Background: Ankle fractures are one of the most common fractures that occur in the United States with an estimated incidence of 4.22/10,000 per year. Trimalleolar ankle fractures make up about 7% of all ankle fractures, but these fractures traditionally have worse recovery outcomes as well as a risk of future osteoarthritis. Surgical repair of the ankle after this type of fracture requires the reduction of the malleoli and stabilization of the syndesmosis. However, postoperative complications from this type of fracture include restricted mobility, pain, swelling, and limitation to activities of daily living. Smoking and nicotine use are well described in the literature to increase the risk of bone loss, decrease bone mineral density, and delay the union of fracture sites. The purpose of this study is to evaluate specific postoperative complications between nicotine- and non-nicotine-dependent patients who had surgical open treatment of trimalleolar ankle fracture.

Methods: TriNetX, a global health database with de-identified patient information, was used and analyzed for this study. Cohort A was defined as patients who had surgical open treatment of trimalleolar ankle fractures with or without fixation (Current Procedural Terminology CPT: 27822, 27823) and had a dependence to nicotine (International Classification of Diseases, Tenth Revision, code: F17.2). Cohort B was defined as patients who had surgical open treatment of trimalleolar ankle fractures but did not have a dependence to nicotine. Data were gathered from healthcare organizations over the past 20 years. All post-diagnostic complications were analyzed between 1 and 120 days after the surgical open treatment of trimalleolar ankle fractures.

Results: 4,827 patients in cohort A were propensity matched with 25,467 patients in cohort B for age at the event, ethnicity, race, sex, type 2 diabetes mellitus, and body mass index. Nicotine-dependent patients who had surgical open treatment of trimalleolar ankle fractures experienced a higher associated risk for numerous post-operative complications. When compared to non-dependent patients, nicotine-dependent patients had an increased risk for wound disruption (risk ratio RR 1.656, 95% confidence interval CI 1.28 – 2.14) and infection (RR 1.836, 95% CI 1.5 – 2.25) following a procedure within 120 days post open treatment of trimalleolar ankle fractures. Instances of avascular necrosis, deep vein thrombosis, pulmonary embolism, and revision surgeries were found not to be statistically different between the two cohorts.

Conclusion: This propensity-matched study showed that nicotine-dependent patients who were surgically treated with open treatment of trimalleolar ankle fractures were correlated with an increased risk for wound disruption and infection compared to their non-nicotine-dependent counterparts.