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Perioperative Ketorolac Is Not Associated with Nonunion After Scaphoid Fracture Surgery
David Momtaz, MPH
1; Dafang Zhang, MD
21UT Health San Antonio School of Medicine, San Antonio, TX; 2Brigham and Women's Hospital, Boston, MA
Introduction: Ketorolac, a non-steroidal anti-inflammatory drug (NSAID), is an effective adjunct for postoperative analgesia in fracture management and has been shown to decrease the use of opioids. However, the literature is limited regarding the impact of ketorolac on scaphoid fracture healing. This study aims to assess the effect of perioperative ketorolac use on scaphoid fracture union in the setting of operatively managed scaphoid fractures in the adult population using a large database and propensity score matching for relevant comorbidities.
Methods: We conducted a retrospective cohort study using TriNetX, a global database with access to electronic medical records from over 50 healthcare organizations and exceeding 110 million patients. Adult patients with surgically treated scaphoid fractures from 2003 to 2020 were identified using the procedural code. Cohorts were divided by ketorolac exposure within the 30-day postoperative window, including the day of surgery. Operative management was defined as the index event when each patient entered the analysis. Nonunion, our primary outcome, was identified using pertinent medical codes and confirmed using codes pertaining to subsequent surgical interventions undertaken to rectify nonunion, ensuring internal validity. Follow-up for nonunion began at 90 days and ended at 3 years post-exposure. Patients in the ketorolac and non-ketorolac cohorts were matched using the criteria of age, sex, body mass index, diabetes mellitus, smoking status, and date of surgery no more than 2 months apart, and other prescription analgesics. Hazard ratios were derived from Cox regression models for risk of nonunion.
Results: A total of 6,112 adult patients who underwent primary scaphoid fracture surgery were identified. 1,317 (21.54%) patients had ketorolac exposure within 30 days of surgery, while 4,795 (78.45%) did not. Of the 1,317 patients with ketorolac exposure, 1,314 patients were successfully matched and included in the final analysis. We had 100% follow-up at 90-days and 81% follow-up at 3 years with a mean follow-up time of 856 days. The overall nonunion rate in our matched cohort after primary scaphoid fracture surgery was 6.39%. In patients with ketorolac exposure, the nonunion rate was 6.45%. In the no-ketorolac matched cohort, the nonunion rate was 6.32%. Patients with ketorolac exposure, relative to those without, had no significant difference in the risk of nonunion (HR 1.011 [95% CI 0.731 - 1.392], p=0.815).
Conclusions: Ketorolac use in the 30-day postoperative window is not associated with an increased risk of nonunion in the setting of primary scaphoid fracture surgery in the adult population.
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