Intended for healthcare professionals

Rapid response to:

Feature Head to head

Should smokers be refused surgery?

BMJ 2007; 334 doi: (Published 04 January 2007) Cite this as: BMJ 2007;334:20

Rapid Response:

Primum non nocere

My main activity is joint replacement: while most of my
patients will do well, a small minority will not.  Of those who have a
complication,a tiny number will end up with an absolute catastrophe,  complete
and utter disaster.  Infected knee replacement is a typical example (1,2).

Orthopaedic surgery can radically change people’s lives,
but not always for the best.  It can restore mobility and quality of life to a
lady whose knee replacement is uncomplicated.  It can also ruin the last years
of another lady whose knee replacement is complicated by a deep infection. 
There is in fact no doubt that no surgery is better than failed surgery.

There has been good evidence in the literature for many
years that the outcome of spinal surgery was adversely affected by cigarette
smoking (3-5).  We now also have conclusive scientific evidence that the same
applies to joint replacement (6).  If we really want to have a modern
evidence-based practice, we cannot ignore the results of this powerful Swedish
epidemiological study.

First: do no harm.  By performing elective orthopaedic
surgery in smokers, we could make them far worse than when they first came to
see us in clinic.  A good surgeon knows when not to operate.  It is our duty to
protect cigarette smokers from the harmful effects of our scalpel.


1)         Barrack RL, Engh G, Rorabeck C, Sawhney J,
Woolfrey M. Patient satisfaction and outcome after septic versus aseptic
revision total knee arthroplasty. J Arthroplasty.2000; 15:990 -3

2)         Blom AW, Brown J, Taylor AH, Pattison G,
Whitehouse S, Bannister GC. Infection after total knee arthroplasty. J Bone
Joint Surg Br. 2004 Jul;86(5):688-91

3)         Brown CW; Orme TJ; and Richardson HD: The rate
of pseudarthrosis (surgical nonunion) in patients who are smokers and patients
who are nonsmokers: a comparison study. Spine, 1986.11: 942-3

4)         Hadley MN, and Reddy SV: Smoking and the human
vertebral column: a review of the impact of cigarette use on vertebral bone
metabolism and spinal fusion. Neurosurgery, 1997.41: 116-24

5)         Hanley EN, and Levy JA: Surgical treatment of
isthmic lumbosacral spondylolisthesis. Analysis of variables influencing
results. Spine, 1989.14: 48-50

6)         Sadr Azodi O, Bellocco R, Eriksson K, Adami J.
The impact of tobacco use and body mass index on the length of stay in hospital
and the risk of post-operative complications among patients undergoing total hip
replacement. J Bone Joint Surg Br. 2006 Oct;88(10):1316-20

Competing interests:
None declared

Competing interests: I am an orthopaedic surgeon, and welcome the debate on smoking and elective surgery. 

15 January 2007
Jac Ciampolini
Consultant Orthopaedic Surgeon
Peninsula Orthopaedic Treatment Centre, Brest Road, Plymouth, PL6 5XP