Patients who are actively smoking at the time of primary total joint arthroplasty (TJA) are at considerably increased risk of perioperative complications. Therefore, strategies to assist patients with smoking cessation before surgery have become routine practice. A secondary benefit is the theoretical catalyst for long-term smoking cessation. However, questions remain as to whether patients actually cease smoking prior to the procedure, and if so, how long this lasts postoperatively. Our high-volume, academic institution documents self-reported smoking status at each clinic visit (at 6-month intervals), as well as at the time of surgery through a total joint registry. As such, all patients who underwent TJA from 2007 to 2018 were identified and grouped as: non-smokers, smokers (regularly smoking cigarettes within 1 year from surgery), and former smokers (those who quit smoking within a year before surgery). Thereafter, smoking status in the postoperative period was assessed, with special attention to the former smokers in order to see who remained smoke-free. From the 28,758 primary TJAs identified, 91.3% (26,244) were non-smokers, 7.3% (2,109) were smokers, and 1.4% (405) had quit smoking before surgery. Among patients who quit smoking before surgery, only 38% were still abstinent at 9 years from surgery. Conversely, 24% of smokers at the time of surgery eventually quit and 3.1% of non-smokers started smoking over the same time period. Despite a concerted effort to help patients stop smoking before TJA, an important proportion (7.3%) are unsuccessful. Among those patients who do manage to stop smoking, only a minority (38%) remain smoke-free after surgery. Compared to current smokers, patients who managed to quit before surgery are more likely to remain smoke-free after surgery. These findings highlight that smoking remains a tremendous challenge in contemporary TJA practices. Additional strategies targeting smoking cessation before after surgery are needed

Over the past 40 years information from large institutional total joint registries have aided in patient clinical care and follow-up efforts, have helped drive improvements in clinical practice, and have been a powerful tool for generating research studies on large well documented populations of patients. Still, these efforts are limited in that they are expensive, usually reflect a single institutional experience, and results can be biased by the larger volumes or experience at the typically large academic centers which have such registries in place. National registry efforts in other countries including Scandinavia, Australia, and the UK have resulted in improved outcomes and a decreased number of revision procedures by a combination of early identification and withdrawal of poorly performing implants, altered surgical techniques, implant choices and behaviors by surgeons, changes in practices by hospitals, and modification in requirements and incentives by payors and regulatory agencies. The American Joint Replacement Registry (AJRR) is a collaborative multi-stakeholder, independent, not-for-profit 501 c3 organisation established in 2009 for data collection and quality improvement initiatives relating to total hip and knee arthroplasty. AJRR is a national registry effort with the goal of enrolling more than 90% of the over 5,000 hospitals performing nearly 1 million hip and knee arthroplasties each year in the US. AJRR is supported by contributions from the American Academy of Orthopedic Surgeons (AAOS), the American Association of Hip and Knee Surgeons (AAHKS), the Hip Society, the Knee Society, Health Insurers, Medical Device Manufacturers, and individual orthopaedic surgeons via designated contributions through the Orthopedic Research and Education Foundation (OREF). The overarching goal of AJRR is to improve arthroplasty care for patients through the collection and sharing of data on all primary and revision total joint replacement procedures in the U.S. The mission of the registry is to enhance patient safety, and improve the value of arthroplasty care. This will be accomplished by providing national benchmarks for implant, surgeon and hospital performance which serves to modify behaviors thereby decreasing the revision burden, improving outcomes and reducing costs. From the time of incorporation in 2009 up to October 2013 the AJRR has secured the participation of 218 hospitals in 47 different states in the formal enrollment process, and have level one data submission from more than 100 institutions on over 63,000 hip and knee procedures. In addition to publicly available annual reports, confidential specific individual reports for hospitals, surgeons and manufacturers will be available by subscription with an option for future confidential online direct data queries by an individual or entity regarding their own individual performance compared to national benchmark values. In summary, registry studies have provided a rich source of information for improving arthroplasty care over the past four decades, with the emergence and increasing interaction of national registries a major factor in current efforts to increase both the quality and value of the health care of entire populations. The development, support and continued expansion of a national registry in the US must remain a central focus if we wish to improve as much as possible the arthroplasty care provided to all patients in our country