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The Effects of Smoking on Your Healing Bones: A Q&A with Jeremy Truntzer, MD


woman with cigaretterCan smoking affect the way your bones heal after surgery? Jeremy Truntzer, MD, the lead author on a paper recently published in the European Journal of Orthopaedic Surgery & Traumatology, said it definitely can have an impact.

The paper, written by the second-year orthopedic surgery resident is titled, “Smoking cessation and bone healing: Optimal cessation timing.” 

So what does that mean? We checked in with Dr. Truntzer to find out.

How does smoking affect bone healing after orthopedic surgery?  

The simple answer is that we know smoking leads to higher surgical complication rates in the form of poor wound healing, infections, as well as increased rates of bone non-union and mal-union. Some studies have demonstrated increased rates greater than two-fold in patients with a peri-operative smoking history. However, while we are gaining a better understanding of why smoking leads to increased complication rates, we still have a long-way to go in order to completely comprehend its complexity.

Studies have shown that toxins from cigarettes impart numerous changes on our ability to heal. For example, studies have shown that toxins in cigarettes reduce blood flow to our extremities such that the more we smoke the less blood reaches important areas. Also, smoking reduces the amount of oxygen we can carry, which also impairs our ability to heal. On a more molecular level, cigarettes toxins change the way certain pathways interact that play vital roles in bone healing.

These changes include a decrease in production of important messengers and growth factors. Lastly, we also know that cigarettes release more than 4,000 known toxins that potentially play a role in compromised bone healing along with other systems. Much research is currently ongoing to better understand the relationships between many of these pathways. It will be exciting to follow the progress in the coming years and its impact on bone healing as well as many other diseases in the smoking population.

If you quit smoking before surgery, how much time needs to elapse before you’re in the clear?  

This is a great question and really the focus of our research. Again, we know that smoking leads to higher complication rates. However, we truly don’t know the temporal relationship between smoking cessation before or after surgery and the associated risk reduction. Currently, orthopaedic surgeons rightfully take a very conservative approach knowing that the longer a patient stops smoking, the lower the risk.

Unfortunately, this delays some elective procedures and we also encounter cases contingent on emergent or semi-urgent timeframes such as acute fracture cases common to a trauma service. For the latter, it would be helpful to know when we should supplement with alternative treatment options including bone grafting or other modalities. What we have tried to demonstrate is that for a variety of reasons, bone healing in the context of smoking behavior follows a similar time sequence as observed in wound healing, where the literature is more established. When looking at wound healing, the data highlights an important inflection point after roughly four weeks of smoking cessation, when the risk of complications converges with that of non-smokers. This is not to say a patient is in the clear after four weeks (unfortunately, smokers maintain a higher life-time risk), but we feel this is a timeframe worth considering going forward as a possible goal for peri-operative smoking cessation.

What about chewing tobacco or e-cigarettes – do they have the same impact on bone healing as regular cigarettes?  

We really don’t know that much about the impact of chewing tobacco or e-cigarettes from peer-reviewed studies. Only a handful of publications exists that comment on alternative modes of smoking and complication rates. For example, one study found no delay in bone healing or increased risk in postoperative complications in oral tobacco users. However, logic would suggest that tobacco in any form as well as toxins from e-cigarettes likely has negative effects to some extent. Unfortunately, we cannot give a formal answer at this time because it hasn’t been studied.

Anything else you want the public to know about the effects of smoking on bone healing?  

There’s no debate that smoking negatively impacts bone healing following treatment of fractures or other orthopaedic procedures. To what extent remains unclear. Moreover, the necessary time between cessation of smoking and surgery in order to reduce complications is also uncertain. The safest approach is to never smoke or quit as soon as possible before undergoing a procedure. Hopefully, we will have more data in the next few years linking timing and complication rates for bone healing as well as other important processes.