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

Association of Smokeless Tobacco and Complications Following Ankle and Hindfoot Arthrodesis

BACKGROUND

The purpose of this study was to (1) evaluate the rates of postoperative complications following ankle or hindfoot arthrodesis among current smokeless tobacco users and people who smoke compared to matched controls, and (2) compare rates of postoperative complications in current smokeless tobacco users vs people who smoke tobacco cigarettes.

METHODS

A retrospective cohort study was conducted using a large national database. For patients who underwent ankle or hindfoot arthrodesis, smokeless tobacco users (n = 131) and people who smoke (n = 1948) were matched 1:4 with controls, and smokeless tobacco users (n = 131) were matched 1:4 with people who smoke tobacco cigarettes (n = 524). Orthopaedic complications within 90 days, 1 year, and 2 years were compared using multivariable logistic regressions.

RESULTS

Within 90 days of ankle or hindfoot arthrodesis, smokeless tobacco users demonstrated significantly higher rates of hardware removal (odds ratio [OR] 5.01, 95% CI 1.65-15.20), wound disruption or dehiscence (OR 3.00, 95% CI 1.21-7.44), and pooled complications (16.0% vs 5.9%, OR 2.84, 95% CI 1.50-5.38) compared with tobacco-naïve controls. The rates of hardware removal, wound disruption and dehiscence, and pooled complications remained significant in the smokeless tobacco cohort at 1 and 2 years. At 2 years following ankle or hindfoot arthrodesis, smokeless tobacco users additionally demonstrated significantly higher rates of infection (OR 6.08, 95% CI 1.15-32.05) and nonunion (OR 2.35, 95% CI 1.31-4.20) compared with tobacco-naïve controls. Within 90 days of ankle or hindfoot arthrodesis, smokeless tobacco users demonstrated significantly lower rates of malunion or nonunion than patients who smoke tobacco cigarettes (OR 0.34, 95% CI 0.12-0.97), whereas all other complications were not significantly different.

CONCLUSION

Smokeless tobacco use is associated with higher rates of complications following ankle or hindfoot arthrodesis compared with tobacco-naïve controls, and physicians should screen for smokeless tobacco use specifically and encourage cessation before operating electively.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Impact of Surgical Timing After Ankle Fracture on Clinical and Long-Term Patient Reported Outcomes

The goal of this study is to evaluate the effect of time-to-surgery following closed ankle fractures on long-term patient reported outcomes, fracture healing, and wound complications. To date, little research has been done focusing on the impact "time to definitive fixation" has on patient reported outcomes. We performed a retrospective analysis of 215 patient records who underwent open reduction and internal fixation (ORIF) for an ankle fracture from July 2011 to July 2018. A total of 86 patients completed the patient reported outcome measurement information systems (PROMIS) survey at long-term follow-up. Primary outcomes were the rate of delayed union, postoperative wound complications, patient reported outcome measurement information system (PROMIS) pain interference (PI), and physical function (PF) scores. No differences were found when comparing time to surgery on a continuous scale with rates of delayed union, nonunion, or wound complications (p = .84, .47, and .63, respectively). PROMIS scores were collected at a median of 4.5 years (2.0 interquartile range (IQR), range 2.5-12.3) postoperatively. The time from ankle fracture to surgery was independently associated with worse PROMIS PI scores (unstandardized β 0.38, 95% CI 0.07-0.68) but not PROMIS PF scores. Severe Lauge-Hansen injuries were independently associated with decreased PROMIS PF scores (unstandardized β -7.02, 95% CI -12.0 to -2.04). Increased time to surgical intervention and severe Lauge-Hansen injuries were independently associated with worse long-term patient reported outcomes. Surgical timing did not impact union rates or wound complications. Surgeons should be aware that delaying ankle fracture repair beyond 12 days after injury may negatively affect long-term patient reported pain scores.

Arthroscopic Ankle Arthrodesis

Despite the increasing popularity of total ankle replacement, ankle arthrodesis remains the gold standard for the treatment of end-stage ankle arthritis. Historically, open techniques have been utilized for ankle arthrodesis. There have been many variations and techniques described, including transfibular, anterior, medial, and miniarthrotomy. Inherent disadvantages to these open techniques include postoperative pain, delayed or nonunion, wound complications, shortening, prolonged healing times, and prolonged hospital stays. Arthroscopic ankle arthrodesis provides the foot and ankle surgeon with an alternative to the traditional open techniques. Arthroscopic ankle arthrodesis has demonstrated faster union rates, decreased complications, reduced postoperative pain, and shorter hospital stays.

Serology and Comorbidities in Patients With Fracture Nonunion: A Multicenter Evaluation of 640 Patients

INTRODUCTION

This multicenter cohort study investigated the association of serology and comorbid conditions with septic and aseptic nonunion.

METHODS

From January 1, 2011, to December 31, 2017, consecutive individuals surgically treated for nonunion were identified from seven centers. Nonunion-type, comorbid conditions and serology were assessed.

RESULTS

A total of 640 individuals were included. 57% were male with a mean age of 49 years. Nonunion sites included tibia (35.2%), femur (25.6%), humerus (20.3%), and other less frequent bones (18.9%). The type of nonunion included septic (17.7%) and aseptic (82.3%). Within aseptic, nonvascular (86.5%) and vascular (13.5%) nonunion were seen. Rates of smoking, alcohol abuse, and diabetes mellitus were higher in our nonunion cohort compared with population norms. Coronary artery disease and tobacco use were associated with septic nonunion (P < 0.05). Diphosphonates were associated with vascular nonunion (P < 0.05). Serologically, increased erythrocyte sedimentation rate, C-reactive protein, parathyroid hormone, red cell distribution width, mean platelet volume (MPV), and platelets and decreased absolute lymphocyte count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and albumin were associated with septic nonunion while lower calcium was associated with nonvascular nonunion (P < 0.05). The presence of four or more of increased erythrocyte sedimentation rate, C-reactive protein, or red cell distribution width; decreased albumin; and age younger than 65 years carried an 89% positive predictive value for infection. Hypovitaminosis D was seen less frequently than reported in the general population, whereas anemia was more common. However, aside from hematologic and inflammatory indices, no other serology was abnormal more than 25% of the time.

DISCUSSION

Abnormal serology and comorbid conditions, including smoking, alcohol abuse, and diabetes mellitus, are seen in nonunion; however, serologic abnormalities may be less common than previously thought. Septic nonunion is associated with inflammation, younger age, and malnourishment. Based on the observed frequency of abnormality, routine laboratory work is not recommended for nonunion assessment; however, specific focused serology may help determine the presence of septic nonunion.

Impact of cigarette smoke on osteogenic and osteoclast signaling in middle palatal suture

Considering that smoking is a public health problem that has been growing among adolescents, the aim of this study was to investigate the impact of cigarette smoke on osteogenic and osteoclastogenic signaling in middle palatal suture of rats. Male Wistar rats exposed (n = 30) or not to cigarette smoke (n = 30) were used. Exposure to smoke was carried out for two daily periods of 3 minutes each, with an interval of 12 hours between exposures. After the experimental periods of 3, 7, 14 and 21 days, the animals were euthanized. The collected tissues were analyzed using light microscopy and real-time RT-PCR was performed to investigate gene expression. The data obtained were compared using the Kruskal Wallis and Dunn tests (⍺ = 5%). Morphologically, there were no significant changes in the middle palatal suture of rats exposed or not to cigarette smoke during 3, 7, 14 and 21 days (p> 0.05). On the other hand, osteoclastogenic signaling was increased in animals exposed to smoke and was characterized by a higher production of RANKL at 3 and 14 days (p <0.05), with no change in the synthesis of RANK and osteoprotegerin (p> 0.05). Interestingly, in the exposed animals, an early increase in the synthesis of osteocalcin, bone sialoprotein and osteopontin was also identified at 3 days of exposure (p <0.05), not sustained over time (p> 0.05). Cigarette smoke modulates osteogenic and osteoclastogenic signaling in the middle palatal suture of young rats, although morphological changes have not been evidenced.

Do the successful revision surgery for humeral nonunion solve all the effects on health-related quality of life? A retrospective cohort study

Background

The aim of this study is to evaluate the effects of successful revision operation on health quality of life(QoL) and functional outcome in humeral nonunion patients.

Methods

This retrospective study included 62 patients with humeral nonunion from Northwest China, who were admitted to the Department of Trauma Surgery, Honghui Hospital between March 2013 and September 2019. The following data were retrospectively evaluated: demographic data, clinical data, imaging findings, and treatment methods. The QoL assessment indicators for humeral nonunion patients included the SF-12 mental component summary (MCS) and physical component summary (PCS),brief pain inventory-severity(BPI-S) and brief pain inventory-interference (BPI-I). The mayo elbow performance score (MEPS) was used to assess the elbow function of the patients.

Results

Successful revision surgery significantly improved the patient's PCS, MCS, BPI-S and BPI-I scores (p<0.001). According to the MEPS criteria, the excellent and good rates were 95.16% in this study. The impact of humeral nonunion on mental health was comparable with the reported impact of stroke and type II diabetes (p>0.05).The impact of post-op on physical health was comparable with the reported impact of COPD, silicosis, hypertension, barrentt’s esophagus and lower urinary tract symptoms(p>0.05).

Conclusion

Humeral nonunion is a devastating chronic medical condition that negatively affects both physical and mental health as well as quality of life. Although the effects of pain in the body can be completely relieved by treatment, the entire medical process may cause everlasting psychological trauma to the patient.

The treatment of the atrophic clavicular nonunion by double-plate fixation with autogenous cancellous bone graft: a prospective study

Background

The objective of this study is to assess prospectively the effectiveness of double-plate fixation combined with autogenous cancellous bone graft in the treatment for the atrophic clavicular nonunion.

Methods

Between February 2013 and November 2017, a total of 12 patients with atrophic clavicular nonunion (mean age, 40.4 ± 9.0 years, range, 27–60 years) were treated by double-plate fixation with autogenous cancellous bone graft in our institute. The Constant Score System was used to evaluate the preoperative and final outcomes. The Short Form-36 (SF-36) outcome questionnaire was used to assess the final clinical results.

Results

All patients were followed-up, with the average follow-up of 34.7 ± 6.7 months (range, 24–48 months). The healing rate was 100% in our study. The mean time of bony union was 9 weeks (range, 8–10 weeks). One patient had a postoperative superficial infection, and the patient was cured by oral antibiotics and wound dressing. No implant-related complications (plate-screw loosening or breakage) were observed postoperatively. No vascular injury, neural impairment, or thoracic outlet syndrome was discovered preoperatively or postoperatively. There is a statistical significance between the preoperative and the postoperative constant scores (P < 0.05). All the patients were satisfied with their final clinical results by SF-36 outcome questionnaire. Average scores of the physical function and bodily pain components of the SF-36 were 94.2 ± 7.3 and 92.5 ± 5.8, respectively.

Conclusion

Our results presented that double-plate fixation with autogenous cancellous bone graft is an effective treatment for atrophic clavicular nonunion, especially for those with a significant bone defect.

Smoking and Radiolucent Periapical Lesions in Root Filled Teeth: Systematic Review and Meta-Analysis

AIM

This systematic review and meta-analysis aimed to investigate the association between smoking habits and the prevalence of radiolucent periapical lesions (RPLs) in root-filled teeth (RFT).

METHODS

The Population, Intervention, Comparison, and Outcome (PICO) question was: in adult patients who have RFT, does the absence or presence of a smoking habit affect the prevalence of RPLs associated with RFT? Systematic MEDLINE/PubMed, Wiley Online Database, Web of Science, Scopus, and PRISMA protocol were used to evaluate and present the results. Studies comparing smokers with control non-smoker subjects, including RFT, and providing data on the prevalence of RFT with RPLs, were included. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used for certainty in the evidence. The risk of bias was assessed according to Cochrane Collaboration common scheme for bias and ROBINS-I tool. Cumulative meta-analysis was performed with a random effects model. PROSPERO registration code: CRD42020165279.

RESULTS

Four studies reported data on inclusion criteria, representing data from 9257 root-filled teeth-4465 from non-smokers and 4792 from smoker patients. The meta-analysis provided an odds ratio indicating a significant association between smoking and higher prevalence of root filled teeth with radiolucent periapical lesions (OR = 1.16; 95% CI = 1.07-1.26; p = 0.0004). The certainty of the literature assessment was moderate per GRADE. The ROBINS-I tool classified three studies as low risk of bias, and the fourth as moderate risk of bias.

CONCLUSIONS

Moderate, quality scientific evidence indicates a weak but significant relationship between smoking and the prevalence of RPLs in RFT. Smoking can be considered a negative prognostic factor for the outcome of root canal treatment. Endodontic providers should be aware of the relationship between smoking and persistent apical periodontitis, assessed as RPLs, in RFT.

Cigarette Smoking and Root Filled Teeth Extraction: Systematic Review and Meta-Analysis

AIM

The aim of this systematic review and meta-analysis was to investigate the possible association between smoking habits and the occurrence of root-filled teeth (RFT) extraction.

MATERIAL AND METHODS

The Population, Intervention, Comparison, and Outcome (PICO) question was in adult patients who had RFT, does the absence or presence of smoking habits affect the prevalence of extracted RFT? Systematic MEDLINE/PubMed, Wiley Online Database, Web of Science, and PRISMA protocol was used to evaluate and present the results. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used for certainty in the evidence. The risk of bias was assessed according to Cochrane Collaboration common scheme for bias and ROBINS-I tool. Cumulative meta-analysis was performed with a random effects model. PROSPERO registration code: CRD42020165279.

RESULTS

After search strategy, 571 articles were recovered, seven were selected for full-text analysis, and two reported data on inclusion criteria, including 516 RFT, 351 in non-smokers, and 165 in smoker subjects. The meta-analysis provided an odds ratio indicating significant association between smoking and the prevalence of extracted RFT (OR = 3.43, 95% CI = 1.17-10.05, p = 0.02, I² = 64%). The certainty of the literature assessment was low per GRADE. Both studies were considered as moderate risk of bias.

CONCLUSIONS

Tobacco smoking should be considered a negative prognostic factor for the outcome of root canal treatment, although the quality of the evidence is low. RFT of smoking patients are three times more likely to be extracted. Continuing to smoke after endodontic treatment may increase the risk of treatment failure. However, the overall strength of evidence is low. This must be considered a limitation of the present study and the conclusion should be valued with caution.

Does tobacco smoking predispose to apical periodontitis and endodontic treatment need? A systematic review and meta-analysis

BACKGROUND

Controversial findings exist in the literature regarding the association between tobacco smoking and development of apical periodontitis or need for root canal treatment, with some studies reporting an increase in the prevalence of these outcomes in smokers, whilst others reporting no association.

AIM

To evaluate if there is scientific evidence to support an association between tobacco smoking and a greater prevalence of apical periodontitis and/or root canal treatments.

DATA SOURCES

A systematic search was performed using MeSH terms and free terms in the PubMed, Scopus, Virtual Health Library (VHL), Cochrane library and Open Gray databases.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Observational studies that evaluated the association between smoking and the development or healing of periapical lesion and/or the prevalence of root canal treatment in humans were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

A quality assessment of included studies was performed, and the relevant information and findings were evaluated. A meta-analysis using nine included studies was performed through RevMan software, and the certainty of evidence was evaluated through GRADE.

RESULTS

Fifteen studies were included, of which 10 were classified as low risk of bias, 4 were considered as moderate risk of bias and 1 as high risk of bias. Ten studies reported that smoking was associated with a greater prevalence of periapical periodontitis and/or root canal treatment. Five studies reported no association. Nine studies were included in the pooled meta-analysis, comprising two subgroups: apical periodontitis and root canal treatment. From these nine studies, eight studies were included in the apical periodontitis subgroup meta-analysis and demonstrated that this condition was significantly more prevalent in smokers when compared to the nonsmokers (odds ratio = 2.78[CI: 1.60, 4.85], P < 0.001; I²  = 79%; no adjusted odds ratio). Three studies were included in the root canal treatment subgroup meta-analysis and demonstrated an increased prevalence in smokers when compared to the nonsmokers (odds ratio = 2.73 [CI: 1.06, 2.83], P < 0.001; I²  = 72%; no adjusted odds ratio). The pooled meta-analysis demonstrated that smokers had twice the chance of having apical periodontitis and/or root canal treatment when compared to nonsmokers (odds ratio of 2.42 [CI: 1.59, 3.68], P < 0.01; I²  = 85%). The GRADE analysis demonstrated moderate certainty of evidence.

LIMITATIONS

Several confounding factors were identified such as misinformation regarding the period of time subjects had smoked, as well as the frequency of smoking and the number of cigarettes consumed. No adjustment in odds ratio data for confounding was performed.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

This systematic review and meta-analysis indicate that tobacco smokers have an increased prevalence of periapical periodontitis and root canal treatments with moderate certainty of evidence.

The effect of post-operative NSAID administration on bone healing after elective foot and ankle surgery

BACKGROUND

Post-operative pain is a common concern following elective foot and ankle surgery. NSAIDs used for pain relief have led to bone-healing complications in animal models and in vitro studies. This retrospective study examined the rate of bone-healing complications in post-surgical patients using NSAIDs.

METHODS

Participants underwent elective foot surgeries between January 2016 and May 2018. Radiographs were used to identify bony nonunion at osteotomy sites 12 weeks post-surgery.

RESULTS

Two-hundred thirty-two patients were evaluated; 59 (25.43%) were prescribed ibuprofen, 62 (27%) ketorolac, 15 (6.47%) acetaminophen, and 92 (40%) hydrocodone-acetaminophen. Two-hundred and twelve (91.38%) patients exhibited radiographic evidence of osseous union at 12 weeks and 20 (8.62%) had radiographic evidence of non-union of the osteotomy sites. There was no significant relationship between NSAID use and osseous non-union (p<0.05).

CONCLUSIONS

Short-term use of oral ibuprofen and ketorolac in the post-operative period was not associated with bony non-union.

Cigarette smoke inhalation impairs angiogenesis in early bone healing processes and delays fracture union

Aims

Cigarette smoking has a negative impact on the skeletal system, causes a decrease in bone mass in both young and old patients, and is considered a risk factor for the development of osteoporosis. In addition, it disturbs the bone healing process and prolongs the healing time after fractures. The mechanisms by which cigarette smoking impairs fracture healing are not fully understood. There are few studies reporting the effects of cigarette smoking on new blood vessel formation during the early stage of fracture healing. We tested the hypothesis that cigarette smoke inhalation may suppress angiogenesis and delay fracture healing.

Methods

We established a custom-made chamber with airflow for rats to inhale cigarette smoke continuously, and tested our hypothesis using a femoral osteotomy model, radiograph and microCT imaging, and various biomechanical and biological tests.

Results

In the smoking group, Western blot analysis and immunohistochemical staining revealed less expression of vascular endothelial growth factor (VEGF) and von Willebrand factor (vWF). The smoking group also had a lower microvessel density than the control group. Image and biochemical analysis also demonstrated delayed bone healing.

Conclusion

Cigarette smoke inhalation was associated with decreased expression of angiogenic markers in the early bone healing phase and with impaired bone healing.

Cite this article:Bone Joint Res. 2020;9(3):99–107.

Open ankle fractures are associated with complications and reoperations

Objectives:

To assess clinical and functional outcomes after open versus closed ankle fracture.

Design:

Retrospective comparative study.

Location:

Level 1 Trauma Center.

Patients/Participants:

1303 patients treated for ankle fractures (Weber B and C) between 2003 and 2015. One hundred sixty-five patients (12.7%) presented with open fracture and 1138 (87.3%) with closed fracture.

Intervention:

Surgical or conservative management of ankle fracture.

Main Outcome Measure:

Rates of complications and reoperations. Patient-reported functional outcomes were assessed with the Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA), after a minimum of 12 months.

Results:

Mean age was 46 years and 49% of patients were male. Higher mean age was associated with open injuries (51 vs 45 years, P < 0.001), and fractures were increasingly open with aging. Open fractures were associated with high-energy mechanisms: 44% following motor vehicle or motorcycle collisions, although the majority of open fractures in patients >65 years occurred after ground-level fall. Complications occurred more often after open fracture (33% vs 11%) and necessitated more secondary procedures (19% vs. 7%), both P < 0.001. Multivariate regression analysis identified open fracture as a predictor of complications and of worse scores on the activity categories of both the FFI and SMFA.

Conclusion:

Open fractures occurred more often after high energy mechanisms, and were generally more complex than closed fractures. Advanced age was common among open fracture patients, likely contributing to higher complication and secondary procedure rates. Greater morbidity after open ankle fractures was associated with minor differences on activity functions of the FFI and SMFA.

Level of Evidence: Level 3, prognostic

The Effectiveness of Tobacco Dependence Education in Health Professional Students' Practice: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The objective of this study was to perform a systematic review to examine the effectiveness of tobacco dependence education versus usual or no tobacco dependence education on entry-level health professional student practice and client smoking cessation. Sixteen published databases, seven grey literature databases/websites, publishers’ websites, books, and pertinent reference lists were searched. Studies from 16 health professional programs yielded 28 RCTs with data on 4343 healthcare students and 3122 patients. Two researchers independently assessed articles and abstracted data about student knowledge, self-efficacy, performance of tobacco cessation interventions, and patient smoking cessation. All forms of tobacco were included. We did not find separate interventions for different kinds of tobacco such as pipes or flavoured tobacco. We computed effect sizes using a random-effects model and applied meta-analytic procedures to 13 RCTs that provided data for meta-analysis. Students’ counseling skills increased significantly following the 5As model (SMD = 1.03; 95% CI 0.07, 1.98; p < 0.00001, I² 94%; p = 0.04) or motivational interviewing approach (SMD = 0.90, 95% CI 0.59, 1.21; p = 0.68, I² 0%; p < 0.00001). With tobacco dependence counseling, 78 more patients per 1000 (than control) reported quitting at 6 months (OR 2.02; 95% CI 1.49, 2.74, I² = 0%, p = 0.76; p < 0.00001), although the strength of evidence was moderate or low. Student tobacco cessation counseling improved guided by the above models, active learning strategies, and practice with standardized patients.

Bone Marrow Aspirate Concentrate Does Not Improve Osseous Integration of Osteochondral Allografts for the Treatment of Chondral Defects in the Knee at 6 and 12 Months: A Comparative Magnetic Resonance Imaging Analysis

BACKGROUND

Poor osseous integration after fresh osteochondral allograft transplantation (OCA) may be associated with graft subsidence and subchondral bone collapse after implantation. The augmentation of OCA with bone marrow aspirate concentrate (BMAC) has been hypothesized to improve osseous incorporation of the implanted allograft.

PURPOSE

To evaluate the effect of autogenous BMAC treatment on osseous integration at the graft-host bony interface after OCA.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of patients treated with OCA+BMAC or OCA alone for full-thickness chondral defects of the distal femur from March 2015 to December 2016 was conducted. Seventeen knees treated with OCA+BMAC and 16 knees treated with OCA alone underwent magnetic resonance imaging (MRI) in the early postoperative phase (mean, 6 months). Eighteen knees treated with OCA+BMAC and 16 knees treated with OCA alone underwent MRI in the late postoperative phase (mean, 12 months). Bone, cartilage, and ancillary features on MRI were graded using the Osteochondral Allograft MRI Scoring System (OCAMRISS) by a musculoskeletal radiologist blinded to the patient's history and treatment.

RESULTS

There were no significant differences in the demographics or lesion characteristics between treatment groups in either postoperative phase. In the early postoperative phase, the mean OCAMRISS bone score was 3.0 ± 0.7 and 3.3 ± 0.7 for the OCA+BMAC group and OCA alone group, respectively ( P = .76); 71% (OCA+BMAC) and 81% (OCA alone) of MRI scans demonstrated discernible clefts at the graft-host junction ( P = .69), and 41% (OCA+BMAC) and 25% (OCA alone) of MRI scans demonstrated cystic changes at the graft and graft-host junction ( P = .46). In the late postoperative phase, the mean OCAMRISS bone score was 2.7 ± 0.8 and 2.9 ± 0.8 for the OCA+BMAC group and OCA alone group, respectively ( P = .97); 44% (OCA+BMAC) and 63% (OCA alone) of MRI scans demonstrated discernible clefts at the graft-host junction ( P = .33), and 50% (OCA+BMAC) and 31% (OCA alone) of MRI scans demonstrated the presence of cystic changes at the graft and graft-host junction ( P = .32). The mean OCAMRISS cartilage, ancillary, and total scores were not significantly different between groups in either postoperative phase.

CONCLUSION

OCA augmented with BMAC was not associated with improved osseous integration; decreased cystic changes; or other bone, cartilage, and ancillary feature changes compared with OCA alone.

Outcome of Locked Compressive Nailing in Aseptic Tibial Diaphyseal Nonunions without Bone Defect

BACKGROUND

Treatment of tibial diaphyseal nonunions are rather difficult. Plate-screw, intramedullary nailing and external fixation are the methods used for treatment. The aim of this study is to evaluate the treatment results of aseptic diaphyseal nonunions following tibia fractures by intramedullary compressive tibia nailing (IMCN) with or without bone graft.

MATERIALS AND METHODS

Twenty eight patients who had aseptic tibial nonunion without bone defects operated between 2005 and 2015 were included in the study. The mean age of our patients was 36.4 years (range 20-56 years). There were 22 males and 6 females. Fifteen of the patients exhibited hypertrophic nonunion and thirteen exhibited atrophic nonunion. The average time between fracture occurrence and presentation to our department was 1.6 years (range 1-20 years). All patients underwent fibular osteotomy by removal of a 2 cm bone block from the middle one-third of the fibulas. In all cases, IMCN was applied following the reaming procedure, then maximum bone contacts were achieved manually between proximal and distal bone fragments afterward, and dynamic compressive fixation with 1 mm of compression was performed by a single rotation of the compression screw at the top of the nail. Direct X-ray images were assessed according to the Rust criteria, and functional outcomes were assessed according to the Johner-Wrush criteria. Finite-element analysis was performed for 1 mm of compression. For statistical analysis, Fisher's exact test, Pearson's Chi-square test, and Mann-Whitney U-test were used.

RESULTS

Union was achieved in all patients. Radiological union was obtained at an average of 15.5 ± 1.86 weeks. Functional results were found to be good or excellent in 25 (89.2%) patients and average or poor in 3 (10.8%) patients. One patient developed skin necrosis at the wound site, which was treated with rotational flap and skin graft. None of the patients developed implant failure, thromboembolism, deep-vein thrombosis, or infection.

CONCLUSIONS

The use of compressive intramedullary nailing with or without bone graft is an effective method for the treatment of tibial nonunion.

Identifying Risk Factors for 30-Day Readmissions After Triple Arthrodesis Surgery

Rigid flatfoot deformity is a debilitating condition that can be managed by triple arthrodesis surgery. Triple arthrodesis has the potential to restore health-related quality of life, but it is also associated with several complications. Few studies have examined the 30-day readmission rates after triple arthrodesis. The objective of this study was to investigate risk factors for 30-day all-cause readmissions after triple arthrodesis. The nationwide readmission database was queried from 2013. By using International Classification of Disease, Ninth Revision, procedure codes, all triple arthrodesis procedures were identified. Demographic factors, comorbidities, insurance status, and hospital characteristics were statistically compared between patients who experienced a 30-day readmission and those who did not. Multivariable logistic regression was used to identify independent risk factors for 30-day readmission. Overall, 1916 triple arthrodesis cases were identified. The overall 30-day readmission rate after triple arthrodesis was 4.6%. Univariate analysis revealed a statistically higher proportion of patients with electrolyte abnormalities (13.8% vs 4.6%; p < .01) in the patients who were readmitted within 30 days compared with those who were not. Multivariable analysis demonstrated Medicaid insurance, relative to private insurance, as the only statistically significant predictor of 30-day readmission with an odds ratio of 4.43 (p < .05). These results suggest that patients of lower socioeconomic status may be at a greater risk for development of a short-term readmission after triple arthrodesis surgery. These findings are important for surgeon and patient communication, counseling, and postoperative care when choosing to pursue triple arthrodesis surgery.

Fracture Site Mobility at 6 Weeks After Humeral Shaft Fracture Predicts Nonunion Without Surgery

OBJECTIVES

To assess the presence of fracture site gross motion on physical examination to predict humeral shaft fracture progression to nonunion in patients managed nonoperatively.

DESIGN

Retrospective cohort study.

SETTING

Single trauma level 1 institutional center.

PATIENTS

Eighty-four consecutive patients undergoing nonoperative treatment of a diaphyseal humeral shaft fracture were identified. The average age of the population was 48.3 years, and 50% of the cohort was men.

INTERVENTION

Clinical examination for fracture stability was routinely performed on patients by the treating physicians and documented it in the medical record. Patients were followed until union or surgery for persistent fracture mobility.

MAIN OUTCOME MEASUREMENTS

Stability was graded if there was motion at the site (1: motion of any kind and 0: moved as a unit).

RESULTS

Seventy-three patients (87%) healed their fracture within our study cohort by 6 months postfracture. Of the remaining 11 patients, after discussion with their treating physicians about the option of surgical intervention, 8 chose to undergo open reduction internal fixation at an average of 8 months, 1 proceeded nonsurgical interventions, and 2 were lost of follow-up. If the humeral shaft fracture site was mobile at 6 weeks follow-up visit, it identified future fracture nonunion with 82% sensitivity and 99% specificity (only 1 patient with motion at 6 weeks proceeded to fracture union).

CONCLUSION

With a high negative predictive value, clinical examination of fracture motion at 6 weeks should be assessed in every patient to determine which patients should obtain closer follow-up for the risk of nonunion progression. Knowledge of gross fracture motion can be used in the shared decision-making model in counseling about early surgical options.

LEVEL OF EVIDENCE

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

Treatment of critical-sized bone defects: clinical and tissue engineering perspectives

Critical-sized bone defects are defined as those that will not heal spontaneously within a patient's lifetime. Current treatment options include vascularized bone grafts, distraction osteogenesis, and the induced membrane technique. The induced membrane technique is an increasingly utilized method with favorable results including high rates of union. Tissue engineering holds promise in the treatment of large bone defects due to advancement of stem cell biology, novel biomaterials, and 3D bioprinting. In this review, we provide an overview of the current operative treatment strategies of critical-sized bone defects as well as the current state of tissue engineering for such defects.

Arthroscopic Ankle Arthrodesis: An Update

Arthroscopic ankle arthrodesis provides an alternative to open techniques. Advancements in arthroscopic techniques and instrumentation have made the procedure easier to perform. Arthroscopic ankle arthrodesis has demonstrated faster rates of union, fewer complications, reduced postoperative pain, and shorter hospital stays. Sound surgical techniques, particularly with regard to joint preparation, are critical for success. Comorbidities such as increased body mass index, history of smoking, malalignment, and posttraumatic arthritis should be considered when contemplating arthroscopic ankle arthrodesis. Although total ankle replacement continues to grow in popularity, arthroscopic ankle arthrodesis remains a viable alternative for management of the end-stage arthritic ankle.

Predictors of Time to Union After Operative Fixation of Closed Ankle Fractures

BACKGROUND

Ankle fractures are common and represent a significant burden to society. We aim to report the rate of union as determined by clinical and radiographic data, and to identify factors that predict time to union.

METHODS

A cohort of 112 consecutive patients with isolated, closed, operative malleolar ankle fractures treated with open reduction and internal fixation was retrospectively reviewed for time to clinical union. Clinical union was defined based on radiographic and clinical parameters, and delayed union was defined by time to union >12 weeks. Injury characteristics, patient factors and treatment variables were recorded, and statistical techniques employed included the Chi-square test, the Student's T-test, and multivariate linear regression modeling.

RESULTS

Forty-two (37.5%) of patients who achieved union did so in less than 12 weeks, and 69 (61.6%) of these patients demonstrated delayed union at a mean of 16.7 weeks (range, 12.1-26.7 weeks), and the remaining patient required revision surgery. Factors associated with higher rates of delayed union or increased time to union included tobacco use, bimalleolar fixation, and high energy mechanism (all p<0.05). In regression analysis, statistically significant negative predictors of time to union were BMI, dislocation of the tibiotalar joint, external fixation for initial stabilization and delay of definitive management (all p<0.05).

CONCLUSION

Patient characteristics, injury factors and treatment variables are predictive of time to union following open reduction and internal fixation of closed ankle fractures. These findings should assist with patient counseling, and help guide the provider when considering adjunctive therapies that promote bone healing.

LEVELS OF EVIDENCE

Prognostic, Level IV: Case series.

Is It Worth Discriminating Against Patients Who Smoke? A Systematic Literature Review on the Effects of Tobacco Use in Foot and Ankle Surgery

Although numerous studies have linked smoking with lower extremity wound and bone healing complications, a comprehensive study on the effects of smoking in foot and ankle surgery has not yet been reported. The purpose of the present study was to report the results of our systemic literature review, identifying the effects of tobacco use on common foot and ankle procedures. The systematic literature review was performed according to guidelines set by the PRIMSA statement (Preferred Reporting Items for Systematic Review and Meta-Analyses). Smoking, as a single risk factor, was analyzed and used to compare adverse outcomes in the postoperative setting of foot and ankle surgery. We reviewed 528 abstracts that met our initial identification criteria. After an extensive review process, 46 of the articles (8.71%) met the eligibility requirements to be included in the present study. Distal bunionectomy with osteotomy, first metatarsophalangeal joint arthrodesis, Lapidus bunionectomy, toe amputation, transmetatarsal amputation, Syme's amputation, open reduction internal fixation (ORIF) of calcaneal fractures, ankle fracture ORIF, pilon fracture ORIF, subtalar arthrodesis, rearfoot arthrodesis, tibiocalcaneal arthrodesis, ankle arthrodesis, total ankle arthroplasty, and plastic surgery procedures and their respective negative association with smoking was identified and described in our review. Our systematic literature review revealed that procedures involving arthrodesis, fracture ORIF, and plastic surgery were associated with negative outcomes in smokers. Procedures that did not involve osseous unions such as total ankle arthroplasty and amputations did not appear to have negative outcomes associated with smoking.

Risk Factors Associated With Nonunion After Elective Foot and Ankle Reconstruction: A Case-Control Study

Postoperative nonunion is not uncommon in the lower extremity, and significant morbidity can be associated with nonunion of the foot and ankle after surgical reconstruction. For the purposes of the present study, we retrospectively reviewed and compared a cohort of patients who had undergone elective foot and ankle reconstruction to better assess the modifiable risk factors associated with postoperative nonunion. We hypothesized that the presence of endocrine and metabolic abnormalities are often associated with nonunion after foot and ankle surgical reconstruction. We formulated a matched case-control study that included 29 patients with nonunion and a control group of 29 patients with successful fusion to assess the prevalence of certain modifiable risk factors known to have an association with nonunion after foot and ankle arthrodesis. The modifiable risk factors assessed included body mass index, tobacco use, diabetes mellitus, vitamin D abnormality, thyroid dysfunction, and parathyroid disease. A statistically significant (p < .05) difference was found between the 2 groups for endocrine and metabolic disease diagnoses in the medical records of the 58 patients identified. Thus, 76% versus 26% (p < .05) of patients experienced nonunion in the endocrine disease group versus the nonendocrine disease group, respectively. Patients with vitamin D deficiency or insufficiency were 8.1 times more likely to experience nonunion (95% confidence interval 1.996 to 32.787). No statistically significant differences were found between the groups in terms of age, sex, tobacco use, body mass index, or procedure selection (p = .56, p = .43, p = .81, p = .28, and p = 1.0, respectively). A greater prevalence of endocrine abnormalities, in particular, vitamin D deficiency and insufficiency, was associated with nonunion after elective foot and ankle reconstruction. Patients with such abnormalities appear to have a greater risk of developing nonunion after arthrodesis procedures.

Revisiting Tension Band Fixation for Difficult Patellar Fractures

Patella fractures with comminution, osteoporotic bone, and/or previously failed fixation are exceedingly difficult to reduce and fix. Moreover, the risk of symptomatic constructs and patients who are poorly compliant with postoperative activity restrictions can make these complex fracture patterns an even more challenging scenario. Although there is an array of techniques described for comminuted patella fractures, there lacks an accepted surgical technique for these difficult cases. In this clinical series, we describe an enhancement to the traditional tension band construct that uses additional wires and multiple tension bands to gather and fix comminuted fracture patterns in nontransverse planes, bolster osteoporotic bone, and secure fractures in patients undergoing a revision and/or have potential to be poorly compliant with postoperative activity restrictions. The clinical outcomes of 27 patients demonstrate high rates of bony union, functional range of motion, and low rates of both infection and failure. In conclusion, using the basic principles of tension band wiring remains highly versatile, useful, and economical in approaching difficult patella fractures.

Perceived risk factors for nonunion following foot and ankle arthrodesis

BACKGROUND

A major complication of foot and ankle arthrodesis is nonunion, which occurs in approximately 12% of cases. Various factors influence a patient's risk for nonunion following foot and ankle arthrodesis. We surveyed international foot and ankle surgeons to determine (1) risk factors perceived most important for nonunion, (2) factors considered absolute contraindications for arthrodesis, and (3) differences among expert groups regarding perceived risk factors and their stratification.

METHODS

A questionnaire was e-mailed to members of a major foot and ankle journal editorial board and four foot and ankle society executive committees. The relative risk of 18 potential nonunion risk factors was rated from 1 to 10, using smoking 1 pack/day as a benchmark score of 5.00.

RESULTS

The response rate was 72% (100/139); 81% declared foot and ankle surgery encompasses >90% of their practice. The highest perceived risk factors ( p < 0.001) were smoking 2 packs/day (mean score 8.69), lack of fusion site stability (8.66), and poor local vascularity (7.66). The least important risk factors ( p < 0.001) were perceived to be age >60 years (mean score 2.54), rheumatoid arthritis (3.05), and osteoporosis (3.56). The most frequently cited absolute contraindications to arthrodesis surgery were local infection (46%), poor local vascularity (41%), and smoking (32%).

CONCLUSION

To improve arthrodesis outcomes, resource allocation and patient and surgeon education should focus on smoking, construct stability, and local vascularity. Development of an objective nonunion risk assessment tool to identify patients at risk for nonunion using these results could help maximize the efficiency of available resources.

Effectiveness of tobacco intervention education in health professional students' practice: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to examine the effectiveness of entry-level education on smoking cessation or prevention and tobacco-dependence interventions on health professional student practice in promoting client health and on client smoking cessation behaviors.The specific review question to be addressed: what is the effect of entry-level tobacco dependence education on: (1) health professional students' knowledge and skills and self-efficacy, (2) performance of tobacco prevention and cessation interventions, and (3) client smoking cessation behaviors?

Treatment of Nonunions After Malleolar Fractures

Ankle fracture nonunion is a rare occurrence following closed or operative intervention. When it does occur, patients can experience debilitating symptoms that limit daily function. Malleolar nonunion can be caused by patient factors, such as smoking, malnutrition, or vascular insufficiency. Surgeon factors, such as insufficient or inappropriate operative fixation, also play a role. Several adjuncts, such as bone grafting, bone morphogenic protein, and bone stimulation, are useful in treating nonunions. Through a multimodal approach, malleolar nonunions are reliably treated with operative fixation leading to good patient outcomes with minimal complications.

Benzo[a]pyrene/aryl hydrocarbon receptor signaling inhibits osteoblastic differentiation and collagen synthesis of human periodontal ligament cells

BACKGROUND AND OBJECTIVE

Cigarette smoking has detrimental effects on periodontal tissue, and is known to be a risk factor for periodontal disease, including the loss of alveolar bone and ligament tissue. However, the direct effects of cigarette smoking on periodontal tissue remain unclear. Recently, we demonstrated that benzo[a]pyrene (BaP), which is a prototypic member of polycyclic aryl hydrocarbons and forms part of the content of cigarettes, attenuated the expression of extracellular matrix remodeling-related genes in human periodontal ligament (PDL) cells (HPDLCs). Thus, we aimed to examine the effects of BaP on the osteoblastic differentiation and collagen synthesis of HPDLCs.

MATERIAL AND METHODS

HPDLCs were obtained from healthy molars of three patients, and quantitative reverse transcription-polymerase chain reaction were performed for gene expression analyses of cytochrome P450 1A1 and 1B1, alkaline phosphatase, bone sialoprotein and aryl hydrocarbon receptor (AhR), a receptor for polycyclic aryl hydrocarbons. We have also analyzed the role of the AhR, using 2-methyl-2H-pyrazole-3-carboxylic acid (2-methyl-4-o-tolylazo-phenyl)-amide (CH-223191), which is an AhR antagonist.

RESULTS

The treatment of HPDLCs with BaP reduced mRNA expression of osteogenic genes, alkaline phosphatase activity, mineralization and collagen synthesis. The treatment with CH-223191 subsequently restored the observed suppressive effects of BaP on HPDLCs.

CONCLUSIONS

The present results suggest that BaP exerts inhibitory effects on the maintenance of homeostasis in HPDL tissue, such as osteoblastic differentiation and collagen synthesis of HPDLCs, and that this signaling pathway could be suppressed by preventing the transactivity of AhR. Future studies may unveil a role for the inhibition of AhR as a promising therapeutic agent for periodontal disease caused by cigarette smoking.

Complications of tibio-talar-calcaneal fusion using intramedullary nails

BACKGROUND

Hindfoot nails are being increasingly used, however significant complications can occur. The purpose of this study was to assess the complications following the use of hindfoot nails at our institution.

METHODS

We identified patients from a retrospective database. All underwent hindfoot nailing under the care of the senior author. Details of complications were recorded.

RESULTS

We identified 52 patients undergoing 55 procedures. Mean follow up was 44.8 months (18-69). Forty patients achieved ankle fusion and 36 subtalar joint fusion. Complications included prominent metalwork in 13 patients, CRPS in five and one peri-prosthetic fracture. Nine developed deep infection, and of these limb salvage was achieved in six patients by removal of metalwork, debridement and insertion of antibiotic loaded cement beads. The remaining three patients underwent below knee amputation.

CONCLUSION

Significant complications can occur, although limb preservation was possible in most cases of deep infection. Hindfoot nailing should be reserved as salvage procedure.

Comparison of Fusion Rates between Glycerol-Preserved and Frozen Composite Allografts in Cervical Fusion

Background. This retrospective, two cohort series study was designed to compare a room temperature, glycerol-preserved composite pinned bone allograft (G-CPBA) with the same graft type provided in a frozen state (F-CPBA) for use as a cervical interbody spacer in anterior cervical discectomy and fusion (ACDF). Methods. A comprehensive chart review was performed for 67 sequential patients that received either a F-CPBA or a G-CPBA and had at least one-year follow-up. Twenty-eight patients had received G-CPBA grafts and 37 patients had received F-CPBA grafts. Two additional 2-level patients had received one of each type of grafts. Results. At 3 months, 45.3% (29 of 64) of glycerol-preserved and 41.4% (29 of 70) of frozen allografts, respectively, were considered to be fused radiographically. At 12 months, 100% of both treatment groups (41 glycerol-preserved and 45 frozen) were considered fused. Fusion rates for G-CPBA were statistically similar to F-CPBA at both 3 and 12 months (P = 0.6535 and >0.999, resp.). There were no allograft related complications in either treatment group. Conclusions. 100% fusion rates were attained by both treatment groups at 12 months and were similar at short-term follow-up for all comparable levels. Level of Evidence. Level of evidence is III.

Ankle arthrodesis fusion rates for mesenchymal stem cell bone allograft versus proximal tibia autograft

Ankle arthrodesis is commonly used in the treatment of ankle arthritis. The present study compared mesenchymal stem cell (MSC) bone allografts and proximal tibia autografts as adjuncts in performing ankle arthrodesis. A total of 109 consecutive ankle fusions performed from 2002 to 2008 were evaluated retrospectively. Of the 109 fusions, 24 were excluded from the present study, leaving 85 patients who had undergone ankle arthrodesis. Of the 85 patients, 41 had received a proximal tibia autograft and 44, an MSC bone allograft. These 2 groups were reviewed and compared retrospectively at least 2 years postoperatively for the overall fusion rate, interval to radiographic fusion, and interval to clinical fusion. A modified and adjusted American College of Foot and Ankle Surgeons ankle scale was used to measure patient satisfaction. The overall fusion rate was 84.1% in the MSC bone allograft group and 95.1% in the proximal tibia autograft group (p = .158). The corresponding mean intervals to radiographic fusion were 13.0 ± 2.5 weeks and 11.3 ± 2.8 weeks (p ≤ .001). The interval to clinical fusion was 13.1 ± 2.1 weeks and 11.0 ± 1.5 weeks (p ≤ .001) in the MSC bone allograft and proximal tibia autograft group, respectively. No statistically significant difference was found in the fusion rates between the MSC bone allograft and proximal tibia autograft groups. Also, no statistically significant difference was found between the preoperative and postoperative scores using a modified and adjusted American College of Foot and Ankle Surgeons ankle scale between the 2 groups (p = .41 and p = .44, respectively). A statistically significant delay to radiographic and clinical fusion was present in the MSC bone allograft group compared with the proximal tibia autograft group; however, no difference was found in patient satisfaction.

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 objectives of this review are 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 METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register in January 2014.

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 or the incidence of postoperative complications or both outcomes.

DATA COLLECTION AND ANALYSIS

The review authors independently assessed studies to determine eligibility, and discussed the results between them.

MAIN RESULTS

Thirteen trials enrolling 2010 participants met the inclusion criteria. One trial did not report cessation as an outcome. Seven reported some measure of postoperative morbidity. Most studies were judged to be at low risk of bias but the overall quality of evidence was moderate due to the small number of studies contributing to each comparison.Ten trials evaluated the effect of behavioural support on cessation at the time of surgery; nicotine replacement therapy (NRT) was offered or recommended to some or all participants in eight of these. Two trials initiated multisession face-to-face counselling at least four weeks before surgery and were classified as intensive interventions, whilst seven used a brief intervention. One further study provided an intensive intervention to both groups, with the intervention group additionally receiving a computer-based scheduled reduced smoking intervention. One placebo-controlled trial examined the effect of varenicline administered one week preoperatively followed by 11 weeks postoperative treatment, and one placebo-controlled trial examined the effect of nicotine lozenges from the night before surgery as an adjunct to brief counselling at the preoperative evaluation. There was evidence of heterogeneity between the effects of trials using intensive and brief interventions, so we pooled these separately. An effect on cessation at the time of surgery was apparent in both subgroups, but the effect was larger for intensive intervention (pooled risk ratio (RR) 10.76; 95% confidence interval (CI) 4.55 to 25.46, two trials, 210 participants) than for brief interventions (RR 1.30; 95% CI 1.16 to 1.46, 7 trials, 1141 participants). A single trial did not show evidence of benefit of a scheduled reduced smoking intervention. Neither nicotine lozenges nor varenicline were shown to increase cessation at the time of surgery but both had wide confidence intervals (RR 1.34; 95% CI 0.86 to 2.10 (1 trial, 46 participants) and RR 1.49; 95% CI 0.98 to 2.26 (1 trial, 286 participants) respectively). Four of these trials evaluated long-term smoking cessation and only the intensive intervention retained a significant effect (RR 2.96; 95% CI 1.57 to 5.55, 2 trials, 209 participants), whilst there was no evidence of a long-term effect following a brief intervention (RR 1.09; 95% CI 0.68 to 1.75, 2 trials, 341 participants). The trial of varenicline did show a significant effect on long-term smoking cessation (RR 1.45; 95% CI 1.01 to 2.07, 1 trial, 286 participants).Seven trials examined the effect of smoking intervention on postoperative complications. As with smoking outcomes, there was evidence of heterogeneity between intensive and brief behavioural interventions. In subgroup analyses there was a significant effect of intensive intervention on any complications (RR 0.42; 95% CI 0.27 to 0.65, 2 trials, 210 participants) and on wound complications (RR 0.31; 95% CI 0.16 to 0.62, 2 trials, 210 participants). For brief interventions, where the impact on smoking had been smaller, there was no evidence of a reduction in complications (RR 0.92; 95% CI 0.72 to 1.19, 4 trials, 493 participants) for any complication (RR 0.99; 95% CI 0.70 to 1.40, 3 trials, 325 participants) for wound complications. The trial of varenicline did not detect an effect on postoperative complications (RR 0.94; 95% CI 0.52 to 1.72, 1 trial, 286 participants).

AUTHORS' CONCLUSIONS

There is evidence that preoperative smoking interventions providing behavioural support and offering NRT increase short-term smoking cessation and may reduce postoperative morbidity. One trial of varenicline begun shortly before surgery has shown a benefit on long-term cessation but did not detect an effect on early abstinence or on postoperative complications. 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.

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 objectives of this review are 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 METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register in January 2014.

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 or the incidence of postoperative complications or both outcomes.

DATA COLLECTION AND ANALYSIS

The review authors independently assessed studies to determine eligibility, and discussed the results between them.

MAIN RESULTS

Thirteen trials enrolling 2010 participants met the inclusion criteria. One trial did not report cessation as an outcome. Seven reported some measure of postoperative morbidity. Most studies were judged to be at low risk of bias but the overall quality of evidence was moderate due to the small number of studies contributing to each comparison.Ten trials evaluated the effect of behavioural support on cessation at the time of surgery; nicotine replacement therapy (NRT) was offered or recommended to some or all participants in eight of these. Two trials initiated multisession face-to-face counselling at least four weeks before surgery and were classified as intensive interventions, whilst seven used a brief intervention. One further study provided an intensive intervention to both groups, with the intervention group additionally receiving a computer-based scheduled reduced smoking intervention. One placebo-controlled trial examined the effect of varenicline administered one week preoperatively followed by 11 weeks postoperative treatment, and one placebo-controlled trial examined the effect of nicotine lozenges from the night before surgery as an adjunct to brief counselling at the preoperative evaluation. There was evidence of heterogeneity between the effects of trials using intensive and brief interventions, so we pooled these separately. An effect on cessation at the time of surgery was apparent in both subgroups, but the effect was larger for intensive intervention (pooled risk ratio (RR) 10.76; 95% confidence interval (CI) 4.55 to 25.46, two trials, 210 participants) than for brief interventions (RR 1.30; 95% CI 1.16 to 1.46, 7 trials, 1141 participants). A single trial did not show evidence of benefit of a scheduled reduced smoking intervention. Neither nicotine lozenges nor varenicline were shown to increase cessation at the time of surgery but both had wide confidence intervals (RR 1.34; 95% CI 0.86 to 2.10 (1 trial, 46 participants) and RR 1.49; 95% CI 0.98 to 2.26 (1 trial, 286 participants) respectively). Four of these trials evaluated long-term smoking cessation and only the intensive intervention retained a significant effect (RR 2.96; 95% CI 1.57 to 5.55, 2 trials, 209 participants), whilst there was no evidence of a long-term effect following a brief intervention (RR 1.09; 95% CI 0.68 to 1.75, 2 trials, 341 participants). The trial of varenicline did show a significant effect on long-term smoking cessation (RR 1.45; 95% CI 1.01 to 2.07, 1 trial, 286 participants).Seven trials examined the effect of smoking intervention on postoperative complications. As with smoking outcomes, there was evidence of heterogeneity between intensive and brief behavioural interventions. In subgroup analyses there was a significant effect of intensive intervention on any complications (RR 0.42; 95% CI 0.27 to 0.65, 2 trials, 210 participants) and on wound complications (RR 0.31; 95% CI 0.16 to 0.62, 2 trials, 210 participants). For brief interventions, where the impact on smoking had been smaller, there was no evidence of a reduction in complications (RR 0.92; 95% CI 0.72 to 1.19, 4 trials, 493 participants) for any complication (RR 0.99; 95% CI 0.70 to 1.40, 3 trials, 325 participants) for wound complications. The trial of varenicline did not detect an effect on postoperative complications (RR 0.94; 95% CI 0.52 to 1.72, 1 trial, 286 participants).

AUTHORS' CONCLUSIONS

There is evidence that preoperative smoking interventions providing behavioural support and offering NRT increase short-term smoking cessation and may reduce postoperative morbidity. One trial of varenicline begun shortly before surgery has shown a benefit on long-term cessation but did not detect an effect on early abstinence or on postoperative complications. 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.

Mediatory myths in the U.S. military: tobacco use as "stress relief"

PURPOSE

To examine perceptions of military personnel about tobacco use.

DESIGN

Secondary analysis of (1) focus group and (2) interview data.

SETTING

U.S. military.

SUBJECTS

Total participants (n = 241): Enlisted personnel, supervisors (n = 189 individuals participating in 23 focus groups), tobacco control managers, and policy leaders (n = 52 interview participants).

INTERVENTION

Not applicable.

MEASURES

Not applicable.

ANALYSIS

Inductive, iterative coding for salient themes using an interpretive approach. Application of the concept of mediatory myths, used by institutions to cover over internal contradictions.

RESULTS

All types of participants endorsed the idea that tobacco was needed in the military for stress relief. Types of stress identified included fitting in, (relationships with coworkers and superiors) and control of workflow (taking breaks). Participants also discussed beliefs about the impact of tobacco on the military mission, and institutional sanction of tobacco use.

CONCLUSION

Despite tobacco's well-documented negative effects on fitness, the myth that tobacco relieves stress serves several institutional functions in the military. It serves to minimize perceptions of stress on the fitness of personnel, suggests that stress can be managed solely by individuals, and institutionalizes tobacco use. Growing recognition among military leadership that countering stress is essential to fitness offers an opportunity to challenge this myth.

Percutaneous autologous bone marrow injection in the treatment of distal meta-diaphyseal tibial nonunions and delayed unions

OBJECTIVE

To report the outcomes of percutaneous autologous bone marrow injection for nonunion or delayed union of the distal tibial metaphysis in patients with prior plating.

DESIGN

Consecutive case series.

SETTING

Tertiary center.

PATIENTS

Eleven consecutive patients (aged 24-51 years) were referred to us with a nonunion or delayed union of the distal tibial metaphysis after open reduction and internal fixation (plates and screws) at the time of fracture. The average time from initial injury to nonunion or delayed union and bone marrow treatment was 8 months (range, 3-20 months).

INTERVENTION

A total of 40-80 mL of bone marrow aspirated from the posterior iliac crest and injected in and around the nonunion or delayed union site under fluoroscopic guidance.

MEASUREMENTS

Healing at the injury site was evaluated using clinical and radiographic criteria, including computed tomography. Measures included American Academy of Orthopaedic Surgeons Lower Limb Core Scale (LLCS), Brief Pain Inventory, and Short Form 12 Physical Component Summary.

RESULTS

Nine of the 11 patients attained bony union within 6 months of bone marrow injection. Six of these 9 patients who were followed-up an average of 4.4 years (range, 1.3-8.2 years) after the injection reported significant (P < 0.05) improvements in Lower Limb Core Scale (59.9-89.7), pain intensity (2.9-1.7), pain interference (4.6-2.3), and Short Form 12 Physical Component Summary (29.5-46.6) and 5.6 years improvement in quality-adjusted life years.

CONCLUSIONS

Percutaneous autologous bone marrow injection is a minimally invasive, safe, and inexpensive treatment option for distal metaphyseal tibial nonunions or delayed unions after internal fixation and should be considered when the retained hardware seems to be intact and stable.

LEVEL OF EVIDENCE

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

Cigarette smoke inhalation increases the alveolar bone loss caused by primary occlusal trauma in a rat model

BACKGROUND AND OBJECTIVE

Occlusal trauma (OT) and smoking are both factors that alter alveolar bone metabolism and therefore could synergistically act on alveolar bone loss. The aim of this experimental study was to evaluate the influence of short-term cigarette smoke inhalation (CSI) on inter-radicular alveolar bone loss promoted by primary OT in a rat model.

MATERIAL AND METHODS

Forty-eight animals were randomly assigned to one of three groups based on treatment type: OT + CSI (n = 16), animals were exposed to CSI three times per day, for 8 min per exposure, and they concomitantly received unilateral vertical augmentation creating an occlusal interference inducing experimental OT; OT (n = 16), animals received only unilateral vertical augmentation; negative control (NC; n = 16), animals maintained for equal periods to achieve periodontal baseline values of periodontal ligament dimension. Each group was divided into two subgroups (n = 8) based on treatment length: 7 or 14 d.

RESULTS

After 7 d, the OT + CSI group exhibited significantly higher bone loss compared to the NC group (p = 0.0022). After 14 d, the OT (p < 0.0001) and OT + CSI (p < 0.0001) groups presented significantly higher bone loss compared to the NC group, and OT + CSI resulted in significantly higher bone loss than OT alone (p = 0.0241). The number of tartrate-resistant acid phosphatase-positive cells on the linear surface of the bone crest after 7 d was significantly higher in the OT + CSI group as compared to the NC and OT groups (p < 0.0001 and p = 0.0045, respectively) and remained significantly higher in the OT + CSI group after 14 d, compared to the OT group (p < 0.0001).

CONCLUSION

Short-term CSI increases early bone loss in association with OT after 7 d, and this worsens in severity after 14 d of exposure.

Operative treatment of nonunion following distal fibula and medial malleolar ankle fractures

BACKGROUND

The purpose of this study was to evaluate the outcomes following operative treatment of nonunited rotational distal fibula and medial malleolar ankle fractures.

METHODS

Seventeen patients were identified as having a nonunion of a rotational ankle fracture. All patients were evaluated clinically, radiographically, and functionally with the Short Musculoskeletal Functional Assessment (SMFA) questionnaire. They were divided into lateral and medial malleolus groups and compared with 44 patients following a nonoperative (SE2/3) ankle fracture and 25 patients who underwent operative fixation of their SE4 ankle fracture for functional comparison.

RESULTS

Two of the 17 patients were excluded. The patients in the medial malleolar group were notably older than those in the other groups. Nonunions included 12 distal fibulas and 3 medial malleoli. All patients were treated with open reduction with plate and screw fixation or screw fixation alone. Adjunctive grafting was performed in all but 2 cases. The average time to healing was 5.2 months post surgery. At latest follow-up, mean 33.9 months, all nonunions had resolved. Standardized SMFA scores differed notably among the groups in the Bothersome, Emotional, and Mobility categories. There was no difference between lateral malleolar nonunion patients and surgically treated SE4 patients.

CONCLUSIONS

Reports of nonunions of fractures of lateral and medial malleoli have been rarely reported. Operative treatment of these nonunions in this study led to reliable bony healing. Patients who underwent surgery for these nonunions ultimately had similar outcomes and range of motion compared with patients who underwent operative treatment for acute ankle fractures.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

The in vitro and in vivo effects of nicotine on bone, bone cells and fracture repair

INTRODUCTION

Cigarette smoke has negative effects on bone metabolism and fracture repair. However, no study has reviewed effects of nicotine on bone and fracture repair independent of other constituents of cigarette smoke. The authors review the existing evidence of the effect of nicotine on 'bone' and 'bone cells' and fracture repair, drawing conclusions relevant to clinical practice and future research.

AREAS COVERED

A literature review was conducted using PRISMA guidelines and PubMed, Cochrane, MEDLINE/OVID, EMBASE, NHS Evidence and Google scholar databases. Articles were included if they specifically investigated the effects of nicotine on 'bone' or fracture repair in animal or human models or in vitro effects on 'bone cells'. A total of 64 papers were included in this review, of which 15 were human in vitro studies and 49 animal studies wherein 9 were in vitro and 40 in vivo. In vivo studies of the effects of nicotine in animals demonstrated widespread effects on bone including osteoneogenesis, osseointegration, steady-state skeletal bone and genes and cytokines relevant to bone cell physiology and bone homeostasis. In these studies, nicotine's effects are predominately negative, inhibiting bone cell metabolism and fracture repair, whereas most in vitro studies reported biphasic responses in all bone cells except osteoclastic cells.

EXPERT OPINION

The review suggests that nicotine has effects on osteoneogenesis, osseointegration and steady-state skeletal bone in animal in vivo models, as well as effects on all 'bone cells', via several mechanisms in both animal and human cell in vitro studies. The effect of nicotine is dose-dependent, with higher concentrations having predominantly negative effects, whereas at low concentrations a stimulatory effect is seen. Stimulatory effects on certain cells may indicate a possible, limited therapeutic role; advice regarding smoking cessation perioperatively should remain due to the other harmful components of cigarette smoke, but there may be scope for allowing the use of nicotine patches instead of complete abstention. Further research into clinical outcomes is required before the exact response of bone and fracture repair in humans to nicotine is known.

Military exceptionalism or tobacco exceptionalism: how civilian health leaders' beliefs may impede military tobacco control efforts

Smoking impairs the readiness and performance of military personnel, yet congressional opposition has thwarted military tobacco control initiatives. Involvement of civilian organizations might alter this political dynamic. We interviewed 13 leaders of national civilian public health and tobacco control organizations to explore their perspectives on military tobacco control, inductively analyzing data for themes. Leaders believed that military tobacco use was problematic but lacked specific knowledge. Most supported smoke-free policies and prohibiting smoking in uniform; however, they opposed banning tobacco use, arguing that it would violate smokers' rights. Most leaders inappropriately applied civilian models of policy development to the military context. A tobacco-free military is unlikely to be achieved without military-civilian partnerships that include educating civilian health leaders about military policy development and implementation.

Factors affecting healing of ankle fractures

Ankle fractures have been widely described in orthopedic and podiatric studies. These injuries have been associated with significant patient morbidity, infection, malunion, nonunion, and arthritis. Avoiding complications and optimizing outcomes demands an awareness of the factors affecting the healing of ankle fractures. The prognosis of surgical treatment of these injuries has varied according to patient factors or injury severity, or a combination. Cigarette smoking, obesity, and diabetes are some of the factors linked to the prognosis of ankle fractures. We conducted a retrospective cohort study of 58 patients treated for an ankle fracture at a single center. The objective of the present study was to comprehensively evaluate the factors affecting the clinical outcome of surgically treated ankle fractures.

Association between ankle fractures and obesity

Obesity is an epidemic in the United States and is associated with an increased risk of musculoskeletal problems. Rotational injuries of the ankle with a Weber C fibula fracture have a greater risk of syndesmosis disruption and instability. The goal of the present study was to explore the association between obesity and ankle fractures. Using a retrospective review, the radiographs of 280 patients with an ankle fracture were reviewed and classified using the Weber classification, which was then associated with the body mass index, gender, age, diabetes, tobacco use, and osteoporosis. Patients with a body mass index of 30 kg/m(2) or greater (odds ratio 1.78), men (odds ratio 1.74), and age 25 years or younger (odds ratio 3.97) had greater odds of having a Weber C ankle fracture (compared with Weber A and B) and Weber C and B (compared with Weber A). Diabetes mellitus, osteoporosis/osteopenia, and current tobacco use were not significantly associated with the severity of the ankle fracture. The results from the present study suggest that obesity presents a greater risk of sustaining a more proximal distal fibula fracture.

Ankle fractures

Ankle fractures are important injuries involving a weight-bearing joint critical to mobility. This article will discuss the necessity of and justification for surgical correction of virtually all ankle fractures. Various ankle fracture types will be explored, mechanisms illuminated and proper treatment outlined for these complex injuries.

The effects of smoke carcinogens on bone

The greatest cause of preventable morbidity and mortality is smoking, and one of the often-underappreciated effects of smoking is profound bone loss. The existing clinical paradigm for smoking is that there is a low turnover osteoporosis. This review highlights findings from recent clinical trials and animal research demonstrating either support or conflict with the existing paradigm. Clinically, it is noted that markers of bone formation are often normal in smokers; these clinical findings conflict with well-conducted animal research demonstrating that carcinogens acting on the aryl hydrogen receptor can significantly reduce osteoblast formation and function. Regarding bone resorption, highlights from recent clinical studies suggest that bone remodeling is increased in smokers. Directly contradicting this enhanced osteoclastogenesis are several animal studies all demonstrating significant inhibition of osteoclast formation and function upon exposure to smoke carcinogens. Future research is needed to clarify whether smoking is truly a low bone remodeling osteoporosis, or an osteoclast-driven bone destruction, with inappropriately normal bone formation.

Arthroscopic ankle arthrodesis

Arthroscopic ankle arthrodesis provides the surgeon with an alternative to traditional open techniques. Arthroscopic ankle arthrodesis has demonstrated faster union rates, decreased complications, reduced postoperative pain, and shorter hospital stays. Adherence to sound surgical techniques, particularly with regard to joint preparation, is critical for success. Although total ankle replacement continues to grow in popularity, arthroscopic ankle arthrodesis remains a viable alternative for the management of end-stage arthritic ankle.