Penn Study Finds Smoking Prolongs Fracture Healing and Increases Risk of Infection

Paper 591 - Blowing Smoke: A Meta-Analysis of Smoking on Fracture Healing and Post-Operative Infection

PHILADELPHIA – Research has long shown the negative effects cigarette smoking has on cardiovascular health. But now, a new study from the Department of Orthopaedic Surgery at the Perelman School of Medicine at the University of Pennsylvania corroborates early evidence showing that cigarette smoking leads to longer healing times and an increased rate of post-operative complication and infection for patients sustaining fractures or traumatic injuries to their bone. The full results of the study are being presented this week at the 2013 American Academy of Orthopaedic Surgeons annual meeting in Chicago.

“Cigarette smoking is widely recognized as one of the major causes of preventable disease in the US, but there has been a lack of evidence showing other side effects of smoking, such as how it changes the way our bones heal,” said Samir Mehta, MD, chief of the Orthopaedic Trauma and Fracture Service at Penn Medicine. “Our study adds substantial support to a growing body of evidence showing that smoking presents a significant risk to fracture patients. These risks need to be addressed with the patient both at the time of injury and when considering surgical treatment.”

Results of the study show that for all injury types, fractured bones in patients who smoke take roughly six weeks longer to heal than fractured bones in a non-smoker (30.2 weeks compared to 24.1 weeks). Additional results show that fractured bones in patients who smoke are 2.3 times more likely to result in non-unions (non-healed fractures) than in non-smokers. 

Using Medline, EMBASE and Cochrane computerized literature databases, the researchers collated previous studies that have examined the effects of smoking on bone and soft tissue healing. By analyzing these studies, the team sought to find an association between smoking and healing time, and various complications such as post-surgical infection. Studies included in the analysis focused on fractures of the tibia, femur or hip, ankle, humerus, and multiple long bones. In total, 6,480 patient cases (treated both surgically and non-surgically) were evaluated in the studies.

With approximately 6.8 million fractures requiring medical treatment in the US annually, the researchers say the overall burden of musculoskeletal disease is substantial. Though recent efforts have been made to promote bone health through vitamin and mineral supplements and nutritional support, the research team says that altering social factors such as encouraging smoking cessation have been under-addressed. This void is causing both a disconnect in the short-term treatment for patients and a missed opportunity to improve long-term health.

“The effects of smoking intervention programs need to be discussed and instituted to promote better outcomes for post-fracture patients,” says Mehta. “We have an opportunity to help patients understand that it’s about more than just heart health, and that smoking puts you at a higher risk of complications and leads to longer healing times.”

The research team says future studies are needed to evaluate the dose-dependent effects of smoking on fracture healing. In addition, the increasing use and production of smokeless tobacco presents new questions about the effects of nicotine, and other tobacco products, through non-combustable forms. Finally, studies that better delineate the impact of directed education and the effects of the timing of smoking cessation (both before and after surgery) on the post-operative complication rate are also needed to provide the best care for fracture patients.

Lead author on the study is Jaimo Ahn, MD, assistant professor of Orthopaedic Surgery at Penn Medicine. Other Penn authors include Mara L. Schenker, MD, John A. Scolaro, MD, Sarah M. Yannascoli, MD, and Keith D. Baldwin, MD. Results of the study were presented at AAOS by Dr. Schenker.