JSES - 2026-05-13 - Journal Article; Review
Impact of Smoking on Structural Failure After Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis".
Nguyen VT, Kuo YJ, Wu LC, Lian YZ, Chen YP
Topics
Key Takeaway
Smoking increases imaging-confirmed structural failure after arthroscopic rotator cuff repair by 53% (RR 1.53, 95% CI 1.13–2.08) across 1,683 shoulders with low heterogeneity (I² = 24.7%).
Summary Depth
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Summary
This PRISMA 2020-registered meta-analysis asked whether smoking independently increases structural failure after arthroscopic rotator cuff repair using imaging-confirmed outcomes. Ten cohort studies (1,683 shoulders) were pooled using a random-effects model with Hartung-Knapp adjustment; smoking conferred RR 1.53 (95% CI 1.13–2.08, P=.011) for retear with I²=24.7%. ASES scores were marginally lower in smokers but VAS pain and forward flexion showed no significant between-group difference, suggesting the structural failure penalty does not translate proportionally into functional deficit.
Key Limitation
All included studies are cohort-level observational data assessed by Newcastle-Ottawa Scale, meaning residual confounding by tear size, tissue quality, repair technique, and pack-year dose is not fully controlled across the pooled analysis.
Original Abstract
BACKGROUND
Rotator cuff tears cause significant shoulder pain and functional limitation. Arthroscopic rotator cuff repair improves symptoms, yet structural failure rates remain substantial. Smoking may impair tendon-to-bone healing, but clinical studies report mixed findings due to heterogeneous methodology. Therefore, a systematic synthesis of imaging-confirmed outcomes is needed to clarify the association between smoking and structural failure after arthroscopic rotator cuff repair.
METHODS
This review followed PRISMA 2020 and was registered in PROSPERO. PubMed, Embase, Scopus, Web of Science, and the Cochrane Library were searched from inception to 12 December 2025. Comparative clinical studies of adults undergoing arthroscopic rotator cuff repair that reported imaging-confirmed structural integrity (magnetic resonance imaging or ultrasonography) at ≥6 months were included. Two reviewers independently screened studies, extracted data, and assessed quality using the Newcastle-Ottawa Scale. The primary outcome (structural failure) was pooled as risk ratios using a random-effects model with the restricted maximum likelihood estimator and Hartung-Knapp adjustment. Secondary continuous outcomes were synthesized using Bayesian random-effects models; subgroup, sensitivity, and meta-regression analyses explored heterogeneity.
RESULTS
Ten cohort studies (1,683 shoulders) were included. Smoking was associated with a higher risk of imaging-confirmed structural failure (risk ratio 1.53; 95% confidence interval 1.13-2.08; P = .011) with low heterogeneity (I 2 = 24.7%). Subgroup and sensitivity analyses supported robustness, with no evidence of effect modification by region, follow-up duration, tear size, or smoking definition. Meta-regression showed no significant influence of age, smoking prevalence, or diabetes prevalence on the pooled effect. Secondary outcomes (three studies) suggested slightly lower postoperative American Shoulder and Elbow Surgeons scores among smokers, while visual analog scale pain scores and forward flexion showed no clear between-group differences. No publication-bias signals were detected for the primary outcome.
CONCLUSION
Smoking is associated with a higher risk of imaging-confirmed structural failure after arthroscopic rotator cuff repair. Functional outcomes were broadly similar between groups, with only a small, likely clinically negligible reduction in American Shoulder and Elbow Surgeons scores among smokers. These findings support careful smoking history assessment and perioperative risk modification, including smoking cessation strategies.
LEVEL OF EVIDENCE
Level III, Systematic Review/ Meta-analysis.