Foot & Ankle International – February 2026 Podcast Roundtable

Date: February 20, 2026
Host: Dr. Mark Easley
Guests: Dr. Alex Rascoe, Dr. Chris Gross, Dr. Tabs Iyer, Dr. Dane Wukich

Episode Overview

This special roundtable episode of the Foot & Ankle International Podcast brings together the authors of four recent studies, each exploring the impact of tobacco, nicotine (including non-tobacco sources like vaping and e-cigarettes), and cannabis use on outcomes of open reduction internal fixation (ORIF) of ankle fractures. All studies utilized the same large TriNetX multi-institutional database, enabling unprecedented, data-driven cohort comparison. The discussion weaves through the studies’ key findings, shared challenges of database research, differences in methodology, and real-world implications for patient counseling and surgical practice.

Key Discussion Points & Insights

1. Study Summaries & Major Findings

Rascoe et al. – Non-Tobacco Nicotine and Ankle ORIF Complications

[02:57]

• Scope: Retrospective database study (TriNetX), identifying patients with bi- or trimalleolar ankle fractures between 2004–2023.
• Groups: Non-tobacco nicotine users, tobacco users, and controls.
• Findings:
  • At 90 days: Higher rates of surgical site infection, wound dehiscence, stroke, and pneumonia among both non-tobacco nicotine and tobacco users versus controls.
  • At 2 years: Increased rates of nonunion/malunion, nonunion repair, and hardware removal. Differences between tobacco and non-tobacco nicotine users also emerged at this point.
  • Quote:

    "...there was a significant effect of the non tobacco nicotine dependence and this is something that really hasn't been highlighted before." (Dr. Rascoe, 04:17)

Gross et al. – Comparing Tobacco & Non-Tobacco Nicotine

[04:52]

• Scope: Used three propensity-matched cohorts for head-to-head comparison.
• Findings:
  • Both non-tobacco nicotine and tobacco users had increased admissions, MI rates, and more emergency department visits at 90 days.
  • At 1 year: Higher wound dehiscence, implant-related infection, and surgical site infection in both nicotine groups versus controls.
  • No significant differences between traditional tobacco and non-tobacco nicotine users.
  • Quote:

    "...non tobacco nicotine products like vapes and e cigarettes are not safer alternatives to traditional tobacco when it comes to ankle fracture surgery outcomes." (Dr. Gross, 05:47)

Iyer et al. – Nicotine vs. Cannabis Outcomes

[05:58]

• Scope: Evaluated both nicotine and/or cannabis use.
• Findings:
  • Nicotine, with or without cannabis, linked to higher complications, wound disruption, infection, and non/malunion.
  • Cannabis use in isolation did not significantly increase complication risk using their 1-year window definition.
  • Quote:

    "...nicotine was kind of the primary driver [of] adverse outcomes... again kind of giving pause to hey, does cannabis necessarily have as detrimental effect as... we often think..." (Dr. Iyer, 06:56)

Wukich et al. – Focus on Cannabis Use

[07:49]

• Scope: Matched patients using cannabis within 3 months pre-surgery to non-users.
• Findings:
  • Cannabis users had increased risk for postoperative surgical site infection, wound dehiscence, hardware complications, nonunion, and reoperation at all measured intervals (90 days, 60 days, 3 years).
  • Cannabis exposure viewed as a modifiable risk factor.
  • Quote:

    "...people that admitted to cannabis use ... demonstrated increased risk of postoperative infections..." (Dr. Wukich, 08:01)

2. Experiences with the TriNetX Database

Advantages

• Massive sample size (~132 million patients).
• Ability to power studies for rare outcomes.
• Built-in propensity matching helps with rigorous covariate balancing (19 variables).
• Feasibility for multi-center, population-based research.
• A unique tool for involving medical students and fast-tracking research ideas.

Challenges

• Access barriers (cost, limited to institutions).
• Reliance on billing and coding accuracy ("garbage in, garbage out").
• Inability to capture some variables (e.g., exact dose, socioeconomic status).
• Inherent risk of bias and data entry errors.

Memorable Quotes

"It certainly requires kind of going through with a fine tooth comb to examine its applicability at large." (Dr. Iyer, 10:28)
"You just have to trust the process." (Dr. Gross, 23:30)

3. On Propensity Score Matching & Residual Confounding

• Propensity matching controls for measured confounders (demographics, comorbidities), but not unmeasured variables (e.g., nicotine dose, socioeconomic status, adherence).
• Causality cannot be claimed, only associations.
• Shared message among panelists: Findings have "biological plausibility," but database research cannot replace prospective study rigor.

"Correlation is not causation... if someone tells you that they're using [a] non-tobacco nicotine product, should that trigger a response... I think we have a nice cadre of papers now that say that it might."
— Dr. Rascoe, 18:55

4. Data Reliability: Can We Trust These Results?

• Overall agreement: Database results are trustworthy for identifying trends with large sample sizes, but must be interpreted acknowledging their inherent limitations.
• Similar findings across studies bolster confidence.
• Variabilities in method (slightly different cohort definitions, time windows, etc.) explain divergent details, not fundamental disagreements.

5. Reconciling Discordant Cannnabis & Nicotine Outcomes

Cannabis:

• Dr. Wukich’s study (3 months window) showed increased risk with cannabis use; Dr. Iyer’s (1 year window) did not.
• Possible reasons: Time window differences, exposure definitions, and coding uncertainties.
• Both agree nicotine is clearly detrimental; cannabis risk remains less certain but merits further caution.

"I think both articles did a wonderful job... there’s nuggets of wisdom to be taken from both, to believe both articles and interpret for what they represent.”
— Dr. Iyer, 29:06

Nicotine:

• Dr. Rascoe found increased odds for complications in non-tobacco nicotine users compared to tobacco users; Dr. Gross found no significant difference.
• Explanations: Variations in fracture types included, follow-up duration, size and matching variables.
• Shared conclusion: Both agree nicotine in any form worsens outcomes; vaping is "not safer."

“...frankly, I tell my patients that smoking tobacco seems healthier than vaping and putting a piece of chaw in your mouth all day.”
— Dr. Gross, 33:21

6. Practical Preoperative Management Advice

Panelists’ recommendations for elective foot/ankle surgery:

• Universal agreement: Do NOT operate on patients actively consuming nicotine.
• Most require cessation for at least 4 weeks and test for nicotine use (cotinine, blood tests).
• Some rely on patient honesty, others employ strict testing and willingness to cancel surgery (sometimes with humor).
• Emphasize shared decision-making and optimization—hold nicotine/cannabis users to high standards of compliance.

“My preference is to postpone or cancel surgery if [a nicotine test is] positive... 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."
— Dr. Rascoe, 36:25

"If you smoke that day or if you smell like cigarettes, I'm just going to go get a burrito. And they understand that..."
— Dr. Gross, 37:30

Notable Quotes & Memorable Moments

• On Database Research:
  “Correlation is not causation. We’re all looking to globally understand possibility” (Dr. Rascoe, 18:56)
• On Cannabis Research Divergence:
  “The most important takeaways are that, hey, nicotine is a problem, bottom line... 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.” (Dr. Iyer, 30:21)
• On Hotdogging Traditional Smoking:
  “Frankly, I tell my patients that smoking tobacco seems healthier than vaping...” (Dr. Gross, 33:21)
• On Patient Candidness:
  "I'm not a high school principal or a policeman...I take their word for it, I think people have to have responsibility." (Dr. Wukich, 39:53)

Closing Thoughts from the Panel

[41:11–44:09]

• Dr. Rascoe: Read critically and broadly; be ready for new evidence to shape future practice.
• Dr. Gross: Non-tobacco nicotine is not safer; optimization matters; ask broader, better screening questions.
• Dr. Iyer: Take database findings with a grain of salt; nicotine is always a problem; have open, honest, risk-focused discussions with patients.
• Dr. Wukich: Value in involving learners; wisdom grows from mistakes; trust the research while recognizing its limits.

Key Timestamps for Further Listening

• Study Summaries: [02:57–08:40]
• TriNetX Database Advantages/Limitations: [09:22–14:29]
• On Confounding/Propensity Matching: [15:12–20:20]
• Data Reliability & Bias: [21:58–26:34]
• Reconciling Study Differences (Cannabis/Nicotine): [26:34–34:42]
• Clinical Recommendations: [35:47–40:52]
• Final Thoughts: [41:11–44:09]

Summary in a Nutshell:
Large-scale database studies now unambiguously show that both traditional tobacco and non-tobacco nicotine (vapes, e-cigarettes) significantly worsen outcomes in ankle fracture surgery. Cannabis remains a more nuanced risk; recent use may be problematic. These findings, while not proving direct causality, are sufficient for orthopedic surgeons to counsel rigorously against nicotine use and potentially cannabis use before and after surgery, employing both laboratory testing and robust patient engagement.