Polyaxial locking plates in treating distal humeral fractures: a comparative randomized trial for clinical outcome

Moritz Crönlein
Martin Lucke
Marc Beirer
Dominik Pförringer
Chlodwig Kirchhoff
Peter Biberthaler
Karl F Braun
Sebastian Siebenlist
Polyaxial locking plates in treating distal humeral fractures: a comparative randomized trial for clinical outcome
10.1186/s12891-017-1910-9R E S E A R C H A R T I C L E Open Access
Background: Management of distal humeral fractures remains to be one of the most challenging aspects in trauma surgery. Low profile plating systems with variable angle screw fixation represent a crucial advancement to the established angular stable locking plates with considerable attention in current research. The aim of the prospective randomized trial was to review the preliminary results and patients' outcome following treatment with these newly developed implants and to rule out potential differences in fracture treatment of two different plating systems. Methods: Twenty patients with distal humeral fractures (AO 13-A1 -AO 13-C3) were included in the current study since 2014. After completing the randomization plan, patients were distributed into two groups for different variable angle locking plates (DePuy Synthes® VA-LCP vs. Medartis® Aptus Elbow). Functional elbow scoring (ROM, MEPS, QuickDASH) served as primary outcome parameter, while radiological fracture consolidation served as secondary outcome parameter. Follow-ups were conducted 6 weeks, 12 weeks, 6 months and 12 months after the operation.Results: Seventeen of 20 patients (85%) concluded all follow-up examinations. Postoperative elbow extension deficiencies showed significant differences between the two groups in all follow-up examinations with a mean of Ø 18 +/− 7.4 degrees in the DePuy Synthes® VA-LCP group compared to a mean of Ø 6.5 +/− 7.5 degrees in the Medartis® Aptus Elbow group (p = 0.002) 12 months postoperatively. Functional scoring showed a disparate pattern. The Medartis® Aptus Elbow group achieved significantly better MEP scores during follow-up. However, the analysis of the QuickDash revealed better results of the DePuy Synthes® VA-LCP group in the first half and better results of the Medartis® Aptus Elbow group in the second half of the follow-up examination instead.Conclusions: Considering the complexity of distal humeral fractures, the usage of anatomically preshaped low profile variable angle locking plates for operative treatment leads to good clinical results. Even though there might be some advances of the Medartis® Aptus Elbow plating system concerning postoperative ROM and elbow function, a consistent difference in the overall clinical outcome between the two plating systems could not be detected. Trial registration: https://clinicaltrials.gov/ct2/show/NCT03272490 Retrospectively Registered 1. September 2017.

Background

Distal humeral fractures are still very rare accounting for only 1-2% of all fractures [1]. Concerning the complex fracture pattern of these fractures together with the growing age of the patients, management remains to be one of the most challenging aspects in modern trauma surgery [2]. Dealing with these challenges, a large variety of different treatment options can be found in current literature, ranging from conservative treatment [3,4] to different operative fixation techniques [5][6][7][8] up to total joint replacements [9].

The essential goal to achieve best results for patients suffering from distal humeral fractures is to restore joint congruency irrespective of patient's age. Considering that, conservative treatment frequently leads to a painful limited range of motion (ROM) quite often. Over the last decades, therefore, open reduction and internal fixation (ORIF) is known to be the treatment of choice [10]. Due to the importance of the distal humerus for elbow function and stability, new specific angular stable implant systems and innovative fixation techniques have been developed in the recent past [11]. Biomechanical analysis of angle stable locking plates already show promising results for fracture treatment especially in the osteoporotic bone [12]. As an advancement to the known angle stable locking plates where screws can only be placed in the predetermined direction, low profile plating systems with a variable angle for screw fixation gain considerable attention in current research. The usage of anatomically preshaped plates with variable possibilities for angular stable screw fixation already showed promising results in dealing with various complex fracture types like distal femur fractures [13], distal tibial fractures [14], distal radial fractures [15], clavicle fractures [16] or radial head fractures [15,17]. However, little about these modern implants is known in terms of dealing with distal humeral fractures.

With the Medartis® Aptus Elbow distal Humerus Plates 2.8 (Medartis®, Basel, Switzerland) and the DePuy Synthes® VA-LCP distal Humerus Plates 2.7/ 3.5 (DePuy Synthes®, Umkirch, Germany), two modern plating systems have recently been introduced. Both plating systems consist of an anatomically preshaped low-profile design with variable angle for locking screw fixation and especially designed for fracture treatment of the distal humerus. Therefore, the aim of the present prospective randomized trial was to review the preliminary functional outcomes following treatment with these anatomically preshaped low-profile plating implants in the short-term and to rule out potential differences between both plating systems.

Methods

Patients

Before study initiation the approval of the local ethics committee of (Trial Number 253/14) was obtained. The comparative prospective randomized clinical trial included 20 patients with fractures of the distal humerus recruited from a level-one university trauma centre. Patient recruitment was conducted between 03/2014 and 12/2015. Fractures of the distal humerus, as defined by the AO classification system (AO 13-A1 -AO 13-C3), were included in this study as they were identified by the treating surgeon being applicable for locking plate treatment and after written informed consent of the patients was obtained. All patients were randomized following a randomization plan (Randlist®, DatInf GmbH, Tübingen, Germany) for either being treated with the DePuy Synthes® VA-LCP 2.7/3.5 mm (DePuy Synthes®, Umkirch, Germany) or with the Medartis® Aptus Elbow system 2.0/3.8 mm (Medartis®, Basel, Switzerland). Both include anatomically preshaped, polyaxial angular stable locking plates in various sizes. Angle stable screw positioning with the freedom of +/− 15°offaxis screw placement gives the surgeon a large variety in both systems.

The inclusion criteria involve all patients from the age of 18 to 95 years who suffered from a distal humeral fracture (AO 13-A1 -AO 13-C3) that had to undergo operative treatment. The exclusion criteria involve all under-aged patients (< 18 years), pregnant patients and patients with a mental disorder as well as patients under comprehensive legal support. In addition, pathological fractures had been excluded from the study.

Surgical technique

All patients were operated by consultant orthopaedic and trauma surgeons, experienced in upper extremity surgery. The mean interval between injury and operation was 2.4 days (range 0-12 days). General anaesthesia was used in all cases and a single dose of 1.5 mg cephalosporin was given preoperatively for prophylaxis. Patients were positioned in prone position with the injured arm on a radiolucent, small padded arm holder. Under tourniquet control, the posterior approach (Bryan-Morrey) to the distal humerus was performed in all cases. Additional olecranon osteotomy was performed in 7 cases (3× DePuy Synthes® vs. 4× Medartis® Aptus Elbow) presenting with AO type 13 C2 and AO type 13 C3 fractures. Postoperatively, physiotherapy was initiated using the same rehabilitation protocol for both groups. Passive and active assisted ROM was permitted immediately without limitations, while weight bearing was restricted for 6 weeks.

Follow-up evaluation

All patients were initially followed-up 6 weeks after operation. Additional follow-ups were performed 3, 6 and 12 months postoperatively. The follow-up examinations were carried out by an independent investigator not involved in patient's initial surgical treatment (MC) in the outpatient clinic of our level-one university trauma centre.

For the assessment of pain, the visual analogue scale (VAS), ranging from 0 "no pain" to 10 "worst imaginable pain" was documented. ROM and collateral ligament stability were registered on standardized scoring sheets. For subjective evaluation, patients rated their satisfaction for elbow use on a scale of 1 to 6 (1-highly satisfied; 2satisfied; 3-moderate; 4-sufficient; 5-unsatisfied; 6-very unsatisfied). Moreover, sensomotoric disturbances and postoperative complications were recorded. Minor complications had been defined as complications that could be treated conservatively (e.g. superficial wound infections, delayed union etc.), whereas major complications needed operative revision (e.g. secondary loss of reduction, non-unions, severe wound infections etc.). For functional upper extremity and elbow scoring the shortened Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) and the Mayo Elbow Performance Score (MEPS) were comprised. Postoperative x-rays were evaluated with special respect to bony healing, secondary loss of reduction and heterotopic ossifications.

Statistics

Statistical analyses were performed using the statistical software SigmaStat (version 3.5; Systat Software, San Jose, CA, USA). The scores at certain time points were compared with an independent t test after a normality check had been passed and equal variances had been detected. Normal distributed data with unequal variances would have been compared with Welch's t test. Arbitrarily data was tested with Mann-Whitney U test. The significance level was set at p = 0.05.

Results

Epidemiological data

Seventeen of 20 patients (85%) were able to conclude all follow up examinations (see Fig. 1). Three patients were lost to follow-up. One patient died 6 months postoperatively of unrelated cause to the surgery, the other two patients never returned for postoperative clinical and radiological control of unknown cause. These both patients also couldn't be found for follow-up survey. The remaining 17 patients presented with a mean age of 79 years (range 31-91 years) at the time of injury with no statistically differences between groups. Most common injury types were falls from less than three meters. Gender distribution showed differences with only 1 male patient compared to 16 female patients (see Table 1).

Clinical outcome

Clinical follow-up included documentation of swelling, redness, joint effusion, delay of wound healing, crepitation and muscular atrophy. At no timepoint during the follow-up survey any differences could be determined between the two groups concerning these clinical parameters. Even though pain levels of the DePuy Synthes® VA-LCP group turned out to be higher in all of the follow-up examinations, significant  Table 2). Nerve injury had been detected in one patient with a partial sensomotoric palsy of the ulnar nerve, following ORIF of a comminuted AO type 13-C3 fracture using the DePuy Synthes® VA-LCP plating system (see Table 3). After neurolysis of the ulnar nerve the motoric palsy fully recovered whereas sensory ulnar nerve palsy remained.

Compared to the uninjured arm postoperative elbow extension deficiencies showed significant differences between both groups at every follow-up examination with a mean value of Ø 18 +/− 7.4 degrees in the DePuy Synthes® VA-LCP group compared to a mean value of Ø 6.5 +/− 7.5 degrees in the Medartis® Aptus Elbow group (p = 0.002) at 12 months postoperatively (see Fig. 2). For flexion and pronosupination no differences were seen between groups. Likewise, there were no signs of collateral ligament instability in both groups.

For subjective evaluation, patients rated their satisfaction for elbow use. Overall, 14 patients rated their satisfaction from very satisfied to sufficient (3× very satisfied, 6× satisfied, 4× moderate, 1× sufficient) and would undergo surgery again. The remaining three patients were not satisfied at time of last survey (2× Medartis® Aptus Elbow, 1× DePuy Synthes®). Differences between the two plating systems could not be detected for this subgroup analysis.

The elbow scoring showed a different result pattern for the QuickDash. In the first two clinical follow-ups (after 6 and 12 weeks) the DePuy Synthes® VA-LCP group showed better results than the Medartis® Aptus Elbow group, however not statistically significant. After 6 and 12 months on the other hand statistically significant better results were determined in the Medartis® Aptus Elbow group (see Table 2). The Medartis® Aptus Elbow group achieved significantly better MEP Scores in all of the postoperative follow-up examinations with good results 6 weeks postoperatively and excellent results 12 weeks, 6 months and 12 months   Table 2).

Radiological follow-up

Eleven fractures showed a fracture healing without complications at final follow-up of 12 months (4× DePuy Synthes® vs. 7 x Medartis® Aptus Elbow) (see Figs. 3 and 4). Nonunions were detected in two patients, both following treatment of an AO type 13 C3 fracture with the Medartis® Aptus Elbow system. One of them, a 74-year-old female suffering from multiple comorbidities (i.e. diabetes type 2, obesity, COPD), presented with a non-union which resulted in secondary plate loosening. The other patient, 68-year-old female, presented as a heavy smoker (>25 pack years) and a history of recurrent falls of unknown cause, following initial distal humeral plating. Both patients have been revised using allogenic bone grafts with subsequent osseous healing. A secondary loss of reduction was seen in one 80-year-old female patient following treatment with the DePuy Synthes®, VA-LCP system. Due to her age and comorbidities, elbow replacement after plate removal was performed 5 months after index operation. Heterotopic ossifications were seen in two patients, one of each treatment group (see Table 3). One of them, a 55-years-old female (Medartis® Aptus Elbow), had to be revised due to ROM deficiencies based on massive heterotopic ossifications 13 months following plate osteosynthesis. In the sequel, an open arthrolysis and implant removal was performed after fracture consolidation. According to medical records, this patient was satisfied with the postoperative result 6 months after implant removal and arthrolysis.

Discussion

A recent advance in the treatment of complex distal humeral fractures has been the introduction of anatomically preshaped, polyaxial angular stable locking plates [18][19][20]. Besides acting as internal fixators due to their locking fixation, screw positioning within a total range of up to 30°can be chosen, giving the surgeon a larger variety of screw placement [15]. The purpose of the present study therefore was to review the short-term results following treatment with these novel implants.

The most important finding was that usage of polyaxial angular stable plating systems leads to reliable results with good functional outcome in the majority of patients. Substantial differences between both evaluated plating systems could neither be detected for subjective evaluation nor for functional elbow scoring. Patients' satisfaction is directly constrained to elbow mobility. The postoperative ROM showed significant better results with decreased extension deficits in the Medartis® Aptus Elbow group compared to the DePuy Synthes® group (see Fig. 2). However, an overall extension deficit of 12.3°( see Fig. 2) 12 months after osteosynthesis was found for both groups which is sufficient to fulfil most of the personal daily routine activities (functional arc of elbow  At all times of follow-up evaluation, the extension deficits showed significant differences between the two groups (p < 0.05) motion according to BF Morrey) [10]. While both plating systems provide comparable implants in terms of diameter, length and material, there might be advantages in the plate design of the lateral Medartis® Aptus Elbow plates, which are twisted from distal lateral to proximal posterior for parallel plating in order to reduce soft tissue detachment during the operation and postoperative soft tissue irritation as well. This design feature might at least explain parts of the slightly higher postoperative ROM, even though not proven based on the present data. Obvious restrictions in the postoperative ROM or postoperative stiffness, however, defy explanation by implant size or configuration. Rather reasonable for postoperative stiffness in general, is the prolonged postoperative immobilization, often used to compensate inadequate fixation [21]. As another reason for postoperative stiffness, heterotopic ossifications or capsule adhesions are described with rates up to 8.6% in the current literature [22]. Two patients with extension deficiencies due to heterotopic ossifications were determined in our trial (see Table 3), with only one of them needing revision after fracture consolidation. In cases of major extension deficiencies open arthrolysis and implant removal is recommended [22], as we performed in our case with good clinical outcome. Postoperative Indomethacin therapy seems promising to prevent from heterotopic ossifications following ORIF of distal humeral fractures, though significant advantages are still missing in current literature [22]. In this survey no postoperative prophylaxis for heterotopic ossifications was performed. However, different plate configurations are not known to have an impact on postoperative heterotopic ossifications. Known risk factures are rather associated brain injury or delayed surgical treatment [22]. Knowing that bicolumnar plating is an effective and reliable method in treating complex distal humeral fractures [6,23], there is little evidence of the ideal plate positioning [24,25]. Especially the differences of orthogonal plating vs. parallel plating are discussed controversially in current literature. While few authors showed higher biomechanical stability following orthogonal (90°-90°) plating, especially in the osteoporotic bone [23,26], other authors refer to higher stability rates following parallel plaiting [21,27,28]. Current biomechanical examinations of Kudo et al. [29], using the DePuy Synthes® VA-LCP system showed a higher rate of secondary displacement in the orthogonal plating orientation than in the parallel orientation. In matters of theses controversial studies we believe, according to the latest publication of Govindasamy et al. [25], that plate orientation should be chosen according to the fracture pattern, as both variants seem to provide enough stability to fix distal humerus fractures.

Besides the previously discussed plate positioning, screw orientation is known to influence fracture stability, with conventional angle stable locking systems providing higher stability especially against rotational failure than variable locking systems [30]. Highest stability in variable angle locking systems can be achieved inserting the screws perpendicular to the plate [30]. So, a higher variability in fragment fixation using variable plating systems, seems to be at the expense of stability. However, statistically significant differences in postoperative stability due to the used two different implant systems, with only one patient showing a secondary loss of reduction following treatment with the DePuy Synthes® VA-LCP and orthogonal plating position could not be detected in our study.

The complication rates in our study (see Table 3) are consistent with the rates described in the current literature, accounting up to 35% [19]. These high rates can be explained due to numerous reasons, such as the complexity of distal humerus fractures, the low amount of cancellous bone in the distal fragments and the tendency of the elbow joint to develop joint stiffness [10,19,31].

This study has several limitations, including the small number of only 17 examined patients at last follow-up survey and the disparity of both groups (7 patients DePuy Synthes® VA-LCP vs. 10 patients Medartis® Aptus Elbow). Due to the small number of patients, a differentiation between the treated fracture types and the used plate positioning (parallel plating vs. perpendicular plating) was not reasonable with respect to functional outcomes. Also, the influence of implant removal was not analysed. However, the presented follow-up rate of 85%, the wide assessment of functional parameters and the prospective randomized character certainly present the strengths of the present survey. To the best of our knowledge, moreover, this is the first randomized controlled trial to compare two modern polyaxial plating systems in distal humeral fracture treatment.

Conclusion

The usage of anatomically preshaped low profile locking plates in fracture treatment of distal humeral fractures leads to good clinical results. Even though there might be a trend of some advances of the Medartis® Aptus Elbow plating system concerning postoperative ROM and elbow scoring, a crucial difference in the overall clinical outcome between the two plating systems could not be detected in the short-term follow-up. Further trials with higher sample sizes are needed to prove the advantages of these novel implant systems in the treatment of these challenging fractures.

To sum up, successful management of distal humerus fractures is essentially constrained to a correct fracture reduction, a sufficient reconstruction of the articular surface and a high primary stability for early functional rehabilitation.

Abbreviations MEPS: Mayo elbow performance score; ORIF: Open reduction internal fixation; QuickDASH: Disabilities of the arm, shoulder and hand score; ROM: Range of motion; VAS: Visual analogue scale

Fig. 1
1Flow diagram of the progress through the phase of the prospective randomized trial differences could only be observed in the 6 weeks and 12 months follow-ups compared to the Medartis® Aptus Elbow group (see

Fig. 2
2Illustration of the extension deficits. Comparison of extension deficits (Mean Value and Standard Deviation) following distal humeral plating (DePuy Synthes® vs. Medartis® Aptus Elbow) 6 weeks, 12 weeks, 6 months and 12 months postoperatively are presented in this figure.

Fig. 3
3ORIF of a distal humerus fracture (AO 13-C3) with the Medartis® Aptus Elbow System. Radiographs of a 55-year-old female patient with a AO type 13-C3 fracture resulting from a bicycle accident: preoperative x-rays (a), postoperative results, 6 weeks (b), 12 weeks (c) and 6 months (d) following Medartis® Aptus Elbow plating. Implant removal could be obtained after fracture consolidation (e) Fig. 4 ORIF of a distal humerus fracture (AO 13-C3) with the DePuy Synthes® VA-LCP System. Radiographs and CT Scans of a 82-year-old female patient with a AO type 13-C3 fracture resulting from a fall. Preoperative x-rays and CT Scans (a), postoperative results, 6 weeks (b) and 12 months (c) following DePuy Synthes® VA-LCP plating

Table 1 A
1total of 17 patients, presenting with a distal humeral fracture (AO-type 13 A-C), were recruited to this prospective randomized trial, either being treated with DePuy Synthes® VA-LCP or Medartis® Aptus Elbow plating systems. There were no statistically significant differences in patients`demographics or injury characteristics between the groupsCharacteristics
DePuy Synthes®
VA-LCP

Medartis® Aptus
Elbow

Mean age (years)
81
76

Sex (male: female)
0:7
1:9

AO classification

13-A
2
1

13-B
0
0

13-C
5
9

Table 2
2Functional elbow scoring was assessed using MEPs and QuickDash Scores for each plating system (DePuy Synthes® vs. Medartis® Aptus Elbow) separately, 6 weeks, 12 weeks, 6 months and 12 months postoperatively.Scoring System
Plating System
6 weeks
12 weeks
6 months
12 months

VAS
DePuy
Synthes®
VA-LCP

Ø 4.7 +/− 1.1
Ø 1.4 +/−0.8
Ø 3.5 +/− 1.7
Ø 2.3 +/− 1.8

Medartis®
Aptus
Elbow

Ø 2,3 +/− 2.2
Ø 0.8 +/− 0.9
Ø 1.1 +/− 1.5
Ø 1 +/− 0.9

p value
0.006
0.163
0.630
0.074

Quick Dash
DePuy
Synthes®
VA-LCP

Ø 69.5 +/− 13.1
Ø 19.5 +/− 10.5
Ø 56.4 +/− 15.6
Ø 57.2 +/− 16

Medartis®
Aptus
Elbow

Ø 74.1 +/− 21.1
Ø 52.3 +/− 4.8
Ø 25.5 +/− 21.2
Ø 25.5 +/− 10.1

p value
0.634
0.092
0.002
0.002

MEPS
DePuy
Synthes®
VA-LCP

Ø 53 +/− 5.2
Ø 80 +/− 10
Ø 74 +/− 12.1
Ø 75.7 +/− 12.1

Medartis®
Aptus
Elbow

Ø 75 +/− 10
Ø 91.4 +/− 12.1
Ø 90.6 +/− 10.7
Ø 90.9 +/− 10.7

p value
0.001
0.009
0.004
0.007

Results are given as Ø mean +/− standard deviation

Table 3
3Overview of the complications following fracture treatment for each plating system (DePuy Synthes® vs. Medartis® Aptus Elbow)Complication
DePuy Synthes®
VA-LCP

Medartis® Aptus
Elbow

Non-union
0
2

Secondary fracture
dislocation

1
0

Nerve injuries
1
0

Infections
0
0

Heterotopic ossifications
1
1

AcknowledgmentsWe thank Fritz Seidl, M.A. Interpreting and Translating, for professional language editing.FundingNo funding was obtained for this study.Availability of data and materialsTo request the raw data, the first author of the manuscript can contacted: Moritz Crönlein, Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81,675 Munich, Germany, Tel.: 0049-89-4140-2126, E-Mail: firstname.lastname@example.com' contributions MC, ML and SS were substantially involved in conception and design of the study. MC and DP carried out patients evaluation and drafted the manuscript. KFB and MB assisted in the literature research and performed the statistical analysis. PB, SS and CK participated in the design of the study, helped to draft the manuscript and noted critical revisions of the manuscript for important intellectual content. All authors read and approved the final manuscript.Ethics approval and consent to participate
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A Content Analysis of Media Coverage of the Introduction of a Smoke-Free Bylaw in Vancouver Parks and Beaches
2013

Arezu Moshrefzadeh
British Columbia Centre of Excellence for Women's Health
E311, 4500 Oak Street, Box 48V6H 3N1VancouverBCCanada

Wendy Rice
British Columbia Centre of Excellence for Women's Health
E311, 4500 Oak Street, Box 48V6H 3N1VancouverBCCanada

Ann Pederson firstname.lastname@example.com.
British Columbia Centre of Excellence for Women's Health
E311, 4500 Oak Street, Box 48V6H 3N1VancouverBCCanada

Experimental Medicine Program
Department of Medicine
University of British Columbia
Room 10226, 2775 Laurel StreetV5Z 1M9VancouverBCCanada

Chizimuzo T C Okoli email@example.com
College of Nursing
College of Nursing Building
University of Kentucky
315, 40536LexingtonKYUSA

International Journal of Environmental Research and Public Health

A Content Analysis of Media Coverage of the Introduction of a Smoke-Free Bylaw in Vancouver Parks and Beaches

Int. J. Environ. Res. Public Health
10201310.3390/ijerph10094444Received: 4 July 2013; in revised form: 3 September 2013 / Accepted: 4 September 2013 /* Author to whom correspondence should be addressed; E-Mail: email@example.com; OPEN ACCESS Int. J. Environ. Res. Public Health 2013, 10 4445smoke-free policyequitycontent analysismedia
The Board of Parks and Recreation in Vancouver, BC approved a smoke-free bylaw in the city's parks, beaches and recreational facilities, effective 1 September 2010. We analyzed local news coverage and portrayal of the bylaw to understand the potential influence of news media on public perception of the bylaw in order to inform the media advocacy work of public health interest groups. We compiled a data set of newspaper articles (n = 90) and conducted a quantitative content analysis to examine content related to the outdoor smoke-free policy, including article slant, topics related to smoking and tobacco control, and any equity-related concerns raised. Newspaper coverage in Vancouver was largely supportive of the outdoor smoke-free bylaw. However, concerns over rights were frequently discussed in letters to the editor. Such equity concerns were rarely discussed in news articles, showing a potential disconnect between the concerns expressed in the media by members of the public and the coverage provided by print media.

Introduction

In April 2010, the Vancouver Board of Parks and Recreation approved a bylaw completely banning smoking in the city's parks and on the beaches. The bylaw was initiated by Vancouver Parks Board staff in an effort to reduce secondhand smoke exposure, eliminate potential environmental problems (such as fire risk and litter) and ensure smoke-free role-modeling for children and young people [1].

There was some consultation with the public during the development of the bylaw, most notably a public web-based survey conducted through the Board of Parks and Recreation website during October 2009. The general public was also able to provide feedback regarding the bylaw to the Park Board Commissioners at the April 2010 Board Meeting at which the bylaw was debated. Following consultation with the public, the Park Board members voted unanimously in favour of the bylaw. After the necessary amendments to the existing health code were made by the City Council, the implementation date was set for autumn 2010. The Park Board spent the intervening months focused on educating the public about the impending bylaw. They actively worked with local media to raise awareness in the months leading up to the formal implementation of the bylaw on 1 September 2010 [1].

From the perspective of the Parks Board and City of Vancouver, raising public awareness of the bylaw was particularly important in ensuring that the bylaw was successful in its primary aim of reducing smoking and secondhand smoke exposure in outdoor public recreation areas [2]. The city of Vancouver has over 200 parks and ten ocean-side beaches; given the large area of outdoor space that would be affected by the bylaw and the relatively limited number of Park Ranger staff-who were designated as key enforcers of the bylaw-compliance with the bylaw was anticipated to be a challenge [1]. Park Board staff and Board Members therefore envisioned that with sufficient public awareness and acceptance, the bylaw would be essentially self-enforcing [1].

Given the important role of news media in the dissemination and impact of health-related issues and policies [3][4][5], we examined print news reports concerning the development and implementation of the outdoor smoke-free bylaw in Vancouver. Our objective was to assess media coverage and content both pre-and post-bylaw implementation in order to understand the role local print media may have played in the public's perception of the bylaw through generating a description of the media's coverage of the bylaw. The majority of existing media analyses have only examined indoor smoke-free regulations or tobacco control regulations in general [4,[6][7][8][9], without specifically addressing the issues of outdoor smoke-free policies. We were particularly interested in the coverage of issues that were unique to the regulation of public spaces, namely equity concerns. These concerns included the rights of smokers and non-smokers, fairness, and effects on disproportionately affected population groups.

Media and Public Opinion

News media are an important source of information for the general public regarding health and health policy news [3][4][5]. Previous studies have confirmed the strong agenda setting effects of print media. While news media do not necessarily tell the public what to think about particular issues, they are remarkably successful at telling the public what issues to think about [3,[10][11][12]. By covering an issue, the media increases the relative importance of that issue [8], and by reporting on some issues and not others, the media influences what issues people think about [7]. The news media acts as a conduit for information between policy-makers and the general public, and 'provides cues about what issues should be on the forefront of people's concerns' [3]. Hence, print media, as a major information source for many citizens, particularly in relation to local issues [7], 'can shape public opinion and expectations about policies that, in turn, influence policy development processes' [5].

Local news media have a potentially influential role to play as community resources in communicating local health policies [7]. Print media, in particular, play a valuable role in the adoption of tobacco control policies, with Menashe and Siegel [9] finding that tobacco-related news coverage helped determine people's thoughts on tobacco and guided how they approached tobacco use as a social issue. Indeed, Clegg Smith et al. [4] found that print media had a stronger relationship to municipal tobacco bylaw uptake than either scientific research dissemination or political discourse. In an event history analysis of municipal smoking bylaws in Canada, Asbridge [6] also found that the print media and health advocacy play the strongest role in explaining the adoption of local-level smoking bylaws.

Methods

We conducted a quantitative content analysis of print news media to examine content related to the smoke-free bylaw in Vancouver such as article slant, appearance of topics and themes related to smoking and tobacco control, and equity concerns. Four popular local and provincial newspapers were selected and articles were obtained using the Canadian Newsstand Database as well as independent newspaper archives for newspapers not included in the database. Articles from 1 January 2010 to 31 December 2011 were included in order to examine both the period prior to the announcement of the bylaw and the period following its announcement and implementation. The following search terms were used to identify articles pertaining to the bylaw: -smoking, or tobacco, or smokefree or smokers or smoke-free, and, -ban*, or bylaw, or control or regulation* or restrict*, and -park*, or beach*, or outdoor*.

Articles were excluded from our study if the depth of discussion regarding smoking or tobacco use was limited to the mention of the search term only (e.g., mention of tobacco-stained teeth in an article otherwise unrelated to smoking/tobacco), or if the search terms were used in a manner unrelated to smoking/tobacco use (e.g., colloquial use of the word "smoking" to mean "attractive"). After 68 articles were excluded, the final dataset was comprised of 90 articles.

Coding of the articles was performed in two phases. The first phase involved using a Perl script that was designed for this specific set of articles. This script scanned the articles and identified the newspaper name, article date, author, word count and page number, which was then automatically entered into a spreadsheet from which a random sample was checked by a coder for accuracy. As these articles' details were consistent across all the articles and did not require interpretation, it was thought that automating this process would minimize human error. In the second stage, articles were coded using a Media Framing Codebook adapted from Clegg Smith [13] and An Intervention for Promoting Smoke-free Policy in Rural Kentucky [14]. The codebook consisted primarily of categorical variables in order to reduce the possibility of coder subjectivity and to allow for both a descriptive and quantitative approach to the data analysis.

The codebook contained approximately 45 content variables related to smoking and smoke-free regulations in six categories:

1. Article Relevance: an indication of the relevance of the article content towards smoking and/or smoking regulation (smoking focus/non-smoking focus) 2. Geographic Focus: the geographical focus of the story (local, provincial, national or international) 3. Slant: the article's slant towards smoke-free policy (positive for smoke-free regulation, neutral towards smoke-free regulation, negative towards smoke-free regulation or n/a) 4. Primary Approach: the primary approach taken to tell the story (Social, Environmental, Health, Rights, Factual, Regulation or Other) 5. Theme: the overall theme of the article that made it a news story for that day 6. Topics: coding the mention of numerous topics related to smoking/tobacco control (such as financial issues, health information and equity issues).

Coding was conducted by one team member who was blinded to all identifying information except for a randomly assigned article identification number. A second coder coded a random selection of 20% of the articles to assess inter-coder reliability. Using Cohen's kappa, there was a mean score of k = 0.768 with scores ranging from k = 0.643 to 0.913 showing substantial to almost perfect agreement [15], indicating a high level of inter-coder reliability.

Results

A total of 90 articles were coded, of which 82.2% (n = 74) had a smoking-related focus. The majority of articles were focused on Vancouver (61.1%, n = 55), with the remaining articles concentrated on international news (11.1%, n = 10), unspecified geographic areas (7.8%, n = 7), provincial news from British Columbia (6.7%, n = 6), other localities within the province (5.6%, n = 5), other provinces within Canada (4.4%, n = 4) and a national focus (3.3%, n = 3). Almost two-thirds of the articles were news stories (60%, n = 54), 18.9% were letters to the editor (n = 17) and the remainder were columns, opinion pieces and editorials (n = 19).

The article publication dates ranged from 19 January 2010 to 27 December 2011, as illustrated in Figure 1. Peak coverage of the bylaw occurred in April 2010, when 19 articles were identified, likely due to the public announcement of the approval of the bylaw on 20 April of that year. This month also had a greater number of letters to the editor than other months (n = 9). To a lesser extent, coverage rose in July 2010 (n = 10), primarily due to a temporary smoking ban implemented at that time due to fire risks. The number of articles showed a slight increase in September 2010 (n = 8) when the bylaw was implemented, and again in September 2011 (n = 8) with the announcement of a similar smoke-free policy across the Greater Vancouver Regional District.

Article Slant

The slant of each article was examined showing that 38.9% (n = 35) of the coverage was positive towards the bylaw, 30.0% (n = 27) was neutral, 22.2% (n = 20) was negative towards the bylaw, while the slant could not be determined in the remaining 8.9% (n = 8) as there was not enough content related to smoke-free policy in the article. The article slant was then analyzed for the two most prominent article types: news articles (n = 54) and letters (n = 17) (see Table 1). Among news articles, half held a positive slant towards the smoke-free policy and only 7.4% of the articles were negative towards the bylaw. Comparatively, letters were mainly opposed to the bylaw, with 64.7% of articles having a negative slant. When examining slant over time (Figure 2), articles with a positive slant were spread throughout the two-year study timeframe, while articles with a negative slant were more concentrated in April 2010 when the bylaw was announced, and were not found in every month.

Quantity of coverage over time

Article Approach

The most frequent approach used was a health approach (38.9%, n = 35) which encompassed articles emphasizing various health-related issues in relation to smoking and/or the bylaw. Articles that were simple factual accounts, and articles with an environmental approach (emphasizing the environmental implications of smoking and/or the bylaw) each accounted for 18.9% of all articles (n = 17 for each approach). The remaining articles used either a social approach emphasizing the social issues relating to smoking (such as nuisance and social modeling, n = 11), a rights approach raising issues regarding rights in relation to smoking and/or bans (such as the right to smoke and the right not to be exposed to smoke, n = 11) and a regulation approach emphasizing issues related to the creation of bylaws and/or regulation of laws (such as overregulation or the need for more social laws, n = 10).

Articles that were news reports primarily used a health approach (n = 32) followed by a factual approach (n = 14) and environmental approach (n = 13). In contrast, letters to the editor most frequently used a rights approach (n = 5), followed by a regulation approach (n = 4).

In analysis of the relationship between article approach and slant, we found the following principal slant for each article approach: Regulation and rights approaches contained more negativity towards the bylaw, while support for the bylaw was strongest in articles with a health approach.

Topics

A range of specific smoking/tobacco control topics were coded if there was any mention of the topic in the article. These topics were grouped into six major topics, as outlined in Table 2. The most frequently mentioned topic was that of enforcement and implementation (mentioned in 64 articles). This group of articles included those covering issues such as signage regarding the smoke-free bylaw, Park Rangers and police officers as enforcement agents and general implementation issues. The second most frequent topic was unintended consequences of smoking, mentioned in 39 articles, which primarily covered mentions of litter, fire and public nuisance. The topics mentioned least frequently were financial issues (mentioned in 14 articles) and equity issues (mentioned in 21 articles). Financial issues covered topics such as the societal and environmental costs of smoking, cigarette taxes, costs of bylaw enforcement and healthcare costs of smoking and second hand smoke. Equity issues were topics concerned with rights of smokers and non-smokers, fairness and groups disproportionately affected by the bylaw.

Discussion

Over the time period examined, there was generally low coverage of the smoke-free bylaw, with only 90 articles over a two year period. This was most likely due to competing news stories, and particularly the news coverage of British Columbia's harmonized sales tax (HST). The debate surrounding the introduction of the HST, as well as the crusade-like efforts to petition against it, dominated news coverage in the summer months of 2010, and again during the HST referendum over the summer of 2011. This likely impacted the coverage of the smoke-free bylaw, which would have been most relevant to the public over the summer months as well.

Overall, Vancouver's new outdoor smoke-free bylaw was presented with a positive slant in the news media. Notably, the voice of the public portrayed in the news media, represented by letters to the editor, was primarily negative toward the bylaw; however, as there were fewer letters than news articles, readers were left with an overall generally supportive slant towards the smoke-free bylaw.

General coverage of the smoke-free policy focused on health reasons for introducing the ban. This focus increases the potential for the public to view health as the salient issue regarding the new smoking regulation. News articles-which made up over half the sample-identified health and environmental factors as the primary reasons for supporting the smoke-free policy. Letters to the editor, however, had largely different concerns, namely, issues of individual rights and over-regulation of public spaces. While these concerns were overwhelmingly raised in letters, they were rarely addressed in news articles themselves, showing a potential disconnect between the concerns of some members of the public and coverage of the issues surrounding the bylaw by news media. Support for the smoke-free bylaw was largely centered on health concerns as a justification for the bylaw, as articles with a positive slant focused primarily on a health approach. However, health-related topics themselves were not frequently mentioned in the articles, showing a lack of presentation of health information. Thus health concerns were used as validation for the need for the bylaw despite a lack of presentation of any scientific evidence of health impact of smoking in outdoor public spaces. This lack of presentation of evidence in the media to support health statements is consistent with previous findings regarding other Canadian health initiatives [16] and should be highlighted as an area to be further examined by media advocacy groups.

By a large margin, the topic addressed most frequently in the news was that of enforcement and implementation of the bylaw. Financial issues and concerns regarding equity were infrequently mentioned, and as such, could be regarded as less important issues by readers. The low presence of equity-related issues could be of particular concern because the smoke-free bylaw in Vancouver affects public spaces. As such, discussion of concerns unique to regulating individual behaviour within a public environment is important in order to understand the context in which the bylaw is implemented and its potential impact on the community. This discussion was clearly lacking in the media coverage of the bylaw, despite an overwhelming indication in letters to the editor that these issues were a topic of public concern.

Coverage of Vancouver's smoke-free policy was greatest in the month that the ban was announced, and to a lesser extent, in the weeks prior to its implementation. In the month with the greatest quantity of coverage (April 2010), however, articles that were negative towards the bylaw were more frequent than coverage supporting the bylaw. It would appear that the voice of the public as presented in the media through letters outnumbered the voice of the news media itself at that time. In short, for a brief period, the media were a platform for the voice of the public rather than a source of news and information regarding the smoke-free bylaw.

Previous research has highlighted the relationship between the quantity of media coverage of an issue and the subsequent importance the public then attributes to that particular issue [5,17,18]. These findings suggest that the potential for the Vancouver-area news-reading public to have perceived the smoke-free bylaw as an issue of importance would have been the highest at the time of the announcement of the bylaw due to the increased coverage. As such, the month immediately following the announcement of the bylaw would likely have been the most favourable time to affect public opinion regarding the policy through the news media.

Conclusions

Local print media's coverage of Vancouver's smoke-free bylaw had a mainly positive slant, particularly in news stories. Coverage focused on health reasons for the ban, increasing the potential for the public to place importance on health as the salient issue regarding smoking regulation. There was a lack of coverage of equity issues despite the concerns expressed in letters to the editor as well as the relevance of these issues to the regulation of public spaces. The potential for agenda setting effects was greatest when the concept of the ban was introduced to the public. Health advocates, human rights advocates and other groups with a vested interest in bylaws such as this may wish to use the time immediately following the announcement of the bylaw to inform the public of their respective platforms.

Figure 1 .
1Quantity of coverage over time.

Figure 2 .
2Slant over time.

•
Health-Positive (65.7%, n = 23) • Environmental-Neutral (52.9%, n = 9) • Factual-Neutral (58.8%, n = 10) • Rights-Negative (81.8%, n = 9) • Social-Positive (63.6%, n = 7) • Regulation-Negative (60.0%, n =

Table 1 .
1Article slant.Article Slant
Positive (%, n) Neutral (%, n) Negative (%, n)
N/A (%, n)
All Articles
38.9%, 35
30.0%, 27
22.2%, 20
8.9%, 8
News reports
50.0%, 27
38.9%, 21
7.4%, 4
3.7%, 2
Letters to the Editor
23.5%, 4
5.9%, 1
64.7%, 11
5.9%, 1

Table 2 .
2Article Major Topics.Topic
Number of Articles
Enforcement and Implementation
64
Unintended Consequences of Smoking
39
Second Hand Smoke
31
Negative Health effects to Smoker
28
Equity Issues
21
Financial Issues
14

© 2013 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution license (http://creativecommons.org/licenses/by/3.0/).
AcknowledgmentsThis research was funded by the Canadian Institutes for Health Research (CIHR).Conflicts of InterestThe authors declare no conflict of interest.
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