JAAOS - 2026-07-15 - Journal Article
Elevated Risk of Postoperative Complications With Non-tobacco Nicotine Use Following Open Reduction and Internal Fixation of Ankle Fractures.
Sontam TR, Toussaint L, Hlavinka WJ, Chavda H, Mbilinyi RH, Zide JR
Topics
Key Takeaway
Non-tobacco nicotine users undergoing ankle ORIF had 2.36x higher 30-day infection risk and 1.95x higher 2-year nonunion risk compared to nicotine-independent controls after propensity matching (n=10,162).
Summary Depth
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Summary
This study used the TriNetX database to determine whether perioperative non-tobacco nicotine (NTN) use—defined as active nicotine dependence diagnosis within 3 months of ankle ORIF with no tobacco documentation—increases postoperative complications versus nicotine-independent controls. After 1:1 propensity matching controlling for demographics and comorbidities, NTN users demonstrated significantly elevated risks of infection (RR 2.36), wound disruption (RR 2.59), and readmission (RR 1.74) at 30 days. Nonunion risk remained elevated at both 1 year (RR 1.83) and 2 years (RR 1.95).
Key Limitation
Reliance on ICD diagnosis codes cannot distinguish between nicotine replacement therapy (patches, gum) used for smoking cessation versus active vaping, making it impossible to determine which NTN product drives the observed complication risk.
Original Abstract
BACKGROUND
Smoking is a well-established risk factor for postoperative complications following open reduction and internal fixation (ORIF) for rotational ankle fractures. However, the effect of non-tobacco nicotine (NTN) use on these outcomes remains unclear, despite the increasing use of products such as vapes. This retrospective cohort study investigates whether perioperative NTN use is associated with increased postoperative complications following ankle ORIF compared with a nicotine-independent (NI) control group.
METHODS
The TriNetX Research Network was used to identify patients who underwent isolated unimalleolar, bimalleolar, trimalleolar, or syndesmosis ORIF. Patients were defined as having NTN dependence if they had an active diagnosis of nicotine dependence within 3 months before or after ORIF, but no mention of tobacco use at any point. Patients were defined as NI if they had no documentation of nicotine or tobacco dependence at any point. NTN and NI cohorts were created and 1:1 propensity-matched, controlling for demographics and comorbidities. Relative risks of outcomes were assessed at 30 days, 90 days, 1 year, and 2 years postoperatively.
RESULTS
Following propensity matching, 5,081 patients were included in each cohort. At 30 days, NTN users had increased risks of infection (relative risks = 2.36, P < 0.0001), wound disruption (2.59, P < 0.0001), and readmission (1.74, P < 0.0001). At 90 days, infection (1.86, P < 0.0001), cellulitis (1.81, P = 0.0002), readmissions (1.85, P < 0.0001), and emergency department visits (1.22, P = 0.0010) remained elevated in the NTN cohort. At 1 year and 2 years postoperatively, nonunion risk remained significantly higher (1.83, P = 0.0002; 1.95, P < 0.0001, respectively) in the NTN cohort.
CONCLUSION
NTN use is associated with increased postoperative complications-including infection, wound disruption, nonunion, and malunion-following ORIF for rotational ankle fractures. These findings emphasize the need for further research to guide perioperative risk assessment and improve surgical outcomes.