Preoperative Cannabis Use and Ankle ORIF Outcomes: Higher Risks of Infection, Nonunion, and Reoperation

With the widespread legalization and rising prevalence of cannabis use, understanding its impact on perioperative outcomes has become clinically critical. Although recent orthopaedic research has examined cannabis-related risks following various procedures, its implications following surgical fixation of ankle fractures remain unexplored. Given the increasing incidence and complexity of ankle fractures, clarifying these risks is essential for effective perioperative management and patient counseling.

A retrospective cohort analysis was conducted using a nationally representative research database. Patients undergoing open reduction and internal fixation (ORIF) for rotational ankle fractures were identified using standardized Current Procedural Terminology (CPT) codes and stratified by preoperative active cannabis use. Propensity score matching (PSM) was used to control for 27 demographic and clinical confounders; data were drawn from the TriNetX Research Network; postmatch balance is reported. Outcomes assessed included medical complications and health care utilization at 90 days and 6 months, and surgical outcomes at 3 years postoperatively. Relative risks (RRs) with 95% confidence intervals were calculated. To account for multiple testing across 34 outcomes, a Bonferroni correction was applied, with statistical significance defined as P < .0015.

After PSM, 3126 matched pairs were included in the analysis. At 90 days postoperatively, cannabis use was significantly associated with increased risks of postoperative infection (RR = 1.696, 95% CI 1.230-2.337, P < .001), wound dehiscence (RR = 1.781, 95% CI 1.268-2.502, P < .001), and inpatient readmissions (RR = 1.724, 95% CI 1.221-2.435, P < .001). These associations persisted at 6 months, including elevated risks of postoperative infection (RR = 1.745, 95% CI 1.304-2.337, P < .001), sepsis (RR = 2.847, 95% CI 1.477-5.488, P < .001), and hardware infection (RR = 1.944, 95% CI 1.291-2.929, P < .001). At 3 years, the cannabis-use cohort was associated with significantly increased risks of nonunion (RR = 2.308, 95% CI 1.207-4.413, P < .001) and reoperation (RR = 2.168, 95% CI 1.353-3.475, P < .001). No significant differences were observed for other measured outcomes following Bonferroni adjustment.

Preoperative cannabis use is associated with significantly increased complications following ankle ORIF, notably systemic and hardware infections, nonunion, and reoperation. These findings support recognizing cannabis use as a potentially modifiable perioperative risk factor, akin to tobacco use, underscoring the importance of targeted counseling and strategies aimed at optimizing surgical and patient outcomes.