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- [00:04]
A
This is Mark Easley and I have the distinct honor of talking with doctors Alex Rascoe, Chris Gross, Tabs Iyer, Dan Dane Wokich. These four authors, along with their respective institutions co authors recently published four Foot and Ankle International papers reporting on the effects of tobacco, non nicotine, tobacco and or cannabis on outcomes of ORIF of ankle fractures. Dr. Saltzman and I selected these authors four articles for this podcast roundtable discussion, not only for their common objectives, but especially for each investigation using the same large network database. Alex Rascoe's article is titled Non Tobacco Nicotine Dependence is Associated with Increased Risk of Reoperation and Complications after Ankle Fracture Orifiable A Propensity matched database study. Dr. Gross's article is Both tobacco and non tobacco nicotine dependence are associated with increased complications following ankle fracture, Open Reduction Internal Fixation, A Propensity Matched TriNetX Analysis 2005-2025 and Dr. Iyer's article is titled Post Operative Outcomes after Ankle Fracture ORIF in Patients with Documented Nicotine and or Cannabis Use An Observational analysis and finally, Dr. Wukic's article is preoperative Cannabis Use and Ankle ORIF High Risk of Infection Non Union and reoperation. Briefly, Dr. Alex Rasco is a Foot and Ankle Specialist at the University Hospital's Cleveland Medical center and would like to acknowledge his paper's lead author, Sam Florentino and senior author and mentor, Josh Napora. Dr. Chris Gross is a Professor of Orthopedic Surgery, Director of the Foot and Ankle Division, and Fellowship Director at the Medical University of South Carolina in Charleston. Dr. Tab Zaire is Chief of the Foot and Ankle Service and Associate professor in the Department of Orthopedics at Johns Hopkins University in Baltimore. Dr. Dane Wickic is a Professor of Orthopedic Surgery and has served as the Medical Director and Chair at the University of Texas Southwestern Medical Center's Departments of Orthopedic Surgery and Prosthetics and Orthotics in Dallas. Alex, Chris, Tabs, and Dane, welcome to the program. Gentlemen, thank you for participating in this relatively unique podcast format, one that diverges from Foot and Ankle International's traditional podcast featuring a single article. I'm excited about this roundtable discussion on your similar investigative objectives. Would each of you please provide the listeners a brief summary of your papers and your major findings? Let's start with Alex and then followed by Chris and then Tabs and finally Dane.
- [02:57]
B
So this study was a retrospective database study. This is Trinetics the hot topic of conversation here. Evaluating patients who underwent ORF of a bimilleal or trimilial ankle fracture. From 2004 to 2023 patients were divided into cohorts of non tobacco nicotine dependents, tobacco use and non nicotine cohorts. Outcomes were assessed at 90 days and two years following the initial screening there were over 60,000 patients available, 4,716 who used non tobacco nicotine and 8,234 who used tobacco only. This was compared to the control Group of 50,903 who had no tobacco or nicotine use. After the propensity matching process, which we'll talk about a little bit later, 4638 non tobacco nicotine dependent users were matched to 4638 controls. Similarly, 4606 tobacco users were matched to 4606 non tobacco nicotine dependent users. Looking at 90 day outcomes, there were higher rates of surgical site infection, wound dehiscence, stroke, pneumonia when comparing the match controls that was those of no tobacco or nicotine use. Importantly, there were no differences noted between the traditional and non tobacco nicotine dependent users. This is highlighted in our Table two. At two years there were higher rates of non or malunion, nonunion repair and hardware removal when compared to controls. This is highlighted in Table 3. Also in Table 3, when comparing tobacco users and non tobacco nicotine dependents, there was higher odds of nonunion or malunion as well as hardware removal at that two year mark. So overall our study showed pretty comprehensively that there was a significant effect of the non tobacco nicotine dependence and this is something that really hasn't been highlighted before.
- [04:48]
A
Thanks Alex, that's great. Chris, what did you find?
- [04:52]
C
Thanks Mark. So we did something very similar to what Alex said with some key differences and I think we'll be talking about those later. But we used three distinct propensity match analyses. Non tobacco nicotine we had 15,600 pairs versus controls. Tobacco nicotine we had 12,000 pairs versus controls and direct head to head. Basically at 90 days we showed that non nicotine, non tobacco nicotine and tobacco nicotine cohorts had increased rates of admission, heart attacks, emergency department visits at one year as opposed to two years that Alex looked at. We looked at there's increased wound dehiscence, implant related infections and surgical site infections
- [05:31]
D
but we did not, as opposed to
- [05:33]
C
Alex, find any difference between tobacco nicotine and non tobacco nicotine dependent patients. So basically when directly comparing these we found no significant differences. But bottom line is non tobacco nicotine products like vapes and e cigarettes are not Safer alternatives to traditional tobacco when it comes to ankle fracture surgery outcomes.
- [05:55]
A
Great, thanks. And tabs, what did you find?
- [05:59]
D
First off, thanks for having me and I probably wish I had Duke as part of my pedigree in the background seeing some of these amazing faces, we decided to use the same database. Obviously we'll talk about that further, but our study was trying to look at what are the impacts of nicotine relative to cannabis and impacts on outcomes after ankle fracture. Specifically, it was a nicotine and or cannabis use. And what was interesting in this study that we did using the same database was that nicotine use interestingly was as, as also mentioned by Alex and Chris, associated with higher rates of complications, wound disruptions, you know, ssi, surgical side infections, revision surgeries and nonunion malunion. But what was interesting is that when in isolation, cannabis use alone did not show or demonstrate significant association with increased complication. When we went ahead and did the kind of inclusion criteria we kind of used a year out or how do you use cannabis use, abuse or dependency, sort of within a year, not tracking that sort of further along, ie for continued use as it were. But when you put cannabis along with nicotine, they had similar complications rate complication rates to nicotine only users. And so at least with the data that came forward, it was suggestive that nicotine was kind of the primary driver adverse outcomes. So highlighting sort of that important risk factor about nicotine as we sort of know, but again kind of giving pause to hey, does cannabis necessity have as detrimental effect as you know, we often think that it might. Those sort of some of the major things, you know. Of course this is a large, large study. MET score propensity scoring, match scoring was completed and multiple time point analyses also sort of add to strengths this particular case as well as with the other studies.
- [07:45]
A
Perfect, thanks a lot. Dane, what can you tell us?
- [07:49]
E
Like the other three papers, we used the Trinet database as well and our comparison was people who used cannabis in the preceding three months versus people who did not use cannabis. And in treating rotational ankle fractures and like them, we did propensity score matching and we ended up with a little over 3,000 patients in each group. We found that people that admitted to cannabis UTIs in this study demonstrated increased risk of postoperative infections like surgical site infections, wound dehiscence and even, you know, hardware complications. And that persisted at 90 days, 60 days and even at 3 years postoperatively we found that they had elevated risk of non union reoperation rates and hardware infections. So this potentially is a modifiable risk factor that we need to think about.
- [08:40]
A
Great. Thank you very much for summaries from each of your papers. I'll take it the next question. So, gentlemen, in Foot and Ankle International's December 2025 podcast with Mike Anardi and Avani Chopra, Mike Avani and I candidly discuss their use of the TriNetX research database. Each of your four distinct investigations feature the same TriNetX research database. Would each of you please share with the listeners your experiences using this database and in particular, what are the advantages of using this database and conducting foot and ankle research? Let's start with Tabs and then followed by Chris, then Dane and Alex.
- [09:23]
D
Yeah, thanks. I think databases like this, which are not always readily available, which I think is a limitation at large because it's an access point, right. Many times you have to pay for these database access as a whole. And I think when you have something that has large volumes of data, it makes for interesting analysis because you can power things appropriately. Now of course, while you can go in and sort of build cohorts and whether you de identify it or actually allow for actual identified patient data, which requires an IRB in these de identified cohorts that I think like our paper is, you know, certainly you can explore various, you know, population attributes. You can look at, it can support protocol feasibility and really look at outcomes research in some capacity. I think that, you know, in the context of patient reported outcome measures that we're looking at on a regular basis and foot and angles such as promis, this is not quite, you know, kind of right up that alley, but it does allow us to do a more population based evaluation. I think some of the challenges we have to sort of think about as we, you know, kind of code for these various studies that we're coming up with, including the ones that are being wonderful studies being presented today, are that they're really reliant on how the data has been entered, know how it's been coded and limitations therein. Because you're relying on some, you know, potentially a biller or someone else to put in data into a system who may not necessarily understand the difference between nicotine or non nicotine psycho dependence. So these are various elements that we also have to sort of bear in mind. And while there is probably some degree of applicability even across these different studies, there are obviously differences, you know, having used the same data set. So I think it's valuable, it's a great starting point, but it certainly requires kind of going through with a fine tooth comb to Examine its applicability at large.
- [11:11]
E
Perfect.
- [11:12]
A
Thanks Tabs. And Chris, what do you think?
- [11:14]
C
Yeah, I really agree with Tabs on a whole, but a few things about the Trinex database. It's, you know, when we did this study, we had access to over 118 million patients. So when I logged in today, there's like close 132 million patients across 68 plus healthcare organizations. You know, the platform has this built in propensity scoring, matching, and a lot of us keep on talking about that, but it allows rigorous covariate balancing. So they have 19 variables, demographics, comorbidities, and it helps us achieve standardized mean differences below 0.1 as extremely good for all CO variants. So we get to rapidly test these hypotheses we can to refine our inclusion criteria. You know, Mark, you taught me to surround myself with smarter people. So I look smart. And I have a team of research assistants that code this very well and we're just tossing ideas at them all the time and it's just a lot of fun to work with this data set. But you know, we will be talking about some of the limitations of this later.
- [12:17]
A
Great, thanks Chris Andane, what are your thoughts?
- [12:21]
E
I'm going to take a little bit of a different approach. Obviously everything that they said I couldn't agree more with. But I think all five of us are in academic medicine and working with orthopedic residents and we've all experienced the incredible competitiveness of trying to get a residency. And now we have all these medical students wanting to do research. And I think this has become a wonderful tool for me in particular to work with my medical students. And in fact the first author on the paper that we're reviewing of ours tonight, he had finished college last December and had six months before he started medical school. And he called me and he said I hadn't met him and he said could anything I could do. And I said well, what do you want to look at? So I think for me this trinet has been really, really great. Two of the authors are medical students. One is just the first year and the other the fourth year. And I think it has really allowed them to go and look at a topic that of interest to theirs. And although I do mostly foot and ankle now, I've done projects, other areas of orthopedics just based on their interests. So for me that's a kind of a unique approach to this.
- [13:25]
A
Mark, thanks. I like that perspective. Yeah. Alex, what are your perspectives?
- [13:30]
B
10 agree. I think, you know, in general this is a database Tool in the toolbox. It's not the end all, be all. You know, the activation energy required to do a study like this, depending on the institutional protocols that you have, may or may not require an irb. And so in terms of tossing ideas and seeing what sticks, generating hypotheses and being able to sort of mechanize the study quickly is really advantageous. If you have an interesting research question, this one in particular with kind of keeping up with recent trends. If you did this at a single institution level, to collect for something like this would take 5, 10, 15 years probably. And so it doesn't mean that we shouldn't do it. I mean, we probably should, right? But at least gives us some insight to what already is available with a broader reach. And I think that there is going to be more of this. But like any registry or repository or database, there are serious questions that we have to ask and things that we have to define as real limitations that will be flushed out in time.
- [14:30]
A
Thanks, Alex. We'll go to the next question. You and your co investigators balanced key demographic variables and mitigated confounding through propensity score matching that's been mentioned. You acknowledged that you did not perform additional multivariable regression after matching and therefore could not exclude residual confounding. So my next question for each of you is, when using a large database like TrinetX, how do you reliably isolate specific variables and accurately confirm that they are indeed directly responsible for the findings you are reporting? So Chris, would you please comment? And then followed by tabs and then Dane and Alex.
- [15:13]
C
Yeah, I mean, it's a fundamental challenge of observational research and you have to be transparent about what we can and cannot claim. So the propensity scoring match or score matching is our primary tool for addressing this confounding variables. There are 19 variables. It's not all perfect. And then we create these comparison groups that are balanced on these measured confounders. But we have to acknowledge that this propensity matching only addresses measured confounders. Right? So we can't test for socioeconomic status, exact nicotine dosage, duration of use, someone's using skull packets or like chewing tobacco, you don't know. So you just try your best. And you have to understand that there are fundamental limitations with research that we're doing. But you know, all of us are kind of talking about the same thing and there's biological plausibility for of our findings that strengthens these causal interference. We can't say one thing causes another. But we can only infer.
- [16:10]
A
Great, thanks. And tabs, what are your insights?
- [16:14]
D
Yeah, I would totally agree with that. And I think you have to sort of, you know, it's a little bit of how you kind of code for the question you're asking and what sort of evaluation you're trying to make. And you have to be careful to make inferences. And I don't think you can make total say, hey, like this leads to this the Chris's point. But I think that you have to do your level best, not only take the data provided but then go back and say, hey, does this make sense in the context of the comparisons that you're making? And I think that's an important thing. And what I find particularly important, especially as we talk about these papers that you and Dr. Saltzman have picked out, is that for two similar topics, the variations in the results. Right. And while we know and that to me sort of is reflective of some of the challenges of using database at large, but even one that's fairly balanced and to this point again about you can co vary a balance as a whole and that's part of the propensity score matching and that's designed to account for confounders. But you're still reliant on the data input. Right. So if the data was put in incorrectly, then unfortunately the data out is still going to be, as you might say, very callously, garbage in, garbage out. But if it is. So we're banking on the quality of the data to be adequate enough to be able to make inferences. But that's the tough part. And so I think that we all have to recognize the limitations as part of sort of the research at hand.
- [17:45]
A
Thanks, Tabs. Yeah, Dane, what do you have to say about this?
- [17:49]
E
I think it's a great question and I think when you work with these large real database sets like Trinex, you know, isolating the variables and confirming causality is really challenging because these are not looking at randomized control studies. These are observational research. And I think what you need to do is you need to define clearly what you're trying to look at. And I think the propensity score matching really helps and then you do the statistical analysis. But the bottom line is this data is de identified, it's de aggregated, so we can't really look at it at an individual causality level. So as mentioned, we can't really say that it's causally related, but you can find associations. And I think residual confounding is always possible because there are some things that we can't look at. For instance, in our area, socioeconomic status is really important at outcomes is adherence. I work at a safety net Hospital where 50% of my patients don't speak English and so you can't measure that. So I think confounding is really possible, but I think it gives you trends.
- [18:52]
A
Thanks Dane And Alex, what are your thoughts?
- [18:56]
B
My highlighted point here was really that correlation is not causation. We're all looking to kind of globally understand, I guess, possibility. And if someone tells you that they're using on tobacco nicotine product, should that trigger a response? As an orthopedic surgeon preparing to take a patient back for ankle fracture surgery and if someone asks a question, does it matter? I think we have a nice cadre of papers now that say that it might. Does it definitively? That's really hard to say. But there's certainly some suggestion and biologic plausibility that this would make sense. I thought long and hard about how or why this could be. I've looked deep into sort of the pharmacokinetics of a distribution between cigarette traditional smoking or some of the packets and the nicotine salts. And thing that keeps coming to my mind for this study in particular is how easy or how much easier is it if you're non weight bearing after a fracture, which we could debate if you should be doing that anymore or not. That's a different discussion to use a non nicotine product or a non tobacco product as opposed to having to go outside to smoke a cigarette. And so it may actually be more accessible. And if you had a patient that's inpatient, level one trauma center or otherwise who's had other injuries, these are products that would be available. And so the dosing may actually be higher than it would be in a traditional sense. And these are not things that we can quantify, but it's very interesting to think about.
- [20:20]
A
Great, thanks. I know I might end up with my moderating here be the department of redundancy department, but we will probably rehash some things here. But one of the things as more traditional view of research, this is where I come from. So in using this database method of study, is it really reliable and can your results that you've reported in these four papers be trusted? And so as I mentioned to Mike Anardi and Avani Chopra in December, I am an old dog and to confirm conclusions I would like to follow these patients myself, perform my own clinical exams and interpret my own imaging tabs. And Alex and their co authors suggest that leveraging a large multi institutional database with robust sample sizes may afford reasonable statistical power. And that's been mentioned already in this podcast. However, does strengthening validity of cohort comparisons through propensity score matching really overcome biases common to retrospective data analysis? And most importantly, as you guys have already touched on, can we really trust the database that depends on non investigator and non patient data entry? I just want to be sure that your recommendations based on the Tri Netx database are sound and reproducible. And may I just relax and know that it is okay for FAI readers to rely on conclusions drawn from this database to manage and educate their patients. Dane, why don't you start us off and then Chris and Alex and followed by tabs.
- [21:58]
E
That is an excellent and another very, very important question to ask. And I think that there clearly are limitations such as when people enter the data and the variability, missing data, et cetera, and the confounding that we talked about. But the question is, can we trust it? And I think we can, because with the statistical adjustments like propensity matching and even multivariable regression, you can really start to trust these things. And I think again we mentioned you can't really make it causally related, but with any retrospective study that's really going to be an issue. So the bottom line is I do think that it's something you can trust, but you have to recognize any study there's going to be limitations.
- [22:42]
A
Great, thanks. And Chris, what are your views here?
- [22:45]
C
Yeah, I think we can talk about some of the common biases in retrospective data analysis selection biases inherent to any database study. This one, Trinax captures patients within participating healthcare systems. So we may miss complications treated elsewhere or those who lack healthcare access, but you try to overcome that with a huge large sample size and multi institutional nature help mitigate this bias. Another one is that information bias that I kind of talked about earlier and I think Alex brought it up as well. This is information bias because nicotine dependence is likely undercoated. The amount of times that I specifically ask a patient if they're smoking or not really depends if I'm wanting to do surgery on them or if they need surgery or not. So it lacks some documentation, but this would bias our results towards null, meaning the true effect may be even stronger than we observe. And then we have our confounding variables and that's what the propensity score matching addresses. But they match on 19 covariates. You achieve standardized mean differences below 0.1 and you just have to trust the process Got it.
- [23:50]
A
Thank you. And Alex, what are your thoughts here?
- [23:53]
B
Tabs already took my line for this, which is you don't have good quality sort of input. You're going to get bad output. And I think in general, we wouldn't be here talking about these studies in a sort of communal setting if they weren't showing similar results. And I don't think that that's mistake. If we had wildly different results, we'd probably be questioning these things a lot more closely. Not that we shouldn't. We should always stay vigilant, but I think the trends are what the trends are at this point.
- [24:20]
D
Good.
- [24:20]
A
So, Tabs, Alex just said that you stole his thunder. You want to give him a little playback?
- [24:27]
D
I was shocked. He didn't say exactly what I said, but here we are. Everything has been said, I think is spot on. And I think if you were to. If you look at the questions and the way they were asked, right, they're all slightly different. And so I think what you would probably find it obviously is inclusive of the topics at large, but they're still slightly different in terms of, you know, how it was and the question is different. And even sort of like with the ask or the analysis. Oh, that's a little bit different. So I think that's where probably, if you can kind of hang your hat on the fact that, hey, you probably went back and did the same exact thing and probably would get something very similar, if you like, with AI as an example. Not to go down that rabbit hole too much, but it's like prompt engineering. Depending on how you ask that, you may get one answer versus how someone else asks it, you may get another answer. So what I think it's. And going back to Dan's point earlier, it provides us an opportunity to really look at sort of these data that's there, kind of bring in folks who are really interested in North Peaks with nicholstep or otherwise, get them excited, push our ability to understand, hey, what's out there and what do we need to be more thoughtful of with our patients? What can we then study further in a more traditional sense and not replace our kind of traditional research methods at all that use this as sort of a catalyst for some of that? I'll also say it's in the last pieces with these. There's sort of these major. To Chris's point, we don't really know what we know, but it's also like major academic institutions that are here. And then you kind of have to like be tricky with how you kind of get out of academic only and to kind of the outpatient side can be done, but filtering it in that way also can play a role because it probably depends on what sort of center you're going to, where the data is coming from. Right. If it's a tertiary referral center versus some sort of community practice may still have different outcomes just based on the, you know, on the patients. But again, you obviously try to balance that out with the propensity score matching. I think things like that also play a role in terms of how the data can be interpreted. But I think it's at least a great start for future research as a whole.
- [26:35]
A
Great. Well, thank you guys. I'm going to just focus in on Tabs and Dane for just a moment and just looking at the papers and what some of the major conclusions were. So using the same Tri Netx database for Tabs and Dane for your papers over essentially the same investigation dates, you and your respective co authors conducted similar studies with the same purposes. And so I would anticipate similar outcomes. Why do you think that? Dane and his co investigators observed significantly increased postoperative complication in cannabis patients, while Tabbs and his co investigators demonstrated no significant increase in postoperative complications for patients using cannabis. So whom should we believe? Dane? Maybe you first and then Tabs. You tell us what you think first.
- [27:27]
E
I would like to compliment the group from Hopkins for doing a really well designed study and I was surprised by reading it, especially in view of what we had found. But I think one of the things, when I tried to look at their study in ours, I think that we used the same database at the same time, but we asked slightly different questions and we use cannabis exposure a little bit differently. I think that they used it within one year, we used it within three months. So perhaps this is speculation. Our people may have been using it more frequently with regard to that, but I think with regard to who we should believe, I think that both are really, really important studies. I think cannabis use is not something that's very homogeneous. It varies on intensity, how much people use current exposure, even the method by which they take it, whether they ingest it or smoking. If you smoke weed, so to speak, you're going to have carbon monoxide in your blood like nicotine. So I think for us it made us be aware that this is potentially a risk. And we're not saying causally, but I think their study is really good and when they looked at it, they find a little different result. The one thing I will say though, when I looked at the Absolute numbers. Our infection rates were very, very close. They were around the 2 to 3% range of both studies. So it's a matter of interpretation. I think all of us, when we do an ankle fracture want to minimize complication rates. And if there's anything we can do to modify that, great. But the problem with an ankle fracture is not. You can't say, well, I'm going to test you in 30 days and see if you're clean. So that's it.
- [29:01]
A
Great. Tabs your response?
- [29:04]
D
I can't say much more. I mean, that was really well put. And obviously I'm a pretty verbose person. I would just share that. I think both articles did a wonderful job. I think there's nuggets of wisdom to be taken from both to believe both articles and interpret for what they represent. I do think, you know, they both captured kind of adequately the sort of the F12 codes, which were inclusive of sort of cannabis use, dependency and abuse, for that matter. But I think it also goes back to a little bit of how sort of you code it. Right. And that was where Dean and his group very astutely said, hey, let's just not look at sort of remote history, let's look at continued use. Right. Within three months of their surgery. And I think that's an important thing that may have been a difference maker as a whole. One thing that I think is hard to also tease out is it goes back to what we've been talking about. The way the data is entered and things get sort of like, hey, stuff gets coded incorrectly is. And they could probably clarify this, but I didn't quite see that or appreciate it. We really tried to tease out the nicotine element from the cannabis element, whereas I don't know if I recall seeing that it was excluded completely. So if that ends up, even though there's maybe some propensity matching, score matching from the tobacco piece to agree, if it was inadvertently coded incorrectly, then that sort of recalled bias may be part of what's driving some of that. But again, hard to know. But I think the most important takeaways and are that, hey, you've definitely, we know nicotine is a problem, bottom line, you know, it's a problem whether you're smoking or not. And of course, I think we have to be able to tell patients, yeah, there is still data out there that suggests if you're using within three months of surgery, you might have a poor outcome at large. And that's definitely important things for me to hang my hat on.
- [30:49]
A
Great. So tabs and Dane. Thanks. So Alex and Chris, you're not off the hook. Using the same Tri Net X database over essentially the same investigation dates. You and your representative co authors conducted similar studies with the same purposes and the same propensity matched study design. Why do you think that? Alex and his co investigators observed increased odds for postoperative complications in non tobacco nicotine dependent NTND patients compared to tobacco users, while Chris and his co investigators demonstrated no significant differences between the non tobacco nicotine dependent in TND and tobacco patient cohorts? Who is correct? Chris, why don't you start us off?
- [31:35]
C
That's an excellent question, but I think the apparent discrepancy actually reflects methodological nuances relative to contradictory findings. Our cohort definitions differ subtly. Alex's group focused on bind trimalar fractures. We included that plus isolated medial malleolar fractures and distal fibular fractures. So different fracture patterns have different complication profiles. They use 90 day and two year endpoints. We only did a one year endpoint. And that two year nonunion data may capture different healing trajectories. Our sample sizes were pretty vastly different. When we compared non tobacco nicotine versus tobacco nicotine, we had 13,261 pairs. Alex's group in their head to head comparison had 4,606 pairs. So that's a third of ours. And these larger sample sizes can detect smaller differences but also at the same time provide stable estimates. Both studies matched on similar but not identical covariates and these residual confounding could differ between the studies. And essentially I don't think our findings fundamentally different or contradict Alex's. We both agree that nicotine increases complications versus non users. The real difference is does non tobacco nicotine? Is it actually worse than tobacco? And frankly, I do think so. As Alex intimated earlier, the usability and ease of use for vaping and things like that, I mean people's concentrations of nicotine in their blood is extremely high. You're not going out in the middle of a Chicago winter to smoke a cigarette, but you're sure it's not going to vape and puff all day long, all night long in your home and without seemingly secondary secondhand smoke. So frankly, I tell my patients that smoking tobacco seems healthier than vaping and putting a piece of chaw in your mouth all day.
- [33:26]
D
Wow.
- [33:28]
A
Put a positive spin on smoking. That's pretty good. Alex, what do you think?
- [33:33]
B
Completely agree. Obviously I think the major differences here are in how the cohorts were designed and they yield different results for that reason, but I think our results really fundamentally more agree than they disagree. At a two year time point I think it's easier to capture nonunion data. Another question being too what is the follow up to get? 2 years. So I think that's a reason that our sample size was a little bit smaller on that end as well. But Chris's group did an outstanding job in terms of a much more comprehensive list of sort of demographic variables and covariates to sort of do the propensity matching for ours is a little bit more targeted towards things that tend to draw towards worse outcomes for ankle fracture in general. That was based on a literature search to begin with and so again similar results. Overall, I think it's more speculative at this point to say is a non tobacco nicotine product worse? Don't know. Again, we don't really know. A lot of this is correlation as opposed to causation, but certainly things that are suggestive that is not benign. And it's something that I will spend much more time thinking about in counseling patients when able to Great.
- [34:43]
A
Well thank you there. And then we're getting a little close to the end of our podcast, but I just had one more final just practical question given the topics you studied. So as I'm sure all of you have experienced, when pressed on their smoking habits in preparation for surgery, patients often say they will quit smoking and had planned to do so anyway. And yes, I'm talking more about the elective surgery obviously. And I I don't know if we can extrapolate from your ORIF studies, but tobacco and non tobacco nicotine products and cannabis use are difficult habits to break. So what are each of your preferred preoperative protocols and recommendations for patients for whom you recommend elective foot and ankle surgery provided you plan to operate? What are your requirements for patients, when to stop smoking preoperatively and how long do you have a patient refrain from smoking postoperatively. And if you use a nicotine test preoperatively, what test do you use? Let's start with Alex and then followed by Chris, then Tabs and finish with Dane.
- [35:47]
B
So to make things as succinct as possible, in general, I tend to follow the smarter people that came before me. So look towards Dr. Marcus, our former chairman. In general, I don't offer elective surgery for folks that are consuming nicotine or tobacco products. My personal protocol is to obtain blood testing at the time of pre admission testing. I inform most of my patients or all of them. My preference is to postpone or cancer Surgery, if positive. I think that it's a personal sort of win as a physician to convince or recommend to patients that they quit smoking or using nicotine products. And it's part of my personal mission to make that something to look forward to as a part of getting their comprehensive care for their foot and ankle. I tell people I count as much of a win to get them to quit smoking as it is to actually get to do the surgery and get them a great outcome.
- [36:41]
A
Perfect. Followed by Chris Mark.
- [36:44]
C
I think I'm a little bit more realist living in the south here a lot of my patients smoke, chew tobacco, vape and things like that. If they are having a real big get down surgery, like a hindquart fusion charcoal reconstruction, I'm 3D printing something they are absolutely testing with a coating level that's a lot more sensitive for active usage. But in reality I talk to them like adults. If you tell me you are smoking, I'm not going to operate on you. If you lie to me about telling me you quit, that's on you. I try to explain to them the severe risks of choosing tobacco over their limb. But ultimately they are the adult and they're responsible for their health. And I'm not going to preoperatively test every single patient. I tell them I have a very low threshold to cancel their surgery. We have a very good breakfast burrito place within walking distance. And I say I have no problem getting a breakfast burrito and canceling your surgery. If you smoke that day or if you smell like cigarettes, I'm just going to go get a burrito. And they understand that. And so it's mutual respect for the patient. But ultimately they are responsible for their own health care sometimes.
- [37:56]
A
What's going on in Balma, it was
- [37:58]
D
actually kind of shocking when I first got here, the number of patients that in Miami, anyway, it was not nearly. There was other stuff that they were doing beyond the scope of this talk. But suffice to say, the amount of smoking that's happening, and I shouldn't even just say smoking, but nicotine consumption at large is actually pretty robust. And I think what I got in the habit of doing pretty aggressively when I started here was also asking about the vaping piece because I think people will say, no, I don't smoke. But unless you probe them to ask about the vaping, which I do every single time, especially for having a surgical conversation, then I really do ask and I've gotten a habit and I've also been burned where if they do smoke, I say, you Got to quit. I'll give you four weeks. We'll start working on things. Get out of your system. And I do the nicotine code metabolite because of sensitive sensitivity elements as well. And if they're actively smoking, I don't do it. And I go over with them, to Alex's point, about from a personal perspective, that, you know, if they were family and I genuinely feel that way, they were genuinely family and smoking and wanting a big surgery of whatever type there's osteotomy is involved, wound issues or doesn't matter how big or small the incisions are, those things can still pass out. And that is a thing that can be a terrible outcome for the patient. And if they don't feel comfortable with that, then to me, it's a little bit of a litmus test of their compliance with restrictions post op. And that is sort of where I kind of draw the line in the sand. Well, hey, you got to get this under control. Otherwise it's not worth us taking the risk. And so I had that conversation very candidly with them, and I would say the vast majority kind of acquiesce to it and come back to me when they've sort of, all right, I'm ready. I don't test them post op. And part of me is just like, maybe ignorance is bliss, but I definitely think I do ask them on a regular, hey, are you smoking so much? Especially if they have an exposure to secondhand smoke because of a partner, because whoever lives with them who may be consuming cigarettes in particular.
- [39:49]
A
All right, Dane, you're the big D and the big D. What happens in Dallas?
- [39:54]
E
I'm also the oldest person here. So I've decided in my life at this stage, I'm not a high school principal or a policeman. And so I don't test people. I don't do any elective surgery on people who are actively using tobacco products. And based on our study, I would say that if they're admitting to using cannabis, I would say that the research that I've done in preparation for tonight actually was I looked at some of the anesthesiology literature, and they Recommend at least 72 hours of no cannabis, ideally 2 to 4 weeks. The bottom line is I like people to be off of tobacco for at least one month. And if they're off, and I take their word for it, I think people have to have responsibility. And like I said, if they have a complication, that's partly on them too. Realize that we have to really be selective. But you have to trust people. So my spine guys, they test people all the time, but I think foot and ankle, we have a lot of complications and so maybe I should be, but I don't.
- [40:53]
A
All right, well, we're at the end of our podcast here. We'll give you one more chance to finalize your thoughts. So as our podcast comes to its conclusion, is there anything else each of you would like to share with the listeners? And as for the previous question, we'll have Alex go first and followed by Chris Tabs and finish with Dane.
- [41:11]
B
In general, with respect to these studies and forthcoming studies will continue to be like this. Read critically, read broadly and think hard about it. I think there's a lot of trends that will continue to change and new information will become available that may not change your practice today, but may change your practice in the coming years.
- [41:31]
C
Chris Dr. Eze, thank you again for hosting this roundtable discussion. But three takeaways that I hope to convey. Non tobacco nicotine products are not safe alternatives and they may even be worse than smoking optimization matters. I address routine diabetic control all the time in nutrition and things like that. And this is something that deserves equal attention.
- [41:54]
D
And our patient counseling should evolve.
- [41:56]
C
I mean, I find myself asking, hey, do you smoke? But really I have to get a lot more broad than that. Right. And we have to kind of be use better screening questions for our patients to help identify these risk factors.
- [42:11]
A
Got in tabs.
- [42:13]
D
Dr. Easley, thank you again for being here and to Dr. Rascoe, Dr. Gross and Dr. Lukic, really a pleasure and an honor to be up here with all of you and wonderful job on all these papers. I do want to give a special shout out to my co authors on the paper and especially to med students Issa Lee and Arianna Roshan, who along with Gene Forskar, one of our residents, kind of really put this paper through along with one of my partners, Nigel Xu. I'll say as far as research and using these databases take a little bit of grain of salt. Ask important questions, understand what data you're pulling, understand how it works and think critically about the data you are putting into a paper before you submit in the context of how you use this for your practice. Understand that nicotine is a problem, cannabis can be a problem, and we have to be able to take this data and share that with patients, get them to understand what the real risks are. And I think as far as a practical application is having an open conversation about risks at large, whether it be in the sort of trauma setting of ankle fractures as we've been discussing tonight or in the context of elective foot and ankle surgery. We need to be open and honest with them so they can make, you know, the best educated decision for themselves to optimize the outcome for that sense of accountability that we've been talking about on the patient and so not just from a provider or surgeon perspective. Thanks.
- [43:31]
B
Got it.
- [43:31]
A
And thanks. And Dane, you said that you were the oldest on the call and the podcast that makes you the wisest, so you get the final comment.
- [43:39]
E
Well, I always teach the residents that wisdoms come through making a lot of mistakes over years, so I'm probably wise in that sense. But I also wanted to thank my co authors. The first three authors on this paper are medical students and it's always wonderful to work with them for them to come up with ideas. And I do want to say, Mark, I don't really have anything to add to the summation. It was really great. I enjoyed this, but I think that the roundtable really worked well. You've never done this. I thought it flowed beautifully tonight from my perspective and I enjoyed it very much.
- [44:10]
A
Well, thank you all for participating. Thanks for your comments and insights. So I would like to thank Dr. Rascoe, Gross, Iyer and Dr. Wickish for sharing insights on the Foot and Ankle International publications that you put together. And I would like to thank everyone for participating in this month's Foot and Ankle International podcast. This is Mark Easley and I look forward to next month's podcast.