This survey study is the first and only time the orthopaedic surgery community has been assessed for its knowledge and opinion regarding cannabinoids. Our results provide the best available consensus on cannabinoids among practicing orthopaedic surgeons and allow them to understand how their peers are responding to the recent flood of cannabinoid products that are popular among patients, yet lack any endorsable research support.

Cannabis and its derivatives have become more mainstream, with a variety of products used by the young and the old, for recreation and for medicinal purposes.¹⁹ Medical professionals, including orthopaedic surgeons, are increasingly being approached for guidance on the use of these substances for analgesia and for the treatment of other musculoskeletal conditions. Although some research on cannabinoids regarding fracture healing,²⁰ total knee arthroplasty,^21,22 arthritis,²³ and spine-related pain²⁴ exists, high-quality evidence with respect to cannabis for management of musculoskeletal pain is scarce. The legal status of cannabinoids has been convoluted by regulatory differences between states and the federal government, whereas popular enthusiasm and anecdotal evidence is far outpacing scientific data.¹⁹ Thus, orthopaedic surgeons have had to balance low-quality clinical evidence with their professional opinions to advise patients.⁵

According to our survey results, the interest in cannabinoid products among orthopaedic trauma surgeons seems to mirror that of the public in terms of knowledge and sentiment. Many of the respondents believe in the existence of a role for cannabis or CBD in managing postoperative pain; however, a majority of respondents were not confident with their knowledge of the mechanism of action of cannabis or CBD. Most were correctly informed about the respective psychoactive effects or lack thereof for cannabis and CBD, respectively. As this survey was of fracture specialists, nearly all respondents were in agreement with the belief that no known effect on fracture healing is associated with cannabis or CBD. Previous studies have found that patients using cannabinoid products were stigmatized,^25,26 but most orthopaedic trauma surgeons who responded to this survey did not believe that they would be stigmatized for suggesting them as providers. In particular, respondents felt that even less stigma surrounds the suggestion of CBD products. Most respondents did believe that a topical form of cannabis would be more accepted than an oral or inhaled form. Despite these opinions, only a third of respondents have acted on this belief and suggested cannabis or CBD to patients. Not surprisingly, only two-thirds of respondents were familiar with their states' laws governing marijuana or CBD use as this scenario is rapidly changing. After the November 2020 elections, four more states legalized recreational cannabis: Arizona, Montana, New Jersey, and South Dakota. That is, only three states remain without any form of legalized cannabis in the United States.²⁷ These findings suggest that although orthopaedic trauma surgeons seem to view cannabinoids positively, more clinical research and legal clarification is needed to keep pace with commercial development and public support of these products.

However, state and federal legal differences on cannabinoids pose a significant challenge to studying its effects because it means that the products available to consumers and researchers are not consistent in strain or dosage. Researchers in the United States are restricted to a limited number of cannabis strains and products controlled by the National Institute on Drug Abuse in their studies, whereas commercially, products and strains are growing exponentially.²⁸ Therefore, research findings may not be directly translatable to commercial products. Our study notes significant interest in cannabinoids within the orthopaedic trauma community. However, without support from federal legislation and adequate research, consensus for the use of cannabinoids in the treatment of a variety of medical conditions will be incredibly difficult to attain.

In addition, this survey found that nearly all respondents were unfamiliar with PEA, which is an endogenous cannabinoid classified as a nutraceutical, or a food that has potential health or medicinal benefits.²⁹ PEA has activity at both CB₁ and CB₂ receptors, although it is not itself a component of cannabis²⁹ and possesses anti-inflammatory effects.^30-32 Therefore, the endocannabinoid system could be positively manipulated via PEA without negotiating the legal restrictions surrounding cannabis.

Limitations of this study include an incomplete data set and selection bias. Although the percentage of respondents (16.8%) may not be exceptionally high, the total number of respondents (251) is greater than or on par with other survey studies recently published in the orthopaedic trauma literature.^33-35 Although this survey had 251 respondents, not all participants fully completed the questions, electing to defer their answers for some questions. In particular, 84 respondents did not provide answers to the two questions about whether they would recommend cannabis or CBD to their patients if it were completely legal. Such a loss of responses for two particularly important questions about the sentiment of cannabinoids skews the data and reduces the impact of this specific question. Selection bias is plausible as only orthopaedic traumatologists were invited to participate in the survey. Furthermore, 70% of these orthopaedic traumatologists practice in an academic setting, potentially leading to an additional source of bias. Regardless of these limitations, the findings of this study are invaluable to understanding the knowledge and sentiment of orthopaedic traumatologists regarding cannabis.