Delayed tibial shaft fracture healing associated with smoking: A systematic review and meta‐analysis of observational studies conducted worldwide

Tibial fractures represent a great burden of disease globally, being the most common long-bone fracture; smoking is a known risk factor for delayed skeletal healing and post‐fracture complications. This systematic review and meta‐analysis aims to analyse the effect of smoking on healing of tibial shaft fractures. PubMed, CINAHL, EMBASE, and Cochrane Library databases were searched from inception to March 2021, with no limitation on language, to find relevant research. All observational studies that assessed the association between cigarette smoking and tibial shaft fracture healing in adults (≥18 years) were included. The quality of studies was evaluated using the Newcastle Ottawa Quality Assessment Scale. A random effects model was used to conduct meta-analysis. Tobacco smoking was associated with an increased rate of non‐union and delayed union as well as an increase in time to union in fractures of the tibial shaft. Among the 12 included studies, eight reported an increased rate of non‐union, three reported delayed union, and five reported an increase in time to union. However, the results were statistically significant in only three studies for non‐union, one for delayed union, and two studies for increased time to union. This review confirms the detrimental impact of smoking on tibial shaft fracture healing and highlights the importance of patient education regarding smoking cessation.