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. 2025 Sep 10;12(3):e70422.
doi: 10.1002/jeo2.70422. eCollection 2025 Jul.

Smokers present a three times higher risk of graft failure after ACL reconstruction: A single-centre retrospective analysis

Filip R Hendrikx  1   2 , Pietro Conte  1   3   4 , Annemieke Van Haver  1   5 , Kristien Vuylsteke  1   5 , Koen Carl Lagae  1   5 , Peter Verdonk  1   2   5   6   7
Affiliations

Smokers present a three times higher risk of graft failure after ACL reconstruction: A single-centre retrospective analysis

Filip R Hendrikx et al. J Exp Orthop. .

Abstract

Purpose: To determine whether patients actively smoking at the time of primary anterior cruciate ligament reconstruction (ACLR) have higher failure rates, defined as the need for revision ACLR procedures over time, compared to non-smokers.

Methods: This was a retrospective evaluation on a single-centre cohort of patients who underwent primary ACLR between 2010 and 2015. Patients were included if they had a minimum follow-up of two years and were classified according to their smoking status at the time of the surgery. The primary outcome was graft failure, defined as the need for revision ACLR surgery due to symptomatic ACL instability. Additionally, subgroup analyses were performed on patient groups known to be at high risk of ACLR failure.

Results: The cohort consisted of 537 patients, including 96 (18%) smokers and 441 (82%) non-smokers, with a mean follow-up of 56 months (range 24-89). Demographic characteristics were similar between smokers and non-smokers at baseline. Overall, 22 patients (4.1%) underwent revision ACLR. The failure rate was significantly higher in smokers (9.4%, 9/96) compared to non-smokers (2.9%, 13/441) (p = 0.008, odds-ratio (OR): 3.41, 95% confidence interval (CI): 1.41-8.22). This difference was even greater in specific subgroups: smokers had significantly higher failure rates than non-smokers among patients under 25 years of age (31% vs. 9.8%, p = 0.006, OR: 4.13, 95% CI: 1.54-11.07), highly active patients (20.7% vs. 7.7%, p = 0.044; OR; 3.13, 95% CI: 1.01-9.30) and male patients (13.3% vs. 3.9%, p = 0.010; OR: 3.83, 95% CI: 1.41-10.40).

Conclusions: Smoking at the time of ACLR was associated with a threefold increased risk of ACLR failure. The ACLR failure risk was even greater in patients under 25 years of age, male and those participating in high-activity sports. Notably, a failure rate of 31% was observed in smokers under 25 years of age.

Level of evidence: Level IV, case series with no comparison group.

Keywords: ACL; failure; knee; risk factor; smoke; tobacco.

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Conflict of interest statement

The authors declare no conflicts of interest.

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