The effect of smoking on outcomes following primary total hip and knee arthroplasty: a population-based cohort study of 117,024 patients

Gulraj S Matharu*, Sofia Mouchti, Sarah Twigg, Antonella Delmestri, David W Murray, Andrew Judge, Hemant G Pandit

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

7 Citations (Scopus)
199 Downloads (Pure)


Background and purpose
Smoking is a modifiable risk factor that may adversely affect post-operative outcomes. Healthcare providers are increasingly denying smokers access to total hip and knee arthroplasty (THA/TKA) until they stop smoking. Evidence supporting this is unclear. We assessed the effect of smoking on outcomes following arthroplasty.

Patients and methods
We identified THAs and TKAs from the Clinical Practice Research Datalink, which were linked with datasets from Hospital Episode Statistics and the Office for National Statistics to identify outcomes. The effect of smoking on post-operative outcomes (complications, medications, revision, mortality, patient-reported outcome measures (PROMs)) was assessed using adjusted regression models.

We studied 60,812 THAs and 56,212 TKAs (10.8%=smokers, 32.6%=ex-smokers, 56.6%=non-smokers). Following THA, smokers had an increased risk of lower respiratory tract infection (LRTI) and myocardial infarction compared with non-smokers and ex-smokers. Following TKA, smokers had an increased risk of LRTI compared with non-smokers. Compared with non-smokers (THA relative risk ratio (RRR)=0.65; 95% CI=0.61-0.69; TKA RRR=0.82; CI=0.78-0.86) and ex-smokers (THR RRR=0.90; CI=0.84-0.95), smokers had increased opioid usage one-year postoperatively. Similar patterns were observed for weak opioids, paracetamol, and gabapentinoids. One-year mortality rates were higher in smokers compared with non-smokers (THA hazard ratio (HR)=0.37, CI=0.29-0.49; TKA HR=0.52, CI=0.34-0.81) and ex-smokers (THA HR=0.53, CI=0.40-0.70). Long-term revision rates were not increased in smokers. Smokers had improvement in PROMs compared with preoperatively, with no clinically important difference in postoperative PROMs between smokers, non-smokers and ex-smokers.

Smoking is associated with more medical complications, higher analgesia usage, and increased mortality following arthroplasty. Most adverse outcomes were reduced in ex smokers, therefore smoking cessation should be encouraged before arthroplasty.
Original languageEnglish
Pages (from-to)559-567
Number of pages9
JournalActa Orthopaedica
Issue number6
Early online date2 Aug 2019
Publication statusPublished - 2 Nov 2019


  • smoking
  • outcomes
  • mortality
  • Arthroplasty

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