The Effect of Non-tobacco Nicotine on Ankle Arthrodesis

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Non-tobacco nicotine dependence (NTND), associated with products such as e-cigarettes and vaping, has increased in popularity as an alternative to traditional tobacco. NTND has been linked to higher complications in shoulder and knee arthroplasty. However, its effects on foot and ankle surgery remain unclear. This study investigates the association between NTND and outcomes following ankle arthrodesis (AA). Methods: This retrospective study utilized the TriNetX database (2005–2025) to identify patients undergoing AA. Two cohorts were created: NTND patients (n = 16,591) and controls without NTND (n = 68,048). Propensity score matching (1:1) controlled for confounders, yielding 14,954 patients per cohort. The NTND cohort (47.6% female) had a mean age of 45.5 years, BMI of 30.0 kg/m² (range 25.0–40.0), and follow-up of 677.5 days (range 180–730). The control cohort (47.7% female) had a mean age of 46.2 years, BMI of 31.1 kg/m² (range 25.0–40.0), and follow-up of 637.7 days (range 180–730). Results: At six months, NTND patients had increased risks of opioid abuse (RR: 5.700; 95% CI: 2.912–11.157), wound dehiscence (RR: 1.608; 95% CI: 1.215–2.127), implant-related pain (RR: 1.165; 95% CI: 1.059–1.282), and implant-related infection (RR: 1.953; 95% CI: 1.547–2.465). The NTND cohort had a lower risk of nonunion or malunion (RD: -0.001; 95% CI: -0.001 to -0.001), though this is likely not clinically significant. At two years, NTND patients had increased risks of wound dehiscence (RR: 1.720; 95% CI: 1.051–2.814), hardware removal (RR: 1.363; 95% CI: 1.070–1.735), implant-related pain (RR: 1.664; 95% CI: 1.419–1.951), infection (RR: 2.138; 95% CI: 1.376– 3.321), and pulmonary embolism (RR: 1.381; 95% CI: 1.065–1.792). Conclusion: NTND patients undergoing AA had higher risks of various adverse outcomes but did not have increased nonunion/malunion rates. These findings emphasize the importance of NTND avoidance in surgical patients. Further research is needed to clarify these associations.