Document Type : Original Article

Authors

Abstract

Abstract
Introduction: Non-union or delayed union after long bone fracture surgery is very common. This study aimed at evaluating the healing time of closed femoral shaft fractures in smokers and non-smokers following open reduction and internal fixation with plate and intramedullary nailing.
Methods: In a cohort study, patients were divided into two groups of smokers and non-smokers with closed transverse fracture of the femoral shaft bone. The patients who smoked 6 or more cigarettes per day were considered as smoker. Treatment method was based on the patient's preference and not based on being smoker or not. Patients were followed up for one year for clinical and radiological examinations on the status of the union. The collected data were analyzed using SPSS software version 19.
Results: In our study, 220 patients were studied (110 smokers and 110 non-smokers). Most of the patients with closed femoral shaft fractures were men (79.7%). Their mean age was 32.78± 16.93 years. There was a statistically significant relationship between the bone healing in treatment with plate and intramedullary nailing in smokers (P = 0.004). All non-smokers had union (100%), 74.1% in the group treated with plate had union and 78.8% in the group treated with intramedullary nailing had union, respectively (P = 0.234) 180 days after surgery. There was also a statistically significant association between delayed union in plate treatment and intramedullary nailing in patients who smoked (P = 0.04).
Conclusion: The treatment and daily function of smokers is usually worse than non-smokers and needs longer follow-up. It seems that the intramedullary nailing in smokers with closed femoral shaft fracture leads to more delayed union.

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    1. Ge J, Kong K-Y, Cheng X-Q, Li P, Hu X-X, Yang H-L, et al. Missed diagnosis of femoral deep artery rupture after femoral shaft fracture: A case report. World Journal of Clinical Cases. 2020;8(13):2862.
    2. Gandhi RR, Overton TL, Haut ER, Lau B, Vallier HA, Rohs T, et al. Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery. 2014;77(5):787-95.
    3. Denisiuk M, Afsari A. Femoral Shaft Fractures. StatPearls [Internet]: StatPearls Publishing; 2020.
    4. Wu K-J, Li S-H, Yeh K-T, Chen H, Lee R-P, Yu T-C, et al. The risk factors of nonunion after intramedullary nailing fixation of femur shaft fracture in middle age patients. Medicine. 2019;98(29).
    5. Bråten M, Terjesen T, Rossvoll I. Femoral shaft fractures treated by intramedullary nailing. A follow-up study focusing on problems related to the method. Injury. 1995;26(6):379-83.
    6. Patel R, Wilson R, Patel P, Palmer R. The effect of smoking on bone healing: a systematic review. Bone & joint research. 2013;2(6):102-11.
    7. Zhang R, Yin Y, Li S, Jin L, Hou Z, Zhang Y. Traction table versus double reverse traction repositor in the treatment of femoral shaft fractures. Scientific reports. 2018;8(1):1-9.
    8. Chrisovitsinos JP, Xenakis T, Papakostides KG, Skaltsoyannis N, Grestas A, Soucacos PN. Bridge plating osteosynthesis of 20 comminuted fractures of the femur. Acta Orthopaedica Scandinavica. 1997;68(sup275):72-6.
    9. Geissler WB, Powell TE, Blickenstaff KR, Savoie FH. Compression plating of acute femoral shaft fractures. Orthopedics. 1995;18(7):655-60.
    10. Kent ME, Arora A, Owen PJ, Khanduja V. Assessment and correction of femoral malrotation following intramedullary nailing of the femur. Acta Orthop Belg. 2010;76(5):580-4.
    11. Ma Y-G, Hu G-L, Hu W, Liang F. Surgical factors contributing to nonunion in femoral shaft fracture following intramedullary nailing. Chinese Journal of Traumatology. 2016;19(2):109-12.
    12. Moore KL, Dalley AF. Clinically oriented anatomy: Wolters kluwer india Pvt Ltd; 2018.
    13. Pearson RG, Clement R, Edwards K, Scammell BE. Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis. BMJ open. 2016;6(11).
    14. Nawfal A, SEwELL MD, BHAviKATT M, GiKAS PD. The effect of smoking on fracture healing and on various orthopaedic procedures. Acta Orthop Belg. 2012;78:285-90.
    15. Sloan A, Hussain I, Maqsood M, Eremin O, El-Sheemy M. Theeffects of smoking on fracture healing. the surgeon. 2010;8(2):111-6.
    16. Scolaro JA, Schenker ML, Yannascoli S, Baldwin K, Mehta S, Ahn J. Cigarette smoking increases complications following fracture: a systematic review. JBJS. 2014;96(8):674-81.
    17. Al-Mukhtar SA. The Effect of Cigarette Smoking on Bone Healing in Elderly Individuals with Colle's Fracture. Tobacco Use Insights. 2010;3:TUI. S3009.
    18. Wong LS, Martins‐Green M. Firsthand cigarette smoke alters fibroblast migration and survival: implications for impaired healing. Wound repair and regeneration. 2004;12(4):471-84.
    19. Kung MH, Yukata K, O'Keefe RJ, Zuscik MJ. Aryl hydrocarbon receptor‐mediated impairment of chondrogenesis and fracture healing by cigarette smoke and benzo (α) pyrene. Journalof cellular physiology. 2012;227(3):1062-70.
    20. Ahmadi J, Pridmore S, Alimi A, Cheraghi A, Arad A, Parsaeyan H, et al. Epidemiology of opium use in the general population. The American journal of drug and alcohol abuse. 2007;33(3):483-91.
    21. Gaston M, Simpson A. Inhibition of fracture healing. The Journal of bone and joint surgery British volume. 2007;89(12):1553-60.
    22. Farshidi H, Aghamolaei T, Soleimani Ahmadi M, Madani AH. Epidemiological study of cigarette smoking among over 15 years old population of Hormozgan in 2014. Journal of Preventive Medicine. 2016;3(2):29-35.
    23. Shukla R, Jain N, Jain R, Baxi M. Effects of smoking on healing of distal femur intra-articular fractures, treated with distal femur locking compression plate. Journal of Orthopedics, Traumatology and Rehabilitation. 2018;10(1):54.
    24. Tay W-H, de Steiger R, Richardson M, Gruen R, Balogh ZJ. Health outcomes of delayed union and nonunion of femoral and tibial shaft fractures. Injury. 2014;45(10):1653-8.
    25. Hoffmann MF, Khoriaty JD, Sietsema DL, Jones CB. Outcome of intramedullary nailing treatment for intertrochanteric femoral fractures. Journal of orthopaedic surgery and research. 2019;14(1):360.
    26. Schenker M, Scolaro J, Yannascoli S, Baldwin K, Mehta S, Ahn J, editors. Blowing Smoke: A Meta Analysis of Smoking on Fracture Healing and Post Operative Infection. 2013 American Academy of Orthopaedic Surgeons annual meeting in Chicago; 2013.
    27. Thomas JD, Kehoe JL. Bone Nonunion. StatPearls [Internet]: StatPearls Publishing; 202
    28. Duthon V, Ozturk M, El-Achachi S, Menetrey J. Deleterious effects of smoking on the musculoskeletal system. Revue medicale suisse. 2014;10(437):1466-71.
    29. Wang D, Chen X-H, Fu G, Gu L-Q, Zhu Q-T, Liu X-L, et al. Calcium intake and hip fracture risk: a meta-analysis of prospective cohort studies. International journal of clinical and experimental medicine. 2015;8(8):14424.
    30. Lutfy K, Aimiuwu O, Mangubat M, Shin CS, Nerio N, Gomez R, et al. Nicotine stimulates secretion of corticosterone via bothCRH and AVP receptors. Journal of neurochemistry. 2012;120(6):1108-16.
    31. Ward KD, Klesges RC. A meta-analysis of the effects of cigarette smoking on bone mineral density. Calcified tissue international. 2001;68(5):259-70.
    32. Law M, Hackshaw A. A meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture: recognition of a major effect. Bmj. 1997;315(7112):841-6.
    33. Adams C, Keating J, Court-Brown C. Cigarette smoking and open tibial fractures. Injury. 2001;32(1):61-5.
    34. RicciWM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2009;17(5):296-305.
    35. Shah RK. Nonunion Following Intramedullary Nailing of Femoral Shaft Fractures in Low Income Countries. Journal of Bone Reports & Recommendations. 2016;2(2):1-3.
    36. Testa G, Vescio A, Aloj DC, Papotto G, Ferrarotto L, Massé A, et al. Definitive Treatment of Femoral Shaft Fractures: Comparison between Anterograde Intramedullary Nailing and Monoaxial External Fixation. Journal of clinical medicine. 2019;8(8):1119.
    37. Seyed Abdolhossein Mehdinassab NS, Reza Eerabian Surgery in Femoral Shaft Fractures in Adults (A Comparative Study between Plating and Open Interlocking Nailing) Iranian Journal of Orthopaedic Surgery. 2011;9(3):132-24.