Vaping and E-Cigarettes in Orthopaedic Surgery Outcomes: A Systematic Review
Asmi Babu, Paige Harper MD, Emma Kosowski, Damon Ross MD, Tegshjargal Baasansukh MD, Lakin Hatcher MD, Rolanda Willacy MD* and Marvin Dingle MD
ABSTRACT
Introduction: The detrimental impact of traditional tobacco smoking on orthopedic surgical outcomes has been extensively documented, with evidence linking smoking to impaired bone healing, delayed union, higher infection rates, and poorer functional recovery. In recent years, electronic cigarettes (e-cigarettes) and vaping have emerged as increasingly popular alternatives, often perceived as safer substitutes for conventional smoking. Despite their widespread use, the biological effects of e-cigarettes on musculoskeletal health and surgical recovery remain insufficiently understood. Preclinical studies suggest that exposure to nicotine and other aerosolized chemicals may disrupt bone metabolism, angiogenesis, and wound healing, thereby raising concerns for orthopedic patients. Given the rapid rise in e-cigarette consumption among adults and the critical importance of optimal recovery after orthopedic surgery, a systematic evaluation of existing evidence is warranted.
Methods: A systematic review was conducted using the PRISMA method to evaluate the association between e-cigarette/vaping use and non-tobacco nicotine dependence in common orthopaedic procedures. This includes rotator cuff repair, spine surgeries, foot and ankle procedures, total knee arthroplasty, total hip arthroplasty, femur intertrochanteric nailing etc. We focused on studies written in the last 10 years, between 2015 and 2025. Perioperative complications include impaired wound healing, bone healing.
Results: We identified 23 unique studies that met the inclusion criteria: seven clinical cohort/database studies, nine systematic reviews, one meta-analysis, and six preclinical or in vitro investigations. Clinical cohorts (aggregate >175,000 patients) consistently associated vaping or non-tobacco nicotine exposure with worse orthopaedic outcomes. In arthroplasty, exclusive vape or nicotine users had longer operative times, increased length of stay, and higher readmission or complication rates. Large datasets showed that nicotine exposure including e-cigarettes and smokeless forms was associated with elevated perioperative medical complications and, at two years, higher prosthetic joint events. Additionally, preclinical and cellular studies concluded that e-cigarette vapor exposure reduced osteoblast viability, promoted pro-inflammatory and cytotoxic effects, and impaired tendon and bone healing
Conclusion: The growing body of literature highlights that e-cigarette use is not a safer alternative to traditional cigarette smoking in the context of orthopedic surgery. Data is consistently showing that vaping may impair bone healing, impact fracture union, and contribute to higher postoperative complication rates. These risks are especially concerning in adolescent populations, where vaping use continues to rise at alarming rates due to social media platforms promoting vaping as a healthier alternative to traditional smoking. Despite this evidence, current research remains limited by small sample sizes and inconsistent definitions of vaping. Larger prospective studies are necessary to better define the independent effects of e-cigarettes on orthopedic outcomes and to clarify their long-term impact.
