Non-tobacco nicotine dependence and postoperative complications following operative fixation of tibial shaft fractures: a retrospective cohort analysis

With the rising use of alternative nicotine delivery systems such as e-cigarettes and nicotine pouches, this study aims to evaluate the effect of NTND on outcomes following operative fixation of tibial shaft fractures. TriNetX was queried to identify patients aged 18 and older who underwent operative fixation of closed tibial shaft fractures between January 2004 and January 2024. Open fractures and polytrauma patients were excluded. Patients were categorized into two cohorts: those with preoperative NTND and those with no history of nicotine use. Cohorts were propensity-matched by age, gender, race, ethnicity, BMI, and comorbidities. Ninety-day major medical complications and two-year procedure-related complications were assessed. A total of 25,528 patients undergoing operative fixation of tibial shaft fractures were identified, of which 2,701 had a documented history of NTND. After 1:1 propensity score matching, both cohorts included 2,570 patients. Within the 90-day postoperative period, the NTND group experienced significantly higher rates of deep surgical site infection (RR 1.60, 95% CI 1.05–2.43; p = 0.026) and ED visits (RR 1.68, 95% CI 1.44–1.96; p < 0.001). No differences in the rates of deep vein thrombosis, pulmonary embolism, myocardial infarction, superficial surgical site infection, compartment syndrome, or death were noted. At 2-year follow-up, rates of deep surgical site infection (RR 1.55, 95% CI 1.17–2.07; p = 0.002), osteomyelitis (RR 2.16, 95% CI 1.47–3.18; p < 0.001), hardware removal (RR 1.28, 95% CI 1.10–1.48; p = 0.002), hardware failure (RR 1.54, 95% CI 1.12–2.18; p = 0.007), and death (RR 1.90, 95% CI 1.43–2.53; p < 0.001) were higher amongst the NTND group. No difference was observed in the rates of malunion, nonunion, or revision surgery. NTND is associated with significantly increased rates of deep surgical site infection, hardware-related complications, and mortality following operative fixation of tibial shaft fractures. Prognostic Level III.