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Background: Cannabis use may be increasing as countries legalize it and it becomes socially acceptable. A history of cannabis use may increase risk of complications after various kinds of surgery and compromise functional recovery. Data on various outcomes were pooled when appropriate and meta-analyzed. Results: The systematic review included 16 cohort studies involving 5. Meta-analysis linked history of cannabis use to higher risk of the following outcomes: revision RR 1. In addition, cannabis use was associated with significantly greater risk of postoperative transfusion RR 2. Conclusion: History of cannabis use significantly increases the risk of numerous complications and transfusion after THA or TKA, leading to greater healthcare costs. Clinicians should consider these factors when treating cannabis users, and pre-surgical protocols should give special consideration to patients with history of cannbis use. Cannabis, extracted from plants of the Cannabis genus, contains cannabinoids, which have been used in the traditional medicine of various countries against pain, inflammation, spasms, depression and asthma 1 , 2. At the same time, cannabinoids can have wide-ranging effects on cognitive, cardiovascular, respiratory, nervous, and psychological functions, and they can induce addiction 3. As a growing number of countries legalize cannabis use, whether for recreation or specific medical purposes, concerns are growing about how history of cannabis use affects how people respond to medical treatments. For example, some studies have suggested that individuals with cannabis use disorder are at higher risk of various complications than other individuals after diverse elective surgeries 4 , 5. THA and TKA are the most successful surgeries for patients with severe painful, deformed, and damaged joints. In the United States, the annual demand for hip arthroplasty is expected to reach , and demand for knee arthroplasty to reach 1. Total joint arthroplasty patients with history of cannabis use may be also at higher risks of postoperative transfusion 7 , 9 and morphine consumption 11 — However, a comprehensive understanding of the associations between history of cannabis use with complications and poor outcomes after hip or knee arthroplasty is still lacking. We are not aware of any published systematic review or meta-analysis in this field. Our findings may help clinicians and patients predict prognosis after joint arthroplasty surgery, and they may guide future research on the effects of cannabis use on surgical outcomes more generally. Ethics approval was not sought because we retrospectively analyzed studies previously published in peer-reviewed journals. Studies were excluded from the review if the control group involved any additional interventions, involved surgeries other than hip or knee arthroplasty, or did not report relevant outcomes. No restrictions were imposed on study design, language or publication date. References lists in potentially eligible studies were also searched manually in order to identify additional studies. Potentially relevant studies were imported into Zotero 5. They then reviewed the full texts of the remaining articles in order to decide on the final set. Discrepancies were resolved through discussion with a third author. Outcomes of interest included prosthetic complications, systemic complications, transfusions, postoperative morphine consumption, postoperative pain, and hospitalization costs. The methodological quality of included studies was assessed using the Newcastle-Ottawa Scale 19 , which is a validated, widely used tool for evaluating the quality of observational studies with a total point of nine. The scoring items included 1 the methods used to select the study groups 0—4 points , 2 the comparability of cases and controls 0—2 points , and 3 the method used to ascertain the outcome of interest 0—3 points. Assessments were made independently by two researchers, and discrepancies were resolved through discussion with a third researcher. Outcomes were synthesized qualitatively if data could not be directly compared across studies. Outcomes for comparable data were pooled between studies and meta-analyzed using a random-effects model in RevMan 5 software The Cochrane Collaboration, Oxford, United Kingdom. Pooled results were reported as relative risks RRs for dichotomous outcomes or as weighted mean differences WMDs for continuous outcomes. Of 99 potentially relevant publications, 37 were first excluded because they were duplicates. Next, another 36 were excluded because they did not fulfill the inclusion criteria based on titles and abstracts Figure 1. The remaining 26 publications were read in full, leading to the inclusion of 16 in the final review. Two of these were prospective 13 , 22 , while the others were retrospective 7 — 12 , 14 — 16 , 23 — All studies were published in or later, and 10 were published in or later 7 — 9 , 13 — 16 , 25 — These studies analyzed 42, individuals with history of cannabis use and 5,, individuals who reported no cannabis use as a control group. The methodological quality of these studies ranged from 6 to 9 on the Newcastle-Ottawa Scale. The detailed description of the study characteristics is shown in Table 1 , and summary of outcomes data is shown in Table 2. Three studies involving 2,, individuals investigated the rate of revision 9 , 23 , Meta-analysis associated history of cannabis use with significantly higher revision rate RR 1. Similar results were obtained for incidence of mechanical loosening of prosthetic RR 1. Figure 2. Forest plot of the risk of prosthetic complications between patients with or without a history of cannabis use after total knee or hip arthroplasty. Meta-analysis of two studies 7 , 9 involving 78, individuals linked history of cannabis use to significantly higher dislocation rate RR 2. The evidence level was judged to be low for all these meta-analyses Appendix 1. Meta-analysis of three studies involving 2,, individuals associated history of cannabis use with significantly higher incidence of cardiovascular complications RR 2. Meta-analysis of two studies 7 , 9 involving 78, individuals linked cannabis use to significantly higher incidence of cerebrovascular complications RR 3. Figure 3. Forest plot of the risk of system complications between patients with or without a history of cannabis use after total knee or hip arthroplasty. Meta-analysis of two studies 7 , 9 involving 78, individuals associated history of cannabis use with significantly higher incidence of postoperative pneumonia RR 3. Meta-analysis of the same two studies 7 , 9 linked cannabis use to significantly higher incidence of acute kidney injury RR 3. Meta-analysis of three studies 7 — 9 involving 2,, individuals linked history of cannabis use to significantly higher incidence of urinary tract infection RR 2. Meta-analysis of three studies 7 , 9 , 10 involving 96, individuals associated history of cannabis use with significantly higher incidence of venous thromboembolism RR 1. Meta-analysis of four studies 7 — 10 involving 2,, individuals linked cannabis use to significantly higher incidence of deep vein thrombosis RR 1. Figure 4. Forest plot of the risk of thromboembolic complications between patients with or without a history of cannabis use after total knee or hip arthroplasty. Meta-analysis of six studies 11 — 16 involving 2, patients did not detect a significant difference in postoperative morphine consumption between patients with or without history of cannabis use WMD 3. Figure 5. Forest plot of the mean difference of morphine consumption between patients with or without a history of cannabis use after total knee or hip arthroplasty. CI, confidence interval; Random, random-effects model. We were unable to meta-analyze differences in self-reported postoperative pain scores across the five cohort studies 11 , 13 , 22 , 24 , 27 that reported such data, because the studies assessed pain at different time points. Three retrospective studies 11 , 22 , 27 and one prospective study 13 , which together involved participants, reported no significant difference in postoperative pain between patients with or without history of cannabis use, while one retrospective cohort study 24 involving participants linked cannabis use to significantly higher pain. Meta-analysis of two studies 7 , 9 involving 78, individuals linked history of cannabis use to significantly higher rate of postoperative transfusion RR 2. Figure 6. Forest plot of the risk of postoperative transfusion between patients with or without a history of cannabis use after total knee or hip arthroplasty. Five retrospective cohort studies 7 — 10 , 25 involving 2,, individuals reported hospitalization costs related to joint replacement, but we were unable to meta-analyze the comparison between patients with or without history of cannabis use because the studies assessed different types of costs and sometimes differed in how they defined the same cost. All five studies reported that history of cannabis use was associated with higher hospitalization costs, which ranged from 16, to 59, USD for cannabis users and from 16, to 53, USD for controls. Our analyses suggest that cannabis use is associated with greater risk of a range of negative outcomes, implying the need for special preoperative preparation and postoperative management of such patients. The tetrahydrocannabinol in cannabis can cause feelings of euphoria that lead to addiction 28 , it exerts analgesic and sedative effects by activating cannabinoid receptors 1 and 2, and it exerts adverse cardiovascular effects by activating the endocannabinoid system in the central nervous and cardiovascular systems Phytocannabinoids can exacerbate infections by inhibiting the proliferation of T cells in peripheral blood 30 , The effects of phytocannabinoids on the central nervous system may help explain why cannabis use increases risk of prosthetic complications: the plant compounds may decrease proprioception and impair motor coordination 32 , which may contribute to risk of revision, mechanical loosening, periprosthetic fractures, and joint dislocation. Phytocannabinoids may reduce bone density by affecting mesenchymal stem cells 33 , 34 , which may also contribute to the observed increase in fracture risk. The observed higher risk of infection with cannabis use in our meta-analysis may reflect the ability of phytocannabinoids and other compounds in canabis smoke to suppress immune responses, analogously to compounds in cigarette smoke 35 — Consistent with a study linking history of cannabis use to greater risk of thrombotic complications in trauma patients 39 , our meta-analysis confirmed an association between cannabis use and higher risk of venous thromboembolism and deep vein thrombosis. This association can be attributed to the ability of phytocannabinoids, acting through cannabinoid receptor 1, to stimulate the sympathetic nervous system while inhibiting the parasympathetic nervous system. These simultaneous processes increase heart rate and myocardial oxygen demand, leading to endothelial dysfunction and oxidative stress, which in turn may increase risk of myocardial infarction and stroke 40 , In addition, tetrahydrocannabinol may increase risk of thrombotic complications by activating platelets Nevertheless, the evidence level for the effects of cannabis use on venous thromboembolism and deep vein thrombosis is not strong, highlighting the need for further research into these complications. Such research should verify our finding of no association between cannabis use and risk of pulmonary embolism, and it should explore why cannabis use appears to increase risk of thrombotic complications in veins but not arteries Nearly all studies in our review found no significant difference in postoperative pain between patients with or without history of cannabis use, which may help explain why our meta-analysis indicated no significant difference in postoperative morphine consumption between the two groups. This pooled result contrasts with previous work suggesting that cannabis use can reduce postoperative morphine consumption 43 , Nevertheless, the evidence level for this pooled result was very low, highlighting the need for rigorous research into whether cannabis use can mitigate pain after arthroplasty or other surgical procedures. Our finding of an association between history of cannabis use and significantly higher rate of postoperative transfusion may reflect the higher risk of certain complications, such as bleeding. The observed association of cannabis use with higher hospitalization costs likely reflects the higher risk of numerous complications requiring prolonged treatment and management in hospital. Our results should be interpreted with caution in light of several limitations. Indeed, none of the included studies reported sufficient detail about duration and intensity of cannabis use to allow us to evaluate dose—response relationships or control for confounding factors. Whether cannabis us helps reduce pain and the need for morphine after joint replacement remains unclear. Future research should verify and extend our findings, particularly those with a lower evidence level. Clinicians may wish to use our findings to optimize preoperative preparation and postoperative management for patients with a history of cannabis use. GY: Conceptualization, Methodology, Writing — original draft. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. J Ethnopharmacol. Crossref Full Text Google Scholar. Complementary therapies in Parkinson disease: a review of acupuncture, tai chi, qi gong, yoga, and Cannabis. Positive and negative effects of Cannabis and cannabinoids on health. Clin Pharmacol Ther. Cannabis use and cannabis use disorder. Nat Rev Dis Primers. Perioperative cannabis use: a longitudinal study of associated clinical characteristics and surgical outcomes. Reg Anesth Pain Med. Projections and epidemiology of primary hip and knee arthroplasty in Medicare patients to The association of cannabis use disorder and perioperative complications after primary total knee arthroplasty. J Am Acad Orthop Surg. Cannabis use disorder in the setting of primary total hip arthroplasty: understanding the epidemiology, demographic characteristics, and inpatient postoperative outcomes. The association between cannabis use disorder and the outcome following primary total hip arthroplasty: analysis of a nationwide administrative claims database. Bone Joint J. Patients who have Cannabis use disorder have higher rates of venous Thromboemboli, readmission rates, and costs following primary total knee arthroplasty. J Arthroplast. Should cannabinoids be added to multimodal pain regimens after total hip and knee arthroplasty? Cannabis use does not affect outcomes after total knee arthroplasty. Use of Cannabis does not decrease opioid consumption in patients who underwent total joint arthroplasty. Arthroplast Today. Self-reported Cannabis use is associated with a lower rate of persistent opioid use after total joint arthroplasty. Preoperative cannabis use does not increase opioid utilization following primary total hip arthroplasty in a propensity matched analysis. Arch Orthop Trauma Surg. Cannabis use does not affect outcomes after total hip arthroplasty. Int J Surg. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. Stang, A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. GRADE guidelines: 1. J Clin Epidemiol. Quantifying heterogeneity in a meta-analysis. Stat Med. Use of tetrahydrocannabinol and Cannabidiol products in the perioperative period around primary unilateral total hip and knee arthroplasty. Cannabis use increases risk for revision after total knee arthroplasty. Peri-operative opioid and sedation requirements in patients who use marijuana and are undergoing total knee or total hip arthroplasty: a retrospective study. J Clin Anesth. Cannabis use does not increase risk of perioperative complications following primary Total hip arthroplasty: a cohort-matched comparison. Cannabis Cannabinoid Res. Risk of revision surgery and manipulation under anesthesia in patients with Cannabis use disorder undergoing Total knee arthroplasty. Cannabis use among lower-extremity arthroplasty patients does not lead to worse postoperative outcomes. Endocannabinoid system: chemical characteristics and biological activity. Pharmaceuticals Basel. Cardiovascular effects of marijuana and synthetic cannabinoids: the good, the bad, and the ugly. Nat Rev Cardiol. Cannabinoids inhibit T-cells via cannabinoid receptor 2 in an in vitro assay for graft rejection, the mixed lymphocyte reaction. J Neuroimmune Pharmacol. J Neuroimmunol. Disturbances of postural sway components in cannabis users. Drug Alcohol Depend. The cannabinoid receptor type 1 is essential for mesenchymal stem cell survival and differentiation: implications for bone health. Stem Cells Int. Heavy Cannabis use is associated with low bone mineral density and an increased risk of fractures. Am J Med. Marijuana: respiratory tract effects. Clin Rev Allergy Immunol. Mechanisms for impaired effector function in alveolar macrophages from marijuana and cocaine smokers. Enhanced susceptibility of mice to combinations of delta 9-tetrahydrocannabinol and live or killed gram-negative bacteria. Infect Immun. Effects of cannabinoids on host resistance to listeria monocytogenes and herpes simplex virus. Impact of marijuana on venous thromboembolic events: cannabinoids cause clots in trauma patients. J Trauma Acute Care Surg. Medical marijuana, recreational Cannabis, and cardiovascular health: a scientific statement from the American Heart Association. Heavy cannabis users at elevated risk of stroke: evidence from a general population survey. The procoagulatory effects of deltatetrahydrocannabinol in human platelets. Anesth Analg. Le Foll, B. Opioid-sparing effects of cannabinoids: myth or reality? Prog Neuro-Psychopharmacol Biol Psychiatry. Opioid-sparing effect of cannabinoids: a systematic review and meta-analysis. Keywords: Cannabis, total hip arthroplasty, total knee arthroplasty, postoperative outcomes, drug abuse and addiction. Public Health. The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Top bar navigation. About us About us. Sections Sections. About journal About journal. Article types Author guidelines Editor guidelines Publishing fees Submission checklist Contact editorial office. Public Health , 17 May Substance Use Disorders and Behavioral Addictions. Association between history of cannabis use and outcomes after total hip or knee arthroplasty: a systematic review and meta-analysis. Introduction Cannabis, extracted from plants of the Cannabis genus, contains cannabinoids, which have been used in the traditional medicine of various countries against pain, inflammation, spasms, depression and asthma 1 , 2. Assessment of study quality and evidence quality The methodological quality of included studies was assessed using the Newcastle-Ottawa Scale 19 , which is a validated, widely used tool for evaluating the quality of observational studies with a total point of nine. Statistical analysis Outcomes were synthesized qualitatively if data could not be directly compared across studies. Results Of 99 potentially relevant publications, 37 were first excluded because they were duplicates. Figure 1. Flowchart of study selection. Table 1. Characteristics of the included studies. Table 2. Summary of outcomes of the included studies. Keywords: Cannabis, total hip arthroplasty, total knee arthroplasty, postoperative outcomes, drug abuse and addiction Citation: Yang G, Li F, Wang Q, Liu Y, Guo J and Yue C Association between history of cannabis use and outcomes after total hip or knee arthroplasty: a systematic review and meta-analysis. Reviewed by: Robert J.

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