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

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.

Systemic factors that shape cutaneous pathological scarring

“…Smoking has long been believed to be harmful to wound healing since habitual smokers have higher rates of postsurgical complications such as infections, wound dehiscence, and tissue necrosis. 97,98 Moreover, there are multiple studies showing that smoking affects all phases of wound healing: it increases thrombus formation, 99,100 impairs the phagocytic and bactericidal activity of inflammatory cells, 101,102 inhibits fibroblast migration, 103 and reduces collagen deposition. 104 The mechanisms underlying these observations may involve but are not confined to the fact that smoking produces excessive levels of reactive oxygen species 103 and induces vitamin C deficiency.…”

Feasibility of Cell Lines for In Vitro Co-Cultures Models for Bone Metabolism

“…For example in a representative German level 1 trauma center 80.5% of all patients suffer from one or more chronic diseases requiring medication (Ø 4.3 drugs per patient): approx. 13% are diabetics [17,18], 22% are at risk for malnutrition [19], 15% drink alcohol on a daily base, and 42% are smokers [20]. These patients are above-average in developing post-surgical complications, e.g.…”

Primary Human Chondrocytes Affected by Cigarette Smoke—Therapeutic Challenges

“…Cigarette smoke is a toxic and carcinogenic mixture of over 5000 chemicals, including nicotine, tar, heavy metals, and hydrogen cyanide [1]. Several in vitro, in vivo, and clinical studies have shown a positive association between cigarette consumption and musculoskeletal disorders [3,5]. Sporadic studies have evaluated the relationship between cigarette smoke and symptomatic OA, however, these studies showed conflicting results [8,9,36].…”

“…It is known that over 5000 harmful and toxic chemical compounds, as well as free radicals like reactive oxygen species (ROS) are contained in cigarette smoke [1,2]. Several in vitro and in vivo studies have proven the deleterious effects of cigarette smoke on the musculoskeletal system [3][4][5]. Continuous inhalation of cigarette smoke leads to surgical complications and prolonged hospital stays [5].…”

“…Several in vitro and in vivo studies have proven the deleterious effects of cigarette smoke on the musculoskeletal system [3][4][5]. Continuous inhalation of cigarette smoke leads to surgical complications and prolonged hospital stays [5].…”