Paper 10: Impact of non-tobacco nicotine dependence on postoperative outcomes following achilles tendon repair: a propensity-matched analysis

"Objectives: Non-tobacco nicotine dependence (NTND), including the use of e-cigarettes, vaping devices, and nicotine pouches, is increasingly prevalent but its impact on post-surgical outcomes in orthopaedic surgery is largely unknown. Given the tenuous vascular supply to the achilles and the known deleterious effects of nicotine on healing, the objective of this study was to evaluate 90 day and 2-year postoperative outcomes in patients with NTND undergoing Achilles tendon repair, compared to traditional tobacco users and non-nicotine users.
Methods: The TriNetX US Collaborative Network database was queried using ICD-10 and CPT codes to identify patients aged 18 and older who underwent primary Achilles tendon repair between 2004 and 2023. Patients were stratified into three cohorts based on documented history of nicotine exposure: NTND, traditional tobacco users, and non-users control. 1:1 Propensity score matching was performed based on patient demographics and comorbidities.
Results: 25,874 patients were included, of which 1,598 (6.2%) were classified as NTND, 2,554 (9.9%) as traditional tobacco users, and 21,722 (84%) as non-nicotine users. After 1:1 propensity score matching, each cohort included 1,592 patients with no significant differences between groups. At 90 days postoperatively, NTND patients experienced significantly higher rates of wound dehiscence (OR 1.98 95% CI; P<.001), surgical site infection (SSI) (OR 2.01; P=.001), emergency department (ED) visits (OR 2.43; P<.001), and hospitalization (OR 3.346; P<.001) compared to non-nicotine users. Compared to traditional tobacco users, NTND patients had significantly higher odds of wound dehiscence (OR 1.448; P=.045) and SSI (OR 1.894; P = .05). At 2-year follow-up, NTND patients were at significantly higher risk of Achilles tendon re-rupture compared to both non-users (OR 1.385; P=.041) and traditional tobacco users (OR 1.620; P=.007). Conversely, NTND patients had a significantly lower risk of postoperative tendonitis compared to non-nicotine users (OR 0.792; P<.001).
Conclusions: NTND use is associated with significantly increased short- and long-term complication rates following Achilles tendon repair compared to both non-users and traditional tobacco users. Within 90 days, patients with NTND had significantly higher odds of wound dehiscence, SSI, ED visits, and hospital readmissions, while 2-year outcomes demonstrated elevated re-rupture rates compared to both controls and traditional tobacco users. These findings suggest that NTND may pose a distinct and clinically meaningful risk to tendon healing, emphasizing the need for targeted nicotine screening and counseling strategies that address all forms of nicotine exposure."