The musculoskeletal effects of cigarette smoking

Why do patients with urinary diversions have an increased risk of bone fracture? A systematic review on risk factors for osteoporosis and bone mineral density loss in this group of patients

INTRODUCTION

Patients undergoing radical cystectomy with urinary diversions (UD) are at increased risk of bone fractures compared to the general population. Although a loss of bone mineral density (BMD) has been described in patients with UD, we still do not know with certainty why these patients follow this tendency.

OBJECTIVE

We performed a systematic review of the available literature to analyze the prevalence of osteoporosis and bone alterations in patients with ileal UD and the possible associated risk factors.

EVIDENCE ACQUISITION

We systematically searched PubMed® and Cochrane Library for original articles published before December 2022 according to PRISMA guidelines.

EVIDENCE SYNTHESIS

A total of 394 publications were identified. We selected 12 studies that met the inclusion criteria with 496 patients included. Six of the twelve studies showed decreased BMD values. Prevalence of osteoporosis was specified in three articles, with values ranging ​​from 0% to 36%. Risk factors such as age, sex, body mass index, metabolic acidosis and renal function appear to have an impact on bone tissue reduction, while type of UD, follow-up, 25-hydroxyvitamin D and parathormone had less evidence or contradictory data. The heterogeneity of the studies analyzed could led to interpretation bias.

CONCLUSIONS

UD are associated with multiple risk factors for osteoporosis and bone fractures. Identifying patients at highest risk and establishing diagnostic protocols in routine clinical practice are essential to reduce the risk of fractures and the resulting complications.

Promoting musculoskeletal health and preventing ill health

Musculoskeletal conditions are highly prevalent among older adults and can have a significant impact on their quality of life. Musculoskeletal health is an important component of maintaining well-being and independence. A proactive approach is required, with nurses implementing strategies such as healthy diets and physical exercise that will support optimal health. This article considers the importance of musculoskeletal health, examines the risk factors for a decline in musculoskeletal health, and explores approaches that can improve outcomes and promote healthy ageing.

Pack Years of Tobacco Cigarette Smoking as a Predictor of Bony Fusion after Anterior Cervical Discectomy and Fusion

OBJECTIVE

Smoking tobacco cigarettes negatively impacts bone healing after spinal fusion. Smoking history is often assessed based on current smoker and nonsmoker status. However, in current research, smoking history has not been quantified in terms of pack years to estimate lifetime exposure and assess its effects. Our goal was to investigate the influence of smoking history, quantified in pack years, on bony fusion after anterior cervical discectomy and fusion (ACDF).

METHODS

A retrospective chart review of consecutive patients who underwent ACDF for cervical disc degeneration between September 21, 2017 and October 17, 2018 was conducted. Patient demographics, procedural variables, and postoperative outcomes were analyzed. Multivariate logistic regression analysis was performed to identify predictive factors for bony fusion following ACDF. Receiver operating characteristic curve analysis was used to determine the optimal discrimination threshold for smoking history pack years in association with nonfusion.

RESULTS

Among 97 patients identified, 90 (93%) demonstrated bony fusion on postoperative imaging. Mean number of smoking history pack years was 6.1 ± 13 for the fusion group and 16 ± 21 for the nonfusion group. Multivariate logistic regression analysis suggested that increased pack years of tobacco cigarette smoking was a significant predictor of nonfusion (95% confidence interval, [1.0,1.1], P = 0.045). The receiver operating characteristic curve analysis revealed that 6.1 pack years best stratified the risk for nonfusion (area under the curve, 0.8).

CONCLUSIONS

Patients with a history of tobacco cigarette smoking ≥6.1 pack years may have an increased risk of nonfusion after ACDF.

Heated Tobacco Products Have Detrimental Effects on Rotator Cuff Healing, Similar to Conventional Cigarettes

BACKGROUND

Cigarette smoking impairs rotator cuff healing, but no study, to our knowledge, has focused on the association between heated tobacco products and rotator cuff tears.

METHODS

This study retrospectively investigated 1,133 patients who underwent arthroscopic repair of symptomatic rotator cuff tears between March 2011 and April 2021. Patients were grouped on the basis of their smoking patterns as nonsmokers, cigarette smokers, and heated tobacco smokers. Propensity score matching was used to reduce selection bias, and 45 subjects were selected from each group via 1:1:1 matching. Functional scores and active range of motion were compared among the 3 groups preoperatively and at a 2-year follow-up. Postoperative magnetic resonance imaging was performed 6 months after the surgical procedure to assess structural integrity.

RESULTS

Except for sex, similar baseline characteristics were achieved after propensity score matching. There were no differences in the clinical scores or range of motion between the matched groups either preoperatively or at the 2-year follow-up. However, the retear rate for the matched nonsmoker group was significantly lower (8.9%) than those for the matched cigarette smoker group (31.1%) and the heated tobacco smoker group (28.9%) (p = 0.022). Multivariable logistic regression analysis revealed that the retear rates were 3.403 times higher for the cigarette smoker group and 3.397 times higher for the heated tobacco smoker group than that for the nonsmoker group.

CONCLUSIONS

Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. Regardless of the type of cigarette, abstinence from smoking is necessary for patients undergoing rotator cuff repair surgery.

LEVEL OF EVIDENCE

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

The Effect of Timing Between Traumatic Flexor Tendon Injury of the Hand and Surgical Intervention on Repair Failure Rates

Flexor tendon injuries of the hand, especially in zone II, pose a challenge for hand surgeons because of the region's intricate pulley mechanism and local avascularity, and post-surgical complications such as repair failure are not uncommon. One proposed predictor of outcomes following flexor tendon repair has been timing of surgery from initial injury. However, the effect of the timing of flexor tendon repair on failure rates remains controversial and understudied. The purpose of this study was to compare the failure rates of zone II flexor tendon repairs in patients at various time intervals from onset of injury. A retrospective chart review was conducted using data from hand surgery specialists at our level 1 trauma center from January 1, 2010, through May 31, 2020. This retrospective review included 407 zone II flexor tendon repairs. The primary outcome was failure of repair. Among 407 flexor tendon repairs, there were 12 reported repair failures. The failure rate was 2.9%. In the non-failure group, the mean number of days between the date of injury and the date of surgery was 7±13 days. For the failure group, this value was 14±17 days. Repairs occurring within 14 days had a failure rate of 2.3%, while repairs occurring beyond 14 days had a failure rate of 7.7%. This study demonstrates that there is a benefit to repairing the tendon within a 14-day window, as evidenced by a lower failure rate. More research is required to determine if other complications and overall health of the hand are also improved when a repair is performed in a more expedient manner. [Orthopedics. 2024;47(2):113-117.].

Patient Characteristics Associated With Worsening of Neck Pain-Related Disability After Surgery for Degenerative Cervical Myelopathy: A Nationwide Study of 1508 Patients

BACKGROUND AND OBJECTIVES

Functional status, pain, and quality of life usually improve after surgery for degenerative cervical myelopathy (DCM), but a subset of patients report worsening. The objective was to define cutoff values for worsening on the Neck Disability Index (NDI) and identify prognostic factors associated with worsening of pain-related disability 12 months after DCM surgery.

METHODS

In this prognostic study based on prospectively collected data from the Norwegian Registry for Spine Surgery, the NDI was the primary outcome. Receiver operating characteristics curve analyses were used to obtain cutoff values, using the global perceived effect scale as an external anchor. Univariable and multivariable analyses were performed using mixed logistic regression to evaluate the relationship between potential prognostic factors and the NDI.

RESULTS

Among the 1508 patients undergoing surgery for myelopathy, 1248 (82.7%) were followed for either 3 or 12 months. Of these, 317 (25.4%) were classified to belong to the worsening group according to the mean NDI percentage change cutoff of 3.3. Multivariable analyses showed that smoking (odds ratio [OR] 3.4: 95% CI 1.2-9.5: P < .001), low educational level (OR 2.5: 95% CI 1.0-6.5: P < .001), and American Society of Anesthesiologists grade >II (OR 2.2: 95% CI 0.7-5.6: P = .004) were associated with worsening. Patients with more severe neck pain (OR 0.8: 95% CI 0.7-1.0: P = .003) and arm pain (OR 0.8: 95% CI 0.7-1.0; P = .007) at baseline were less likely to report worsening.

CONCLUSION

We defined a cutoff value of 3.3 for worsening after DCM surgery using the mean NDI percentage change. The independent prognostic factors associated with worsening of pain-related disability were smoking, low educational level, and American Society of Anesthesiologists grade >II. Patients with more severe neck and arm pain at baseline were less likely to report worsening at 12 months.

The Use of the Taylor Spatial Frame in Treating Tibial Osteomyelitis Following Traumatic Tibial Fracture

Introduction

Tibial osteomyelitis can follow open fractures with bacteria colonising the wound and persisting through biofilm and sequestrum formation. The treatment is complex, requiring eradication through debridement before limb reconstruction, for which the Taylor spatial frame (TSF) is one option. This study evaluates patient outcomes after reconstruction and identifies factors associated with post-operative complications.

Materials and methods

Fifty-one cases of tibial osteomyelitis were treated by the Ilizarov technique from 2015 to 2021 at a major trauma centre. Bacterial samples and treatment factors were assessed. Patient outcomes were complication rates and time to bony union. Complications were expressed as odds-ratios (OR) with 95% confidence intervals. Linear regression was used to assess factors associated with time to union.

Results

The mean follow-up was 24.1 months with the mean time to radiological union being 11 months. Post-operative complications were noted in 76.5% of patients with pin-site infections most common (52.9%), followed by fracture malunion (29.4%). Smoking was associated with increased fracture malunion (OR = 4.148, 95% confidence Interval [1.13-15.18], p = 0.031). The time to union was positively associated with complications, age and time to full weight-bearing (FWB). All other measured factors were found not significant.

Conclusion

Tibial osteomyelitis is treated reliably by debridement and reconstruction using the Ilizarov technique using a TSF application. The most common complication was pin-site infection. Optimising patients through cessation of smoking and encouraging post-operative weight-bearing can reduce the complication rate and improve time to union.

Clinical significance

The Ilizarov technique using a TSF can treat significant deformities that result from the management of tibial osteomyelitis.

How to cite this article

Geetala R, Zhang J, Maghsoudi D, et al. The Use of the Taylor Spatial Frame in Treating Tibial Osteomyelitis Following Traumatic Tibial Fracture. Strategies Trauma Limb Reconstr 2024;19(1):32-35.

Effect of cigarette smoking on the maintenance of reduction after treatment of acute acromioclavicular joint dislocation with hook plate fixation

BACKGROUND

The purpose of this study was to determine the association between smoking and clinical outcomes of hook plate fixation for acute acromioclavicular (AC) joint injuries.

METHODS

This study retrospectively investigated 82 patients who underwent hook plate fixation for acute AC joint dislocation between March 2014 to June 2022. The patients were grouped by smoking status, with 49 in group N (nonsmokers) and 33 in group S (smokers). Functional scores and active range of motion were compared among the groups at the 1-year follow-up. Coracoclavicular distance (CCD) was measured, and difference with the uninjured side was compared at initial injury and 6 months after implant removal.

RESULTS

No significant differences were observed between the two groups in demographic factors such as age and sex, as well as parameters related to initial injury status, which included time from injury to surgery, the preoperative CCD difference value, and the Rockwood classification. However, the postoperative CCD difference was significantly higher in group S (3.1±2.6 mm) compared to group N (1.7±2.4 mm). Multivariate regression analysis indicated that smoking and the preoperative CCD difference independently contributed to an increase in the postoperative CCD difference. Despite the radiographic differences, the postoperative clinical outcome scores and active range of motion measurements were comparable between the groups.

CONCLUSIONS

Smoking had a detrimental impact on ligament healing after hook plate fixation for acute AC joint dislocations. This finding emphasizes the importance of smoking cessation to optimize reduction maintenance after AC joint injury. Level of evidence: III.

Association of Chronic Pain With Alcohol Consumption and Tobacco Use in Active Duty Soldiers

INTRODUCTION

Chronic pain and lifestyle habits, namely alcohol consumption and tobacco use, impact soldier readiness. This study examines the relationship between chronic pain and these lifestyle habits in soldiers seen at the Interdisciplinary Pain Management Center (IPMC).

MATERIALS AND METHODS

This cross-sectional retrospective review utilized data from active duty soldiers receiving treatment at the IPMC. Soldiers (N = 203, 85% men) treated at the IPMC completed an intake questionnaire that included the Defense and Veterans Pain Rating Scale, the Alcohol Use Disorders Identification Test-Concise, and inquiries about tobacco use. Tobacco use was quantified as the amount and frequency of cigarettes smoked. Other tobacco products were converted to an equivalent number of cigarettes. Data were analyzed using descriptive statistics, Pearson's correlation, and independent samples t-test analyses.

RESULTS

The mean duration of pain reported was 34.73 ± 38.66 months (median = 24.00). Soldiers engaging in hazardous drinking reported significantly higher interference with sleep (mean = 6.53 versus 5.40, P = .03) and greater negative effect on mood (mean = 6.33 versus 5.30, P = .04) compared to the no hazardous drinking group. Nonsignificant differences were found between tobacco users and non-tobacco users regarding pain intensity and pain effect on activity, sleep, mood, and stress (all P > .05). Among tobacco users, a significant negative correlation was found between a daily number of cigarettes used and sleep interference (r = -0.29, P = .024) as well as effect on mood (r = -0.33, P = .010). Years of tobacco use showed a significant negative correlation with the average pain intensity (r = -0.32, P = .025).

CONCLUSIONS

The results suggest that addressing alcohol consumption is an essential part of chronic pain treatment. The finding of a negative association between years of nicotine use and pain intensity suggests that nicotine use may have served as a coping mechanism. Further research is needed.

Strategies for Perioperative Optimization in Upper Extremity Fracture Care

Perioperative optimization in upper extremity fracture care must balance the need for timely treatment with the benefits of medical optimization. Care pathways directed at optimizing glycemic control, chronic anticoagulation, smoking history, nutrition, and frailty can reduce surgical risk in upper extremity fracture care. The development of multidisciplinary approaches that tie risk modification with risk stratification is needed.

The Ankle Joint: Revision Ankle Fusion Options, Nonunion, Malunion, Protocol for Best Outcome

Ankle arthrodesis has been a time-tested procedure for osteoarthritis, avascular necrosis of the talus, deformity correction, and significant trauma of the ankle. Technique guides have created dissection pearls, ease of fixation, and arthroscopic techniques to mitigate complications of the procedure. Major complications, such as nonunion, malunion, or implant infection are the most worrisome and cumbersome complications to handle. The aim of this article is to provide the practicing surgeon evidence to provide innovative management techniques for nonunion, malunion, and infection following primary ankle arthrodesis.

Modifiable and Nonmodifiable Risk Factors Associated with the Development of Recurrent Rotator Cuff Tears

Nonoperative and operative strategies exist to manage rotator cuff pathology. Although surgical repair is successful for most patients, others may experience retear or nonhealing of the rotator cuff. Several modifiable and nonmodifiable risk factors are associated with an increased retear rate. The literature shows consistency and agreement regarding many of these risk factors, most notably, patient age, tear size, and rotator cuff muscular atrophy, whereas others remain controversial. It is important that shoulder surgeons are familiar with modifiable and nonmodifiable risk factors associated with retear, to better advise patients and optimize their chances of success following rotator cuff repair surgery.

A Case of Fibula Regeneration after Below-the-knee Amputation in an Adult

We report the case of an adult with fibula regeneration after below-the-knee amputation. Fibula regeneration conventionally occurs at the donor site of children after autogenous fibula transplantation when the periosteum is preserved. However, the patient was an adult, and the regenerated fibula was 7-cm long and grew directly from the stump. A 47-year-old man was referred to the plastic surgery department owing to stump pain. He had an open comminuted fracture of the right fibula and tibia due to a traffic accident when he was 44 years old and underwent below-the-knee amputation and negative pressure wound therapy for skin defects. The patient recovered and was able to walk using a prosthetic limb. Upon radiography, the fibula was found to have regenerated 7 cm directly from the stump. Pathological examination revealed that the regenerated fibula contained normal bone tissue and neurovascular bundles in the cortex. The periosteum, mechanical stimuli with limb proteases, and negative pressure wound therapy were suspected to have accelerated bone regeneration. He had no inhibitory factors for bone regeneration, including diabetes mellitus, peripheral arterial disease, or active smoking status. After the resection of the regenerated fibula, the patient was ambulatory without further bone regeneration or pain. This case report suggests that bone regeneration may occur even in adults. The surgeon should not leave any part of the periosteum behind in patients undergoing amputation. In adult amputees complaining of stump pain, the possibility of bone regeneration may be considered.

Refracture after plate removal of midshaft clavicle fractures after bone union-incidence, risk factors, management and outcomes

INTRODUCTION

There is a great debate on the routine use of open reduction and internal fixation (ORIF) for midshaft clavicle fractures, and one concern is the adverse events after ORIF, such as implant removal after bone union. In this retrospective study, we assessed the incidence, risk factors, management and outcomes of refracture after plate removal of midshaft clavicle fractures after bone union.

MATERIALS AND METHODS

Three hundred fifty-two patients diagnosed with acute midshaft clavicle fractures who had complete medical records from primary fractures to refracture were recruited. Details of imaging materials and clinical characteristics were carefully reviewed and analysed.

RESULTS

The incidence rate of refracture was 6.5% (23/352), and the average interval from implant removal to refracture was 25.6 days. Multivariate analysis showed that the risk factors were Robinson type-2B2 and fair/poor reduction. Females were 2.4 times more likely to have refracture, although it was not significant in multivariate analysis (p = 0.134). Postmenopausal females with a short interval (≤ 12 months) from primary surgery to implant removal had a significant risk for refracture. Tobacco use and alcohol use during bone healing were potential risk factors for male patients, although they were not significant in multivariate analysis. Ten patients received reoperation with or without bone graft, and they had a higher rate of bone union than 13 patients who refused reoperation.

CONCLUSION

The incidence of refracture following implant removal after bone union is underestimated, and severe comminute fractures and unsatisfactory reduction during primary surgery are risk factors. Implant removal for postmenopausal female patients is not recommended due to a high rate of refracture.

Musculoskeletal Disorder Burden and Its Attributable Risk Factors in China: Estimates and Predicts from 1990 to 2044

Musculoskeletal disorders are one of the three major disabling diseases in the world. However, the current disease burden in China is not well-known. This study aimed to explore the burden and risk factors of musculoskeletal disorders in China from 1990 to 2019, predicting the incidence trend from 2020 to 2044. All data were extracted from the Global Burden of Disease Study 2019 (GBD 2019). Joinpoint regression and age-period-cohort (APC) models were selected to analyze the epidemic trend, and descriptive analyses of the time trends and age distributions of risk factors were performed. The Bayesian APC model was used to foresee the incidence trend from 2020 to 2044. The results indicated that the burden of musculoskeletal disorders is higher in women and older adults. Its attributable risk factors were found to be tobacco, a high body mass index, kidney dysfunction and occupational risks. In 2044, musculoskeletal disorders in China showed a downward trend for 35-59-year-olds and a slight upward trend for 30-34- and 65-84-year-olds. The 70-74 year age group saw the largest increase in incidence at 4.66%. Overall, the incidence increased with age. Therefore, prevention and control policies should focus on women and the elderly, and health interventions should be carried out based on risk factors.

Risk factors for the development of a peri-prosthetic joint infection up to 2 Years following primary reverse shoulder arthroplasty

Background

Reverse shoulder arthroplasty (RSA) has become commonly used to treat glenohumeral osteoarthritis (GHOA), of which complications such as peri-prosthetic joint infections (PJIs) may develop. The objective of this study was to compare patient demographics of those who did and did not develop PJIs within 2 years after primary RSA for GHOA and identify risk factors for this sequela.

Methods

A nationwide database was queried from 2005 to 2014 for Medicare patients treated with primary RSA (International Classification of Disease (ICD-9) procedural code 81.88) for GHOA. Patients who developed PJIs within 2-years of primary RSA defined the study group, whereas those who were devoid of infections represented the comparison group. Our study consisted of 51,824 patients, of which 879 (1.69%) developed a PJI. Patient demographics comprising the Elixhauser comorbidity index (ECI) were compared using Chi-Square analyses. Multivariable logistic regression models were used to compute the odds-ratios (OR) of patient-specific factors associated with acquiring a PJI within 2 years after RSA. P values less than 0.002 were significant.

Results

Patients developing a PJI had higher mean ECI (8 vs. 6; p < 0.0001). The greatest risk factors for developing PJIs within 2-years following RSA were male sex (OR: 2.10, 95%CI: 1.81-2.43, p < 0.0001), pathologic weight loss (OR: 1.78, 95%CI: 1.45-2.17, p < 0.0001), iron deficiency anemia (OR: 1.75, 95%CI: 1.49-2.06, p < 0.0001), morbid obesity (OR: 1.52, 95%CI: 1.21-1.88, p = 0.0001), rheumatoid arthritis (OR: 1.32, 95%CI: 1.13-1.54, p = 0.0003), arrhythmias (OR: 1.26, 95%CI 1.09-1.46, p = 0.001), and depressive disorders (OR: 1.23, 95%CI 1.06-1.43, p = 0.001).

Conclusions

The greatest risk factors for PJIs within 2 years of primary RSA included male sex; additional modifiable risk factors included iron deficiency anemia, pathologic weight loss, and obesity. Preoperative screening can help to identify modifiable risk factors and alter management for high-risk patients to potentially minimize PJIs.

The Effect of Smoking on the Outcome of Matrix-Based Autologous Chondrocyte Implantation: Data from the German Cartilage Registry

Smoking is known to have various deleterious effects on health. However, it is not clear whether smoking negatively affects the postoperative outcome following matrix-based autologous cartilage implantation (MACI) in the knee. The purpose of this study was to evaluate the effect of smoking on the outcome of MACI in the knee. A total of 281 patients receiving MACI in the knee between 2015 and 2018 were registered in the German Cartilage Database. The cohort was divided into ex-smokers, smokers, and nonsmokers. Data regarding the Knee Injury and Osteoarthritis Outcome Score (KOOS), the numeric rating scale (NRS) for pain, and satisfaction with the outcome were analyzed and compared. Follow-ups were performed at 6, 12, and 24 months after surgery. Of the 281 patients, 225 (80.1%) were nonsmokers, 43 (15.3%) were smokers, and 13 (4.6%) were ex-smokers. The three groups were comparable with respect to age, sex, body mass index (BMI), height, defect size, the need for additional reconstruction of the subchondral bone defect, number of previous knee surgeries, and defect location. However, nonsmokers had a significantly lower weight as compared with smokers. Besides a significantly lower preoperative NRS of nonsmokers as compared with smokers, there were no significant differences between the three groups with respect to KOOS, NRS, and satisfaction at 6, 12, and 24 months of follow-ups. The present study of data retrieved from the German Cartilage Registry suggests that the smoking status does not influence the outcome of MACI in the knee.

Therapeutic efficacy of Chinese patent medicine containing pyrite for fractures: A protocol for systematic review and meta-analysis

BACKGROUND

Fractures are a condition in which bone continuity is lost or linear deformity occurs. They are a worldwide public health problem and a significant economic burden. The purpose of this study is to analyze the efficacy of Chinese patent medicine containing pyrite (CPMP) through systematic review and meta-analysis of fracture clinical data.

METHODS

A literature search will be carried out from the inception of CPMP studies to September 2022 using EMBASE, PubMed, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Korean Studies Information Service System, National Digital Science Library, and Oriental Medicine Advanced Searching Integrated System. Randomized controlled trials which include CPMP will be considered as eligible regardless of the type of fracture. After screening the literature, extracting the data, and assessing the risk of bias from the included studies, a meta-analysis will be performed using Review Manager version 5.4.

RESULTS

This study is expected to provide evidence for the efficacy and safety of CPMP for fractures.

CONCLUSION

Our findings will provide evidence to determine whether CPMP can be an effective intervention for patients with fractures, which would expand the possible treatment options.

General Considerations About Foot and Ankle Arthrodesis. Any Way to Improve Our Results?

Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.

Impacts of presenteeism on work-related injury absence and disease absence

Background

Many studies have been conducted on presenteeism and absenteeism, but the relationship between presenteeism and absenteeism is unclear. This study was undertaken to investigate the effect of presenteeism on future absenteeism.

Methods

This study was conducted on non-white collar workers that underwent general health examinations in 2014 and 2015. We asked subjects to fill out a questionnaire about their experiences of presenteeism for the past one year in 2014. In 2015, it was checked whether the same subjects had any experience of absence from work due to injury or disease during the past year. The χ² test was used to analyze relationships between sociodemographic and occupational characteristics, presenteeism, and absence. Odds ratios (ORs) were calculated by logistic regression analysis controlled for confounding factors.

Results

A total of 12,572 workers were included in the study. For workers who experienced presenteeism, the OR for injury absence was 2.705 (95% confidence interval [CI]: 2.044-3.581), and the OR for disease absence was 4.906 (95% CI: 3.996-6.024) after adjusting for sociodemographic and occupational confounding factors. For men that experienced presenteeism, the OR for injury absence was 3.035 (95% CI: 2.258-4.081), and the OR for disease absence was 5.508 (95% CI: 4.340-6.989). For women that experienced presenteeism, the OR for injury absence was 1.322 (95% CI: 0.577-3.028), which was not significant, and the OR for disease absence was 3.629 (95% CI: 2.405-5.475).

Conclusions

This study suggests that presenteeism can influence future absenteeism. The effect of presenteeism may depend on cause of absence. Men who experienced presenteeism showed greater effects on injury and disease absence than women. For women, experience of presenteeism had a significant effect on disease absence but not on injury absence.

Prevalence of osteopenic syndrome and osteoporosis among residents of the older age group of Kyrgyzstan

Osteoporosis is the most common metabolic bone disease. However, because it is asymptomatic, it cannot be diagnosed until a clinical event such as a fracture occurs. It is osteoporotic fractures, not osteoporosis itself, that lead to noticeable clinical and economic consequences.

The aim. To study the frequency of osteopenia and osteoporosis in the older age group of the population of Kyrgyzstan using ultrasound bone densitometry.

Materials and methods. A total of 1988 people were examined – 1105 women, 883 men. By age, the patients were divided into three age groups: 40–59, 60–74 and 75–90 years old. A portable ultrasonic bone densitometer SONOST-3000 (South Korea) was used to measure bone mineral density.

Results. The prevalence of osteoporosis, osteopenia, and normal bone mineral density in the first age group was 20.9 %, 40.0 % and 39.1 %; in the second group – 30.2 %, 38.9 % and 30.9 %, and in the third group – 39.9 %, 34.9 % and 25.2 %, respectively. The incidence of osteoporosis increased with age and was gender-dependent – more common in women (p < 0.05 and p < 0.041, respectively). The probability of developing osteoporosis was lower in patients with a higher body weight (p < 0.002). Smoking had a bad effect on bone density (p < 0.001), physical exercise, on the contrary, inhibited the development of osteoporosis (p < 0.001). The use of alcohol and tea had no effect on the development of osteoporosis in our study (p = 0.421, p = 0.387, respectively).

Conclusions. The study of osteoporosis from an epidemiological point of view in Kyrgyz residents revealed a higher-than-expected incidence of osteoporosis according to densitometry. Further large-scale studies are needed throughout the country, which will help to understand the outcome of low bone mineral density in the population of Kyrgyz residents.

Influence of Smoking in the Clinical Outcomes of Distal Radius Fractures

Introduction  There are various studies that reviewed the effect of cigarette smoking in fracture healing process. Nonunion, delayed union, and residual pain are the significant risk factors associated with smoking and fracture healing. Little has been known about the impact of smoking in distal radius fracture healing. We intend to explore in brief the effect of smoking in distal radius fracture healing and comparing it with nonsmokers having the same fracture fixation and analyze the outcomes with respect to fracture healing and return of function. Materials and Methods  Of the total 186 patients, 92 were included in the study with ( n = male: 31, female: 61) mean age of 60.2 years. They were divided into two groups: smoking ( n = 43) and nonsmoking ( n = 49). All had surgical fixation of the distal radius with volar locking plate and started on early mobilization. The range of motion of the wrist, grip, visual analog scale, quick disabilities of the arm and shoulder and hand score, Mayo wrist score, and bone healing period were noted between these two groups and compared with statistical analysis. Results  The mean follow-up period was 8.7 months. There was a significant association of young age and male patients having distal radius fractures in the smoking group ( p < 0.05). All fractures healed well in both groups without complications. There was no significant difference between these two groups in terms of range of motion, grasp, bone healing period, and functional outcomes. Conclusion  Despite the well-known fact that, smoking has negative implications in the fracture healing process, we found group of patients (smoking and nonsmoking) with distal radius fractures treated by volar locking plates healed well with good radiological union and excellent functional outcome There is no significant influence of smoking in distal radius fracture fixation.

Salvage of Failed Lisfranc/Midfoot Injuries

Salvage of Lisfranc, or tarsometatarsal injuries, may be necessary because of a variety of clinical scenarios. Although rare, these injuries represent a broad spectrum of injury to the midfoot ranging from low-energy ligamentous injuries to high-energy injuries with significant displacement and associated fractures. Poor outcomes and complications may occur including posttraumatic arthritis, instability, pain, infection, and loss of function. Strategies and technical considerations for salvage of these complex injuries are provided.

Surgeon volume and risk of deep surgical site infection following open reduction and internal fixation of closed ankle fracture

Increasing evidences have shown that surgeon volume was associated with postoperative complications or outcomes in a variety of orthopaedics surgeries, but few were focused on ankle fractures. This study aimed to investigate the deep surgical site infection (DSSI) in association with the surgeon volume following open reduction and internal fixation (ORIF) of ankle fractures. This was a retrospective analysis of the prospectively collected data on patients who underwent ORIF for acute closed ankle fractures between October 2014 and June 2020. Surgeon volume was defined as the number of ORIF procedures performed within 12 months preceding the index operation. The receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off value, whereby surgeon volume was dichotomized as high or low. The outcome was DSSI within 1 year postoperatively. Multivariate logistics analysis was performed to examine the DSSI in association with surgeon volume and multiple sensitivity/subgroup analyses were performed to refine the findings. Among 1562 patients, 33 (2.1%) developed a DSSI. The optimal cut-off value was 7/year. Low-volume (<7/year) was significantly associated with a 5.0-fold increased risk of DSSI (95%CI, 2.2-11.3; P < .001). Sensitivity/subgroup analyses restricted to patients aged <65 years, with or without concurrent fractures, with unimalleolar fractures, bi- or trimalleolar fractures, receiving ORIF within 14 days and those operated by ≥10-year experience surgeons showed the consistently significant results (ORs, 2.7-6.8, all P < .05). The surgeon volume of <7 cases/year is associated with an increased risk of DSSI. It is more feasible that patients with complex fractures or conditions (eg, bi- and trimalleolar or presence of concurrent fractures) are preferentially directed to high-volume and experienced surgeons.

Joint Preserving Surgery for Valgus Ankle Osteoarthritis

Valgus ankle OA is a complex problem with multiple etiologies that can either be isolated or superimposed on top of other medical or musculoskeletal disorders. Proper medical history, physical, and preoperative radiological examinations are crucial in deciding on surgery and planning the surgical approach. JPS, especially the varisating medial closing-wedge SMOT with solid plate fixation, has been consistently associated with good outcomes for patients with valgus ankle OA. To further improve JPS for valgus ankle OA, further clinical and biomechanical studies are required to address the long-term clinical and functional outcomes and complications.

Fracture, nonunion and postoperative infection risk in the smoking orthopaedic patient: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to analyse negative effects of smoking in orthopaedic and trauma patients.

A PubMed search was carried out for studies published until July 2020 regarding effects of smoking on fracture risk, nonunion, infection after orthopaedic surgery, and persisting nonunion after scaphoid nonunion surgery. Random effects models calculated for outcome parameters, and relative risks (RR) with 95% confidence intervals are provided. No adjustments for covariates were made. Heterogeneity was assessed with Higgins’ I2, publication bias with Harbord’s p (Hp), sensitivity analysis performed on funnel plots and quality of studies was analysed using the Newcastle-Ottawa Scale.

Of 3362 retrieved entries, 69 were included in the final analysis. Unadjusted RR for smokers to develop vertebral (six studies, seven entries; RR: 1.61; p = 0.008; I2 = 89.4%), hip (11 studies, 15 entries; RR: 1.28; p = 0.007; I2 = 84.1%), and other fractures (eight studies, 10 entries; RR: 1.75; p = 0.019; I2 = 89.3%) was significantly higher. Postoperative infection risk was generally higher for smokers (21 studies; RR: 2.20; p < 0.001; I2 = 58.9%), and remained upon subgroup analysis for elective spinal (two studies; RR: 4.38; p < 0.001; I2 = 0.0%) and fracture surgery (19 studies; RR: 2.10; p < 0.001; I2 = 58.5%). Nonunion risk after orthopaedic (eight studies; RR: 2.15; p < 0.001; I2 = 35.9%) and fracture surgery (11 studies; RR: 1.85; p < 0.001; I2 = 39.9%) was significantly higher for smokers, as was persisting nonunion risk after surgery for scaphoid nonunion (five studies; RR: 3.52; p < 0.001; I2 = 0.0%). Sensitivity analysis for each model reduced heterogeneity whilst maintaining significance (all I2 < 20.0%).

Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections.

Cite this article: EFORT Open Rev 2021;6:1006-1019. DOI: 10.1302/2058-5241.6.210058

In vivo soft tissue compressive properties of the human hand

Background/Purpose

Falls onto outstretched hands are the second most common sports injury and one of the leading causes of upper extremity injury. Injury risk and severity depends on forces being transmitted through the palmar surface to the upper extremity. Although the magnitude and distribution of forces depend on the soft tissue response of the palm, the in vivo properties of palmar tissue have not been characterized. The purpose of this study was to characterize the large deformation palmar soft tissue properties.

Methods

In vivo dynamic indentations were conducted on 15 young adults (21–29 years) to quantify the soft tissue characteristics of over the trapezium. The effects of loading rate, joint position, tissue thickness and sex on soft tissue responses were assessed.

Results

Energy absorbed by the soft tissue and peak force were affected by loading rate and joint angle. Energy absorbed was 1.7–2.8 times higher and the peak force was 2–2.75 times higher at high rate loading than quasistatic rates. Males had greater energy absorbed than females but not at all wrist positions. Damping characteristics were the highest in the group with the thickest soft tissue while damping characteristics were the lowest in group with the thinnest soft tissues.

Conclusion

Palmar tissue response changes with joint position, loading rate, sex, and tissue thickness. Accurately capturing these tissue responses is important for developing effective simulations of fall and injury biomechanics and assessing the effectiveness of injury prevention strategies.

Evaluation of outcome after primary median and/or ulnar nerve(s) repair at wrist: clinical, functional, electrophysiologic, and ultrasound study

Background

A major problem in surgery of peripheral nerve injuries of the upper extremities is the unpredictable final outcome. More insight and understanding of the proper methods of outcome assessment and the prognostic factors is necessary to improve functional outcome after repair of peripheral nerves. The objective of this study is to assess the outcome and identify possible prognostic factors for functional recovery of median and/or ulnar nerves repairs at wrist. Forty patients with median, ulnar or combined median-ulnar nerve injuries were included. Smoking, age, sex, repaired nerve, associated artery and/ or tendon repairs, joint stiffness and scar tissue were analyzed as prognostic factors for functional outcome after repair. Outcome parameters were medical research counsel (MRC) scoring for sensory and motor recovery, grip and pinch strength, disability of arm, shoulder and hand (DASH) questionnaire, electrophysiology and ultrasonographic evaluation.

Results

The mean age of the studied patients was 29.1 ± 8.3 and it was statistically correlated with grip strength (p = 0.045), DASH score (p = 0.046) and hyperesthesia score (p = 0.040). EMG results showed signs of regeneration in all patients in the form of small nascent MUAPs and polyphasic MUAPs. CMAP amplitudes of median and ulnar nerves positively correlated with the MRC scale for muscle strength (p = 0.001)

There were statistically significant negative correlations between DASH score and MRC score for sensory evaluation (p = 0.016), grip (p = 0.001), and pinch strength (p = 0.001). There were statistically significant positive correlations between patient's opinion of recovery and MRC score for sensory evaluation (p = 0.029), grip (p = 0.001), and pinch strength (p = 0.001). The MRC score for muscle strength has statistical significant positive correlations with the MRC score for sensory evaluation, grip (p = 0.003), and pinch strength (p = 0.040)

Conclusions

It was concluded that; MRC scale for muscle power, MRC scale for sensory evaluation, functional scores, grip and pinch strength are valuable tools for evaluation of functional outcome. Age, smoking, associated tendon repair, damaged nerve, compliance to rehabilitation protocol, return to work, clinically visible wound adhesions, residual hand joint stiffness, and scar tissue detected by ultrasound were found to be prognostic factors for outcome after nerve repair.

Septic Arthritis Among Users of Injection Drugs: Clinical Course and Microbial Characteristics

Injection drug use (IDU) is a risk factor for septic arthritis (SA) of native joints. Amid the opioid crisis, IDU rates have increased. This study assessed differences in pre-operative characteristics, microbial characteristics, and postoperative outcomes of 177 cases of SA treated operatively from 2015 to 2019 at 3 US hospitals, by self-reported IDU status. Forty cases (23%) involved patients who reported IDU. Patient characteristics, comorbidities, microbial characteristics, duration of hospital stay, discharge destination, follow-up rates, and rates of persistent/secondary infection were compared by self-reported IDU status. Compared with non-IDU-associated SA (non-IDU-SA), IDU-associated SA (IDU-SA) was associated with female sex (P=.001), younger age (P<.001), lower body mass index (P<.001), tobacco use (P<.001), and psychiatric diagnosis (P=.04) and was more likely to involve methicillin-resistant Staphylococcus aureus (P<.001). The IDU-SA was associated with discharge to a skilled nursing facility or against medical advice (P<.001) and with loss to follow-up (P=.01). The 2 groups did not differ in terms of American Society of Anesthesiologists classification, joint involved, Gram stain positivity, presence of bacteremia, peripherally inserted central catheter placement, return to hospital within 3 months, or persistent/secondary positive results on culture within 3 months. Patients with IDU-SA were younger, were more likely to be female, had lower body mass index, and had fewer medical comorbidities but were more likely to use tobacco and to have a psychiatric diagnosis compared with patients with non-IDU-SA. Methicillin-resistant S aureus was more common in the IDU-SA group, as was discharge to a skilled nursing facility or against medical advice. Patients with IDU-SA were less likely to return for follow-up than patients with non-IDU-SA. [Orthopedics. 2021;44(6):e747-e752.].

Addressing Smoking in Musculoskeletal Specialty Care

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Physicians who advise patients to quit smoking substantially improve cessation rates, but cessation counseling is currently underperformed.

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Counseling, pharmacotherapy, and additional interventions can improve the chance of successful smoking cessation. Most patients require multiple attempts at quitting to be successful.

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A list of referral contacts and resources should be developed and routinely offered to these patients. The national Quitline (1-800-QUIT-NOW) provides free access to trained counselors and "quit coaches" for each state program in the United States.

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Government and private insurance plans in the United States are required (in most cases) to cover the cost of 2 quitting attempts per year including counseling referrals and medications.

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Several biopsychosocial factors that affect orthopaedic outcomes (weight, anxiety, depression, etc.) are also relevant to smoking cessation; management of these factors is thus potentially aggregately advantageous.

Surgical outcome following rotator cuff tear repair in a low-income population. Impact of obesity and smoking

Background

Comorbidities and socioeconomic issues impact outcome of rotator cuff tear (RCT) repair. There are no data on RCT repair outcome from developing regions. We determined the impact of obesity and smoking following RCT repair in a low-income population.

Methods

This is a retrospective case series. Forty-seven shoulders of 42 patients subjected to open or arthroscopic repair of a RCT with a minimum of 2 years follow-up were cross-sectionally evaluated. Patients were seen in the Orthopaedic Service of the Hospital Geral de Fortaleza-CE, Brazil between March and September 2018. RCT were classified as partial or full-thickness lesions. Fatty infiltration (Goutallier) and tendon retraction (Patte) were recorded as well as obesity (BMI > 30), literacy [>/≤ 8 school years (SY)] and smoking status 6 months prior to surgery (present/absent). Outcomes included pain (visual analogue scale; VAS, 0–10 cm), range of motion [active forward flexion and external rotation (ER)], UCLA and ASES scoring.

Results

Patients were 59.9 ± 7.4 years-old, 35(74.4%) female with 19 (17.1–30.2 IQR) median of months from diagnosis to surgery and 25 median months of follow-up (26.9–34.0 IQR); over 90% declared < 900.00 US$ monthly family income and two-thirds had ≤8 SY. Forty patients (85.1%) had full-thickness tears, 7 (14.9%) had Goutallier ≥3 and over 80% had < Patte III stage. Outcomes were similar regardless of fatty infiltration or tendon retraction staging. There were 17 (36.1%) smokers and 13 (27.6%) obese patients. Outcome was similar when comparing obese vs non-obese patients. Smokers had more pain (P = 0.043) and less ER (P = 0.029) with a trend towards worse UCLA and ASES scores as compared to non-smokers though differences did not achieve minimal clinically important difference (MCID) proposed for surgical RCT treatment. After adjusting for obesity, VAS and ER values in smokers were no longer significant (P = 0.2474 and 0.4872, respectively).

Conclusions

Our data document outcomes following RCT repair in a low-income population. Smoking status but not obesity impacted RCT repair outcome though not reaching MCID for surgical treatment.

Impact of smoking on pain and function in rotator cuff repair: A prospective 5-year cohort follow-up of 1383 patients

BACKGROUND

This multicentre cohort study investigates the effect of smoking on the outcome of rotator cuff repair (RCR), with attention to age at presentation for surgery, pre-operative and post-operative pain and function and intra-operative findings.

METHODS

Patient information was collected pre-operatively, including Flex Shoulder Function (Flex SF) and visual analogue scale pain, then at 6 months, 1, 2 and 5 years post-operatively. Intra-operative technical data were collected by the operating surgeon. Current smokers were classified by daily cigarette consumption.

RESULTS

A total of 1383 RCRs in as many patients were included with an 84% 5-year follow-up. Smokers were on average 6.7 years younger than non-smokers (51.8 vs. 58.5, P < 0.001). There was no difference in intra-operatively assessed tear size both in anteroposterior dimension (P = 0.5) and retraction (P = 0.9). Pre-operative Flex SF score in smokers was below that of non-smokers (23.0 vs. 24.5, P = 0.002) and at 6 months (P = 0.02) but no different at 5 years (P = 0.7). Pain scores were higher in smokers than non-smokers both pre-operatively (5.34 vs. 4.67, P < 0.001) and up to 2 years (P < 0.001) but not at 5 years (P = 0.073).

CONCLUSION

Smokers undergoing RCR were younger than non-smokers, and had worse pre-operative pain scores and shoulder function. Poorer post-operative function persisted to 6 months, and with higher reported pain to 2 years in smokers. However, at 5-year follow-up, patient-reported outcomes were not affected by smoking status.

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

OBJECTIVES

To determine the reliability of self-reported smoking status in the orthopaedic trauma population and determine if certain patient factors might predispose inaccurate self-reported smoking cessation.

DESIGN

Prospective.

SETTING

Level I trauma center.

PATIENTS

Two hundred forty-seven orthopaedic trauma patients were included in the study.

INTERVENTION

In-office measurement of exhaled carbon monoxide (CO).

MAIN OUTCOME MEASUREMENTS

Self-reported smoking cessation with exhaled CO measurements.

RESULTS

A total of 906 self-reported surveys were completed over 4 follow-up visits. Of the responses indicating smoking cessation (n = 174), 12.6% [95% confidence interval (CI), 0.081-0.185] reported smoking cessation with positive CO readings, suggesting inaccurate self-reporting of smoking status. Over 20% of those patients inaccurately reporting abstinence did so more than once. The odds of inaccurate self-reporting was 3 times higher in patients with no insurance or government insurance [odds ratio (OR), 3.5; 95% CI, 1.1-11.0; P = 0.043] and in the unemployed (OR, 3.3; 95% CI, 0.97-8.57; P = 0.049).

CONCLUSIONS

Self-reported smoking status in the orthopaedic population is fairly reliable, with 13% of patient's inaccurately self-reporting smoking cessation despite knowing their smoking status was being measured. Clinicians should be aware of the potential for inaccuracy in self-reported smoking cessation, particularly in patients with the identified socioeconomic factors. Point-of-care testing before elective trauma procedures to confirm smoking status might have a role if the procedure outcome is highly dependent on smoking status.

LEVEL OF EVIDENCE

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

The prevalence of upper quadrants work-related musculoskeletal disorders and their predictors among registered nurses

BACKGROUND

Work-related musculoskeletal disorders (WMSDs) represent a significant health challenge facing nurses. However, very few studies investigated the prevalence of WMSDs among nurses and their predictors comprehensively using a valid and reliable set of standardized outcome measures.

OBJECTIVE

This study aimed to investigate the prevalence WMSDs of upper quadrants and their predictors among registered nurses in Jordanian hospitals.

METHODS

A cross-sectional study recruited 597 registered nurses from different hospitals in Jordan. A self-administered survey distributed in targeted hospitals wards. Outcome measures included Nordic Musculoskeletal Questionnaire (NMQ), Depression Anxiety Stress Scale (DASS), Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire (IPAQ), sociodemographic data, and manual handling and work habits. Prevalence of musculoskeletal complaints was reported using descriptive analysis. Logistic regression analyses were used to identify predictors of WMSDs at each upper quadrant body site.

RESULTS

Twelve-month WMSDs prevalence was the highest at the neck (61.1%), followed by the upper back (47.2%), shoulders (46.7%), wrist and hands (27.3%), and finally at the elbow (13.9%). Being a female, poor sleep quality, high physical activity level, poor ergonomics, increased workload, and mental stress were significant predictors of increased upper quadrant WMSDs among nurses.

CONCLUSIONS

Upper quadrant WMSDs among nurses in Jordan are highly prevalent. Identified significant predictors of these WMSDs should be given full consideration by clinicians and health policymakers. Future studies are needed to reveal the progressive nature of upper quadrant WMSDs and strategies to modify their risk factors.

Nonunion Rates in Hind- and Midfoot Arthrodesis in Current, Ex-, and Nonsmokers

BACKGROUND

Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis.

METHODS

In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon's logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes.

RESULTS

Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P < .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection (P = .05) and bone stimulator use (P < .001). Among smokers, there was a trend toward slower union with heavier smoking (P = .004).

CONCLUSION

This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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

BACKGROUND

Smoking increases the risk of complications and related costs after an orthopaedic fracture. Research in other populations suggests that a one-time payment may incentivize smoking cessation. However, little is known on fracture patients' willingness to accept financial incentives to stop smoking; and the level of incentive required to motivate smoking cessation in this population. This study aimed to estimate the financial threshold required to motivate fracture patients to stop smoking after injury.

METHODS

This cross-sectional study utilized a discrete choice experiment (DCE) to elicit patient preferences towards financial incentives and reduced complications associated with smoking cessation. We presented participants with 12 hypothetical options with several attributes with varying levels. The respondents' data was used to determine the utility of each attribute level and the relative importance associated with each attribute.

RESULTS

Of the 130 enrolled patients, 79% reported an interest in quitting smoking. We estimated the financial incentive to be of greater relative importance (ri) (45%) than any of the included clinical benefits of smoking cessations (deep infection (ri: 24%), bone healing complications (ri: 19%), and superficial infections (ri: 12%)). A one-time payment of $800 provided the greatest utility to the respondents (0.64, 95% CI: 0.36 to 0.93), surpassing the utility associated with a single $1000 financial incentive (0.36, 95% CI: 0.18 to 0.55).

CONCLUSIONS

Financial incentives may be an effective tool to promote smoking cessation in the orthopaedic trauma population. The findings of this study define optimal payment thresholds for smoking cessation programs.

Smoking and the patient with a complex lower limb injury

Smoking is known to increase the risk of peri-operative complications in Orthoplastic surgery by impairing bone and wound healing. The effects of nicotine replacement therapies (NRTs) and electronic cigarettes (e-cigarettes) has been less well established. Previous reviews have examined the relationship between smoking and bone and wound healing separately. This review provides surgeons with a comprehensive and contemporaneous account of how smoking in all forms interacts with all aspects of complex lower limb trauma. We provide a guide for surgeons to refer to during the consent process to enable them to tailor information towards smokers in such a way that the patient may understand the risks involved with their surgical treatment. We update the literature with recently discovered methods of monitoring and treating the troublesome complications that occur more commonly in smokers effected by trauma.

Impact of smoking on patient-reported outcome measures after arthroscopic rotator cuff repair: a 2-year comparative cohort study

Background and Hypothesis

Smoking is a well-established risk factor for tendon healing. The purpose of this study was to evaluate the differences in patient-reported outcome measures between smokers and nonsmokers who have undergone arthroscopic rotator cuff repair. It was hypothesized that smokers would have worse self-reported outcomes at 1 and 2 years postoperatively.

Methods

A total of 560 consecutive patients who underwent arthroscopic rotator cuff repair were divided into 2 groups: group I (smokers) n = 25 and group II (nonsmokers) n = 535. All participants were administered preoperative and postoperative surveys consisting of the following outcome-measuring tools: (i) visual analog scale, (ii) Veterans Rand 12-Item Health Survey, (iii) American Shoulder and Elbow Surgeons shoulder score, (iv) standard preoperative form consisting of 4 questions regarding their expectations of recovery, (v) Single Assessment Numeric Evaluation shoulder score, and (vi) Simple Shoulder Test.

Results

At 1 and 2 years postoperative, nonsmokers reported statistically significant differences in Veterans Rand 12-Item Health Survey mental scores (56.2 vs. 51.9, P = .0162 and 56.3 vs. 49.5, P = .0004, respectively). American Shoulder and Elbow Surgeons Shoulder scores showed no differences until the 2-year mark, at which time nonsmokers reported higher scores than smokers (87.9 vs. 79.0, P = .0212). Single Assessment Numeric Evaluation scores also remained similar up until 2-year follow-up, at which time nonsmokers reported statistically significant improvement (80.0 vs. 68.5, P = .0339). Nonsmokers reported higher Simple Shoulder Test scores at baseline and at 2-year follow-up (43.3 vs. 37.0, P = .0417 and 83.7 vs. 68.1, P = .0046, respectively).

Conclusion

At 2 years postoperatively, nonsmokers had significantly higher patient-reported outcome measure scores than smokers. In elective surgery, smoking status should be considered as a risk factor for poorer patient-reported outcomes after arthroscopic rotator cuff repair. However, smokers continue to report a clinical benefit at 2 years postoperatively.

The influence of smoking on foot and ankle surgery: a review of the literature

The effect of tobacco smoking on foot and ankle procedures is likely to be more pronounced when compared to other orthopaedic surgery. This is due to the peripheral nature of the vasculature involved. This paper reviews the current clinical evidence on the effects of smoking foot and ankle surgery. In the trauma setting, the evidence suggests that wound complications and non-unions are significantly higher in the smoking population. In the elective setting there is a significantly increased risk of non-union in ankle and hindfoot arthrodeses in smokers. In the setting of diabetes, ulceration rate in smokers is higher and there may be a higher risk of amputation.

Relationship between long head of the biceps tendon histopathology and long-term functional results in smokers. A time to reevaluate the Bonar score?

Aim

The purpose of this study was to investigate whether there is an association between smoking, the extent of the degeneration process in the biceps tendinopathy, including cells and extracellular matrix (ECM) alterations, and long-term surgical results.

Methods

This study comprised 40 consecutive patients admitted for shoulder arthroscopy due to symptomatic biceps tendinopathy and classified into three groups based on smoking status: active smokers, former smokers, and non-smokers. According to the classical Bonar score criteria, the histopathologic evaluation of the harvested intra-articular portion of the tendon was done. The follow-up examination was based on the American Shoulder and Elbow Surgeons Score (ASES).

Results

A cohort of 32 patients was enrolled in the final follow-up examination; mean 37.56 months. Histopathological evaluation according to the classical Bonar score revealed degeneration of the tendinous tissue in each group but there was no correlation between the extent of degeneration, smoking indexes and the ASES. After revision of Bonar scale within the vascularity criterion, we found a correlation between the extent of degeneration of tendinous tissue, smoking data, ASES score, and the severity of rotator cuff injury.

Conclusion

In this paper, we indicate the ambiguous role of the neovascularization in the biceps tendinopathy, and it was used for modification of the classical Bonar score. Consequently, recalculated, modified Bonar score was correlated positively with smoking indexes and functional outcomes. Furthermore, the morphological alterations of rotator cuff tendons also correlated positively with the extent of biceps tendon degeneration, measured according to the modified scoring system.

The Impact of Smoking on Clinical Results Following the Rotator Cuff and Biceps Tendon Complex Arthroscopic Surgery

The purpose of this study was to investigate the association of smoking and functional outcomes after arthroscopic treatment of complex shoulder injuries: rotator cuff tears (RCTs) with biceps tendon (LHBT) tears. This retrospective case-control study has been conducted on a cohort of patients who underwent shoulder arthroscopy between 2015 and 2017 due to complex injury treatment. The outcomes were assessed using the American Shoulder and Elbow Surgeons Score (ASES), the University of California at Los Angeles (UCLA) Shoulder Score, need for non-steroid anti-inflammatory drugs (NSAIDs) consumption and the visual analog scale (VAS). Complications and changes in smoking status were also noted. A cohort of 59 patients underwent shoulder arthroscopy, due to complex LHBT pathology and RCTs, and were enrolled in the final follow-up examination; with mean duration of 26.03 months. According to smoking status, 27 of patients were classified as smokers, and the remaining 32 were non-smokers. In the examined cohort, 36 patients underwent the LHBT tenotomy and 23 tenodesis. We observed a relationship between smoking status and distribution of various RCTs (p < 0.0001). The mean postoperative ASES and UCLA scores were 80.81 and 30.18 in the smoker's group and 84.06 and 30.93 in the non-smoker's group, respectively. There were no statistically significant differences in pre/postoperative ASES and postoperative UCLA scores between smokers and non-smokers (p > 0.05). The VAS was significantly lower in the non-smokers' group (p = 0.0021). Multi-tendon injuries of the shoulder are a serious challenge for surgeons, and to obtain an excellent functional outcome, we need to limit the negative risk factors, including smoking. Furthermore, there is a significant association between smoking and the occurrence of massive rotator cuff tears, and the pain level measured by the VAS. Simultaneous surgical treatment of RC and LHBT lesions in the smoker population allowed us to obtain the functional outcomes approximated to non-smokers in the long-term follow-up. Of course, we cannot assert that smoking is the real cause of all complications, however, we may assume that this is a very important, negative factor in shoulder arthroscopy.

A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures

PURPOSE

The purpose of the present study was to identify differences in 30-day adverse events, reoperations, readmissions, and mortality for smokers and nonsmokers who undergo operative treatment for a distal radius fracture.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients who had operatively treated distal radius fractures between 2005 and 2017. Patient characteristics and surgical variables were assessed. Thirty-day outcome data were collected on serious (SAEs) and minor adverse events (MAEs), as well as on infection, return to the operating room, readmission, and mortality. Multivariable logistic analyses with and without propensity-score matching was used to compare outcome measures between the smoker and the nonsmoker cohorts.

RESULTS

In total, 16,158 cases were identified, of whom 3,062 were smokers. After 1:1 propensity-score matching, the smoking and nonsmoking cohorts had similar demographic characteristics. Based on the multivariable propensity-matched logistic regression, cases in the smoking group had a significantly higher rate of any adverse event (AAE) (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.28-2.38), serious adverse event (SAE) (OR, 1.75; 95% CI, 1.22-2.50), and minor adverse event (MAE) (OR, 1.84; 95% CI, 1.04-3.23). Smokers also had higher rates of infection (OR, 1.73; 95% CI, 1.26-2.39), reoperation (OR, 2.07; 95% CI, 1.13-3.78), and readmission (OR, 1.83; 95% CI, 1.20-2.79). There was no difference in 30-day mortality rate.

CONCLUSIONS

Smokers who undergo open reduction internal fixation of distal radius fractures had an increased risk of 30-day perioperative adverse events, even with matching and controlling for demographic characteristics and comorbidity status. This information can be used for patient counseling and may be helpful for treatment/management planning.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Smoking Alters Inflammation and Skeletal Stem and Progenitor Cell Activity During Fracture Healing in Different Murine Strains

Smokers are at a higher risk of delayed union or nonunion after fracture repair. Few specific interventions are available for prevention because the molecular mechanisms that result in these negative sequelae are poorly understood. Murine models that mimic fracture healing in smokers are crucial in further understanding the local cellular and molecular alterations during fracture healing caused by smoking. We exposed three murine strains, C57BL/6J, 129X1/SvJ, and BALB/cJ, to cigarette smoke for 3 months before the induction of a midshaft transverse femoral osteotomy. We evaluated fracture healing 4 weeks after the osteotomy using radiography, micro-computed tomography (μCT), and biomechanical testing. Radiographic analysis demonstrated a significant decrease in the fracture healing capacity of smoking 129X1/SvJ mice. μCT results showed delayed remodeling of fracture calluses in all three strains after cigarette smoke exposure. Biomechanical testing indicated the most significant impairment in the functional properties of 129X1/SvJ in comparison with C57BL/6J and BALB/cJ mice after cigarette smoke exposure. Thus, the 129X1/SvJ strain is most suitable in simulating smoking-induced impaired fracture healing. Furthermore, in smoking 129X1/SvJ murine models, we investigated the molecular and cellular alterations in fracture healing caused by cigarette smoking using histology, flow cytometry, and multiplex cytokine/chemokine analysis. Histological analysis showed impaired chondrogenesis in cigarette smoking. In addition, the important reparative cell populations, including skeletal stem cells and their downstream progenitors, demonstrated decreased expansion after injury as a result of cigarette smoking. Moreover, significantly increased pro-inflammatory mediators and the recruitment of immune cells in fracture hematomas were demonstrated in smoking mice. Collectively, our findings demonstrate the significant cellular and molecular alterations during fracture healing impaired by smoking, including disrupted chondrogenesis, aberrant skeletal stem and progenitor cell activity, and a pronounced initial inflammatory response. © 2020 American Society for Bone and Mineral Research (ASBMR).

Impact of Tobacco Smoking on Outcomes After Posterior Decompression Surgery in Patients With Cervical Spondylotic Myelopathy: A Retrospective Multicenter Study

STUDY DESIGN

This was a case-control study.

OBJECTIVE

The objective of this study was to clarify the surgical outcomes after cervical posterior decompression in patients who smoked.

SUMMARY OF BACKGROUND DATA

Smoking is associated with poor outcomes in the field of spinal surgery. However, the impact of tobacco smoking on the outcomes after posterior decompression surgery has not been fully evaluated in patients with cervical spondylotic myelopathy.

MATERIALS AND METHODS

In this retrospective multicenter study, 587 patients with cervical spondylotic myelopathy were enrolled at 17 institutions in Japan. Patients underwent cervical laminoplasty or laminectomy and were followed up for at least 1 year after surgery. Outcome measures were: preoperative smoking status, perioperative complications, the Japanese Orthopedic Association scale, and the Visual Analog Scale for neck pain. After adjusting for age and sex by exact matching, smoking and nonsmoking groups were compared using an unpaired t test for continuous variables or a χ test for categorical variables.

RESULTS

There were 182 (31%) current smokers and 405 (69%) nonsmokers including previous smokers. After matching, 158 patients were extracted from each group. Demographic data and surgical information were almost the same between the groups. Regarding postoperative complications, there was no significant difference in the rate of surgical site infection, cerebrospinal fluid leakage, hematoma, segmental motor paralysis, or neurological deficit. However, smokers showed a significantly higher risk for delirium (3.8% vs. 0.0%, P=0.039). Smokers and nonsmokers showed comparable changes in functional recovery according to Japanese Orthopedic Association scores (3.2±2.1 vs. 3.0±2.1, P=0.425) and in neck pain reduction using the Visual Analog Scale (-1.7±3.1 vs. -1.4±2.8, P=0.417) at the final follow-up.

CONCLUSIONS

Smokers exhibited functional restoration and neck pain reduction after cervical posterior decompression. Attention is required, however, for the postoperative complication of delirium, which could be caused by the acute cessation of tobacco smoking after admission.

LEVEL OF EVIDENCE

Level III.

Contributions of obesity and cigarette smoking to incident disability: A longitudinal analysis

Downward trends in U.S. disability levels are stagnating. Assessing the key contributors to U.S. disability incidence is critical to improving the functional status of the U.S. population. Using longitudinal, nationally representative data from waves 2003-2015 of the Panel Study of Income Dynamics (PSID), we estimated age-specific U.S. disability incidence and quantified the individual and joint contributions of obesity (contemporaneous and earlier-life; BMI ≥ 30) and cigarette smoking to disability incidence. Participants were adults ages 33-96 who participated in PSID in 1986 and at least two consecutive waves 2003-2015 (N = 3247). We conducted age-stratified logistic regressions to predict incident disability at middle and older ages (33-69 years, 70-96 years). Next, counterfactual scenarios were used to estimate the contributions of each risk factor to incident disability. Disability incidence was greater in women than men (5.8 and 4.5 cases per 100 person-years, respectively) and increased with age. Obesity and cigarette smoking jointly explained 17-38% of disability incidence; each factor contributed roughly equal amounts in all groups but older men, for whom smoking history appeared more important. Obesity and smoking appeared to explain more of disability at younger ages (women: 33.1%, 95% CI: 25.1 to 41.0%; men: 37.6%, 95% CI: 28.8 to 46.5%) than at older ages (women: 16.5%, 95% CI: 8.2 to 24.9%; men: 24.5.%, 95% CI: 12.7 to 36.3%). This study provides a benchmark for monitoring trends in U.S. disability incidence. Obesity and smoking are key contributors to disability, accounting for 17-38% of incident disability in U.S. adults.

Smoking is an independent risk factor for complications following open rotator cuff repair

Objectives: Smoking has been associated with poor cuff healing and worse long-term outcomes in patients undergoing rotator cuff repair. The effects of smoking on short-term complications following open rotator cuff repair are not well defined. The purpose of this study is to analyze the effects of smoking on 30-day outcomes following open rotator cuff repair. Methods: The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent open rotator cuff repair from 2011 to 2016. Patients who were current smokers (within 1 year prior to surgery) were identified and compared with nonsmokers. Demographic data and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used to isolate the effect of smoking on complications after surgery. Results: We identified 5,157 patients who underwent open rotator cuff repair, of which 18% (946 patients) were current smokers (within 1 year of surgery). Smokers were younger (54.4 years versus 61.5 years, P < 0.001) and were more likely to be male (60.8% versus 56.9%, P = 0.03). Compared with nonsmokers, smokers had a similar rate of comorbidities (P = 0.35) and similar preoperative functional status (P = 0.53), but had higher mean American Society of Anesthesiologists (ASA) class (P < 0.001). Logistic regression revealed that smoking was an independent predictor for any complication (OR 1.9, P = 0.03), any venous thromboembolic event (OR 4.6, P = 0.01), and pulmonary embolism (OR 6.4, P = 0.02). Conclusion: Patients who smoke are at increased risk for short-term complications after open rotator cuff repair. Smoking is independently associated with increased rate of postoperative venous thromboembolic events such as pulmonary embolism. This further highlights the importance of preoperative smoking cessation in patients undergoing open rotator cuff repair.

Status of circulating bone turnover markers in elderly osteoporosis/osteopenia patients in comparison with healthy subjects

Background

In the aging individuals, osteoporosis is a major health problem. Due to the various limitations of dual X-ray absorptiometry (DEXA) for diagnosis osteoporosis, serum-based biochemical markers have been suggested for the discrimination between the patients and healthy subjects.

Objective

To investigate the serum levels of bone turnover markers in elderly osteoporosis patients.

Methods

The serum samples from elderly subjects (osteoporosis (n = 28), osteopenia (n = 28), and healthy ones (n = 28) were collected from Amirkola Health and Ageing Project study. Furthermore, serum levels of bone formation and bone resorption markers as well as estrogen and progesterone were measured by enzyme-linked immunosorbent assay. Kruskal–Wallis test and receiver operating characteristic curve analysis were used for statistical analysis using SPSS.

Results

Levels of bone alkaline phosphatase (B-ALP) and procollagen type I N-terminal propeptide (PINP) differed between groups (P = 0.003 and 0.009, respectively). Furthermore, PINP and B-ALP levels had the best area under the curve, sensitivity, and specificity for the discrimination between patients with osteoporosis and healthy individuals.

Conclusion

In conditions in which we are not able to assess the bone mineral density by DEXA, analysis of the B-ALP and PINP levels may be a helpful tool.

Differential Impact of Cigarette Smoking on Fracture Risks in Subjective Cognitive Decline and Dementia: A Nationwide Longitudinal Study

OBJECTIVE

We aimed to explore the differential impact of cigarette smoking on fracture risks in SCD and dementia.

METHODS

A nationwide population-based cohort study design was used. Out of all the people aged 66 (n=1,555,103) who went through the National Screening Program from 2009-2014, 968,240 participants with eligible data were included in the study. Time-to-event was calculated as the duration between the NSPTA and fracture incidence. Cox proportional-hazard regression analyses were conducted to evaluate the risk of fractures.

RESULTS

Increased risk of all [adjusted hazard ratio (aHR)=1.184; 95% confidence interval (CI)=1.184, 1.093-1.283], hip (aHR=1.518; 95% CI=1.168-4.972), vertebral (aHR=1.235; 95% CI=1.101-1.386) fractures were increased in current smokers with more than 20 or more pack years (≥20 py) of SCD group, after adjusting for all relevant confounding factors. In dementia group, however, current smokers ≥20 py were at reduced risk of hip fractures (aHR=0.249; 95% CI=0.089-0.97).

CONCLUSION

There was a disparate influence of cigarette smoking on the fracture risks in SCD and dementia group. Further studies are warranted to explicate this phenomenon, and personalized preventive measures according to one's cognitive status are imperative, since risk factors of fractures can exert disparate influence on patients at different stage of cognitive trajectory.