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Impact of Smoking on Fracture Healing and Risk of Complications in Limb-Threatening Open Tibia Fractures
Abstract
Current data show smoking is associated with a number of complications of the fracture healing process. A concern, however, is the potential confounding effect of covariates associated with smoking. The present study is the first to prospectively examine time to union, as well as major complications of the fracture healing process, while adjusting for potential confounders.
Eight Level I trauma centers.
Patients with unilateral open tibia fractures were divided into 3 baseline smoking categories: never smoked (n = 81), previous smoker (n = 82), and current smoker (n = 105).
Time to fracture healing, diagnosis of infection, and osteomyelitis.
Survival and logistic analyses were used to study differences in time to fracture healing and the likelihood of developing complications, respectively. Multivariate models were used to adjust for injury severity, treatment variations, and patient characteristics.
After adjusting for covariates, current and previous smokers were 37% (P = 0.01) and 32% (P = 0.04) less likely to achieve union than nonsmokers, respectively. Current smokers were more than twice as likely to develop an infection (P = 0.05) and 3.7 times as likely to develop osteomyelitis (P = 0.01). Previous smokers were 2.8 times as likely to develop osteomyelitis (P = 0.07), but were at no greater risk for other types of infection.
Smoking places the patient at risk for increased time to union and complications. Previous smoking history also appears to increase the risk of osteomyelitis and increased time to union. The results highlight the need for orthopaedic surgeons to encourage their patients to enter a smoking cessation programs.
... Nicotine decreases blood flow, reduces collagen production, and causes tissue hypoxia, resulting in poor bone and wound healing. [9,[21][22][23][24][25][26][27][28][29] Tobacco smoking has been associated with higher rates of overall complications and wound complications following spine, knee, hip, tibia, and clavicle fractures, as well as total hip arthroplasty. [9,21,23,24,27,[30][31][32][33] Smoking has also been associated with more nonunions following fractures of the tibia, hip, cervical spine, and lumbar spine. ...
... [9,[21][22][23][24][25][26][27][28][29] Tobacco smoking has been associated with higher rates of overall complications and wound complications following spine, knee, hip, tibia, and clavicle fractures, as well as total hip arthroplasty. [9,21,23,24,27,[30][31][32][33] Smoking has also been associated with more nonunions following fractures of the tibia, hip, cervical spine, and lumbar spine. [27,[34][35][36][37] Other work has shown tobacco use to be associated with a significant increase in time to fracture union. ...
... [9,21,23,24,27,[30][31][32][33] Smoking has also been associated with more nonunions following fractures of the tibia, hip, cervical spine, and lumbar spine. [27,[34][35][36][37] Other work has shown tobacco use to be associated with a significant increase in time to fracture union. [38,39] Our results were limited by loss of patients to follow-up. ...
Objective:
The purpose of this study was to assess the impact of current and remote tobacco smoking on clinical and functional outcomes after torsional ankle fracture.
Methods:
Nine hundred thirty-five patients treated surgically for torsional ankle fracture over 9 years were reviewed. Tobacco smoking status at the time of injury was defined as current (48.3%), former (11.7%), and nonsmoker (40.0%). Complications, unplanned secondary procedures, pain medication use, and functional outcome scores, as measured by Foot Function Index and Short Musculoskeletal Function Assessment (SMFA) surveys.
Results:
Mean age was 44.8 years, with 50.3% male. More than 6 months following injury current smokers were more likely than former smokers and nonsmokers to report ankle pain (67.8% vs 45.8% vs 47.5%) and to use prescription pain medicines (23.0% vs 10.4% vs 6.3%), all P < .05. Multiple logistic regression found current tobacco use to be an independent predictor for prescription pain medication use, and worse scores for the Foot Function Index, SMFA Dysfunction, and SMFA Bothersome scores, all P < .05. Complications occurred in 15.5% of all patients, and 10.7% underwent unplanned secondary operations. Tobacco smoking was not associated with more complications or secondary procedures.
Conclusion:
Current smokers are more likely to use prescription pain medications several months after injury and have worse patient-reported functional outcome scores after surgical treatment of torsional ankle fractures than former smokers and nonsmokers.
... Smoking is associated with a wide range of complications in the orthopaedic trauma population [1][2][3][4][5][6]. Specifically, previous studies suggest that smoking and tobacco use may be associated with an increased risk of bone healing complications and infections [7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Fortunately, the physiological effects of smoking and tobacco use observed after a fracture have been shown to be reversible within a short time frame. ...
... The size of the rewards and frequency were informed by a recent randomized trial that studied financial incentives for smoking cessation in the general population [38]. The risk attributes and their levels were designed based on patients' reported outcomes, consultation with orthopaedic trauma surgeons, and a literature review [7,[47][48][49][50]. The experiment design used a D-efficiency approach to maximize the orthogonality of the attributes and levels included in the 12 choice sets [51]. ...
... The sample size was sufficient for precise utility estimates. The characteristics of the patient population were similar to prior smoking cessation studies in orthopaedic trauma patients [7,16]. ...
Background
Smoking increases the risk of complications and related costs after an orthopaedic fracture. Research in other populations suggests that a one-time payment may incentivize smoking cessation. However, little is known on fracture patients’ willingness to accept financial incentives to stop smoking; and the level of incentive required to motivate smoking cessation in this population. This study aimed to estimate the financial threshold required to motivate fracture patients to stop smoking after injury.
Methods
This cross-sectional study utilized a discrete choice experiment (DCE) to elicit patient preferences towards financial incentives and reduced complications associated with smoking cessation. We presented participants with 12 hypothetical options with several attributes with varying levels. The respondents’ data was used to determine the utility of each attribute level and the relative importance associated with each attribute.
Results
Of the 130 enrolled patients, 79% reported an interest in quitting smoking. We estimated the financial incentive to be of greater relative importance (ri) (45%) than any of the included clinical benefits of smoking cessations (deep infection (ri: 24%), bone healing complications (ri: 19%), and superficial infections (ri: 12%)). A one-time payment of $800 provided the greatest utility to the respondents (0.64, 95% CI: 0.36 to 0.93), surpassing the utility associated with a single $1000 financial incentive (0.36, 95% CI: 0.18 to 0.55).
Conclusions
Financial incentives may be an effective tool to promote smoking cessation in the orthopaedic trauma population. The findings of this study define optimal payment thresholds for smoking cessation programs.
... 12 In particular, it was reported that smoking is associated with poorer outcomes following orthopaedic surgical procedures, while most of these reports are derived from studies on bone healing. [13][14][15][16][17] Another research work demonstrated that smoking increases the risk of early meniscus repair failure. 18 In this retrospective study, significantly more smokers than nonsmokers needed revision surgery after meniscus repair leading to the conclusion that smoking status should be added to the list of factors influencing the decision between meniscus repair and meniscectomy. ...
... 12 In particular, there is evidence that smoking is associated with delayed bone healing. [13][14][15][16][17] Also, it was reported that smokers have a higher risk for impaired regeneration of wounds of the skin and other soft tissues. 31,32 The negative effects of smoking on healing of bone and soft tissue are caused by multiple mechanisms, including vasoconstriction, decreased oxygen delivery, and reduced fibroblast migration. ...
Smoking is known to have various deleterious effects on health. However, it is not clear whether smoking negatively affects the postoperative outcome following matrix-based autologous cartilage implantation (MACI) in the knee. The purpose of this study was to evaluate the effect of smoking on the outcome of MACI in the knee. A total of 281 patients receiving MACI in the knee between 2015 and 2018 were registered in the German Cartilage Database. The cohort was divided into ex-smokers, smokers, and nonsmokers. Data regarding the Knee Injury and Osteoarthritis Outcome Score (KOOS), the numeric rating scale (NRS) for pain, and satisfaction with the outcome were analyzed and compared. Follow-ups were performed at 6, 12, and 24 months after surgery. Of the 281 patients, 225 (80.1%) were nonsmokers, 43 (15.3%) were smokers, and 13 (4.6%) were ex-smokers. The three groups were comparable with respect to age, sex, body mass index (BMI), height, defect size, the need for additional reconstruction of the subchondral bone defect, number of previous knee surgeries, and defect location. However, nonsmokers had a significantly lower weight as compared with smokers. Besides a significantly lower preoperative NRS of nonsmokers as compared with smokers, there were no significant differences between the three groups with respect to KOOS, NRS, and satisfaction at 6, 12, and 24 months of follow-ups. The present study of data retrieved from the German Cartilage Registry suggests that the smoking status does not influence the outcome of MACI in the knee.
... The same trend has also been seen in orthopedic trauma patients with open fractures. Smokers were twice as likely to develop an infection, 3.7 times more likely to develop osteomyelitis, and twice as likely to experience non-union after osteotomy [9,10]. These complications can be greatly reduced by at least 40% if smoking cessation is completed at least four weeks prior to surgery [11]. ...
... Smoking has been shown to increase the risk of perioperative complications, including infection, wound complications, and delayed or non-union [4][5][6][7][8][9][10]. As such, clinical care pathways to identify prior and current smoking and urge cessation at each visit have been established [22]. ...
Purpose The purpose of this study was to determine the accuracy of self-reported non-smoking status in subjects undergoing elective orthopedic surgery as confirmed by serum cotinine levels. Methods Institutional Review Board approval was obtained for this retrospective review of consecutive subjects that underwent elective orthopedic surgery by a single fellowship-trained orthopedic surgeon. All patients provided smoking history (active, former, or non-smoker). Serum cotinine levels defined each subject as "non-smoker", "passive tobacco exposure", or "active smoker". Self-reported non-smokers were eligible for inclusion. Subjects were excluded if they failed to provide smoking history, reported themselves as "smokers", and/or had unavailable serum cotinine levels. Self-reported non-smoking status accuracy was determined by dividing the total number of included subjects by the number of subjects that were defined as "non-smoker" or "passive tobacco exposure" on their serum cotinine test. Results A total of 378 patients (mean age of 42.5 (13-78) years and 68% female) self-reported as non-smokers and were included. A total of 369 subjects had serum cotinine levels consistent with "non-smoking" resulting in a self-reported non-smoking status accuracy of 97.6%. None of the former smokers had cotinine levels consistent with active smoker status. Conclusion Subjects undergoing elective orthopedic surgery self-report as non-smokers with an accuracy of 97.6%. This suggests that routine serum cotinine testing of non-smokers in this patient population may not be necessary.
... Nonunion is the most frequent complication and can occur from 5 to 19% of cases [4, 9,10]. The principal causes of nonunion include inadequate fracture fixation, infection, excessive separation of soft tissue during the procedure, which undermines vascular supply at the fracture site, and patient-related factors, such as advanced age, smoking, diabetes, vascular disease, non-steroidal anti-inflammatory drugs and steroid use [11][12][13][14]. Although the use of fixed angle implants provides rigid construct that better withstands bending forces, implant failure is still possible because of significant eccentric load [6,14]. ...
Purpose
To describe the surgical technique and the outcome of a case series of nonunion and malunion of distal femur fractures treated with an endosteal medial plate combined with a lateral locking plate and with autogenous bone grafting.
Methods
We retrospectively analyzed a series of patients with malunion or nonunion of the distal femur treated with a medial endosteal plate in combination with a lateral locking plate, in a period between January 2011 and December 2019, Database from chart review was obtained including all the clinical relevant available baseline data (demographics, type of fracture, mechanism of injury, time from injury to surgery, number of previous surgical procedures, type of bone graft, and type of lateral plate). Time to bone healing, limb alignment at follow-up and complications were documented.
Results
Ten patients were included into the study: 7 male and 3 female with mean age of 48.3 years (range 21–67). The mechanism of trauma was in 8 cases a road traffic accident and in 2 cases a fall from height. According to AO/OTA classification 5 fractures were 33 A3, 3 were 33 C1, 1 was 33 C2 and 1 was 33 C3. The average follow up was 13.5 months. In all cases but one bony union was achieved. Bone healing was observed in average 3.3 months after surgery. No intraoperative or postoperative complications were reported.
Conclusion
A medial endosteal plate is a useful augmentation for lateral plate fixation in nonunion or malunion following distal femur fractures, particularly in cases of medial bone loss, severe comminution, or poor bone quality.
Level of evidence
Level IV (retrospective case series).
... In open fractures, increased time from injury to administration of antibiotics and debridement have both been associated with an increased risk of osteomyelitis [3,[6][7][8]. Other risk factors include diabetes mellitus, hypoxic lung disease, renal or hepatic failure, major-vessel disease, smoking, peripheral neuropathy and increasing age [9][10][11][12][13][14]. ...
Purpose
Whilst recurrence and amputation rates in post-traumatic osteomyelitis (PTOM) are described, limb specific functional outcomes are not, leading to a knowledge gap when counselling patients prior to management. We aim to investigate the patient reported outcomes (PROMS) of this patient group to provide reference for discussions with patients prior to embarking on treatment.
Methods
Single institution cross-sectional retrospective study of all patients presenting with PTOM of the tibia/femur over a 7-year period. Alongside recurrence and amputation rates, patient reported outcomes were recorded including the lower extremity functional scale (LEFS), EQ-5D-3L and EQ-VAS.
Results
Seventy-two patients (59 male; median age 46 years) were identified. Treatment was principle-based and included debridement (with Reamer–Irrigator–Aspirator (RIA) in 31/72), local antibiotics (52/72), soft tissue reconstruction (21/72) and systemic antibiotic therapy in all cases. PROMS were collected in 84% of all eligible patients at a median of 112-month post-treatment. Twelve patients experienced recurrence, whilst nine underwent amputation. The median LEFS was 60, the EQ-5D-3L index score was 0.760, and the EQ-VAS was 80. These scores are substantially lower than those seen in the general population (77, 0.856 and 82.2, respectively). LEFS was significantly higher, where RIA was utilised (69.6 vs 52.8; p = 0.02), and in those classified as BACH uncomplicated (74.4 vs 58.4; p = 0.02). EQ-5D-3L was also higher when RIA was utilised (0.883 vs 0.604; p = 0.04), with no difference in EQ-VAS scores.
Conclusions
Patients with PTOM report functional outcomes below that of the general population, even when in remission. Improved outcomes were associated with uncomplicated disease and the use of RIA.
... In open fractures where wound contamination is more often than not the norm, this implies, the larger the size of the machete wound the greater the surface area for potential contaminants and the risk of wound infection Besides these three independent predictors of wound infection in machete cut open fractures, the other important and significantly associated factors that are modifiable need to be highlighted. Castillo et al demonstrated that current and previous smokers compared to nonsmokers are significantly at a higher risk of wound infection after open fractures [ 21 ]. Furthermore, a recent systematic review indicates smok-ers are at increased risk of infectious complications after open extremity fractures [ 22 ]. ...
Background:
Machete cut fracture is a unique subset of open fracture. The sharp force of a wielded machete that cleanly divides soft tissue envelope with minimal or no contusion results in an open fracture wound that is relatively less prone to infection. However, in resource-limited settings, the wound infection rate after machete cut fracture is relatively high. This study aimed to determine the risk factors for wound infection after extremity machete cut fractures in a Nigerian setting.
Methods:
We undertook a retrospective analysis of the patients who were seen in the Emergency room of two tertiary hospitals in Nigeria with a machete cut extremity fracture from 2009 to 2018. The association of wound infection with population and wound characteristics as well as intervention related factors were evaluated. Statistical significant factors for wound infection in the Univariable analysis were entered into a Multivariable regression analysis to evaluate the risk of each factor when adjusted to other factors.
Results:
There were 113 machete-cut fractured bones in 67 eligible patients and wound infection was a complication in 45 (39.8%) of the cases (95%CI 30.3 - 49.7%).The factors significantly associated with high wound infection rate were smoking, haematocrit < 30%, fractures sustained outdoors, lower extremity fractures, a wound size of >5cm in length, injury-to-hospital arrival interval > 6hrs. Multivariable regression analysis identified wound size >5 cm (aOR 14.142, 95%CI (2.716 - 73.636); p = 0.002), injury-to- hospital arrival interval later than 6hrs (aOR 4.410, 95% CI (1.003-19.394); p = 0.050) and administration of antibiotics later than 3hrs of injury (aOR 5.736, 95%CI (aOR1.362 - 24.151; p = 0.017) as independent risk factors for wound infection.
Conclusion:
Wound infection after open fractures caused by machetecut is more likely to occur in patients that present later than six hours after injury, wounds more than 5cm in length and delayed antibiotic administration. Appropriate treatment protocols can be instituted with this knowledge.
... Current smokers were more than twice as likely to develop an infection and 3.7 times as likely to develop osteomyelitis. Previous smokers were 2.8 times as likely to develop osteomyelitis but were at no greater risk for other infection types [16]. In the current study, 20 (36.4%) smokers were observed to developed infection, whereas none of the nonsmokers showed any signs of infection at the end of one year. ...
Background Tibial shaft fractures account for 17% of all lower limb fractures. Nonunion and infection rates are estimated to be between 2% and 10%. Bone healing is a complex process that is influenced by biological, mechanical, and systemic factors. Adverse smoking effects on cardiovascular and respiratory systems have been well documented. An increasing interest in the effect of smoking on fracture healing following trauma has been noted in recent years. The biological consequence of smoking is relevant, especially in trauma surgery where no way of preventing presurgical smoking has been noted, hence increasing the patient's risk of nonunion. Cigarette smoking has been shown to impair fracture union and wound healing and lead to an increased risk of fracture site infection. Smoking and high-energy trauma are considered important risk factors for the delayed union of tibial shaft fractures. Objectives This study aims to assess the adverse effects of smoking in patients with tibial shaft fractures following trauma and fracture fixation. Materials and methods A retrospective cohort study was done on 110 (55 smokers and 55 nonsmokers) patients treated with intramedullary nailing or plating for tibial shaft fractures between July 2017 and January 2021 in the hospital of the current study. Fracture healing was assessed at the end of months 1, 3, and 6 and year 1. Results The mean time of healing in smokers was >48 weeks, whereas the average time to union was 24 weeks in nonsmokers. The majority (54.6%) of smokers took >48 weeks to heal, whereas 81.8% of patients in the nonsmoking group took 24-28 weeks to heal. Conclusion Similar to the results obtained in previous studies, our study showed that smoking hinders fracture healing after surgical fixation, and smokers have a higher chance of developing surgical site infection and osteomyelitis. Smokers take a longer time for radiological union and also have a high chance of delayed union and nonunion when compared with nonsmokers, which was shown in our study and is consistent with the results obtained in previous studies. Postoperative smoking cessation is as important as preoperative smoking cessation, and patients should be strictly counseled regarding the same.
... Regarding the deleterious biological and social consequences of tobacco smoking on healing and recovery after major fractures, much has been written. [36][37][38][39][40][41][42] Tobacco smokers may have less functional capabilities at baseline, along with reduced capacity for healing and recovery of ambulatory and other functions. [43] Recent reports further suggest that tobacco smoking has effects on intensity of pain and on the incidence of various other mental symptomatology, including depression and anxiety, all of which are likely to impact functional outcome scores. ...
Objectives:
The purposes of this project were to evaluate functional outcomes more than 5 years after acetabulum fracture and to determine factors related to function.
Methods:
This retrospective study consisted of 205 adult patients treated for acetabulum fracture who completed the Musculoskeletal Function Assessment (MFA) a minimum of 5 years following injury. The MFA includes survey of daily activities, gross and fine mobility, social and work function, sleeping, and mood. Higher scores indicate worse function.
Results:
Two hundred five patients with 210 fractures, 69.3% of whom were male, with mean age of 45.7 and mean body mass index 30.1 were included after mean 128 months follow-up. Fracture patterns included OTA/AO 62A (37.1%), 62B (40.5%), or 62C (22.4%), and 80.0% were treated surgically. Late complications were noted in 35.2%, including posttraumatic arthrosis (PTA: 19.5%), osteonecrosis and/or heterotopic ossification. Mean MFA of all patients was 31.4, indicating substantial residual dysfunction. Worse MFA scores were associated with morbid obesity (body mass index >40: 42.3, P>.09), and current tobacco smoking history vs former smoker vs nonsmoker (45.2 vs 36.1 vs 23.0, P < .002). Patients with late complications had worse mean MFA scores (38.7 vs 27.7, P = .001); PTA was the most common late complication, occurring in 19.5%.
Conclusions:
More than 5 years following acetabulum fracture, substantial residual dysfunction was noted, as demonstrated by mean MFA. Worse outcomes were associated with late complications and tobacco smoking. While fracture pattern was not associated with outcome, those patients who had late complications, mostly PTA, had worse outcomes.
... Nicotine is a well-known cause of delayed fracture healing [48][49][50][51][52]. Its vasoconstrictor properties produce a decreased perfusion rate, resulting osteochondral hypoxia and ischemia. ...
Subchondral fractures typically tend to resolve spontaneously with non-surgical treatment; nevertheless, there are some cases in which these lesions persist longer than expected. This delay in healing can be evidenced with persistent “edema like lesions” on MRI and/or persistent articular symptoms. Literature is scarce mainly because it is a silent problem; difficult to evaluate and diagnose in a controlled study. Nevertheless, the problem exists. The main consequence following this injury is the occasional progression to failure of the osteochondral unit with subsequent joint collapse. The aim of this chapter will be to describe and identify the significance of delay in fracture healing; to discuss the main possible modifiable risk factors of delayed bone healing; and to identify early markers of progression and joint failure.
... One might expect a decreased chance of HO in the smoking population due to the well-established negative/inhibitory effect of smoking on bone growth/healing. 23,24 Studies of osteoblastic cells have shown both inhibition of protein synthesis as well as collagen formation with exposure to tobacco smoke. 25 Clinical studies have shown conflicting results depending on the patient situation/clinical picture. ...
Context:
Heterotopic ossification (H.O.) is a common occurrence after total hip arthroplasty (THA) with significant potential clinical ramifications. Controversy still exists regarding the exact etiology of the disorder, including possible risk factors. Surgical technique, surgical approach, postoperative medication protocols and even thromboembolic prophylaxis have been implicated in the formation of H.O. Our study looked at one institution with a single surgeon performing direct anterior THA (DAA THA) in patients who received aspirin (ASA) as monotherapy for thromboembolic prophylaxis.
Methods:
Patients at a single institution who underwent DAA THA between 2015 and 2019 were identified by CPT code. 45 patients ultimately met inclusion criteria. Postoperative radiographs were analyzed retrospectively for H.O. according to the Brooker classification. Several patient characteristics and comorbidities were statistically analyzed using Chi-square tests, Fisher Exact tests, Wilcox rank sum tests, and Pearson correlation.
Results:
12 patients (26.7%) were found to have heterotopic ossification (67% Class 1, 8% Class 2, 25% Class 3, and 0% Class 4); with a median follow up of 35 weeks (range: 12-96). 25% of these patients received ASA 325mg BID while 75% received ASA 81 BID. No statistical differences in development of H.O. were detected among age, gender, BMI, sex, race, diabetes, or NSAID use in the post-operative interval. There were significantly more smokers in the H.O. group (50% vs. 9%, p<0.006).
Conclusions:
Our analysis aimed to quantify the incidence of H.O. with consistency in surgical approach and post-operative protocol. There have been few studies on this topic, and we believe it is very relevant with the increasing use of aspirin in the post-operative protocol for thromboembolic prophylaxis. Our retrospective analysis identified H.O. at rates similar to previous studies in DAA.
... Environmental factors such as wound contamination, infection, and open fractures can contribute to non-healing (Bigham-Sadegh and Oryan, 2015). Patientrelated factors such as smoking, diabetes, rheumatoid arthritis, immunodeficiency, or an immunocompromised state cause alterations in cytokine expression, which affects osteoclast activity and bone remodeling and prolongs fracture healing (Pape et al., 2002;Castillo et al., 2005;Kayal et al., 2007;Claes et al., 2012;Jeffcoach et al., 2014;Schneider et al., 2018). Lastly, sequelae of trauma such as shock and sepsis can impair fracture healing through the complex interplay of the immune system and regenerative response of the body to injury. ...
Achieving bone fracture union after trauma represents a major challenge for the orthopedic surgeon. Fracture non-healing has a multifactorial etiology and there are many risk factors for non-fusion. Environmental factors such as wound contamination, infection, and open fractures can contribute to non-healing, as can patient specific factors such as poor vascular status and improper immunologic response to fracture. Nitric oxide (NO) is a small, neutral, hydrophobic, highly reactive free radical that can diffuse across local cell membranes and exert paracrine functions in the vascular wall. This molecule plays a role in many biologic pathways, and participates in wound healing through decontamination, mediating inflammation, angiogenesis, and tissue remodeling. Additionally, NO is thought to play a role in fighting wound infection by mitigating growth of both Gram negative and Gram positive pathogens. Herein, we discuss recent developments in NO delivery mechanisms and potential implications for patients with bone fractures. NO donors are functional groups that store and release NO, independent of the enzymatic actions of NOS. Donor molecules include organic nitrates/nitrites, metal-NO complexes, and low molecular weight NO donors such as NONOates. Numerous advancements have also been made in developing mechanisms for localized nanomaterial delivery of nitric oxide to bone. NO-releasing aerogels, sol- gel derived nanomaterials, dendrimers, NO-releasing micelles, and core cross linked star (CCS) polymers are all discussed as potential avenues of NO delivery to bone. As a further target for improved fracture healing, 3d bone scaffolds have been developed to include potential for nanoparticulated NO release. These advancements are discussed in detail, and their potential therapeutic advantages are explored. This review aims to provide valuable insight for translational researchers who wish to improve the armamentarium of the feature trauma surgeon through use of NO mediated augmentation of bone healing.
... Desse modo, considera-se que o tabaco modifica a relação peso/altura, e faz com que o feto tenha menor crescimento dos ossos longos. SegundoCastillo et al. (2005), fumar pode provocar efeitos adversos sobre a força do osso através da toxicidade direta da nicotina, pois provoca vasoconstrição periférica e isquemia tecidual, diminuindo a tensão de oxigênio. Além disso, o tabagismo pode afetar indiretamente a força do osso através da diminuição da absorção intestinal de cálcio, aumento do metabolismo e diminuição da produção de estrogênio, tendo um impacto negativo sobre a cicatrização óssea e inibindo a neovascularização e diferenciação dos osteoblastos. ...
... The presence of comorbidities (ie, diabetes, smoking) and their associated hostile tissue microenvironment (ie poor perfusion, infection) have the potential to limit tissue healing, increase the risk of complications, and prolong patient recovery. 20,21 Despite this, the general presence of a comorbidity within our patient population was not associated with worse outcomes. This correlates with previous reports that outcomes of severe extremity injuries may be more affected by the patient's social, economic, and personal resources rather than by their physical status and initial injury treatment. ...
We aimed to identify degloving soft tissue injury (DSTI) patient characteristics, injury and reconstruction patterns, and factors affecting outcomes of DSTI injuries to propose a reconstructive protocol for these injuries.
Methods:
A retrospective analysis of consecutive patients with DSTIs of an extremity over a 22-year period has been done.
Results:
188 patients with 201 extremity DSTIs were included. Mean patient age was 37 years, with follow-up of 19.6 months. In total, 96% of injuries were related to motor vehicles or machinery, and 74.6% of DSTIs had injuries to structures deep to skin/subcutis. The avulsed tissue was utilized in reconstruction in 71.6% of cases and 86.8% of these experienced some loss of the used avulsed tissues. Of the total cases, 82% employed skin grafting in reconstruction. Dermal regeneration templates were used in 32% of patients. An estimated 86.5% of patients had negative pressure wound therapy utilized. Of the injured patients, 21% required flap reconstruction and 22% required some form of amputation. Age, body mass index, and tobacco use did not increase perioperative complications or amputation. DSTIs with injury to structures deep to skin/subcutis were associated with negative pressure wound therapy use (P = 0.02). DSTIs with underlying fractures required more procedures to reach reconstruction completion (P = 0.008), had more minor (P = 0.49) and major perioperative complications (P = 0.001), longer time to heal (P = 0.002), and increased need for amputation (P = 0.02).
Conclusions:
Factors affecting the reconstructive management and outcome of DSTIs include injury to structures deep to the skin/subcutis. We categorized DSTIs based on the level of injury and proposed a systematic approach to extremity DSTIs which may be utilized by plastic surgeons and other surgical services to manage these complex injuries.
... In an analysis of a large national database, Duchman et al. found that smokers had an increased risk of wound complications and deep infections [13]. The Lower Extremity Assessment Project (LEAP) also found that in open fractures, smokers were twice as likely to develop an infection and 3.7 times more likely to develop osteomyelitis [14]. Evidence suggests that smoking cessation as early as four weeks preoperatively significantly reduces the likelihood of complications, although a timeline for the impact of cessation is lacking [15][16][17][18][19]. ...
Purpose To determine the efficacy of mandatory preoperative nicotine cessation on postoperative nicotine use, and to identify independent predictors of nicotine use relapse in subjects undergoing hip preservation surgery or total hip arthroplasty by a single fellowship-trained orthopedic surgeon. Methods Consecutive subjects that underwent hip surgery from November 2014 to December 2017 were reviewed. Subjects who self-reported nicotine use, quit prior to surgery, and completed a minimum one-year follow-up were included. Multiple linear regression models were constructed to determine the effect of independent variables on nicotine use relapse following surgery. Results Sixty subjects were included in the study (mean follow-up 35.1 months (17-57 months), mean age 44.9 years (20-82 years), and 23 (38.3%) males). Twenty-eight subjects (46.7%) remained nicotine-free at final follow-up. The mean number of cigarettes per day decreased from 13.4 preoperatively to 8.4 postoperatively in the subjects who relapsed (P=0.002). The mean time to return to nicotine postoperatively was 2.4 months. The number of preoperative cigarettes per day was the only independent predictor of tobacco use relapse (P=0.005). Conclusion Mandatory preoperative nicotine cessation prior to elective hip surgery demonstrates a 46.7% nicotine-free survivorship at final follow-up with the number of preoperative cigarettes per day found to be the only independent predictor of nicotine use relapse. Level of evidence The level of evidence of this research study is Level III since it is a non-experimental study with a cohort of patients.
... The latter percentage decreased dramatically from an all-time high of 46% in 1974 [13]. Despite this relative decrease, smoking remains a considerable factor in non-union [9,14,15]. As of 2012, Abroms et al. identified 252 smoking cessation smartphone applications for iPhone and android devices [16]. ...
Introduction: The fracture burden of the UK utilises a vast proportion of National Health Service (NHS) resources. Subsequent complications in healing
result in poor patient outcomes (indirect costs) and increased demand on healthcare services (direct costs). Inadequate education regarding risk factors
for poor outcomes provides a target for intervention. The increasing proportion of smartphone users makes smartphone applications (apps) a viable
platform from which to distribute educational resources and conduct research.
Methods: A questionnaire was distributed randomly to 100 patients attending fracture clinic at the Queen Elizabeth Hospital in Birmingham over a
twelve-week period. The mean age was 46 years (range 19 to 78), 52% female and a third were aged over 60 years. Primary questions determined the
proportion of smartphone users, specifically those willing to utilise apps as an educational resource. Secondary information collected included patients’
concerns, smoking status, interest in smoking cessation and awareness of the risk factors affecting fracture healing.
Results: Almost 72% of responders used a smartphone, 71% would use an app for education and 74% would allow their data to be utilised for research.
Some 60% of smokers would engage with cessation therapy through an app. The two greatest concerns identified were healing time (46%) and the longterm consequences of a fracture (46%). NSAID use was reported in 30%, however only 20% identified these as risk factor.
Conclusion: The majority of fracture clinic patients use smartphones and are were willing to utilise apps for both healthcare education and research. This
could provide a cost-effective solution to an existing void in patient awareness. Developing an out-patient data collection tool offers new opportunities
to epidemiological researchers.
Background:
Good clinical outcomes in orthopaedics are largely dictated by the biomedical model, despite mounting evidence of the role of psychosocial factors. Understanding orthopaedic providers' conceptualizations of good clinical outcomes and what facilitates and hinders them may highlight critical barriers and opportunities for training providers on biopsychosocial models of care and integrating them into practice.
Questions/purposes:
(1) How do orthopaedic trauma healthcare providers define good clinical outcomes for their patients after an acute orthopaedic injury? (2) What do providers perceive as barriers to good outcomes? (3) What do providers perceive as facilitators of good outcomes? For each question, we explored providers' responses in a biopsychosocial framework.
Methods:
In this cross-sectional, qualitative study, we recruited 94 orthopaedic providers via an electronic screening survey from three Level I trauma centers in geographically diverse regions of the United States (rural southeastern, urban southwestern, and urban northeastern). This study was part of the first phase of a multisite trial testing the implementation of a behavioral intervention to prevent chronic pain after acute orthopaedic injury. Of the 94 participants who were recruited, 88 completed the screening questionnaire. Of the 88 who completed it, nine could not participate because of scheduling conflicts. Thus, the final sample included 79 participants: 48 surgeons (20 attendings, 28 residents; 6% [three of 48] were women, 94% [45 of 48] were between 25 and 55 years old, 73% [35 of 48] were White, and 2% [one of 48] were Hispanic) and 31 other orthopaedic professionals (10 nurse practitioners, registered nurses, and physician assistants; 13 medical assistants; five physical therapists and social workers; and three research fellows; 68% [21 of 31] were women, 97% [30 of 31] were between 25 and 55 years old, 71% [22 of 31] were White, and 39% [12 of 31] were Hispanic). Using a semistructured interview, our team of psychology researchers conducted focus groups, organized by provider type at each site, followed by individual exit interviews (5- to 10-minute debriefing conversations and opportunities to voice additional opinions one-on-one with a focus group facilitator). In each focus group, providers were asked to share their perceptions of what constitutes a "good outcome for your patients," what factors facilitate these outcomes, and what factors are barriers to achieving those outcomes. Focus groups were approximately 60 minutes long. A research assistant recorded field notes during the focus groups to summarize insights gained and disseminate findings to the broader research team. Using this procedure, we determined that thematic saturation was reached for all topics and no additional focus groups were necessary. Three independent coders identified the codes of good outcomes, outcome barriers, and outcome facilitators and applied this coding framework to all transcripts. Three separate data interpreters collaboratively extracted themes related to biomedical, psychological, and social factors and corresponding inductive subthemes.
Results:
Although orthopaedic providers' definitions of good outcomes naturally included biomedical factors (bone healing, functional independence, and pain alleviation), they were also marked by nuanced psychosocial factors, including the need for patients to recover from psychological trauma associated with injury and feel heard and understood-not just as outcome facilitators, but also as key outcomes themselves. Regarding perceived barriers to good outcomes, providers interwove psychological and biomedical factors (for example, "if they're a smoker, if they have depression, anxiety…") and discussed how psychological dysfunction (for example, maladaptive avoidance or fear of reinjury) can limit key behaviors during recovery (such as adherence to physical therapy regimens). Unprimed, providers also cited resiliency-related terms from psychological research, including (low) "self-efficacy," "catastrophic thinking," and (lack of) psychological "hardiness" as barriers. Regarding perceived facilitators of good outcomes, various social and socioeconomic factors emerged, including a biosocial connection between recovery, social support, and "privilege" (such as occupation or education). These perspectives emerged across sites and provider types.
Conclusion:
Although the biomedical model prevails in clinical practice, providers across all sites, in various roles, defined good outcomes and their barriers and facilitators in terms of interconnected biopsychosocial factors without direct priming to do so. Thus, similar Level I trauma centers may be more ready to adopt biopsychosocial care approaches than initially expected.
Clinical relevance:
Providers' perspectives in this study aligned with a growing body of research on the role of biomedical and psychosocial factors in surgical outcomes and risk of transition to chronic pain. To translate these affirming attitudes into practice, other Level I trauma centers could encourage leaders who adopt biopsychosocial approaches to share their perspectives and train other providers in biopsychosocial conceptualization and treatment.
Background
: High energy open tibial fractures are complex injuries with no consensus on the optimal method of fixation. Treatment outcomes are often reported with union and re-operation rates, often without specific definitions being provided. We sought to describe union, reoperation rates, and patient reported outcomes, using the validated EQ-VAS and Disability Rating Index (DRI) scores, following stabilisation with a Taylor Spatial Frame (TSF) and a combined orthoplastic approach for the management of soft tissues. A literature review is also provided.
Method
: A prospective cross-sectional follow up of open tibial fractures, treated at a level 1 major trauma centre, managed with a TSF using a one ring per segment technique between January 2014 and December 2019 were identified. Demographic, injury and operative data were recorded, along with Patient Reported Outcome Measures (PROM) scores, specifically the EQ-VAS and Disability Rating Index (DRI). Union rates, defined by radiographic union scale in tibia (RUST) scores, and re-operation rates were recorded. Appropriate statistical analyses were performed, with a p<0.05 considered statistically significant.
Results
: Overall, 51 patients were included. Mean age was 51.2 ± 17.4 years, with a 4:1 male preponderance. Diaphyseal and distal fractures accounted for 76% of cases. Mean time in frame was 206.7 ± 149.4 days. Union was defined and was achieved in 41/51 (80.4%) patients. Deep infection occurred in 6/51 (11.8%) patients. Amputation was performed in 1 case (1.9%). Overall re-operation rate was 33%. Time to union were significantly longer if re-operation was required for any reason (uncomplicated 204±189 vs complicated 304±155 days; p=0.0017) . EQ-VAS and DRI scores significantly deteriorated at 1 year follow-up (EQVAS 87.5±11.7 vs 66.5±20.4;p<0.0001 and DRI 11.9±17.8 vs 39.3±23.3;p<0.0001). At 1 year post op, 23/51(45.1%) required a walking aid, and 17/29 (58.6%) of those working pre-injury had returned to work.
Conclusion
: Open tibial fracture have significant morbidity and long recovery periods as determined by EQVAS and DRI outcome measures. We report the largest series of open tibial feature treated primarily with a TSF construct, which has similar outcomes to other techniques, and should therefore be considered as a useful technique for managing these injuries.
Objectives:
The purpose of this study was to identify the patient, injury, and treatment factors associated with infection of bicondylar plateau fractures and to evaluate whether center variation exists.
Design:
Retrospective review.
Setting:
Eighteen academic trauma centers.
Patients/participants:
A total of 1,287 patients with 1,297 OTA type 41-C bicondylar tibia plateau fractures who underwent open reduction and internal fixation were included. Exclusion criteria were follow-up less than 120 days, insufficient documentation, and definitive treatment only with external fixation.
Intervention:
Open reduction and internal fixation.
Main outcome measurements:
Superficial and deep infection.
Results:
One hundred one patients (7.8%) developed an infection. In multivariate regression analysis, diabetes (DM) (OR [odds ratio] 3.24; P ≤ 0.001), alcohol abuse (EtOH) (OR 1.8; P = 0.040), dual plating (OR 1.8; P ≤ 0.001), and temporary external fixation (OR 2.07; P = 0.013) were associated with infection. In a risk-adjusted model, we found center variation in infection rates (P = 0.030).
Discussion:
In a large series of patients undergoing open reduction and internal fixation of bicondylar plateau fractures, the infection rate was 7.8%. Infection was associated with DM, EtOH, combined dual plating, and temporary external fixation. Center expertise may also play a role because one center had a statistically lower rate and two trended toward higher rates after adjusting for confounders.
Level of evidence:
Level IV-Therapeutic retrospective cohort study.
Background:
Nonunion rates following ulnar shortening osteotomy (USO) are reported up to 18% with few known risk factors. While resection length is variable in practice, little is known about the prognostic implications on healing. The purpose of this study was to evaluate whether longer resection lengths increased the odds of nonunion.
Methods:
A retrospective review was performed on patients who underwent an elective USO at a single institution over a 6-year period. Demographic, social, comorbidity, and surgical data were reviewed. Ulnar resection length was obtained from operative notes and dichotomized into smaller (<5.5 mm) and larger (≥5.5 mm) groups. The primary outcome was the rate of nonunion. Univariate analyses and a multivariable logistic regression model were used to assess for significant predictors of nonunion.
Results:
A total of 87 patients were included with a mean age of 45 years. Patient comorbidities included 12.6% with diabetes, 29.9% with an American Society of Anesthesiologists score of ≥ 3, 5.8% reporting current tobacco use, and 29.9% reporting former tobacco use. There were 55 patients (63.2%) with resection lengths < 5.5 mm and 32 patients (36.8%) with ≥ 5.5 mm resections. Multivariable analysis identified longer resection length (≥5.5 mm) and current tobacco use as independent risk factors for nonunion. Patients with a resection length of ≥ 5.5 mm had 20.2 times greater odds of nonunion compared with patients with smaller resections, and current smokers had 72.2 times greater odds of nonunion compared with nonsmokers.
Conclusion:
Longer ulnar resection length (≥5.5 mm) significantly increases the risk of nonunion following USO.
Introduction
Little data exists regarding the effects of vaporized nicotine on healing. Our goal was to compare vaporized nicotine, combusted nicotine and control with respect to bone healing in a rat femur fracture model.
Materials and Methods
Forty-five male Sprague Dawley rats were divided into three equal cohorts. Rats were exposed to two cigarettes daily, an equivalent dose of vaporized nicotine, or control, six days a week. Exposures occurred for 4 weeks prior to iatrogenic femur fracture and intramedullary repair. Four additional weeks of exposure occurred prior to sacrifice. Radiographic, biomechanical and histologic analysis was conducted.
Results
No significant difference between the three groups was identified for total mineralized bone volume (p = 0.14), total volume of mature bone (p = 0.12) or immature bone (p = 0.15). Importantly, less total mineralized bone volume and immature bone volume was seen in the vaporized nicotine group compared to combusted tobacco, but results were not significant. Biomechanical testing revealed no significant difference in group torsional stiffness (p = 0.92) or maximum torque (p = 0.31) between the three groups. On histologic analysis, chi-square testing showed no significant difference in any category.
Conclusions
This exploratory study comped combusted nicotine, vaporized nicotine and a control on rat femur fractures. While no statistically significant differences were identified, there were trends showing less total mineralized bone volume and immature bone volume in the vaporized nicotine group compared to the other groups. Additional study is warranted based on our findings.
Purpose
The purpose of this study was to evaluate the relationship between smoking and delayed radiographic union after hand and wrist arthrodesis procedures. We hypothesized that smoking would be associated with a higher rate of delayed union.
Methods
All cases of hand or wrist arthrodesis procedures in patients aged ≥18 years from 2006 to 2020 were identified. Cases were included if they had >90 days of radiographic follow-up or evidence of union before 90 days. Baseline demographics were recorded for each case including smoking status at the time of surgery. Complications were recorded and all postoperative radiographs were reviewed to assess for evidence of delayed union (defined as lack of osseous union by 90 days after surgery). We compared active smokers and nonsmokers and performed a logistic regression analysis to estimate the odds of experiencing a delayed radiographic union.
Results
A total of 309 arthrodesis cases were included and 24% were active smokers. Overall, radiographic evidence of a delayed union was found in 17% of cases. Smokers were significantly more likely to have a delayed union compared with nonsmokers (27% vs 14%). Results of the adjusted logistic regression analysis demonstrated that there was a significantly increased odds of experiencing a delayed union for patients who were active smokers compared with nonsmokers (odds ratio, 2.20; 95% confidence interval, 1.09–4.43). In addition, the rate of symptomatic nonunion requiring reoperation was higher in smokers (15%) compared with nonsmokers (6%).
Conclusions
Smoking was associated with increased odds of delayed radiographic union in patients undergoing hand and wrist arthrodesis procedures. Patients should be counseled appropriately on the risks of smoking on bone healing and encouraged to abstain from nicotine use in the perioperative period.
Type of study/level of evidence
Prognostic II
Fracture-related infection (FRI) is a serious complication after fracture fixation and imposes a considerable burden on patients and health care providers. Polytraumatized patients are at high risk of developing an FRI since severe trauma is commonly accompanied by complex musculoskeletal injuries and a compromised host immune response. In this chapter, we provide a comprehensive summary of recent consensus recommendations on diagnostic and treatment principles for FRI.An FRI can be definitively diagnosed in the presence of at least one of the five confirmatory criteria. The presence of suggestive criteria requires further investigations in order to look for confirmatory criteria. The surgical strategies of FRI treatment are debridement, antimicrobial therapy, and implant retention (DAIR) or implant removal/exchange. The two main antimicrobial goals are infection eradication or—in selected cases—infection suppression until fracture union is achieved.Successful diagnosis and treatment of an FRI requires a multidisciplinary team approach, or transfer of the patient to a specialized bone infection center.KeywordsFracture-related infectionOsteomyelitisAntimicrobial therapyDiagnostic criteriaFractureInfection
Technological advances in trauma patient management, microvascular repair, and fracture fixation have allowed surgeons to maintain viability in many severe traumatic extremity injuries that would have historically resulted in amputation. Although limb salvage may seem to be the optimal goal for the patient, the end result may be a prolonged treatment course that results in significant morbidity, financial cost, and even mortality in some instances. The emergent management of the mangled extremity therefore poses a difficult decision for both the surgeon and the patient. Numerous factors have been implicated as being significant in the natural history of these injuries, and a number of scoring systems incorporating these factors have been proposed to help guide the treating surgeon. The four most commonly used predictive indices include the Mangled Extremity Severity Score (MESS), the Predictive Salvage Index (PSI), the Limb Salvage Index (LSI), and the Nerve injury, Ischemia, Soft-tissue contamination, Skeletal injury, Shock and Age Scoring System (NISSSA). There has been much controversy over the utility of these grading systems in their ability to predict successful salvage of the mangled extremity. They have also not been shown to be useful in predicting final functional outcome following treatment. The recent data published from the LEAP study group has provided us with much valuable information regarding final outcome following these specific injuries. There is a significant difference between severe traumatic injuries of the upper extremity versus those of the lower extremity, and they require specific mention. A mangled extremity in the setting of a polytrauma patient must also be considered separately as well.
Salvage of Lisfranc, or tarsometatarsal injuries, may be necessary because of a variety of clinical scenarios. Although rare, these injuries represent a broad spectrum of injury to the midfoot ranging from low-energy ligamentous injuries to high-energy injuries with significant displacement and associated fractures. Poor outcomes and complications may occur including posttraumatic arthritis, instability, pain, infection, and loss of function. Strategies and technical considerations for salvage of these complex injuries are provided.
Objectives:
To investigate if any injury to the three primary branches of the popliteal artery in open tibia fractures lead to increased soft-tissue complications, particularly in the area of the affected angiosome.
Design:
Retrospective cohort comparative study.
Setting:
Two academic level one trauma centersPatients/Participants: Sixty-eight adult patients with open tibia fractures with a minimum one-year follow up.
Intervention:
N/A.
Main outcome measurements:
Soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture related infection (FRI) at time of final follow-up.
Results:
Eleven (15.1%) tibia fractures had confirmed arterial injuries via CTA (7), direct intraoperative visualization (3), intraoperative angiogram (3). Ten (91.0%) were treated with ligation and 1 (9.1%) was directly repaired by vascular surgery. Ultimately, 6 (54.5%) achieved radiographic union and 4 (36.4%) required amputation performed at a mean of 2.62 ± 2.04 months, with one patient going on to nonunion diagnosed at 10 months. Patients with arterial injury had significantly higher rates of wound healing complications, FRI, nonunion, amputation rates, return to the OR, and increased time to coverage or closure. After multivariate regression, arterial injury was associated with higher odds of wound complications, FRI, and nonunion. Ten (90.9%) patients with arterial injury had open wounds in the region of the compromised angiosome, with 7 (70%) experiencing wound complications, 6 (60%) FRIs, and 3 (30%) undergoing amputation.
Conclusions:
Arterial injuries in open tibia fractures with or without repair, have significantly higher rates of wound healing complications, FRI, delayed time to final closure, and need for amputation. Arterial injuries appear to effect wound healing in the affected angiosome.
Level of evidence:
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The dramatic increase in average life expectancy during the twentieth century ranks as one of the society’s greatest achievements, and the world’s older population continues to grow at an unprecedented rate. As the proportion of older people, length of life, and health expectations continue to increase, a rise in nonfatal age-related musculoskeletal degenerating diseases, disability, and prolonged dependency is projected. To manage this rise and in order to restore or improve pain-free activity, independence, and quality of life, a significant increase in the number of musculoskeletal surgical and nonsurgical encounters is forecast. As such, the incidence of musculoskeletal infections will also increase, where many will be challenging, complicated, and costly to treat. This chapter describes the impact and growing burden of musculoskeletal disorders, summarizes our current societal challenges, and overviews trends in the ever-growing orthopaedic device market. The chapter also highlights recent successes that have improved our understanding of how to treat musculoskeletal infections as well as the many multifactorial challenges that remain.KeywordsAging populationMusculoskeletalOrthopaedicBurdenDeviceInfectionDisorders
Malalignment around the knee may harbour cosmetic, biomechanical and joint longevity complications [1]. Current literature is inconclusive regarding the long-term implications of angular deformities of the lower limb [1–3]; however, long-bone nonunions have shown a reduction in quality of life that is greater than diabetes, stroke and HIV [4]. Fortunately, these complications, following fracture care, are seen less frequently as a result of a better understanding of fracture biomechanics and better orthopaedic implant design [5–15]. Despite this, malalignment rates as high as 60% have been reported following intramedullary nailing for proximal tibia fractures in particular [16].
Infected nonunion around the knee is a challenging complication to manage. This chapter summarises the problems caused by fracture-related infection and reviews concepts important in maximising successful treatment. An appreciation of the host and local factors that impact outcome is key. The important principles of management include thorough debridement, adequate microbiological sampling, dead space management, osseous stabilisation and soft-tissue coverage.
Tibial fractures represent a great burden of disease globally, being the most common long-bone fracture; smoking is a known risk factor for delayed skeletal healing and post-fracture complications. This systematic review and meta-analysis aims to analyse the effect of smoking on healing of tibial shaft fractures. PubMed, CINAHL, EMBASE, and Cochrane Library databases were searched from inception to March 2021, with no limitation on language, to find relevant research. All observational studies that assessed the association between cigarette smoking and tibial shaft fracture healing in adults (≥18 years) were included. The quality of studies was evaluated using the Newcastle Ottawa Quality Assessment Scale. A random effects model was used to conduct meta-analysis. Tobacco smoking was associated with an increased rate of non-union and delayed union as well as an increase in time to union in fractures of the tibial shaft. Among the 12 included studies, eight reported an increased rate of non-union, three reported delayed union, and five reported an increase in time to union. However, the results were statistically significant in only three studies for non-union, one for delayed union, and two studies for increased time to union. This review confirms the detrimental impact of smoking on tibial shaft fracture healing and highlights the importance of patient education regarding smoking cessation.
:
Physicians who advise patients to quit smoking substantially improve cessation rates, but cessation counseling is currently underperformed.
➤:
Counseling, pharmacotherapy, and additional interventions can improve the chance of successful smoking cessation. Most patients require multiple attempts at quitting to be successful.
➤:
A list of referral contacts and resources should be developed and routinely offered to these patients. The national Quitline (1-800-QUIT-NOW) provides free access to trained counselors and "quit coaches" for each state program in the United States.
➤:
Government and private insurance plans in the United States are required (in most cases) to cover the cost of 2 quitting attempts per year including counseling referrals and medications.
➤:
Several biopsychosocial factors that affect orthopaedic outcomes (weight, anxiety, depression, etc.) are also relevant to smoking cessation; management of these factors is thus potentially aggregately advantageous.
This chapter presents the case scenario of a 27‐year‐old female with a history of depression and tobacco abuse presents to the Emergency Department after falling off a ladder at home. She asks what she can do to improve her chances of walking again and whether she should stop smoking. To improve patient outcomes in orthopedics, it is critical to understand which reversible factors may predispose to poor outcome. Smoking has been associated with increased risk for postoperative wound complication and infection across all surgical subspecialties. A meta‐analysis of randomized trials evaluated the effect of smoking cessation on postoperative complications across a range of surgical subspecialties. Despite the well‐recognized negative impact of smoking on orthopedic patients, there is surprisingly little evidence supporting modalities affecting smoking cessation. Orthopedic surgeons can play an important role in smoking cessation by offering education, support, and encouragement. The chapter also provides recommendations for implementing evidence‐based practice in the clinical setting.
Open fracture is a risk factor for nonunion of diaphyseal tibia fractures. Compared with closed injuries, there is a relative lack of scientific knowledge regarding the healing of open tibia fractures. The objective of this study was to investigate which patient, injury, and surgeon-related factors predict nonunion in open tibial shaft fractures. A cohort of 98 patients with 104 extra-articular open tibial shaft fractures (OTA/AO 41A2-3, 42A-C, and 43A) were treated surgically between 2007 and 2018 at a single level 1 trauma center and were retrospectively reviewed. Patients underwent irrigation and debridement followed by definitive intramedullary nailing or plate fixation. Patient, injury, and perioperative prognostic factors were analyzed as predictors of nonunion based on anteroposterior and lateral radiographs. The nonunion rate was 27.9% (n=29). There were 12 occurrences of deep infection (11.5%). The median follow-up was 14 months. High-energy mechanism of injury (hazard ratio [HR], 5.76), Gustilo-Anderson class IIIA injury (HR, 3.66), postoperative cortical continuity of 0% to 25% (HR, 2.90), early postoperative complication (HR, 4.20), and deep infection (HR, 2.25) were significant predictors of nonunion on univariable analysis (P<.05). On multivariable assessment, only high-energy mechanism of injury, Gustilo-Anderson class IIIA injury, and early postoperative complication reached significance as predictors of nonunion. These data also indicate that lack of cortical continuity is a significant univariable radiographic predictor of nonunion. This is potentially modifiable, may guide surgeons in selecting patients for early bone grafting procedures, and should be assessed carefully in this high-risk population. [Orthopedics. 2021;44(3):142-147.].
Objective:
To determine the rate of acute compartment syndrome (ACS) in a series of patients with Gustilo-Anderson type IIIB open tibial shaft fractures that were treated using a specific 2-stage orthoplastic protocol.
Design:
Consecutive cohort study.
Patients/participants:
Ninety-three (n = 93) consecutive patients with a type IIIB open tibial shaft fracture (OTA/AO-42) treated using a 2-stage orthoplastic approach, between August 2015 and January 2018. After exclusions, 83 (n = 83) were eligible for analysis.
Intervention:
Colloid resuscitation and 2-stage orthoplastic reconstruction of type IIIB open tibial shaft fracture. Stage 1 consists of "3-vessel view" early debridement and temporary internal fixation, with stage 2 consisting of a single-stage fix and flap.
Main outcome measurements:
Rate of ACS. Secondary outcomes included early/late sequelae of missed ACS, deep infection, arterial injury, nonunion, and flap failure.
Results:
Eighty-three (n = 83) patients were included for analysis. The median age was 45.4 years [interquartile range (IQR) 35] with a median follow-up of 1.6 years (IQR 0.8). The median number of operations was 2.0 (IQR 4). For the primary outcome, there were a total of 0 (0/83) patients who required fasciotomy or developed early/late clinical sequelae of missed ACS. Six (6/83, 7.2%) patients developed deep infection, 18 patients (18/83, 21.7%) experienced nonischemic arterial injury, 5 patients (5/83, 6.0%) experienced nonunion, with 4 patients (4/83, 4.8%) experiencing flap failure. Diabetes was the only variable associated with deep infection (P = 0.025) and nonunion (P < 0.001).
Conclusions:
Patients with type IIIB open tibial shaft fractures treated with colloid resuscitation and a 2-stage orthoplastic protocol, which includes early "3-vessel view" exposure and debridement, do not appear to develop ACS. Furthermore, no sequelae of missed compartment syndrome was observed at final follow-up.
Level of evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
the habit of smoking is very diffused all over the world and many diseases may be related to it. current smokers are diffused among orthopedic patients; surgeon and patients must be aware about risks related to this habit in order to comprehend complications and results that may be derived by surgery. in this review we evaluated the epidemiology of complications and damages caused by smoke in orthopedic and traumatology.
Smoking is known to increase the risk of peri-operative complications in Orthoplastic surgery by impairing bone and wound healing. The effects of nicotine replacement therapies (NRTs) and electronic cigarettes (e-cigarettes) has been less well established. Previous reviews have examined the relationship between smoking and bone and wound healing separately. This review provides surgeons with a comprehensive and contemporaneous account of how smoking in all forms interacts with all aspects of complex lower limb trauma. We provide a guide for surgeons to refer to during the consent process to enable them to tailor information towards smokers in such a way that the patient may understand the risks involved with their surgical treatment. We update the literature with recently discovered methods of monitoring and treating the troublesome complications that occur more commonly in smokers effected by trauma
Introduction: Segmental tibia defects remain challenging for orthopedic surgeons to treat. The aim of this study was to demonstrate bone-related and functional outcomes after treatment of complex tibial bone defects using Ilizarov bone transport with a modified intramedullary cable transportation system (CTS).
Patients and Methods: We conducted a single-center, retrospective study including all 42 patients treated for tibial bone loss via Ilizarov bone transport with CTS between 2005 and 2018. Bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system. Complication and failure rates were determined by the patients’ medical files.
Results: Patients had a mean age of 45.5 ± 15.1 years. The mean bone defect size was 7.7 ± 3.4 cm, the average nonunion scoring system (NUSS) score was 59 ± 9.5 points, and the mean follow-up was 40.8 ± 24.4 months (range, 13-139 months). Complete bone and soft tissue healing occurred in 32/42 patients (76.2%). These patients had excellent (10), good (17), fair (2), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 19 patients had excellent, 10 good, and 3 fair results. In total, 37 minor complications and 62 major complications occurred during the study. In 7 patients, bone and soft tissue healing occurred after CTS failure with either an induced membrane technique or classic bone transport; 3 patients underwent lower leg amputation. Patients with treatment failure were significantly older (57.6 vs. 41.8 years; p = 0.003). Charlson score and treatment failure had a positive correlation (Spearman's rho 0.43; p = 0.004).
Conclusion: Bone transport using both intramedullary CTS and Ilizarov ring fixation is viable for treating patients with bone loss of the tibia and complex infection or soft tissue conditions. However, a high number of complications and surgical revisions are associated with the treatment of this severe clinical entity and should be taken into account.
Background
Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis.
Methods
In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon’s logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes.
Results
Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P < .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection ( P = .05) and bone stimulator use ( P < .001). Among smokers, there was a trend toward slower union with heavier smoking ( P = .004).
Conclusion
This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame.
Level of Evidence
Level III, retrospective cohort study.
Objectives:
To determine the reliability of self-reported smoking status in the orthopaedic trauma population and determine if certain patient factors might predispose inaccurate self-reported smoking cessation.
Design:
Prospective.
Setting:
Level I trauma center.
Patients:
Two hundred forty-seven orthopaedic trauma patients.
Intervention:
In-office measurement of exhaled carbon monoxide (CO).
Main outcome measurements:
Self-reported smoking cessation with exhaled CO measurements.
Results:
A total of 906 self-reported surveys were completed over 4 follow-up visits. Of the responses indicating smoking cessation (n = 174), 12.6% (95% confidence interval [CI], 0.081-0.185) reported smoking cessation with positive CO readings, suggesting inaccurate self-reporting of smoking status. Over 20% of those patients inaccurately reporting abstinence did so more than once. The odds of inaccurate self-reporting was 3 times higher in patients with no insurance or government insurance (odds ratio [OR], 3.5; 95% CI, 1.1-11.0; P = 0.043), and in the unemployed (OR, 3.3; 95% CI, 0.97-8.57; P = 0.049).
Conclusions:
Self-reported smoking status in the orthopaedic population is fairly reliable, with 13% of patient's inaccurately self-reporting smoking cessation despite knowing their smoking status was being measured. Clinicians should be aware of the potential for inaccuracy in self-reported smoking cessation, particularly in patients with the identified socioeconomic factors. Point of care testing prior to elective trauma procedures to confirm smoking status might have a role if the procedure outcome is highly dependent on smoking status.
Level of evidence:
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Objectives:
To determine if inpatient counseling with additional counseling could increase smoking cessation.
Design:
Prospective study.
Setting:
Level I trauma center.
Patients/participants:
Current smokers with an operative fracture randomly assigned to control (no counseling), brief counseling (inpatient counseling), or intense counseling (brief counseling plus follow-up) groups.
Intervention:
Brief inpatient smoking counseling and referral to a nationally-based quitline.
Main outcome measurements:
Smoking cessation confirmed by exhaled carbon monoxide, recorded at 12 and 26 weeks.
Results:
Overall, 266 patients participated, with 40, 111, and 115 patients in the control and treatment groups, respectively. At 3 months, 17% of control versus 11% and 10% brief and intense counseling groups quit smoking, respectively. At 6 months, 15% of control, and 10% and 5% of the respective counseling groups quit. No significant difference reported between groups. Forty-three percent of patients accepted quitline referral. Intense counseling patients were 3 times more likely to accept referral (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.4-6.9) and brief counseling patients were more than 2 times as likely to accept referral (OR, 2.3; 95% CI, 1.0-5.1). Overall, 54% of participants who accepted the quitline referral accepted quitline services. Intense counseling (OR, 8.2; 95% CI, 1.0-68.5) and brief counseling (OR, 5.3; 95% CI, 0.6-44.9) patients were more likely to use quitline services.
Conclusion:
Increasing levels of inpatient counseling can improve successful referral to quitline, but it does not appear to influence quit rates amongst orthopaedic trauma patients.
Level of evidence:
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
PurposeThis study aimed to determine the risk factors of aseptic loosening (AL) in complex revision total knee arthroplasty (TKA) cases using rotating hinge knee prosthesis.Methods
Patients who had undergone re-revision rotating hinge prosthesis surgery between January 2012 and December 2017 were included. Parameters related to AL were retrospectively reviewed. For this purpose, 31 aseptic loosening patients and 30 control patients were included in the study. Various risk factors were evaluated. Risk factors for AL after re-revision were determined using univariate and multiple logistic regression analyses.ResultsThirty-one AL patients and 30 control patients were included. In the AL group, tibial tantalum cone and impaction grafting were performed significantly less frequently than the control group (p = 0.002 and p < 0.001). Logistic regression analysis revealed that smoking, right-sided TKA, and large femoral canal anteroposterior diameter were factors that increased the risk of AL after re-revision, while tibial tantalum cone decreased the risk of loosening. Smokers had an 11.847-fold higher risk for AL; right-sided TKA led to a 4.594-fold higher risk for AL. However, the presence of a tibial tantalum cone was associated with an 8.403-fold lower risk for AL.Conclusions
We conclude that smoking, right-sided prosthesis, and large femoral canal diameter increased the risk of AL, while tantalum cone and impaction grafting reduced this risk in patients who underwent re-revision surgery with rotating hinge prosthesis after TKA.
Nonskeletal risk factors can impact either bone mineral density (BMD), fracture risk or both. These factors fall into the general categories of physical characteristics [gender, height, weight, and body mass index (BMI)] and lifestyle factors (smoking and alcohol). Gender-related differences in fracture rates may be related to body size or microarchitectural differences. With age, women have greater loss of trabecular mass and cortical thickness with more cortical porosity, as compared to men. Weight and BMI relate positively to BMD and inversely to fracture rates. Lean mass may be an important determinant of premenopausal bone mass, but fat mass is strongly related to postmenopausal BMD. Obesity is related to higher bone mass and lower rates of osteoporosis-related fractures—but fractures of certain bones, such as humerus and ankle, may occur at higher rates. In obese individuals, weight loss is needed to reduce the risk of comorbid conditions, but this may be detrimental to the skeleton. Smoking and excessive alcohol intakes have adverse skeletal effects, whereas moderate alcohol intake is associated with higher BMD.
Background:
Smoking cessation represents an opportunity to reduce both short and long-term effects of smoking on complications after lumbar fusion and smoking-related morbidity and mortality. However, the cost-effectiveness of smoking-cessation interventions prior to lumbar fusion is not fully known.
Methods:
We created a decision-analytic Markov model to evaluate the cost-effectiveness of 5 smoking-cessation strategies (behavioral counseling, nicotine replacement therapy [NRT], bupropion or varenicline monotherapy, and a combined intervention) prior to single-level, instrumented lumbar posterolateral fusion (PLF) from the health payer perspective. Probabilities, costs, and utilities were obtained from published sources. We calculated the costs and quality-adjusted life years (QALYs) associated with each strategy over multiple time horizons and accounted for uncertainty with probabilistic sensitivity analyses (PSAs) consisting of 10,000 second-order Monte Carlo simulations.
Results:
Every smoking-cessation intervention was more effective and less costly than usual care at the lifetime horizon. In the short term, behavioral counseling, NRT, varenicline monotherapy, and the combined intervention were also cost-saving, while bupropion monotherapy was more effective but more costly than usual care. The mean lifetime cost savings for behavioral counseling, NRT, bupropion monotherapy, varenicline monotherapy, and the combined intervention were $3,291 (standard deviation [SD], $868), $2,571 (SD, $479), $2,851 (SD, $830), $6,767 (SD, $1,604), and $34,923 (SD, $4,248), respectively. The minimum efficacy threshold (relative risk for smoking cessation) for lifetime cost savings varied from 1.01 (behavioral counseling) to 1.15 (varenicline monotherapy). A PSA revealed that the combined smoking-cessation intervention was always more effective and less costly than usual care.
Conclusions:
Even brief smoking-cessation interventions yield large short-term and long-term cost savings. Smoking-cessation interventions prior to PLF can both reduce costs and improve patient outcomes as health payers/systems shift toward value-based reimbursement (e.g., bundled payments) or population health models.
Level of evidence:
Economic Level II. See Instructions for Authors for a complete description of levels of evidence.
Outcome measures for smoking cessation are reviewed and evaluated, including 3 self-report measures and 3 biochemical validation measures. Point prevalence reflects the percentage of participants taking action, prolonged abstinence reflects those in the maintenance stage, and continuous abstinence reflects those who progress from action to maintenance without lapsing or relapsing. Biochemical assessments are primarily measures of point prevalence abstinence. The desirability of biochemical validation is a particularly controversial and critical issue. Three factors affect the accuracy of self-report: Type of Population, Type of Intervention, and Demand Characteristics. False-negative rates are generally low. Three broad issues impact on decisions to use biochemical validation: (a) alternative explanations for false positives, (b) refusal rate problems, and (c) the effect of inaccuracy on intervention assessment.
This study sought to reassess the relationship between cigarette smoking and education.
Data from the 1983 to 1991 National Health Interview Survey for participants aged 25 years and older were used to plot the prevalence of current smoking, ever smoking, heavy smoking, and smoking cessation, as well as the adjusted log odds ratios, by years of education.
The "less than high school graduate" category consisted of two groups with distinct smoking patterns: persons with 0 to 8 years and persons with 9 to 11 years of education. The latter were the most likely to be current, ever, and heavy smokers and the least likely to have quit smoking, whereas the former were similar to persons having 12 years of education. After 11 years of education, the likelihood of smoking decreased and that of smoking cessation increased with each successive year of education. These results persisted after the statistical adjustment for age, sex, ethnicity, poverty status, employment status, marital status, geographic region, and year of survey.
The relationship between smoking and education is not monotonic. Thus, when evaluating smoking in relation to education, researchers should categorize years of education as follows: 0 to 8, 9 to 11, 12, 13 to 15, and 16 or more years.
We have reviewed a series of 56 consecutive patients treated by the Ilizarov circular fixator for various combinations of nonunion, malunion and infection of fractures. We used segmental excision, distraction osteogenesis and gradual correction of the deformity as appropriate. Treatment was effective in eliminating 40 out of 46 nonunions and all 22 infections. There were two cases of refracture some months after removal of the frame, both of which healed securely in a second frame. Correction of malunion was good in the coronal plane but there was a tendency to anterior angulation, often occurring in the regenerate bone rather than at the original fracture site, after removal of the frame. This was associated with very slow maturation of regenerate bone in some patients, occurring largely, but not exclusively, in those who smoked heavily. Patients expressed high levels of satisfaction with the outcome, despite relatively modest improvements in pain and function, presumably because their longstanding and intractable nonunion had been treated. None the less, the degree of satisfaction correlated strongly with the degree of improvement in pain and function. We emphasise the importance of a multidisciplinary team in the assessment and support of patients undergoing long and demanding treatment. The Ilizarov method is valuable, but research is needed to overcome the problems of delayed maturation of the regenerate and slow or insecure healing of the docking site.
A low intensity ultrasound device was investigated as an accelerator of cortical and cancellous bone fracture healing in smokers and nonsmokers. Statistically significant reductions in healing time for smokers and nonsmokers were observed for tibial and distal radius fractures treated with an active ultrasound device compared with a placebo control device. The healing time for a tibial fracture was reduced 41% in smokers and 26% in nonsmokers with the active ultrasound device. Similarly, distal radius fracture healing time was reduced by 51% in smokers and 34% in nonsmokers with the active device. Treatment with the active ultrasound device also substantially reduced the incidence of tibial delayed unions in smokers and nonsmokers. The use of the active ultrasound device accelerates cortical and cancellous bone fracture healing, substantially mitigates the delayed healing effects of smoking, speeds the return to normal activity, and reduces the long-term complication of delayed union.
In the past 15 years, we have seen a marked increase in research on socioeconomic status (SES) and health. Research in the first part of this era examined the nature of the relationship of SES and health, revealing a graded association; SES is important to health not only for those in poverty, but at all levels of SES. On average, the more advantaged individuals are, the better their health. In this paper we examine the data regarding the SES-health gradient, addressing causal direction, generalizability across populations and diseases, and associations with health for different indicators of SES. In the most recent era, researchers are increasingly exploring the mechanisms by which SES exerts an influence on health. There are multiple pathways by which SES determines health; a comprehensive analysis must include macroeconomic contexts and social factors as well as more immediate social environments, individual psychological and behavioral factors, and biological predispositions and processes.
We assessed factors which may affect union in 32 patients with nonunion of a fracture of the diaphysis of the femur and 67 comparable patients whose fracture had united. These included gender, age, smoking habit, the use of non-steroidal anti-inflammatory drugs (NSAIDs) the type of fracture (AO classification), soft-tissue injury (open or closed), the type of nail, the mode of locking, reaming v non-reaming, infection, failure of the implant, distraction at the fracture site, and the time to full weight-bearing. Patients with severe head injuries were excluded. Both groups were comparable with regard to gender, Injury Severity Score and soft-tissue injury.
There was no relationship between the rate of union and the type of implant, mode of locking, reaming, distraction or smoking. There were fewer cases of nonunion in more comminuted fractures (type C) and in patients who were able to bear weight early. There was a marked association between nonunion and the use of NSAIDs after injury (p = 0.000001) and delayed healing was noted in patients who took NSAIDs and whose fractures had united.
Low-intensity ultrasound has demonstrated an acceleration of bone healing and more profound callus formation in animal and human clinical experiments. In this study, the effect of pulsed, low-intensity ultrasound was determined in established nonunion cases.
The enrolled cases were reviewed for the time from their last surgical procedure and evidence of no healing or progression of healing during the 3 or more months before the start of low-intensity ultrasound therapy to determine whether the cases were established nonunions. Twenty-nine cases, located in the tibia, femur, radius/ulna, scaphoid, humerus, metatarsal, and clavicle, met the criteria for established nonunions. On average, the postfracture period before the start of ultrasound treatment was 61 weeks. Initial fracture treatment was conservative in 8 cases and operative in 21 cases. Additional treatments including bone grafting, reosteosynthesis, and other surgical procedures were performed an average of 52 weeks before the start of ultrasound treatment. Daily, 20-minute applications of low-intensity ultrasound at the site of the nonunion were performed by the patients at home.
Twenty-five of the 29 nonunion cases (86%) healed in an average treatment time of 22 weeks (median, 17 weeks). Stratification of the healed and failed outcome for age, gender, concomitant disease, bone location, fracture age, prior last surgery interval, nonunion type, smoking habits, and fixation before and during treatment showed a significant difference only in the smoking habit strata.
Noninvasive ultrasound therapy can be useful in the treatment of challenging, established nonunions.
Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated.
We performed a multicenter, prospective, observational study to determine the functional outcomes of 569 patients with severe leg injuries resulting in reconstruction or amputation. The principal outcome measure was the Sickness Impact Profile, a multidimensional measure of self-reported health status (scores range from 0 to 100; scores for the general population average 2 to 3, and scores greater than 10 represent severe disability). Secondary outcomes included limb status and the presence or absence of major complications resulting in rehospitalization.
At two years, there was no significant difference in scores for the Sickness Impact Profile between the amputation and reconstruction groups (12.6 vs. 11.8, P=0.53). After adjustment for the characteristics of the patients and their injuries, patients who underwent amputation had functional outcomes that were similar to those of patients who underwent reconstruction. Predictors of a poorer score for the Sickness Impact Profile included rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation. Patients who underwent reconstruction were more likely to be rehospitalized than those who underwent amputation (47.6 percent vs. 33.9 percent, P=0.002). Similar proportions of patients who underwent amputation and patients who underwent reconstruction had returned to work by two years (53.0 percent and 49.4 percent, respectively).
Patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation.
In January 1964, the Surgeon General's Advisory Committee on Smoking and Health1 in considering the available information on smoking and coronary heart disease (CHD) (International Statistical Classification [ISC] 420) reported that "male cigarette smokers have a higher death rate from coronary artery disease than nonsmoking males, but it is not clear that the association has casual significance."
Three points should be noted. First, the committee left no doubt that there was a consistent statistically significant association among cigarette smokers of increased mortality and morbidity from CHD in men, particularly during middle life. Seven large completed or current prospective studies of smoking and death rate gave a CHD median mortality ratio (current cigarette smokers to nonsmokers) of 1.7, with no significant excess deaths among cigar and pipe smokers. Second, the committee recognized that certain factors other than smoking were known or thought to predispose to the condition or to be
A method for comparing death rates of groups of injured persons was developed, using hospital and medical examiner data for more than two thousand persons. The first step was determination of the extent to which injury severity as rated by the Abbreviated Injury Scale correlates with patient survival. Substantial correlation was demonstrated. Controlling for severity of the primary injury made it possible to measure the effect on mortality of additional injuries. Injuries that in themselves would not normally be life-threatening were shown to have a marked effect on mortality when they occurred in combination with other injuries. An Injury Severity Score was developed that correlates well with survival and provides a numerical description of the overall severity of injury for patients with multiple trauma. Results of this investigation indicate that the Injury Severity Score represents an important step in solving the problem of summarizing injury severity, especially in patients with multiple trauma.
The veracity of behavioral self-reports is often challenged, particularly when the motivation to avoid stigma and win social approval holds potential to introduce bias into the data collected. This study employed plasma cotinine tests to validate the self-reports of tobacco use collected from 3,841 casino employees as part of a comprehensive health survey. Rates of discordance were calculated by comparing employee self-reports with results from plasma cotinine tests. This study provides evidence that casino employees can provide valid self-report data. Further, discordance rates of self-reported tobacco use vary according to operational definitions of tobacco use. These findings highlight the methodological importance of recognizing the inherent heterogeneity of smoking behavior.
This article presents a summary of the health status of the disadvantaged populations in the United States, with specific regard to the incidence, treatment, and mortality of cancer. It begins with an historical overview of health care for the poor in this country, and continues with an explanation of the risk factors prevalent, if not inherent, in the life-style associated with low socioeconomic status, such as poor diet, cigarette smoking, and ignorance of preventive health measures and screening techniques. It includes a discussion of the different types that are overrepresented in this population and of the barriers to preventive care and treatment that still exist. The most important of these is decreased access to continuous medical care because of a lack of health insurance and an overdependence on emergency room treatment for all health care. The final section reviews solutions that have been preferred by physicians, nurses, lawmakers, public health workers, and community advocates for the poor. The most important parts of the solution are patient education for preventive health care, disease warning signs, and screening techniques and an overhaul of the present system of providing health care to ensure equal access and treatment for all members of the society.
A multicenter study was undertaken to analyze postoperative wound infections after posterior spinal instrumentation and fusion. The infection rate of these procedures has been documented in multiple reports. From these results, a classification scheme was developed that can guide therapy and determine the populations at risk. The patients were categorized according to two parameters, the first being the severity or type of infection, and the second being the host response or physiologic classification of the patient. This classification scheme is based on the clinical staging system for adult osteomyelitis developed by Cierny. The severity of infection is divided into three groups. Group 1 is a single-organism infection, either superficial or deep. Group 2 is a multiple-organism, deep infection. Group 3 is multiple organisms with myonecrosis. The host response, likewise, is divided into three classes. Class A is a host with normal systemic defenses, metabolic capabilities, and vascularity. Class B patients demonstrate local or multiple systemic diseases, including cigarette smoking. Class C requires an immunocompromised or severely malnourished host. Our data have demonstrated that single organisms, Group 1, generally can be dealt with by single irrigation and debridement, and closure over suction drainage tubes without the use of an inflow-irrigation system. The Group 2 patients, with multiple organisms and deep infection, required an average of three irrigation debridements. They have a higher percentage of successful closures with closed inflow-outflow suction irrigation systems when compared to simple suction drainage systems without constant inflow irrigation. Multiple-organism infections with myonecrosis, Group 3, are exceedingly difficult to manage, and portend a poor outcome. Patients without normal host defenses, Classes B and C, are at high risk for developing postoperative wound infection. Specifically, this study demonstrated that cigarette smoking may be a significant risk factor.
In severe traumatic injuries to the lower extremity, it is often a difficult decision to attempt heroic efforts aimed at limb salvage or to amputate primarily. To answer this question, the authors performed a 5-year review of 70 limbs in 67 patients. Patients were identified as presenting with major lower extremity trauma and an associated arterial injury. Nineteen (27%) of the 70 limbs were amputated. Limb salvage was not related to the presence or absence of shock and order of repair (orthopedic or vascular). No statistical difference was noted between the time of injury to operative repair in either the amputated or limb salvage group. Limb salvage was related to warm ischemia time and the quantitative degree of arterial, nerve, bone, muscle, skin, and venous injury. A limb salvage index (LSI) was formulated based on the degree of injury to these systems. All 51 patients with an LSI score of less than 6 had successful limb salvage (p less than 0.001). All 19 patients with an LSI score of 6 or greater had amputations (p less than 0.001). Although statistics cannot replace clinical judgment, this index can be a valuable objective tool in the evaluation of the patient with a severely traumatized extremity.
MESS (Mangled Extremity Severity Score) is a simple rating scale for lower extremity trauma, based on skeletal/soft-tissue damage, limb ischemia, shock, and age. Retrospective analysis of severe lower extremity injuries in 25 trauma victims demonstrated a significant difference between MESS values for 17 limbs ultimately salvaged (mean, 4.88 +/- 0.27) and nine requiring amputation (mean, 9.11 +/- 0.51) (p less than 0.01). A prospective trial of MESS in lower extremity injuries managed at two trauma centers again demonstrated a significant difference between MESS values of 14 salvaged (mean, 4.00 +/- 0.28) and 12 doomed (mean, 8.83 +/- 0.53) limbs (p less than 0.01). In both the retrospective survey and the prospective trial, a MESS value greater than or equal to 7 predicted amputation with 100% accuracy. MESS may be useful in selecting trauma victims whose irretrievably injured lower extremities warrant primary amputation.
This paper deals with the economic and social factors that influence the provision of preventive services in the United States. While preventive services may be provided efficiently and effectively by a variety of health care professionals, physicians are the primary target of this review. Reference is also made to the role of other health professionals who work directly with physicians in providing preventive services. Economic and social factors affecting employer and community-based preventive service programs are excluded from consideration and are mentioned only in passing. In this paper, the term 'preventive services' subsumes both disease prevention and health promotion. Preventive services identify known precursors of serious disease and provide some risk reduction, such as immunizations or follow-up of a patient with a breast lump. Health promotion refers to efforts by physicians and associated health professionals to increase patient awareness and to counsel and otherwise assist the patient in making behavioral changes, both to reduce known risk factors and to improve the quality of life. Despite efforts to define these groups of services differently, their objectives and methods overlap.
This article discusses extensions of generalized linear models for the analysis of longitudinal data. Two approaches are considered: subject-specific (SS) models in which heterogeneity in regression parameters is explicitly modelled; and population-averaged (PA) models in which the aggregate response for the population is the focus. We use a generalized estimating equation approach to fit both classes of models for discrete and continuous outcomes. When the subject-specific parameters are assumed to follow a Gaussian distribution, simple relationships between the PA and SS parameters are available. The methods are illustrated with an analysis of data on mother's smoking and children's respiratory disease.
A retrospective review of 676 tibial-fibular fractures and 985 femoral fractures treated over a 71-month period yielded associated major vascular trauma in 12 (1.7%) tibial-fibular fractures and in five (0.5%) femoral fractures. Vascular trauma combined with orthopedic trauma was also identified in four other cases--two disruptions of the pubic symphysis and two dislocations of the knee without fracture. Nine (43%) of the 21 involved limbs were eventually amputated. Limb survival was not related to the temporal relationship of vessel repair to skeletal stabilization; the presence or absence of shock on admission; the presence of associated but repaired venous injury; or the presence of unrelated injuries. Limb survival was related to the interval from injury to arrival in the operating room; the level of arterial injury; and the quantitative degree of muscle, bone, and skin injury. By combining these variables a limb salvage index was established that identified lower extremities likely to require amputation after combined orthopedic and vascular trauma (sensitivity 78%, specificity 100%). Use of this predictive salvage index may prevent the trauma surgeon from attempting to salvage a doomed or useless lower extremity and may thus permit early prosthetic rehabilitation to follow definitive primary amputation.
To investigate the relationship of smoking with the rate of pseudarthrosis (surgical nonunion), 50 patients, who were smokers, and 50 patients, who were not, and who had had a two-level laminectomy and fusion during 1977 and 1978 were randomly selected for this study. Most of those participating had sustained job-related injuries whereas the others had no common etiology for their back dysfunction. Most of the patients were from the southeastern United States. Ages ranged from 23 to 62 years, with a mean age of 42.4 years for smokers and 42.7 years for nonsmokers. There was an equal representation of males and females, with minorities represented according to their general percentage in the population. Examination 1 to 2 years after surgery revealed that 40% (20) of the smokers had developed a pseudarthrosis, whereas among nonsmokers, the rate was 8% (4). This finding appears to be independent of age, sex, or race and was statistically significant (chi 2 = 14.035, P = .001). It was hypothesized that the higher incidence of surgical nonunion among smokers may be related to blood gas levels. Nonsmokers showed no significant deficiencies, whereas smokers showed a mean PO2 level of 78.5% (normal = 95-97) and a mean O2 saturation level of 92.9% (normal = 95 or above). Implications and suggestions for further research are also discussed.
A method for comparing death rates of groups of injured persons was developed, using hospital and medical examiner data for more than 2,000 persons. The first step was determination of the extent to which injury severity as rated by the Abbreviated Injury Scale correlates with patient survival. Substantial correlation was demonstrated. Controlling for severity of the primary injury made it possible to measure the effect on mortality of additional injuries. Injuries that in themselves would not normally be life threatening were shown to have a marked effect on mortality when they occurred in combination with other injuries. An Injury Severity Score was developed that correlates well with survival and provides a numerical description of the overall severity of injury for patients with multiple trauma. Results of this investigation indicate that the Injury Severity Score represents an important step in solving the problem of summarizing injury severity, especially in patients with multiple trauma. The score is easily derived, and is based on a widely used injury classification system, the Abbreviated Injury Scale. Use of the Injury Severity Score facilitates comparison of the mortality experience of varied groups of trauma patients, thereby improving ability to evaluate care of the injured.
Between 1976-1979, 87 Type III open fractures (in 75 patients) were treated at the Hennepin County Medical Center. Factors leading to increased morbidity in Type III fractures were: massive soft-tissue damage; compromised vascularity; severe wound contamination; and marked fracture instability. This study demonstrates, because of varied severity and prognosis, that the current designation of Type III open fracture is too inclusive. We recommend, therefore, that Type III open fractures be divided, in order of worsening prognosis, into three subtypes. Type IIIA--Adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound. Type IIIB--Extensive soft-tissue injury loss with periosteal stripping and bone exposure. This is usually associated with massive contamination. Type IIIC--Open fracture associated with arterial injury requiring repair. Wound sepsis in the three subtypes were: Type IIIA, 4%, IIIB, 52%; and IIIC, 42%; while amputation rates were, respectively, 0%, 16%, and 42%. Only two patients developed osteomyelitis, and 12 patients had delayed or nonunions. Five patients died, all as a result of multisystem trauma. The bacterial pathogens in infected open fractures have changed dramatically over the years. In the present series (1976-1979), 77% of infections were due to Gram-negative bacteria, compared with 24% previously (1961-1975). A change of antibiotic therapy from a first-generation cephalosporin alone to a combination of a cephalosporin and an aminoglycoside, or a third-generation cephalosporin, is currently indicated in Type III open fractures.
The relative risk of nonunion in smokers versus nonsmokers after ankle arthrodesis was determined in a case control study. Twenty-two patients were matched to 22 controls by age, sex, surgeon, surgical technique, and preoperative diagnosis. Information on duration, amount, and past history of smoking was obtained for these 44 patients. Ten of the patients were actively smoking at the time of surgery compared with four of the controls. Six of the patients had no history of smoking and six had stopped smoking before surgery. Eleven of the controls had no history of cigarette smoking and 7 had stopped smoking before surgery. The relative risk of nonunion was increased 3.75 times for active smokers. When patients did not have any known risk factors for nonunion, the risk of nonunion for smokers was 16 times the risk of nonunion for nonsmokers.
A total of 135 patients with a fresh tibial shaft fracture and with no other significant injuries underwent primary conservative treatment. Data on their smoking habits were obtained from hospital records and by questionnaire. Although the smokers had better prospects for healing of the fracture at the outset than non-smokers (lower mean age and less fractures caused by high-energy injuries), the smokers were found to have a significantly longer mean time to clinical union and a higher incidence of delayed union. According to a crude calculation, smokers had a 4.1-fold risk of tibial shaft fracture caused by low-energy injury, compared with non-smokers. An accelerated failure time model showed that the more comminuted or open the fracture, the higher the number of cigarettes smoked and the older the patient, the longer was the time to clinical union of the tibial shaft fracture. Female sex appeared to be a further risk factor for delayed healing. A logit model indicated that comminution of the fracture, smoking and female sex were associated with delayed union and non-union. If a patient has a markedly raised probability of delayed union of tibial shaft fracture because of many risk factors as reported in the previous literature or in this study, operative treatment should be considered as the primary alternative instead of conservative treatment. Stopping smoking during healing of tibial shaft fracture could also promote the union of the fracture.
Even though treatment protocols of open fractures have been improved in the past two decades, osteitis is still a major complication in these injuries. To investigate the primary factors responsible for posttraumatic osteitis, 19 cases of osteitis out of 297 open fractures (retrospective series from 1981 to 1983) and nine cases of osteitis out of 651 open fractures (prospective series from 1984 to 1989) were analyzed. The Hannover fracture scale was used for quantitative evaluation of the injury. A high prognostic index for bone infections was found for the amount of bone loss, the fracture type, the type of bacteriologic contamination, deep soft-tissue defects, compartment syndromes, vascular injuries, and soft-tissue infections.
Knowledge of the epidemiology of tobacco use and dependence can be used to guide research initiatives, intervention programs, and policy decisions. Both the reduction in the prevalence of smoking among US adults and black adolescents and the decline in per capita consumption are encouraging. These changes have probably been influenced by factors operating at the individual (e.g., school-based prevention programs and cessation programs) and environmental (e.g., mass media educational strategies, the presence of smoke-free laws and policies, and the price of tobacco products) levels (for a discussion of these factors, see, e.g., refs. 2, 48, 52, 183, and 184). The lack of progress among adolescents, especially whites and males, and the high risk for experimenters of developing tobacco dependence present cause for great concern (48, 183-186). In addition to those discussed above, several areas of research can be recommended. 1. Better understanding of the clustering of tobacco use with the use of other drugs, other risk behaviors, and other psychiatric disorders could better illuminate the causal processes involved, as well as the special features of the interventions needed to prevent and treat tobacco dependence. 2. To better understand population needs, trend analyses of prevalence, initiation, and cessation should, whenever possible, incorporate standardized measures of these other risk factors. Future research should compare the effect of socioeconomic status variables on measures of smoking behavior among racial/ethnic groups in the United States. 3. For reasons that may be genetic, environmental, or both, some persons do not progress beyond initial experimentation with tobacco use (2, 48, 183, 187-192), but about one-third to one-half of those who experiment with cigarettes become regular users (48, 193, 194). Factors, both individual and environmental, that can influence the susceptibility of individuals to tobacco dependence need further attention. 4. To estimate their sensitivity and specificity, comparisons of the National Household Survey on Drug Abuse indicators of dependence with DSM-based criteria are needed. Public health action continues to be warranted to reduce the substantial morbidity and mortality caused by tobacco use (195). A paradigm for such action has been recommended and involves preventing the onset of use, treating tobacco dependence, protecting non-smokers from exposure to secondhand smoke, promoting nonsmoking messages while limiting the effect of tobacco advertising and promotion on young people, increasing the real (inflation-adjusted) price of tobacco products, and regulating tobacco products (186).
A basic science study using a rabbit model of bone graft revascularization in the distal femoral metaphysis.
The goal of the present study was to determine the effect of nicotine on the revascularization and incorporation of autogenous iliac crest bone graft implanted in an orthotopic location.
Although nicotine is the major toxin in cigarettes, it has not been confirmed as the primary factor affecting bone metabolism, and although the effects of smoking on bone homeostasis have been well studied, the effect of nicotine on new bone formation and neovascularization in the setting of bone graft transplantation has not been well studied.
Twenty-four New Zealand white rabbits were randomly divided into two groups to be exposed to nicotine or saline control. A cancellous iliac crest bone graft was harvested and implanted in the lateral distal femur. Mini-osmotic pumps were used to deliver continuous serum levels of nicotine. The animals were killed at the following intervals: 1 week (n = 6), 2 weeks (n = 12), and 4 weeks (n = 6). The vascular tree was injected with Microfil silicone rubber solution, and the degree of revascularization was determined with a semiautomated image analysis system to determine the area of vascularization for each specimen.
All seven of the control (no nicotine) animals harvested at 1 or 2 weeks had over 50% bony vascular ingrowth, whereas only four of the nine nicotine-exposed animals showed over 50% bony vascular ingrowth. These differences were statistically significant (P = 0.03) using the Fischer exact test. By the fourth week (after nicotine levels in experimental animals had diminished), the revascularization of the nicotine-exposed grafts was indistinguishable from that of grafts in the animals that were not exposed to nicotine.
We conclude the following. 1) Uniform dosages of nicotine in the rabbit model decreases the vascular ingrowth into autogenous cancellous bone graft. 2) The inhibitory effect of nicotine varies between animals, suggesting predisposition in some. 3) The vascular effects are reversible within 2 weeks of elimination of nicotine, although late bony resorption continues beyond the time of high serum nicotine levels.
Patient compliance is paramount in the effectiveness of therapeutic regimens. Without compliance therapeutic goals cannot be achieved, resulting in poorer patient outcomes. The social and psychological factors thought to influence compliance are identified as (a) knowledge and understanding including communication, (b) quality of the interaction including the patient-provider relationship and patient satisfaction, (c) social isolation and social support including the effect of the family, (d) health beliefs and attitudes-health belief model variables, and (e) factors associated with the illness and the treatment including the duration and the complexity of the regimen. Noncompliance is a significant problem and a major challenge for the health care team. Practical advice is offered for nurses and other health care professionals to increase patient compliance with therapeutic regimens. These include factors involved in the patient-provider relationship, communication skills and information-giving, and the mobilization of existing social support networks. Further research is needed to provide more conclusive results into the factors involved in patient compliance and to test the effectiveness of compliance-enhancing strategies.
Seven patients, with an average age of 53 years, were treated for bone loss or recalcitrant nonunions of the femur. The average duration from initial injury to presentation was 37 months (range 4-92 months). The patients had undergone one to eight (mean, 3.9) previous surgical attempts at achieving union. The nonunion involved the diaphysis in three patients, the diaphyseal-supracondylar junction in three patients, and the pertrochanteric region in one patient. All patients were treated using a standard lateral plate in combination with an endosteal plate and primary iliac crest bone grafting. The mean surgical time was 6.3 h, and the average blood loss was 1.7 L. There were three complications, including one superficial wound infection, one nonfatal pulmonary embolism, and one wound hematoma. At a mean follow-up of 12.6 months (range 4-24 months), all fractures had healed with an average time to union of 19.2 weeks (range 15-36 weeks). Knee flexion averaged 118 degrees (range 100-135 degrees), and all patients were satisfied with the operative procedure. Endosteal plating, in combination with a standard lateral plate and iliac crest bone-grafting, can successfully treat difficult nonunions of the femur.
The authors conducted a study to evaluate the effects of cigarette smoke on the healing of septic pseudarthrosis of the tibia treated by ilizarov external fixator. A total of 31 patients of both sexes were chosen, and the healing time in relation to the habit of smoking was examined. The results have shown that the healing time in non-smokers as compared to smokers was shorter by 33%. The difference is highly significant. This shows that abstention from smoking during treatment should be given maximum importance in prevention.
Although considerable work has been done on the potential health effects of smoking, little is known about the contribution of nicotine to those effects. This paper presents an overview of the immune system, and a discussion of the existing literature on the effects of tobacco smoke and nicotine on immunity. Treatment with nicotine has been shown to influence all aspects of the immune system, including alterations in humoral and cellular immunity. In addition, preliminary data suggest that gender and genetic factors impact on the immunological effects of nicotine. Finally, the possible mechanisms that might mediate the effects of nicotine are discussed.
To determine associations among health care access, cigarette smoking, and change in cigarette smoking status over 7 years.
A cohort of 4,086 healthy young adults was followed from 1985-1986 through 1992-1993. Participants were recruited from four urban sites balanced on gender, race (African Americans and whites), education (high school or less, and more than high school), and age (18-23 and 24-30). Outcome measures were smoking status at Year 7, as well as 7-year rates of smoking cessation and initiation.
For each of three access barriers reported at Year 7 (lack of health insurance, lack of regular source of medical care, and expense), participants experiencing the barrier had a higher prevalence of smoking, quit smoking less frequently, and started smoking more frequently; e.g., only 15% of participants with health insurance lapses quit smoking over the 7-year period, compared with 26% of those with insurance (P < 0.001). Results were similar for each race/gender stratum, and persisted after adjustment for usual markers of socioeconomic status: education, income, employment, and marital status.
Health care access was associated with lower prevalence of smoking and beneficial 7-year changes in smoking, independent of socioeconomic status. The possibility that this is a causal relationship has implications in the prevention of cardiovascular disease, cancer and multiple other smoking-related diseases, and deserves further exploration.
The purpose of the present study was to discover any associations between preoperative variables and the occurrence of wound complications in the surgical treatment of calcaneus fractures.
Retrospective review.
A Level 1 trauma center.
One hundred seventy-nine patients, with 190 fractured calcanei, were studied.
Each patient underwent open reduction and internal fixation for calcaneus fractures with standard techniques.
The age, sex, preexisting medical conditions, social history, and mechanism of injury of each patient were recorded. Note was made of the status of the soft tissue injury, if any. The time from injury to surgical stabilization was recorded, as was the type of incision used, use of preoperative antibiotics, and type of wound closure. The patients' records were reviewed for wound complications. These complications were classified as those that could be treated nonsurgically and those that required surgical management. Results: Records from July 1992 to July 1998 showed 179 patients who underwent operative stabilization of a calcaneus fracture. Eleven had bilateral fractures, for a total of 190 fractured calcanei. The average age was thirty-five years. Nine patients were diabetics. One hundred eleven of the patients reported current use of cigarettes. Eighteen of the fractures were open. A standard, L-shaped lateral approach to the calcaneus was used in each case. Stabilization was achieved by using standard techniques, with plates and screws. In all cases, a two-layer wound closure was used. Forty-eight patients (25 percent) developed some form of wound complication. Forty (21 percent) of these required surgical treatment. Statistical analysis identified diabetes (p = 0.02; relative risk 3.4), smoking (p = 0.03; relative risk 1.2), and open fractures (p < 0.0001; relative risk 2.8) as risk factors for wound complication. The presence of more than one risk factor increased the relative risk of a wound complication requiring surgery.
Smoking, diabetes, and open fractures all increase the risk of wound complication after surgical stabilization of calcaneus fractures. Cumulative risk factors increase the likelihood of wound complications. Patients who have the risk factors identified in this study should be counseled as to the possible complications that may arise after surgery. In patients with multiple risk factors, consideration should be given to nonsurgical management.
We investigated whether -intermittent hyperbaric oxygen (HBO) therapy can mitigate the adverse effects of cigarette smoking on the bone healing of tibial lengthening by using a previously validated rabbit model.
Eighteen male rabbits were randomly divided into three groups of six animals each. Group 1 (smoking plus HBO) went through intermittent cigarette smoke inhalation and hyperbaric oxygen therapy, group 2 (control) did not go through intermittent cigarette smoke inhalation or hyperbaric oxygen therapy and group 3 (smoking) went through intermittent cigarette smoke inhalation. Each animal's right tibia was lengthened 5 mm by using an uniplanar lengthening device. Bone mineral density (BMD) study was performed for all the animals at 1 day before operation and 3, 4, 5, and 6 weeks after operation. All of the animals were killed at 6 weeks postoperatively for biomechanical testing.
By using the preoperative BMD as an internal control, we found that the BMD of group 1 (smoking plus HBO)and group 2 (control) was superior to that of group 3 (smoking). The mean %BMD at 3, 4, 5, and 6 weeks were 58.6%, 66.6%, 73.7%, and 83.8%, respectively, in group 1, whereas the mean %BMD were 52.0%, 64.3%, 70.1%, and 76.2%, respectively, in group 2, and the mean %BMD were 46.2%, 54.0%, 64.9%, and 69.4%, respectively, in group 3 (two-tailed t test, p > 0.05, p > 0.05, p > 0.05, and p < 0.05 at 3, 4, 5, and 6 week respectively between group 1 and group 2, p < 0.01,p < 0.01,p < 0.01, and p < 0.01 at 3, 4, 5, and 6 week, respectively, between group 1 and group 3 and p < 0.05, p < 0.05, p < 0.05, and p < 0.05 at 3, 4, 5, and 6 week respectively between group 2 and group 3). By using the contralateral nonoperated tibia as an internal control, we found that the torsional strength of group 1 (smoking plus HBO) and group 2 (control) was superior to that of group 3 (smoking). The mean percentage of maximum torque was 80.9% in group 1 (smoking plus HBO) and was 78.0% in group 2 (control), whereas the mean percentage of maximum torque was 59.6 % in group 3 (smoking) (two-tailed t test, p < 0.05 between groups land 3 and between groups 2 and 3, whereas p > 0.05 between groups 1 and 2).
This study suggests that smoke inhalation delays the bone healing in tibial lengthening; however, HBO mitigates the delayed healing effect of smoke inhalation and, thus, helps the smoking animal in achieving an expeditious bone healing in tibial lengthening.
Of 146 consecutive closed and Grade I open tibia shaft fractures treated with cast immobilization, external fixation, or intramedullary rod fixation during a 4-year period, 44 of 76 (58%) tibias of patients who smoked and 59 of 70 (84%) tibias of patients who did not smoke had followup to union or followup beyond 1 year. The demographics, fracture patterns, and treatments of the two groups were similar. Two of the 44 patients who smoked had nonunions at the 1-year followup, whereas none of the patients who did not smoke had nonunions. Of the 103 tibias with complete followup to union, the median time to clinical healing for patients who smoked (269 days) was significantly greater than that of patients who did not smoke (136 days). Likewise, there was a 69% delay in radiographic union in the group that smoked as interpreted by a radiologist blinded to the two groups. Statistical differences in clinical and radiographic healing rates between those who smoked and those who did not smoke were observed for patients receiving intramedullary fixation or external fixation. Statistical differences were not seen in the clinical and radiographic healing of tibias treated with cast immobilization, although tibias of patients who smoked took 62% longer to heal. The current data suggest that tibias of patients who smoke who require treatment with intramedullary nailing or external fixation require more time to heal than do those of patients who do not smoke.
In this chapter, we examine the possibility that negative emotions contribute to the relationship between socioeconomic status (SES) and health. A model of the associations among SES, emotion, and health is presented first. We then review the evidence for this model, showing associations of SES with depression, hopelessness, anxiety, and hostile affect and cognition, and of these negative emotions with disease. Notably, most of the data supporting the model provide only indirect evidence that negative emotions serve as a key contributor to the proposed associations. We, therefore, conclude with recommendations for longitudinal research, especially in children, that will more directly and comprehensively examine negative emotions as possible mediators of the SES and health relationship.
Socioeconomic status (SES) is an important predictor of a range of health and illness outcomes. Research seeking to identify the extent to which this often-reported effect is due to protective benefits of higher SES or to toxic elements of lower social status has not yielded consistent or conclusive findings. A relatively novel hypothesis is that these effects are due to chronic stress that is associated with SES; lower SES is reliably associated with a number of important social and environmental conditions that contribute to chronic stress burden, including crowding, crime, noise pollution, discrimination, and other hazards or stressors. In other words, chronic stress may capture much of the variance in health and social outcomes associated with harmful aspects of lower social status. Low SES is generally associated with distress, prevalence of mental health problems, and with health-impairing behaviors that are also related to stress. Research targeting this hypothesis is needed to determine the extent to which stress is a pathway linking SES and health.
The decision to undergo a limb salvage procedure is difficult and multifaceted. This study reviews the outcomes of patients with chronic tibial osteomyelitis who underwent limb salvage and hopes to enhance our understanding of the impact this complex procedure has on the patient's ability to have a functional and fulfilling life.
Forty-six patients, with at least 18 months follow-up, who had undergone limb salvage for chronic, refractory tibial osteomyelitis were evaluated. A modification of the Limb Extremity Outcomes Instrument was utilized emphasizing inquiries pertaining to quality of life.
Thirty-nine (85%) of the 46 patients were able to ambulate independently without pain. All patients younger than 45 years of age had successful outcomes. Thirty-one percent of the patients with a positive smoking history were failures, and 71% of all failures were smokers.
Limb salvage seems to be a satisfactory option for patients with chronic tibial osteomyelitis. A history of smoking and advanced age may have adverse affects and are relative contraindications.
To investigate the success of exchange reamed femoral nailing in the treatment of femoral nonunion after intramedullary (IM) nailing, and to analyze factors that may contribute to failure of exchange reamed femoral nailing.
Retrospective consecutive clinical series.
Level I trauma center and tertiary university hospital.
Twenty-three patients were identified whose radiographs failed to show progression of healing for four months after treatment with a reamed IM femoral nail. Nineteen patients had undergone primary IM nailing of an acute femoral shaft fracture, one patient had been converted to an IM nail after initially being treated in an external fixator, and three patients had previously undergone an unsuccessful exchange reamed nailing.
All patients were treated by exchange reamed femoral nailing. The diameter of the new nail was one to three millimeters larger than that of the previous nail (the majority were two millimeters larger). The intramedullary canal was overreamed by one millimeter more than the diameter of the nail. Most of the nails were statically locked, and care was taken to avoid distraction of the nonunion site by reverse impaction after distal interlocking was performed or by applying compression with a femoral distractor.
Radiographic evaluation of union was determined by the presence of healing on at least three of four cortices. Factors reviewed included the patient's age, smoking history, mechanism of injury, associated injuries, whether the initial fracture was open or closed, the pattern and location of the fracture, the type of nonunion, the increase in nail diameter, whether the nail was dynamically or statically locked, and the results of any intraoperative cultures.
Tobacco use was found to have a detrimental impact on the success of exchange reamed nailing. All eight of the nonsmokers healed after exchange reamed nailing, whereas only ten of the fifteen smokers (66.7 percent) healed after exchange reamed nailing. Overall, exchange reamed femoral nailing was successful in eighteen cases (78.3 percent). Three patients achieved union with additional procedures. Intramedullary cultures were positive in five cases; all of these achieved successful union.
Exchange reamed nailing remains the treatment of choice for most femoral diaphyseal nonunions. Exchange reamed IM nailing has low morbidity, may obviate the need for additional bone grafting, and allows full weight-bearing and active rehabilitation. Tobacco use appears to have an adverse effect on nonunion healing after exchange reamed femoral nailing.