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.

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

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

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

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.