Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis

Comparative Effectiveness of Conservative Management Versus Surgical Fixation in Acute Type II Odontoid Fractures

BACKGROUND AND OBJECTIVES

Managing acute type II odontoid fractures in the elderly is challenging because of comorbidities and frailty. This study evaluates radiological and functional outcomes of conservative vs surgical treatment.

METHODS

A retrospective analysis at a single US institution on elderly patients with acute type II odontoid fractures (January 2015-December 2023) was performed. Bivariate and logistic regression analyses compared outcomes and identified predictors of union.

RESULTS

The study included 273 patients, 20 of which expired during hospital admission, leaving 253 patients available for analysis with outcomes data. The median age was 82 years (IQR: 74-90), and 53% were female. Of 253 patients, 235 (93%) received conservative treatment and 18 (7%) underwent surgical fixation. At a median radiological follow-up of 3.75 months, surgical patients had higher fracture union rates (44% vs 10%, P < .01). Modified Rankin Scale ≤2 rates were similar (75% vs 73%, P = .85), but conservative treatment showed higher excellent pain control (75% vs 47%, P < .01). Logistic regression showed high union prediction accuracy (area under the curve = 0.93). Surgical fixation was the strongest predictor of union (adjusted odds ratio [aOR] = 6.6, 95% CI 1.8-24.5). Age ≥80 years (aOR = 0.1, 95% CI 0.05-0.2), smoking history (aOR = 0.2, 95% CI 0.1-0.6), osteoporosis (aOR = 0.1, 95% CI 0.02-0.6), and mild (aOR = 0.12, 95% CI 0.06-0.3), moderate (aOR = 0.08, 95% CI 0.03-0.2), and severe frailty (aOR = 0.04, 95% CI 0.01-0.1) were negatively associated with union. Angulation ≥11° also reduced union odds (aOR = 0.16, 95% CI 0.07-0.4).

CONCLUSION

Surgical fixation positively predicts fracture union, whereas advanced age, smoking, osteoporosis, frailty, and angulation (≥11°) reduce union odds. Surgery may enhance union odds, but conservative management remains effective with better pain control, without compromising long-term functional outcomes.

Management of Forefoot Nonunions: A Brief Overview with Case Example

Forefoot nonunions present significant challenges in clinical practice due to their complex etiology and the essential role of the forefoot in weight-bearing and ambulation. Risk factors such as poor vascular supply, diabetes, smoking, poor nutritional status, non-compliance, and infection exacerbate the condition. Diagnosis primarily relies on clinical evaluation and imaging modalities. The effective management of forefoot nonunions requires a multifaceted approach that integrates accurate diagnosis, appropriate conservative or surgical treatment, and thorough postoperative care and long-term follow- up. Understanding the underlying causes and appropriately managing patient comorbidities can significantly enhance treatment outcomes and patients' quality of life.

Nontobacco Nicotine Dependence and Rates of Periprosthetic Joint Infection and Other Postoperative Complications in Shoulder Arthroplasty: A Retrospective Analysis

INTRODUCTION

Nontobacco nicotine products, including e-cigarettes and vaping, are marketed as healthier alternatives to tobacco. However, the literature on nontobacco nicotine dependence (NTND) is scarce. It is important to analyze the influence of these products as they pertain to medical and surgical postoperative complications. This study hypothesizes that patients with NTND will experience more postoperative complications.

METHODS

Using the TriNetX database, which aggregates deidentified medical records from 89 healthcare organizations in the Research Network, Current Procedural Terminology and 10th revision of the International Classification of Diseases codes were used to identify patients undergoing primary shoulder arthroplasty (SA) from January 2012 to February 2024. Patients were divided into cohorts based on their NTND status before surgery. 90-day major medical complications and 2-year implant-related complications were assessed. Statistical analyses involved calculating risk ratios for postoperative complications.

RESULTS

This study analyzed a total of 89,910 SA patients, of which 6,756 were 1:1 propensity matched into NTND or control cohorts. Within the 90-day postoperative period, the NTND cohort exhibited significantly higher rates of sepsis (1.80 vs. 1.20, P = 0.012), surgical site infection (1.20 vs. 0.70%, P = 0.007), and wound disruptions (0.70 vs. 0.40%, P = 0.048), average opioids prescribed (4.46 vs. 3.338, P < 0.001), readmission (10.20% vs. 6.20%, P 0.001) compared with the non-NTND cohort. At the 2-year follow-up, mechanical loosening was notably higher in the NTND group (1.10 vs. 0.30%, P 0.001), as were rates of prosthetic joint infections (2.20 vs. 1.20%, P 0.001). No significant difference was observed for revision rates (3.20% vs. 2.90%, P = 0.269).

DISCUSSION

NTND is associated with higher 90-day rates of wound distruptions, infections, sepsis, as well as increased rates of mechanical loosening and prosthetic joint infection at 2 years postoperatively after SA. These results highlight the need for comprehensive NTND preoperative screening and tailored patient counseling in this patient population.

Chest wall soft tissue thickness is associated with humeral shaft non-union: A radiographic study

Background

Anecdotally, upper truncal obesity and large breasts have often been associated with inferior outcomes from non-operative management of diaphyseal humerus fractures. However, this assertion is without basis in the literature.

Aims

To produce radiographic measurements of chest wall soft tissue thickness (STT) and determine association with non-union in diaphyseal humerus fractures.

Methods

Two hundred and seventeen consecutive non-operative humeral shaft fractures were included. Radiographic STT measurements were taken at three standardised points (upper, middle and lower) using a simple reproducible method, with ratios derived (dividing these figures by the mid-humerus diameter). Bivariate and multivariable analyses were used to assess association with non-union.

Results

There were 58 (26.7%) cases of non-union. On multivariable analysis, the middle (odds ratio (OR) 1.39, p <  0.001) and lower (OR 1.23, p = 0.009) STT measurements were independently associated with non-union. Additionally, the middle (OR 1.85, p < 0.001) and lower (OR 1.47, p < 0.001) STT ratios were independently associated with non-union. A receiver operating characteristic curve determined a threshold value of a middle STT ratio of ≥ 3 (OR 3.73, p < 0.001, sensitivity 69.0%, specificity 62.3%), which was independently associated with non-union.

Conclusion

Chest wall STT is independently associated with humeral shaft non-union. Threshold values can assist in decision making for these fractures.

Developing a calculable risk prediction model for sternal wound infection after median sternotomy: a retrospective study

Background

Diagnosing sternal wound infection (SWI) following median sternotomy remains laborious and troublesome, resulting in high mortality rates and great harm to patients. Early intervention and prevention are critical and challenging. This study aimed to develop a simple risk prediction model to identify high-risk populations of SWI and to guide examination programs and intervention strategies.

Methods

A retrospective analysis was conducted on the clinical data obtained from 6715 patients who underwent median sternotomy between January 2016 and December 2020. The least absolute shrink and selection operator (LASSO) regression method selected the optimal subset of predictors, and multivariate logistic regression helped screen the significant factors. The nomogram model was built based on all significant factors. Area under the curve (AUC), calibration curve and decision curve analysis (DCA) were used to assess the model's performance.

Results

LASSO regression analysis selected an optimal subset containing nine predictors that were all statistically significant in multivariate logistic regression analysis. Independent risk factors of SWI included female [odds ratio (OR) = 3.405, 95% confidence interval (CI) = 2.535-4.573], chronic obstructive pulmonary disease (OR = 4.679, 95% CI = 2.916-7.508), drinking (OR = 2.025, 95% CI = 1.437-2.855), smoking (OR = 7.059, 95% CI = 5.034-9.898), re-operation (OR = 3.235, 95% CI = 1.087-9.623), heart failure (OR = 1.555, 95% CI = 1.200-2.016) and repeated endotracheal intubation (OR = 1.975, 95% CI = 1.405-2.774). Protective factors included bone wax (OR = 0.674, 95% CI = 0.538-0.843) and chest physiotherapy (OR = 0.446, 95% CI = 0.248-0.802). The AUC of the nomogram was 0.770 (95% CI = 0.745-0.795) with relatively good sensitivity (0.798) and accuracy (0.620), exhibiting moderately good discernment. The model also showed an excellent fitting degree on the calibration curve. Finally, the DCA presented a remarkable net benefit.

Conclusions

A visual and convenient nomogram-based risk calculator built on disease-associated predictors might help clinicians with the early identification of high-risk patients of SWI and timely intervention.

Risk factors for delayed bone union in opening wedge high tibial osteotomy

OBJECTIVES

The purpose of this study was to investigate the relationship between patient demographics and potential intraoperative factors and delayed bone union in opening wedge high tibial osteotomy (OWHTO).

PATIENTS AND METHODS

A retrospective review of 65 patients (37 females, 28 males; mean age: 60.1±10.1 years; range, 44 to 77 years) who underwent OWHTO using an angle-stable implant with beta-tricalcium phosphate gap filling between September 2016 and October 2019 was conducted. The osteotomy site was divided into five zones from the lateral hinge on anteroposterior radiographs, and we defined the zone in which bone healing was observed. The bone union area was assessed according to this definition at three, six, nine, and 12 months after surgery, and bone union was defined as union at the fourth zone or greater. A generalized estimating equations approach was employed to investigate longitudinal data pertaining to bone union area as a dependent variable. In addition, the association of bone union at six months postoperatively and predictors were evaluated using cross-sectional statistical methods. The categorical predictors included in the models were smoking, diabetes, hinge fracture, and autologous osteophyte grafting. The continuous variables included in the models were age, body mass index, opening gap width, and plate position.

RESULTS

Smoking (odds ratio [OR]=0.478, p<0.01), large opening gap width (OR=0.941, p=0.014), and anterior plate placement (OR=0.971, p<0.01) were significantly associated with decreased bone union area. Union rate at six months in smokers was significantly lower compared to nonsmokers (16.6% and 67.8%, respectively; OR=0.10, p=0.023). Area under the curve in the receiver operating characteristic analysis for bone union at six months was 0.60 for gap width and 0.63 for plate placement.

CONCLUSION

Smoking, large opening gap width, and anterior plate placement are risk factors for delayed bone union after OWHTO. Surgeons should avoid anterior placement of the plate and carefully consider other options for smokers and those who require a large correction.

Immunomodulation Pathogenesis and Treatment of Bone Nonunion

Fractures and bone nonunion commonly require surgical intervention. Serious outcomes of non-healing in the late stages of fracture place a significant financial burden on society and families. Bone nonunion occurs when a fracture stops healing, for many reasons, and leads to a variety of bad outcomes. Numerous factors, including biomechanics and immunology, are involved in the complicated mechanisms of bone nonunion. The immune-inflammatory response plays a significant part in the emergence of bone nonunion, and the occurrence, control, and remission of inflammation in the bone healing process have a significant influence on the ultimate success of bone tissue repair. In the bone microenvironment, immune cells and associated cytokines control bone repair, which is significantly influenced by macrophages, T cells, and fibroblast growth factor. To limit acute inflammation and  balance osteogenesis and osteoblastogenesis for tissue repair and regeneration, immune cells and various cytokines in the local microenvironment must be precisely regulated. As a bad complication of late-stage fractures, bone nonunion has a significant effect on patients' quality of life and socioeconomic development. Therefore, in-depth research on its pathogenesis and treatment methods has important clinical value. To provide more precise, focused therapeutic options for the treatment of bone nonunion, we discuss the regulatory roles of the key immune cells engaged in bone healing within the microenvironment during bone healing and their effect on osteogenesis.

Adverse effect of smoking on surgical site infection following ankle and calcaneal fracture fixation: a meta-analysis

Purpose

Studies have reported conflicting findings on the relationship between smoking and surgical site infection (SSI) post fixation for ankle and calcaneal fractures. This meta-analysis explored the effect of smoking on SSI incidence following open reduction and internal fixation (ORIF) of these fractures.

Methods

Full-text studies on smoking's influence on post-ORIF SSI rates for closed ankle and calcaneal fractures were sourced from the PubMed, Embase, and Cochrane databases, with no consideration given to language or publication date. Study quality was appraised using the Newcastle-Ottawa Scale. Odds ratios (OR) and the corresponding 95% CIs were determined using random-effects models. This meta-analysis adhered to the PRISMA guidelines and was registered with PROSPERO (CRD42023429372).

Results

The analysis incorporated data from 16 cohort and case-control studies, totaling 41 944 subjects, 9984 of whom were smokers, with 956 SSI cases. Results indicated smokers faced a higher SSI risk (OR: 1.62; 95% CI: 1.32-1.97, P < 0.0001) post ORIF, with low heterogeneity (I 2 = 26%). Smoking was identified as a significant deep SSI risk factor (OR: 2.09; 95% CI: 1.42-3.09; P = 0.0002; I 2 = 31%). However, the subgroup analysis revealed no association between smoking and superficial SSI (OR: 1.05; 95% CI: 0.82-1.33; P = 0.70; I 2 = 0%).

Conclusion

Smoking is associated with increased SSI risk after ORIF for closed ankle and calcaneus fractures. Although no clear link was found between superficial SSI and smoking, the data underscore the negative influence of smoking on deep SSI incidence.

Smoking increases risk of complication after musculoskeletal surgery: analysis of single immune parameter to predict complication risk

Smoking is the most significant and modifiable risk factor for a range of conditions, including cancer, cardiovascular and respiratory diseases. Furthermore, it significantly reduces bone mass and increases the risk of fragility fractures due to its detrimental effects on bone metabolism and regeneration. Moreover, smoking is a known cause of chronic systemic inflammation, leading to an imbalance of cytokines. Comprehending the pathological mechanisms that underlie cytokine production and its impact on post-surgical healing is essential to prevent post-surgical complications. The present study recruited a total of 1144 patients, including 897 patients, among them non-smokers (N = 413), current smokers (N = 201) and ex-smokers (N = 283). Human proteome profiler arrays were used to screen for smoking-dependent differences in the serum cytokine and protein profiles, after matching samples for age, gender, body mass index (BMI), alcohol use, and diabetes risk. Cytokines and immune checkpoint proteins such as CD28, B7-1, MIG, TGFβ2 and IL-1α/β were quantified by ELISA. Our study demonstrates a comprehensive understanding of the relationship between smoking, the development of complications, the systemic immune inflammation index (SII) and cytokine/protein levels. We found that a comparison of non-smokers, former smokers, and active smokers in our study cohort did not exhibit significantly altered cytokine and protein serum levels although other studies reported differences between smokers and non-smokers. We were unable to identify single blood circulating markers that could predict complications in smokers after trauma. However, we found the ratio of women to men to be inverted between non-smokers and active smokers resulting in a ratio of 0.62 in smokers. Furthermore, we demonstrate a higher complication rate, longer hospitalizations and elevated SII values among smokers, indicating an involvement of the immune system. See also the graphical abstract(Fig. 1).

Identification and validation of miR-29b-3p and LIN7A as important diagnostic markers for bone non-union by WGCNA

Bone non-union is a common fracture complication that can severely impact patient outcomes, yet its mechanism is not fully understood. This study used differential analysis and weighted co-expression network analysis (WGCNA) to identify susceptibility modules and hub genes associated with fracture healing. Two datasets, GSE125289 and GSE213891, were downloaded from the GEO website, and differentially expressed miRNAs and genes were analysed and used to construct the WGCNA network. Gene ontology (GO) analysis of the differentially expressed genes showed enrichment in cytokine and inflammatory factor secretion, phagocytosis, and trans-Golgi network regulation pathways. Using bioinformatic site prediction and crossover gene search, miR-29b-3p was identified as a regulator of LIN7A expression that may negatively affect fracture healing. Potential miRNA-mRNA interactions in the bone non-union mechanism were explored, and miRNA-29-3p and LIN7A were identified as biomarkers of skeletal non-union. The expression of miRNA-29b-3p and LIN7A was verified in blood samples from patients with fracture non-union using qRT-PCR and ELISA. Overall, this study identified characteristic modules and key genes associated with fracture non-union and provided insight into its molecular mechanisms. Downregulated miRNA-29b-3p was found to downregulate LIN7A protein expression, which may affect the healing process after fracture in patients with bone non-union. These findings may serve as a prognostic biomarker and potential therapeutic target for bone non-union.

Anterior Plate-Supported Cannulated Screw Surgery for Ankle Arthrodesis: Clinical and Radiologic Results in Patients with Trauma-Related End-Stage Ankle Osteoarthritis

BACKGROUND This retrospective study included 31 patients from 2 centers in Türkiye with posttraumatic ankle osteoarthritis treated with anterior tibiotalar arthrodesis using an anterior plate and cannulated screw fixation, with 6 months of follow-up. MATERIAL AND METHODS In this bi-center study, conducted between January 2018 and July 2022, we retrospectively reviewed the digital records of 31 patients with end-stage posttraumatic ankle osteoarthritis who were treated with anterior tibiotalar arthrodesis surgery using 2 or 3 cannulated screws and the anterior plating technique. Data on age, gender, comorbidities, and smoking were recorded, as were operative technique and graft use. Union characteristics, complications, visual analog scale (VAS) results, and Maryland functional scoring were assessed preoperatively and at the 6-month follow-up visit. RESULTS The mean age of the 31 (n=13 male, n=18 female) patients was 55.5 (19-82) years. The union findings were good in 26 (83.9%) of the patients and late in 3 (9.7%) of them. Nonunion was seen in 2 (6.5%) patients. Complications were observed in 7 (22.6%) patients. Union formation was statistically significantly prolonged among the cases with complications (P=0.002). The smoking rate was significantly higher in patients encountering complications (P=0.001). Among cases with complications, the VAS and Maryland scores recorded in the postoperative sixth month were significantly higher (P=0.027, P=0.018, respectively). The mean union time was 13.5±6.5 weeks among all of the patients. CONCLUSIONS Our study showed that cannulated screw fixation, strengthened with the common and easy-to-supply anterior reconstruction plating technique, had high fixation power and good functional results in patients with end-stage posttraumatic ankle osteoarthritis.

Cervical Sagittal Alignment and Related Factor Analysis and Prediction Model in Patients Undergoing Revision Surgery After Anterior Cervical Fusion

INTRODUCTION

Patients with myelopathy or radiculopathy commonly undergo anterior cervical fusion surgery (ACFS), which has a notable failure rate on occasion. The goal of this study was to compare revision and nonrevision surgery patients in cervical sagittal alignment (CSA) subsequent to ACFS; additionally, to identify the best CSA parameters for predicting clinical outcome after ACFS; and furthermore, to create an equation model to assist surgeons in making decisions on patients undergoing ACFS.

METHODS

The data of 99 patients with symptomatic cervical myelopathy/radiculopathy who underwent ACFS were analyzed. Patients were divided into group A (underwent revision surgery after the first surgery failed) and group B (underwent only the first surgery). We measured and analyzed both preoperative and postoperative CSA parameters, including C2 slope, T1 slope, cervical lordosis C2-C7 (CL), C2-C7 sagittal vertical axis (C2C7 SVA), occiput-C2 lordosis angle (C0-C2), and chin brow vertical angle, and we further computed the correlation between the CSA parameters and created a prediction model.

RESULTS

The (T1S-CL)-C2S mismatch differed significantly between groups A and B ([9.95 ± 9.95] 0 , [3.79 ± 6.58] 0 , P < 0.05, respectively). A significant correlation was observed between C2 slope and T1CL in group B relative to group A postoperatively (R 2 = 0.42 versus R 2 = 0.09, respectively). Compared with group B, patients in group A had significantly higher C2C7SVA values, more levels of fusion, and more smokers. The sensitivity, specificity, accuracy, and discrimination of the model were, respectively, 73.5%, 84%, 78.8%, and 85.65%.

CONCLUSION

The causes of revision surgery in cervical myelopathic patients after anterior cervical corpectomy and fusion/anterior cervical diskectomy and fusion are multifactorial. (T1S-CL)-C2S mismatch and high C2C7SVA are the best cervical sagittal parameters that increase the odds of revision surgery, and the effect is more enhanced when comorbidities such as smoking, low bone-mineral density, and increased levels of fusion are taken into account.

Tibio-Talo-Calcaneal Arthrodesis: Evaluation of the Effectiveness of a Specific Surgical Technique in 17 Cases

INTRODUCTION

Ankle arthrodesis is a crucial surgical intervention for advanced hindfoot conditions, aiming to restore plantigrade walking and alleviate pain. This study evaluates the effectiveness of a specific surgical approach for tibiotalocalcaneal arthrodesis (TTCA), focusing on rigorous risk factor control, corticocancellous grafting, and internal fixation using an angled retrograde femoral nail in the sagittal plane, and assesses the outcomes of this approach in terms of bone fusion and reduction of postoperative complications.

MATERIALS AND METHODS

This retrospective analysis includes 17 patients who underwent TTCA in a trauma-orthopedic department over seven years. Data were collected from medical records, the HOSIX software, and patient consultations. Preoperative assessments, surgical techniques, postoperative care, and follow-up evaluations were documented.

RESULTS

The mean age of patients was 42.4 years, with a male predominance. Surgical indications included post-traumatic arthropathy (53%), inflammatory arthropathy, ankle infectious pathologies, and Charcot foot and ankle prosthesis failures. All patients underwent standard preoperative evaluations and received corticocancellous grafts. An angled retrograde femoral nail in the sagittal plane was used for internal fixation. Postoperative immobilization lasted 6 to 8 weeks, with subsequent rehabilitation. The bone fusion rate was 100%, with a low complication rate (23.5%).

DISCUSSION

Our study showed a younger patient population with a male predominance, different from some previous studies. Surgical techniques, including the anterior approach combined with a lateral subtalar approach, were consistent with some studies but differed from others. Corticocancellous grafts and the angled retrograde femoral nail in the sagittal plane demonstrated favorable outcomes in terms of fusion. Complication rates were lower compared to some previous reports, highlighting potential improvements in postoperative management.

CONCLUSION

The surgical approach described for TTCA, emphasizing rigorous risk factor control, corticocancellous grafting, and internal fixation using an angled retrograde femoral nail in the sagittal plane, led to satisfactory bone fusion and reduced postoperative complications. These results underscore the importance of this approach in achieving optimal functional outcomes in ankle arthrodesis.

Promoting bone callus formation by taking advantage of the time-dependent fracture gap strain modulation

Delayed union and non-union of fractures continue to be a major problem in trauma and orthopedic surgery. These cases are challenging for the surgeon. In addition, these patients suffer from multiple surgeries, pain and disability. Furthermore, these cases are a major burden on healthcare systems. The scientific community widely agrees that the stability of fixation plays a crucial role in determining the outcome of osteosynthesis. The extent of stabilization affects factors like fracture gap strain and fluid flow, which, in turn, influence the regenerative processes positively or negatively. Nonetheless, a growing body of literature suggests that during the fracture healing process, there exists a critical time frame where intervention can stimulate the bone's return to its original form and function. This article provides a summary of existing evidence in the literature regarding the impact of different levels of fixation stability on the strain experienced by newly forming tissues. We will also discuss the timing and nature of this "window of opportunity" and explore how current knowledge is driving the development of new technologies with design enhancements rooted in mechanobiological principles.

The impact of high nicotine concentrations on the viability and cardiac differentiation of mesenchymal stromal cells: a barrier to regenerative therapy for smokers

Background: Current treatment methods are not successful in restoring the lost cardiomyocytes after injury. Stem cell-based strategies have attracted much attention in this regard. Smoking, as a strong cardiovascular risk factor, not only affects the cardiac cells adversely but also deteriorates the function of stem cells. Since mesenchymal stem cells (MSCs) are one of the popular candidates in cardiovascular disease (CVD) clinical trials, we investigated the impact of nicotine on the regenerative properties (viability and cardiac differentiation) of these cells. Methods: MSCs were isolated from rat bone marrow and characterized based on morphology, differentiation capability, and the expression of specific mesenchymal markers. The MTT assay was used to assess the viability of MSCs after being exposed to different concentrations of nicotine. Based on MTT findings and according to the concentration of nicotine in smokers' blood, the growth curve and population doubling time were investigated for eight consecutive days. Cells were treated with 5-azacytidine (an inducer of cardiac differentiation), and then the expressions of cardiac-specific markers were calculated by qPCR. Results: MSCs were spindle-shaped, capable of differentiating into adipocyte and osteocyte, and expressed CD73 and CD90. The viability of MSCs was reduced upon exposure to nicotine in a concentration- and time-dependent manner. The growth curve showed that nicotine reduced the proliferation of MSCs, and treated cells needed more time to double. In addition, the expressions of GATA4 and troponin were downregulated in nicotine-treated cells on day 3. However, these two cardiac markers were overexpressed on day 7. Conclusion: Nicotine decreased normal growth and reduced the expression of cardiac markers in MSCs. This aspect is of eminent importance to smokers with cardiovascular disease who are candidates for stem cell therapy.

Arthrodesis of distal interphalangeal and thumb interphalangeal joint: a retrospective cohort study of 149 cases

BACKGROUND

Arthrodesis of finger joints is often the last line of treatment of severe pain due to osteoarthritis, rheumatoid arthritis, or mallet finger. At the Department of Orthopedic and Hand Surgery, Örebro University Hospital (ÖUH) in Sweden, the Kirschner-wire technique was standard until 2020, when the headless compression screw technique was introduced as a complement. There is no consensus on which method is superior. The purpose of this study was to examine the outcomes and complications associated with distal interphalangeal (DIP) joint and thumb interphalangeal (IP) joint arthrodesis, and to see whether these correlated with patient-dependent and treatment-related factors.

METHODS

In a retrospective cohort study, we evaluated a total of 149 consecutive arthrodeses (118 DIP joint and 31 thumb IP joint) performed between 2012 and 2022. The primary outcome was risk factors for complications after arthrodesis.

RESULTS

Osteoarthritis was the most common indication (56%) for arthrodesis. The majority of the patients were females (74%), and the median age was 62 (range 18-86). The complication frequency was 35%, with infection being the most common (25%). Time to completed follow up was < 12 weeks in the majority of the cases (58%). There were no significant differences in complication rate between the 136 joints operated using Kirschner wire and the 13 joints operated using headless compression screws. There was no significant increased risk of complications among smokers or patients with rheumatoid arthritis. Diabetes and surgeon experience had a significant influence on the risk of complication (p = 0.036 and p = 0.006, respectively).

CONCLUSIONS

Osteoarthritis was the most common indication for arthrodesis and postoperative complications occurred at a rate similar to that reported in the existing literature. Diabetes and surgeon experience were identified as factors increasing the risk of postoperative complications in these DIP/thumb IP joint arthrodeses. However, there was no significant difference between the two techniques (Kirschner wire and headless compression screws) regarding complications. Further studies are needed in order to determine the optimal type of operation and choice of implant.

TRIAL REGISTRATION

Researchweb CRIS #280,998, 26th of July 2023.

Incidence of Complications After Tibial Tubercle Osteotomy and Tibial Tubercle Osteotomy With Distalization

BACKGROUND

Tibial tubercle osteotomy (TTO) is a well-established surgical treatment option for patellofemoral instability and pain. TTO with distalization (TTO-D) is indicated for patients with patellofemoral instability, patellar malalignment, and patella alta. The current literature demonstrates several complications that may be associated with TTO, with reportedly higher rates of complications associated with TTO-D.

PURPOSE

To analyze and compare complication rates after TTO without distalization (TTO-ND) and TTO-D and assess risk factors associated with complications.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All skeletally mature patients who underwent TTO with or without distalization by a single surgeon between September 2014 and May 2023 with a minimum of 6 months of clinical follow-up were retrospectively reviewed. Patient factors, surgical indications, perioperative data, and complications were collected via a retrospective review of electronic medical records. Concomitant procedures were categorized as intra-articular, extra-articular, and osteotomies.

RESULTS

A total of 251 TTOs (117 TTO-D, 134 TTO-ND) were included in the study group. Postoperative complications were observed in 15 operations (6%), with arthrofibrosis as the most common complication (10 operations [4%]). TTO-D and TTO-ND had similar rates of complication (5% vs 7%; P = .793). Clinical nonunion was observed in 3 operations (3%) in the TTO-D cohort and 1 operation (1%) in the TTO-ND cohort. In the TTO-D cohort, concomitant intra-articular procedures were significantly associated with an increased likelihood of complications in a univariate model. In the TTO-ND cohort, an increased tourniquet time was significantly associated with an increased likelihood of complications in a univariate model. For all TTOs as well as the TTO-D and TTO-ND cohorts, there were no significant associations between patient or surgical variables in a multivariate model.

CONCLUSION

TTO with and without distalization is a safe procedure with low rates of complication. TTO-D was not associated with a higher rate of complications compared with TTO-ND. There was no association between complications and surgical variables for TTO procedures.

Surgical outcomes of anterior column reconstruction for spinal fractures caused by minor trauma-preoperative examination of the number of intervertebral bone bridges is key to obtaining good bone fusion

BACKGROUND

To achieve good bone fusion in anterior column reconstruction for vertebral fractures, not only bone mineral density (BMD) and bone metabolism markers but also lever arms due to bone bridging between vertebral bodies should be evaluated. However, until now, no lever arm index has been devised. Therefore, we believe that the maximum number of vertebral bodies that are bony and cross-linked with the contiguous adjacent vertebrae (maxVB) can be used as a measure for lever arms. The purpose of this study is to investigate the surgical outcomes of anterior column reconstruction for spinal fractures and to determine the effect of bone bridging between vertebral bodies on the rate of bone fusion using the maxVB as an indicator of the length of the lever arm.

METHODS

The clinical data of 81 patients who underwent anterior column reconstruction for spinal fracture between 2014 and 2022 were evaluated. The bone fusion rate, back pain score, between the maxVB = 0 and the maxVB ≥ 2 patients were adjusted for confounding factors (age, smoking history, diabetes mellitus history, BMD, osteoporosis drugs, surgical technique, number of fixed vertebrae, materials used for the anterior props, etc.) and analysed with multivariate or multiple regression analyses. The bone healing rate and incidence of postoperative back pain were compared among the three groups (maxVB = 0, 2≦maxVB≦8, maxVB ≧ 9) and divided by the maxVB after adjusting for confounding factors.

RESULTS

Patients with a maxVB ≥ 2 had a significantly higher bone fusion rate (p < 0.01) and postoperative back pain score (p < 0.01) than those with a maxVB = 0. Among the three groups, the bone fusion rate and back pain score were significantly higher in the 2≦maxVB≦8 group (p = 0.01, p < 0.01).

CONCLUSIONS

Examination of the maxVB as an indicator of the use of a lever arm is beneficial for anterior column reconstruction for vertebral fractures. Patients with no intervertebral bone bridging or a high number of bone bridges are in more need of measures to promote bone fusion than patients with a moderate number of bone bridges are.

Predictive Factors of Functional Outcomes and Quality of Life in Patients with Ankle Fractures: A Systematic Review

Background: Evaluating the predictors of unfavorable outcomes in patients with ankle fractures is crucial for identifying high-risk patients and implementing personalized treatment strategies. This study aimed to analyze factors that influence quality of life in patients with ankle fractures. Methods: Four databases were consulted. The main outcomes were functionality and quality of life scales combined using the standard mean difference (SMD) (Review Manager 5.4). Results: Eight studies with 2486 patients were included. A significant correlation was found between female sex and worse functionality scores (beta 4.15, 95% CI 1.84-6.46). Additionally, older age was correlated with worse functionality scores (beta -0.24, 95% CI -0.29 to -0.19). Patients with diabetes or metabolic syndrome also had worse outcomes (SMD 0.27, 95% CI 0.18-0.36). High BMI and obesity were also associated with worse quality of life scores (beta 2.62, 95% CI 0.77-4.48). Smokers had greater disability in the analyzed scales (SMD 0.22, 95% CI 0.05-0.39). No significant differences were observed with respect to syndesmotic involvement. Conclusions: Age, sex, diabetes, high BMI, and smoking negatively impact functional outcomes and quality of life in patients with ankle fractures.

Failure after operative repair is higher for ballistic femoral neck fractures than for closed, blunt-injury fractures: a multicenter retrospective cohort study

Introduction

The purpose of this study was to describe the outcomes after operative repair of ballistic femoral neck fractures. To better highlight the devastating nature of these injuries, we compared a cohort of ballistic femoral neck fractures to a cohort of young, closed, blunt-injury femoral neck fractures treated with open reduction and internal fixation (ORIF).

Methods

Retrospective chart review identified all patients presenting with ballistic femoral neck fractures treated at three academic trauma centers between January 2016 and December 2021, as well as patients aged ≤50 with closed, blunt-injury femoral neck fractures who received ORIF. The primary outcome was failure of ORIF, which includes the diagnosis of non-union, avascular necrosis, conversion to total hip arthroplasty, and conversion to Girdlestone procedure. Additional outcomes included deep infection, postoperative osteoarthritis, and ambulatory status at last follow-up.

Results

Fourteen ballistic femoral neck fractures and 29 closed blunt injury fractures were identified. Of the ballistic fractures, 7 (50%) patients had a minimum of 1-year follow-up or met the failure criteria. Of the closed fractures, 16 (55%) patients had a minimum of 1-year follow-up or met the failure criteria. Median follow-up was 21 months. 58% of patients with ballistic fractures were active tobacco users. Five of 7 (71%) ballistic fractures failed, all of which involved non-union, whereas 8 of 16 (50%) closed fractures failed (p=0.340). No outcomes were significantly different between cohorts.

Conclusion

Our results demonstrate that ballistic femoral neck fractures are associated with high rates of non-union. Large-scale multicenter studies are necessary to better determine optimal treatment techniques for these fractures.

Level of evidence

Level III. Retrospective cohort study.

Mandibular angle fractures: a demographic review, with particular reference to post-operative complications

BACKGROUND

Mandibular angle fractures (MAF) have a recognized complexity of treatment and an increased risk of incurring complications.

METHODS

This retrospective study included 45 consecutive patients who were diagnosed with an isolated MAF and no other facial fractures. The average age was 27.3 (SD = 7.7).

RESULTS

A comparatively low rate of complications (11.1%) and a low rate of reoperation (1.8%) are reported, along with a significant role of smoking in complications (p = 0.022). A non-significant association was noted between complications, male gender and assault as an aetiological factor.

CONCLUSIONS

Review of the data from this study confirms that complication rates for patients attending the National Maxillofacial Unit are similar to or better than that of international studies. An overview of the aetiology of fracture complications is included.

Use of Autologous Bone Graft with Bioactive Glass as a Bone Substitute in the Treatment of Large-Sized Bone Defects of the Femur and Tibia

BACKGROUND

Managing bone defects in non-union surgery remains challenging, especially in cases of large defects exceeding 5 cm in size. Historically, amputation and compound osteosynthesis with a remaining PMMA spacer have been viable and commonly used options. The risk of non-union after fractures varies between 2% and 30% and is dependent on various factors. Autologous bone grafts from the iliac crest are still considered the gold standard but are limited in availability, prompting consideration of artificial grafts.

OBJECTIVES

The aims and objectives of the study are as follows: 1. To evaluate the radiological outcome of e.g., the consolidation and thus the stability of the bone (three out of four consolidated cortices/Lane-Sandhu-score of at least 3) by using S53P4-type bioactive glass (BaG) as a substitute material for large-sized bone defects in combination with autologous bone using the RIA technique. 2. To determine noticeable data-points as a base for future studies.

METHODS

In our clinic, 13 patients received bioactive glass (BaG) as a substitute in non-union therapy to promote osteoconductive aspects. BaG is a synthetic material composed of sodium, silicate, calcium, and phosphate. The primary endpoint of our study was to evaluate the radiological consolidation of bone after one and two years. To assess bone stabilization, we used a modified Lane-Sandhu score, considering only radiological criteria. A bone was considered stabilized if it achieved a minimum score of 3. For full consolidation (all four cortices consolidated), a minimum score of 4 was required. Each bone defect exceeded 5 cm in length, with an average size of 6.69 ± 1.92 cm.

RESULTS

The mean follow-up period for patients without final bone consolidation was 34.25 months, with a standard deviation of 14.57 months, a median of 32.00 months and a range of 33 months. In contrast, patients with a fully consolidated non-union had an average follow-up of 20.11 ± 15.69 months and a range of 45 months. Overall, the mean time from non-union surgery to consolidation for patients who achieved final union was 14.91 ± 6.70 months. After one year, six patients (46.2%) achieved complete bone consolidation according to the Lane-Sandhu score. Three patients (23.1%) displayed evident callus formation with expected stability, while three patients (23.1%) did not develop any callus, and one patient only formed a minimal callus with no expected stability. After two years, 9 out of 13 patients (69.2%) had a score of 4. The remaining four patients (30.8%) without expected stability either did not heal within two years or required a revision during that time.

CONCLUSIONS

Bioactive glass (BaG) in combination with autologous bone (RIA) appears to be a suitable filler material for treating extensive non-unions of the femur and tibia. This approach seems to show non-inferiority to treatment with Tricalcium Phosphate (TCP). To ensure the success of this treatment, it is crucial to validate the procedure through a randomized controlled trial (RCT) with a control group using TCP, which would provide higher statistical power and more reliable results.

Vascularized Bone Grafting Versus the 2-Stage Masquelet Technique for Upper-Extremity Bone Reconstruction: A Meta-Analysis

PURPOSE

Vascularized bone grafting (VBG) has been described as the technique of choice for larger bone defects in bone reconstruction, yielding excellent results at the traditional threshold of 6 cm as described in the literature. However, we hypothesize that the 2-stage Masquelet technique provides equivalent union rates for upper-extremity bone defects regardless of size, while having no increase in the rate of patient complications.

METHODS

A systematic literature review was conducted using PubMed and Scopus for outcomes after VBG and the Masquelet technique for upper-extremity bone defects of the humerus, radius, ulna, metacarpal, or phalanx (carpal defects were excluded). A meta-analysis was performed to compare outcomes following VBG and the Masquelet technique at varying defect sizes.

RESULTS

There were 77 VBG (295 patients) and 25 Masquelet (119 patients) studies that met inclusion criteria. Patients undergoing the Masquelet technique had defect sizes ranging from 0-15 cm (average 4.5 cm), while patients undergoing VBG had defect sizes ranging from 0-24 cm (average 5.9 cm). The union rate for Masquelet patients was 94.1% with an average time to union of 5.8 months, compared to 94.9% and 4.4 months, respectively, for VBG patients. We did not identify a defect size threshold at which VBG demonstrated a significantly higher union rate. No statistically significant difference was found in union rates between techniques when using multivariable logistic regression analysis.

CONCLUSION

There was no statistically significant difference in union rates between VBG and the Masquelet technique in upper-extremity bone defects regardless of defect size. Surgeons may consider the Masquelet technique as an alternative to VBG in large bone defects of the upper extremity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Current Concepts: Corrective Osteotomy for Extra-Articular Deformity Following a Distal Radius Fracture

Fracture malunion alters wrist and distal radioulnar joint (DRUJ) biomechanics, resulting in incongruence and instability of the DRUJ. Selected patients with painful functional limitation and significant deformity of the radius, but without advanced degenerative joint disease, may benefit from corrective distal radial osteotomy. Non-union and complications arising from metalwork are the most common reasons for reoperation. Surgeons should have a good understanding of risks and complications in order to fully inform their patients and manage expectations. This article reviews the biomechanical effects of radial malunion and the current concepts for treatment. Distal radial osteotomy is suitable for symptomatic patients with angular radial deformity and shortening. Evidence supports a volar approach without bone grafts for modest corrections. Bone grafts or synthetic bone substitutes are appropriate for larger corrections. Functional improvements are reported regardless of technique. Despite a high complication rate, patient satisfaction with the corrective radial osteotomy is high.

The effect of smoking on union rates following corrective osteotomies around the knee: A systematic review and meta-analysis

BACKGROUND

Distal femur osteotomies (DFO) and high tibial osteotomies (HTO), are well-established treatment options for joint preservation in active patients with uni-compartmental osteoarthritis. Optimal outcomes are contingent on adequate preoperative evaluation of patient-specific factors. This systematic review and meta-analysis aims to explore the difference in union rates between smokers and non-smokers following corrective osteotomies around the knee.

METHODS

A systematic search of the MEDLINE and EMBASE databases was performed in accordance with the PRISMA guidelines to identify studies reporting smoking status in adults who developed delayed and/or non-union following HTO or DFO. Studies were pooled using a random effect model [Review Manager (RevMan) software, V.5.4] and heterogeneity was estimated using I2.

RESULTS

Data for meta-analysis was available for 1,406 osteotomies from 10 studies, performed in patients with mean age ranging from 38-54 years, and 65% were male. The union rate among non-smokers was 97.3% (1100/1131) compared with 89.5% (246/275) among smokers; OR 4.59 [95% CI 1.99 to 10.62], p-value < 0.001. Subgroup analysis revealed that the risk of non-union in smokers after opening wedge osteotomy was almost double (OR 4.8) that of closing wedge osteotomies (OR 2.9).

CONCLUSION

Smoking increases the risk of non-union during elective knee osteotomy surgery. Our findings also suggest that smokers have a better chance of achieving union with closing wedge osteotomy compared to open wedge osteotomy.

Distal femoral osteotomy for the valgus knee: indications, complications, clinical and radiological outcome

INTRODUCTION

The aim of this study was to describe the indications and technical aspects of medial closing and lateral opening distal femoral osteotomy (MCDFO and LODFO) for patients with a valgus knee and to report clinical and radiological outcomes and complications.

METHODS

Over 6 years, 28 DFOs (22 MCDFO, 6 LODFO) were performed in 22 Patients. In this cohort study, we retrospectively analyzed clinical and radiological outcome measures as well as complications.

RESULTS

The median (range) age was 47 (17-63) years, height 1.68 (1.56-1.98) m, body mass 80 (49-105) kg, and body mass index (BMI) 27.4 (18.6-37.0) kg/m2. The clinical follow-up was 21 (7-81) months, the need for total or unicompartmental knee arthroplasty (TKA/UKA) and hardware removal was followed up for 59 (7-108) months postoperatively. Preoperatively, hip-knee-ankle angle (HKA, negative values denote varus) was 7.0 (2.0-13.0)°, mechanical lateral distal femoral angle (mLDFA) was 83.7 (79.9-88.2)°, and mechanical proximal tibial angle (MPTA) was 89.0 (86.6-94.5)°. Postoperatively, HKA was -1.3 (-9.0-1.2)° and mLDFA was 90.8 (87.3-97.3)°. The incidence of minor and major complications was 25% and 14%, the incidence of delayed and nonunion was 18% and 4%, respectively. At the last follow-up, 18% of the patients had pain at rest, 25% during activities of daily living, and 39% during physical activity, and 71% were satisfied with the outcome. 7% of the cases received a TKA/UKA, 71% received a hardware removal.

CONCLUSION

DFO is a reasonable treatment for lateral osteoarthritis in younger patients to avoid disease progression and the need for an UKA/TKA. However, there is a long rehabilitation time, a considerable risk for complications, and a high need for hardware removal. While many patients experienced symptoms at the long-term follow-up, most were satisfied with the outcome. Appropriate patient information is essential. Level of evidence Level IV, Case Series. Trial registration number NCT04382118, clinicaltrials.gov, May 11, 2020.

Number of contiguous vertebral cross-links in the spine indicates bone formation: a cross-sectional study

BACKGROUND

As an indicator to evaluate the risk of fracture in diffuse idiopathic skeletal hyperostosis, the maximum number of vertebral bodies' bone cross-linked with contiguous adjacent vertebrae (max VB) was developed. This study retrospectively investigates the relationship between max VB, bone mineral density (BMD), and bone metabolic markers (BMM).

METHODS

In this cross-sectional study (from April 2010 to January 2022), males (n = 114) with various max VB from the thoracic vertebra to the sacrum, measured using computed tomography scans, were selected to assess femur BMD and BMM. The association of max VB with the total type I procollagen N-terminal propeptide (P1NP), tartrate-resistant acid phosphatase 5b (TRACP-5b), and bone turnover ratio (BTR = TRACP-5b/P1NP) as well as its relationship with femur BMD with P1NP and TRACP-5b, were investigated. Furthermore, the relationship between P1NP and TRACP-5b was investigated.

RESULTS

P1NP increased in proportion to max VB and TRACP-5b increased in proportion to P1NP. Moreover, BTR was inversely proportional to max VB. Finally, femur BMD was inversely proportional to P1NP and TRACP-5b.

CONCLUSION

As max VB increased with P1NP-a potential osteogenesis indicator-and BTR was inversely proportional to max VB with compensatory TRACP-5b increase, max VB can be considered as a possible predictor of bone fusion.

Factors and Radiographic Findings Influencing Patient-Reported Outcomes Following Maisonneuve Fractures

BACKGROUND

This research adds to the literature by providing prognostic information for physicians and patients regarding the outcomes of operative management of Maisonneuve fractures (MFs). To date, this is the only cohort study of patient-reported outcomes measurement information systems (PROMIS) scores following surgical fixation of MF. Patient outcomes were compared focusing on the mean population with an inter-analysis using basic demographic information, radiographic findings, and patient comorbidities and their respective impact on PROMIS scores.

METHODS

A total of 24 patients between 2012 and 2020 met the inclusion criteria and completed PROMIS surveys at a minimum of 18 months postoperatively. Patient charts were reviewed through the electronic medical record (EMR) for demographic information and comorbidities as well as operative variables. PROMIS scores for physical function (PF), pain interference (PI), and depression were obtained via follow-up visits and phone calls. The impact of categorical variables on complications was compared using Chi-Squared tests. Variables were analyzed with a type 3 SS test to stratify independent risk factors' effect on PROMIS scores and to account for confounding variables.

RESULTS

PROMIS PF averaged 44.84 and was significantly affected by BMI>30 (p=.033), hypertension (HTN) (p=.026), patients with clinical anxiety or depression (p=.047), and subsequent screw removal (p=.041). PROMIS PI averaged a score of 54.57 and was significantly affected by BMI>30 (p=.0046), coronary artery disease (CAD) (p=.0123), patients with clinical anxiety or depression (p=.0206), and subsequent screw removal (p=.0039). PROMIS depression scores averaged 46.03 and were significantly affected by the presence of CAD (p=.049) and subsequent screw removal (p=.023).

CONCLUSION

Patient-reported outcomes following MF surgery demonstrated PROMIS scores within +/- 1 standard deviation of the population-based control, and thus many patients can reasonably expect to return to a level of function comparable to the general population. Nonetheless, the significant effects of patient comorbidities and surgical variables ought to be evaluated and utilized as prognostic indicators when managing patient expectations prior to operative treatment of an MF injury.

Management of High-Energy Tibial Pilon Fractures

➤ Pilon fractures in the younger patient population are frequently high-energy, intra-articular injuries and are associated with devastating, long-term impacts on patient-reported outcomes and health-related quality of life, as well as high rates of persistent disability.➤ Judicious management of associated soft-tissue injury, including open fractures, is essential to minimizing complications. Optimizing medical comorbidities and negative social behaviors (e.g., smoking) should be addressed perioperatively.➤ Delayed internal fixation with interval temporizing external fixation represents the preferred technique for managing most high-energy pilon fractures presenting with characteristically substantial soft-tissue trauma. In some cases, surgeons elect to utilize circular fixation for these scenarios.➤ Although there have been treatment advances, the results have been generally poor, with high rates of posttraumatic arthritis, despite expert care.➤ Primary arthrodesis may be indicated in cases with severe articular cartilage injury that, in the opinion of the treating surgeon, is likely unsalvageable at the time of the index management.➤ The addition of intrawound vancomycin powder at the time of definitive fixation represents a low-cost prophylactic measure that appears to be effective in reducing gram-positive deep surgical site infections.

Influence of smoking on the healing of conservatively treated displaced midshaft clavicle fractures

Aims

Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures.

Methods

A systematic review and meta-analysis were performed for conservatively treated displaced midshaft clavicle fractures. Embase, PubMed, and Cochrane Central Register of Controlled Trials (via Cochrane Library) were searched from inception to 12 May 2022, with supplementary searches in Open Grey, ClinicalTrials.gov, ProQuest Dissertations & Theses, and Google Scholar. The searches were performed without limits for publication date or languages.

Results

The meta-analysis included eight studies, 2,285 observations, and 304 events (nonunion). The random effects model predicted a pooled risk ratio (RR) of 3.68 (95% confidence interval 1.87 to 7.23), which can be considered significant (p = 0.003). It indicates that smoking more than triples the risk of nonunion when a fracture is treated conservatively.

Conclusion

Smoking confers a RR of 3.68 for developing a nonunion in patients with a displaced middle third clavicle fracture treated conservatively. We know that most patients with pseudarthrosis will have pain and a poor functional outcome. Therefore, patients should be informed of the significantly higher risks of nonunion and offered smoking cessation efforts and counselling. Moreover, surgery should be considered for any patient who smokes with this type of fracture.

Factors Informing the Development of a Clinical Pathway and Patients' Quality of Life after a Non-Union Fracture of the Lower Limb

Patients with non-union fractures spend extended periods of time in the hospital following poor healing. Patients have to make several follow-up visits for medical and rehabilitation purposes. However, the clinical pathways and quality of life of these patients are unknown. This prospective study aimed to identify the clinical pathways (CPs) of 22 patients with lower-limb non-union fractures whilst determining their quality of life. Data were collected from hospital records from admission to discharge, utilizing a CP questionnaire. We used the same questionnaire to track patients' follow-up frequency, involvement in activities of daily living, and final outcomes at six months. We used the Short Form-36 questionnaire to assess patients' initial quality of life. The Kruskal-Wallis test compared the quality of life domains across different fracture sites. We examined CPs using medians and inter-quantile ranges. During the six-month follow-up period, 12 patients with lower-limb non-union fractures were readmitted. All of the patients had impairments, limited activity, and participation restrictions. Lower-limb fractures can have a substantial impact on emotional and physical health, and lower-limb non-union fractures may have an even greater effect on the emotional and physical health of patients, necessitating a more holistic approach to patient care.

Nonunion in Orthognathic Surgery: A Case-Series of 15 Patients

BACKGROUND

Bone nonunion is extensively studied in the orthopedic literature, but the knowledge in oral and maxillofacial surgery, specifically orthognathic surgery, is scarce. Since this complication has a significant negative impact on postoperative management of patients, more studies are needed.

PURPOSE

To report the characteristics of patients presenting with bone nonunion after orthognathic surgery.

STUDY DESIGN, SETTING, SAMPLE

This is a retrospective case-series study on subjects who underwent orthognathic surgery between 2011 and 2021 and developed nonunion. Inclusion criteria were mobility at the site of the osteotomy and the need for a second surgical intervention. Exclusion criteria were an incomplete medical chart; the absence of nonunion upon surgical exploration, or radiological evidence of nonunion; cleft lip/palate; or syndromic patients.

MAIN OUTCOME VARIABLE

The outcome variable was bone healing after nonunion care.

COVARIATES

Demographics (age, sex), medical/dental comorbidities, type of surgery (type of fixation, bone grafts, Botox injection), amplitude of movements, nonunion treatment.

ANALYSES

Descriptive statistics were computed for each study variable.

RESULTS

The sample was composed of 15 patients (11 females, mean age 40.4 years old) with nonunion (maxilla: 8 cases, mandible: 7 cases) out of 2036 patients who underwent orthognathic surgery during the period studied (incidence 0.74%). Nine (60%) were bruxers, three were smokers (20%) and one had diabetes. Mean forward movement of the maxilla was 6.55 mm (4-9 mm) and 7.71 mm (4.8-12 mm) for the mandible. All patients but one (who refused surgery) were treated by curettage of fibrous tissue and new hardware placement. In addition, 11 received a bone graft, and 4 had Botox injections. All osteotomies healed after the second surgical intervention.

CONCLUSION

Curettage with or without grafting appears to be a good strategy for the cure of nonunion. Bruxism may be a risk factor (60% of patients were bruxers in this study).

Smoking Cessation for Preoperative Optimization

Cigarette smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. Smoking cessation in the weeks before surgery can mitigate these risks, and surgeons should screen patients for smoking before a scheduled operation so that appropriate smoking cessation education and resources can be given. Interventions that combine nicotine replacement therapy, pharmacotherapy, and counseling are effective to achieve durable smoking cessation. When trying to stop smoking in the preoperative period, surgical patients experience much higher than average cessation rates compared with the general population, indicating that the time around surgery is ripe for motivating and sustaining behavior change. This chapter summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.

Factors Associated With Poor Patient-Reported Outcomes in Isolated Gastrocnemius Recession for Heel Pain

Background

Gastrocnemius recession is commonly performed for a variety of pathologies of the foot and ankle, yet studies characterizing risk factors associated with patient-reported outcomes are limited. In this cohort study, patient outcomes were compared against the general population for PROMIS scores with correlation analysis comparing demographics and comorbidities. Our primary goal in this study is to identify risk factors associated with poor patient-reported outcomes following isolated gastrocnemius recession for patients with plantar fasciitis or insertional Achilles tendinopathy.

Methods

A total of 189 patients met inclusion criteria. The open Strayer method was preferred. However, if the myotendinous junction could not be adequately visualized without expanding the excision, then a Baumann procedure was performed. The decision between the two did not depend on preoperative contracture. Patient demographics and visual analog scale (VAS) scores were obtained via the electronic medical record. Telephone interviews were completed to collect postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) and Foot Function Index (FFI) scores. The data were analyzed using the type 3 SS analysis of variance test to identify individual patient factors associated with reduced PROMIS, FFI, and VAS scores.

Results

No demographic variables were found to be significantly associated with postoperative complications. Patients who reported tobacco use at the time of surgery had significantly decreased postoperative PROMIS physical function (P = .01), PROMIS pain interference (P < .05), total FFI scores (P < .0001), and each individual FFI component score. Patients undergoing their first foot and ankle surgeries reported numerous significant postoperative outcomes, including decreased PROMIS pain interference (P = .03), higher PROMIS depression (P = .04), and lower FFI pain scores (P = .04). Hypertension was significantly associated with an increased FFI disability score (P = .03) and, along with body mass index (BMI) >30 (P < .05) and peripheral neuropathy (P = .03), significantly higher FFI activity limitation scores (P = .01). Pre- and postoperative VAS scores demonstrated improvement in patient-reported pain from a mean of 5.53 to 2.11, respectively (P < .001).

Conclusion

We found in this cohort that numerous patient factors were independently associated with differences in patient-reported outcomes following a Strayer gastrocnemius recession performed for plantar fasciitis or insertional Achilles tendinopathy. These factors include, but are not limited to, tobacco use, prior foot and ankle surgeries, and BMI. This study strengthens previous reports demonstrating the efficacy of isolated gastrocnemius recession and elucidates variables that may affect patient-reported outcomes.

Level of Evidence

Level III, retrospective cohort study.

Use of Teriparatide in preventing delayed bone healing and nonunion: a multicentric study on a series of 20 patients

BACKGROUND

Delayed bone healing and nonunions represent a great challenge for the orthopedic surgeon. In addition to traditional surgical approaches, increasing attention is being given to the use of systemic anabolic therapy with Teriparatide, whose efficacy in preventing osteoporotic fractures is widely validated and whose application as a promoter of bone healing has been described but it is still debated. The aim of the study was to evaluate bone healing in a series of patients with delayed unions or nonunions treated with Teriparatide in conjunction with eventual appropriate surgical procedure.

METHODS

Twenty patients with an unconsolidated fracture that were treated at our Institutions from 2011 to 2020 with Teriparatide were retrospectively included into the study. The pharmacological anabolic support was used off-label with a planned duration of 6 months; radiographic healing was evaluated at 1-, 3- and 6-months follow-up outpatient visits over plain radiographs. Also, eventual side-effects were registered.

RESULTS

Radiographic signs indicative of favorable evolution of the bone callus were observed as early as at 1 month of therapy in 15% of cases; at 3 months, healing progression was appreciated in 80% of cases and complete healing in 10%; at 6 months, 85% of delayed and nonunions had healed. In all patients, the anabolic therapy was well tolerated.

CONCLUSIONS

In accordance to Literature, this study suggests that Teriparatide plays a potentially important role in the treatment of some forms of delayed unions or nou-nions, even in the presence of failure of hardware. The results suggest a greater effect of the drug when associated with a condition in which the bone is in an active phase of callogenesis, or with a "revitalizing" treatment which represents a local (mechanical and/or biological) stimulus to the healing process. Despite the small sample size and the variety of cases, the efficacy of Teriparatide in treating delayed unions or nonunions emerged, highlighting how this anabolic therapy can represent a useful pharmacological support in the treatment of such a pathology. Although the results obtained are encouraging, further studies, particularly prospective and randomized, are needed to confirm the efficacy of the drug, and define a specific treatment algorithm.

Arthroscopic treatment of stable nonunion, unstable nonunion, or nonunion of the scaphoid with early degenerative radioscaphoid arthritis

BACKGROUND

This study was designed to analyze the clinical follow-up results (minimum of 2 years) in patients with stable nonunion, unstable nonunion, or nonunion of the scaphoid with early degenerative radioscaphoid arthritis (Lichtman classification stage I-III) treated with arthroscopic osteosynthesis with autogenous bone graft.

METHODS

We retrospectively recruited 44 consecutive patients with scaphoid fracture nonunion treated with arthroscopy-assisted percutaneous internal fixation with autogenous bone grafts from January 2010 to November 2019. We recorded union and return to activity and analyzed data with regular clinical follow-up at a mean duration of 33 months (range 24-46 months). Clinical (i.e., visual analog scale pain score, grip strength, and range of motion), radiographic, and functional (Mayo Modified Wrist Score (MMWS)) outcomes at the final follow-up were compared with the preoperative assessments and analyzed in patients with different stages.

RESULTS

We confirmed union in 39 of the 44 patients (88.6%) after a mean 15.4 weeks post-operatively according to clinical examinations and standard radiography. All clinical parameters improved significantly. For the MMWS, there were 25 excellent and 14 good results. Of the 44 patients, 40 (90.9%) returned to work or sports activities at their preinjury levels. Comparisons of the outcomes between patients in different stages of scaphoid nonunion revealed no significant difference in the aspect of union rate, VAS pain score, and functional score improvement.

CONCLUSIONS

Arthroscopic osteosynthesis with autogenous bone grafts is a reliable and minimally invasive method for achieving nonunion healing and improving clinical outcomes in stage I-III scaphoid nonunion.

LEVEL OF EVIDENCE

Level IV, case series.

The Impact of Smoking on Delayed Osseous Union After Arthrodesis Procedures in the Hand and Wrist

PURPOSE

The purpose of this study was to evaluate the relationship between smoking and delayed radiographic union after hand and wrist arthrodesis procedures. We hypothesized that smoking would be associated with a higher rate of delayed union.

METHODS

All cases of hand or wrist arthrodesis procedures in patients aged ≥18 years from 2006 to 2020 were identified. Cases were included if they had >90 days of radiographic follow-up or evidence of union before 90 days. Baseline demographics were recorded for each case including smoking status at the time of surgery. Complications were recorded and all postoperative radiographs were reviewed to assess for evidence of delayed union (defined as lack of osseous union by 90 days after surgery). We compared active smokers and nonsmokers and performed a logistic regression analysis to estimate the odds of experiencing a delayed radiographic union.

RESULTS

A total of 309 arthrodesis cases were included and 24% were active smokers. Overall, radiographic evidence of a delayed union was found in 17% of cases. Smokers were significantly more likely to have a delayed union compared with nonsmokers (27% vs 14%). Results of the adjusted logistic regression analysis demonstrated that there was a significantly increased odds of experiencing a delayed union for patients who were active smokers compared with nonsmokers (odds ratio, 2.20; 95% confidence interval, 1.09-4.43). In addition, the rate of symptomatic nonunion requiring reoperation was higher in smokers (15%) compared with nonsmokers (6%).

CONCLUSIONS

Smoking was associated with increased odds of delayed radiographic union in patients undergoing hand and wrist arthrodesis procedures. Patients should be counseled appropriately on the risks of smoking on bone healing and encouraged to abstain from nicotine use in the perioperative period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Bone Healing Gone Wrong: Pathological Fracture Healing and Non-Unions-Overview of Basic and Clinical Aspects and Systematic Review of Risk Factors

Bone healing is a multifarious process involving mesenchymal stem cells, osteoprogenitor cells, macrophages, osteoblasts and -clasts, and chondrocytes to restore the osseous tissue. Particularly in long bones including the tibia, clavicle, humerus and femur, this process fails in 2-10% of all fractures, with devastating effects for the patient and the healthcare system. Underlying reasons for this failure are manifold, from lack of biomechanical stability to impaired biological host conditions and wound-immanent intricacies. In this review, we describe the cellular components involved in impaired bone healing and how they interfere with the delicately orchestrated processes of bone repair and formation. We subsequently outline and weigh the risk factors for the development of non-unions that have been established in the literature. Therapeutic prospects are illustrated and put into clinical perspective, before the applicability of biomarkers is finally discussed.

Symptomatic Hammertoes Treatment Comparison: Peg-in-Hole Arthrodesis Versus End-to-End Screw Fixation

Proximal interphalangeal (PIP) arthrodesis technique utilizing the peg-in-hole arthrodesis was founded to avoid the use of retained internal fixation implants and thereby potentially decrease the concern of hardware complication. The specific aim of this study was to report the complication rates of the modified peg-in-hole arthrodesis technique and the end-to-end arthrodesis with single screw fixation technique for correcting symptomatic hammertoe deformities in lesser digits. This retrospective chart review included patients who underwent surgical hammertoe correction of lesser digits between the dates of January 2012 and December 2019. Patient demographic data and charts were reviewed to evaluate need for revision including screw/pin removal and complications related to corrective surgery. Five hundred ninety-three symptomatic hammertoe deformity cases (443 female, 150 male) were identified, with 113 cases (88 female, 25 male) treated with peg-in-hole arthrodesis technique and 480 cases (355 female, 125 male) treated with end-to-end arthrodesis with a single screw technique. The deformity recurrence rate was not significantly different between the two techniques (peg-in-hole: 10%, end-to-end: 13%, p = .428). There were 97 cases with postoperative complications that required re-operation (peg-in-hole: 7 cases, end-to-end: 90 cases) with the majority detected at <6 months. There was no statistically significant difference in reoperation rate between the peg-in-hole technique and the end-to-end arthrodesis technique reoperated with reasons excluding simple screw removal (p = .068). This study tended to show these two arthrodesis techniques have equivalent risks and similar success in bone healing; however, the peg-in-hole arthrodesis technique offers an advantage that does not result in retained hardware.

Endosteal plating for the treatment of malunions and nonunions of distal femur fractures

PURPOSE

To describe the surgical technique and the outcome of a case series of nonunion and malunion of distal femur fractures treated with an endosteal medial plate combined with a lateral locking plate and with autogenous bone grafting.

METHODS

We retrospectively analyzed a series of patients with malunion or nonunion of the distal femur treated with a medial endosteal plate in combination with a lateral locking plate, in a period between January 2011 and December 2019, Database from chart review was obtained including all the clinical relevant available baseline data (demographics, type of fracture, mechanism of injury, time from injury to surgery, number of previous surgical procedures, type of bone graft, and type of lateral plate). Time to bone healing, limb alignment at follow-up and complications were documented.

RESULTS

Ten patients were included into the study: 7 male and 3 female with mean age of 48.3 years (range 21-67). The mechanism of trauma was in 8 cases a road traffic accident and in 2 cases a fall from height. According to AO/OTA classification 5 fractures were 33 A3, 3 were 33 C1, 1 was 33 C2 and 1 was 33 C3. The average follow up was 13.5 months. In all cases but one bony union was achieved. Bone healing was observed in average 3.3 months after surgery. No intraoperative or postoperative complications were reported.

CONCLUSION

A medial endosteal plate is a useful augmentation for lateral plate fixation in nonunion or malunion following distal femur fractures, particularly in cases of medial bone loss, severe comminution, or poor bone quality.

LEVEL OF EVIDENCE

Level IV (retrospective case series).

Tear size, general health status and smoking influence functional outcome at 5 years following arthroscopic rotator cuff repair

Introduction

There is limited medium-term outcome data regarding the predictors of functional outcome and patient satisfaction after arthroscopic rotator cuff repair.

Methods

287 patients that underwent arthroscopic rotator cuff repair under a high-volume single surgeon were contacted at a minimum of 4 years following surgery. Patient demographics, tear size and co-morbidities were pre-operatively recorded. The Oxford shoulder score, EuroQol 5-dimensional score and patient satisfaction were recorded at final follow-up.

Results

234 (81.5%) patients completed follow-up at a mean of 5.5 (4-9) years. There were 126 males and 108 females with a mean age of 60 (range 25-83) years. The majority of patients (n = 211, 90%) were satisfied with their final outcome. Multivariate linear regression analysis (R 2 = 0.64) identified that increasing tear size (p = 0.04), worsening general health assessed by the EuroQol 5-Dimensional (p < 0.001), and smoking (p = 0.049) were associated with a worse Oxford shoulder score. Logistic regression analysis (R 2 = 0.13) identified that worsening general health assessed by the EuroQol 5-Dimensional (p < 0.001), and smoking (p = 0.01) were associated with an increased risk of patient dissatisfaction.

Conclusion

General health status and smoking are independent predictors of functional outcome and patient satisfaction at medium-term follow-up following arthroscopic rotator cuff repair.

Factors Associated With Unplanned Reoperation After 4-Corner Arthrodesis: A Study of 478 Wrists

Purpose

The 4-corner arthrodesis (FCA) is a reliable, motion-sparing technique used to treat scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis, particularly in stage III wrists in which the capitolunate articulation is compromised. Surgical technique and patient-level variables may influence complications following FCA. We sought to evaluate the rate of complications in a large, combined database and manual chart review study.

Methods

Current Procedural Terminology codes were used to search the United States Veteran's Health Administration corporate database to identify wrists treated with FCA over a 24-year period. A retrospective chart review was completed to collect data regarding scapholunate advanced collapse/scaphoid nonunion advanced collapse stage, implant used, the use of a bone graft, smoking status, and comorbidities for all patients undergoing an FCA. A multivariable cox proportional hazards regression was used to assess hazard ratios for reoperation. Incidence rates and the standard error of the mean for reoperation and conversion to total wrist fusion were calculated after grouping patients by 10-year age categories.

Results

A total of 478 wrists underwent FCA during the study period, with a mean follow-up of 63 months. Seventy-three (16%) wrists required reoperation. The most frequent secondary procedures included unplanned implant removal (8.2%), total wrist arthrodesis (4.6%), and revision FCA (1.7%). Positive smoking history increased the risk of reoperation, whereas posterior interosseous nerve neurectomy, arthritis stage, and fixation type did not have a statistically significant association with reoperation. Younger age demonstrated an increased incidence of overall reoperation and wrist fusion.

Conclusions

The most common reason for reoperation after FCA was implant removal. Smoking history is associated with increased rates of reoperation and wrist arthrodesis. Knowledge of these factors may assist with accurately counseling and indicating patients for FCA.

Type of study/level of evidence

Therapeutic III.

Cortical bridging a union predictor: A prospective study after intramedullary nailing of the femoral shaft fractures

Early prediction of the union helps for timely intervention, reduction of hospitalization, treatment costs, and disability in cases of nonunion. With this in mind, we tried to find how long any cortical bridging predicts the union in femoral shaft fractures. A prospective study of 113 femoral shaft fractures treated with reamed, locked intramedullary nailing was performed. Radiographs were taken during months 2 to 4, 6, 9, and one-year follow-up. The cortical bridging (presence and number) was assessed by anterior-posterior and lateral views. The ROC curve provides the prediction of the union. The overall nonunion rate was 10.6% (12 of 113 fractures). Age and diabetes mellitus were statistically significant with nonunion (p value < 0.001). The final analysis demonstrated that any cortical bridging at four months postoperatively was the most accurate and earlier indicator (105 of 113, 92.9% accuracy), while it was 84.9% at six months in bicortical and 80.5% accuracy at nine months in tricortical bridging. Low-cost and simple radiographic imaging presents cortical bridging in any form 4 months after surgery that precisely predicts a union in femoral shaft fractures.

A practical guide for perioperative smoking cessation

The perioperative management of patients who are smokers presents anesthesiologists with various challenges related to respiratory, circulatory, and other clinical problems. Regarding 30-day postoperative outcomes, smokers have higher risks of mortality and complications than non-smokers, including death, pneumonia, unplanned tracheal intubation, mechanical ventilation, cardiac arrest, myocardial infarction, and stroke. Given the benefits of smoking cessation and the adverse effects of smoking on perioperative patient management, patients should quit smoking long before surgery. However, anesthesiologists cannot address these issues alone. The Japanese Society of Anesthesiologists established guidelines in 2015 (published in a medical journal in 2017) to enlighten surgical staff members and patients regarding perioperative tobacco cessation. The primary objective of perioperative smoking cessation is to reduce the risks of adverse cardiovascular and respiratory events, wound infection, and other perioperative complications. Perioperative preparations constitute a powerful teachable moment, a "golden opportunity" for smoking cessation to achieve improved primary disease outcomes and prevent the occurrence of tobacco-related conditions. This review updates the aforementioned guidelines as a practical guide to cover the nuts and bolts of perioperative smoking cessation. Its goal is to assist surgeons, anesthesiologists, and other medical professionals and to increase patients' awareness of smoking risks before elective surgery.

Use of the Straight Retrograde Intramedullary Nail for Tibiotalocalcaneal Arthrodesis: A Single-Institution, Single-Surgeon, Single-Implant Retrospective Series

Background:

The hindfoot fusion nail has become a popular implant for tibiotalocalcaneal (TTC) arthrodeses given its rigidity, ease of insertion, and potential for less invasive surgical approaches. The purpose of this study was to evaluate fusion and complication rates following the use of a straight, retrograde intramedullary nail for TTC arthrodeses, and the influence of diabetes and smoking on these results.

Methods:

A review of patient cases performed by a single surgeon at a single institution was performed. Variables included age, comorbidities, smoking history, BMI, hemoglobin A1c, preoperative and postoperative visual analog scale pain scores, assessment of healing, and complications. Relative and absolute risk were assessed for smoking, diabetes, fusion, and surgical complications through risk ratios. Cox proportional hazards survival analyses were performed to assess the effects of smoking and diabetes on fusion rates and complications. Linear regressions were performed to investigate the effects of smoking and diabetes on patient-reported pain levels.

Results:

Of 103 patients, there were 37 cigarette smokers and 30 diabetic patients. Eighty-three patients achieved union of all involved joints and 19 patients achieved union of 1 or 2 joints. Smokers demonstrated a 1.46 (risk ratio) (95% CI 1.03-2.07) times greater risk of nonunion but were not at an increased risk of experiencing surgical complications (0.86, 95% CI 0.56-1.33). Diabetic patients did not demonstrate an increased risk of nonunion (0.86, 95% CI 0.56-1.33) or complications (1.18, 95% CI 0.76-1.83).

Conclusion:

Because of increased nonunion risk, patients undergoing elective tibiotalocalcaneal arthrodesis should be counseled increased nonunion risks associated with smoking. In this series, we did not find a relationship between diabetes and complications or nonunion.

Level of Evidence:

Level III, retrospective cohort study.

Relationship between smoking and postoperative complications of cervical spine surgery: a systematic review and meta-analysis

To determine whether smoking has adverse effects on postoperative complications following spine cervical surgery (PROSPERO 2021: CRD42021269648). We searched PubMed, Embase, Cochrane Library, and Web of Science through 13 July 2021 for cohort and case–control studies that investigated the effect of smoking on postoperative complications after cervical spine surgery. Two researchers independently screened the studies and extracted data according to the selection criteria. The meta-analysis included 43 studies, including 27 case–control studies and 16 cohort studies, with 10,020 patients. Pooled estimates showed that smoking was associated with overall postoperative complications (effect estimate [ES] = 1.99, 95% confidence interval [CI]: 1.62–2.44, p < 0.0001), respiratory complications (ES = 2.70, 95% CI: 1.62–4.49, p < 0.0001), reoperation (ES = 2.06, 95% CI: 1.50–2.81, p < 0.0001), dysphagia (ES = 1.49, 95% CI: 1.06–2.10, p = 0.022), wound infection (ES = 3.21, 95% CI: 1.62–6.36, p = 0.001), and axial neck pain (ES = 1.98, 95% CI: 1.25–3.12, p = 0.003). There were no significant differences between the smoking and nonsmoking groups in terms of fusion (ES = 0.97, 95% CI: 0.94–1.00, p = 0.0097), operation time (weighted mean difference [WMD] = 0.08, 95% CI: −5.54 to 5.71, p = 0.977), estimated blood loss (WMD = −5.31, 95% CI: −148.83 to 139.22, p = 0.943), length of hospital stay (WMD = 1.01, 95% CI: −2.17 to 4.20, p = 0.534), Visual Analog Scale-neck pain score (WMD = −0.19, 95% CI: −1.19 to 0.81, p = 0.707), Visual Analog Scale-arm pain score (WMD = −0.50, 95% CI: −1.53 to 0.53, p = 0.343), Neck Disability Index score (WMD = 11.46, 95% CI: −3.83 to 26.76, p = 0.142), or Japanese Orthopedic Association Scores (WMD = −1.75, 95% CI: −5.27 to 1.78, p = 0.332). Compared with nonsmokers, smokers seem to be more significantly associated with overall complications, respiratory complications, reoperation, longer hospital stay, dysphagia, wound infection and axial neck pain after cervical spine surgery. It is essential to provide timely smoking cessation advice and explanation to patients before elective cervical spine surgery.

What Is the Impact of Smoking on Patient-Reported Outcomes Following Posterior Cervical Decompression and Fusion?

OBJECTIVE

The purpose of this retrospective cohort study was to investigate the impact of smoking on patient-reported outcome measures (PROMs) following elective posterior cervical decompression and fusion (PCF).

METHODS

Electronic medical records at a single institution were reviewed for patients undergoing elective PCF. Patients were grouped based on smoking history: current smokers, former smokers, and never smokers. A delta score (Δ) was calculated for all PROMs (postoperative minus preoperative scores). Continuous and categorical data were compared using analysis of variance or χ2 tests. Regression analysis controlled for demographics. Patients were then regrouped into current smokers and nonsmokers for reanalysis.

RESULTS

A total of 195 patients were included, of whom 35 (22.1%) were current smokers, 51 (26.2%) were former smokers, and 101 (51.8%) were never smokers. Preoperative and postoperative Short-Form 12 Mental Component Score (MCS-12) were significantly lower in the current smoker group (preoperative: current 42.7, former 49.9, and never 46.6; P = 0.024; postoperative: current 44.6, former 53.7, and never 52.2; P = 0.003). Only never smokers improved in MCS-12 and Neck Disability Index following surgery. On regrouping, current smokers had significantly lower preoperative MCS-12 (42.7 vs. 47.7, P = 0.031), lower preoperative modified Japanese Orthopaedic Association (12.2 vs. 14.0, P = 0.039), greater preoperative visual analog scale Arm (6.39 vs. 4.94, P = 0.025), and lower postoperative MCS-12 (44.6 vs. 52.7, P = 0.001). Only the nonsmokers improved in MCS-12 and Neck Disability Index following surgery. On regression analysis, smoking was not an independent predictor of ΔPROMs.

CONCLUSIONS

Univariate analysis found that smokers have worse symptoms at baseline. However, smoking status was not an independent predictor of improvement in ΔPROMs following elective PCF.

Racial Differences in Patients Undergoing Anterior Cervical Discectomy and Fusion: A Multi-Site Study

STUDY DESIGN

This was a retrospective chart review.

OBJECTIVE

The objective of this study was to examine disparities within patients undergoing anterior cervical discectomy and fusion (ACDF) at a multi-site tertiary referral center with specific focus on factors related to length of stay (LOS).

SUMMARY OF BACKGROUND DATA

There are previously described racial disparities in spinal surgery outcomes and quality metrics.

METHODS

A total of 278 consecutive patients undergoing ACDF by 8 different surgeons over a 5-year period were identified retrospectively. Demographic data, including age at time of surgery, sex, smoking status, and self-identified race [White or African American (AA)], as well as surgical data and postoperative course were recorded. Preoperative health status was recorded, and comorbidities were scored by the Charlson Comorbidity Index. Univariable and multivariable linear regression models were employed to quantify the degree to which a patient's LOS was related to their self-identified race, demographics, and perioperative clinical data.

RESULTS

Of the 278 patients who received an ACDF, 71.6% (199) self-identified as White and 28.4% (79) identified as AA. AA patients were more likely to have an ACDF due to myelopathy, while White patients were more likely to have an ACDF due to radiculopathy (P=0.001). AA patients had longer LOS by an average of half a day (P=0.001) and experienced a larger percentage of extended stays (P=0.002). AA patients experienced longer overall operation times on average (P=0.001) across all different levels of fusion. AA race was not an independent driver of LOS (β=0.186; P=0.246).

CONCLUSIONS

As hypothesized, and consistent with previous literature on racial surgical disparities, AA race was associated with increased LOS, increased operative times, and increased indication of myelopathy in this study. Additional research is necessary to evaluate the underlying social determinants of health and other factors that may contribute to this study's results.

LEVEL OF EVIDENCE

Level III.

Patient and Surgical Factors Affecting Fusion Rates After Arthroscopic and Open Ankle Fusion: A Review of a High-Risk Cohort

ABSTRACT

We present a case series with the objective of identifying risk factors for nonunion after open and arthroscopic primary ankle arthrodesis. Eighty-seven patients who underwent primary ankle arthrodesis and met inclusion criteria were divided into open (N = 46) and arthroscopic (N = 41) groups. Patient and operative characteristics were retrospectively analyzed as possible risk factors for nonunion within each technique. The nonunion rate was 11% in the open and 12% in the arthroscopic group. Obesity, smoking, and ASA class 3 were highly prevalent in both groups. In the arthroscopic group, a remote history of infection and the use of headed screws had notably higher risk of nonunion, though not statistically significant. In the open group, use of bone graft trended toward lower risk of nonunion, though also not statistically significant. The results of this study demonstrated, nonunion rates are comparable between open and arthroscopic ankle arthrodesis in high-risk patients. For patients with a remote history of infection, open ankle arthrodesis may be preferable, and bone graft importance may vary with open versus arthroscopic technique.

LEVEL OF EVIDENCE

III.