Cigarette smoking and open tibial fractures
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.
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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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