Impact of Smoking and Drinking on Complications After Revision Total Joint Arthroplasty

A Matched Cohort Analysis

Venkatsaiakhil Tirumala, MS; Georges Bounajem, MD; Christian Klemt, PhD; Ameen Barghi, MD; Young-Min Kwon, MD, PhD


J Am Acad Orthop Surg. 2021;29(15):e769-e781. 

In This Article

Abstract and Introduction


Introduction: Smoking and drinking have been shown to impair postoperative outcomes in primary hip and knee total joint arthroplasty (TJA). This study aimed to evaluate the potential impact of smoking and drinking on complications after revision TJA.

Methods: We retrospectively evaluated a total of 4,302 consecutive patients who underwent revision TJA. Patient demographics and complications were compared between four cohorts based on smoking and drinking status: (1) nonusers (nonsmokers and nondrinkers), (2) smokers, (3) drinkers, and (4) concurrent users.

Results: A total of 1,924 patients were matched using propensity score analysis: 808 nonusers (42.0%), 421 smokers (21.9%), 483 drinkers (25.0%), and 212 concurrent users (11.1%). When compared with nonusers, smokers, drinkers, and concurrent users (simultaneous smokers and drinkers) exhibited higher odds for both inhospital complications (odds ratios, smokers: 2.40, drinkers: 1.55, and concurrent users: 5.13, P < 0.01). Among the user cohorts, although smokers and drinkers showed similar rates of 90-day postdischarge complications (smokers: 14.95% and drinkers: 14.80%, P = 0.95), concurrent users demonstrated the highest significant odds for these complications (odds ratio, 1.64, P = 0.02).

Discussion: Our propensity-score-matched cohort study results demonstrate that although the smokers and drinkers groups shared similarly poor outcomes after discharge, concurrent users were found to have the worst outcomes compared with either single user group.


Because the volume of primary hip and knee total joint arthroplasty (TJA) is expected to increase worldwide, the burden of revision TJA is also expected to increase.[1,2] Despite markedly improving patients' quality of life, revision TJA procedures are associated with higher complications relative to primary TJA.[3–5] Currently, substantial attention is being focused on optimizing modifiable risk factors, such as smoking and drinking, before surgery to improve patient outcomes.[6,7] By intervening early on such modifiable risk factors, healthcare providers can minimize complications, reduce costs, and improve outcomes.[8] Many studies have shown that smokers and drinkers are at increased risk of having complications and poor outcomes after various surgical procedures,[9,10] including primary hip and knee TJA.[11,12]

Several studies have examined the effects of smoking and drinking in primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). There are reports of increased risks for respiratory morbidity, wound infections and dehiscence, deep surgical site infection, prosthetic loosening, and higher intraoperative blood loss.[11,13–15] However, there have been only a few studies that have reported similar investigations in revision TJA. Bedard and colleagues[16,17] retrospectively evaluated the effect of smoking in revision TKA and revision THA using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Although using multi-institutional databases, such as the ACS-NSQIP, have advantages because of the large sample sizes afforded, there are a number of potential limitations in the data, including the lack of surgical history, restriction of complications to the 30-day postoperative period, and absence of subsequent re-revision surgery. The relationships between smoking and drinking as separate independent risk factors in primary TJA have been well-studied. However, a high rate of concurrent smoking and drinking in the population has also been noted.[18] Therefore, in this study, we aimed to evaluate the potential impact of smoking, drinking, and concurrent usage on outcomes after revision TJA.