The effect of Cox-2 specific inhibition on direct fracture healing in the rabbit tibia

Effect of non-steroidal anti-inflammatory drugs on fracture healing in children: A systematic review

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications in the United States. Although they are safe and effective means of analgesia for children with broken bones, there is considerable variation in their clinical use due to persistent concerns about their potentially adverse effect on fracture healing.

AIM

To assess whether NSAID exposure is a risk factor for fracture nonunion in children.

METHODS

We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included all clinical studies that reported on adverse bone healing complications in children with respect to NSAID exposure. The outcomes of interest were delayed union or nonunion. Study quality was assessed using the Newcastle-Ottawa scale for non-randomized studies. A final table was constructed summarizing the available evidence.

RESULTS

A total of 120 articles were identified and screened, of which 6 articles were included for final review. Nonunion in children is extremely rare; among the studies included, there were 2011 nonunions among 238822 fractures (0.84%). None of the included studies documented an increased risk of nonunion or delayed bone healing in those children who are treated with NSAIDs in the immediate post-injury or peri-operative time period. Additionally, children are likely to take these medications for only a few days after injury or surgery, further decreasing their risk of adverse side-effects.

CONCLUSION

This systematic review suggests that NSAIDS can be safely prescribed to pediatric orthopaedic patients absent other contraindications without concern for increased risk of fracture non-union or delayed bone healing. Additional prospective studies are needed focusing on higher risk fractures and elective orthopaedic procedures such as osteotomies and spinal fusion.

The effect of NSAIDs on postfracture bone healing: a meta-analysis of randomized controlled trials

To determine whether nonsteroidal anti-inflammatory drugs (NSAIDs) have an adverse effect on bone healing by evaluating all available human randomized controlled trials (RCTs) on this subject.

Data Sources

A comprehensive search of electronic databases (PubMed, MEDLINE, and Cross-References) until October 2018 comparing the occurrence of nonunion in patients who received NSAIDs to the control group through RCTs.

Study Selection

Inclusion criteria were English-only studies, and the type of studies was restricted to RCTs.

Data Extraction

Two authors independently extracted data from the selected studies, and the data collected were compared to verify agreement.

Data Synthesis

Nonunion was the main outcome evaluated in each study. Regression analysis was used to estimate the relative risk comparing the duration and the type of NSAIDs by calculating the odds ratio (OR) for dichotomous variables. Studies were weighed by the inverse of the variance of the outcome, and a fixed-effects model was used for all analyses.

Conclusions

Six RCTs (609 patients) were included. The risk of nonunion was higher in the patients who were given NSAIDs after the fracture with an OR of 3.47. However, once the studies were categorized into the duration of treatment with NSAIDs, those who received NSAIDs for a short period (<2 weeks) did not show any significant risk of nonunion compared to those who received NSAIDs for a long period (>4 weeks). Indomethacin was associated with a significant higher nonunion rate and OR ranging from 1.66 to 9.03 compared with other NSAIDs that did not show a significant nonunion risk.

The effect of NSAIDs on spinal fusion: a cross-disciplinary review of biochemical, animal, and human studies

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) play an important role in postoperative pain management. However, their use in the setting of spine fusion surgery setting has long been a topic of controversy. In this review we examined relevant research, including in vivo, animal, and clinical human studies, with the aim of understanding the effect of NSAIDs on spinal fusion.

STUDY DESIGN/SETTING

Systematic review of study designs of all types from randomized controlled trials and meta-analyses to single-institution retrospective reviews.

METHODS

A search of PubMed and Embase was conducted using the keywords: "spine," "spinal fracture," NSAIDs, anti-inflammatory non-steroidal agents, bone, bone healing, fracture, fracture healing, yielding a total of 110 studies. Other 28 studies were identified by cross-referencing, resulting in total 138 studies.

RESULTS

There is no level I evidence from human studies regarding the use of NSAIDs on spinal fusion rates. The overall tone of the spine literature in the early 2000s was that NSAIDs increased the rate of non-union; however, nearly all human studies published after 2005 suggest that short-term (<2 weeks) postoperative use have no such effect. The dose dependency that is seen with a 2-week postoperative course is not present when NSAIDs are only used for 48 h after surgery.

CONCLUSIONS

NSAID appear to have dose-dependent and duration-dependent effects on fusion rates. The short-term use of low-dose NSAIDs around the time of spinal fusion surgery is reasonable. Spine surgeons can consider the incorporation of NSAIDs into pain control regimens for spinal fusion patients with the goal of improving pain control and reducing the costs and complications associated with opioids.

The Effect of Cyclooxygenase Inhibition on Tendon-Bone Healing in an In Vitro Coculture Model

The effects of cyclooxygenase (COX) inhibition following the reconstruction of the anterior cruciate ligament remain unclear. We examined the effects of selective COX-2 and nonselective COX inhibition on bone-tendon integration in an in vitro model. We measured the dose-dependent effects of ibuprofen and parecoxib on the viability of lipopolysaccharide- (LPS-) stimulated and unstimulated mouse MC3T3-E1 and 3T3 cells, the influence on gene expression at the osteoblast, interface, and fibroblast regions measured by quantitative PCR, and cellular outgrowth assessed on histological sections. Ibuprofen led to a dose-dependent suppression of MC3T3 cell viability, while parecoxib reduced the viability of 3T3 cultures. Exposure to ibuprofen significantly suppressed expression of Alpl (P < 0.01), Bglap (P < 0.001), and Runx2 (P < 0.01), and although parecoxib reduced expression of Alpl (P < 0.001), Fmod (P < 0.001), and Runx2 (P < 0.01), the expression of Bglap was increased (P < 0.01). Microscopic analysis showed a reduction in cellular outgrowth in LPS-stimulated cultures following exposure to ibuprofen and parecoxib. Nonselective COX inhibition and the specific inhibition of COX-2 led to region-specific reductions in markers of calcification and cell viability. We suggest further in vitro and in vivo studies examining the biologic and biomechanical effects of selective and nonselective COX inhibition.

NSAIDs and fracture healing

PURPOSE OF REVIEW

Published data raise concerns about the use of nonselective NSAIDs and selective cyclo-oxygenase (COX)-2 inhibitors as anti-inflammatory or analgesic drugs in patients after a recent fracture or who are undergoing (uncemented) arthroplasty or osteotomy. However, clinical reports on the effect of COX-2 inhibition on fracture healing in humans have been variable and inconclusive. This review gives an overview of the published data and an advice when to avoid NSAIDs.

RECENT FINDINGS

Prostaglandins play an important role as mediators of inflammation and COX are required for their production. Inflammation is an essential step in the fracture healing process in which prostaglandin production by COX-2 is involved. Data from animal studies suggest that NSAIDs, which inhibit COX-2, can impair fracture healing due to the inhibition of the endochondral ossification pathway. Animal data suggest that the effects of COX-2 inhibitors are dependent on the timing, duration, and dose, and that these effects are reversible.

SUMMARY

These animal data, together with the view of limited scientifically robust clinical evidence in humans, indicate that physicians consider only short-term administration of COX-2 inhibitors or other drugs in the pain management of patients who are in the phase of fracture or other bone defect healing. COX-2-inhibitors should be considered a potential risk factor for fracture healing, and therefore to be avoided in patients at risk for delayed fracture healing.

Effects of a selective cyclooxygenase-2 inhibitor (celecoxib) on fracture healing in rats

BACKGROUND

Several studies suggested that celecoxib interferes with bone healing while others contradict these findings. This study was conducted to investigate the effects of celecoxib on bone healing in rats femur mold with a dose based on body surface area conversion.

MATERIALS AND METHODS

72 adult female Sprague Dawley rats were randomly divided into three groups after the internal fixation operation of nondisplaced transverse mid diaphyseal fractures of the right femurs. Each group was treated with 1% methylcellulose, celecoxib (21 mg/kg/d) for 1 week, or celecoxib (21 mg/kg/d) for 4 weeks after surgeries respectively. Bone healing scores and callus formation were evaluated by radiographs at 3, 4, 6 weeks after surgeries. Half of these rats were sacrificed for histological analysis at 4 weeks after surgery. The remaining fractured femurs were evaluated by biomechanical tests at 6 weeks after surgery.

RESULTS

The mean radiographic scores for fracture healing of both short and long term groups were lower than that of the control group and the differences among the three groups were statistically significant (P < 0.05) at 3, 4, 6 weeks after surgery. The mean bone trabecula density of both groups was smaller than that of the control group and the differences were also statistically significant (P < 0.05) at 4 week. The maximum load, total energy and stiffness in both the short term and long term groups were significantly decreased compared with those in the control group (P < 0.05) at 6 week.

CONCLUSION

Both short term and long term sustained use of celecoxib in rat models has significantly inhibitory effects on rat fracture healing.

Do nonsteroidal anti-inflammatory drugs affect bone healing? A critical analysis

Nonsteroidal anti-inflammatory drugs (NSAIDs) play an essential part in our approach to control pain in the posttraumatic setting. Over the last decades, several studies suggested that NSAIDs interfere with bone healing while others contradict these findings. Although their analgesic potency is well proven, clinicians remain puzzled over the potential safety issues. We have systematically reviewed the available literature, analyzing and presenting the available in vitro animal and clinical studies on this field. Our comprehensive review reveals the great diversity of the presented data in all groups of studies. Animal and in vitro studies present so conflicting data that even studies with identical parameters have opposing results. Basic science research defining the exact mechanism with which NSAIDs could interfere with bone cells and also the conduction of well-randomized prospective clinical trials are warranted. In the absence of robust clinical or scientific evidence, clinicians should treat NSAIDs as a risk factor for bone healing impairment, and their administration should be avoided in high-risk patients.