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Modifiable risk factors for soft-tissue healing

Overview

Smoking status and elevated Disabilities of the Arm Shoulder and Hand scores predict symptomatic nonunion in displaced midshaft clavicle fractures, warranting early surgical fixation to avoid nonunion morbidity [1]. Smoking independently increases infection risk while diminishing fracture union, fusion, wound healing, and soft-tissue healing rates [2]. In rotator cuff pathology, older age and higher body mass index (BMI) are independent risk factors for tendon healing in small- to medium-sized tears, with successful repair more likely in patients younger than 63 years and with a BMI less than 28.1 kg/m2 [3].

Obesity significantly influences the risk of tendinopathy, tendon tear or rupture, and complications following tendon repair [4]. For arthroscopic rotator cuff repair, pack-years and the duration of smoking cessation serve as independent predictors of tendon healing [5]. In elderly patients with distal humeral fractures, both low and high BMI are risk factors for nonunion, as are lower numbers of screws in the articular segment; nonunion is associated with poor clinical outcomes [6]. Greater BMI and tobacco use also influence lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty [7].

Contradictory findings regarding BMI outcomes in ambulatory knee and shoulder surgery may stem from variations in measuring anthropometry, postoperative outcomes, and follow-up time [8]. Smoking remains a modifiable risk factor for postoperative complications after elective upper extremity surgery [10]. Strict BMI and hemoglobin A1c cutoffs at top orthopaedic institutions may limit access to total joint arthroplasty and restrict resources for smoking cessation and dental care, suggesting that proceeding with arthroplasty is not always the best option [17]. Appropriate patient selection and intraoperative judgment are required to ensure wound closure in complex diabetic foot wound repair [20], while realignment and extended fusion with a medial column screw for midfoot deformities secondary to diabetic neuropathy carries an acceptable complication rate but a high rate of nonunion [21].

Anatomy & Pathophysiology

Demographics and Recurrence Risk: Male gender and age 20–29 years represent the most significant non-modifiable risk factors for recurrence following primary post-traumatic shoulder dislocation [19], whereas female gender and age ≥ 80 years constitute the highest risk factors for a first-time post-traumatic dislocation [19]. Conversely, female gender and age ≥ 80 years act as protective factors against recurrence after the initial dislocation event [19].

Obesity and Metabolic Factors: Obesity significantly increases the risk of requiring total shoulder arthroplasty [39], and patients with a higher BMI require shoulder replacement at a significantly younger age [45]. While severely obese patients achieve overall excellent outcomes after rotator cuff repair with noninferior clinical differences compared to healthy weight patients, they and their associated comorbid conditions pose unique challenges in rotator cuff tear management [23]. Up to 43% of patients undergoing shoulder arthroscopy can be classified as obese [43], and there has been an increase in shoulder dislocations in morbidly obese individuals in the United States over time [32]. This trend correlates with an overall increase in the average BMI of patients presenting with shoulder dislocations [32]. Maintaining a healthy weight is highly associated with better shoulder health [33]. Prior bariatric surgery is associated with an increased rate of complications after primary shoulder arthroplasty independent of body mass index, a risk that is more pronounced when the arthroplasty is performed within 2 years of the bariatric surgery [31]. There does not appear to be a linear association between BMI and the risk of dislocation of total shoulder arthroplasty in the first 30 days [36].

Smoking and Pulmonary Health: Smoking is hazardous to shoulder health, predisposing patients to rotator cuff pathology and shoulder dysfunction [29]. It is associated with rotator cuff tears, shoulder dysfunction, and shoulder symptoms [30], and is only one of several risk factors for complications after arthroscopic shoulder surgery [29]. Smoking negatively affects anatomical total shoulder arthroplasty functional outcomes, a detriment that may persist even after quitting [28]. Furthermore, smoking is associated with an increased risk of surgical complications following total shoulder arthroplasty [40], though medical complications are not significantly increased in smokers following this procedure [40].

Diabetes and Inflammatory Pathophysiology: Patients with painful shoulders, irrespective of having type 2 diabetes mellitus, seem to have abnormal shoulder muscles [35]. Elevated interleukin 1β levels are present in the subacromial fluid of diabetic patients with rotator cuff lesions compared with nondiabetic patients, a finding that may explain the likelihood of pain and shoulder stiffness developing in this population [48]. Elevated preoperative HbA1c is a statistically significant predictor of postoperative shoulder stiffness after posterior-superior rotator cuff repair [49]. Despite these inflammatory markers, good pain relief and improved shoulder function were reported at a mean of 5 years postoperatively for arthroscopic capsular release for adhesive capsulitis in patients with Type I Diabetes Mellitus [34].

Classification

Smoking Status: Smoking is an early predictor of symptomatic nonunion in displaced midshaft clavicle fractures [1] and independently predicts tendon healing outcomes after arthroscopic rotator cuff repair based on pack-years and duration of cessation [5]. Clinically, smoking increases infection risk, diminishes fracture union and fusion rates, and impairs wound and soft-tissue healing [2]. Tobacco use also negatively influences lesser tuberosity healing in both stemmed and stemless anatomic shoulder arthroplasty [7].

Body Mass Index (BMI): In small- to medium-sized rotator cuff tears, higher BMI is an independent risk factor for poor tendon healing, with successful repair more likely in patients with a BMI <28.1 kg/m² [3]. Conversely, low BMI is a risk factor for nonunion of distal humeral fractures in the elderly [6]. Obesity plays a clinically significant role in the development of tendinopathy, tendon tears/ruptures, and complications following tendon repair [4]. Higher BMI also influences lesser tuberosity healing in anatomic shoulder arthroplasty [7].

Age: Older age is an independent risk factor for tendon healing in small- to medium-sized rotator cuff tears [3]. Successful rotator cuff repair is more likely in patients younger than 63 years [3].

Other Considerations: Diabetic Pathophysiology: Musculoskeletal disorders are frequent in diabetes mellitus and associated with various factors [14]. Macrophage dysfunction impairs inflammation resolution, prolongs the inflammatory phase, and complicates wound healing in diabetic models [11]. Four variables independently predict amputation outcomes in diabetic patients with surgically treated finger infections; these variables decrease digital salvage likelihood and increase the risk of uncontrolled infection [12]. A high frequency of foot ulcers must be anticipated in patients with diabetic Charcot arthropathy [9]. Diabetic Foot Management: Modern approaches focus on pathophysiology, risk stratification using tools like the Wagner-Meggitt system, and proactive management including patient education, offloading, and appropriate footwear [18]. The Wound Score outperforms other systems on 10 evaluation criteria, characterized by simplicity, user-friendliness, ability to integrate wound/patient data, and design to reflect progress [53]. Metabolic Syndrome: Common inflammatory pathways suggest a central role for loss of muscle integrity in musculoskeletal pathology associated with metabolic syndrome [15]. Anthropometric Variability: Contradictory findings regarding BMI effects on ambulatory knee and shoulder surgery outcomes may stem from variations in measuring/classifying anthropometry, postoperative outcomes, and follow-up time [8]. Distal Humerus Specifics: In elderly distal humeral fractures, lower numbers of screws in the articular segment are a risk factor for nonunion, which is associated with poor clinical outcomes [6].

Clinical Presentation

Smoking status serves as an early predictor of symptomatic nonunion in displaced midshaft clavicle fractures [1] and acts as a modifiable risk factor for postoperative complications following elective upper extremity surgery [10]. Tobacco use diminishes fracture union, fusion, wound healing, and soft-tissue healing rates [2], while pack-years and the duration of smoking cessation independently predict tendon healing after arthroscopic rotator cuff repair [5]. In shoulder arthroplasty, tobacco use affects lesser tuberosity healing in both stemmed and stemless anatomic constructs [7].

Age and body mass index (BMI) are critical determinants of healing potential across multiple pathologies. Older age and higher BMI are independent risk factors for tendon healing in small- to medium-sized rotator cuff tears, with successful repair more likely in patients younger than 63 years and with a BMI less than 28.1 kg/m² [3]. Conversely, obesity plays a clinically significant role in the development of tendinopathy, tendon tears or ruptures, and complications after tendon repair [4]. In the elderly, both low and high BMI are risk factors for nonunion of distal humeral fractures, which is associated with poor clinical outcomes [6]. Greater BMI also affects lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty [7]. However, variation in measuring anthropometry, postoperative outcomes, and follow-up time may contribute to contradictory findings regarding the effect of BMI on ambulatory knee and shoulder surgery outcomes [8].

Diabetes mellitus presents distinct challenges requiring specific inspection and risk stratification. Musculoskeletal disorders are frequent in these patients and are associated with various factors, with common inflammatory pathways suggesting a central role for loss of muscle integrity in metabolic syndrome [14, 15]. Macrophage dysfunction impairs resolution of inflammation, prolongs the inflammatory phase, and complicates wound healing in diabetic models [11]. A high frequency of foot ulcers must be anticipated in patients with diabetic Charcot arthropathy [9]. Optimal management requires clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, offloading in high-risk patients, local wound care, and diagnosis and control of osteomyelitis and ischaemia [25]. Modern approaches focus on pathophysiology, risk stratification using tools like the Wagner-Meggitt system, and proactive management including patient education and offloading [18]. Management requires a multisystem approach addressing the nervous, vascular, skeletal, immune, and integumentary systems via a multidisciplinary team to prevent ulceration, infection, and amputation [27]. Postoperatively, ulcers on the plantar surface of the great toe in diabetics healed promptly with no recurrences at follow-up after two to five years [16].

In the context of infection and trauma, four variables independently predict the outcome of amputation in diabetic patients with surgically treated finger infections; these variables decrease the likelihood of successful digital salvage and increase the potential consequence of ongoing uncontrolled infection [12]. Regarding shoulder instability, male gender and age 20–29 years are the most important non-modifiable risk factors for recurrence after primary post-traumatic dislocation [19]. Female gender and age ≥ 80 years represent the highest risk factors for first-time post-traumatic dislocation but are protective factors for recurrence [19].

Finally, specific anatomical outcomes vary by patient demographics. Raised BMI and reduced muscle bulk reduce the incidence of Popeye's deformity following tenotomy of the long head of the biceps brachii, though the deformity does not affect clinical outcomes at 24 months [13].

Investigations

Other Considerations: Smoking status serves as an early predictor of symptomatic nonunion in displaced midshaft clavicle fractures [1]. The Disabilities of the Arm Shoulder and Hand score also predicts this outcome [1]. Smoking confers a risk ratio of 3.68 for developing nonunion in patients with displaced middle third clavicle fractures treated conservatively [46]. Smoking increases the risk of infection, diminishes fracture union rates, fusion rates, wound healing, and soft-tissue healing [2]. Tobacco use has a deleterious impact on fracture incidence, the development of nonunions, and postoperative infections [22]. Smoking is a significant risk factor for complications after total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) [51, 52]. It is also a modifiable risk factor for postoperative complications after elective upper extremity surgery [10].

Age and body mass index (BMI) are critical prognostic factors for tendon healing. Older age and higher BMI are independent risk factors for tendon healing in small- to medium-sized rotator cuff tears [3]. Successful rotator cuff repair is more likely in patients younger than 63 years and those with a BMI less than 28.1 kg/m² [3]. Pack-years and the duration of smoking cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [5]. Obesity plays a clinically significant role in the risk of developing tendinopathy, suffering tendon tears or ruptures, and experiencing complications after tendon repair [4]. Conversely, low BMI is a risk factor for non-union of distal humeral fractures in the elderly, while high BMI is also a risk factor for this outcome [6]. Greater BMI influences lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty [7]. Tobacco use similarly influences lesser tuberosity healing in these procedures [7].

Anthropometric measurement and follow-up variability may contribute to contradictory findings regarding BMI outcomes in ambulatory knee and shoulder surgery [8]. Raised BMI reduces the incidence of Popeye's deformity post tenotomy of the long head of biceps brachii, as does reduced muscle bulk [13]. However, Popeye's deformity does not affect clinical outcomes at 24 months [13]. In distal humeral fractures in the elderly, lower numbers of screws in the articular segment are a risk factor for non-union, which is associated with poor clinical outcomes [6]. Musculoskeletal disorders are frequent in patients with diabetes mellitus and are associated with various factors [14]. Musculoskeletal pathology with metabolic syndrome should be evaluated comprehensively, as common inflammatory pathways suggest a central role for loss of muscle integrity [15]. The procedure for realignment and extended fusion with a medial column screw for midfoot deformities secondary to diabetic neuropathy has a high rate of nonunion [21]. Preoperative CTA use is a significant risk factor for culture positivity after primary Latarjet procedure, increasing positive culture risk 4-fold [44].

Treatment

Non-Operative

Conservative management for diabetic foot and ankle pathology focuses on symptom management, protection from mechanical trauma, and off-loading pressure to prevent ulceration and amputation [50]. No proven method exists to reverse peripheral neuropathy in the diabetic foot and ankle [50]. Preoperative risk management programs at top orthopaedic institutions frequently enforce strict cutoffs for hemoglobin A1c and may limit access to total joint arthroplasty [17].

Operative

Indications: Smoking status is an early predictor of symptomatic nonunion of displaced midshaft fractures of the clavicle, and patients with smoking status or Disabilities of the Arm Shoulder and Hand score warrant further investigation for early surgical fixation to avoid the morbidity of a nonunion [1]. Older age is an independent risk factor for tendon healing in small‐ to medium‐sized rotator cuff tears, with successful repair more likely in patients younger than 63 years [3]. Higher body mass index is an independent risk factor for tendon healing in these tears, with successful repair more likely in patients with a BMI less than 28.1 kg/m2 [3]. Conversely, low body mass index is a risk factor for non-union of distal humeral fractures in the elderly [6].

Surgical Approach / Technique: Simultaneous surgical treatment of rotator cuff and long head of biceps tendon lesions in smokers allowed for functional outcomes approximating non-smokers in long-term follow-up [47]. More attention should be paid to appropriate patient selection and intraoperative judgment to ensure wound closure in complex diabetic foot wounds [20]. Surgeons should consider smoking a modifiable risk factor for postoperative complications in elective upper extremity surgery [10].

Implant Selection: Greater body mass index influences lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty [7]. Former tobacco users obtain outcomes similar to those of nonusers after primary reverse total shoulder arthroplasty [38].

Alignment / Balancing Strategy: Lower numbers of screws in the articular segment are a risk factor for non-union of distal humeral fractures in the elderly [6]. Non-union of distal humeral fractures is associated with poor clinical outcomes [6].

Pain Management: Tobacco use is a modifiable risk factor to achieve optimal pain relief after reverse total shoulder arthroplasty [38]. Smoking is a significant negative factor associated with higher pain levels [47].

Adjuncts: An initial failure rate of approximately one-third may be considered for manipulation under general anesthesia for the management of frozen shoulder in patients with diabetes mellitus [41].

Other Considerations: Smoking increases the risk of infection, leads to diminished fracture union rates, fusion rates, wound healing, and soft-tissue healing [2]. Pack-years serve as an independent predictor of tendon healing after arthroscopic rotator cuff repair, and duration of smoking cessation serves as an independent predictor of the same [5]. Obesity has a clinically significant role in the risk that tendinopathy will develop, that patients will have a tendon tear or rupture, and that patients will suffer complications after tendon repair [4]. Severely obese patients achieve overall excellent outcomes after arthroscopic rotator cuff repair and achieve noninferior clinical differences when compared to healthy weight patients [23]. Obesity is a risk factor for venous thromboembolism after hip arthroscopy [37]. A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach for diabetic Charcot arthropathy [9]. Raised body mass index reduces the incidence of Popeye's deformity post tenotomy of long head of biceps brachii, while reduced muscle bulk also reduces this incidence; however, Popeye's deformity does not affect clinical outcomes at 24 months [13]. Preoperative risk management programs at the top 50 orthopaedic institutions may provide limited resources for smoking cessation and dental care [17].

Complications

Wound complications: Smoking is a modifiable risk factor for postoperative complications in elective upper extremity surgery [10] and increases the risk of infection [2, 22]. Specifically, smoking leads to diminished wound healing [2] and soft-tissue healing [2], while also having a deleterious impact on postoperative infections [22]. In diabetic patients, macrophage dysfunction impairs resolution of inflammation, prolongs the inflammatory phase, and complicates wound healing [11]. A high frequency of foot ulcers must be anticipated and addressed in the treatment of diabetic Charcot arthropathy [9], though resistant ulcers on the plantar surface of the great toe in diabetics can heal promptly with treatment and show no recurrence at two to five years [16]. Surgeons should appropriately counsel patients on outcomes and complications given the elective nature of upper extremity surgery [10].

Nonunion: Smoking status is an early predictor of symptomatic nonunion of displaced midshaft fractures of the clavicle [1] and has a deleterious impact on the development of nonunions [22]. Smoking leads to diminished fracture union rates [2] and fusion rates [2]. In the elderly, both low and high body mass index are risk factors for non-union of distal humeral fractures [6], as are lower numbers of screws in the articular segment [6]. Non-union is associated with poor clinical outcomes [6]. Patients with smoking status or Disabilities of the Arm Shoulder and Hand score warrant further investigation for early surgical fixation to avoid the morbidity of a nonunion [1].

Tendon Healing and Repair Failure: Older age is an independent risk factor for tendon healing in small‐ to medium‐sized rotator cuff tears [3], with successful repair more likely in patients younger than 63 years [3]. Higher body mass index is an independent risk factor for tendon healing in these tears [3], with successful repair more likely in patients with a BMI less than 28.1 kg/m2 [3]. Pack-years serve as an independent predictor of tendon healing after arthroscopic rotator cuff repair, as does the duration of smoking cessation [5]. Obesity has a clinically significant role in the risk that tendinopathy will develop, that patients will have a tendon tear or rupture, and that patients will suffer complications after tendon repair [4]. Tobacco use influences lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty [7], as does greater body mass index [7].

Other Considerations: Variation in measuring and classifying anthropometry, postoperative outcomes, and follow-up time may contribute to contradictory findings regarding body mass index effects on outcomes of ambulatory knee and shoulder surgery [8]. Four variables independently predict the outcome of amputation in diabetic patients with surgically treated finger infections; these variables decrease the likelihood of successful digital salvage and increase the potential consequence of ongoing uncontrolled infection [12]. Raised body mass index reduces the incidence of Popeye's deformity post tenotomy of long head of biceps brachii, as does reduced muscle bulk [13]. However, Popeye's deformity does not affect clinical outcomes at 24 months [13]. Smoking has a deleterious impact on fracture incidence [22].

Recovery

Light activity (weeks): Evidence does not specify a discrete week range for light activity or desk work return in the provided literature. However, clinical decision-making regarding early surgical fixation is critical for patients with smoking status or elevated Disabilities of the Arm Shoulder and Hand scores to avoid the morbidity of nonunion [1].

Full activity (months): The literature does not define a specific month range for full activity or sport return. Successful rotator cuff repair is more likely in patients younger than 63 years and those with a body mass index less than 28.1 kg/m2 [3]. Conversely, older age and higher body mass index are independent risk factors for tendon healing in small‐ to medium‐sized rotator cuff tears [3]. Obesity significantly influences the risk of tendinopathy, tendon tear or rupture, and complications after tendon repair [4].

Complete recovery / outcome plateau (months): No specific month range for outcome plateau is provided in the evidence base. For diabetic patients with surgically treated finger infections, four variables independently predict amputation outcomes, decreasing the likelihood of successful digital salvage and increasing the potential consequence of ongoing uncontrolled infection [12]. In contrast, postoperatively, resistant ulcers on the plantar surface of the great toe in diabetics healed promptly with no recurrence at follow-up after two to five years [16]. There were no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus [54].

Rehabilitation protocol: The provided evidence does not contain specific details regarding PT phasing, immobilisation duration, or weight-bearing progression. However, smoking cessation duration serves as an independent predictor of tendon healing after arthroscopic rotator cuff repair [5]. Pack-years also serve as an independent predictor of tendon healing after arthroscopic rotator cuff repair [5]. Smoking increases the risk of infection and leads to diminished fracture union rates, fusion rates, wound healing, and soft-tissue healing [2].

Functional milestones: The Disabilities of the Arm Shoulder and Hand score is an early predictor of symptomatic nonunion of displaced midshaft fractures of the clavicle [1]. Smoking status is also an early predictor of symptomatic nonunion of displaced midshaft fractures of the clavicle [1]. Patients with smoking status or elevated Disabilities of the Arm Shoulder and Hand scores warrant further investigation for early surgical fixation to avoid the morbidity of a nonunion [1]. Non-union of distal humeral fractures is associated with poor clinical outcomes [6].

Other Considerations: Lower numbers of screws in the articular segment are a risk factor for non-union of distal humeral fractures in the elderly [6]. Both low and high body mass index are risk factors for non-union of distal humeral fractures in the elderly [6]. Obesity is an independent risk factor for longer operative times following soft tissue arthroscopic shoulder instability repair, though it does not confer a higher risk of recurrent instability, revision surgery, or lower outcome scores one year following arthroscopic shoulder instability repair [55]. Variation in measuring and classifying anthropometry, postoperative outcomes, and follow-up time may contribute to contradictory findings regarding body mass index and outcomes of ambulatory knee and shoulder surgery [8]. Macrophage dysfunction impairs resolution of inflammation, prolongs the inflammatory phase, and complicates wound healing in the wounds of diabetic mice [11]. A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach for diabetic Charcot arthropathy [9].

Key Evidence

  • [L3] Patients with either risk factor warrant further investigation for early surgical fixation to avoid the morbidity of a nonunion. (10.1302/0301-620x.98b1.36260)
  • [L5] Smoking increases the risk of infection and leads to diminished fracture union, fusion rates, and wound and soft-tissue healing. (10.5435/jaaos-20-06-359)
  • [L3] Age and BMI are independent predictive factors for healing, with successful repair more likely in patients younger than 63 years and with BMI less than 28.1 kg/m2. (10.1007/s00167-022-07234-6)
  • [L2] Obesity had a clinically significant role in the risk that tendinopathy will develop, that these patients will have a tear or rupture, and suffer complications after tendon repair. (10.1097/corr.0000000000001261)
  • [L3] Pack-years and duration of cessation serve as independent predictors of tendon healing. (10.1177/03635465261422620)
  • [L3] Non-union is associated with poor clinical outcomes. (10.1177/17585732221131923)
  • [L3] In addition to the surgical technique, patient factors that influence tuberosity healing include a greater BMI and tobacco use. (10.3390/jcm12030834)
  • [L4] Several factors may have contributed to contradictory findings, including variation in measuring and classifying anthropometry, postoperative outcomes, and follow-up time. (10.1016/j.arthro.2014.02.031)
  • [L3] A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach. (10.1097/corr.0000000000002546)
  • [L3] Surgeons should consider smoking a modifiable risk factor for postoperative complications and appropriately counsel patients on outcomes and complications given the elective nature of upper extremity surgery. (10.1177/1558944720926638)
  • [L5] This burden, in turn, prolongs the inflammatory phase and complicates wound healing. (10.1371/journal.pone.0009539)
  • [L3] The 4 variables found to independently predict the outcome of amputation can be understood as factors which decrease the likelihood of successful digital salvage and increase the potential consequence of ongoing uncontrolled infection. (10.1177/15589447221082160)
  • [L3] However, this complication is well tolerated and does not affect clinical outcomes at 24 months. (10.1016/j.jisako.2024.07.001)
  • [L4] Musculoskeletal disorders are frequent in this population and associated with various factors. (10.1155/2018/3839872)
  • [L5] Musculoskeletal pathology with metabolic syndrome should be evaluated in a comprehensive and integrated manner to understand risk for other musculoskeletal-related conditions, as common inflammatory pathways suggest a central role for loss of muscle integrity. (10.3389/fphys.2018.00112)
  • [L4] Postoperatively the ulcers healed promptly, and no ulcers had recurred at follow-up after two to five years. (10.2106/00004623-198264060-00017)
  • [L4] Proceeding with TJA may not be the best option for all patients; however, surgeons and patients should come to this consensus together after a thoughtful discussion of the risks and benefits for that particular patient. (10.1097/corr.0000000000002315)
  • [L3] Female gender and age ≥ 80 years are highest risk factors for the first-time post-traumatic dislocation of the shoulder joint and protective factors for recurrences after the first-time shoulder dislocation. (10.1007/s00167-018-4924-4)
  • [L4] More attention should be paid to appropriate patient selection and intraoperative judgment to ensure wound closure and avoid undue complications. (10.1186/s13018-021-02405-6)
  • [L4] The procedure described has an acceptable degree of complications although it has a high rate of nonunion. (10.2106/jbjs.i.01288)
  • [L1] Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections. (10.1302/2058-5241.6.210058)
  • [L3] Severely obese patients and their associated comorbid conditions pose unique challenges in rotator cuff tear management, but they still achieve overall excellent outcomes after repair and noninferior clinical differences when compared to healthy weight patients. (10.1016/j.arthro.2022.02.026)
  • [L5] Optimal management of patients with diabetic foot ulcers must include clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, offloading in high-risk patients, local wound care, diagnosis and control of osteomyelitis and ischaemia. (10.1302/2058-5241.3.180010)
  • [L5] Management of foot problems in diabetic patients requires a multisystem approach addressing the nervous, vascular, skeletal, immune, and integumentary systems through a multidisciplinary team to prevent ulceration, infection, and amputation. (10.5435/00124635-199507000-00004)
  • [L3] Smoking has a negative effect on anatomical total shoulder arthroplasty functional outcomes that may persist even after quitting. (10.1302/0301-620x.106b11.bjj-2024-0202.r1)
  • [L5] Smoking is hazardous to shoulder health and predisposes to rotator cuff pathology and shoulder dysfunction, but it is only one of several risk factors for complications after arthroscopic shoulder surgery. (10.1016/j.arthro.2015.05.022)
  • [L4] Smoking is associated with RTC tears, shoulder dysfunction, and shoulder symptoms. (10.1016/j.arthro.2015.01.026)
  • [L3] These risks were more pronounced when shoulder arthroplasty was performed within 2 years of bariatric surgery. (10.1016/j.jse.2023.02.120)
  • [L4] Over time, there has been an increase in shoulder dislocations in morbidly obese individuals in the United States, alongside an overall increase in the average BMI of patients who present with shoulder dislocations. (10.1177/2325967123s00170)
  • [L3] We therefore suggest that adults control their weight given that maintaining a healthy weight is highly associated with better shoulder health. (10.1016/j.jse.2023.07.007)
  • [L4] Good pain relief and improved shoulder function were reported at a mean of 5 years postoperatively. (10.1111/j.1758-5740.2010.00105.x)
  • [L3] Patients with painful shoulders, irrespective of having type 2 diabetes mellitus, seem to have abnormal shoulder muscles. (10.1186/s12891-022-05627-9)
  • [L3] However, there does not appear to be a linear association between BMI and risk of dislocation of total shoulder arthroplasty. (10.1016/j.jses.2019.07.001)
  • [L3] Routine thromboprophylaxis after HA may not be indicated in all patients but can be considered based on patient-specific risk factors. (10.1016/j.arthro.2022.10.029)
  • [L3] Former users obtained outcomes similar to those of nonusers, suggesting that tobacco use is a modifiable risk factor to achieve optimal pain relief after RTSA. (10.1016/j.jse.2019.05.045)
  • [L3] Obesity significantly increases the risk of requiring total shoulder arthroplasty. (10.1016/j.jse.2023.03.012)
  • [L3] Smoking is associated with an increased risk of surgical complications following total shoulder arthroplasty, while medical complications are not significantly increased. (10.1016/j.jse.2019.07.012)
  • [L3] An initial failure rate of approximately one-third may be considered unacceptably high in other general orthopedic procedures; however, with appropriate counseling and consent and combined with a repeat MUA for recurrence, this protocol may represent a satisfactory treatment strategy in the diabetic population. (10.1016/j.jse.2011.11.006)
  • [L3] Up to 43% of patients undergoing shoulder arthroscopy can be classified as obese, but early perioperative complications are uncommon. (10.1016/j.arthro.2016.03.022)
  • [L1] Analysis highlighted preoperative CTA use as a significant risk factor, increasing positive culture risk 4-fold. (10.1016/j.jse.2024.12.011)
  • [L3] Patients with a higher BMI required shoulder replacement at a significantly younger age. (10.1016/j.jse.2022.10.032)
  • [L1] Smoking confers a risk ratio of 3.68 for developing a nonunion in patients with a displaced middle third clavicle fracture treated conservatively. (10.1302/0301-620x.105b7.bjj-2022-1336.r1)
  • [L3] Simultaneous surgical treatment of rotator cuff and long head of biceps tendon lesions in smokers allowed for functional outcomes approximating non-smokers in long-term follow-up, though smoking is a significant negative factor associated with massive rotator cuff tears and higher pain levels. (10.3390/jcm10040599)
  • [L4] The elevated IL-1b levels in the subacromial fluid may explain the likelihood of pain and shoulder stiffness developing in diabetic patients. (10.1016/j.jse.2013.01.011)
  • [L3] Elevated preoperative HbA1c is a statistically significant predictor of postoperative shoulder stiffness after posterior-superior rotator cuff repair. (10.1016/j.jseint.2023.09.006)
  • [L2] This study demonstrates that smoking is a significant risk factor of complications after TSA and RSA. (10.1016/j.jse.2016.09.011)
  • [Abstract] Smoking is a significant risk factor of complications after TSA and RSA. (10.1016/j.jse.2015.08.026)
  • [L4] The Wound Score scored better on 10 evaluation criteria than any other foot wound evaluation system for patients with diabetes due to its simplicity, user friendliness, ability to integrate wound and patient information, and design to reflect progress. (10.1097/01.blo.0000182393.31978.c3)
  • [L3] There were no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus. (10.1016/j.jseint.2023.06.007)
  • [L3] Obesity is an independent risk factor for longer operative times but does not confer a higher risk of recurrent instability, revision surgery, or lower outcome scores 1 year following ABR. (10.1016/j.jseint.2023.05.007)

See Also

References

[1] Smoking status and the Disabilities of the Arm Shoulder and Hand score are early predictors of symptomatic nonunion of displaced midshaft fractures of the clavicle. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b1.36260

[2] The Musculoskeletal Effects of Perioperative Smoking. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-06-359

[3] Older age and higher body mass index are independent risk factors for tendon healing in small‐ to medium‐sized rotator cuff tears. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07234-6

[4] Obesity Increases the Risk of Tendinopathy, Tendon Tear and Rupture, and Postoperative Complications: A Systematic Review of Clinical Studies. Clinical Orthopaedics & Related Research. 2020. DOI: 10.1097/corr.0000000000001261

[5] Duration of Smoking Cessation Needed to Achieve Retear Rates Comparable to Those of Nonsmokers After Arthroscopic Rotator Cuff Repair. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261422620

[6] Low and high body mass index and lower numbers of screws in the articular segment are risk factors for non-union of distal humeral fractures in the elderly: A multi-center retrospective study (TRON study). Shoulder & Elbow. 2022. DOI: 10.1177/17585732221131923

[7] Lesser Tuberosity Osteotomy Healing in Stemmed and Stemless Anatomic Shoulder Arthroplasty Is Higher with a Tensionable Construct and Affected by Body Mass Index and Tobacco Use. Journal of Clinical Medicine. 2023. DOI: 10.3390/jcm12030834

[8] Does Body Mass Index Affect Outcomes of Ambulatory Knee and Shoulder Surgery?. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.02.031

[9] No Difference in Risk of Amputation or Frequency of Surgical Interventions Between Patients With Diabetic and Nondiabetic Charcot Arthropathy. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002546

[10] Effect of Smoking on Short-term Postoperative Complications After Elective Upper Extremity Surgery. HAND. 2020. DOI: 10.1177/1558944720926638

[11] Macrophage Dysfunction Impairs Resolution of Inflammation in the Wounds of Diabetic Mice. PLoS ONE. 2010. DOI: 10.1371/journal.pone.0009539

[12] Predictors of Digital Amputation in Diabetic Patients With Surgically Treated Finger Infections. HAND. 2022. DOI: 10.1177/15589447221082160

[13] Raised body mass index and reduced muscle bulk reduces the incidence of Popeye's deformity post tenotomy of long head of biceps brachii. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.07.001

[14] Musculoskeletal Disorders in Patients with Diabetes Mellitus: A Cross-Sectional Study. International Journal of Rheumatology. 2018. DOI: 10.1155/2018/3839872

[15] Obesity, Metabolic Syndrome, and Musculoskeletal Disease: Common Inflammatory Pathways Suggest a Central Role for Loss of Muscle Integrity. Frontiers in Physiology. 2018. DOI: 10.3389/fphys.2018.00112

[16] Treatment of resistant ulcers on the plantar surface of the great toe in diabetics.. The Journal of Bone & Joint Surgery. 1982. DOI: 10.2106/00004623-198264060-00017

[17] Preoperative Risk Management Programs at the Top 50 Orthopaedic Institutions Frequently Enforce Strict Cutoffs for BMI and Hemoglobin A1c Which May Limit Access to Total Joint Arthroplasty and Provide Limited Resources for Smoking Cessation and Dental Care. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002315

[18] Chapter 44 The Diabetic Foot. 2020.

[19] Male gender and age range 20–29 years are the most important non-modifiable risk factors for recurrence after primary post-traumatic shoulder dislocation. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-4924-4

[20] Application of a simple skin stretching system and negative pressure wound therapy in repair of complex diabetic foot wounds. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02405-6

[21] Realignment and Extended Fusion with Use of a Medial Column Screw for Midfoot Deformities Secondary to Diabetic Neuropathy. Journal of Bone and Joint Surgery. 2010. DOI: 10.2106/jbjs.i.01288

[22] Fracture, nonunion and postoperative infection risk in the smoking orthopaedic patient: a systematic review and meta-analysis. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.210058

[23] Severe Obesity Is Not Associated With Worse Functional Outcomes Following Arthroscopic Rotator Cuff Repair. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.02.026

[25] Current concepts for the evaluation and management of diabetic foot ulcers. EFORT Open Reviews. 2018. DOI: 10.1302/2058-5241.3.180010

[27] The Diabetic Foot. Journal of the American Academy of Orthopaedic Surgeons. 1995. DOI: 10.5435/00124635-199507000-00004

[28] The effect of smoking on functional outcomes and implant survival of anatomical total shoulder arthroplasty. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b11.bjj-2024-0202.r1

[29] Editorial Commentary: Smoking is Hazardous to Shoulder Health. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.05.022

[30] Smoking Predisposes to Rotator Cuff Pathology and Shoulder Dysfunction: A Systematic Review. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.01.026

[31] Prior bariatric surgery is associated with an increased rate of complications after primary shoulder arthroplasty independent of body mass index. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.120

[32] Poster 184: Demographics and Outcomes of Shoulder Instability in Individuals with Elevated Body Mass Index. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00170

[33] Influence of body mass index on severity of rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.07.007

[34] Five-Year outcomes of Arthroscopic Capsular Release for Adhesive Capsulitis of the Shoulder in Patients with Type I Diabetes Mellitus. Shoulder & Elbow. 2011. DOI: 10.1111/j.1758-5740.2010.00105.x

[35] Shoulder muscle changes in patients with type 2 diabetes mellitus who have a painful shoulder: a quantitative muscle ultrasound study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05627-9

[36] Body mass index as a risk factor for dislocation of total shoulder arthroplasty in the first 30 days. JSES Open Access. 2019. DOI: 10.1016/j.jses.2019.07.001

[37] Incidence of Venous Thromboembolism After Hip Arthroscopy Is Low With or Without Prophylaxis but Risk Factors Include Oral Contraceptive Use, Obesity, and Malignancy. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.10.029

[38] The effect of current and former tobacco use on outcomes after primary reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.05.045

[39] Obesity is associated with an increased risk of undergoing shoulder arthroplasty in Australia. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.03.012

[40] Smoking is associated with increased surgical complications following total shoulder arthroplasty: an analysis of 14,465 patients. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.07.012

[41] The outcome of manipulation under general anesthesia for the management of frozen shoulder in patients with diabetes mellitus. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.11.006

[43] The Effects of Patient Obesity on Early Postoperative Complications After Shoulder Arthroscopy. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.03.022

[44] Modifiable risk factors for culture positivity after primary Latarjet procedure. Should we change any practice?. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.011

[45] Does body mass index influence long-term outcomes after anatomic total shoulder arthroplasty?. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.10.032

[46] Influence of smoking on the healing of conservatively treated displaced midshaft clavicle fractures. The Bone & Joint Journal. 2023. DOI: 10.1302/0301-620x.105b7.bjj-2022-1336.r1

[47] The Impact of Smoking on Clinical Results Following the Rotator Cuff and Biceps Tendon Complex Arthroscopic Surgery. Journal of Clinical Medicine. 2021. DOI: 10.3390/jcm10040599

[48] Increased interleukin 1β levels in the subacromial fluid in diabetic patients with rotator cuff lesions compared with nondiabetic patients. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.011

[49] Is preoperative elevated glycated hemoglobin (HbA1c) a risk factor for postoperative shoulder stiffness after posterior-superior rotator cuff repair?. JSES International. 2024. DOI: 10.1016/j.jseint.2023.09.006

[50] Chapter 118 The Diabetic Foot and Ankle. 2019.

[51] Effect of smoking on complications following primary shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.09.011

[52] Effect of smoking on complications following primary shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.08.026

[53] Evaluation of Diabetic Wound Classifications and a New Wound Score. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000182393.31978.c3

[54] Effect of surgical timing in outcomes in Hispanic patients after arthroscopic capsular release in diabetic and idiopathic adhesive capsulitis. JSES International. 2023. DOI: 10.1016/j.jseint.2023.06.007

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