Tobacco's toll: Comparable anterior cruciate ligament graft failure rates and inferior functional outcomes in smokers compared to non-smokers: A systematic review and meta-analysis.

Abstract

Anterior cruciate ligament reconstruction (ACLR) is among the most performed orthopaedic procedures. Evaluating the effect of smoking on postoperative outcomes following ACLR could benefit many patients. This study investigated the impact of smoking on graft failure and functional outcomes following ACLR. PubMed, MEDLINE, and Embase were searched up until March 9, 2025. The primary outcome was ACL graft failure after ACLR. Inclusion criteria were: age ≥18 years, ≥1-month follow-up (FU), ACL reconstruction, and articles in English. Exclusion criteria were: cadaveric studies, ACL repair, ≤5 participants, reviews, and case reports. Meta-analysis results were reported as odds ratios (OR) and proportions with 95% confidence intervals (CI). A total of 12 studies were included (92,208 patients) (mean FU: 42.8 ± 17.0 months; mean age: 35.9 ± 6 years; 6.8% smokers; 57.9% male). The quality of included studies was moderate, (MINORS score range: 9 to 21). In smoker's reoperation rate was 7.6% (FU 59.4 months). For non-smokers the reoperation rate was 5.2% (59.9 months FU). Three studies (2,823 patients) compared ACL graft failure rates, with similar pooled failure rates of 5.0% and 5.5% in smokers and non-smokers, respectively (OR 1.12 [95% CI: 0.38-3.29]). Four studies (1285 patients) compared postoperative IKDC scores with mean scores of 79.6 ± 10.3 in smokers and 84.0 ± 9.5 in non-smokers, respectively (OR 5.12 [95% CI: 3.59-6.65]). One study reported Tegner scores that were not different between smokers (5.0) and non-smokers (5.4). This systematic review demonstrated that ACL graft failure and all-cause reoperation rates did not differ significantly between smokers and non-smokers. Nonetheless, non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction. Level IV.