Tobacco Use Is Associated With Increased Complications After Anterior Cruciate Ligament Reconstruction

Am J Sports Med. 2016 Jan;44(1):99-104. doi: 10.1177/0363546515610505. Epub 2015 Nov 2.


Background: The use of tobacco is a well-established cause of preventable morbidity and mortality. There have been few studies examining the effect of tobacco use on outcomes and complications after arthroscopic knee procedures such as anterior cruciate ligament (ACL) reconstruction.

Purpose: To investigate the relationship between tobacco use and rates of postoperative infection, venous thromboembolism (VTE), arthrofibrosis, and subsequent ACL reconstruction after primary ACL reconstruction.

Study design: Cohort study; Level of evidence, 3.

Methods: A national insurance database was queried for patients who underwent arthroscopic-assisted ACL reconstruction using Current Procedural Terminology code 29888. Patients underage for tobacco use in all regions of the United States (age <20 years), those with prior ACL reconstruction, and those with the following concomitant procedures were excluded: open cruciate or collateral ligament reconstruction, open or arthroscopic cartilage procedures, patellar stabilization, extra-articular ligamentous reconstruction, and posterior cruciate ligament reconstruction. Tobacco use and non-tobacco use cohorts were queried using International Classification of Diseases-9th Revision coding. The non-tobacco use patients were then matched to the patients with coded tobacco use by age, sex, obesity, diabetes, meniscal repair, and meniscectomy. Complications within 90 days postoperatively were assessed for both cohorts, including infection, VTE, arthrofibrosis, and subsequent ipsilateral or contralateral ACL reconstruction after the index procedure.

Results: A total of 13,358 patients who underwent ACL reconstruction met inclusion and exclusion criteria, including 1659 patients with documented tobacco use and 11,699 matched controls. The incidence of infection was significantly higher in patients who use tobacco (2.0%) versus matched controls (0.9%; odds ratio [OR], 2.3; P < .0001). The rate of VTE was also significantly higher in patients who use tobacco (1.0%) compared with matched controls (0.5%; OR, 1.9; P = .035). The rate of subsequent ACL reconstruction was significantly higher in the tobacco use cohort (12.6%) compared with matched controls (7.8%; OR, 1.7; P < .0001). There was no significant difference in the rate of postoperative stiffness after ACL reconstruction between patients who use tobacco (2.0%) and matched controls (2.3%; OR, 0.9; P = .656).

Conclusion: ACL reconstruction in patients who use tobacco is associated with significantly increased rates of infection, VTE, and subsequent ACL reconstruction compared with controls. There was no association between tobacco use and postoperative arthrofibrosis after primary ACL reconstruction.

Keywords: ACL reconstruction; VTE; infection; smoking; stiffness; tobacco.

MeSH terms

  • Adult
  • Anterior Cruciate Ligament / surgery
  • Anterior Cruciate Ligament Reconstruction*
  • Cohort Studies
  • Female
  • Humans
  • Incidence
  • Infections / epidemiology
  • Joint Diseases / epidemiology
  • Knee Joint / surgery*
  • Male
  • Middle Aged
  • Odds Ratio
  • Postoperative Complications / epidemiology*
  • Reoperation
  • Smoking / adverse effects
  • Tobacco Use / adverse effects*
  • United States / epidemiology
  • Venous Thrombosis / epidemiology
  • Young Adult