Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis
Open accessAbstract
Objectives: Systematic review and meta-analysis of published observational cohort studies. To quantify the increased risk smokers have of experiencing a delayed and/or non-union in fractures, spinal fusion, osteotomy, arthrodesis or established non-unions. Setting: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), Allied and Complementary Medicine Database (AMED) and Web of Science Core Collection from 1966 to 2015. Study eligibility criteria, participants and interventions: Observational cohort studies that reported adult smokers and non-smokers with delayed and/or non-union or time to union of the fracture, spinal fusion, osteotomy, arthrodesis or established non-union were eligible. Data extraction and outcome measures: 2 authors screen titles, abstracts and full papers. Data were extracted by 1 author and checked independently by a second. The relative risk ratios of smoking versus non-smoking and the mean difference in time to union patients developing a delayed and/or non-union were calculated. Results: The search identified 3013 articles; of which, 40 studies were included. The meta-analysis of 7516 procedures revealed that smoking is linked to an increased risk of delayed and/or non-union. When considered collectively, smokers have 2.2 (1.9 to 2.6) times the risk of experiencing delayed and/or non-union. In all the subgroups, the increased risk was always ≥1.6 times that of non-smokers. In the patients where union did occur, it was a longer process in the smokers. The data from 923 procedures were included and revealed an increase in time to union of 27.7 days (14.2 to 41.3). Conclusions: Smokers have twice the risk of experiencing a non-union after fracture, spinal fusion, osteotomy, arthrodesis or treatment of non-union. Time to union following fracture, osteotomy, arthrodesis or treatment of an established non-union is longer in smokers. Smokers should be encouraged to abstain from smoking to improve the outcome of these orthopaedic treatments.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Hypoxia and modifications in cellular metabolic activity are the main physiological changes occurring at the fracture site, mainly caused by nicotine and carbon monoxide.
“In this regard, it is now generally accepted that hypoxia and modifications in cellular metabolic activity are the main physiological changes occurring at the fracture site [52], mainly caused by nicotine and CO.”
From Skeletal System Biology and Smoke Damage: From Basic Science to Medical Clinic (2021) · cites this paper as [52]
Carbon monoxide limits oxygen flow to tissues by inhibiting binding sites for hemoglobin.
“On the other hand, CO is known to limit oxygen flow to tissues by inhibiting binding sites for hemoglobin (Hb).”
From Skeletal System Biology and Smoke Damage: From Basic Science to Medical Clinic (2021) · cites this paper as [52]
Smoking delays the healing time after fractures.
“In addition to altering the bone healing process, smoking also delays the healing time after fractures [52]”
From Skeletal System Biology and Smoke Damage: From Basic Science to Medical Clinic (2021) · cites this paper as [52]
Nicotine is a powerful vasoconstrictor that causes a reduction in peripheral blood flow by increasing the production of thromboxane A2 and catecholamines and reducing the secretion of prostaglandin I2.
“Nicotine is known to be a powerful vasoconstrictor that causes a reduction in peripheral blood flow by increasing the production of thromboxane A2 and catecholamines and reducing the secretion of prostaglandin I2.”
From Skeletal System Biology and Smoke Damage: From Basic Science to Medical Clinic (2021) · cites this paper as [52]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
The citation lists haven’t been fetched yet
References 75 · Cited by 174
- Authors
- Pearson, R. G., Clement, R. G. E., Edwards, K. L., & Scammell, B. E.
- Affiliations
- University of Nottingham (GB)
- Corresponding author
- Pearson, R G
- ORCID
- Scammell, B E
- Venue
- BMJ Open
- Publisher
- BMJ
- Published
- 2016-11
- Volume
- 6
- Issue
- 11
- Pages
- e010303
- ISSN
- 2044-6055 (ISSN-L)
- PMC
- PMC5129177
- OpenAlex
- W2556820428
- Cited by
- 174
- References
- 75
- Citations by year
- 2026: 25 · 2025: 14 · 2024: 23 · 2023: 26 · 2022: 15 · 2021: 28 · 2020: 22 · 2019: 15 · 2018: 4 · 2017: 2
- FWCI
- 0.95
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by-nc
- Locations
- BMJ Open (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Repository@Nottingham (University of Nottingham) (publishedVersion, cc-by-nc)
- Repository@Nottingham (University of Nottingham) (submittedVersion, cc-by-nc)
- Nottingham ePrints (University of Nottingham) (submittedVersion, cc-by-nc)
- HighWire Press Open Archive (submittedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Bone fractures and treatments
- Health Sciences › Medicine › Physiology › Smoking Behavior and Cessation
- Health Sciences › Medicine › Surgery › Spinal Fractures and Fixation Techniques
- Keywords
- smoking, delayed union, nonunion, fracture healing, spinal fusion, osteotomy, arthrodesis, time to union, orthopedic surgery outcomes, tobacco use
- MeSH terms
- Arthrodesis, Fractures, Ununited, Humans, Osteotomy, Postoperative Complications, Risk Factors, Smoking, Surgical Wound Infection, Fracture Healing, Fractures, Malunited, Fractures, Bone
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
