Effects of Smoking on Bone Fracture and Post Surgical Healing

FDA and anti-smoking movements inform us about carcinogenic properties of cigarettes and their negative effects on heart and respiratory organs on a daily basis. However, deleterious implications of nicotine smoking are not limited to pulmonary and cardiovascular systems. Numerous studies, as well as our clinical practice, have shown tobacco impact on musculoskeletal system and slower rate of bone fracture and post surgical healing. Compromised orthopedic outcomes and more frequent complications have been found in smoking patients that underwent spinal surgery, joint fusion, ACL reconstruction, just to name a few.

Smoking has been identified as a significant risk factor for surgical site infection. It inhibits function of macrophages, a type of white blood cells, that clean up dead tissue and engulf bacteria present in the wound. White blood cells also produce chemical messengers, called growth factor, which helps repair wounds. Compromised performance of white blood cells prolongs healing process and increases the risk of infection.

Carbon monoxide, which is present in cigarette smoke, binds to hemoglobin in red blood cells, preventing them from delivering oxygen to the body tissues. Nicotine and other chemicals present in cigarettes cause blood vessels to constrict, which further reduces the level of oxygen in the blood. The oxygen and nutrients, that blood carries to the wound, are essential to successful healing. Oxygen deprivation results in delayed healing, lingering of post-operative pain, and a higher rate of complications. Nicotine smoking not only affects outcomes of surgeries but it contributes to the development of conditions which require surgery. Associations have been found between the duration of smoking and development of osteoporosis, arthritis, progression of spondylolisthesis and intervertebral disc degeneration (1).

Many studies have demonstrated that smoking has direct effects on the health of bones and their ability to heal. Nicotine and free radicals suppress osteoblast, that is responsible for the synthesis and mineralization of bone, and impede the hormon called calcitonin, which inhibits bone resorption. Smoking increases levels of hormone cortical, which leads to bone breakdown. The researchers at the University of Pennsylvania, led by Mara L. Schenker, MD, found that smokers have higher incidence of long bone fracture nonunion (15%) and prolonged healing times. The mean fracture healing time for nonsmokers was 24.1 weeks, compared to 30.2 weeks for smokers (2).

Quitting smoking is the best thing a patient can do to ensure the maximum benefits from an orthopedic surgery. Whether you are a candidate for a surgery or recovering from fracture, or a surgical procedure, smoking cessation is not out of your reach. Believe it, believe in yourself.
Maggie Garbiec, PTA

1. Smoking and Intervertebral Disc Degeneration. Fogelholm R. Med Hypotheses. 2001 Apr;56(4):537-9.
2. Smoking Associated with Fracture Nonunion, Longer Healing Times. Leahy M., American Academy of Orthopedic Surgeons, April 2013.