INTRODUCTION: Humeral shaft fractures are common, often affecting younger patients through high-energy mechanisms. With rising use of e-cigarettes, vapes, and nicotine pouches, the impact of non-tobacco nicotine dependence (NTND) on fracture healing remains unclear. This study evaluates postoperative outcomes following fixation of humeral shaft fractures among NTND patients compared with traditional tobacco users and non-nicotine controls.
METHODS: The US collaborative network (TriNetX) was queried to identify adults undergoing humeral shaft ORIF between the dates of January 1, 2004, and June 1, 2023. Three cohorts were stratified by nicotine status: NTND, tobacco, and nicotine-naive controls. Patients were 1:1 propensity matched by demographics and comorbidities. Significance was set at p < 0.05.
RESULTS: A total of 16,404 patients met inclusion: 1250 with NTND, 2515 with tobacco use, and 12,639 controls. After matching, NTND and control groups each included 1250 patients; NTND and tobacco groups had 1243 each. At 90 days, NTND patients demonstrated higher rates of postoperative complications, including pneumonia (OR 2.19, 95 % CI 1.44-3.31), acute blood loss anemia (OR 1.34, 95 % CI 1.01-1.78), surgical site infection (SSI) (OR 1.785, 95 % CI 1.04-3.07), and ED visits (OR 1.56, 95 % CI 1.22-1.98) compared to non-nicotine controls. Relative to tobacco users, NTND patients experienced increased pneumonia (OR 1.72, 95 % CI 1.17-2.52) at 90 days. At 2 years, NTND patients experienced higher rates of nonunion or malunion (OR 1.63, 95 % CI 1.07-2.49), hardware failure (OR 1.28, 95 % CI 1.01-1.64), and opioid dependence (OR 2.37, 95 % CI 1.289-4.36) compared to non-nicotine controls. There were no significant differences between NTND patients and traditional tobacco users at 2 years.
CONCLUSION: NTND is associated with increased perioperative complications and long-term morbidity following humeral shaft fixation. These findings demonstrate that NTND is not a risk-free alternative to traditional tobacco use and may pose even greater perioperative and long-term risks. NTND should be recognized as a distinct risk factor, underscoring the importance of surgeon awareness in patient counseling and the need for future studies evaluating product-specific effects.
