SLR - April 2020 - Kelly J. Rogers

How Does Perioperative Ketorolac Affect Opioid Consumption and Pain Management after Ankle Fracture Surgery?

Reference: McDonald EL, Daniel JN, Rogero RG, Shakked RJ, Nicholson K, Pedowitz DI, Raikin SM, Bilolikar V, Winters BS. How Does Perioperative Ketorolac Affect Opioid Consumption and Pain Management after Ankle Fracture Surgery? Clinical Orthopaedics Related Research. 2020 Jan;478(1):144-151

Scientific Literature Review

Reviewed By: Kelly J. Rogers, DPM
Residency Program: Northwell Health Long Island Jewish Forest Hills Hospital – Queens, NY

Podiatric Relevance: The rising opioid epidemic has led to cautious prescribing habits for post-operative pain in the orthopedic community. Minimizing post-operative pain in foot and ankle surgery, especially in the setting of fracture repair is critical to patient satisfaction and clinical outcome. NSAID use remains controversial due to concerns for increased risk of delayed bone healing. This prospective randomized study included 128 patients and investigated whether postoperative ketorolac use reduced opioid use and improved VAS pain control after open reduction internal fixation (ORIF) of ankle fractures while also assessing its impact on fracture healing.  

Methods: This is a Level I, randomized, controlled, therapeutic study of 128 patients from August 2016 to December 2017 who had undergone ORIF of isolated lateral malleolar, bimalleolar or trimalleolar ankle factures. Patients who met inclusion criteria were randomized into treatment with or without ketorolac in a parallel design. Treatment group received 30 miligrams IV ketorolac intra-op and 20 tablets of 10 miligrams ketorolac PO Q6hrs plus 30 tabs of Percocet as needed. The control group only received 30 tabs Percocet as needed. The primary outcome of the study wasnarcotic consumption during the first seven days after surgery. Clinical assessment was based on patient’s ability to ambulate 12 weeks postoperative while fracture healing was assessed by blinded surgeons for radiographic resolution of fracture line. Delayed union was defined as presence of fracture line at 12 weeks post op. No advanced images were used. Medication compliance was self-reported by patients based on surveys.

Results: Opioid consumption was reduced in the grouptreated with ketorolac. In the treatment group a mean of 14.0 ± 11.8 tablets of Percocet was used in the first seven days post-op versus 19.3 ± 13.9 in the control group. More specifically, patients who received ketorolac consumed less Percocet the first two days after surgery. However patient-reported pain scores and sleep scores didn’t show statistical significance. No differences were found between the study groups in fracture union rate by 12 weeks after surgery. No other complications were reported including gastrointestinal adverse events. 
Conclusions: The addition of ketorolac decreased the use of opioid medication. This study shows no evidence of interference with osteogenesis and fracture nonunion although the sample size is underpowered to effectively assess affects on fracture healing. Other limitations include the determination of healing was without assistance of advanced imaging such as CT. Patients self-reported the number of opioids used, which may introduce bias. On average, a difference of five opioid tablets were reported between the two groups with the greatest reduction of consumption occurring the first two days after surgery. Twelve weeks after ORIF, greater than 80 percent of patients in both groups had evidence of clinical and radiographic fracture healing with no differences between the two groups. Adjunct use of ketorolac in ankle ORIF is generally safe in terms of fracture healing with a low side effect profile making it a valid option in reducing post-op pain and reducing opioid use.  

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