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The influence of alcohol misuse on outcomes following primary total hip (THA) or knee (TKA) arthroplasty is poorly understood. Using the National Hospital Discharge Survey, a cohort representative of 8,372,232 patients (without cirrhosis) who underwent THA or TKA between 1990 and 2007 was identified and divided into two groups: (1) those who misused alcohol (n = 50,861) and (2) those who did not (n = 8,321,371). Differences in discharge status, comorbidities and perioperative complications were analyzed. Compared to patients with no diagnosis of alcohol misuse, alcohol misusers were nine times more likely to leave against medical advice and had longer hospital stays (P < 0.001). Alcohol misuse was independently associated with higher odds of in hospital complications (OR: 1.334, range: 1.307–1.361), surgery related complications (OR: 1.293, range: 1.218–1.373) and general medical complications …