Smoking Dependent Alterations in Bone Formation and Inflammation Represent Major Risk Factors for Complications Following Total Joint Arthroplasty

Ehnert, Sabrina; Aspera-Werz, Romina H.; Ihle, Christoph; Trost, Markus; Zirn, Barbara; Flesch, Ingo; Schröter, Steffen; Relja, Borna; Nussler, Andreas K.

doi:10.3390/jcm8030406

Cited by 45Total Knee Arthroplasty OutcomesOrthopedic Infections and TreatmentsOrthopaedic implants and arthroplasty

Smoking Dependent Alterations in Bone Formation and Inflammation Represent Major Risk Factors for Complications Following Total Joint Arthroplasty

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Ehnert, Sabrina, Aspera-Werz, Romina H., Ihle, Christoph, Trost, Markus, Zirn, Barbara, Flesch, Ingo, Schröter, Steffen, Relja, Borna +1 more·2019·Journal of Clinical Medicine

DOI 10.3390/jcm8030406PMC PMC6462941

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Abstract

Numerous studies have described a correlation between smoking and reduced bone mass. This not only increases fracture risk but also impedes reconstruction/fixation of bone. An increased frequency of complications following surgery is common. Here, we investigate the effect of smoking on the clinical outcome following total joint arthroplasty (TJA). 817 patients receiving primary or revision (including clinical transfers) TJA at our level-one trauma center have been randomly interviewed twice (pre- and six months post-surgery). We found that 159 patients developed complications (infections, disturbed healing, revisions, thrombosis, and/or death). Considering nutritional status, alcohol and cigarette consumption as possible risk factors, OR was highest for smoking. Notably, mean age was significantly lower in smokers (59.2 ± 1.0a) than non-smokers (64.6 ± 0.8; p < 0.001). However, the number of comorbidities was comparable between both groups. Compared to non-smokers (17.8 ± 1.9%), the complication rate increases with increasing cigarette consumption (1–20 pack-years (PY): 19.2 ± 2.4% and >20 PY: 30.4 ± 3.6%; p = 0.002). Consequently, mean hospital stay was longer in heavy smokers (18.4 ± 1.0 day) than non-smokers (15.3 ± 0.5 day; p = 0.009) or moderate smokers (15.9 ± 0.6 day). In line with delayed healing, bone formation markers (BAP and CICP) were significantly lower in smokers than non-smokers 2 days following TJA. Although, smoking increased serum levels of MCP-1, OPG, sRANKL, and Osteopontin as well as bone resorption markers (TRAP5b and CTX-I) were unaffected. In line with an increased infection rate, smoking reduced 25OH vitamin D3 (immune-modulatory), IL-1β, IL-6, TNF-α, and IFN-γ serum levels. Our data clearly show that smoking not only affects bone formation after TJA but also suppresses the inflammatory response in these patients. Thus, it is feasible that therapies favoring bone formation and immune responses help improve the clinical outcome in smokers following TJA.

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Following total joint replacement, heavy smokers had a greater risk of prolonged hospital stay due to reduced levels of CICP compared to nonsmokers.
“Ehnert and colleagues demonstrated that following total joint replacement, heavy smokers had a greater risk of prolonged hospital stay due to reduced levels of CICP as compared to nonsmokers [80].”
From An Overlooked Bone Metabolic Disorder: Cigarette Smoking-Induced Osteoporosis (2022) · cites this paper as [80]

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Increased complication rate in smokers following total joint arthroplasty displays in an altered composition of blood cytokines
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Authors: Ehnert, S., Aspera-Werz, R. H., Ihle, C., Trost, M., Zirn, B., Flesch, I., Schröter, S., Relja, B., & Nussler, A. K.
Affiliations: University of Tübingen (DE)
Goethe University Frankfurt (DE)
Corresponding author: Ihle, Christoph
ORCID: Ehnert, Sabrina
Aspera-Werz, Romina H.
Ihle, Christoph
Schröter, Steffen
Relja, Borna
Nussler, Andreas K.
Venue: Journal of Clinical Medicine
Publisher: MDPI AG
Published: 2019-03-24
Volume: 8
Issue: 3
Pages: 406
ISSN: 2077-0383 (ISSN-L)
DOI: 10.3390/jcm8030406
PMC: PMC6462941
OpenAlex: W2923041576
Cited by: 45
References: 63
Citations by year: 2026: 6 · 2025: 2 · 2024: 9 · 2023: 3 · 2022: 10 · 2021: 6 · 2020: 8 · 2019: 1
FWCI: 5.97
Type: journal article
Language: en
Open access: gold
dx.doi.org
Licence: cc-by
creativecommons.org/licenses/by/4.0/ (vor)
Locations: Journal of Clinical Medicine (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Publication Server of Goethe University Frankfurt am Main (Goethe University Frankfurt) (submittedVersion, cc-by)
Funders: Elsbeth Bonhoff Foundation (168)
Deutsche Forschungsgemeinschaft (EH471/2)
Topics: Health Sciences › Medicine › Surgery › Total Knee Arthroplasty Outcomes
Health Sciences › Medicine › Surgery › Orthopedic Infections and Treatments
Health Sciences › Medicine › Surgery › Orthopaedic implants and arthroplasty
Keywords: smoking, total joint arthroplasty, postoperative complications, bone formation, bone resorption, bone formation markers, bone formation inhibition, inflammation, osteoprotegerin, RANKL, osteopontin, bone-specific alkaline phosphatase, C-terminal telopeptide, vitamin D, cytokines, infection, delayed healing, revision arthroplasty, thrombosis, pack-years, length of hospital stay

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Smoking Dependent Alterations in Bone Formation and Inflammation Represent Major Risk Factors for Complications Following Total Joint Arthroplasty

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