Cigarette smoking and open tibial fractures

doi:10.1016/S0020-1383(00)00121-2

Injury

Volume 32, Issue 1, January 2001, Pages 61-65

https://doi.org/10.1016/S0020-1383(00)00121-2 Get rights and content

Abstract

Complication rates were compared in 140 smoking and 133 non-smoking patients with open tibial fractures. Both the groups were evenly matched demographically and in terms of primary fracture treatment. Flap failure complicated 7 (20%) patients in the smoking group and 4 (14%) in the non-smoking group. The mean time to union was 32 weeks for smokers and 28 weeks for non-smokers (P<0.05). Bone grafting to stimulate union was required in 36 (26%) smoking patients compared with 24 (18%) non-smoking patients. In patients treated by intramedullary nailing exchange, nailing to achieve union was carried out in 24 (38%) smoking cases compared with 13 (26%) of non-smoking cases. Smoking is associated with an increased risk of complications in patients with open tibial fractures. There is an increased rate of flap failure, delayed union and non-union. We recommend patients with open tibial fractures should be advised to stop smoking to minimise these complications.

Introduction

The adverse effects of cigarette smoking and its strong association with cardiovascular and respiratory disease have been well documented. In recent years there has been increasing interest in possible adverse effects of nicotine consumption on soft tissue and bone healing following injury. Experimental studies [1], [2] have suggested that nicotine may impair wound healing and perfusion of skin flaps. Adverse effects on bone healing have been noted in patients after spinal fusion, with a higher pseudarthrosis rate in smokers [3], [4]. A more recent study of smoking in a small series of closed and grade I open tibial fractures suggested there may be a higher incidence of delayed union in smokers [5].

The rate of non-union in closed tibial fractures is low with modern methods of treatment. In contrast, open tibial fractures are associated with higher rates of non-union and reoperation to achieve union, particularly in the more severe grades of soft tissue injury. If smoking has an adverse effect on bone and soft tissue healing, the consequences might be more apparent in patients with open tibial fractures.

The present study assesses the influence of smoking on complication rates following open tibial fractures. In particular, the study aimed to evaluate whether smokers are at a higher risk of flap failure, infection and non-union following open tibial fractures.

Section snippets

Materials and methods

Between 1983 and 1995, there were 502 open tibial fractures treated at the Royal Infirmary of Edinburgh. Case records were reviewed to identify patients with a clearly documented smoking history. Patients smoking ten cigarettes or more per day were considered regular smokers. Patients documented as non-smokers were used as a comparison group. Patients with no clearly documented history regarding cigarette use or patients smoking intermittently or amounts less than ten per day were excluded. On

Early complications

The mean inpatient stay was 45 days for group I patients and 37 for group II patients, although this was not significant. The median number of outpatient visits required was 12 for smokers and 11 for non-smokers. Fat embolus syndrome affected three group I patients and five group II patients. The cases affected in each group were patients with multiple long bone fractures and there was no relationship to smoking history. Compartment syndrome occurred in 11 (8%) cases in group I and 12 (9%)

Discussion

Our results show that smoking is deleterious to fracture union. Smokers healed their fractures more slowly and had a higher rate of non-union than non-smokers. The delay in union was most apparent in patients with grade IIIA fractures. As a consequence of the higher rates of non-union there was a correspondingly greater requirement for further surgical intervention in the smoking group.

There were other trends in the data, which suggested an adverse effect of smoking but did not reach

Conclusions

The findings of the present study are consistent with the experimental data and clinical data in other studies suggesting smoking is associated with a higher rate of complications in patients with open tibial fractures. The main risks are increased rates of flap failure, delayed union and non-union. There is now adequate evidence available from this and other studies to advise patients with open tibial fractures to stop smoking to minimise these complications.

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To compare fusion rate and fusion mass characteristics between cohorts receiving nicotine, varenicline, or concurrent nicotine and varenicline after lumbar fusion.
Rodent noninstrumented spinal fusion model.
Sixty eight-week-old male Sprague-Dawley rats weighing approximately 300 grams underwent L4-5 posterolateral fusion (PLF) surgery. Four experimental groups (control: C, nicotine: N, varenicline: V, and combined: NV [nicotine and varenicline]) were included for analysis. Treatment groups received nicotine, varenicline, or a combination of nicotine and varenicline delivered through subcutaneous osmotic pumps beginning two weeks before surgery until the time of sacrifice at age 14 weeks. Manual palpation testing, microCT imaging, bone histomorphometry, and biomechanical testing were performed on harvested spinal fusion segments.
Control (p=0.016) and combined (p=0.032) groups, when compared directly to the nicotine group, demonstrated significantly greater manual palpation scores. The fusion rate in the control (93.3%) and combined (93.3%) groups were significantly greater than that of the nicotine group (33.3%) (p=0.007, both). Biomechanical testing demonstrated greater Young's modulus of the fusion segment in the control (17.1 MPa) and combined groups (34.5 MPa) compared to the nicotine group (8.07 MPa) (p<0.001, both). MicroCT analysis demonstrated greater bone volume fraction (C:0.35 vs N:0.26 vs NV:0.33) (p<0.001, all) and bone mineral density (C:335 vs N:262 vs NV:328 mg Ha/cm³) (p<0.001, all) in the control and combined groups compared to the nicotine group. Histomorphometry demonstrated a greater mineral apposition rate in the combined group compared to the nicotine group (0.34 vs 0.24 μm/day, p=0.025).
In a rodent spinal fusion model, varenicline mitigates the adverse effects of high nicotine serum levels on the rate and quality of spinal fusion.
These findings have the potential to significantly impact clinical practice guidelines and the use of pharmacotherapy for active nicotine users undergoing fusion surgery.
Comprehensive analysis of patients with failure of mandibular hardware
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The purpose of the study was to characterize patients who had failure of mandibular hardware (FMH).
This retrospective cohort study consisted of patients with mandible fractures (MFs) that required surgical intervention from 2012 to 2020. Patients were included when mandibular hardware failed. Descriptive variables were collected.
During the study period, 57 patients (47 male, average age 38.7 years) met the inclusion criteria. Incidence of FMH was 7.4%. Most patients were African American (n = 45, 78.9%) with American Society of Anesthesiologists classification II (n = 40, 70.2%). Tobacco use (n = 31, 54.4%) and/or alcohol (n = 33, 57.9%). The most common etiology was assault (n = 28, 49.1%). The most common location was the angle of the mandible. Most mandibles had fracture at 1 location (n = 31, 54.4%) and a tooth was involved in the fracture line (n = 44, 77.2%). More than half of patients were treated with transoral surgical approach (n = 35, 61.4%). The majority of patients received preoperative antibiotics (n = 51, 89.4%). Patients had varying levels of compliance with postoperative care, and most were not compliant. Infection (n = 45) was the most common presentation of FMH.
High American Society of Anesthesiologists score, smoking, excessive alcohol use, parafunctional habits, and compliance with postoperative instructions may affect surgical outcome.
Scaphoid Nonunion Vascularized Bone Grafting in 2021: Is Avascular Necrosis the Sole Determinant?
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The decision regarding the use of vascularized bone grafting (VBG) or nonvascularized bone grafting for the treatment of scaphoid nonunion (SNU) needs guidelines based on patient- and fracture-specific risk factors. Historically, the presence of avascular necrosis was viewed as the primary indication for VBG; however, avascular necrosis is not the only indicator to determine whether VBG can improve our treatment of difficult SNU cases. The methods of detecting scaphoid avascular necrosis lack consensus and accuracy, limiting their use as decision-making tools. Additionally, many other preoperative risk factors for SNU surgery failure have been reported and require careful and standardized study, including the location of nonunion in the scaphoid proximal pole, the duration of nonunion, previous failed nonunion surgery, smoking, and fracture nonunion displacement or collapse. An appropriate study size and design are needed to determine the factors that guide the use of VBG or nonvascularized bone grafting to optimize the outcomes of SNU surgery.
Identifying risk factors for missed compartment syndrome in patients with tibia shaft fractures: An analysis of the national trauma data bank
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Acute compartment syndrome (CS) is a common complication of tibia shaft fractures (TSFs), and occurs when the pressure inside a myofascial compartment rises and impairs tissue perfusion. If treatment is delayed due to a missed diagnosis, amputation or permanent loss of function can result. This study aims to determine the incidence, clinical associations, and risk factors for missed CS following surgical stabilization of tibia shaft fractures (TSFs) using data from the National Trauma Data Bank (NTDB).
NTDB data files from 2007 to 2016 were accessed to collect information on patients undergoing surgical fixation of TSFs. Patients with an Injury Severity Score (ISS) > 15 or inferred Gustilo-Anderson IIIB/IIIC fractures were excluded to create a more homogenous sample of lower-grade TSFs. Compartment syndrome that was originally missed leading to late intervention was the main outcome under investigation. Bivariate tests were used to assess the relationships between missed CS and the preoperative variables. If a variable and a complication had an association with a P ≤ 0.2, it was included in a multivariate logistic regression model.
A total of 184,612 patients met our inclusion criteria, and 1,269 patients (0.76%) had a missed CS diagnosis. Bivariate analysis demonstrated that male gender had a significant positive association with a missed CS diagnosis, while older age had a significant negative association (odds ratio [OR] = 2.17, 0.99; P < 0.001). Multivariate analysis revealed that male gender was the most significant independent risk factor for a missed diagnosis of compartment syndrome (OR = 1.84, P < 0.00001), followed by alcoholism, penetrating trauma, and smoking (OR = 1.51, 1.46, 1.43; P < 0.02). The only significant protective factor was open fracture (OR = 0.70, P < 0.0001).
Our research identified several significant risk factors for missed CS after TSF, as well as positive and negative associations. Male gender, age, and lifestyle choices such as alcohol use and smoking conferred increased risks. These variables may assist physicians in identifying at-risk patients who may benefit from increased monitoring, and potentially prevent the high morbidity associated with this condition.
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Intramedullary nailing is the standard of care for tibial shaft fractures. The risk factors for infectious and/or mechanical complications, notably non-union, remain incompletely understood. The objective of this study was to evaluate risk factors for complications, notably non-union.
Active smoking and an initial open wound are independent risk factors for complications.
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We included 184 patients [mean age, 38.5 ± 17.6 (range, 15–91), 72.2% of males]. One or more complications developed in 28 (15.2%) patients and non-union occurred in 15 (8.1%) patients. There were three significant risk factors for complications: active smoking (OR, 7.93; 95%CI, 2.76–22.7), a residual interfragmentary gap > 5 mm (OR, 4.92; 95%CI, 1.72–14.02), and an initial open wound (OR,5.16; 95%CI, 1.62–16.43) (p < 0.05). The same three factors were significant risk factors for non-union. Energy of the trauma, age, sex, and early or delayed weight bearing were not significantly associated with an excess risk of complications.
Active smoking, a residual interfragmentary gap > 5 mm, and an initial open wound are risk factors for postoperative complications after intramedullary nailing to treat a tibial shaft fracture. Preventive strategies and specific information could be implemented for these patients.
IV; single-centre retrospective cohort study.
Risk factors for complications after primary intramedullary nailing to treat tibial shaft fractures: A cohort study of 184 consecutive patients
2021, Revue de Chirurgie Orthopedique et Traumatologique
L’enclouage centromédullaire (ECM) est le traitement de référence des fractures diaphysaires de tibia. Les facteurs de risque de complications septiques et/ou mécaniques, et particulièrement de pseudarthrose, restent mal connus, et imparfaitement rapportés. L’objectif de cette étude était d’évaluer ces facteurs de complications, notamment concernant la pseudarthrose.
Le tabagisme actif et l’ouverture cutanée initiale sont des facteurs de risque de complications indépendants.
Tous les patients pris en charge pour des fractures diaphysaires de tibia, fermées et ouvertes, par ECM en première intention, entre 2013 et 2018, étaient inclus dans cette série. Etaient évalués les facteurs préopératoires liés au patient et au mécanisme (âge, sexe, tabac, énergie, ouverture cutanée), peropératoires (espace interfragmentaire (EIC)) et postopératoire (appui précoce ou retardé) et étaient étudiées leurs associations avec la survenue de complications, notamment de pseudarthrose. Une analyse uni- puis multivariée était réalisée. Un total de 184 patients ont été inclus (âge moyen : 38,5 ± 17,6 (15–91), 72,2 % hommes).
Une ou plusieurs complication(s) est/sont survenue(s) chez 28 (15,2 %) patients, et une pseudarthrose chez 15 (8,1 %) patients. Le tabac (OR : 7,93, IC 95 % [2,76–22,7]), l’EIC (OR : 4,92, IC 95 % [1,72–14,02]), et l’ouverture cutanée initiale (OR : 5,16, IC 95 % [1,62–16,43]) étaient des facteurs de risque significatifs de complications (p < 0,05). Ces mêmes facteurs étaient des facteurs de risque significatifs de pseudarthrose. La cinétique du traumatisme, l’âge, le sexe, l’appui précoce ou retardé n’étaient pas associés de manière significative à un sur-risque de complication.
Le tabagisme actif, un large EIF et l’ouverture cutanée sont des facteurs de risque de complication postopératoire après ECM de fracture tibiale. Des stratégies de prévention, et une information spécifique pourraient être mises en place pour ces sujets.
IV ; étude rétrospective monocentrique de cohorte.

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View full text

Cigarette smoking and open tibial fractures

Abstract

Introduction

Section snippets

Materials and methods

Early complications

Discussion

Conclusions

Nicotine and its effect on wound healing

Plast. Reconstr. Surg.

The acute effects of cigarette smoke exposure on experimental skin flaps

Plast. Reconstr. Surg.

Controversies: smoking abstinence. Is it necessary before spinal fusion?

Spine

The effect of nicotine on spinal fusion

Spine

Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analysis

J. Bone Jt. Surg. (Am.)

Problems in the management of type III (severe) open fractures: a new classification of type III open fractures

J. Trauma

Are smokers a risk group for delayed healing of tibial shaft fractures?

Ann. Chir. Gynaecol.

Evidence for defective osteoblastic function. A role for alcohol and tobacco consumption in osteoporosis in middle-aged men

Clin. Orthop. Rel. Res.

Osteoporosis of the slender smoker

Arch. Intern. Med.