Durability of Smoking Cessation for Elective Lower Extremity Orthopaedic Surgery

Does Marijuana Smoking Increase the Odds of Surgical Site Infection After Orthopaedic Surgery? A Retrospective Cohort Study

OBJECTIVES

Does marijuana smoking increase the risk of surgical site infection (SSI) after open reduction and internal fixation of fractures?

METHODS

DESIGN

Retrospective.

SETTING

Single academic level 1 trauma center in Southern California.

PATIENT SELECTION CRITERIA

Adult patients who underwent open treatment for closed fractures between January 2009 and December 2021, had hardware placed, and had at least 6 months of postoperative follow-up.

OUTCOME MEASURES AND COMPARISONS

Risk factors associated with the development of SSI were compared between current inhalational marijuana users and nonmarijuana users.

RESULTS

Complete data were available on 4802 patients after exclusion of 82 who did not have a complete variable set. At the time of surgery, 24% (1133 patients) were current users of marijuana. At the final follow-up (minimum 6 months), there was a 1.6% infection rate (75 patients). The average age of the infection-free group was 46.1 ± 23.1 years, and the average age of the SSI group was 47.0 ± 20.3 (P = 0.73) years. In total, 2703 patients (57%) in the infection-free group were male compared with 48 (64%) in the SSI group (P = 0.49). On multivariate analysis, longer operative times (OR 1.002 [95% CI, 1.001-1.004]), diabetic status (OR 2.084 [95% CI, 1.225-3.547]), and current tobacco use (OR 2.493 [95% CI, 1.514-4.106]) (P < 0.01 for all) were associated with an increased risk of SSI; however, current marijuana use was not (OR 0.678 [95% CI, 0.228-2.013], P = 0.48).

CONCLUSIONS

Tobacco use, diabetes, and longer operative times were associated with the development of SSI after open reduction and internal fixation of fractures; however, marijuana smoking was not shown to be associated with the development of SSI.

LEVEL OF EVIDENCE

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

Smoking cessation prior to elective total joint arthroplasty results in sustained abstinence postoperatively

BACKGROUND

Tobacco use is a well-documented modifiable risk factor for perioperative complications.

AIM

To determine the tobacco abstinence rates of patients who made cessation efforts prior to a total joint arthroplasty (TJA) procedure.

METHODS

A retrospective evaluation was performed on 88 self-reported tobacco users who underwent TJA between 2014-2022 and had tobacco cessation dates within 3 mo of surgery. Eligible patients were contacted via phone survey to understand their tobacco use pattern, and patient reported outcomes. A total of 37 TJA patients participated.

RESULTS

Our cohort was on average 61-years-old, 60% (n = 22) women, with an average body mass index of 30 kg/m2. The average follow-up time was 2.9 ± 1.9 years. A total of 73.0% (n = 27) of patients endorsed complete abstinence from tobacco use prior to surgery. Various cessation methods were used perioperatively including prescription therapy (13.5%), over the counter nicotine replacement (18.9%), cessation programs (5.4%). At final follow up, 43.2% (n = 16) of prior tobacco smokers reported complete abstinence. Patients who were able to maintain cessation postoperatively had improved Patient-Reported Outcomes Measurement Information System (PROMIS)-10 mental health scores (49 vs 58; P = 0.01), and hip dysfunction and osteoarthritis outcome score for joint replacement (HOOS. JR) scores (63 vs 82; P = 0.02). No patients in this cohort had a prosthetic joint infection or required revision surgery.

CONCLUSION

We report a tobacco cessation rate of 43.2% in patients undergoing elective TJA nearly 3 years postoperatively. Patients undergoing TJA who were able to remain abstinent had improved PROMIS-10 mental health scores and HOOS. JR scores. The perioperative period provides clinicians a unique opportunity to assist active tobacco smokers with cessation efforts and improve postoperative outcomes.

Smoking Is Markedly Associated With 30-Day Readmission and Revision Surgery After Surgical Treatment of Clavicle Fracture

BACKGROUND

A recent database study found that 15.2% of clavicle fractures underwent surgical treatment. Recent evidence accentuates the role of smoking in predicting nonunion. The purpose of this study was to further elucidate the effect of smoking on the 30-day postoperative outcomes after surgical treatment of clavicle fractures.

METHODS

The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent open reduction and internal fixation of clavicle fracture between 2015 and 2020. Multivariate logistic regression, adjusted for notable patient demographics and comorbidities, was used to identify associations between current smoking status and postoperative complications.

RESULTS

In total, 6,132 patients were included in this study of whom 1,510 (24.6%) were current smokers and 4,622 (75.4%) were nonsmokers. Multivariate analysis found current smoking status to be significantly associated with higher rates of deep incisional surgical-site infection (OR, 7.87; 95% CI, 1.51 to 41.09; P = 0.014), revision surgery (OR, 2.74; 95% CI, 1.67 to 4.49; P < 0.001), and readmission (OR, 3.29; 95% CI, 1.84 to 5.89; P < 0.001).

CONCLUSION

Current smoking status is markedly associated with higher rates of deep incisional surgical-site infection, revision surgery, and readmission within 30 days after open reduction and internal fixation of clavicle fracture.

"We're On The Same Team": A Qualitative Study On Communication And Care Coordination Surrounding The Requirement To Quit Smoking Prior To Elective Orthopaedic Surgery

INTRODUCTION

Many surgeons require patients to quit smoking prior to elective surgeries to reduce the risk of postoperative complications. Our aim was to qualitatively evaluate the communication and care experiences of patients and clinicians involved in conversations about quitting smoking prior to elective orthopaedic surgery.

METHODS

A qualitative interview study of rural-residing Veterans, primary care providers (PCPs), and Veterans Administration (VA) orthopaedic surgery staff and pharmacists, who care for rural Veterans. We performed a combination of deductive and inductive approaches to support conventional content analysis using a Patient-Centered Care framework.

RESULTS

Patients appreciated a shared approach with their PCP on the plan and reasons for cessation. Despite not knowing if the motivation for elective surgeries served as a teachable moment to facilitate long-term abstinence, almost all clinicians believed it typically helped in the short-term. There was a lack of standardized workflow between primary care and surgery, especially when patients used care delivered outside of VA.

CONCLUSIONS

While clinician-provided information about the reasons behind the requirement to quit smoking preoperatively was beneficial, patients appreciated the opportunity to collaborate with their care teams on developing a plan for cessation and abstinence. Other aspects of patient-centered care need to be leveraged, such as the therapeutic alliance or patient-as-person, to build trust and improve communication surrounding tobacco use treatment. System-level changes may need to be made to improve coordination and connection of clinicians within and across disciplines.

IMPLICATIONS

This study included perspectives from patients, primary care teams, and surgical teams and found that, in addition to providing information, clinicians need to address other aspects of patient-centered care such as the therapeutic alliance and patient-as-person domains to promote patient engagement in tobacco use treatment. This, in turn, could enhance the potential of surgery as a teachable moment and patient success in quitting smoking.

Risk Factors for Loss of Reduction After Open Reduction and Internal Fixation of Isolated Olecranon Fractures in Adults

BACKGROUND

We sought to determine whether any relevant patient, fracture, surgical, or postoperative characteristics are associated with loss of reduction after plate fixation of isolated olecranon fractures in adults.

METHODS

Patients who underwent open reduction and internal fixation of an olecranon fracture at our institution over an 11-year period were analyzed. Electronic patient charts and radiographic images were reviewed to gather patient, fracture, surgical, and postoperative data. Statistical analysis to explore the differences between groups was performed.

RESULTS

Seven of 96 patients experienced a loss of fracture reduction diagnosed at a median of 19 days after their initial surgery (range: 4-116 days). The radiographic mode of failure of all patients who lost reduction was proximal migration of the proximal fracture fragment with or without implant failure. The group that lost reduction had a significantly smaller proximal fragment (14.2 vs 18.6 mm), a higher incidence of malreduction with a persistent articular step-off greater than 2 mm (6/7 vs 14/89), a greater distance between the most proximal screw and the olecranon tip (19.8 vs 13.5 mm), a higher proportion of constructs with screws placed outside of the primary plate (4/7 vs 14/89), and a higher proportion of patients that were not immobilized postoperatively (3/7 vs 8/89).

CONCLUSIONS

Our results suggest anatomical reduction at the articular surface and adequate fixation of the proximal fragment are key factors in maintenance of reduction, with smaller proximal fragments being at higher risk for failure. A period of postoperative immobilization may decrease the risk of loss of reduction.

Surgical Optimization for Charcot Patients

Reconstruction of the Charcot foot and ankle demonstrates significant challenges to the foot and ankle surgeon. At present, there is limited clear consensus on the best approach for preoperative optimization. The primary aim of Charcot reconstructions is to limit the risk of ulceration by providing a stable plantigrade foot allowing ambulation. The focus of this article is the discussion of modifiable risk factors associated with Charcot reconstruction for preoperative optimization.

Resistance narratives in patients' accounts of a mandatory pre-operative health optimisation scheme: A qualitative study

Background

Pre-operative Health Optimisation is the engagement of patients in health behavior change, such as smoking cessation and weight reduction prior to surgery. Programmes which routinely delay surgery while some patients undergo preoperative optimisation are increasingly used within the UK. Advocates of this approach argue that it reduces perioperative risk and encourages longer term change at a teachable moment. However, critics have argued that mandatory preoperative optimisation schemes may perpetuate or exacerbate inequalities.

Aim

To understand patients' experience of a mandatory preoperative optimisation scheme at the time of referral for elective surgery.

Design and setting

Qualitative interview study in one area of the UK.

Method

Participants were recruited through GP practices and participating weight-loss schemes. Data was collected from nine semi-structured face-to-face interviews. Thematic analysis was informed by the concept of narratives of resistance.

Results

Four forms of resistance were found in relation to the programme. Interviewees questioned the way their GPs presented the scheme, suggesting they were acting for the health system rather than their patients. While interviewees accepted personal responsibility for health behaviors, those resisting the scheme emphasized that the wider system carried responsibilities too. Interviewees found referral to the scheme stigmatizing and offset this by distancing themselves from more deviant health behaviors. Finally, interviewees emphasized the logical contradictions between different health promotion messages.

Conclusion

Patients described negative experiences of mandatory pre-operative health optimisation. Framing them as resistance narratives helps understand how patients contest the imposition of optimisation and highlights the risk of unintended consequences.

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.

Mandatory Nicotine Cessation for Elective Orthopedic Hip Procedures Results in Reduction in Postoperative Nicotine Use

Purpose

To determine the efficacy of mandatory preoperative nicotine cessation on postoperative nicotine use, and to identify independent predictors of nicotine use relapse in subjects undergoing hip preservation surgery or total hip arthroplasty by a single fellowship-trained orthopedic surgeon.

Methods

Consecutive subjects that underwent hip surgery from November 2014 to December 2017 were reviewed. Subjects who self-reported nicotine use, quit prior to surgery, and completed a minimum one-year follow-up were included. Multiple linear regression models were constructed to determine the effect of independent variables on nicotine use relapse following surgery.

Results

Sixty subjects were included in the study (mean follow-up 35.1 months (17-57 months), mean age 44.9 years (20-82 years), and 23 (38.3%) males). Twenty-eight subjects (46.7%) remained nicotine-free at final follow-up. The mean number of cigarettes per day decreased from 13.4 preoperatively to 8.4 postoperatively in the subjects who relapsed (P=0.002). The mean time to return to nicotine postoperatively was 2.4 months. The number of preoperative cigarettes per day was the only independent predictor of tobacco use relapse (P=0.005).

Conclusion

Mandatory preoperative nicotine cessation prior to elective hip surgery demonstrates a 46.7% nicotine-free survivorship at final follow-up with the number of preoperative cigarettes per day found to be the only independent predictor of nicotine use relapse.

Level of evidence

The level of evidence of this research study is Level III since it is a non-experimental study with a cohort of patients.

Smoking Effects in Foot and Ankle Surgery: An Evidence-Based Review

BACKGROUND

The purpose of this article was to review the basic science pertaining to the harmful effects of cigarette smoke, summarize recent clinical outcome studies, and examine the benefits of smoking cessation and the efficacy of current smoking cessation strategies.

METHODS

The literature concerning basic science, clinical outcomes, and smoking cessation was reviewed; over half (56%) of the 52 articles reviewed were published in the last 5 years.

RESULTS

Smoking is associated with low bone mineral density, delayed fracture union, peri-implant bone loss, and implant failure. Orthopedic surgical patients who smoke have increased pain and lower overall patient satisfaction, along with significantly increased rates of wound healing complications.

DISCUSSION/CONCLUSION

Active smoking is a significant modifiable risk factor and should be discontinued before foot and ankle surgery whenever possible. Orthopedic surgeons play an important role in educating patients on the effects of smoking and facilitating access to smoking cessation resources.

LEVEL OF EVIDENCE

Level V, expert opinion.