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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 welve 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 III. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Objective: The primary aim was to describe the epidemiology of the Holstein-Lewis humeral shaft fracture, its association with radial nerve palsy, and the outcome regarding recovery from the radial nerve palsy and fracture healing. The secondary aim was to analyze the long-term functional outcome., Setting: Six major hospitals in Stockholm County., Design: Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome., Patients: Twenty-seven patients with a 12A1.3 humeral shaft fracture according to the OTA classification satisfying the criteria of a Holstein-Lewis fracture in a population of 358 patients with 361 traumatic humeral shaft fractures., Intervention: Nonoperative or operative treatment according to the decision of the attending orthopaedic surgeon., Main Outcome Measurements: Recovery of the radial nerve, fracture healing, and functional outcome according to the Short Musculoskeletal Function Assessment (SMFA)., Results: The Holstein-Lewis humeral shaft fracture constitutes 7.5% of all humeral shaft fractures and was associated with an increased risk of acute radial nerve palsy compared with other types of humeral shaft fractures, 22% versus 8% (P < 0.05). The fractures of 6 of the 7 operatively treated patients healed after the primary surgical procedure while 1 fracture healed after revision surgery. The fractures of all patients treated nonoperatively healed without any further intervention. All 6 radial nerve palsies (2 patients treated nonoperatively and 4 operatively) recovered. The functional outcome according to the SMFA was good with no differences between the nonoperatively and operatively treated patients: SMFA dysfunction index 7.6 and 9.7, respectively, and SMFA bother index 6.1 and 6.8, respectively., Conclusions: The Holstein-Lewis humeral shaft fracture was associated with a significantly increased risk of acute radial nerve palsy. The overall outcome regarding fracture healing, radial nerve recovery, and function was very good regardless of the primary treatment modality, that is, operative or nonoperative treatment. The indication for primary operative intervention in this fracture type appears to be relative.

Objective: To determine whether an intervention with smoking cessation starting 4 weeks before general and orthopedic surgery would reduce the frequency of postoperative complications., Summary Background Data: Complications are a major concern after elective surgery and smokers have an increased risk. There is insufficient evidence concerning how the duration of preoperative smoking intervention affects postoperative complications., Methods: A randomized controlled trial, conducted between February 2004 and December 2006 at 4 university-affiliated hospitals in the Stockholm region, Sweden. The outcome assessment was blinded. The follow-up period for the primary outcome was 30 days. Eligibility criteria were active daily smokers, aged 18 to 79 years. Of the 238 patients assessed, 76 refused participating, and 117 men and women undergoing surgery for primary hernia repair, laparoscopic cholecystectomy, or a hip or knee prosthesis were enrolled., Intervention: Smoking cessation therapy with individual counseling and nicotine substitution started 4 weeks before surgery and continued 4 weeks postoperatively. The control group received standard care. The main outcome measure was frequency of any postoperative complication., Results: An intention-to-treat analysis showed that the overall complication rate in the control group was 41%, and in the intervention group, it was 21% (P = 0.03). Relative risk reduction for the primary outcome of any postoperative complication was 49% and number needed to treat was 5 (95% CI, 3-40). An analysis per protocol showed that abstainers had fewer complications (15%) than those who continued to smoke or only reduced smoking (35%), although this difference was not statistically significant., Conclusion: Perioperative smoking cessation seems to be an effective tool to reduce postoperative complications even if it is introduced as late as 4 weeks before surgery.

Objective: The primary aim was to report on the recovery of radial nerve function in patients with acute closed humeral shaft fractures and associated primary radial nerve palsy. The secondary aim was to report on the long-term functional outcome and health-related quality of life (HRQoL) in patients with this specific injury., Setting: Six major hospitals in Stockholm County., Design: Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome and HRQoL., Patients: Thirty-three patients with acute radial nerve palsy and a closed humeral shaft fracture in a population of 358 patients with 361 humeral shaft fractures., Intervention: Nonoperative or operative treatment as per decision of the attending orthopedic surgeon., Main Outcome Measurements: Recovery of the radial nerve, fracture healing, functional outcome according to the Short Musculoskeletal Function Assessment (SMFA) and the Disabilities of the Arm, Shoulder and Hand (DASH). HRQoL according to Short Form 36 (SF-36)., Results: Among the 18 patients treated nonoperatively, 16 (89%) displayed a complete recovery from their radial nerve palsy while 2 (11%) presented minor sequelae. In 11 (73%) of the 15 patients treated primarily operatively, the nerve function recovered completely while 2 patients (13%) had minor sequelae and 2 (13%) had major sequelae, i.e. 1 partial nerve palsy and 1 total radial nerve palsy. Sixteen patients (48%) were available for assessment of the long-term functional outcome and HRQoL at a mean of 7 years (range, 6 to 8 years). The range of motion and the muscular strength of the injured arm, the functional outcome according to the SMFA, and HRQoL according to the SF-36 showed results comparable to those previously reported for patients with healed humeral shaft fractures without associated radial nerve palsy., Conclusion: This study confirms the high spontaneous recovery rate of primary radial nerve palsies in patients with closed humeral shaft fractures. Primary radial nerve palsy should not be regarded as an isolated indication for primary surgical intervention.

Objective: The aim of this study was to investigate the outcome after an isolated humeral shaft fracture treated primarily nonoperatively with a fracture brace., Setting: University hospital., Design: Descriptive study. Retrospective assessment of clinical and radiographic healing. Prospective assessment of functional outcome and health-related quality of life (HRQoL)., Patients: Seventy-eight patients (female, n = 45), mean age 58 (range, 16-91) years with isolated humeral shaft fractures., Intervention: Closed functional treatment with a fracture brace., Main Outcome Measurements: Fracture healing, need for revision surgery, Short Musculoskeletal Functional Assessment (SMFA), HRQoL according to the Short Form 36 (SF-36) and patient-reported recovery., Results: Ninety percent of the fractures healed after nonoperative treatment, and nearly 90% of the nonunions healed after revision surgery. There was a trend toward more frequent nonunions in simple fractures, that is, type A according to the Orthopedic Trauma Association (OTA) classification (P = 0.08). The nonunion rate in type A fractures located in the proximal and middle part of the shaft was approximately 20%. Nearly 50% of the patients reported full recovery after successful nonoperative treatment, but none of the patients with a healed nonunion did after revision surgery (P < 0.05). The SMFA scores for arm/hand function were acceptable for the patients who healed after the primary fracture-brace treatment, but the values were worse for those with a healed nonunion after revision surgery. The SF-36 scores were generally slightly lower compared with a Swedish reference population., Conclusion: This study confirms the high overall rate of union of humeral shaft fractures and an acceptable functional outcome after successful fracture-brace treatment. However, in simple (type A) fractures, the nonunion rate seems to be higher, and patients with healed nonunions after revision surgery reported worse functional outcomes. Based on these findings, it seems reasonable to explore the use of plate fixation compared with nonoperative treatment for selected fracture types in a randomized controlled trial.

Background and Methods: The incidence of readmissions because of delayed intracranial complications within 3 weeks after observation for the sole diagnosis of concussion was examined in a national cohort. A nested case-control design was used to analyze the association between clinical factors as well as early computed tomography (CT) scan examination and these complications., Results: Out of 100,784 patients hospitalized because of concussion during ten years, 127 (0.13%) patients were readmitted because of a delayed intracranial complication. High clinical severity grade (odds ratio [OR] 2.0, confidence interval [CI] 1.2-3.6), minor CT scan abnormalities (OR 1.7, CI 0.8-3.4) and male gender (OR 2.2, CI 1.4-3.5) were associated with an increased risk of delayed, intracranial complications., Conclusion: The incidence of delayed intracranial complications after primarily uncomplicated concussion was low. High clinical severity grade and male gender were risk factors. We failed to demonstrate an additional value of the acute CT scan examination to predict these complications.