Orthopaedic trauma patients and smoking: Knowledge deficits and interest in quitting

The Hawkins Sign of the Talus: The Impact of Patient Factors on Prediction Accuracy

BACKGROUND

Osteonecrosis is a complication of talar neck fractures associated with chronic pain and poor functional outcomes. The Hawkins sign, the radiographic presence of subchondral lucency seen in the talar dome 6 to 8 weeks after trauma, is a strong predictor of preserved talar vascularity. This study sought to assess the accuracy of the Hawkins sign in a contemporary cohort and assess factors associated with inaccuracy.

METHODS

A retrospective review of talar neck fractures at a level-I trauma center from 2008 to 2016 was conducted. Both the Hawkins sign and osteonecrosis were evaluated on radiographs. The Hawkins sign was determined on the basis of radiographs taken approximately 6 to 8 weeks after injury, whereas osteonecrosis was determined based on radiographs taken throughout follow-up. The Hawkins sign accuracy was assessed using proportions with 95% confidence intervals (CIs), and associations were examined with Fisher exact testing.

RESULTS

In total, 105 talar neck fractures were identified. The Hawkins sign was observed in 21 tali, 3 (14% [95% CI, 3% to 36%]) of which later developed osteonecrosis. In the remaining 84 tali without a Hawkins sign, 32 (38% [95% CI, 28% to 49%]) developed osteonecrosis. Of the 3 tali that developed osteonecrosis following observation of the Hawkins sign, all were in patients who smoked.

CONCLUSIONS

A positive Hawkins sign may not be a reliable predictor of preserved talar vascularity in all patients. We identified 3 patients with a positive Hawkins sign who developed osteonecrosis, all of whom were smokers. Factors impairing the restoration of microvascular blood supply to the talus may lead to osteonecrosis despite the presence of preserved macrovascular blood flow and an observed Hawkins sign. Further research is needed to understand the factors limiting Hawkins sign accuracy.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Quitline usage does not improve rates of smoking cessation in orthopaedic trauma patients unless combined with nicotine replacement therapy

PURPOSE

The negative effects of smoking following traumatic orthopaedic injury can lead to serious complications and decreased quality of life. The widely available quitline could be easily implemented in the orthopaedic postoperative period to improve outcome, but the effectiveness of this intervention in this population is unknown. The goal of this study was to determine if active referral to a quitline would improve rates of smoking cessation in this population.

METHODS

This is a secondary analysis of a randomized control trial assessing the effectiveness of an inpatient intervention with varying intensities to promote smoking cessation. Participants were actively referred to the quitline as part of their intervention. Participants were surveyed at 6 weeks, 3 months and 6 months following their injury for 7-day abstinence, chemically confirmed with exhaled carbon monoxide monitoring.

RESULTS

Smoking quitline use alone does not independently improve 7-day abstinence. Quitline and nicotine use are synergistic (OR, 5.6 vs. 2.3 at 3 months in patients who used nicotine patch and quitline vs. patch; OR, 7.8 vs. 2.1 at 3 months in patients who used any NRT and quitline vs. NRT alone).

CONCLUSIONS

NRT use improves smoking cessation rates in orthopaedic trauma patients. Although smoking quitline use might not independently improve cessation rates in orthopaedic trauma patients postoperatively, concomitant use of NRT with quitline improves quit rates over NRT alone. Patients referred to quitline should be encouraged to use NRT.

Salvage of Failed Lisfranc/Midfoot Injuries

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.

Is Psychiatric Illness Associated With Worse Outcomes Following Pilon Fracture?

BACKGROUND

Patients with psychiatric comorbidities represent a significant subset of those sustaining pilon fractures. The purpose of this study is to examine the association of psychiatric comorbidities (PC) in patients with pilon fractures and clinical outcomes.

METHODS

A multi-institution, retrospective review was conducted. Inclusion/exclusion criteria were skeletally mature patients with a tibia pilon fracture (OTA Type 43B/C) who underwent definitive fracture fixation utilizing open reduction internal fixation (ORIF) with a minimum of 24 weeks of follow-up. Patients were stratified into two groups for comparison: PC group and no PC group.

RESULTS

There were 103 patients with pilon fractures that met the inclusion/exclusion criteria of this study. Of these patients, 22 (21.4%) had at least one psychiatric comorbidity (PC) and 81 (78.6%) did not have psychiatric comorbidities (no PC). There was a higher percentage of female patients (PC: 59.1% vs no PC: 25.9%, p=0.0.005), smokers (PC: 40.9% vs no PC: 16.0%, p=0.02), and drug users (PC: 22.7% vs no PC: 8.6%, p=0.08) amongst PC patients. Fracture comminution (PC: 54.5% vs no PC: 32.1%, p=0.05) occurred more frequently in PC patients. The PC group had a higher incidence of weightbearing noncompliance (22.7% vs 7.5%, p=0.04) and reoperation (PC: 54.5% vs no PC: 29.6%, p=0.03).

CONCLUSION

Patients with psychiatric comorbidities represent a significant percentage of pilon fracture patients and appear to be at higher risk for postoperative complication. Risk factors that may predispose patients in the PC group include smoking/substance use, weightbearing noncompliance, and fracture comminution. Level of Evidence: III.

Temporizing Care of Acute Traumatic Foot and Ankle Injuries

Temporizing care has become a critical part of the treatment armamentarium for select foot and ankle injuries. Indications for performing temporizing care are based on the specific injury pattern, the host, associated injuries, as well as surgeon resources. Foot and ankle injuries are often associated with severe adjacent injury to the soft tissue sleeve. An acute procedure performed through a traumatized soft tissue envelope will often lead to the failure of wound healing and/or infectious complications. Thus, delayed reconstruction of acute foot and ankle injuries is often advisable in these cases.

Prospective Randomized Trial on Smoking Cessation in Orthopaedic Trauma Patients: Results From the Let's STOP (Smoking in Trauma Orthopaedic Patients) Now Trial

OBJECTIVES

Determine if extended inpatient counseling increases smoking cessation.

DESIGN

Prospective randomized trial.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Current smokers with an operative fracture.

INTERVENTION

Randomly assigned to control (no counseling), brief counseling (inpatient counseling), or extended counseling (brief counseling plus follow-up counseling) groups in a 1:3:3 ratio.

MAIN OUTCOME MEASUREMENTS

Smoking cessation confirmed by exhaled carbon monoxide at 3 and 6 months. Secondary outcomes are proportion accepting services from a nationally based quitline.

RESULTS

Overall, 266 patients participated, with 40, 111, and 115 patients in the control and 2 treatment groups, respectively. At 3 months, 17% of control patients versus 11% in the brief counseling and 10% in the extended counseling groups quit smoking, respectively (P = 0.45, 0.37). At 6 months, 15% of control, and 10% and 5% of the respective counseling groups quit (P = 0.45, 0.10). Extended counseling patients were 3 times more likely to accept referral to a quitline [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) than the control group. Extended 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 than the control group.

CONCLUSION

Increasing levels of inpatient counseling can improve successful referral to a smoking quitline, but it does not seem to influence quit rates among orthopaedic trauma patients. Extended counseling does not appear to provide substantial benefit over brief counseling.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Can You Believe Your Patients If They Say They Have Quit Smoking?

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 were included in the study.

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 before 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.

Can financial payments incentivize short-term smoking cessation in orthopaedic trauma patients? Evidence from a discrete choice experiment

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.

Smoking and the patient with a complex lower limb injury

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.

Novel Application of Exhaled Carbon Monoxide Monitors: Smoking Cessation in Orthopaedic Trauma Patients

OBJECTIVES

To determine whether an in-office exhaled carbon monoxide (CO) monitor can increase interest in smoking cessation among the orthopaedic trauma population.

DESIGN

Prospective.

SETTING

Level I trauma center.

PATIENTS

One hundred twenty-four orthopaedic trauma patients.

INTERVENTION

In-office measurement of exhaled CO.

MAIN OUTCOME MEASURES

Stage of change, Likert scale score on willingness to quit today, patient's request for referral to a quitline, and increase in readiness to quit.

RESULTS

The use of an exhaled CO monitor increased willingness to quit in 71% of participants still smoking and increased willingness to quit on average by 0.8 points on a 10-point Likert scale (P < 0.001). Fifteen percent of patients modified their stage of change toward quitting. Forty percent of patients after exhaled CO monitor requested referral to a quitline, compared with 4% presurvey (P < 0.001). Anecdotally, most participants were very interested in the monitoring device and its reading, expressing concern with the result. The value of exhaled CO was not associated with any measured outcomes.

CONCLUSIONS

The use of an exhaled CO monitor increased willingness to quit smoking in 71% of patients, but the effect size was relatively small (0.8 points on a 10-point Likert scale). However, use of the CO monitor resulted in a large increase (40% vs. 4%) in referral to the national Quitline. Use of the Quitline typically increases the chance of smoking cessation by 10 times the baseline rate, suggesting that this finding might be clinically important.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Smoking, Quitting, and the Provision of Smoking Cessation Support: A Survey of Orthopaedic Trauma Patients

OBJECTIVE

This study investigates orthopaedic trauma patients smoking cessation history, intentions to quit, receipt of smoking cessation care during hospital admission, and patient-related factors associated with receipt of smoking cessation care.

METHODS

An online cross-sectional survey of orthopaedic trauma patients was conducted in 2 public hospitals in New South Wales, Australia. Prevalence of smoking and associated variables were described. Logistic regressions were used to examine whether patient characteristics were associated with receipt of smoking cessation care.

RESULTS

Eight hundred nineteen patients (response rate 73%) participated. More than 1 in 5 patients (21.8%) were current smokers (n = 175). Of the current smokers, more than half (55.3%) indicated making a quit attempt in the last 12 months and the majority (77.6%) were interested in quitting. More than a third of smokers (37.4%) were not advised to quit; 44.3% did not receive any form of nicotine replacement therapy; and 24.1% reported that they did not receive any of these 3 forms of smoking cessation care during their admission. Provision of care was not related to patient characteristics.

CONCLUSIONS

The prevalence of smoking among the sample was high. Respondents were interested in quitting; however, the provision of care during admission was low. Smoking cessation interventions need to be developed to increase the provision of care and to promote quit attempts in this Australian population.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Smoking cessation advice in limb reconstruction: An opportunity not to be missed

The adverse health effects of smoking are well known, including its effects on the musculoskeletal system. Limb reconstruction using external fixators is a high intensity process with high levels of patient contact time, complications and cost. The aim of this study was to examine smoking patterns in this group and in particular to assess trends in smoking cession. Data was collected from 41 patients all undergoing treatment using circular frame external fixation, for a variety of pathologies, most commonly acute tibial trauma. A patient reported questionnaire was used. Data was collected over a six-month period. In our population 56.1% of patients were smokers. During the study 47.8% patients stopped smoking and a further 39.1% decreased their smoking behaviour. 78.3% of patients could recall being given smoking cessation advice. In our group, 87% of patients were unaware of the effects of smoking on bone healing. Once made aware during discussion of proposed treatment, 73.9% stated that it was, in part, this knowledge that prompted them to positively change their smoking habits. The results of this study show that advice regarding smoking cessation during limb reconstruction treatment can potentially have a positive impact on patients smoking habits. The effect of smoking should be linked to the patient pathology and discussed during the consent process. Taking the time with the patient for this simple free intervention can have a positive impact on patient health, and potentially on the outcome of their current treatment, and is an opportunity not to be missed.