Nicotine raises surgical complication risk after ankle fracture repair — but cannabis alone doesn't

A large database study presented at the American Orthopaedic Foot & Ankle Society Annual Meeting found that nicotine use within the year before open reduction and internal fixation (ORIF) for ankle fractures significantly increases the risk of postoperative complications. Patients who used nicotine alone had higher revision rates at both 1 and 3 years due to nonunion and malunion, as well as elevated rates of surgical site infection.

Cannabis use on its own was not associated with higher complication rates — a finding that challenges some common assumptions about the drug's impact on surgical healing. However, patients who used both nicotine and cannabis had complication rates similar to the nicotine-only group, suggesting nicotine is the primary driver of poor outcomes.

Key Takeaways:

• Nicotine use alone was linked to higher revision rates for nonunion and malunion at 1 and 3 years post-surgery
• Nicotine + cannabis use was associated with increased surgical site infection and a trend toward higher wound disruption vs. cannabis alone
• Cannabis use alone showed no significant increase in complication rates
• Hardware removal rates did not differ between any groups at 1 or 3 years

Why it matters: As nicotine and cannabis use remain widespread, surgeons need clear, evidence-based guidance to counsel patients before orthopedic procedures. This study gives clinicians a stronger foundation to flag nicotine as a meaningful surgical risk factor — while opening the door for more nuanced conversations about cannabis.