Cigarette smoking and bone healing: implications in foot and ankle surgery

Interventions for preoperative smoking cessation

BACKGROUND

Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions.

OBJECTIVES

The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation at the time of surgery and 12 months postoperatively and on the incidence of postoperative complications.

SEARCH STRATEGY

The specialized register of the Cochrane Tobacco Addiction Group was searched using the free text and keywords (surgery) or (operation) or (anaesthesia) or (anesthesia). MEDLINE, EMBASE and CINAHL were also searched, combining tobacco- and surgery-related terms. Most recent search April 2010.

SELECTION CRITERIA

Randomized controlled trials that recruited people who smoked prior to surgery, offered a smoking cessation intervention, and measured preoperative and long-term abstinence from smoking and/or the incidence of postoperative complications.

DATA COLLECTION AND ANALYSIS

The authors independently assessed studies to determine eligibility. Results were discussed between the authors.

MAIN RESULTS

Eight trials enrolling a total of 1156 people met the inclusion criteria. One of these did not report cessation as an outcome. Two trials initiated multisession face to face counselling at least 6 weeks before surgery whilst six used a brief intervention. Nicotine replacement therapy (NRT) was offered or recommended to some or all participants in seven trials. Six trials detected significantly increased smoking cessation at the time of surgery, and one approached significance. Subgroup analyses showed that both intensive and brief intervention significantly increased smoking cessation at the time of surgery; pooled RR 10.76 (95% confidence interval (CI) 4.55 to 25.46, two trials) and RR 1.41 (95% CI 1.22 to 1.63, five trials) respectively. Four trials evaluating the effect on long-term smoking cessation found a significant effect; pooled RR 1.61 (95% CI 1.12 to 2.33). However, when pooling intensive and brief interventions separately, only intensive intervention retained a significant effect on long-term smoking cessation; RR 2.96 (95% CI 1.57 to 5.55, two trials).Five trials examined the effect of smoking intervention on postoperative complications. Pooled risk ratios were 0.70 (95% CI 0.56 to 0.88) for developing any complication; and 0.70 (95% CI 0.51 to 0.95) for wound complications. Exploratory subgroup analyses showed a significant effect of intensive intervention on any complications; RR 0.42 (95% CI 0.27 to 0.65) and on wound complications RR 0.31 (95% CI 0.16 to 0.62). For brief interventions the effect was not statistically significant but CIs do not rule out a clinically significant effect (RR 0.96 (95% CI 0.74 to 1.25) for any complication, RR 0.99 (95%CI 0.70 to 1.40) for wound complications).

AUTHORS' CONCLUSIONS

There is evidence that preoperative smoking interventions including NRT increase short-term smoking cessation and may reduce postoperative morbidity. The optimal preoperative intervention intensity remains unknown. Based on indirect comparisons and evidence from two small trials, interventions that begin four to eight weeks before surgery, include weekly counselling, and use NRT are more likely to have an impact on complications and on long-term smoking cessation.

Arthroscopic ankle arthrodesis

Arthroscopic ankle arthrodesis provides the foot and ankle surgeon with an alternative to traditional open techniques. Advancements in arthroscopic techniques and instrumentation have made the procedure easier to perform. Advantages include faster rates of union, decreased complications, reduced postoperative pain, shorter hospital stays, minimal loss of length of the lower limb, and minimal clinical deformity or shapechanges to the ankle. This article reviews the literature on the subject and discusses the procedure's indications and contraindications, and surgical technique. It concludes that while total ankle replacement continues to grow in popularity, arthroscopic ankle arthrodesis is a viable alternative for management of the end-stage arthritic ankle.

An approach to the failed ankle arthrodesis

Ankle arthrodesis remains the gold standard of surgical treatment for advanced ankle joint arthritis. Failure can occur as a result of infection, nonunion or malunion, resulting in pain and poor function. This paper offers a systematic approach to preventing, and managing these problems should they occur. Revision arthrodesis performed with a detailed understanding of the appropriate alignment and mechanics of the ankle joint, combined with meticulous attention to understanding and reversing the cause of the failure can result in successful salvage and restoration of function.

High prevalence of apical periodontitis amongst smokers in a sample of Spanish adults

AIM

To study the prevalence of apical periodontitis in smoker and nonsmoker patients.

METHODOLOGY

In a cross-sectional study, the records of 180 subjects, 109 smokers and 71 nonsmokers, were examined. All participants underwent a full-mouth radiographic survey incorporating 14 periapical radiographs. The periapical region of all teeth, excluding third molars, was examined. Periapical status was assessed using the Periapical Index score. Statistical analyses were conducted using the Cohen's Kappa test, analysis of variance and logistic regression.

RESULTS

Apical periodontitis in at least one tooth was found in 74% of smokers and in 41% of nonsmokers (P < 0.01; odds ratio = 4.2; 95% C. I. = 2.2-7.9). Amongst smoker patients 5% of the teeth had apical periodontitis, whereas in nonsmoker subjects 3% of teeth were affected (P = 0.008; odds ratio = 1.5; 95% C. I. = 1.1-2.1). The percentage of root filled teeth in smoker and nonsmoker patients was 2.5% and 1.5%, respectively (P < 0.05; odds ratio = 1.7; C. I. 95% = 1.0-2.6).

CONCLUSIONS

In this study population, smoking was significantly associated with a greater frequency of root canal treatment and with an increased prevalence of apical periodontitis.

Revision lapidus arthrodesis: rate of union in 17 cases

This multicenter study retrospectively reviewed the medical records and radiographs of 15 consecutive patients (17 feet; mean patient age, 54.1 years), who underwent revision "bone-block" Lapidus arthrodesis for a symptomatic nonunion. In all cases but one, the procedure was performed with ipsilateral autogenous bone grafting. All cases used either screw fixation or a combination of screw and plate fixation. Patients were monitored for a minimum of 6 months postoperatively to assess clinical and radiographic union. Successful union was seen in 14 (82%) of the 17 feet that underwent revision. Nonunion was documented in 3 (18%) cases. These results support a favorable rate of union with the described surgical technique. Chi-square tests of association were used to determine whether gender, fixation, bone stimulation, and smoking were predictive of or associated with bone healing. Active smoking in the perioperative period was a predictor of nonunion (P = .05). Based on these findings, the authors recommend aggressive preoperative counseling, and smoking should be considered a relative contraindication to revision surgery.

Triple arthrodesis for the adult-acquired flatfoot deformity

Triple arthrodesis is often the procedure of choice for end-stage adult-acquired flatfoot. The benefits of triple arthrodesis include resolution of symptoms, hindfoot realignment, and stability. This article reviews the operative technique, realignment considerations, and postoperative management when performing triple arthrodesis. When taken into account, these recommendations provide a favorable outcome for both the patient and the surgeon.

Radiographic healing of conservative versus operative management of supination-external rotation II fractures in a smoking and premature weight-bearing population

The treatment of supination-external rotation II fibular fractures continues to be an area of debate. In the event of minimal displacement at the fracture, both surgical management and casting have been supported. This study aims to compare the time interval of radiographic healing in both the surgically and conservatively managed patient. Additional factors such as premature weight bearing and smoking were also examined. Fifty-two charts were examined retrospectively. This included 26 patients in both the surgical and conservative populations. Radiographs were examined for the presence of healing. Anterior-posterior, mortise, and lateral-view x-rays were examined. The presence of cortical bridging and a resolution of fracture line primarily on lateral view at the posterior spike were used to evaluate healing. The mean time for cortical bridging to occur was 89.38 days in the conservative group and 48.69 days in the surgical group. Mean times for healing were significantly longer in both smokers and patients who prematurely bore weight when treated in both the surgical and conservative populations. In the treatment of isolated fibular fractures, surgical intervention appears to offer a faster time to radiographic healing. Smoking and premature weight bearing are shown to prolong the time to radiographic healing in both the surgically and conservatively treated patient populations.

Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients

With the introduction of Locking Compression Plates (LCP), Minimally Invasive Plate Osteosynthesis (MIPO) has become widely used. The plates act as internal fixators in a bridging manner, thus resulting in secondary bone healing. We retrospectively evaluated the healing pattern and the clinical evolution of diaphyseal and distal tibial shaft fractures over two and a half years in 32 patients (6 females, 26 males). Fractures were classified according to AO classification and included all 42A-C, 43A-B and 43C1-2 types. For open fractures, Gustillo Anderson classification was used. Plates consisted of the 4.5mm LCP and 3.5mm LCP-Pilon form plate. Clinical and radiological assessment was performed at 6 weeks, and at 3, 6, 9, and 12 months. Two patients were lost to follow-up. Fracture healing was defined as callus bridging of one cortex, seen on both lateral and posterior-anterior X-ray, and full, painless weight bearing. Ten patients at 3 months, 23 at 6 months, and 27 at 9 months met the criteria for a healed fracture. Plate bending was observed in one patient and called for re-operation at 5 months. Two patients required re-operation at 13 months secondary to pseudoarthrosis. Though MIPO seems more advantageous for soft tissue and bone biology, prolonged healing was observed in simple fracture patterns when a bridging plate technique was used.

The potential association between smoking and endodontic disease

The aim of this review was to analyse the literature to assess the possibility of an association between smoking and endodontic disease and the prognosis of endodontically treated teeth. The review of the prognosis of endodontically treated teeth involved taking account of any potential associations with smoking and endodontic disease and marginal periodontitis, and smoking and prosthodontic outcomes. In addition, the role of smoking in implant failure and surgical wound healing was analysed with a view to drawing parallels regarding the possible implications of smoking on the outcome of surgical endodontics. A MEDLINE and Cochrane library search including smoking and various endodontic keyword searches identified three papers which discussed the variables, and did not just mention them separately in the text. The literature demonstrates a paucity of evidence relating smoking with endodontic disease and prognosis, but nevertheless presents evidence of a possible influence on the prognosis of endodontically treated teeth in smokers and a likely increase in surgical complications. The possible merits of a smoking cessation protocol prior to surgical endodontics are also discussed.

Arthroscopic ankle arthrodesis: factors influencing union in 39 consecutive patients

BACKGROUND

Arthroscopic ankle arthrodesis is an effective alternative to open techniques with established advantages in select patient populations. The purpose of this study was to evaluate patients who had arthroscopic ankle arthrodesis for end-stage arthritis with minimal to no deformity of the ankle and to report factors influencing union.

METHODS

Thirty-nine consecutive patients had arthroscopic ankle arthrodesis between 1994 and 2003. Clinical records and radiographs were retrospectively reviewed to evaluate variables that could predispose patients to nonunion. Union outcomes were correlated with etiology of arthritis, ankle deformity, medical co-morbidities, and the use of demineralized bone matrix or platelet-rich plasma. Arthroscopic ankle arthrodesis was accomplished with a consistent technique using crossed transmalleolar cannulated screw fixation.

RESULTS

Thirty-four of 39 patients (87.2%) achieved radiographic and clinical union. The average time to fusion was 47 (range 37 to 70) days. Poor bone quality and inherent positional ankle deformity were identified as risk factors for nonunion. Patients who smoked, had diabetes mellitus, peripheral neuropathy, or other medical co-morbidities attained ankle union in nearly all cases. In obese patients, there was an observed trend towards ankle nonunion (relative risk 5.81, p = 0.049, Fisher's Exact test). The addition of demineralized bone matrix or platelet-rich plasma did not improve the rate of ankle union. Aside from nonunion, 10 patients developed minor complications.

CONCLUSION

Arthroscopic ankle arthrodesis achieves high union rates, facilitates short time to union, and permits rapid patient mobility. Careful patient selection is important for the procedure. Synthetic allograft or platelet-rich plasma did not enhance the fusion rate. Obese patients showed a trend towards nonunion in this series.

Ankle fractures

Although ankle injuries are common, it is imperative for the treating physician to be able to identify the mechanism of injury and accurately restore the normal anatomy of the ankle joint. Attention must be given to restoring the normal alignment and length of the fibula because of its dominant role in controlling talar stability. The medial ankle must not be overlooked, with the role of the deltoid taken into consideration. With a thorough understanding of the anatomy, biomechanics, mechanism of injury, and fixation techniques, repair of the damaged ankle joint can lead to rewarding outcomes for the patient and physician.

Smoking affects the self-healing capacity of periodontal tissues. A histological study in the rat

This study aimed to evaluate in rats the impact of cigarette smoke inhalation (CSI) and nicotine administration (NA) on a periodontal healing model in the absence of a plaque biofilm. Wistar rats (n = 42) were assigned to three groups: Group 1, control (n = 14); Group 2, NA (3 mg kg(-1)) (n = 14); and Group 3, CSI (n = 14). Thirty days after CSI and NA exposure, fenestration defects were created buccally to the distal root of the first mandibular molar. The animals were killed 21 d later and their mandibles were processed for histological examination. The percentage of bone fill and the density of newly formed bone were assessed histometrically. Intergroup analysis demonstrated that compared to the control and NA groups, CSI was associated with a reduced rate of bone repair. No new cementum had been formed along the root surface in any of the three groups. It is concluded that cigarette smoke reduces the self-healing capacity of periodontal tissues.

Inhibition of osteoclast differentiation by polycyclic aryl hydrocarbons is dependent on cell density and RANKL concentration

We investigated the effect of representative polycyclic aryl hydrocarbons (PAHs), benzo[a]pyrene (BaP), and 7,12-dimethylbenz[a]anthracene (DMBA) on osteoclast differentiation and function by using dispersed cancellous bone derived rabbit osteoclasts and the RAW264.7 cells. These cells differentiate into osteoclasts when exposed to receptor activator of NF-kappaB ligand (RANKL). The rabbit osteoclasts were exposed to 10(-6) to 10(-9)M BaP or DMBA and the tartrate-resistant acid phosphatase (TRAP)-positive cells were counted. The effect of PAHs on osteoclast differentiation in dispersed rabbit osteoclast-containing stromal cell populations was cell density dependent, suggesting that the cell density of stromal cells, osteoclast precursors, and/or mature osteoclasts are factors regulating the effect of PAHs. To investigate the direct effect of BaP on osteoclast differentiation, RAW264.7 cells were exposed to 10(-5) to 10(-6) M BaP. Treatment of RAW264.7 cells cultured with 25 ng/ml soluble RANKL and 10(-5)M BaP for 5 days decreased osteoclast differentiation, TRAP activity levels, and resorption of bone-like substrata. The inhibition was prevented by 10(-6) to 10(-7) M resveratrol, an aryl hydrocarbon receptor (AhR) antagonist, and by higher concentrations of RANKL. To investigate the ability of RANKL to reverse BaP-mediated inhibition, gene expression was determined by RT-PCR. Cytochrome P450 1B1 (CYP1B1) mRNA, one of the genes activated by BaP, was present only in the groups exposed to BaP; the levels of CYP1B1 mRNA decreased in the presence of increasing concentrations of RANKL. These results suggest that the inhibitory effects of PAHs on osteoclastogenesis are direct and likely involve interaction of the RANKL and PAH signaling pathways.

Interventions for preoperative smoking cessation

BACKGROUND

Smokers have a substantially increased risk of intra- and postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence. The preoperative period may be a well chosen time to offer smoking cessation interventions due to increased patient motivation.

OBJECTIVES

The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation in the postoperative period and longer term. We also set out to determine the effect of smoking cessation on the incidence of postoperative complications.

SEARCH STRATEGY

The specialized register of the Cochrane Tobacco Addiction Group was searched using the free text and keywords (surgery) OR (operation) OR (anaesthesia) or (anesthesia). MEDLINE, EMBASE and CINAHL were also searched, combining tobacco- and surgery-related terms. Most recent search February 2005.

SELECTION CRITERIA

We considered randomized trials which recruited smokers prior to surgery, offered a smoking cessation intervention, and measured abstinence from smoking in the preoperative and postoperative periods. We also considered randomized trials of the effect of smoking cessation on the incidence of intra- and postoperative complications.

DATA COLLECTION AND ANALYSIS

The authors independently assessed studies to determine eligibility. The results were discussed between the authors.

MAIN RESULTS

Four trials met the inclusion criteria. All trials significantly reduced preoperative smoking but the effect sizes were heterogeneous so a pooled effect was not estimated. Only two trials reported the effect of the smoking intervention on wound complications, and the results were heterogeneous, with a significant reduction in wound-related complications, cardiopulmonary complications and the overall risk of any complication in one trial, and no evidence of a difference in complications in the other. The effect on longer term smoking cessation was not significant in either of the two trials with follow up beyond the perioperative period.

AUTHORS' CONCLUSIONS

Preoperative smoking interventions are effective for changing smoking behaviour perioperatively. Direct evidence that reducing or stopping smoking reduces the risk of complications is based on two small trials with differing results. The impact on complications may depend on how long before surgery the smoking behaviour is changed, whether smoking is reduced or stopped completely, and the type of surgery.

Smoking Cessation: Techniques and Potential Benefits

Smokers have a significantly greater risk of complications during and after operations. Cigarette smoke has significant effects on cardiac function, circulation, and respiratory function. Preliminary studies suggest that smoking cessation for a minimum of 6 to 8 weeks before surgery is required to reduce the perioperative and postoperative risks of smoking. Smoking cessation programs that employ advice, support groups, nicotine replacement therapy, or some anti-depressants have been used successfully in many situations and should be used to discourage smoking preoperatively. Further research is needed, however, to clarify the best approach to smoking cessation for surgical patients.

Trends in tobacco use

The use of tobacco can be traced back to ancient times. Its popularity grew exponentially during the twentieth century, surging during wartime and with the advent of mass media. The tobacco industry in the United States has been under constant legal pressure during the past 40 years. Despite the well-known and continually increasing morbidity and mortality related to smoking, it continues to be a prominent feature in worldwide culture and health.

Treatment of nonunited hindfoot fusions

The management of delayed union and nonunion is complex and is contingent on appropriate diagnosis and classification. Detection techniques and treatment options, including cast immobilization, electrical stimulation, surgical repair, or a combination of regimens, are discussed in this article.

Pantalar arthrodesis

Pantalar arthrodesis is a demanding procedure that serves a useful purpose for stabilization of the ankle, rearfoot, and midfoot. These fusions should be recognized as salvage procedures in the treatment of unstable and debilitating conditions as a result of severe degenerative joint disease, rheumatoid arthritis, neuropathic joint destruction, and paralytic or flail extremity dysfunction. As with all salvage-type procedures, patient and physician expectations must be the same to afford an acceptable and functional postoperative result.

Triple arthrodesis

The triple arthrodesis is a definitive, end-stage procedure for multiple pedal deformities. Appropriate patient selection, operative technique, and postoperative management are essential to achieve the desired outcome for the patient and the surgeon.

Efficacy of a smoking-cessation intervention for elective-surgical patients

We tested an intervention to help smokers abstain (fast) from smoking before surgery, maintain abstinence postoperatively, and achieve long-term cessation. A randomized experiment included 237 patients admitted for presurgical assessment who smoked. The intervention included counseling and nicotine replacement therapy. Treatment group participants (73.0%) were more likely to fast than were controls (53.0%): chi(2)(1, N = 228) = 8.89, p =.003, and more likely to be abstinent 6 months after surgery (31.2% vs. 20.2%). There was no significant difference in the abstinence rates at 12 months after surgery, chi(2)(1, N = 169) <.001, p = 1.00. Encouraging patients to fast from smoking before surgery and postoperative support are efficacious ways to reduce preoperative and immediate post-operative tobacco use.

Modified lapidus arthrodesis: rate of nonunion in 227 cases

Several studies of Lapidus arthrodesis have commented on the rate of nonunion (ranging from 3.3% to 12.0%), although these figures are based on relatively small patient populations. This study retrospectively reviewed the medical records and radiographs of 211 consecutive patients (32 men, 179 women; mean age, 46.9 years) who received modified Lapidus arthrodesis for forefoot pathology in 227 feet. In all cases, the procedure was performed using joint curettage with subchondral plate preservation and screw fixation. Patients remained nonweightbearing for 6 to 8 weeks and were monitored for a minimum of 6 months postoperatively. Nonunion was seen in 12 (5.3%) of the 227 feet that underwent modified Lapidus arthrodesis.

Impact of lifestyle on perioperative smoking cessation and postoperative complication rate

OBJECTIVE

The aim was to examine to what extent lifestyle, education, social support, and comorbidity predict the ability of perioperative smoking cessation, and are associated with the development of important postoperative complications.

DESIGN

The design was a randomized clinical trial.

SETTING

University hospitals in Copenhagen, Denmark, were the settings.

PARTICIPANTS AND METHODS

One hundred twenty patients scheduled for primary elective hip or knee arthroplasty were randomized to either smoking intervention or standard care. Tobacco and alcohol consumption, exercise and eating habits, level of education, matrimonial status, and the presence of social support were registered. The data gathered concerned smoking cessation/reduction and severe postoperative morbidity.

RESULTS

Men and patients with a good social network were more likely to successfully quit smoking. Smoking intervention successfully reduced the incidence of postoperative complications, as did weekly exercise exceeding 4 h, and having a high education level.

CONCLUSIONS

This study emphasizes that smoking intervention programs in health care settings are highly effective in reducing postoperative risks in hip and knee arthroplasty.

Risk indicators for apical periodontitis

OBJECTIVES

The aim of the study was to identify risk indicators for apical periodontitis (AP) in the individual. A parameter was defined as a 'risk indicator' when its presence increased the individual's risk of exhibiting AP. Risk indicators may, but need not be directly associated with the disease.

METHODS

The study included full-mouth surveys of 613 randomly selected individuals, who were 20-60 years old and living in Aarhus County. Logistic regression analyses were performed. The outcome variable was >or=1 AP/no AP. The independent variables were obtained from information on socioeconomic and dental status.

RESULTS

It was found that smoking, no usage of services from the dentist, >or=2 secondary caries lesions, >or=3 inadequate coronal fillings and the presence of root filling(s) were statistically associated with AP. A separate analysis for individuals with no previous root fillings showed that individuals with regular dental visits as well as individuals who had all their teeth (third three molars excluded) were less likely to have AP, whereas individuals who had >or=3 inadequate coronal fillings were more likely to have AP.

CONCLUSIONS

The results from the present study of a Danish population showed that the most important risk indicator of having AP in the individual was the radiographic evidence of root fillings. The presence of several caries lesions, the quality of the dental treatment, the regularity of dental visits and smoking were also statistically associated with AP. Further, the socioeconomic status of the individual did not provide much additional information on the periapical status.

Effect of tenoxicam on fracture healing in rat tibiae

BACKGROUND

Nonsteroidal anti-inflammatory drugs have been implicated in the development of delayed unions and nonunion after fractures in animal models. Previous investigations have identified two important factors as determinants of delayed fracture healing: early drug administration and a dose-dependent effect.

OBJECTIVE

The purpose of this investigation was to study the effect of tenoxicam, a nonsteroidal anti-inflammatory drug, on the fracture healing process in rat tibiae.

METHODS

Fifty-eight Wistar rats were randomly divided in four groups (I, II, III, and IV). Group I (control group, n=12) was given 0.1ml saline solution per day intramuscularly. Groups II (n=12), III (n=12), and IV (n=12) were administered 10mg per kg per day of tenoxicam intramuscularly. Administration of substances was begun on a week before to 48h after the fracturing procedure and continued during the entire experiment. Callus formation was studied histologically and histomorphologically, using light microscopy. In addition, a histologic grading based on the morphologic stage of fracture healing was carried out at 4 weeks, according to the criteria proposed by Allen et al.

RESULTS

There was a significant difference in treatment effect between Group I (saline solution) and Groups II, III, and IV (tenoxicam) (P=0.07). Histologically and histomorphologically, there were qualitative and quantitative delay in callus formation at all tenoxicam groups. This was more pronounced the earlier the nonsteroidal anti-inflammatory drug was started, although no significant difference could be detected between Groups II, III, and IV (P>(alpha=10%)). Four weeks after fracture, Group I (n=3) showed complete osseous union, Groups II (n=3) and III (n=3), complete cartilaginous union, and Group IV (n=3), incomplete osseous union, according to Allen et al. By using this rating scale, the difference between control and drug-treated groups was statistically significant (P<0.1).

CONCLUSION

Under studied conditions, this investigation shows that administration of tenoxicam intramuscularly delays fracture healing process in rat tibiae. These results suggest the hypothesis that early drug administration may delay bone healing after experimental fractures in animals, although it could not be detected statistically significant.

Failure of triple arthrodesis

In the longest-term follow-up study on triple arthrodesis published to date, Saltzman et al found at 44 years post-fusion, 95% of surviving patients were satisfied with their outcomes despite deteriorating function and some increase in pain with time [13]. All of the cases in this review were performed through a single anterolateral surgical approach and without internal fixation. In symptomatic severe or arthritic pes planovalgus or cavovarus deformity, few operative alternatives to triple arthrodesis are available. Attempts at subtalar resurfacing prostheses led to poor results and subsequent abandonment [46,47], whereas tendon transfer procedures and osteotomy realignments are not always possible or feasible in every patient. Although the indications for and surgical techniques used in triple arthrodesis have evolved and improved with time (predictably improving results in the intermediate term), triple arthrodesis remains a salvage procedure. Thus, deteriorating results with time may be an expected consequence and should not necessarily represent a failure of the technique. The surgical procedure is technically challenging and should be reserved for those surgeons trained and comfortable with all aspects of the surgery. Patient selection is vital, with most triple arthrodeses reserved for older patients. The two-incision approach allows better visualization, particularly of the talonavicular articulation, allowing for adequate resection of cartilage and alignment of the joints. Avoidance of excessive bony resection or wedge resection and the use of rigid internal fixation has increased the reliability of the procedure and diminished the pseudarthrosis rate and the rate of recurrence of the deformity. Failure to perform the procedure in an optimal fashion, however, can lead to a devastating failure with severe pain and dysfunction for the patient.

The musculoskeletal effects of smoking

Currently, there are more than 50 million smokers in this country, and approximately 800 billion cigarettes are smoked each year. Smoking is now the leading avoidable cause of morbidity and mortality in the United States. According to one report, over 500,000 deaths per year in the United States alone can be attributed to smoking. For years, orthopaedic surgeons have known about the relationships that putatively exist between smoking and an array of orthopaedic conditions and complications. It has been shown to adversely affect bone mineral density, lumbar disk disease, the rate of hip fractures, and the dynamics of bone and wound healing. Although scientific and clinical information on smoking and its consequences suggests differing degrees of correlation between smoking and orthopaedic conditions, most available data do suggest a real and reproducible relationship. In the past, there have been many individual reports that deal with these relationships separately but very few published comprehensive reviews. This summary of the current literature regarding the relationship between smoking and musculoskeletal diseases and their treatment provides information that can be used clinically by both the practitioner and the patient.

Interventions for preoperative smoking cessation

BACKGROUND

Smokers have a substantially increased risk of intra and postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence. The preoperative period may be a well chosen time to offer smoking cessation interventions due to increased patient motivation.

OBJECTIVES

The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation in the postoperative period and longer term. We also set out to determine the effect of smoking cessation on the incidence of postoperative complications.

SEARCH STRATEGY

The specialised register of the Tobacco Addiction Group was searched using the free text and keywords (surgery) OR (operation) OR (anaesthesia) or (anesthesia). The databases "EMBASE" and "CINAHL" were also searched, combining tobacco and surgery related terms.

SELECTION CRITERIA

We considered randomised trials which recruited smokers prior to surgery, offered a smoking cessation intervention, and measured abstinence from smoking in the pre-operative and post-operative periods. We also considered randomised trials of the effect of smoking cessation on the incidence of intra and post-operative complications.

DATA COLLECTION AND ANALYSIS

The reviewers independently assessed studies to determine eligibility. The results were discussed between the reviewers.

MAIN RESULTS

No trial meeting the inclusion criteria was found.

REVIEWER'S CONCLUSIONS

We found no evidence to determine the effectiveness of pre-operative interventions in helping people to stop smoking, or of the effectiveness of smoking cessation in reducing peri-operative complications. However, observational evidence suggests benefits in stopping smoking before surgery. Although there is no direct evidence about which interventions work best in patients preparing for surgery, behavioural and pharmacological interventions shown to be effective in other settings should be considered.

Cigarette smoking and exercise-related injuries among young men and women

BACKGROUND

We evaluate whether a recent history of cigarette smoking is a risk factor for exercise-related injuries sustained during Army basic training, controlling for factors such as demographic, physical fitness, and health variables.

METHODS

We conducted an observational cohort study in 1087 male and 915 female Army recruits undergoing 8-week basic military training. Data were collected from questionnaires, anthropometric measurements, physical fitness tests, company training logs, and medical records of all clinic visits.

RESULTS

During the 8-week training period, 33% of men and 50% of women had at least one clinic visit for injury, including 14% of men and 25% of women who lost more than 5 days of training due to injury. Recruits who reported smoking at least one cigarette in the month prior to beginning basic training (which was conducted in a smoke-free environment) had significantly higher injury rates during training than those who did not report smoking (40% versus 29% for men, and 56% versus 46% for women). The relationship with smoking history was present most strongly for overuse injuries (32% versus 24% in men and 51% versus 40% in women). Multiple logistic regression analyses controlling for all other factors consistently showed adjusted odds ratios of about 1.5 for injury rate in those with a history of smoking compared to those without.

CONCLUSIONS

The association of history of cigarette smoking with injury occurrence was consistent throughout the analyses, with very little confounding by other factors. The detrimental effects of smoking on injuries appears to persist at least several weeks after cessation of smoking.