Elevated Risk of Postoperative Complications With Non-tobacco Nicotine Use Following Open Reduction and Internal Fixation of Ankle Fractures.

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.