Hafiz F. Kassam

➢ Biologic and synthetic augmentation grafts have been developed to enhance both the mechanical integrity of rotator cuff repairs and the biologic healing at the tendon-bone interface, particularly in the setting of compromised tissue quality. ➢ Xenograft augmentation is no longer favored because of inconsistent clinical outcomes, inflammatory responses, and a lack of supportive high-quality evidence. ➢ Allograft and synthetic graft augmentation may provide benefit in selected cases; however, optimal indications, implant selection, and long-term outcomes remain incompletely defined. ➢ Bioinductive collagen implants currently demonstrate the highest level of clinical evidence, with Level-I studies supporting improved structural healing and reduced retear rates in appropriately selected patients. ➢ The long head of the biceps tendon autograft represents a viable, cost-effective biologic augmentation option when available, providing favorable biologic compatibility and surgical versatility.

Background: Tobacco dependence is well established to impair bone healing and increase postoperative complications. However, the independent effects of nicotine, separate from combustion-related factors, remain unclear. This study aimed to evaluate the impact of non-tobacco nicotine dependence (NTND) following open reduction and internal fixation (ORIF) of clavicle fractures, including midshaft and lateral fracture subtypes. Methods: A retrospective cohort study was performed using a large national database. Patients undergoing ORIF of clavicle fractures were identified using procedural and diagnostic codes. Patients with non-tobacco nicotine dependence (e.g., vaping, patches, or gum) were identified and propensity score matched to (1) patients without nicotine exposure and (2) patients with tobacco nicotine dependence. In a secondary analysis, patients were stratified by fracture type (midshaft and lateral), and outcomes were compared between nicotine exposure and no nicotine exposure within each subgroup. Outcomes were assessed at 90 days and 1 year and included medical complications, number of opioid prescriptions, and implant-related outcomes. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated, with p < 0.05 considered significant. Results: After matching, 936 non-tobacco nicotine users were identified. Non-tobacco nicotine dependence was associated with increased implant removal at 90 days (RR 2.50) and higher opioid prescriptions ( p < 0.05). At 1-year, non-tobacco nicotine use was associated with increased implant removal (RR 1.74), infection (RR 1.73), and nonunion (RR 1.78) ( p < 0.05). In direct comparisons between non-tobacco nicotine and tobacco nicotine users ( n = 897), there were no significant differences in postoperative complications or implant-related outcomes (all p > 0.05). In fracture-specific analyses, nicotine use was associated with increased infection (RR 2.17), nonunion (RR 1.42), and implant removal (RR 1.24) in midshaft fractures ( p < 0.05), with no significant differences observed in lateral fractures. Conclusion: Non-tobacco nicotine dependence was associated with increased risks of infection, opioid utilization, implant removal, and nonunion following clavicle fracture fixation. These associations were observed predominantly in midshaft fractures, with no significant differences in lateral fractures. These findings suggest that non-tobacco nicotine dependence may carry a risk profile similar to that of tobacco use. Level of evidence: III.