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Solaiman RH, Dirnberger J, Kennedy NI, DePhillipo NN, Tagliero AJ, Malinowski K, Dimmen S, LaPrade RF. The effect of nonsteroidal anti-inflammatory drug use on soft tissue and bone healing in the knee: a systematic review. ANNALS OF JOINT 2024; 9:3. [PMID: 38529297 PMCID: PMC10929375 DOI: 10.21037/aoj-23-58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/21/2023] [Indexed: 03/27/2024]
Abstract
Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to mitigate pain and inflammation associated with musculoskeletal conditions; however, there is conflicting data on the adverse effects of these drugs on tissue and bone healing. The objective of this study was to investigate the effect of NSAIDs on the healing of knee, soft tissue, and bone. Methods A systematic literature search was conducted across PubMed/MEDLINE, Excerpta Medical Database (Embase)/Ovid, and the Cochrane Central Register of Controlled Trials databases. Clinical, animal, and in vitro studies on the effect of NSAIDs on knee healing were included. Risk of bias assessment was performed using the Cochrane bias assessment tool and Methodological Index for Non-Randomized Studies scoring system for included clinical studies, and the Systematic Review Center for Laboratory Animal Experimentation assessment tool for all included animal studies. General study population characteristics, interventions used, NSAIDs utilized, outcome measures, and study results were analyzed using descriptive statistics. Results Fifteen articles met the inclusion criteria. Of the 15 studies, there were three clinical, ten animal, and two in vitro studies. In clinical studies, nonselective cyclooxygenase (COX) inhibitors and selective COX-2 inhibitors did not cause a significant increase in failure of anterior cruciate ligament (ACL) reconstructions or meniscal repairs with NSAID administration pre-, peri-, or post-operatively in comparison to placebo or no NSAID administration. Among animal studies assessing COX-2 inhibitor effects on soft tissue, healing was impaired (2/4), delayed but unaffected (1/4), or unaffected (1/4). In animal studies assessing COX-1 inhibitors, ligament healing was either increased (1/4), unaffected (2/4), or impaired (1/4). Meanwhile, administration of non-selective COX inhibitors in animals did not affect soft tissue (3/3) and cartilage (1/1) healing. Two in vitro studies identified a negative outcome on patellar tendon and ACL cell proliferation or viability after non-selective COX inhibition and variable results after selective COX-2 inhibition. Conclusions Animal studies on postoperative NSAID use after knee surgery suggest that administration of selective and nonselective COX-2 inhibitors may impair healing of soft tissue, bone and tendon-to-bone; however, further clinical studies are needed to better characterize dose and duration dependent risks of NSAIDs.
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Affiliation(s)
| | - Jack Dirnberger
- University of North Dakota School of Medicine, Grand Forks, ND, USA
| | | | | | - Adam J. Tagliero
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Safety and Efficacy of Postoperative Nonsteroidal Anti-inflammatory Drugs in Sports Medicine. J Am Acad Orthop Surg 2022; 30:535-542. [PMID: 35576538 DOI: 10.5435/jaaos-d-21-01228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/25/2022] [Indexed: 02/01/2023] Open
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for multimodal pain control after surgery. These medications work by selective or nonselective inhibition of cyclooxygenase, which has downstream effects on thromboxanes, prostaglandins, and prostacyclins. Clinical studies have shown beneficial effects for alleviating pain and reducing opioid consumption after surgery. Within hip arthroscopy, there is evidence that postoperative NSAIDs can also reduce the risk of symptomatic heterotopic bone formation. However, preclinical and animal studies have raised concern over the effect of NSAIDs on bone and soft-tissue healing. In addition, selective and nonselective cyclooxygenase 2 inhibitors may have different safety profiles regarding postoperative soft-tissue healing. The purpose of this review was to outline the mechanisms of action, efficacy, and effect on soft-tissue healing of postoperative NSAIDs and to provide evidence-based recommendations for appropriate use.
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Bolia IK, Haratian A, Bell JA, Hasan LK, Saboori N, Palmer R, Petrigliano FA, Weber AE. Managing Perioperative Pain After Anterior Cruciate Ligament (ACL) Reconstruction: Perspectives from a Sports Medicine Surgeon. Open Access J Sports Med 2021; 12:129-138. [PMID: 34512045 PMCID: PMC8426642 DOI: 10.2147/oajsm.s266227] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022] Open
Abstract
Anterior cruciate ligament reconstructions (ACLR) are a relatively common procedure in orthopedic sports medicine with an estimated 130,000 arthroscopic operations performed annually. Most procedures are carried out on an outpatient basis, and though success rates of ACLR are as high as 95%, pain remains the most common postoperative complication delaying patient discharge, and thereby increasing the costs associated with patient care. Despite the success and relative frequency of ACLR surgery, optimal and widely accepted strategies and regimens for controlling perioperative pain are not well established. In recent years, the paradigm of pain control has shifted from exclusively utilizing opiates and opioid medications in the acute postoperative period to employing other agents and techniques including nerve blocks, intra-articular and periarticular injections of local anesthetic agents, NSAIDs, and less commonly, ketamine, tranexamic acid (TXA), sedatives, gabapentin, and corticosteroids. More often, these agents are now used in combination and in synergy with one another as part of a multimodal approach to pain management in ACLR, with the goal of reducing postoperative pain, opioid consumption, and the incidence of delayed hospital discharge. The purpose of this review is to consolidate current literature on various agents involved in the management of postoperative pain following ACLR, including the role of classically used opiate and opioid medications, as well as to describe other drugs currently utilized in practice either individually or in conjunction with other agents as part of a multimodal regimen in pain management in ACLR.
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Affiliation(s)
- Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Jennifer A Bell
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Nima Saboori
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ryan Palmer
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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Murray MM, Fleming BC, Badger GJ, Freiberger C, Henderson R, Barnett S, Kiapour A, Ecklund K, Proffen B, Sant N, Kramer DE, Micheli LJ, Yen YM. Bridge-Enhanced Anterior Cruciate Ligament Repair Is Not Inferior to Autograft Anterior Cruciate Ligament Reconstruction at 2 Years: Results of a Prospective Randomized Clinical Trial. Am J Sports Med 2020; 48:1305-1315. [PMID: 32298131 PMCID: PMC7227128 DOI: 10.1177/0363546520913532] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preclinical studies suggest that for complete midsubstance anterior cruciate ligament (ACL) injuries, a suture repair of the ACL augmented with a protein implant placed in the gap between the torn ends (bridge-enhanced ACL repair [BEAR]) may be a viable alternative to ACL reconstruction (ACLR). HYPOTHESIS We hypothesized that patients treated with BEAR would have a noninferior patient-reported outcomes (International Knee Documentation Committee [IKDC] Subjective Score; prespecified noninferiority margin, -11.5 points) and instrumented anteroposterior (AP) knee laxity (prespecified noninferiority margin, +2-mm side-to-side difference) and superior muscle strength at 2 years after surgery when compared with patients who underwent ACLR with autograft. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS One hundred patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were enrolled and underwent surgery within 45 days of injury. Patients were randomly assigned to receive either BEAR (n = 65) or autograft ACLR (n = 35 [33 with quadrupled semitendinosus-gracilis and 2 with bone-patellar tendon-bone]). Outcomes-including the IKDC Subjective Score, the side-to-side difference in instrumented AP knee laxity, and muscle strength-were assessed at 2 years by an independent examiner blinded to the procedure. Patients were unblinded after their 2-year visit. RESULTS In total, 96% of the patients returned for 2-year follow-up. Noninferiority criteria were met for both the IKDC Subjective Score (BEAR, 88.9 points; ACLR, 84.8 points; mean difference, 4.1 points [95% CI, -1.5 to 9.7]) and the side-to-side difference in AP knee laxity (BEAR, 1.61 mm; ACLR, 1.77 mm; mean difference, -0.15 mm [95% CI, -1.48 to 1.17]). The BEAR group had a significantly higher mean hamstring muscle strength index than the ACLR group at 2 years (98.2% vs 63.2%; P < .001). In addition, 14% of the BEAR group and 6% of the ACLR group had a reinjury that required a second ipsilateral ACL surgical procedure (P = .32). Furthermore, the 8 patients who converted from BEAR to ACLR in the study period and returned for the 2-year postoperative visit had similar primary outcomes to patients who had a single ipsilateral ACL procedure. CONCLUSION BEAR resulted in noninferior patient-reported outcomes and AP knee laxity and superior hamstring muscle strength when compared with autograft ACLR at 2-year follow-up in a young and active cohort. These promising results suggest that longer-term studies of this technique are justified. REGISTRATION NCT02664545 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Martha M. Murray
- Martha M. Murray, MD, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Ave, Hunnewell 2, Boston, MA 02115, USA ()
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Everhart JS, Magnussen RA, Cavendish PA, Axcell K, Blackwell R, Kaeding CC, Flanigan DC. Subjective Knee Function and Risk of Failure Are Equivalent for Men and Women at 5 Years After Meniscus Repair. Arthroscopy 2020; 36:816-822. [PMID: 31919022 DOI: 10.1016/j.arthro.2019.09.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether subjective knee function or risk of repair failure differ between men and women at mean 5 years following meniscal repair with or without concomitant anterior cruciate ligament reconstruction. METHODS A total of 235 patients (97 women, 138 men; mean age, 29.1 years; standard deviation, 11.3) were assessed for meniscus repair failure and postoperative knee function at mean 5.8 years follow-up. Knee symptoms were assessed with International Knee Documentation Committee Subjective (IKDC-S) scores. Postoperative activity scores were assessed with Marx activity score. Independent effects of patient age and activity level on meniscus failure risk and patient-reported outcomes were determined by multivariate analysis with adjustment for age, body mass index, anterior cruciate ligament status, tear pattern, and number of implants used at the time of surgery. RESULTS Failures occurred in 18.9% of men and 21.0% of women with no difference in mean time to failure (P = .75) or risk of failure for men vs women (P = .57) in the univariate analysis. Male sex was not an independent risk factor for failure after adjustment for patient age, body mass index, concomitant anterior cruciate ligament status, tear pattern, or number of implants used (P = .16). Marx activity scores at follow-up were higher among men in multivariate analysis (P = .009). Men and women had similar IKDC-S scores at follow-up in the unadjusted (P = .25) and multivariate analyses (P = .21). CONCLUSIONS Following meniscus repair, both sexes report similar subjective knee function, though men have higher self-reported activity scores. Meniscus repair failure risk does not differ between men or women at mid-term follow up. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Joshua S Everhart
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Parker A Cavendish
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Kent Axcell
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Ryan Blackwell
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Christopher C Kaeding
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A.
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Hamilton C, Flanigan DC, Patel KH, Lundy N, Blackwell R, Magnussen RA. Meniscus repair failure risk does not differ by sex: a systematic review. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Tabrizian P, Giacca M, Prigoff J, Tran B, Holzner ML, Chin E, Palese M, Herron D, Arvelakis A, Rudow DL, Florman S, Shapiro R. Renal Safety of Intravenous Ketorolac Use After Donor Nephrectomy. Prog Transplant 2019; 29:283-286. [PMID: 31185805 DOI: 10.1177/1526924819855360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The benefit and short-term safety of ketorolac have been established in previous studies however, the risk of bleeding and long-term renal impairment in patients undergoing donor nephrectomy remain unclear. We report our experience at a high-volume transplant center. METHOD Between January 1996 and January 2014, 862 consecutive patients underwent laparoscopic donor nephrectomy. Exclusion criteria included nonsteroidal anti-inflammatory drug allergy, asthma, bleeding disorders, long-term opioid use, intraoperative blood loss >700 mL, peptic ulcer disease, bleeding diathesis, and baseline creatinine greater than 1.9 mg/dL. Intravenous ketorolac was administered within 30 minutes following the surgical procedure at a dose of 15 to 30 mg every 6 hours. Patients were categorized into 2 groups according to the administration of ketorolac after surgery. Differences between the groups were analyzed. Primary outcomes were changes in serum creatinine and hemoglobin levels. Poor outcome was defined as postsurgical complications. RESULTS During this time, 469 (55.3%) received ketorolac. The mean donor age was 39 years, and 360 (42.5%) were male. Left kidneys were procured in 82%. Operative time averaged 210 minutes and warm ischemia time117 seconds. Baseline demographic and operative outcomes were comparable in both groups. No statistically significant differences were found between the ketorolac group and the nonketorolac group in preoperative and postoperative hemoglobin levels and serum creatinine at 1 week, 1 year, and 5 years (P = .6). Ketorolac use was not associated with increased perioperative morbidity (P = NS). CONCLUSION The use of intravenous ketorolac in patients undergoing donor nephrectomy was not associated with an increased risk of bleeding or renal impairment.
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Affiliation(s)
- Parissa Tabrizian
- 1 Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Massimo Giacca
- 1 Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jake Prigoff
- 1 Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Benjamin Tran
- 1 Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew L Holzner
- 1 Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Edward Chin
- 2 Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael Palese
- 2 Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Herron
- 2 Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Antonios Arvelakis
- 1 Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dianne LaPointe Rudow
- 1 Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sander Florman
- 1 Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ron Shapiro
- 1 Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Constantinescu DS, Campbell MP, Moatshe G, Vap AR. Effects of Perioperative Nonsteroidal Anti-inflammatory Drug Administration on Soft Tissue Healing: A Systematic Review of Clinical Outcomes After Sports Medicine Orthopaedic Surgery Procedures. Orthop J Sports Med 2019; 7:2325967119838873. [PMID: 31019986 PMCID: PMC6469280 DOI: 10.1177/2325967119838873] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: The effects of perioperative nonsteroidal anti-inflammatory drugs (NSAIDs) on
soft tissue healing in humans have yet to be established. Purpose: To systematically review the literature addressing the effects of
perioperative NSAID administration on soft tissue healing and clinical
patient outcomes. Study Design: Systematic review; Level of evidence, 3. Methods: This review study was conducted in accordance with the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) statement. A
review of the literature regarding the existing evidence for clinical
effects of NSAID use on soft tissue healing was performed through use of the
Cochrane Database of Systematic Reviews, the Cochrane Central Register of
Controlled Trials, PubMed (1980 to present), and MEDLINE. Inclusion criteria
for articles were as follows: outcome studies after soft tissue (ligament,
meniscus, tendon, muscle) healing after surgical procedure with
perioperative NSAID administration, at least 1 year of follow-up, English
language, and human participants. Results: A total of 466 studies were initially retrieved, with 4 studies satisfying
all inclusion criteria. Among the surgical procedures reported, 93% of the
patients (4144/4451) underwent anterior cruciate ligament (ACL)
reconstruction, 3% (120/4451) underwent rotator cuff repair, 3% (155/4451)
underwent Bankart shoulder repair, and 1% (32/4451) underwent meniscal
repair. The reported surgical failure rate among patients administered
NSAIDs was 3.6% (157/4360). The reported surgical failure rate among control
participants not given NSAIDs was 3.7% (147/3996). NSAID use showed no
statistically significant effect on need for reoperation in meniscal repair
(P = .99), ACL reconstruction (P =
.8), and Bankart repair (P = .8) compared with no NSAID
administration. Celecoxib administration had a significantly higher rate of
retear (37%) after rotator cuff repair compared with ibuprofen (7%)
(P = .009). Conclusion: Insufficient data are available to definitively state the effects of
perioperative NSAIDs on soft tissue healing. Use of NSAIDs should be
considered on a case-by-case basis and may not affect healing rates
following either meniscal, ACL, rotator cuff, or Bankart repair. However,
celecoxib (a selective COX-2 inhibitor) may inhibit tendon-to-bone healing
in rotator cuff repair. Further research through clinical trials is required
to fully determine whether NSAIDs have an adverse effect on soft tissue
healing.
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Affiliation(s)
- David S Constantinescu
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael P Campbell
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Alexander R Vap
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
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