Nontobacco Nicotine Dependence Shows Worse Outcomes for Patients Undergoing Total Ankle Arthroplasty - A Large Database Study

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Total ankle arthroplasty (TAA) has gained popularity in recent years as an effective treatment for severe ankle arthritis. The procedure has seen a rise in annual volumes due to advancements in implant technology and better outcomes. Concurrently, nontobacco nicotine products advertised as a safer alternative to smoking and aid in smoking cessation, have become widely popular. While nontobacco nicotine does not involve tobacco and contains fewer carcinogens, it still presents with health risks, including impaired wound healing, increased infection risks, and prolonged hospital stays. There are limited studies regarding its effect on surgical procedures, and healing, especially concerning the musculoskeletal system. This study aims to examine the impact of nontobacco nicotine dependence (NTND) on TAA complications, hypothesizing that NTND may increase postoperative risks. Methods: The global collaborative network on TriNetX is an online health record database that retrospectively explored outcomes for patients with ankle arthroplasty based upon their nicotine dependence. Three cohorts were created: (1) NTND (n=869), (2) no nicotine usage cohort (n=15,413), and (3) nicotine with tobacco usage cohorts (2,043). Propensity score matching was completed for age, sex, race, ethnicity, diseases of the musculoskeletal system and connective tissue, factors influencing health status and contact with health services, BMI, diabetes mellitus, peripheral vascular disease, and alcohol abuse. Outcomes evaluated were 90-day major medical complications and 2-year implant-related complications. The 90-day outcomes compared were sepsis, pulmonary embolism, stroke, readmission, infection, embolism, opioid usage, opioid dependence, pneumonia, and emergency department (ED) visits. The 2-year outcomes included revision surgery, mechanical loosening, infection, mechanical prosthesis complication and periprosthetic fracture. Statistical analyses involved calculating relative risk, odds ratios, and risk differences. Results: Propensity score matching for 90-day outcomes of NTND compared to no nicotine usage, NTND had an increase in opioid usage (p=0.0236, odds ratio of 1.244) and increased ED visits with 83.92% compared to 75.7% (p= 0.0008, odds ratio of 1.492). At two years, NTND had a 16.6% risk of infection compared to a 10.3% risk in no nicotine usage group (p=0.0010, odds ratio of 1.507). When comparing NTND to nicotine with tobacco usage cohorts, the outcomes and complication rates were similar at 90 days and two years. The only statistical difference was with hospital readmission, where the NTND had a 16.46% had a risk compared to 21.46% for the nicotine with tobacco usage cohort (p=0.0142, odds ratio 0.721). Conclusion: NTND had worse outcomes than the no tobacco cohort at both 90-day and two-year outcomes. NTND had similar outcomes and complications to nicotine with tobacco usage. Nicotine is well-known for causing worse surgical outcomes, and this is further confirmed for the ankle arthroplasty patient population. The lack of significance among the two nicotine cohorts highlights the need for more nontobacco nicotine-specific language when assessing patients before surgical intervention. With a rise in variety and availability of nontobacco nicotine products, more research needs to explore the surgical outcomes of these products within the foot and ankle patient population.