Clinicians › Shoulder

Modifiable risk factors for soft-tissue healing

84 citationsUpdated Oct 2026

Overview

Soft tissue integrity is a critical determinant of surgical success in orthopaedic trauma and oncology, where management requires strict adherence to established protocols to minimize fracture-related infection [1]. Wound complications following soft-tissue sarcoma resection are common and significantly increase episode-of-care expenses [3], while large resections may warrant primary use of muscle flaps or vacuum-assisted wound closure devices to decrease healing complications [4]. In the context of fracture treatment, previous use of external fixators and the need for muscle or skin flap repair are factors associated with infection after intramedullary nailing of femoral and tibial diaphyseal fractures [14]. However, when managed with proper soft tissue coverage techniques, fracture healing rates and functional elbow range of motion do not appear to be affected by major wound complications [15].

Several modifiable patient factors independently predict adverse soft-tissue and bone healing outcomes. Smoking increases the risk of infection and leads to diminished fracture union, fusion rates, and wound healing [6], with smoking status and Disabilities of the Arm Shoulder and Hand scores serving as early predictors of symptomatic nonunion in displaced midshaft clavicle fractures [5]. Obesity is a modifiable risk factor that negatively affects outcomes following arthroscopic rotator cuff repair at four-year follow-up [12], and a body mass index greater than 30 is associated with increased hospital length-of-stay and complications following orthopaedic trauma surgery [20]. Additionally, greater body mass index and tobacco use influence lesser tuberosity osteotomy healing in stemmed and stemless anatomic shoulder arthroplasty [21].

Preoperative evaluation is essential to identify these risk factors and implement mitigation measures, particularly in obese patients [26]. Validated nomograms have been established to provide individualized prediction of wound complications and surgical site infection in patients with resected soft-tissue sarcoma of the extremity [7, 11]. While transcutaneous oximetry does not reliably predict wound-healing complications in preoperatively radiated soft tissue sarcoma [25], preoperative risk management programs at top orthopaedic institutions frequently enforce strict cutoffs for body mass index and hemoglobin A1c, which may limit access to total joint arthroplasty [50]. These programs often provide limited resources for smoking cessation and dental care [50], necessitating a consensus between surgeons and patients on proceeding with surgery after a thoughtful discussion of risks and benefits [50].

Anatomy & Pathophysiology

Soft Tissue Injury and Wound Healing

Management of soft tissue damage during fracture treatment requires surgical proficiency and meticulous care adhering to established treatment protocols to minimize the risk of fracture-related infection [1]. Extensive soft tissue injury associated with fractures is one of the most frequently seen risk factors for infection following surgical treatment of musculoskeletal injuries [27]. In diabetics with poor blood glucose control, occlusive vascular disease can induce idiopathic muscle infarction of the thigh, which may be misdiagnosed as a tumor secondary to latency of onset of symptoms [27]. Pathologic tissue alterations on biopsy in diabetic muscle infarction include microangiopathy, necrosis, and scarring [27]. In diabetics, pathologic enzymatic conversion of glucose to sorbitol and enhanced capillary permeability can increase tissue swelling [27]. Neuromuscular ischemia for more than 12 hours can result in irreversible tissue damage in the context of diabetic compartment syndrome [27]. Diabetes is a risk factor for infection following surgical treatment of musculoskeletal injuries [27].

The presence of shoulder adhesive capsulitis may indicate presence of organ involvement [48]. Elevated interleukin 1β levels in the subacromial fluid may explain the likelihood of pain and shoulder stiffness developing in diabetic patients with rotator cuff lesions [135]. Delayed repair impaired tendon-to-bone healing after rotator cuff tear, and obesity further exacerbated the detrimental effects of repair delay, resulting in the weakest structural, functional, and molecular outcomes when both factors co-occur [136].

Diabetes and Musculoskeletal Pathophysiology

Diabetics are more susceptible to chronic exertional compartment syndrome secondary to changes in microvascular flow and collagen metabolism [27]. Peripheral neuropathy associated with diabetes may have a negative impact on balance and thus diminish the response to rehabilitation following ankle sprains [27]. Several pathophysiologic mechanisms appear to be involved in the development of limited joint mobility in diabetic patients, including overuse, inflammation, trauma, and mechanical impingement [83]. Postoperative shoulder stiffness in the diabetic patient is reflected in all planes of shoulder motion [85]. The hand was the most common area of the body affected by musculoskeletal disorders in patients with diabetes mellitus, followed by the shoulder [89]. Shoulder limited joint mobility, in particular decreased external rotation, was seen in individuals with diabetes as compared to control participants [100]. Patients with diabetes had substantial reductions in shoulder range of motion, shoulder muscle strength, and grip and key pinch strength compared with non-diabetic controls [113].

Diabetes increases the likelihood of nonunion and delayed union of fractures as well as other perioperative complications such as infection [114]. Perioperative glycemic control may decrease the risk of perioperative complications, especially surgical site infection [114]. Shoulder pain and disability are common and persistent in adults with diabetes [118]. Carpal tunnel syndrome and shoulder pain (adhesive capsulitis) are frequent musculoskeletal disorders in diabetes mellitus patients [127]. Patients with painful shoulders, irrespective of having type 2 diabetes mellitus, seem to have abnormal shoulder muscles [106].

Smoking and Tissue Integrity

Smoking is associated with rotator cuff tears, shoulder dysfunction, and shoulder symptoms [101]. Relationships exist between cigarette smoking, patient reported shoulder stiffness and an objective loss of range of motion within 12 weeks of arthroscopic rotator cuff repair [111]. Smoking has a negative effect on anatomical total shoulder arthroplasty functional outcomes that may persist even after quitting [95]. Smoking is associated with an increased risk of surgical complications following total shoulder arthroplasty, while medical complications are not significantly increased [121]. Nicotine treatment alters the material properties of the normal supraspinatus tendon, a change that may predispose to a tear [117]. Smoking is hazardous to shoulder health and predisposes to rotator cuff pathology and shoulder dysfunction [98].

Obesity and Biomechanical Impact

Morbid obesity increases the risk of postoperative wound complications, infection, and repeat surgical procedures following upper extremity limb salvage surgery for soft tissue sarcoma [19]. Obesity significantly increases the risk of requiring total shoulder arthroplasty [120]. There has been an increase in shoulder dislocations in morbidly obese individuals in the United States, alongside an overall increase in the average BMI of patients who present with shoulder dislocations [103]. Maintaining a healthy weight is highly associated with better shoulder health [104]. Prior bariatric surgery is associated with an increased rate of complications after primary shoulder arthroplasty independent of body mass index [102]. Risks of complications after primary shoulder arthroplasty were more pronounced when the surgery was performed within 2 years of bariatric surgery [102].

Up to 43% of patients undergoing shoulder arthroscopy can be classified as obese, but early perioperative complications are uncommon [125]. Severely obese patients achieve overall excellent outcomes after rotator cuff repair and noninferior clinical differences when compared to healthy weight patients [128]. Patients with a higher BMI required shoulder replacement at a significantly younger age [129]. There does not appear to be a linear association between BMI and risk of dislocation of total shoulder arthroplasty [109].

Shoulder Anatomy and Vascular Supply

The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [55]. The anterior humeral circumflex artery provides vascular inflow to the humeral head by way of its terminal anterolateral branch known as the artery of Laing (also known as the arcuate artery) [55]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [55]. Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [55]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [58]. The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [58]. Quantitative assessment has shown that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [62]. The high contribution of the posterior humeral circumflex artery explains the exceedingly low rate of osteonecrosis associated with anterior shoulder dislocations [62].

The glenoid is a convex structure of shallow depth shaped like an inverted pear [55]. The articular head of the humerus is spherical and has a diameter of 37 to 57 mm [55]. The most superior portion of the articular surface of the humeral head averages 8 mm above the greater tuberosity [55]. The humeral version averages 29.8 degrees with a range of 10 to 55 degrees [55]. The head is inclined approximately 130 degrees with respect to the humeral shaft [55]. The neck-shaft angle measures an average of 135 degrees [56]. The humeral head is retroverted an average of 30 degrees [56]. The humeral head averages 19° of retroversion and 41° of inclination (neck-shaft angle) [58]. The glenoid averages 5° of retroversion in relation to the axis of the scapular body [58]. The subchondral bone of the glenoid is relatively flat, and the articular concavity is augmented by cartilage and a circumferential labrum [58]. The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [58].

The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [58]. Contracture of the rotator interval is seen with adhesive capsulitis [58]. The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [58]. The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [58]. The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90° of abduction and external rotation [58]. The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [58].

The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [58]. The suprascapular artery runs superior to the superior transverse scapular ligament, and the nerve runs deep to the ligament [58]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and the infraspinatus [58]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [58]. Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus [58]. The subscapular bursa lies between the subscapularis tendon and the neck of the scapula and communicates with the joint cavity between the superior and middle glenohumeral ligaments [59]. The subscapular bursa protects the tendon of the subscapularis at the point where it passes under the base of the coracoid process and over the neck of the scapula [59]. The subscapular bursa often houses loose bodies in the shoulder and is a region in which synovitis of the shoulder may be most intense [59]. The rotator interval includes the region of the superior glenohumeral ligament and coracohumeral ligament, in addition to the middle glenohumeral ligament [59]. The average area of the rotator interval was found to be 20.96 mm [59]. Enlargement of the rotator interval can cause instability in certain shoulders [59].

The humeroscapular motion interface lies between the inner structures of the proximal humerus, rotator cuff, coracohumeral ligament, and biceps tendon sheath and the superficial layer of the acromion, deltoid, coracoacromial ligament, coracoid process, and the conjoined tendon [61]. Smooth, unrestricted motion at the humeroscapular motion interface is vital to shoulder mobility [61]. Subacromial adhesions in cuff disease and after proximal humerus fracture can compromise the humeroscapular motion interface [61]. The axillary nerve is a terminal branch coming off the posterior cord of the brachial plexus just proximal to the coracoid process [61]. The axillary nerve passes beneath the conjoined tendon anterior to the subscapularis 3 to 5 mm medial to the musculotendinous junction [61]. The axillary nerve splits into the anterior and posterior branches within the quadrangular space [61]. The anterior and middle deltoid muscle receives sole innervation from the anterior branch of the axillary nerve [61]. The posterior deltoid muscle innervation varies, with supply only from the anterior branch in 2.3% of cases, from the posterior branch in 8.5%, and from both branches in 89.1% [61]. The posterior branch of the axillary nerve branches to supply the teres minor muscle and then terminates as the superior lateral brachial cutaneous nerve [61]. In the anterolateral deltoid splitting approach, the axillary nerve crosses approximately 5 cm inferior to the anterolateral acromial corner [61]. Shoulder abduction brings the axillary nerve closer to the acromion landmark [61]. No accessory motor branches to the anterior deltoid cross the tendinous raphe between the anterior and lateral deltoid [61]. In the posterior deltoid splitting approach, the axillary nerve is approximately 7 cm from the posterior acromial corner [61].

The capsule of the glenohumeral joint extends from the glenoid rim, progressing laterally toward the surgical neck of the humerus and blending with the tendons of the rotator cuff musculature [62]. Static stability of the glenohumeral joint is maintained by capsulolabral attachments and intracapsular ligamentous thickenings [62]. The rotator cuff and periscapular musculature afford dynamic stability to the glenohumeral joint [62]. The posteromedial metaphysis, a portion of the physis, and the epiphysis are intracapsular in the proximal humerus [62]. A large part of the proximal humeral physis is extracapsular, making it susceptible to traumatic injury [62]. The periosteum is thicker and stronger in the posteromedial portion of the proximal humerus as opposed to the anterolateral portion [62]. The thickness difference in periosteum explains the tendency of proximal humeral metaphyseal fracture fragments to penetrate the anterolateral periosteum [62].

The subscapularis originates from the anterior scapula and inserts anteriorly onto the lesser tuberosity [62]. The greater tuberosity provides attachment superiorly and posteriorly for the supraspinatus, infraspinatus, and teres minor [62]. The deltoid forward flexes and abducts the shoulder and courses from the clavicle and acromion superiorly, coalescing into a common tendinous insertion onto the lateral upper third of the humeral shaft [62]. The pectoralis major powers adduction and internal rotation due to its tendinous insertion anteriorly onto the lateral wall of the bicipital groove [62]. The pectoralis major forms the roof of the distal continuation of the bicipital tunnel, which is a closed space that extends proximally to the glenohumeral joint [62]. The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [62]. The rotator cuff is a sheet of conjoined tendons closely applied over the shoulder capsule and inserting mainly into the greater tuberosity of the humerus [63]. The subscapularis is inserted into the lesser tuberosity [63]. The rotator cuff has an important function in stabilizing the head of the humerus by pulling it firmly into the glenoid whenever the deltoid lifts the arm forwards or sideways [63]. The coracoacromial arch is formed by the acromion process posterosuperiorly, the coracoid process anteriorly and the coracoacromial ligament joining them [63]. The subacromial bursa separates the tendons from the coracoacromial arch and allows them to glide [63].

The clavicle is the only long bone to ossify by intramembranous ossification [58, 64]. The primary blood supply to the clavicle is periosteal; there is no nutrient blood supply [58, 64]. The medial (sternal) epiphysis of the clavicle is the last ossification center to fuse, at age 20 to 25 years [58]. The clavicle serves as the primary stabilizer between the axial skeleton and the appendicular skeleton [64]. The coracoclavicular ligaments are the primary stabilizers to superior (vertical) translation of the distal clavicle [58, 64]. The superior shoulder suspensory complex provides a stable connection between the scapula and the axial skeleton [58]. The superior shoulder suspensory complex is composed of the glenoid, the coracoid process, the coracoclavicular ligaments, the distal clavicle, the acromioclavicular joint, and the acromion [58]. The scapula is attached to the axial skeleton by the clavicle, specifically by the acromioclavicular and sternoclavicular joints [57]. The scapula is enveloped in multiple layers of muscles and separated from the chest wall by thin gliding fibro-fatty tissue, allowing its smooth excursion over the chest wall [57]. The basic part of the scapula is the body, which is triangular when viewed anteroposteriorly [57]. The glenoid is connected with the flat body of the scapula by the scapular neck [57]. The hook-shaped coracoid process curves forwards from the superior surface of the scapular neck [57]. The scapular spine ends in a flattened bony process, the acromion, which curves forwards [57]. The highest concentration of bony mass in the scapula is in the glenoid, the scapular neck, and the lateral border of the scapular body [57]. Two bony pillars extend between the glenoid and the scapular body to transmit compressive forces from the glenoid foss

Classification

Risk factors for nonunion are characterized as either patient-dependent or patient-independent [16]. Established patient-dependent risk factors include advanced age, various medical comorbidities, sex, smoking, non-steroidal anti-inflammatory use, various genetic disorders, metabolic disease, and nutritional deficiency [16]. Patient-independent risk factors include fracture pattern, location, displacement, and severity of soft tissue injury [16].

Gustilo–Anderson: The Gustilo classification is applicable to patients with open fractures as a method of identifying increased risk of infection because of comorbid medical illness [44]. Class A host status has no immune system compromising factors, Class B has one or two compromising factors, and Class C has more than three compromising factors [44]. The incidence of infection in patients with open fractures was 4% in Class A, 15% in Class B, and 30% in Class C [44]. Patients in Class B were 2.86 times more likely to have an infection compared with patients in Class A [44], while patients in Class C were 5.72 times more likely to have an infection compared with patients in Class A [44]. The Gustilo classification, location of fracture, and tobacco use are all factors associated with infection after open fracture [44].

Other Considerations: Smoking has previously been identified as a risk factor for nonunion in the setting of clavicle fractures [24]. Smoking status is an early predictor of symptomatic nonunion of displaced midshaft fractures of the clavicle [5]. At two years, obese patients demonstrated increased risks of malunion, nonunion, and revision following surgical fixation of upper extremity fractures [36]. Obese pediatric patients had a markedly increased time to radiographic union compared with non-obese patients when age, sex, fracture type, race, and ethnicity were controlled for [41]. The mean time to union for obese pediatric patients was 152 days compared with 93.59 days for non-obese patients [41]. Obese pediatric patients had 3.39 times increased odds of having increased time to union [41] and 6.64 times increased odds of having fractures with delayed union of 4 months or greater [41]. Macrophage dysfunction in diabetic mice impairs the resolution of inflammation in wounds [33]. The burden of macrophage dysfunction in diabetic wounds prolongs the inflammatory phase and complicates wound healing [33]. Modern approaches to the diabetic foot focus on pathophysiology, risk stratification using tools like the Wagner-Meggitt system, and proactive management including patient education, offloading, and appropriate footwear [139].

Clinical Presentation

Smoking

Tobacco smoking is a contributory factor to delayed union, with smokers experiencing significantly prolonged healing times [17]. In the context of arthroscopic rotator cuff repair, pack-years and duration of cessation serve as independent predictors of tendon healing [10]. Additionally, tobacco use is a patient factor that influences lesser tuberosity osteotomy healing in both stemmed and stemless anatomic shoulder arthroplasty [21].

Obesity and Body Mass Index

Obesity plays a clinically significant role in the risk of developing tendinopathy, sustaining a tear or rupture, and suffering complications after tendon repair [32]. For small- to medium-sized rotator cuff tears, age and BMI are independent predictive factors for healing; successful repair is more likely in patients younger than 63 years and with a BMI less than 28.1 kg/m2 [9]. Obesity negatively affects outcomes following arthroscopic rotator cuff repair at four-year follow-up [12] and is associated with increased odds of superficial wound-related complications [20]. Specifically, a BMI >30 is associated with increased hospital length-of-stay and complications following orthopaedic trauma surgery [20]. In shoulder arthroplasty, a greater BMI influences lesser tuberosity osteotomy healing [21]. In pediatric populations, obese patients exhibit markedly increased time to union compared with non-obese patients, with mean times of 152 and 93.59 days respectively [41]. Obese pediatric patients have 3.39 times increased odds of having increased time to union and 6.64 times increased odds of having fractures with delayed union of 4 months or greater [41]. Furthermore, both low and high body mass index are risk factors for non-union of distal humeral fractures in the elderly [23].

Diabetes Mellitus

Diabetes mellitus is associated with a great variety of musculoskeletal manifestations, many of which are subclinical and correlated with disease duration and its inadequate control [45]. Musculoskeletal disorders are frequent in the diabetic population and associated with various factors [31]. In diabetics with poor blood glucose control, occlusive vascular disease can induce idiopathic muscle infarction of the thigh, which may be misdiagnosed as a tumor [27]. At the cellular level, macrophage dysfunction in diabetic mice impairs resolution of inflammation in wounds, prolonging the inflammatory phase and complicating wound healing [33].

Wound Complications and Infection

Wound complications after a soft-tissue sarcoma resection are common and add considerable expense to the episode of care [3]. The management of soft tissue damage during fracture treatment requires surgical proficiency and meticulous care adhering to established treatment protocols to minimize the risk of fracture-related infection [1]. Previous use of external fixators and the need for muscle or skin flap repair were factors associated with the occurrence of infection after intramedullary nailing of femoral and tibial diaphyseal fractures [14]. Unexpected low-grade infection is frequently associated with nonunion, detected in 28% of presumed aseptic nonunion patients [28]. In patients with Charcot arthropathy, a high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach [43].

Risk Prediction and Assessment

The Wound Score scored better on 10 evaluation criteria than any other foot wound evaluation system for patients with diabetes due to its simplicity, user friendliness, ability to integrate wound and patient information, and design to reflect progress [40]. The 4 variables found to independently predict the outcome of amputation in diabetic patients with surgically treated finger infections can be understood as factors which decrease the likelihood of successful digital salvage and increase the potential consequence of ongoing uncontrolled infection [34].

Investigations

Other Considerations: Smoking status and the Disabilities of the Arm Shoulder and Hand score serve as early predictors of symptomatic nonunion in displaced midshaft clavicle fractures [5]. Patients presenting with either smoking status or a high Disabilities of the Arm Shoulder and Hand score warrant further investigation for early surgical fixation to avoid the morbidity of a nonunion [5].

CT: Preoperative computed tomography angiography (CTA) use is a significant risk factor, increasing positive culture risk 4-fold after primary Latarjet procedure [126].

Plain radiography: Radiographic parameters were not predictive of postoperative outcomes in the comparison of anterior and postero-lateral approaches for shoulder arthroplasty [92].

Treatment

Non-Operative

The evidence base provided does not detail specific conservative management protocols such as physical therapy regimens, NSAID usage, or injection strategies. However, the data highlights that modifiable risk factors, including tobacco use and obesity, are critical targets for preoperative optimization to achieve optimal pain relief and healing outcomes [119, 12].

Operative

Indications: Surgical intervention is indicated when conservative measures fail or specific risk profiles warrant early fixation. Patients with either smoking status or high Disabilities of the Arm Shoulder and Hand scores require further investigation for early surgical fixation to avoid the morbidity of nonunion in displaced midshaft clavicle fractures [5]. For rotator cuff repairs, successful healing is more likely in patients younger than 63 years and with a BMI less than 28.1 kg/m² for small- to medium-sized tears [9].

Surgical Approach / Technique: In shoulder arthroplasty, patient factors including greater BMI and tobacco use influence lesser tuberosity healing alongside surgical technique [21]. For open lower-leg fractures, primary wound closure is preferred over secondary closure, which carries a significantly higher risk for fracture-related infection (odds ratio = 3.3; p = 0.004) [90]. A consensus document proposes 22 evidence-based recommendations to promote best practices in surgical wound closure and soft tissue management, aiming to reduce variability in clinical practice and improve patient outcomes [2].

Adjuncts: Negative pressure wound therapy requires a clear healing goal; if no improvement is observed between two consecutive dressing changes or after 1 week of treatment, discontinuation should be considered [13].

Other Considerations: Smoking has a negative influence on rotator cuff repair clinical outcomes and is associated with decreased healing of small-medium rotator cuff tears after repair [35]. Former tobacco users obtained outcomes similar to those of nonusers after primary reverse total shoulder arthroplasty, suggesting that tobacco use is a modifiable risk factor to achieve optimal pain relief [119]. Nontobacco nicotine dependence is a notable risk factor for worse long-term outcomes after total shoulder arthroplasty, reverse total shoulder arthroplasty, and rotator cuff repair [122]. Specifically, nontobacco nicotine use was associated with a modestly increased risk of lysis of adhesions after rotator cuff repair but did not significantly elevate the risk of major medical or surgical complications compared to nonnicotine users [123]. At 2 and 5 years, nontobacco nicotine dependence showed increased odds of subsequent cuff repair and manipulation under anesthesia or debridement versus controls after arthroscopic rotator cuff repair [130]. Identification and understanding of obesity as a modifiable risk factor is particularly valuable to patients, surgeons, and the health care system as a whole following arthroscopic rotator cuff repair [12]. Surgeons must perform a careful preoperative evaluation to identify risk factors for postoperative adverse events and implement measures to mitigate these complications in obese patients [26]. Proceeding with total joint arthroplasty may not be the best option for all patients; however, surgeons and patients should come to this consensus together after a thoughtful discussion of the risks and benefits for that particular patient [50].

Complications

Smoking: Patients who smoke face an increased risk for short-term complications following open rotator cuff repair [51]. Both pack-years and the duration of cessation serve as independent predictors of tendon healing [10]. Patients presenting with either smoking status or a Disabilities of the Arm Shoulder and Hand score warrant further investigation for early surgical fixation to avoid the morbidity of a nonunion [5].

Obesity: Obesity is associated with increased odds of superficial wound-related complications, while a BMI >30 correlates with increased hospital length-of-stay and complications [20]. At 2 years, obese patients demonstrate increased risks of malunion, nonunion, and revision following surgical fixation of upper extremity fractures [36]. Age and BMI are independent predictive factors for healing, with successful repair more likely in patients younger than 63 years and with a BMI less than 28.1 kg/m2 [9]. Identification and understanding of obesity as a modifiable risk factor is particularly valuable to patients, surgeons, and the health care system as a whole [12].

Diabetes: Diabetes adversely affects properties of native ECM proteins and delays tendon healing after injury by affecting a variety of factors [53]. A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach for diabetic Charcot arthropathy [43].

Wound complications: The incidence of infection was 4%, 15%, and 30% in patients in Gustilo Classes A, B, and C, respectively [44]. Patients in Gustilo Class B were 2.86 times more likely to have an infection, and patients in Class C were 5.72 times more likely to have an infection when both groups of patients were compared with patients in Class A [44].

Other Considerations: A clear wound healing goal must be determined, and if no improvement is observed between two consecutive dressing changes or after 1 week of negative pressure wound therapy treatment, discontinuation should be considered [13]. It has been estimated that 100,000 fractures go on to nonunion each year in the United States [16].

Recovery

Other Considerations: Diabetes adversely affects the properties of native extracellular matrix proteins and delays tendon healing after injury by affecting a variety of factors [53]. Macrophage dysfunction in diabetic wounds prolongs the inflammatory phase and complicates wound healing [33]. Age and body mass index are independent predictive factors for tendon healing in small- to medium-sized rotator cuff tears, with successful repair more likely in patients younger than 63 years and with a body mass index less than 28.1 kg/m2 [9].

Key Evidence

• [Paper] The management of soft tissue damage during fracture treatment requires surgical proficiency and meticulous care adhering to established treatment protocols to minimize the risk of fracture-related infection (FRI). [1] (10.1016/j.injury.2024.111935)
• [L5] The document proposes 22 evidence-based recommendations to promote best practices in surgical wound closure and soft tissue management, aiming to reduce variability in clinical practice and improve patient outcomes. [2] (10.1530/eor-24-0002)
• [L4] Wound complications after a soft-tissue sarcoma resection are common and add considerable expense to the episode of care. [3] (10.5435/jaaosglobal-d-21-00147)
• [L4] Large soft tissue resections may warrant primary use of either a muscle flap or a vacuum assisted wound closure device to decrease the incidence of wound healing complications. [4] (10.1097/blo.0b013e3180514c50)
• [L3] Patients with either risk factor warrant further investigation for early surgical fixation to avoid the morbidity of a nonunion. [5] (10.1302/0301-620x.98b1.36260)
• [L5] Smoking increases the risk of infection and leads to diminished fracture union, fusion rates, and wound and soft-tissue healing. [6] (10.5435/jaaos-20-06-359)
• [L3] A validated nomogram has been established to provide individualized prediction of wound complications in patients with resected soft-tissue sarcoma of the extremity. [7] (10.1097/corr.0000000000000959)
• [L4] The authors discuss the implications for further clarity on bone healing and smoking cessation within orthopedics including improved risk stratification and better identification of circumstances where adjunct therapy is appropriate. [8] (10.1007/s00590-014-1488-y)
• [L3] Age and BMI are independent predictive factors for healing, with successful repair more likely in patients younger than 63 years and with BMI less than 28.1 kg/m2. [9] (10.1007/s00167-022-07234-6)
• [L3] Pack-years and duration of cessation serve as independent predictors of tendon healing. [10] (10.1177/03635465261422620)
• [L3] A nomogram was developed to allow patient-specific risk assessment for SSI after soft-tissue sarcoma resection. [11] (10.1302/0301-620x.106b5.bjj-2023-1052.r1)
• [L4] Identification and understanding of this modifiable risk factor is particularly valuable to patients, surgeons, and the health care system as a whole. [12] (10.1177/17585732221095846)
• [L4] A clear wound healing goal must be determined, and if no improvement is observed between two consecutive dressing changes or after 1 week of treatment, discontinuation should be considered. [13] (10.1016/j.otsr.2016.04.018)
• [L2] Previous use of external fixators and need for muscle or skin flap repair were factors associated with the occurrence of infection. [14] (10.1016/j.injury.2018.07.024)
• [L4] Fracture healing rates and functional elbow range of motion do not appear to be affected by major wound complications when managed with proper soft tissue coverage techniques. [15] (10.1016/j.jse.2013.09.014)
• [L5] [16] (10.1016/j.injury.2014.04.002)
• [L5] Tobacco smoking is a contributory factor to delayed union, and smokers are significantly disadvantaged as healing times are often prolonged. [17] (10.1016/j.surge.2009.10.014)
• [L3] [19] (10.1177/1558944718797336)
• [L3] Obesity was associated with increased odds of superficial wound-related complications, and BMI >30 was associated with increased hospital length-of-stay and complications. [20] (10.1007/s00068-016-0642-0)
• [L3] In addition to the surgical technique, patient factors that influence tuberosity healing include a greater BMI and tobacco use. [21] (10.3390/jcm12030834)
• [L3] Surgeons should consider smoking a modifiable risk factor for postoperative complications and appropriately counsel patients on outcomes and complications given the elective nature of upper extremity surgery. [22] (10.1177/1558944720926638)
• [L3] Non-union is associated with poor clinical outcomes. [23] (10.1177/17585732221131923)
• [L3] Smoking has previously been identified as a risk factor for nonunion in the setting of clavicle fractures. [24] (10.5435/jaaosglobal-d-23-00278)
• [L5] Transcutaneous oximetry does not reliably predict wound-healing complications in preoperatively radiated soft tissue sarcoma. [25] (10.1097/corr.0000000000002424)
• [L4] The authors emphasize the need for a careful preoperative evaluation to identify risk factors for postoperative adverse events and implement measures to mitigate these complications. [26] (10.1186/s12871-015-0079-8)
• [Paper] [27] (10.1016/j.csm.2009.02.007)
• [L2] Unexpected low-grade infection is frequently associated with nonunion, detected in 28% of presumed aseptic nonunion patients. [28] (10.1016/j.injury.2024.112137)
• [L4] Musculoskeletal disorders are frequent in this population and associated with various factors. [31] (10.1155/2018/3839872)
• [L2] Obesity had a clinically significant role in the risk that tendinopathy will develop, that these patients will have a tear or rupture, and suffer complications after tendon repair. [32] (10.1097/corr.0000000000001261)
• [L5] This burden, in turn, prolongs the inflammatory phase and complicates wound healing. [33] (10.1371/journal.pone.0009539)
• [L3] The 4 variables found to independently predict the outcome of amputation can be understood as factors which decrease the likelihood of successful digital salvage and increase the potential consequence of ongoing uncontrolled infection. [34] (10.1177/15589447221082160)
• [L1] Smoking has a negative influence on rotator cuff repair clinical outcomes and is associated with decreased healing of small-medium rotator cuff tears after repair. [35] (10.1177/0363546514533776)
• [L3] At 2 years, obese patients demonstrated increased risks of malunion, nonunion, and revision. [36] (10.1016/j.injury.2025.112891)
• [L4] The Wound Score scored better on 10 evaluation criteria than any other foot wound evaluation system for patients with diabetes due to its simplicity, user friendliness, ability to integrate wound and patient information, and design to reflect progress. [40] (10.1097/01.blo.0000182393.31978.c3)
• [L4] [41] (10.5435/jaaosglobal-d-21-00185)
• [L3] A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach. [43] (10.1097/corr.0000000000002546)
• [L2] [44] (10.1097/01.blo.0000150345.51508.74)
• [L4] Diabetes mellitus is associated with a great variety of musculoskeletal manifestations, many of which are subclinical and correlated with disease duration and its inadequate control. [45] (10.1590/s0482-50042012000400010)
• [L4] The presence of shoulder adhesive capsulitis may indicate presence of organ involvement. [48] (10.1016/s1056-8727(99)00037-9)
• [L4] Proceeding with TJA may not be the best option for all patients; however, surgeons and patients should come to this consensus together after a thoughtful discussion of the risks and benefits for that particular patient. [50] (10.1097/corr.0000000000002315)
• [L3] Patients who smoke are at increased risk for short-term complications after open rotator cuff repair. [51] (10.1080/00913847.2020.1753482)
• [L5] Diabetes adversely affects properties of native ECM proteins and delays tendon healing after injury by affecting a variety of factors. [53] (10.1007/978-3-319-33943-6_16)
• [L4] [83] (10.2147/dmso.s33943)
• [L3] Postoperative shoulder stiffness in the diabetic patient is reflected in all planes of shoulder motion, although in our series this did not significantly affect functional outcome. [85] (10.1016/s1058-2746(03)00172-1)
• [L1] The hand was the most common area of the body affected being 33.05% (95% CI 21.1-46.13) followed by the shoulder. [89] (10.3233/bmr-171086)
• [L4] [90] (10.1016/j.injury.2025.112303)
• [L3] Radiographic parameters were not predictive of postoperative outcomes. [92] (10.1016/j.arth.2026.02.001)
• [L3] Smoking has a negative effect on anatomical total shoulder arthroplasty functional outcomes that may persist even after quitting. [95] (10.1302/0301-620x.106b11.bjj-2024-0202.r1)
• [L5] Smoking is hazardous to shoulder health and predisposes to rotator cuff pathology and shoulder dysfunction, but it is only one of several risk factors for complications after arthroscopic shoulder surgery. [98] (10.1016/j.arthro.2015.05.022)
• [L3] Shoulder limited joint mobility, in particular decreased external rotation, was seen in individuals with diabetes as compared to control participants. [100] (10.1016/j.clinbiomech.2014.12.013)
• [L4] Smoking is associated with RTC tears, shoulder dysfunction, and shoulder symptoms. [101] (10.1016/j.arthro.2015.01.026)
• [L3] These risks were more pronounced when shoulder arthroplasty was performed within 2 years of bariatric surgery. [102] (10.1016/j.jse.2023.02.120)
• [L4] Over time, there has been an increase in shoulder dislocations in morbidly obese individuals in the United States, alongside an overall increase in the average BMI of patients who present with shoulder dislocations. [103] (10.1177/2325967123s00170)
• [L3] We therefore suggest that adults control their weight given that maintaining a healthy weight is highly associated with better shoulder health. [104] (10.1016/j.jse.2023.07.007)
• [L3] Patients with painful shoulders, irrespective of having type 2 diabetes mellitus, seem to have abnormal shoulder muscles. [106] (10.1186/s12891-022-05627-9)
• [L3] However, there does not appear to be a linear association between BMI and risk of dislocation of total shoulder arthroplasty. [109] (10.1016/j.jses.2019.07.001)
• [L3] Relationships exist between cigarette smoking, patient reported shoulder stiffness and an objective loss of range of motion within 12 weeks of arthroscopic rotator cuff repair. [111] (10.1097/bte.0000000000000146)
• [L3] Compared with non-diabetic controls, patients with diabetes had substantial reductions in shoulder range of motion, shoulder muscle strength, and grip and key pinch strength. [113] (10.1016/j.physio.2014.07.003)
• [L5] [114] (10.2106/jbjs.18.01297)
• [L5] This change may predispose to a tear in the supraspinatus tendon. [117] (10.3109/17453674.2010.524595)
• [L4] Shoulder pain and disability are common, and persistent in adults with diabetes. [118] (10.1093/rheumatology/ken333)
• [L3] Former users obtained outcomes similar to those of nonusers, suggesting that tobacco use is a modifiable risk factor to achieve optimal pain relief after RTSA. [119] (10.1016/j.jse.2019.05.045)
• [L3] Obesity significantly increases the risk of requiring total shoulder arthroplasty. [120] (10.1016/j.jse.2023.03.012)
• [L3] Smoking is associated with an increased risk of surgical complications following total shoulder arthroplasty, while medical complications are not significantly increased. [121] (10.1016/j.jse.2019.07.012)
• [L3] Nontobacco ND is a notable risk factor for worse longterm outcomes after TSA, rTSA, and RCR. [122] (10.5435/jaaosglobal-d-25-00035)
• [L3] While nontobacco nicotine use was associated with a modestly increased risk of lysis of adhesions after RCR, it did not significantly elevate the risk of major medical or surgical complications when compared to those of nonnicotine users. [123] (10.1177/23259671261470573)
• [L3] Up to 43% of patients undergoing shoulder arthroscopy can be classified as obese, but early perioperative complications are uncommon. [125] (10.1016/j.arthro.2016.03.022)
• [L1] Analysis highlighted preoperative CTA use as a significant risk factor, increasing positive culture risk 4-fold. [126] (10.1016/j.jse.2024.12.011)
• [L4] Carpal tunnel syndrome and shoulder pain (adhesive capsulitis) are frequent also. [127] (10.1016/j.rehab.2016.07.261)
• [L3] Severely obese patients and their associated comorbid conditions pose unique challenges in rotator cuff tear management, but they still achieve overall excellent outcomes after repair and noninferior clinical differences when compared to healthy weight patients. [128] (10.1016/j.arthro.2022.02.026)
• [L3] Patients with a higher BMI required shoulder replacement at a significantly younger age. [129] (10.1016/j.jse.2022.10.032)
• [L3] At 2 and 5 years, NTND showed increased odds of subsequent cuff repair and manipulation under anesthesia or debridement versus controls. [130] (10.1002/arj.70189)
• [L4] The elevated IL-1b levels in the subacromial fluid may explain the likelihood of pain and shoulder stiffness developing in diabetic patients. [135] (10.1016/j.jse.2013.01.011)
• [Paper] Delayed repair impaired tendon-to-bone healing after rotator cuff tear in this rat model, and obesity further exacerbated the detrimental effects of repair delay, resulting in the weakest structural, functional, and molecular outcomes when both factors co-occur. [136] (10.1177/03635465261434037)

See Also

• Fractures
• Rotator Cuff Repair
• Shoulder Arthroplasty
• Rotator Cuff
• Total shoulder arthroplasty
• Shoulder Arthroscopy
• Proximal Humerus Fracture
• Latarjet Procedure

References

[1] Initial treatment of severe soft-tissue injuries in closed and open fractures to prevent fracture-related infection. Injury. 2024. DOI: 10.1016/j.injury.2024.111935

[2] Consensus document on the management of wound closure in orthopaedic surgery. EFORT Open Reviews. 2025. DOI: 10.1530/eor-24-0002

[3] Cost Variance in Patients With Soft Tissue Sarcoma Who Develop Postoperative Wound Complications. JAAOS: Global Research and Reviews. 2021. DOI: 10.5435/jaaosglobal-d-21-00147

[4] Soft Tissue Sarcoma Resection Volume Associated with Wound-healing Complications. Clinical Orthopaedics & Related Research. 2007. DOI: 10.1097/blo.0b013e3180514c50

[5] Smoking status and the Disabilities of the Arm Shoulder and Hand score are early predictors of symptomatic nonunion of displaced midshaft fractures of the clavicle. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b1.36260

[6] The Musculoskeletal Effects of Perioperative Smoking. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-06-359

[7] Is a Nomogram Able to Predict Postoperative Wound Complications in Localized Soft-tissue Sarcomas of the Extremity?. Clinical Orthopaedics & Related Research. 2019. DOI: 10.1097/corr.0000000000000959

[8] Smoking cessation and bone healing: optimal cessation timing. European Journal of Orthopaedic Surgery & Traumatology. 2014. DOI: 10.1007/s00590-014-1488-y

[9] Older age and higher body mass index are independent risk factors for tendon healing in small‐ to medium‐sized rotator cuff tears. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07234-6

[10] 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

[11] Development and validation of a nomogram to predict surgical site infection after soft-tissue sarcoma resection. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b5.bjj-2023-1052.r1

[12] Obesity negatively affects outcomes following arthroscopic rotator cuff repair at four-year follow-up. Shoulder & Elbow. 2022. DOI: 10.1177/17585732221095846

[13] Negative pressure wound therapy in orthopaedic surgery. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.04.018

[14] Incidence and risk factors associated with infection after intramedullary nailing of femoral and tibial diaphyseal fractures: Prospective study. Injury. 2018. DOI: 10.1016/j.injury.2018.07.024

[15] Wound complications after distal humerus fracture fixation: incidence, risk factors, and outcome. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.09.014

[16] Delayed union and nonunions: Epidemiology, clinical issues, and financial aspects. Injury. 2014. DOI: 10.1016/j.injury.2014.04.002

[17] The effects of smoking on fracture healing. The Surgeon. 2010. DOI: 10.1016/j.surge.2009.10.014

[19] Morbid Obesity Increases the Risk of Postoperative Wound Complications, Infection, and Repeat Surgical Procedures Following Upper Extremity Limb Salvage Surgery for Soft Tissue Sarcoma. HAND. 2018. DOI: 10.1177/1558944718797336

[20] Body mass index predicts perioperative complications following orthopaedic trauma surgery: an ACS-NSQIP analysis. European Journal of Trauma and Emergency Surgery. 2016. DOI: 10.1007/s00068-016-0642-0

[21] 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

[22] Effect of Smoking on Short-term Postoperative Complications After Elective Upper Extremity Surgery. HAND. 2020. DOI: 10.1177/1558944720926638

[23] Low and high body mass index and lower numbers of screws in the articular segment are risk factors for non-union of distal humeral fractures in the elderly: A multi-center retrospective study (TRON study). Shoulder & Elbow. 2022. DOI: 10.1177/17585732221131923

[24] Smoking Is Markedly Associated With 30-Day Readmission and Revision Surgery After Surgical Treatment of Clavicle Fracture. JAAOS: Global Research and Reviews. 2024. DOI: 10.5435/jaaosglobal-d-23-00278

[25] CORR Insights®: Transcutaneous Oximetry Does Not Reliably Predict Wound-healing Complications in Preoperatively Radiated Soft Tissue Sarcoma. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002424

[26] Obesity: physiologic changes and implications for preoperative management. BMC Anesthesiology. 2015. DOI: 10.1186/s12871-015-0079-8

[27] Common Injuries in Athletes with Obesity and Diabetes. Clinics in Sports Medicine. 2009. DOI: 10.1016/j.csm.2009.02.007

[28] Low-grade infections in nonunion of the femur and tibia without clinical suspicion of infection – Incidence, microbiology, treatment, and outcome. Injury. 2025. DOI: 10.1016/j.injury.2024.112137

[31] Musculoskeletal Disorders in Patients with Diabetes Mellitus: A Cross-Sectional Study. International Journal of Rheumatology. 2018. DOI: 10.1155/2018/3839872

[32] Obesity Increases the Risk of Tendinopathy, Tendon Tear and Rupture, and Postoperative Complications: A Systematic Review of Clinical Studies. Clinical Orthopaedics & Related Research. 2020. DOI: 10.1097/corr.0000000000001261

[33] Macrophage Dysfunction Impairs Resolution of Inflammation in the Wounds of Diabetic Mice. PLoS ONE. 2010. DOI: 10.1371/journal.pone.0009539

[34] Predictors of Digital Amputation in Diabetic Patients With Surgically Treated Finger Infections. HAND. 2022. DOI: 10.1177/15589447221082160

[35] The Effect of Smoking on Rotator Cuff and Glenoid Labrum Surgery. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514533776

[36] Obesity is associated with higher 90-day and 2-year complication rates following surgical fixation of upper extremity fractures: A nationwide analysis. Injury. 2025. DOI: 10.1016/j.injury.2025.112891

[40] Evaluation of Diabetic Wound Classifications and a New Wound Score. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000182393.31978.c3

[41] Obesity Increases Time to Union in Surgically Treated Pediatric Fracture Patients. JAAOS: Global Research and Reviews. 2022. DOI: 10.5435/jaaosglobal-d-21-00185

[43] No Difference in Risk of Amputation or Frequency of Surgical Interventions Between Patients With Diabetic and Nondiabetic Charcot Arthropathy. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002546

[44] Host Classification Predicts Infection after Open Fracture. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000150345.51508.74

[45] Manifestações musculoesqueléticas em diabetes mellitus. Revista Brasileira de Reumatologia. 2012. DOI: 10.1590/s0482-50042012000400010

[48] Shoulder Adhesive Capsulitis and Shoulder Range of Motion in Type II Diabetes Mellitus. Journal of Diabetes and its Complications. 1999. DOI: 10.1016/s1056-8727(99)00037-9

[50] Preoperative Risk Management Programs at the Top 50 Orthopaedic Institutions Frequently Enforce Strict Cutoffs for BMI and Hemoglobin A1c Which May Limit Access to Total Joint Arthroplasty and Provide Limited Resources for Smoking Cessation and Dental Care. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002315

[51] Smoking is an independent risk factor for complications following open rotator cuff repair. The Physician and Sportsmedicine. 2020. DOI: 10.1080/00913847.2020.1753482

[53] Does Diabetes Mellitus Affect Tendon Healing?. Advances in Experimental Medicine and Biology. 2016. DOI: 10.1007/978-3-319-33943-6_16

[55] Rockwood And Matsen S The Shoulder. Shoulder and Elbow Specialty Clinic Workers’ Survey > ANATOMY.

[56] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > SHOULDER AND ARM INJURIES.

[57] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Applied Anatomy Related to Scapular Fractures.

[58] Aaos Comprehensive Orthopaedic Review 3. Anatomy of the Shoulder, Arm, and Elbow > I. Shoulder.

[59] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > Bursae.

[61] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > EDITOR COMMENTARY.

[62] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > FRACTURES OF THE PROXIMAL HUMERUS.

[63] Apley And Solomon S Concise System Of Orthopaedics And Trauma. DISORDERS OF THE ROTATOR CUFF.

[64] Aaos Comprehensive Orthopaedic Review 3. Fractures of the Clavicle, Scapula, and Glenoid > I. Clavicular Fractures.

[83] Management of limited joint mobility in diabetic patients. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2013. DOI: 10.2147/dmso.s33943

[85] Rotator cuff repair in patients with type I diabetes mellitus. Journal of Shoulder and Elbow Surgery. 2003. DOI: 10.1016/s1058-2746(03)00172-1

[89] Prevalence of musculoskeletal disorders in patients with diabetes mellitus: A systematic review and meta-analysis. Journal of Back and Musculoskeletal Rehabilitation. 2019. DOI: 10.3233/bmr-171086

[90] Open fractures of the lower leg: Outcome and risk-factor analysis for fracture-related infection and nonunion in a single center analysis of 187 fractures. Injury. 2025. DOI: 10.1016/j.injury.2025.112303

[92] Impact of Body Mass Index and Radiographic Parameters on Complications and Operative Times Comparing Anterior and Postero-lateral Approaches. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.02.001

[95] 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

[98] Editorial Commentary: Smoking is Hazardous to Shoulder Health. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.05.022

[100] Shoulder limited joint mobility in people with diabetes mellitus. Clinical Biomechanics. 2015. DOI: 10.1016/j.clinbiomech.2014.12.013

[101] Smoking Predisposes to Rotator Cuff Pathology and Shoulder Dysfunction: A Systematic Review. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.01.026

[102] Prior bariatric surgery is associated with an increased rate of complications after primary shoulder arthroplasty independent of body mass index. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.120

[103] Poster 184: Demographics and Outcomes of Shoulder Instability in Individuals with Elevated Body Mass Index. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00170

[104] Influence of body mass index on severity of rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.07.007

[106] Shoulder muscle changes in patients with type 2 diabetes mellitus who have a painful shoulder: a quantitative muscle ultrasound study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05627-9

[109] Body mass index as a risk factor for dislocation of total shoulder arthroplasty in the first 30 days. JSES Open Access. 2019. DOI: 10.1016/j.jses.2019.07.001

[111] The Effects of Smoking on Shoulder Stiffness Following Arthroscopic Rotator Cuff Repair. Techniques in Shoulder & Elbow Surgery. 2018. DOI: 10.1097/bte.0000000000000146

[113] Upper extremity impairments, pain and disability in patients with diabetes mellitus. Physiotherapy. 2015. DOI: 10.1016/j.physio.2014.07.003

[114] Bone Quality and Fracture-Healing in Type-1 and Type-2 Diabetes Mellitus. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.18.01297

[117] Alteration of the material properties of the normal supraspinatus tendon by nicotine treatment in a rat model. Acta Orthopaedica. 2010. DOI: 10.3109/17453674.2010.524595

[118] Predictors of shoulder pain and shoulder disability after one year in diabetic outpatients. Rheumatology. 2008. DOI: 10.1093/rheumatology/ken333

[119] The effect of current and former tobacco use on outcomes after primary reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.05.045

[120] Obesity is associated with an increased risk of undergoing shoulder arthroplasty in Australia. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.03.012

[121] Smoking is associated with increased surgical complications following total shoulder arthroplasty: an analysis of 14,465 patients. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.07.012

[122] Nontobacco Nicotine Dependence as a Risk Factor for Poor Long-Term Outcomes After Shoulder Arthroplasty and Rotator Cuff Repair. JAAOS: Global Research and Reviews. 2026. DOI: 10.5435/jaaosglobal-d-25-00035

[123] Comparative Postoperative Outcomes After Rotator Cuff Repair in Tobacco and Nontobacco Nicotine Users. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261470573

[125] The Effects of Patient Obesity on Early Postoperative Complications After Shoulder Arthroscopy. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.03.022

[126] Modifiable risk factors for culture positivity after primary Latarjet procedure. Should we change any practice?. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.011

[127] Musculoskeletal disorders in diabetes mellitus patients in a Physical Medicine and Rehabilitation department. Annals of Physical and Rehabilitation Medicine. 2016. DOI: 10.1016/j.rehab.2016.07.261

[128] Severe Obesity Is Not Associated With Worse Functional Outcomes Following Arthroscopic Rotator Cuff Repair. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.02.026

[129] Does body mass index influence long-term outcomes after anatomic total shoulder arthroplasty?. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.10.032

[130] Nontobacco Nicotine Dependence Is Associated With Perioperative Complications and Repeat Surgery After Arthroscopic Rotator Cuff Repair. Arthroscopy. 2026. DOI: 10.1002/arj.70189

[135] Increased interleukin 1β levels in the subacromial fluid in diabetic patients with rotator cuff lesions compared with nondiabetic patients. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.011

[136] Obesity Amplifies the Detrimental Effects of Delayed Repair on Tendon-to-Bone Healing After Rotator Cuff Injury in a Rat Model. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261434037

[139] Chapter 44 The Diabetic Foot. 2020.