The Effect of Postoperative Nonsteroidal Anti-inflammatory Drugs on Nonunion Rates in Long Bone Fractures

Abstract

The association of nonsteroidal anti-inflammatory drugs (NSAIDs) with non-union in long bone fractures has been controversial. The purpose of this study was to evaluate whether NSAID exposure results in increased risk of non-union in operatively treated long bone fractures. The authors used International Classification of Diseases and Current Procedural Terminology codes to identify patients under a single-payer private insurance with operatively treated humeral shaft, tibial shaft, and subtrochanteric femur fractures from a large database. Patients were divided into cohorts based on NSAID use in the immediate postoperative period, and nonunion rates were compared. A cost analysis and a multivariate analysis were performed. Between 2007 and 2016, a total of 5310 tibial shaft, 3947 humeral shaft, and 8432 subtrochanteric femur fractures underwent operative fixation. Patients used NSAIDs in the first 90 days postoperatively in 900 tibial shaft, 694 humeral shaft, and 967 subtrochanteric femur fractures. In these patients, nonunion rates were 18.8%, 17.4%, and 10.4%, respectively. When no NSAIDs were used, the rates were 11.4%, 10.1%, and 4.6% for each fracture type, respectively ( P <.05). Among patients taking NSAIDs, subtrochanteric femur fractures had a 2.4 times higher risk of nonunion and humeral shaft and tibial shaft fractures both had a 1.7 times higher risk of nonunion ( P <.05). Multivariate analysis showed NSAID use to be an independent risk factor in all 3 types. Cost analysis showed a great increase in economic burden ( P <.05). This study indicated that NSAID exposure was associated with fracture nonunion. [ Orthopedics . 2020;43(4):221–227.]

The Effect of Nonsteroidal Anti-inflammatory Drugs and Selective COX-2 Inhibitors on Bone Healing

“…The average duration of NSAID use in this study was 21.2 weeks [10]. Similarly, in a large private insurance database study, Tucker et al showed an increased nonunion rate in operatively treated tibial shaft, humeral shaft, and subtrochanteric femur fractures when any NSAIDs were used in the 90-day postoperative period [20]. Conversely, a study looking at posterior spinal fusion showed 48 hours of exposure to ketorolac postoperatively had no negative effect on fusion rates [15].…”

“…In addition, Gerstenfeld et al showed a temporal relationship between selective COX-2 inhibitor (valdecoxib) exposure and delayed fracture healing in rats [9]. While animal studies are somewhat aligned in their consensus, human studies demonstrate predominantly mixed results [2,4,7,10,13,15,17,20]. A retrospective clinical study of 377 patients out of England showed both a delay in fracture union and a higher incidence of fracture nonunion in patients treated with any NSAIDs after their injury.…”

Multimodal analgesia is superior to opiates alone after tibial fracture in patients with substance abuse history

“…Nonsteroidal anti-inflammatory drugs are not prescribed because of a minimal risk of nonunion. [12,13]…”

Nonsteroidal anti-inflammatory drugs for pain relief in case of injuries: Is there a risk of bone metabolism disorders and nonunion of bone fractures?

“…Tucker и соавт. [26] оценивали частоту несращений переломов большеберцовой (n=5310), плечевой (n=3947) и бедренной (n=8432) костей за период с 2007 по 2016 г. Данное осложнение в зависимости от перелома конкретной кости было зафиксировано соответственно у 18,8%, 17,4% и 10,4% принимавших НПВП и у 11,4%, 10,1% и 4,6% не принимавших НПВП (при всех сравнениях р<0,05). НПВП оказались независимым фактором, ассоциированным с замедлением консолидации кости, при любой локализации травмы.…”