Impact of Non-Tobacco Nicotine Use on Outcomes Following Total Ankle Arthroplasty

Background: Non-tobacco nicotine (NTN) products including e-cigarettes, nicotine pouches, and synthetic nicotine devices have become increasingly popular. Although the adverse effects of tobacco-derived nicotine on other surgical outcomes are well established, the impact of NTN use on orthopaedic procedures such as total ankle arthroplasty (TAA) remains unclear. Given nicotine’s known effects on vascularity and wound repair, understanding NTN-related perioperative risks is clinically important. Methods: A retrospective cohort study was conducted using the TriNetX Research Network. Adults (≥18 years) who underwent primary TAA between January 1, 2004, and December 31, 2024, were identified. Two matched cohorts were constructed: NTN-dependent users and non–nicotine-dependent controls. Outcomes were assessed at 6 months and 1 year included surgical site complications, implant/prosthesis complications, health care use, and nicotine-specific healing outcomes. Implant/prosthesis complications and health care use were also examined at 3 years and 5 years. Results: After matching, 401 patients were included in each cohort (mean age 58.2 years; 34.7% female). At 6 months and 1 year, surgical site complications were significantly higher among NTN users (6 months: P = .017, OR 1.909, 95% CI 1.113-3.275; 1 year: P = .039, OR 1.662, 95% CI 1.021-2.705). With the numbers available, no significant differences were observed for implant/prosthesis complications, health care use, or nicotine-specific healing outcomes at any time point. At 3 years and 5 years, implant and health care-related outcomes were not significantly different between groups. Conclusion: NTN use is primarily associated with early wound-healing complications, specifically surgical site issues, whereas no significant difference was detected for implant-related outcomes. Consequently, including NTN products in routine preoperative screening could facilitate risk stratification and inform patient counseling.