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Smoking and Musculoskeletal Healing

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How smoking and nicotine affect bone healing, fracture union, spinal fusion, tendon and wound healing, and surgical complications — and the benefits of stopping before surgery.

Updated Sep 202619 citations
A person smoking.
Smoking narrows blood vessels and slows bone and wound healing, raising the risk of complications after surgery. Kieran Hirpara 4.0

What it is

Smoking and other forms of tobacco and nicotine affect how well your body heals after bone, tendon and joint surgery. This matters for many orthopaedic operations, including joint replacements, rotator cuff repairs, ligament reconstructions, fracture fixation and spinal fusion surgery. It also matters for heated tobacco products and smokeless tobacco, such as chewing tobacco, because these carry similar risks to cigarettes.

The link comes down to nicotine, the addictive chemical in tobacco. Research in animals and laboratory studies shows nicotine affects bone healing in a dose-dependent way, meaning the more you are exposed to, the stronger the effect [1]. Nicotine can also slow bone growth and make it harder for an implant to bed into your bone [1].

The effects show up in real operations too. Studies have linked smoking and nicotine use to higher rates of wound infections, wound breakdown, bone that fails to heal, and the need for further surgery [2, 3, 4]. After some joint replacements and tendon repairs, smokers tend to have more pain and poorer function than people who never smoked [5, 6, 7].

The good news is this is a risk you can change. Doctors call it a modifiable risk factor, meaning something you can act on before surgery [8, 9]. Quitting smoking well before your operation gives your body time to recover. One study found people who quit more than 6 months before rotator cuff repair had no detectable rise in infection or revision surgery compared with people who never smoked [10]. Your doctor will ask about all forms of tobacco and nicotine use as part of planning your operation, so you can talk openly about it and make a plan together.

Does it work?

The honest answer is that results vary, and the evidence is stronger for some operations than others. After knee replacement, people who use smokeless tobacco tend to have worse results than people who do not [1]. After ligament reconstruction in the knee, non-smokers were more likely to gain better function than smokers [2]. For rotator cuff repair, people who use heated tobacco have worse healing than people who have never smoked [3].

Nicotine itself seems to be part of the problem, not just tobacco. Research has linked nicotine dependence from sources other than tobacco to more wound breakdowns, infections and serious infections after shoulder replacement [4]. It has also been linked to implants loosening and becoming infected within 2 years [4], and to more follow-up procedures after keyhole rotator cuff repair [5]. Cannabis use has been linked to more complications after upper limb fracture surgery too [6].

Not every finding points the same way. After cartilage restoration surgery in the ankle, one study found no real difference in activity levels between smokers and non-smokers [7]. And for spinal fusion, newer surgical techniques and biologic augmentation, which means adding materials that encourage healing, may reduce some of the harm smoking causes [8].

There are gaps in what we know. Much of this research compares groups of people after the fact rather than running careful trials where quitting is tested directly. So it is hard to say exactly how much benefit quitting brings for any one operation. What the evidence does support is the general principle covered earlier: quitting well before surgery lowers your risk, and one study found no detectable rise in infection or revision surgery among people who quit more than 6 months before rotator cuff repair [9].

Your doctor can talk through what this means for your specific operation, and whether stopping or cutting down beforehand would help in your case.

What are the risks?

The risks depend on your operation, but they follow a pattern. The most common problems affect how your wound heals. Smoking and nicotine use have been linked to wound breakdown, wound infections and serious infections after surgery [1, 2, 3]. After ankle fracture surgery, smoking is a significant risk factor for infection in the wound itself [3].

Nicotine matters even without tobacco. People who are dependent on nicotine from sources other than tobacco have higher rates of wound breakdown, infection and sepsis, which is a serious whole-body infection, within 90 days of shoulder replacement [2]. Their implants are also more likely to loosen or become infected within 2 years [2].

Some risks show up later rather than straight away. After shoulder replacement, current smokers may have poorer function than former smokers and people who never smoked, even though their rates of complications and revision surgery are similar [4]. Smoking has also been linked to more pain and poorer function at midterm follow-up after cartilage restoration surgery in the ankle [5]. For ligament reconstruction in the knee, smokeless tobacco has been linked to more complications and revision surgery [6].

Bone healing itself can be affected. Before surgery to fix a broken upper arm bone, nicotine dependence has been linked to a 60-110% increased risk of complications, including infection, wound breakdown, bone that fails to heal and the need for further surgery [1]. Cannabis use has also been linked to more complications after upper limb fracture surgery [7].

Not every operation carries the same risk. One study found cigarette smoking was not linked to poorer bone fusion after one type of spinal fusion performed with a standardised technique [8]. And people who quit more than 6 months before rotator cuff repair had no detectable rise in infection or revision surgery compared with people who never smoked [9].

Your doctor can talk through which of these risks apply to your operation, and what you can do to lower them.

Is it right for you?

If you smoke or use any form of tobacco or nicotine, this topic matters for your operation. It applies whether you smoke cigarettes or use heated tobacco or chewing tobacco. It also applies if you use nicotine from other sources, such as replacement products, because nicotine alone affects healing.

There is one practical point worth knowing. If you are a current or recent smoker and you are planning a shoulder replacement, your doctor may recommend staying in hospital for at least 2 nights after your operation, even when the surgery would otherwise be a day procedure [1]. This gives your care team time to watch your wound and manage any early problems.

Whether you should change your plans around surgery is a decision to make together with your doctor. Quitting or cutting down well before your operation is something you can act on, and your doctor will help you plan it. The risks section above sets out what can go wrong if healing is affected, and which operations carry more risk than others.

If you have never smoked and do not use nicotine, the general risks described here are unlikely to apply to you. Your doctor will still ask about tobacco and nicotine use as a routine part of planning, so the right steps can be taken for your operation.

The bottom line

If you smoke or use nicotine, it is worth stopping or cutting down well before your operation. Healing after bone, tendon and joint surgery tends to go better without tobacco or nicotine, and quitting is one risk you can act on yourself. The realistic expectation is a lower chance of wound problems, infection and further surgery, though results vary between operations and the evidence is stronger for some than others. The most important caveat: nicotine itself, not just tobacco, affects healing, so replacement products and other non-tobacco sources still count and are worth raising with your doctor.

Reviewed by Kieran Hirpara · 13 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References
  1. The effect of non-tobacco nicotine on bone healing: a systematic review and application to total joint arthroplasty. *Journal of Orthopaedic Surgery and Research*. 2026. 10.1186/s13018-026-06733-3
  2. The impact of nicotine dependence on postoperative complications following humeral shaft fracture repair. *JSES Reviews, Reports, and Techniques*. 2026. 10.1016/j.xrrt.2026.100732
  3. Nontobacco Nicotine Dependence and Rates of Periprosthetic Joint Infection and Other Postoperative Complications in Shoulder Arthroplasty: A Retrospective Analysis. *Journal of the American Academy of Orthopaedic Surgeons*. 2024. 10.5435/jaaos-d-24-00706
  4. Adverse effect of smoking on surgical site infection following ankle and calcaneal fracture fixation: a meta-analysis. *EFORT Open Reviews*. 2024. 10.1530/EOR-23-0139
  5. The effect of smoking on outcomes of reverse total shoulder arthroplasty. *Journal of Shoulder and Elbow Surgery*. 2025. 10.1016/j.jse.2024.07.052
  6. Smoking is associated with inferior postoperative outcomes after autologous osteochondral transplantation for osteochondral lesions of the talus: a minimum 5-year clinical follow-up study. *Journal of Orthopaedic Surgery and Research*. 2025. 10.1186/s13018-025-06428-1
  7. The effect of smoking on functional outcomes and implant survival of anatomical total shoulder arthroplasty. *The Bone & Joint Journal*. 2024. 10.1302/0301-620x.106b11.bjj-2024-0202.r1
  8. Influence of smoking on shoulder arthroplasty outcomes: A meta-analysis of postoperative complications. *Shoulder & Elbow*. 2025. 10.1177/17585732251327368
  9. Editorial Commentary
  10. Does timing matter? The effect of preoperative smoking cessation on the risk of infection or revision following rotator cuff repair. *Journal of Shoulder and Elbow Surgery*. 2023. 10.1016/j.jse.2023.03.007
  11. Smokeless Tobacco Use is Associated With Worse Outcomes Following Total Knee Arthroplasty. *The Journal of Arthroplasty*. 2023. 10.1016/j.arth.2023.01.035
  12. Tobacco's toll: Comparable anterior cruciate ligament graft failure rates and inferior functional outcomes in smokers compared to non‐smokers: A systematic review and meta‐analysis. *Knee Surgery, Sports Traumatology, Arthroscopy*. 2025. 10.1002/ksa.70146
  13. Heated Tobacco Products Have Detrimental Effects on Rotator Cuff Healing, Similar to Conventional Cigarettes. *Journal of Bone and Joint Surgery*. 2024. 10.2106/jbjs.23.00804
  14. Nontobacco Nicotine Dependence Is Associated With Perioperative Complications and Repeat Surgery After Arthroscopic Rotator Cuff Repair. *Arthroscopy*. 2026. 10.1002/arj.70189
  15. Cannabis and nicotine use are independently associated with adverse surgical, medical, and psychosocial outcomes following upper extremity fracture fixation. *Journal of Orthopaedic Surgery and Research*. 2026. 10.1186/s13018-025-06635-w
  16. Editor’s Spotlight/Take 5: Cigarette Smoking Was Not Associated With Lower Odds of Radiographic Fusion After Combined TLIF and Posterolateral Lumbar (270°) Arthrodesis: A CT-based Retrospective Cohort Evaluation. *Clinical Orthopaedics & Related Research*. 2026. 10.1097/corr.0000000000003999
  17. Poster 132: Smokeless Tobacco Use is Associated with Increased Perioperative Complications and Revision Surgery After Anterior Cruciate Ligament Reconstruction. *Orthopaedic Journal of Sports Medicine*. 2025. 10.1177/2325967125s00229
  18. Cigarette Smoking Was Not Associated With Lower Odds of Radiographic Fusion After Combined TLIF and Posterolateral Lumbar (270°) Arthrodesis: A CT-based Retrospective Cohort Evaluation. *Clinical Orthopaedics & Related Research*. 2026. 10.1097/corr.0000000000003844
  19. Smoking is an independent risk factor for complications in outpatient total shoulder arthroplasty. *JSES International*. 2023. 10.1016/j.jseint.2023.07.009
Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking on radiographic fusion after combined TLIF and posterolateral lumbar arthrodesis [1].
  • Pack-years and duration of cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [2].
  • Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke to identify patients at risk for nonunions [3].
  • Active smokers are at an increased risk of both medical and surgical complications following elective knee or hip arthroplasty [4].
  • Heated tobacco users have worse clinical outcomes with respect to rotator cuff healing than nonsmokers [5].
  • Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol for total knee arthroplasty [13].
  • Smokeless tobacco use is associated with increased perioperative complications and revision surgery after anterior cruciate ligament reconstruction [16, 17].
  • Static scintigrams obtained in the early stages following tibial fracture showed 'cold spots' in 10 per cent of cases [23].
  • 'Cold spots' on static scintigrams obtained in the early stages following tibial fracture did not bear any definite relationship to the normal progression of union [23].

How It Works

  • Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking in combined TLIF and posterolateral lumbar arthrodesis [1].
  • Tobacco use is a patient factor that influences lesser tuberosity osteotomy healing in stemmed and stemless anatomic shoulder arthroplasty [6].
  • Smoking is associated with a higher risk for complications than smokeless tobacco use following total knee arthroplasty [7].
  • Smoking is associated with higher residual pain and poorer functional outcomes at midterm follow-up after autologous osteochondral transplantation for osteochondral lesions of the talus [8].
  • Cessation of smoking is highly advised for meniscus repair performed in the presence of concurrent ligamentous injury [9].
  • Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce costs associated with complications in patients undergoing shoulder arthroplasty [10].
  • Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary total hip arthroplasty [11].
  • Cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique [12].
  • Heated tobacco use has a similar deleterious effect on rotator cuff repair healing as cigarette smoking [14].
  • Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration [18].

What the Evidence Shows

Spine

Shoulder

  • Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce the costs associated with complications and joint replacement in patients undergoing shoulder arthroplasty [10].
  • Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers [15].
  • The incidence of complications and revision surgery after reverse total shoulder arthroplasty does not differ significantly between current smokers, former smokers, and nonsmokers [15].
  • Current smokers and former smokers who quit smoking within 6 months of rotator cuff repair are at an elevated risk of postoperative infection and revision surgery at 90 days, 1 year, and 2 years postoperatively compared with never smokers [22].

Knee

  • Smokeless tobacco use is associated with worse outcomes following total knee arthroplasty [7].
  • Smoking is associated with higher risk for complications than smokeless tobacco use following total knee arthroplasty [7].
  • Smoking within 30 days of total knee arthroplasty was associated with greater postoperative pain and lower odds of achieving an acceptable pain state compared to former and never-smokers [20].
  • Non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction [21].
  • Meniscus repair performed in the presence of concurrent ligamentous injury requires reduction of factors that may contribute to failure, and cessation of smoking is highly advised [9].

Hip

Foot and Ankle

  • There are no significant differences in activity levels based on Tegner scores between smokers and non-smokers after autologous osteochondral transplantation for osteochondral lesions of the talus [8].

Hand

  • Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke to further identify patients at risk for nonunions [3].

General and Nicotine

  • Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol [13].

Practical Considerations

Preoperative Screening and Risk Assessment

  • Surgeons should ask all patients with scaphoid fractures about smokeless tobacco or smoking use and add this to the intake history to identify patients at risk for nonunions [3].
  • Specific forms of tobacco use should be considered in preoperative screening for patients undergoing anterior cruciate ligament reconstruction [16, 17].

Arthroplasty and Joint Replacement

  • Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers, despite no significant differences in the incidence of complications and revision surgery [15].
  • Current or recent smokers may benefit from an inpatient setting of minimum 2 nights for outpatient total shoulder arthroplasty [19].

Spine and Fusion

  • Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking in the setting of combined TLIF and posterolateral lumbar arthrodesis [1].

Soft Tissue and Ligament Healing

  • Heated tobacco users have worse clinical outcomes with respect to rotator cuff healing than nonsmokers, similar to conventional cigarette smokers [5].
  • Cessation of smoking is highly advised for meniscus allograft transplantation and meniscus repair performed in the presence of concurrent ligamentous injury to reduce factors that may contribute to failure [9].

Bone and Cartilage Healing

  • Smoking is associated with higher residual pain and poorer functional outcomes at midterm follow-up after autologous osteochondral transplantation for osteochondral lesions of the talus, despite no significant differences in activity levels based on Tegner scores [8].

Key Evidence

  • [L3] Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking in this setting. [1] (10.1097/corr.0000000000003999)
  • [L3] Pack-years and duration of cessation serve as independent predictors of tendon healing. [2] (10.1177/03635465261422620)
  • [L3] Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke and consider adding this to the patient's intake history to further identify patients at risk for nonunions. [3] (10.5435/jaaos-d-23-00188)
  • [L1] The literature reveals that active smokers are at an increased risk of both medical and surgical complications. [4] (10.1016/j.arth.2024.10.035)
  • [L3] Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. [5] (10.2106/jbjs.23.00804)
  • [L3] In addition to the surgical technique, patient factors that influence tuberosity healing include a greater BMI and tobacco use. [6] (10.3390/jcm12030834)
  • [L3] However, smoking is associated with higher risk for complications than smokeless tobacco use. [7] (10.1016/j.arth.2023.01.035)
  • [L3] However, smoking is associated with higher residual pain and poorer functional outcomes at midterm follow-up, despite no significant differences in activity levels based on Tegner scores. [8] (10.1186/s13018-025-06428-1)
  • [L2] Nevertheless, MAT and meniscus repair performed in the presence of concurrent ligamentous injury require reduction of factors that may contribute to failure, and cessation of smoking is highly advised. [9] (10.1530/eor-24-0097)
  • [L1] Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce the costs associated with complications and joint replacement in patients undergoing shoulder arthroplasty. [10] (10.1177/17585732251327368)
  • [L3] Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. [11] (10.1016/j.arth.2023.05.041)
  • [L2] Cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique. [12] (10.1097/corr.0000000000003844)
  • [L3] Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol. [13] (10.5435/jaaos-d-23-01053)
  • [L4] This novel study shows that heated tobacco use has a similar deleterious effect on rotator cuff repair healing as cigarette smoking. [14] (10.2106/jbjs.24.00192)
  • [L3] Current smokers may have poorer functional outcomes after rTSA compared to former smokers and nonsmokers, despite the incidence of complications and revision surgery not differing significantly between cohorts. [15] (10.1016/j.jse.2024.07.052)
  • [L3] These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR. [16] (10.1177/2325967125s00229)
  • [L3] These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR. [17] (10.1177/03635465241303487)
  • [L2] Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration, as demonstrated in various animal and in vitro studies. [18] (10.1186/s13018-026-06733-3)
  • [L3] Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. [19] (10.1016/j.jseint.2023.07.009)
  • [L3] Smoking within 30 days of TKA was associated with greater postoperative pain and lower odds of achieving an acceptable pain state compared to former and never-smokers. [20] (10.1016/j.arth.2026.04.018)
  • [L1] Nonetheless, non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction. [21] (10.1002/ksa.70146)
  • [L3] Current smokers and former smokers who quit smoking within 6 months of rotator cuff repair are at an elevated risk of postoperative infection and revision surgery at 90 days, 1 year, and 2 years postoperatively compared with never smokers. [22] (10.1016/j.jse.2023.03.007)
  • [L3] Static scintigrams obtained in the early stages following injury showed 'cold spots' in 10 per cent of cases, but these did not bear any definite relationship to the normal progression of union. [23] (10.1016/s0020-1383(86)80005-5)

References

[1] Editor’s Spotlight/Take 5: Cigarette Smoking Was Not Associated With Lower Odds of Radiographic Fusion After Combined TLIF and Posterolateral Lumbar (270°) Arthrodesis: A CT-based Retrospective Cohort Evaluation. Clinical Orthopaedics & Related Research. 2026. DOI: 10.1097/corr.0000000000003999

[2] Duration of Smoking Cessation Needed to Achieve Retear Rates Comparable to Those of Nonsmokers After Arthroscopic Rotator Cuff Repair. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261422620

[3] The Snuffbox: The Effect of Smokeless Tobacco Use on Scaphoid Fracture Healing. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00188

[4] Should Smoking Cessation Be Recommended and Required for Patients Undergoing Elective Knee or Hip Arthroplasty?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.10.035

[5] Heated Tobacco Products Have Detrimental Effects on Rotator Cuff Healing, Similar to Conventional Cigarettes. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00804

[6] Lesser Tuberosity Osteotomy Healing in Stemmed and Stemless Anatomic Shoulder Arthroplasty Is Higher with a Tensionable Construct and Affected by Body Mass Index and Tobacco Use. Journal of Clinical Medicine. 2023. DOI: 10.3390/jcm12030834

[7] Smokeless Tobacco Use is Associated With Worse Outcomes Following Total Knee Arthroplasty. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2023.01.035

[8] Smoking is associated with inferior postoperative outcomes after autologous osteochondral transplantation for osteochondral lesions of the talus: a minimum 5-year clinical follow-up study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06428-1

[9] The impact of smoking on meniscus surgery: a systematic review. EFORT Open Reviews. 2025. DOI: 10.1530/eor-24-0097

[10] Influence of smoking on shoulder arthroplasty outcomes: A meta-analysis of postoperative complications. Shoulder & Elbow. 2025. DOI: 10.1177/17585732251327368

[11] Smokeless Tobacco Use is Associated With Worse Medical and Surgical Outcomes Following Total Hip Arthroplasty. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2023.05.041

[12] Cigarette Smoking Was Not Associated With Lower Odds of Radiographic Fusion After Combined TLIF and Posterolateral Lumbar (270°) Arthrodesis: A CT-based Retrospective Cohort Evaluation. Clinical Orthopaedics & Related Research. 2026. DOI: 10.1097/corr.0000000000003844

[13] Non-Tobacco Nicotine Dependence and Rates of Postoperative Complications in Total Knee Arthroplasty: A Propensity-Matched Comparison. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01053

[14] All Forms of Tobacco Products Adversely Affect Rotator Cuff Healing. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.24.00192

[15] The effect of smoking on outcomes of reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.07.052

[16] Poster 132: Smokeless Tobacco Use is Associated with Increased Perioperative Complications and Revision Surgery After Anterior Cruciate Ligament Reconstruction. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00229

[17] Association of Smokeless Tobacco Use With Perioperative Complications and Revision Surgery After Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241303487

[18] The effect of non-tobacco nicotine on bone healing: a systematic review and application to total joint arthroplasty. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06733-3

[19] Smoking is an independent risk factor for complications in outpatient total shoulder arthroplasty. JSES International. 2023. DOI: 10.1016/j.jseint.2023.07.009

[20] Impact of Smoking Status on Early Outcomes and Healthcare Utilization Following Primary Total Knee Arthroplasty: A Retrospective Cohort Study. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.04.018

[21] Tobacco's toll: Comparable anterior cruciate ligament graft failure rates and inferior functional outcomes in smokers compared to non‐smokers: A systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70146

[22] Does timing matter? The effect of preoperative smoking cessation on the risk of infection or revision following rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.03.007

[23] Static and sequential dynamic scintigraphy of the tibia following fracture. Injury. 1986. DOI: 10.1016/s0020-1383(86)80005-5

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2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.