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Increased Nonunion Rates for Scaphoid Fractures Treated Nonoperatively with Recent NSAID Prescription
Amy Phan, MD
1, Christopher M Dussik, MD
2, Jeffrey Coombs, MD
2, Ronald M Gonzalez, DO
2, Bilal Mahmood, MD
1, Danielle M Wilbur, MD
2; Constantinos Ketonis, MD, PhD
2(1)University of Rochester, Rochester, NY, (2)University of Rochester Medical Center, Rochester, NY
Introduction: Acute scaphoid fractures constitute up to 80% of all carpal bone fractures with reported union rates of nondisplaced scaphoid fractures between 90-95% after casting and immobilization.
1 The purpose of our study was to evaluate the relationship of usage of prescription non-steroidal anti-inflammatory drugs (NSAIDs) and nonunion rates in nonoperatively and operatively managed scaphoid fractures.
Methods: We queried the TriNetX database to identify all patients diagnosed with scaphoid fractures using a combination of International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes. Patients were stratified by operative versus nonoperative management, as well as by receipt of a prescription for NSAIDs within one month of scaphoid fracture diagnosis. We then assessed the incidence of scaphoid nonunion and the rate of salvage procedures for nonunion within two years of the initial diagnosis or scaphoid ORIF. Analyses were matched for comorbidities, smoking status, and alcohol use. Chi-squared testing and odds ratio analysis were used to determine statistical significance.
Results: After matching, there were 17,241 patients in the nonoperative group and 1,410 patients in the operative group (Table 1). Within the matched nonoperative treatment cohort, patients with prescription NSAIDs had a significantly increased incidence of scaphoid nonunion (3.6% vs. 1.7%, odds ratio (CI): 2.17 (1.88-2.51)) and significantly increased incidence of salvage procedures (1.2% vs. 0.6%; odds ratio (CI): 1.98 (1.56-2.52)) (Table 2). In contrast, within the matched operative fracture group with and without perioperative NSAID prescriptions, there were no significant differences between the incidence of scaphoid nonunion (7.0% vs. 8.1%; OR (CI): 1.18 (0.89-1.56)), or of salvage procedures (2.5 vs. 2.8%, OR (CI): 0.90 (0.56-1.42)) (Table 2).
Conclusions: Among patients with nonoperatively managed scaphoid fractures, those prescribed NSAIDs within one month of diagnosis demonstrated an approximate two-fold increase in the risk of nonunion and subsequent salvage procedures. This association was not observed in operatively managed patients with peri-operative prescribed NSAIDs, suggesting that mechanical fixation may offset the potential adverse effects of NSAIDs on bone healing. These findings highlight the importance of advising patients to avoid NSAID use in the early post-injury period after scaphoid fractures, especially when nonoperative management is planned.
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