October 07, 2019
3 min read

Tobacco smoking endangers orthopaedic operations and trauma surgery

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Technical innovations led to excellent results in orthopaedic surgery. Quality management efforts like registers, patient-reported outcome measure, and certifications, like EndoCert, brought us, in many cases, to even higher success rates. Emerging evidence is, however, making it clear that more attention has to be drawn to non-technical factors, such as prevention and perioperative optimization, including lifestyle changes. Perioperative smoking cessation is maybe the most influencing factor for further improvement in orthopaedic operations.

This influence of smoking on the locomotive system is rarely known to the public. During the EFORT Congress in Lisbon, there was an interesting session showing that clearly these risks exist. Furthermore, the EFORT Foundation has started the ESCAPE project — European Smoking Cessation Activities as a project of EFORT — to enhance attention to this area.

The negative effects of tobacco can be seen not only in elective orthopaedic surgery, but also in case of post-traumatic wound and bone healing. Tobacco increases the risk for perioperative complications, nonunion and delayed union of fractures, infection, soft tissue and wound healing complications.

As the perspective of an upcoming operation is a strong motivation to enhance optimal results, the factor of perioperative smoking cessation intervention should be more discussed and systematically included in preoperative planning. The reason for a higher complication rate is not primarily nicotine, but the increased carbon monoxide levels in the circulation that result in lower tissue levels of oxygen. This markedly reduces the wound and bone healing capacity.

Keeping in mind that smoking rates are still 8.7% to 27% in Europe, there is a wide opportunity for smoking cessation programs.

Tobacco consumption EU 28 rates

Eurostat data from European health interview survey (EHIS) Update 2017:

Acute traumatic disorders

The effect of smoking on bone healing is clearly documented in several systematic reviews showing not only a significant difference in bone healing, but also a higher rate of nonunions after tibial fractures (odds ratio 2.16), and a 4 to 6 weeks longer healing time for smokers compared to nonsmokers. Looking at the influence of smoking following tendon ruptures and surgical repair, a highly significant difference was found in an MRI study of 29.4% reruptures for smokers vs. 5.9 % for nonsmokers.

Elective orthopaedic surgery

In a large study of more than 17,000 total joint arthroplasties, results showed that smokers had a higher rate of revison for infection (OR 1.82). A prospective study published in 2015 showed an even higher infection rate for smokers compared to nonsmokers (OR 2.37).


Following primary shoulder arthroplasty, analyses showed current smokers had a signicantly higher risk of periprosthetic infection (HR 7.27) and a higher risk of postoperative fractures (HR 6.99) compared to nonsmokers.

Revision hip arthroplasty data analyzed data from the American College of Surgeons National Surgical Quality Improvement Program showed a significantly higher risk for deep infections (OR 1.58) and for further reoperations (OR 1.37) among smokers.

For the healing of osteotomies, spinal fusions and following arthrodeses, a large meta-analysis showed a 27-day delay together with a significantly greater risk of incidence of nonunion.

In forefoot surgery and hallux valgus operations, a 4.3-times higher infection rate and up to 7 weeks longer time for bone healing was seen among patients who were smokers.

Lumbago and degenerative disc destruction were found to occur 1.7- to 2.4-times more often in smokers.

Preoperative planning, patient information

Cessation of smoking before both elective and acute surgery has shown that complications can be reduced significantly. A systematic approach with a structured intervention program that includes not smoking 4 to 6 weeks before and 4 to 6 weeks after elective surgery demonstrated that postoperative complication rates can be reduced up to 50%. In cases of acute fracture surgery, postoperative smoking cessation intervention 6 weeks after surgery proved effective in reducing the number of complications by about 40%.

Undergoing elective surgery represents a major decision for patients. Patients need to be informed about risk factors for surgery, as well as about measures that can be taken for risk reduction and prevention of complications. In light of the growing body of evidence demonstrating the risk reduction of smoking cessation in conjunction with surgery, the conversation with the patient should include informing the patient that cessation of smoking in conjunction to surgery is equally important to reduce the risk of complications. This is undoubtedly part of a state of the art ethical framework for all surgeons and is highly recommended by the EFORT Ethics Committee.


The negative effects of tobacco use can be seen not only in elective orthopaedic surgery, but also in cases of post-traumatic wound and bone healing. The time for bone healing is up to 7 weeks longer and infection rates are up to five-times higher. Perioperative smoking cessation of 6 weeks before and 6 weeks after surgery can improve the results by 50%. Preoperative information given to patients and a proposal for smoking cessation has to be an indispensable part of what is done to prepare our patients for the operation.