Smoking
Physicians should not consider a patient’s smoking/nicotine use as a critical decision making factor at time zero; Physicians should recommend nicotine education/cessation (abstinence of nicotine) for all patients with high energy lower limb trauma as there is moderate evidence to suggest that smoking/nicotine use has a detrimental effect on outcomes for both amputation and limb salvage.
Limb Salvage or Early Amputation
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: AOFAS, OTA

Rationale

RATIONALE:

One high quality (MacKenzie, 2006) and three moderate quality (Bosse, 2002; MacKenzie, 2004, 2005) studies revealed significantly worse physical, psychosocial, and overall function measures on the Sickness Index Profile (SIP) among recent and current smokers versus never smokers. Despite the focus of this literature on smoking specifically, the work group recommends cessation of all forms of nicotine given that it is the active ingredient that contributes most to the majority of negative physiological side effects. Physicians should recommend nicotine education/cessation (abstinence of nicotine) for all patients with high energy lower limb trauma and engage in shared decision-making with patients as there is moderate evidence to suggest that smoking/nicotine has a detrimental effect.

BENEFITS/HARMS:

It is well known that smoking has been linked to a multitude of other health risks including, but not limited to multiple cancers, cardiac and pulmonary diseases, PVD, wound complications (including infection), slower bone healing and nonunion, etc. Hence, smoking/nicotine cessation may have multitude of positive effects on outcomes without having any known risks among patients with severe lower extremity trauma regardless of treatment strategy.

IMPORTANT/PRIORITY OUTCOMES:

Successful limb salvage and achieving optimal overall outcomes while minimizing costs/complications are ideal for both patients and health care systems. These ideals will more likely be realized when patients are able to successfully quit smoking/nicotine use.

COST EFFECTIVENESS/RESOURCE UTILIZATION:

Smoking/nicotine cessation has the potential to significantly decrease the costs associated with complications and improve quality of life outcomes in patients with severe lower extremity trauma regardless of treatment strategy. Smoking/nicotine cessation programs are often covered comprehensively by insurers, and thus, little out-of-pocket expense to patients. Therefore, it is likely that smoking/nicotine cessation would prove cost-effective over a life-time to both patients and health care systems.

ACCEPTABILITY:

Most patients, even smokers and users of other nicotine products, will acknowledge that smoking/nicotine may lead to poor general health, and thus, would accept the notion that continued smoking/nicotine use may lead to worse outcomes after severe lower extremity injury.

FEASIBILITY:

There is no evidence to suggest recommending one technique over another for achieving successful smoking/nicotine cessation. Discussion of various techniques is beyond the scope of this paper.

FUTURE RESEARCH:

Defining the incidence of specific complications directly related to smoking/nicotine use for both limb salvage and amputation will enable more detailed physician-patient counseling. Additionally, defining the risk of failure of limb salvage specifically related to smoking/nicotine use could be a powerful adjunct for educating patients undertaking this strategy.


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