Objectives: Alcohol use disorder (AUD) has been associated with post-surgical complications, but previous studies were limited by national, single-database sources. The purpose of this study was to characterize differences in complications of matched cohorts of patients with versus without AUD undergoing primary total knee arthroplasty (TKA) and to evaluate the effect of AUD-associated comorbidities on the hazard of post-operative complications.

Methods: A total of 6,634 patients were extracted from the TriNetX global database for patients undergoing primary TKA from 2015 to 2025. Univariate analysis was performed to examine the relationship between AUD and postoperative complications. A subgroup analysis was performed using the TKA/AUD cohort with surgical complications compared to AUD patients without surgical complications. Cox proportional hazards modeling evaluated the impact of comorbidities and pre-operative labs on the hazard of post-operative complications.

Results: Patients with AUD had a significantly higher risk of acute renal failure, respiratory failure, delirium, transfusion, joint infection, wound dehiscence, superficial skin and soft tissue infection, infection following procedure, periprosthetic fracture around knee joint, and revision arthroplasty. The cohort of TKA/AUD patients with surgical complications had a significantly higher percentage of diabetes, tobacco use, essential hypertension, depression, anxiety, bipolar disorder, and atrial fibrillation than the cohort without surgical complications. These patients also had significantly lower pre-operative hemoglobin, albumin, ALT, and higher INR than patients without complications. The Cox proportional hazards model showed a significantly increased hazard of post-operative complications for hypertension, hemoglobin of 6 – 10 g/dL, and albumin of 2.5 – 3 g/dL in a cohort of patients with AUD.

Conclusion: AUD has a significant effect on both medical and surgical complications following primary TKA at 30 days, 90 days, 1 year, and 5 years post-operatively. Certain pre-operative labs can predict the hazard of post-operative complications. This data supports a multidisciplinary approach to optimize care for high-risk individuals.