Non-Tobacco Nicotine Dependence Is Associated With Increased Risk of Reoperation and Complications After Ankle Fracture ORIF: A Propensity-Matched Database Study

Background: Tobacco use is known to have adverse outcomes in ankle open reduction and internal fixation (ORIF). Non-tobacco nicotine dependence (NTND), driven by the rising popularity of e-cigarettes and alternative nicotine products, is increasingly prevalent, but its relationship with ankle ORIF is unknown. This study evaluated the association of NTND on perioperative and long-term outcomes following ankle ORIF. Methods: A retrospective cohort study was conducted using a large database to identify patients ≥18 years who underwent bimalleolar and trimalleolar ankle ORIF from 2004 to 2023. Patients were stratified into NTND, tobacco use, and non-nicotine control cohorts based on International Classification of Disease, Tenth Revision ( ICD-10 ) coding. Propensity score matching (1:1) was performed to balance demographics and comorbidities. Outcomes were assessed at 90 days and 2 years. Odds ratios with 95% CIs and P values were calculated. Results: 63 853 patients were eligible for analysis. A total of 4716 NTND patients were matched with 50 903 controls and 8234 tobacco users. NTND patients had higher odds of complications within 90 days, including stroke (OR 2.25, 95% CI 1.46-3.47), pneumonia (OR 1.81, 95% CI 1.27-2.58), surgical site infection (OR 1.82, 95% CI 1.37-2.41), wound dehiscence (OR 1.53, 95% CI 1.18-2.00), emergency department utilization (OR 1.68, 95% CI 1.47-1.92), and hospitalizations (OR 1.42, 95% CI 1.20-1.68). At 2 years, NTND patients showed higher rates of non‑union or mal‑union (OR 3.04, 95% CI 2.34-3.87), non‑union repair (OR 1.33, 95% CI 1.08-1.74), and hardware removal (OR 1.19, 95% CI 1.06-1.34) versus controls. Compared with tobacco users, NTND patients had increased odds of non‑union or mal‑union (OR 2.46, 95% CI 1.97-3.08) and hardware removal (OR 1.21, 95% CI 1.07-1.35). Conclusion: NTND is associated with significantly increased short-term and long-term complications following ankle ORIF. These findings suggest NTND is not a benign alternative and may confer risks comparable to or greater than tobacco use, warranting further prospective investigation.