Journal of American Science 2014;10(3) http://www.jofamericanscience.org 124 Investigation of smoking effects on percutaneous autologous bone marrow injection for nonunion patients Taher Abd Elsattar Aid 1 , Adel Ibrahim Alseedy 1 , Ahmed F. Shams 1 , Ahmed Abd Elfattah Khalil 2 . 1 Department of Orthopedic Surgery, Faculty of Medicine, Menufiya University, Egypt 2 Department of Orthopedic Surgery, Al-Menshawy Hospital, Tanta, Egypt midoorthopedics@yahoo.com Abstract: Regarding the effects of smoking on fracture healing and post-operative infection after long-bone fracture surgery, there is little reported analysis. Our study aimed to report the smoking effect on percutaneous autologous bone marrow injection for nonunion patients. Twenty patients, 10 smokers and 10 nonsmokers, were referred to us with a nonunion of the tibia and femur after number of previous interventions on bone to procure healing at the time of fracture. A total of 40–80 mL of bone marrow aspirated from the anterior iliac crest and injected in and around the nonunion site under fluoroscopic guidance. The overall success rate obtained from the operation was 70.0% (14/20), but there was a significant difference between the success rates of smokers and non-smokers [50.0% (5/10) vs 90.0% (9/10)]. Generally, smoking was associated with increased nonunion for all fractures. Additionally, smokers trended towards longer mean healing times. [Taher Abd ElsattarAid, Adel Ibrahim Alseedy, Ahmed F. Shams, Ahmed Abd Elfattah Khalil. Investigation of smoking effects on percutaneous autologous bone marrow injection for nonunion patients. J Am Sci 2014;10(3):124-128]. (ISSN: 1545-1003). http://www.jofamericanscience.org . 16 Key Words: nonunion, bone marrow, injection, smoking 1.Introduction: Bone healing is a complex process that is influenced by biological, mechanical and systemic factors (1). There is growing evidence that smoking delays or inhibits bone healing after surgery or trauma. This evidence has largely been derived from animal studies and human studies focusing on spinal fusion (2-5). Causes of nonunion may be related either to the fracture (type and site of fracture, degree of comminution, infection, instability, vascular injury) or to systemic factors including diabetes (6), peripheral vascular disease (7), and non-steroidal anti-inflammatory drugs (NSAiDS) (8). Smoking has a well documented negative effect on the cardiac and respiratory systems. Moreover, there is little reported analysis regarding the effects of smoking on fracture healing and post-operative infection after long bone fracture surgery (9). The current study tries to bring in arguments for a similar negative effect on bone healing. There are 4000 chemicals found in cigarettes (10). Nicotine, carbon monoxide and hydrogen cyanide are often cited as the causes of adverse effects. However the exact mechanism and effect of smoking on fracture healing has yet to be established (11). Bone marrow contains osteoprogenitor cells capable of forming bone (12,13). Percutaneous bone marrow grafting involves harvesting autogenous bone marrow from the anterior or posterior iliac crest using a trochar needle (13). The technique is minimally invasive, has low morbidity (13- 15). Percutaneous bone marrow injection has been reported with favorable results as a clinical treatment for diaphyseal fracture nonunions in humans in the upper extremity (16), femur (17), and tibia (14,18). Giannoudis (19) described a “diamond concept of requirements” for fracture healing to occur successfully: osteogenic cells, osteoconductive scaffold, mechanical stability and adequate growth factors. Whilst it is unlikely that smoking affects the mechanical stability, it may have effects on the other three aspects of the diamond. This study looks specifically at the effect of smoking on the outcome of bone marrow injection for the nonunited long bone fractures. 2. Patients and Methods A total of randomized 20 prospective patients were admitted to Menufiya University hospital and El Menshawy Hospital, Egypt, from November 2009 and February 2013. Out of 20 patients, 10 patients were smokers and the remaining patients were non smokers, with nonunion were treated with bone marrow injection. The patient's age ranged between 20-63 years. Selection criteria for treatment with percutaneous autogenous bone marrow injection in patients were described by Willkins (20) as follows: established nonunion more than six months after injury with no evidence of healing for the previous three months, no evidence of motion seen at nonunion site, no intervention in past three months, no evidence of active infection, no smoking for last six weeks, no pre-existing angular deformity or shortening. Additionally, the hardware components seemed to be intact by radiographic evaluation, and there was no apparent or compelling reason to remove the hardware (e.g, poorly oriented or