Association Between Non-Tobacco Nicotine Dependence and Postoperative Complications After Ankle and Hindfoot Arthrodesis

Background: Hindfoot and ankle arthrodesis, although routinely performed for arthritis, trauma, and deformity correction, carries risks of several postoperative complications. Cigarette smoking is a well-established risk factor for impaired bone healing, but the effects of non-tobacco nicotine dependence (NTND) are poorly understood. This study aims to evaluate the association between NTND and postoperative complications following ankle and hindfoot fusion. Methods: This retrospective cohort study used the TriNetX database to identify patients who underwent hindfoot arthrodesis. Patients were categorized into NTND ( International Classification of Diseases, Tenth Revision ICD-10 : F17, excluding tobacco-specific codes) and nonsmoker cohorts. Propensity score matching (1:1) was performed to balance demographics and comorbidities. Outcomes were assessed at 90 days and 2 years postoperatively from date of surgery using risk ratios (RRs), absolute risk differences, with corresponding 95% CIs. Results: After matching, 2172 patients were included in each cohort. NTND patients had significantly higher 90-day rates of opioid prescriptions (RR 1.20, 95% CI: 1.16-1.24), emergency department visits (RR 1.31, 95% CI: 1.10-1.57), hospitalizations (RR 1.20, 95% CI: 1.07-1.35), postoperative infections (RR 1.61, 95% CI: 1.20-2.17), and wound complications (RR 1.68, 95% CI: 1.26-2.84) (all P < .05). At 2 years, NTND patients experienced increased rates of pseudoarthrosis (RR 1.52, 95% CI: 1.37-1.68), mechanical implant failure (RR 1.42, 95% CI: 1.21-1.67), infection-related implant failure (RR 1.39, 95% CI: 1.12-1.71), and periprosthetic fractures (RR 1.59, 95% CI 1.36-1.87) (all P < .05). No differences in revision arthrodesis rates were observed. Conclusion: NTND is associated with increased short- and long-term complications following hindfoot fusion, suggesting that vaping may negatively impact surgical recovery. Surgeons should incorporate NTND considerations in preoperative risk assessments and promote cessation strategies to optimize patient outcomes.