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


It is well-established that alcohol consumption and cigarette smoking are modifiable risk factors for cardiovascular disease, chronic respiratory disease, and diabetes.[22,25] Drinking and smoking, although individually detrimental and contributors to poor outcomes, can act synergistically when combined.[26,27] In primary THA and TKA, studies have shown that drinking and smoking, separately, contribute to the development of various complications after surgery, including wound dehiscence, infection, prosthetic loosening, and respiratory morbidity.[28] Revision TJA has been shown to be associated with increased postoperative complications and overall morbidity relative to primary TJA. In this matched cohort study, we found that compared with nonusers, substance users had markedly higher risks for longer LOS, both inhospital and postdischarge complications, and re-revision surgery for PJI. In addition, we found that smokers and drinkers shared many similar postdischarge outcomes, including readmissions, complications, and re-revisions with concurrent users having the worst outcomes.

Our study found notable increases in the rate of inhospital complications and 90-day major complications occurring in smokers, drinkers, and concurrent users when compared with nonusers. Transfusion was the most commonly encountered inhospital complication, the incidence of which was found to be markedly increased in all user groups compared with nonusers. The observed increase in transfusion rates in these groups is consistent with previous studies. Best et al performed a retrospective review using the National Discharge Hospital Survey database and found that blood transfusion, among several other adverse events, was more common in patients who misused alcohol than in patients who did not.[11,13–15,29] Bedard et al,[17] in a retrospective study using the ACS-NSQIP database, evaluated 30-day complication rates after revision TKA in smokers. They reported that smokers had a markedly higher rate of several complications, including postoperative blood transfusion. Smoking may predispose to increased blood loss by affecting the clotting cascade and platelet membrane characteristics.[30] Interestingly, we found that concurrent users had 76% higher odds for postoperative blood transfusion than smokers and 59% higher odds than drinkers.

Regarding major complications, incidence of wound dehiscence, deep infection, and revision surgery were all markedly increased in all user groups compared with nonusers at 90 days. In addition, we found that compared with drinkers, concurrent users had 189% increased odds for wound dehiscence, suggestive of a synergistic, negative effect on wound healing. These findings mirror those seen in primary TJA literature. Best et al[30] observed markedly increased rates of acute postoperative infection in patients who misused alcohol in primary TJA. Teng et al,[31] in a meta-analysis of cohort studies investigating smoking and complications after primary THA, found that smokers had a markedly increased risk of deep infection. Tischler et al[32] performed a retrospective study using their institutional database to analyze 90-day outcomes after TJA. They found that current smokers were markedly more likely to undergo revision surgery for infection within this period. Bedard and colleagues[16,17] observed that smokers exhibited markedly increased rates of wound dehiscence, deep infection, and revision surgery at 30 days after revision THA and TKA than nonsmokers in the ACS-NSQIP database. The association between cigarette use and postoperative wound complications and infection is commonly thought to stem from smoking-induced vasoconstriction and resultant tissue hypoxia.[33] Smoking has also been shown to have detrimental effects on immune cell function and collagen production.[34,35] The pathogenesis of alcohol use and its effects on wound healing and infection are less well understood. Increased rates of periprosthetic infection in patients with cirrhosis have been attributed to reticuloendothelial impairment and immune cell dysfunction.[36,37] The common coincidence between alcohol misuse and malnutrition has been identified as a risk factor for postoperative wound complications and infection after TJA. Acute alcohol exposure has also been associated with the suppression of anti-inflammatory cytokine release (tumor necrosis factor, interleukin 2, and interleukin 6), whereas chronic alcohol exposure has been associated with impaired chemotaxis of neutrophils.[38]

Although we found smoking and drinking status to be unassociated with re-revisions for aseptic failure modes, drinkers and concurrent users were found to be at markedly higher odds for septic re-revision compared with nonusers. Alcohol usage has been shown in the literature to have a notable effect on the immune status. Consistent usage over time has been reported to decrease granulocyte and lymphocyte counts and therefore an overall decrease in the immunoprotective abilities of these cells.[39] Our results indicate that concurrent users were not markedly disposed to higher rates of PJI than smokers or drinkers. In this study, smokers and drinkers had similar 30-, 60-, and 90-day readmission rates; 90-day postdischarge complications, and re-revision rates at the final follow-up for both aseptic and septic etiologies. When compared with drinkers, smokers had higher odds for developing inhospital complications, having a longer LOS and being discharged to inpatient rehabilitation. The similarity in postdischarge complications, readmissions, and re-revisions between smokers and drinkers is a novel finding of our study that, to our knowledge, has not been demonstrated in the current literature.

Our study poses several inherent limitations given that it is a retrospective observational study. First, we acknowledge there are limitations of using a database associated with the quality of the data evaluated retrospectively. However, our institutional database was prospectively collected and maintained. Second, our classifications of smokers and drinkers are binary largely because of the limitations of our electronic medical record system. Further quantification and stratification are required to more thoroughly investigate the degree to which different levels of usage (nonuse, light, moderate, and heavy) of both alcohol and tobacco affect the outcomes and complications. The collection of smoking and drinking status through retrospective chart review may additionally be associated with inaccuracies. In addition, this retrospective study does not quantify for how long smoking and/or drinking should be stopped before surgery to markedly reduce postoperative complications. Finally, propensity score matching was used to reduce selection bias and discrepancies in health status, but there may be potentially unobserved variables that could affect the outcomes of interest. Because they remained unaccounted for in our analysis, these factors may be heterogeneously distributed. However, we used clinically relevant covariates for propensity score matching in accordance with previous published studies and have judiciously chosen exclusion criteria that would mitigate this unknown bias.

In conclusion, our propensity-score-matched cohort study results demonstrate that smoking and drinking markedly increases the risks for inhospital complications, longer length of stay, major postdischarge complications, and re-revision for PJI compared with nonusers. 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. Our results suggest that cessation of smoking, drinking, or both remains an important modifiable risk factor in the outcome of revision hip and knee TJA.