Cannabis users had significantly higher rates of infection, nonunion, and reoperation after ankle fracture surgery | Research

The takeaway

In a propensity-matched study of 6,252 patients undergoing ankle fracture surgery, preoperative cannabis use was associated with significantly increased risks of infection (70% higher), nonunion, and reoperation over 3 years.

Orthopedic surgeons, patients facing ankle surgery, and anesthesiologists managing perioperative risk.

70% higher infection risk; increased nonunion and reoperation

What the researchers found

After propensity score matching for 27 confounders, preoperative cannabis use was significantly associated with increased risks of postoperative infection (RR=1.696), nonunion, and reoperation following ankle ORIF. The study applied Bonferroni correction for 34 outcomes with significance set at p<.0015.

Why it matters

This study positions cannabis alongside tobacco as a potentially modifiable perioperative risk factor for orthopedic surgery, which could change preoperative counseling and optimization protocols.

The numbers in context

3,126 matched pairs. Infection: RR=1.696 (CI 1.230-2.337, p<.0015). Nonunion and reoperation also significantly elevated at 3 years. Bonferroni correction applied across 34 outcomes. No significant differences in other measured outcomes after correction.

How the study worked

Retrospective cohort analysis using the nationally representative TriNetX Research Network database. 3,126 matched pairs (cannabis users vs. non-users) undergoing ankle fracture ORIF. Propensity score matching controlled for 27 demographic and clinical confounders. Outcomes assessed at 90 days, 6 months, and 3 years.

What this study cannot tell us

Retrospective database study. Cannabis use identified from records, likely underestimating true prevalence. Cannot determine dose, frequency, or method of cannabis use. Cannot distinguish between recreational and medical use or control for cannabis cessation perioperatively.

How to read the evidence

Strong: large propensity-matched cohort from a national database with stringent Bonferroni correction for multiple comparisons.

When this study was published

Published 2026.

The bigger picture

Cannabis is increasingly recognized as affecting wound healing and immune function. This large matched cohort adds orthopedic-specific evidence to a growing body of literature suggesting cannabis may impair surgical recovery.

Questions still open

What biological mechanisms drive the increased infection and nonunion rates? Would preoperative cannabis cessation reduce these risks, similar to smoking cessation protocols? Is there a dose-response relationship between cannabis use and surgical complications?

Common questions

Does cannabis use affect surgical outcomes?

In this study of ankle fracture surgery, preoperative cannabis users had 70% higher infection rates and significantly more nonunion and reoperation compared to matched non-users.

Should you stop cannabis before surgery?

This study suggests cannabis may be a modifiable risk factor similar to tobacco. The researchers recommend targeted preoperative counseling, though optimal cessation timing before surgery is not yet established.

Read the original research

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

Foot & ankle international, 47(1), 43-51

View on PubMed ↗Publisher’s paper ↗

Citation

Tummala, Sri; Wood, Brandon A; Mittal, Mehul M; Sambandam, Senthil N; Wukich, Dane K. (2026). Preoperative Cannabis Use and Ankle ORIF Outcomes: Higher Risks of Infection, Nonunion, and Reoperation.. Foot & ankle international, 47(1), 43-51. https://doi.org/10.1177/10711007251385971