The effect of non-tobacco nicotine on bone healing: a systematic review and application to total joint arthroplasty.

BACKGROUND

Bone healing and joint repair are complex biological processes impacted by vascular supply, cellular activity, and the local environment of the affected tissues. Nicotine is a widely used substance that can affect multiple processes needed for adequate bone formation and healing after total joint arthroplasty. The purpose of this review was to evaluate the isolated effects of nicotine, independent of tobacco smoke, cigarette combustion products, or vaping aerosols, on bone healing, bone formation, and implant integration relevant to arthroplasty outcomes.

METHODS

A systematic review was conducted from its inception in May 2024. The review included 62 studies that analyzed nicotine's effects on bone healing, health, or growth in humans and animals. Studies were evaluated using the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) assessment tool.

RESULTS

Animal models exposed to nicotine demonstrated delayed bone healing and decreased new bone formation while increasing bone necrosis and chondrocyte density. Nicotine slows osseointegration of titanium implants, reducing implant stability and bone-to-implant contact. Higher doses of nicotine inhibit osteoblast proliferation and increase osteonecrosis. However, at lower doses, nicotine demonstrates anti-inflammatory properties that can partially offset these effects.

CONCLUSIONS

Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration, as demonstrated in various animal and in vitro studies. However, the lack of human studies that isolate the effects of nicotine from those of tobacco or cigarette smoke underscores the urgent need for further research in this area.