Effect of Post-Operative Ketorolac Administration on Bone Healing in Ankle Fractures Elizabeth McDonald, BA Brian Winters, MD Rachel Shakked, MD David I. Pedowitz, MD Steven M. Raikin, MD Joseph N. Daniel, DO
Disclosure Elizabeth McDonald, BA; Rachel Shakked, MD; Brian S. Winters, MD; Joseph N. Daniel, DO; and Steven M. Raikin, MD have no conflicts to disclose. David I. Pedowitz, MD reports personal fees from Integra LLC, Zimmer-Biomet, and Arthrex, outside the submitted work. In addition, Dr. Pedowitz has a patent Cadence Total Ankle Replacement with royalties paid.
Background Ketorolac reported to delay bone healing after spine surgery 1-3 Valuable non-narcotic adjunct for post-operative pain Not well defined in foot and ankle literature 4-5
Purpose To report clinical and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures. Methods Single-center, retrospective review w/ minimum 4 month follow-up Post-Op received 20 tablets of 10mg ketorolac Q6 hours Surgical Indication Lateral malleolus fx Bimalleolar fx Trimalleolar fx
Methods Clinical healing walking comfortably, minimally tender on palpation, and evidence of radiographic healing Radiographic healing blinded review by 2 fellowship-trained foot and ankle surgeons Wound complications post-operative need for local wound care, antibiotics, or repeat surgery Severity fibula, medial malleolus, and posterior malleolus involvement
Demographics Obese 54% 112/281 Female 54% 152/281 mean age 50 yrs Current smoker 13% 37/281 Former smoker 13% 37/281 mean BMI 29.8 Diabetic 19% 53/281 Rheumatoid 2% 6/281 Oral steroids 6% 17/281 281 patients
Results Clinically healed 265 of 281 patients (94%) within 12 wks Radiographically healed 261 of 281 patients (92%) within 12 wks Wound complications 17/281 (6%) total complications 4/16 (25%) not healed by 12 wks 13/265 (5%) healed by 12 wks Pts not healed by 12 wks were significantly more likely to have a wound complication than those pts who were healed by 12 wks (p=0.006)
Results Radiographic healing 13 wks men v 12 wks women (p=0.004) other demographic variables not significant Not healed 12 wks mean clinical healing 16.94 wks radiographic healing 17.10 wks no difference in severity (p=0.500)
Conclusion Comparable mean time to healing in this cohort and historical control taking no NSAIDs 6 Mean healing time was delayed when a wound complication occurred Ketorolac can safely be administered to improve pain control after ankle fracture surgery
References 1. Glassman, S. D., Rose, S. M., Dimar, J. R., Puno, R. M., Campbell, M. J., & Johnson, J. R. (1998). The effect of postoperative nonsteroidal anti-inflammatory drug administration on spinal fusion. Spine, 23(7), 834-838. 2. Reuben, S. S., Ablett, D., & Kaye, R. (2005). High dose nonsteroidal antiinflammatory drugs compromise spinal fusion. Canadian Journal of Anesthesia, 52(5), 506-512. 3. Li, Q., Zhang, Z., & Cai, Z. (2011). High-dose ketorolac affects adult spinal fusion: a meta-analysis of the effect of perioperative nonsteroidal antiinflammatory drugs on spinal fusion. Spine, 36(7), E461-E468. 4. DeAndrade, J. R., Maslanka, M., Maneatis, T., Bynum, L., & Burchmore, M. (1994). The use of ketorolac in the management of postoperative pain. Orthopedics, 17(2), 157-166. 5. Gillis, Jane C., and Rex N. Brogden. "Ketorolac." Drugs 53.1 (1997): 139-188. 6. Matson, Andrew P; Hamid, Karmin S; Adams, Samuel B. (2016). Predictors of Time to Union After Operative Fixation of Closed. Foot and Ankle Specialist. 20(10), 1-7.
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