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Scientific Articles   |    
Effect of Smoking Cessation Intervention on Results of Acute Fracture SurgeryA Randomized Controlled Trial
Hans Nåsell, MD1; Johanna Adami, MD, PhD2; Eva Samnegård, MD, PhD3; Hanne Tønnesen, PhD4; Sari Ponzer, MD, PhD1
1 Section of Orthopaedics, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, S-118 83 Stockholm, Sweden. E-mail address for H. Nåsell: nasell@sodersjukhuset.se. E-mail address for S. Ponzer: sari.ponzer@ki.sehans
2 Department of Medicine, Clinical Epidemiology Unit, Karolinska University Hospital, Solna, S-17176 Stockholm, Sweden. E-mail address: Johanna.adami@vinnova.se
3 Section of Orthopaedics, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, S-182 88 Stockholm, Sweden. E-mail address: Eva.samnegard@ki.se
4 WHO-Collaborating Centre for Evidence-Based Health Promotion, Bispebjerg Hospital, Bispebjerg Bakke 23, 2400 København NV Denmark. E-mail address: ht02@bbh.regionh.dk
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Swedish National Institute of Public Health and the Stockholm County Council Research Fund and of less than $10,000 from Pfizer. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Bactiguard AB).

Investigation performed at the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Jun 01;92(6):1335-1342. doi: 10.2106/JBJS.I.00627
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Abstract

Background: 

Tobacco smoking is a major health and economic concern and is also known to have a significant negative effect on surgical outcomes. The benefits of a smoking cessation intervention prior to elective orthopaedic surgery have been evaluated previously. Our aim was to assess whether a smoking cessation program, initiated during the acute hospitalization period and carried out for six weeks, could reduce the number of complications following emergency surgical treatment of fractures.

Methods: 

In a multicenter, single-blinded, randomized, controlled clinical trial, 105 smokers with a fracture of the lower or upper extremity that needed acute surgical treatment were randomized to an intervention group (n = 50) or a control group (n = 55). The intervention group was offered a standardized smoking cessation program for six weeks, and all patients were followed at two to three weeks, four weeks, and six to twelve weeks.

Results: 

The proportion of patients with at least one postoperative complication was significantly larger in the control group than it was in the intervention group (38% and 20%, respectively; p = 0.048). The development of two or more postoperative complications was also more common among the controls (p = 0.039). The rates of superficial wound infection, the most frequently recorded complication in both groups, were 20% and 8%, but this difference was not significant. A secondary analysis showed that the odds of having a complication were 2.51 times (95% confidence interval, 0.96 to 6.9 times) higher in the control group than in the intervention group, but this difference was not significant.

Conclusions: 

Our results indicate that a smoking cessation intervention program during the first six weeks after acute fracture surgery decreases the risk of postoperative complications.

Level of Evidence: 

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

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Tanujan Thangarajah, MBChB (Hons), MRCS
    Posted on July 03, 2010
    Drs. Thangarajah and Narayan respond to Dr NÃ¥sell
    Birmingham Heartlands Hospital, Birmingham, United Kingdom

    To the Editor:

    NÃ¥sell and colleagues should be congratulated on their efforts to elucidate the effect of smoking cessation on the outcome of acute fracture surgery (1). The paper filled a substantial void in the existing literature that has thus far failed to provide Level 1 evidence implicating smoking in a poor outcome following operative intervention for acute fractures. While it was a well designed trial, patient recruitment was an issue given that 75% of eligible participants were not included. The study group may not therefore have been a representative sample.

    We wish to highlight an article published by ourselves in an indexed journal that retrospectively reviewed the rate of surgical site infections (SSIs) following open reduction and internal fixation of ankle fractures (2). Albeit a retrospective analysis, the results were similar to those presented by NÃ¥sell et al. (1) in that smoking was found to be significantly associated (p=0.02) with SSIs. Accordingly, we advocated counseling for all smokers undergoing internal fixation for ankle fractures. This evidence is by no means conclusive though. We would like to draw the authors' attention to another study (3) that assessed the effect of smoking, amongst other variables, on the short-term functional outcome following ankle fracture fixation. The results indicated that, contrary to its effect on the healing of other bodily tissues, smoking did not exert the same deleterious influence on ankle fractures treated by plate osteosynthesis.

    Despite this, we believe that NÃ¥sell et al. (1) have now provided sufficient evidence to suggest that patients who smoke are indeed at greater risk of complications following surgery for acute fractures. It is for this reason that we as clinicians should make decisions regarding fracture management with this in mind as it is surely better to have reasonable function with a course of conservative treatment, rather than an operative site infection that may require the removal of all metal work and even amputation!

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Nåsell H, Adami J, Samnegård E, Tønnesen H, Ponzer S. Effect of smoking cessation intervention on results of acute fracture surgery: a randomized controlled trial. J Bone Joint Surg Am. 2010;92:1335-42.

    2. Thangarajah T, Prasad PS, Narayan B. Surgical site infections following open reduction and internal fixation of ankle fractures. Open Orthop J. 2009;3:56-60.

    3. Egol KA, Tejwani NC, Walsh MG, Capla EL, Koval KJ. Predictors of short-term functional outcome following ankle fracture surgery. J Bone Joint Surg Am. 2006;88:974-9.

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