Presentation Abstract

Session: 586-600-Trauma V
Date/Time: Friday, Mar 22, 2013, 8:36 AM - 8:42 AM
Location McCormick Place, Room N426
Presentation Number: Paper 591
Title: Blowing Smoke: A Meta-Analysis of Smoking on Fracture Healing and Post-Operative Infection
Classification: +Other (Trauma)
Keywords: Fracture Healing; Nonunion/Malunion; Epidemiology/Procedural/Outcomes
Author(s): Mara L. Schenker, MD, Philadelphia, Pennsylvania
John A. Scolaro, MD, Seattle, Washington
Sarah M. Yannascoli, MD, Philadelphia, Pennsylvania
Keith D. Baldwin, MD, Sicklerville, New Jersey
Samir Mehta, MD, Philadelphia, Pennsylvania
Jaimo Ahn, MD, PhD, Philadelphia, Pennsylvania
Abstract: INTRODUCTION: Cigarette smoking is recognized as one of the major causes of preventable disease in the United States. However, there is little reported analysis regarding the effects of smoking on fracture healing and post-operative infection after long-bone fracture surgery. The aim of this study was to systematically review the association between smoking and fracture healing (nonunion and healing time) and post-operative infections.
METHODS: Medline, EMBASE and Cochrane computerized literature databases and manual search of bibliographies were performed. Randomized controlled trials, and cohort studies (retrospective and prospective) evaluating the association between smoking and long bone fracture healing and smoking and infection were included. Descriptive and quantitative data were extracted. A meta-analysis was performed using a random effects model for nonunion, superficial and deep infections in smoking and non-smoking cohorts. Time to healing was evaluated using frequency-weighted means, and group weighted standard deviations. Three sensitivity analyses were performed to evaluate the effects of tibia fractures, open fractures and level of evidence. Study heterogeneity, criteria of methodological quality and publication bias were also evaluated, and adjusted for using trim and fill analysis.
RESULTS: Initial search identified 7,110 references. Of the 237 articles further inspected by title, 20 were included (seven prospective and 13 retrospective cohort studies), and 18 offered sufficient data for meta-analysis. The adjusted odds of nonunion was 2.3 times in the smoking group compared to the non smoking group (95% confidence interval: 1.8, 3.0; p<0.01). There was increased nonunion in smokers with tibia fractures (OR 2.42, 95% CI: 1.7, 3.4; p<0.01) and with open fractures only (2.42, 95% CI: 1.7, 3.4; p<0.01). For all fracture types, the mean healing time was longer for smokers (30.2 weeks, 95% CI: 22.7, 37.7) than non-smokers (24.1 weeks, 95% CI: 17.3, 30.9). For tibia fractures, the mean healing time was longer for smokers (32.0 weeks, 95% CI: 23.2, 41.0) than non-smokers (25.1 weeks, 95% CI: 16.4, 33.9). There was no difference in post-operative superficial and deep infections between smokers and non-smokers undergoing long bone fracture surgery (p=0.13). Publication bias was noted in the small studies showing a larger effect size than larger studies. Trim and fill analysis was performed which resulted in similar results to the original meta-analysis.
CONCLUSION: Smoking was associated with increased nonunion for all fractures, tibia fractures and open fractures. Additionally, smokers trended towards longer mean healing times. The potential risks need to be discussed with all fracture patients, and the effects of smoking intervention programs should be instituted to promote better outcomes in post-fracture patients.
Disclosures: Presenting Author
Author 1
Author 2
Author 3
4 - Pfizer; 7 - Journal of Bone and Joint Surgery - American
Author 4
2 - Zimmer Smith & Nephew AO North America; 3B - Smith &a

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