie Saltzman

• On Thorough Patient Counseling:
  (05:57) “We have a responsibility… to alert patients that these are risk factors. And if that’s a journey we’re going to go down, certainly your risk of complications is higher, the risk of revisions and the risks of further surgeries are higher, and your expectations might not be met with this operation.” —Dr. Adam Schiff

• On Collaborative Academic Medicine:
  (02:46) “[Collaboration] turned into a really fun opportunity where we’re teaching medical students, we’re mentoring medical students and residents, and now hopefully having a long lasting collaboration on research.” —Dr. Adam Schiff

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Timestamps for Key Segments

• [00:04] Introduction; guests and study significance
• [01:20] Study motivation, history, and findings overview
• [02:26] Story of academic collaboration across institutions
• [03:22] Definition and coding of smokeless tobacco in the database
• [04:48] Surprising risk from chewing tobacco; is nicotine the main culprit?
• [05:40] Clinical implications: necessity for broader preoperative counseling
• [07:10] Impact on future clinical practice: screening and patient education
• [08:26] Future research directions: nicotine vs. tobacco byproduct effects

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Conclusion

This episode underscores the comparable dangers posed by smokeless tobacco and smoking in orthopedic outcomes after ankle and hindfoot fusion. The hosts and guests call for an expanded scope in both preoperative assessment and patient education—urging clinicians to address all forms of tobacco and nicotine use. The promising collaborations highlighted, paired with future research aims, spotlight an ongoing commitment to improving surgical results and patient safety in the lower-extremity community.

Transcript

[A]

This is Charlie Saltzman, editor of Foot and Ankle International. Today I have the distinct honor of talking with Dr. Adam Schiff and Jacob Boudin who are the co authors of July's lead paper and put in Ankle International entitled Association of Smokeless Tobacco and Complications following Ankle and hind foot arthrodesis. Dr. Adams Schiff is an associate professor in the Department of Orthopedic Surgery at Loyola University Medical center and also serves as the Residency Program Director. Jacob Boudin is a 4th year medical student at Tulane Medical School and is an aspiring orthopedic surgeon. So anyone out there who is on the review of medical students applying for residencies, please keep in mind the name Jacob Boudin. I selected this study to highlight an extremely well done large database analysis of a not well recognized, at least not by me and probably many of our listeners. Cause of problems associated with ankle and Hindfoot fusion. Welcome to the program Adam and Jake. I'd like to start by asking you to give a brief summary of your paper and its major findings.

[B]

Thanks Dr. Saltzman. It's a pleasure to be here. This is Adam Schiffsman speaking. This was a fun and unique paper that we had the opportunity to do and it started from Dr. Bill Sherman's work at Tulane where he's done this very similar project with hip and knee replacements and other types of surgeries and we thought of applying it to the foot and ankle space. Basically we know that tobacco users and smokers in particular have a higher rate of complications in our world. It's higher rate of nonunion, but also medical problems, breathing issues, cardiac troubles and infections post operatively. And so Dr. Sherman had the idea of looking at those in other kinds of tobacco users. Not smokers mainly chew less or smokeless tobacco, chewing tobacco, but other types of things like vaping. And so we sought to look at that as a risk factor and sure enough it is associated with all sorts of complications like non union malunion, medical problems, infection, almost the same as that smoking.

[A]

I'm really curious on how the idea of a study between a New Orleans group and a Chicago group actually developed. It's such a good thing to see multi center interest in a problem. Can you just give us a little insight into how that occurred and maybe it'll be a path forward for others?

[B]

Well, I think this is the power of academic medicine. Dr. Sherman at Tulane has been a mentor to many medical students and we actually overlapped on a common medical student who ended up being a resident Loyola. And through that collaboration we've established Kind of a research connection through medical student mentorship. It kind of started out of nowhere and now has turned into a really fun opportunity where we're teaching medical students, we're mentoring medical students in residents, and now hopefully having a long lasting collaboration on research.

[A]

That's fantastic. So, just for our listeners, and to be clear, how do you define smokeless tobacco use?

[B]

So I think one of the limitations of this study is that it's a large database study. And so in this we used smokeless tobacco as essentially chewing tobacco or other codes that that were smokeless tobacco. So it actually has to be coded in a chart for that to pick up. We use the code of essentially nicotine dependence other than smoking or smokeless tobacco, chewing tobacco as a code.

[A]

Okay. And so just so I'm clear, because I know there's been some other work on vaping that suggests at least my understanding is that it's about as bad as smoking tobacco were this vapor is included possibly in this group?

[B]

We don't think so. Certainly if it was coded such that it was considered NIC independence other than smoking, it might have been. But vaping in of itself was not listed as one of the factors. We think that this is essentially a surrogate for vaping. I mean, we think that other forms of tobacco use other than smoking are going to be the exact same or very similar, vaping included. But this study did not pick out vaping per se.

[A]

Isn't that interesting that just chewing tobacco can change your whole risk profile? It's just fascinating to me and I would never personally have imagined that. So I guess. Do you think it's nicotine or what.

[B]

Do you think Nicotine or another byproduct of. I think all of these certainly set up for risk factors. I never would have thought this was so bad. And I think from experience we have so many patients who try to quit smoking cigarettes by using other types of nicotine products. And while that's great and probably better for their lungs, I don't think that's actually reducing their risk factors at all. I was sort of shocked and saddened to see that. It really seems that if we want to give our patients the best outcomes possible, we have to eliminate all forms of tobacco or tobacco byproducts.

[A]

So you've just mentioned the major clinical implications of this work. I think somehow we have to. If we want the patients to do as well as possible, we have to navigate or help them navigate around the use of tobacco. Any thoughts on that?

[B]

Why? I think that's exactly right. We have to help Them navigate. We have a responsibility. I think there was a point in time, Dr. Saltzman, where we had discussions of should we take on these higher risk surgeries in smokers at all. And unfortunately, so much of our patient population smoke. We're not in the position where we can turn down surgeries just because they're smokers. I think we have to identify risk factors and control for them the best we can. I think this highlights there are more risk factors than we appreciate or that probably that we're aware of. And I think it's our obligation to alert patients that these are risk factors. And if that's a journey, we're going to go down. Certainly your risk of complications is higher, the risk of revisions and the risks of further surgeries are higher, and your expectations might not be met with this operation. I think, you know, this highlights, at least to me, that these are discussions that we have to have with our patients. We can't make these assumptions.

[A]

Well put. How will this, Adam, affect your practice?

[B]

Well, I think it affects in a lot of ways, mostly that on sort of preoperative education and counseling. But it also highlights to me a risk factor going into these fusion surgeries. It's hard to get bones to fuse and I certainly didn't have this appreciation in training, but now that I'm maybe a little bit more seasoned. These unions are hard to achieve and there's a lot of risk factors for them, some of which we can control as our own technique, but a lot of them is our patients receptors. And I think now I'm going to ask about their risk factors and try to control for risk factors as best we can be able to try to educate patients that stopping smoking is not necessarily enough. It's tobacco or nicotine or all these byproducts are all factors. And you know, anything that we can do to decrease a patient's risk through counseling is important. But I'm certainly going to screen or ask patients about this where before I would really only ask about smoking.

[A]

I think I'm going to do the same. So I appreciate your paper. Anything else you'd like to add.

[B]

Jacob?

[A]

Yeah, so this is Jacob Boone talking. Something that we could definitely look into going forward with. This is kind of parsing out how much of this is the tobacco by products versus nicotine. So something we've looked into going into going forward is maybe looking not specifically at tobacco use, but even just nicotine replacement therapy and seeing how much of an impact that might have on these types of post operative complications and see how much of this is nicotine versus tobacco byproducts versus just the like, the socioeconomic or other factors that are related to people that are using these products. And going forward to see how we can maximize the best chances for our patients to have successful surgeries. Well, that will be great if someone can sort that out. I can't believe the companies that make this don't want to put nicotine in everything because that's probably what addicts people and makes them come back and buy another tin of Skoal or whatever they buy. But that's great and I agree that's an excellent direction. Jacob. Well, thank you both. I am Charlie Saltzman, editor of Foot and Ankle International Today. I've had the distinct pleasure of talking with Dr. Adam Schiff and Jacob Boudin, who are co authors of this July's lead paper in Foot and Ankle International entitled Association of Smokeless Tobacco and Complications Following Ankle and Hind Foot Arthrodesis. On behalf of all of our listeners, I want to thank both of you for taking the time to be with us today. Thank you.