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Smoking and Musculoskeletal Healing

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.

Overview

Smoking and tobacco use significantly impair musculoskeletal healing and increase perioperative risks across a broad spectrum of orthopaedic procedures. In spinal fusion, contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking on radiographic fusion after combined TLIF and posterolateral lumbar (270°) arthrodesis [1]. However, in soft-tissue repair, pack-years and duration of cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [2], while heated tobacco users have worse clinical outcomes with respect to rotator cuff healing than nonsmokers, similar to conventional cigarette smokers [4].

In joint arthroplasty, active smokers are at an increased risk of both medical and surgical complications in elective knee or hip arthroplasty [3]. Smokeless tobacco use is associated with worse outcomes following total knee arthroplasty [8] and higher rates of medical- and joint-related complications following primary total hip arthroplasty [9]. In shoulder arthroplasty, patient factors influencing lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty include greater BMI and tobacco use [5]. Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers, despite no significant difference in complication or revision surgery incidence [7].

The impact of smoking on meniscus repair outcomes is conflicting [10]. For scaphoid fractures, surgeons should consider asking all patients if they use smokeless tobacco or smoke to identify patients at risk for nonunions [6]. Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce costs associated with complications and joint replacement in patients undergoing shoulder arthroplasty [14].

Background & Causes

Active smoking is associated with increased medical and surgical complications in elective knee or hip arthroplasty [3]. It is a significant risk factor for surgical site infection following ankle and calcaneal fracture fixation [21]. Smokeless tobacco use correlates with higher rates of medical and joint-related complications after primary total hip arthroplasty [9] and worse outcomes following total knee arthroplasty [8]. Additionally, smokeless tobacco increases the risk of medical complications, emergency department utilization, and subsequent procedures after anterior cruciate ligament reconstruction compared to non-users and traditional smokers [13].

Smoking adversely affects healing across multiple orthopaedic procedures. Nicotine dependence prior to surgical fixation of humeral shaft fractures increases the risk for surgical complications, including postoperative infection, wound disruption, nonunion, and reoperation, by 60-110% [22]. Smoking is associated with inferior postoperative outcomes after autologous osteochondral transplantation for osteochondral lesions of the talus, including higher residual pain and poorer functional outcomes at midterm follow-up [11]. Patient factors influencing lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty include tobacco use, alongside surgical technique and body mass index [5].

Tobacco use negatively impacts rotator cuff healing. Heated tobacco products have detrimental effects on rotator cuff healing similar to conventional cigarettes, with users experiencing worse clinical outcomes than nonsmokers [4]. All forms of tobacco products adversely affect rotator cuff healing, with heated tobacco use having a similar deleterious effect as cigarette smoking [12]. Pack-years and duration of cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [2]. Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers, despite no significant difference in complication or revision surgery incidence [7].

Smoking cessation timing influences infection and revision risks. Former smokers who quit more than 6 months prior to rotator cuff repair are not at a detectably elevated risk of infection or revision surgery compared with those who have never smoked [15]. Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce costs associated with complications and joint replacement in patients undergoing shoulder arthroplasty [14]. Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke to identify patients at risk for nonunions [6].

The impact of smoking on specific procedures shows variability or mitigation potential. The results regarding the impact of smoking on meniscus repair outcomes are conflicting [10]. Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking on radiographic fusion after combined TLIF and posterolateral lumbar (270°) arthrodesis [1].

Symptoms & Presentation

Active Smoking: Active smokers face an increased risk of medical and surgical complications [3]. Current smokers may experience poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers [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 [11]. Smoking negatively affects anatomical total shoulder arthroplasty functional outcomes, a detriment that may persist even after quitting [18]. Differences in follow-up communication suggest smoking primarily affects the early recovery trajectory rather than pain-related outcomes alone following primary total knee arthroplasty [17].

Heated Tobacco: Heated tobacco users have worse clinical outcomes regarding rotator cuff healing than nonsmokers [4]. All forms of tobacco products adversely affect rotator cuff healing, with heated tobacco use having a similar deleterious effect as cigarette smoking [12].

Smokeless Tobacco: Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary total hip arthroplasty [9]. Smokeless tobacco use is associated with worse outcomes following total knee arthroplasty [8]. Smokeless tobacco use was associated with an increased risk of medical complications, emergency department utilization, and subsequent procedures compared to non-user controls and traditional smokers after anterior cruciate ligament reconstruction [13].

Nontobacco Nicotine: Nontobacco nicotine dependence is associated with a significantly higher risk of postoperative complications following distal radius open reduction and internal fixation, including infection, loosening of open reduction and internal fixation hardware, and nonunion [23]. Nontobacco nicotine dependence is associated with a lower risk of wrist stiffness following distal radius open reduction and internal fixation [23].

Meniscus Repair: The results regarding the impact of smoking on meniscus repair outcomes are conflicting [10].

Management

Smoking significantly impairs musculoskeletal healing across multiple orthopaedic procedures. Nicotine exerts a dose-dependent effect on bone healing, bone growth, and implant integration [19]. Consequently, active smokers face an increased risk of both medical and surgical complications compared to nonsmokers [3]. This risk extends to heated tobacco users, who demonstrate worse clinical outcomes regarding rotator cuff healing similar to conventional cigarette smokers [4]. Smokeless tobacco use is associated with worse medical and surgical outcomes following total knee arthroplasty [8] and higher rates of medical- and joint-related complications following primary total hip arthroplasty [9].

Specific procedural outcomes are adversely affected by tobacco use. Radiographic fusion after combined TLIF and posterolateral lumbar (270°) arthrodesis is negatively impacted, though contemporary techniques and biologic augmentation may mitigate these adverse effects [1]. Tendon healing after arthroscopic rotator cuff repair is independently predicted by pack-years and the duration of smoking cessation [2]. Healing of the lesser tuberosity in stemmed and stemless anatomic shoulder arthroplasty is influenced by greater BMI and tobacco use [5]. Functional outcomes after reverse total shoulder arthroplasty are poorer in current smokers compared to former smokers and nonsmokers, despite no significant difference in complication or revision surgery incidence [7]. Postoperative outcomes after autologous osteochondral transplantation for osteochondral lesions of the talus are inferior, characterized by higher residual pain and poorer functional outcomes at midterm follow-up [11].

Smoking cessation timing is critical for risk stratification. Former smokers who quit >6 months prior to rotator cuff repair are not at a detectably elevated risk of infection or revision surgery compared with those who have never smoked [15]. Given the pervasive impact of nicotine and other tobacco constituents, orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol [20].

Key Considerations

Smoking significantly impairs musculoskeletal healing and increases perioperative risks across diverse orthopaedic procedures. Medical and surgical complications: Active smokers face elevated risks compared to nonsmokers in elective knee or hip arthroplasty [3]. Smokeless tobacco use specifically increases the risk of medical complications, emergency department utilization, and subsequent procedures after anterior cruciate ligament reconstruction [13].

Spinal and Scaphoid Fusion: Contemporary techniques and biologic augmentation may mitigate adverse effects on radiographic fusion after combined TLIF and posterolateral lumbar (270°) arthrodesis [1]. Smokeless tobacco use is a risk factor for nonunion in scaphoid fractures and must be included in patient intake history [6].

Shoulder Arthroplasty and Repair: Tobacco use influences lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty, alongside surgical technique and body mass index [5]. Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers, despite similar complication and revision rates [7]. Smoking negatively affects functional outcomes after anatomical total shoulder arthroplasty, potentially persisting even after quitting [18]. Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce costs associated with complications and joint replacement in shoulder arthroplasty [14].

Rotator Cuff and Knee Outcomes: Pack-years and duration of smoking cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [2]. Former smokers who quit more than 6 months prior to rotator cuff repair are not at a detectably elevated risk of infection or revision surgery compared with those who have never smoked [15]. Heated tobacco users have worse clinical outcomes with respect to rotator cuff healing than nonsmokers, similar to conventional cigarette smokers [4]. 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 [11]. Smoking may primarily affect the early recovery trajectory and follow-up communication rather than pain-related outcomes alone following primary total knee arthroplasty [17].

Preoperative Screening: Specific forms of tobacco use, such as smokeless tobacco, should be considered in preoperative screening for patients undergoing anterior cruciate ligament reconstruction [16].

Key Evidence

  • [L3] Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking in this setting. (10.1097/corr.0000000000003999)
  • [L3] Pack-years and duration of cessation serve as independent predictors of tendon healing. (10.1177/03635465261422620)
  • [L1] The literature reveals that active smokers are at an increased risk of both medical and surgical complications. (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. (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. (10.3390/jcm12030834)
  • [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. (10.5435/jaaos-d-23-00188)
  • [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. (10.1016/j.jse.2024.07.052)
  • [L3] However, smoking is associated with higher risk for complications than smokeless tobacco use. (10.1016/j.arth.2023.01.035)
  • [L3] Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. (10.1016/j.arth.2023.05.041)
  • [L2] This systematic review found that the results regarding the impact of smoking on meniscus repair outcomes were conflicting. (10.1530/eor-24-0097)
  • [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. (10.1186/s13018-025-06428-1)
  • [L4] This novel study shows that heated tobacco use has a similar deleterious effect on rotator cuff repair healing as cigarette smoking. (10.2106/jbjs.24.00192)
  • [L3] Smokeless tobacco use was associated with increased risk of medical complications, ED utilization, and subsequent procedures compared to non-user controls and traditional smokers. (10.1177/2325967125s00229)
  • [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. (10.1177/17585732251327368)
  • [L3] Former smokers who quit >6 months prior to rotator cuff repair are not at a detectably elevated risk of infection or revision surgery compared with those who have never smoked. (10.1016/j.jse.2023.03.007)
  • [L3] These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR. (10.1177/03635465241303487)
  • [L3] Differences in follow-up communication suggest that smoking may primarily affect the early recovery trajectory rather than pain-related outcomes alone. (10.1016/j.arth.2026.04.018)
  • [L3] Smoking has a negative effect on anatomical total shoulder arthroplasty functional outcomes that may persist even after quitting. (10.1302/0301-620x.106b11.bjj-2024-0202.r1)
  • [L2] Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration, as demonstrated in various animal and in vitro studies. (10.1186/s13018-026-06733-3)
  • [L3] Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol. (10.5435/jaaos-d-23-01053)
  • [L1] Smoking is a significant risk factor for surgical site infection following ankle and calcaneal fracture fixation. (10.1530/EOR-23-0139)
  • [L3] Nicotine dependence prior to surgical fixation of humeral shaft fractures is associated with a 60-110% increased risk for surgical complications including postoperative infection, wound disruption, nonunion and reoperation. (10.1016/j.xrrt.2026.100732)
  • [L2] Nontobacco nicotine dependence is associated with significantly higher risk of postoperative complications following distal radius ORIF, including infection, loosening of ORIF hardware, and nonunion, but a lower risk of wrist stiffness. (10.1016/j.jhsa.2025.08.003)

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] 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

[4] 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

[5] 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

[6] 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

[7] 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

[8] 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

[9] 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

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

[11] 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

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

[13] 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

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

[15] 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

[16] 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

[17] 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

[18] The effect of smoking on functional outcomes and implant survival of anatomical total shoulder arthroplasty. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b11.bjj-2024-0202.r1

[19] 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

[20] 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

[21] Adverse effect of smoking on surgical site infection following ankle and calcaneal fracture fixation: a meta-analysis. EFORT Open Reviews. 2024. DOI: 10.1530/EOR-23-0139

[22] The impact of nicotine dependence on postoperative complications following humeral shaft fracture repair. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2026.100732

[23] Association of Nontobacco Nicotine Dependence with Postoperative Complications After Distal Radius ORIF: A Retrospective Analysis. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2025.08.003

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