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The effect of NSAIDs on postfracture bone healing: a meta-analysis of randomized controlled trials. OTA Int 2021; 4:e092. [PMID: 34746650 PMCID: PMC8568409 DOI: 10.1097/oi9.0000000000000092] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/18/2020] [Accepted: 08/12/2020] [Indexed: 01/08/2023]
Abstract
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.
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Al-Waeli H, Reboucas AP, Mansour A, Morris M, Tamimi F, Nicolau B. Non-steroidal anti-inflammatory drugs and bone healing in animal models-a systematic review and meta-analysis. Syst Rev 2021; 10:201. [PMID: 34238360 PMCID: PMC8268344 DOI: 10.1186/s13643-021-01690-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 04/26/2021] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAID) have excellent anti-inflammatory and analgesic properties and are extensively used to treat post-traumatic or surgical musculoskeletal pain. Although an extensive literature exists on the administration of NSAID on animal bone healing, no systematic review and meta-analysis of animal studies that investigate the effect of NSAID administration on bone fracture healing. Objective of this study is to conduct a systematic review and meta-analysis to estimate the effect of NSAIDs administration on bone healing biomechanical and histomorphometric measurements in different animal models after bone fracture surgery. METHODS We performed a systematic review and meta-analysis of animal studies to estimate the effect of NSAID administration after bone fracture on healing outcomes. We searched eight databases without limiting the search to starting date up to 1 February 2021 for articles on fractured bone healing in animal models in which NSAID were administered. RESULTS Out of 6732 articles screened, 47 were included and 3 common bone healing outcomes were analysed: biomechanical properties (maximum force to break, stiffness, and work-to-failure), micro-computed tomography (μ-CT), and histomorphometric measurements. The studies were generally of low-quality scores because crucial information, especially concerning randomization, blinding, and allocation concealment, was poorly reported. Our results show that the negative effects of NSAID after bone fracture on certain biomechanical properties of the healing bones was not statistically significant in mice compared with other animals, in females compared with males, and in younger compared with older animals. CONCLUSION The findings demonstrated that NSAIDs administration decreased the biomechanical properties of healing bones after fracture surgery in comparison to the control group. Moreover, different effect on certain outcomes was detected among different sites, sex of the animals, and the time of assessment. TRIAL REGISTRATION Protocol published and registered in SYstematic Review Center for Laboratory animal Experimentation (SYRCLE) in 2017, https://www.radboudumc.nl/getmedia/757ec408-7a9e-4635-8233-ae951effea54/Non-Steroidal-Anti-inflammatory-Drugs-and-bone-healing-in-animal-Models-Systematic-Review-and-Meta-Analysis.aspx.
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Affiliation(s)
- Haider Al-Waeli
- Faculty of Dentistry, Dalhousie University, 5981 University Ave, Halifax, Nova Scotia, B3H 4R2, Canada.
| | - Ana Paula Reboucas
- Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
- College of Dental Medicine, Qatar University, University Street, Doha, Qatar
| | - Alaa Mansour
- School of Dental Medicine, University at Buffalo, Buffalo, NY, 14214, USA
| | - Martin Morris
- Schulich Library, McGill University, 2001 Avenue McGill College Suite 500, Montréal, QC, H3A 1G1, Canada
| | - Faleh Tamimi
- College of Dental Medicine, Qatar University, University Street, Doha, Qatar
| | - Belinda Nicolau
- Faculty of Dentistry, McGill University, 2001 Avenue McGill College Suite 500, Montréal, QC, H3A 1G1, Canada
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Rothe R, Schulze S, Neuber C, Hauser S, Rammelt S, Pietzsch J. Adjuvant drug-assisted bone healing: Part I – Modulation of inflammation. Clin Hemorheol Microcirc 2020; 73:381-408. [DOI: 10.3233/ch-199102] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Rebecca Rothe
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Department of Radiopharmaceutical and Chemical Biology, Dresden, Germany
| | - Sabine Schulze
- University Center of Orthopaedics & Traumatology (OUC), University Hospital Carl Gustav Carus, Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus and Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Christin Neuber
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Department of Radiopharmaceutical and Chemical Biology, Dresden, Germany
| | - Sandra Hauser
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Department of Radiopharmaceutical and Chemical Biology, Dresden, Germany
| | - Stefan Rammelt
- University Center of Orthopaedics & Traumatology (OUC), University Hospital Carl Gustav Carus, Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus and Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Center for Regenerative Therapies Dresden (CRTD), Dresden, Germany
| | - Jens Pietzsch
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Department of Radiopharmaceutical and Chemical Biology, Dresden, Germany
- Technische Universität Dresden, School of Science, Faculty of Chemistry and Food Chemistry, Dresden, Germany
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Xie Y, Pan M, Gao Y, Zhang L, Ge W, Tang P. Dose-dependent roles of aspirin and other non-steroidal anti-inflammatory drugs in abnormal bone remodeling and skeletal regeneration. Cell Biosci 2019; 9:103. [PMID: 31890152 PMCID: PMC6929289 DOI: 10.1186/s13578-019-0369-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 12/20/2019] [Indexed: 01/10/2023] Open
Abstract
The failure of remodeling process that constantly regenerates effete, aged bone is highly associated with bone nonunion and degenerative bone diseases. Numerous studies have demonstrated that aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) activate cytokines and mediators on osteoclasts, osteoblasts and their constituent progenitor cells located around the remodeling area. These cells contribute to a complex metabolic scenario, resulting in degradative or synthetic functions for bone mineral tissues. The spatiotemporal effects of aspirin and NSAIDs in the bone remodeling are controversial according the specific therapeutic doses used for different clinical conditions. Herein, we review in vitro, in vivo, and clinical studies on the dose-dependent roles of aspirin and NSAIDs in bone remodeling. Our results show that low-dose aspirin (< 100 μg/mL), which is widely recommended for prevention of thrombosis, is very likely to be benefit for maintaining bone mass and qualities by activation of osteoblastic bone formation and inhibition of osteoclast activities via cyclooxygenase-independent manner. While, the roles of high-dose aspirin (150-300 μg/mL) and other NSAIDs in bone self-regeneration and fracture-healing process are difficult to elucidate owing to their dual effects on osteoclast activity and bone formation of osteoblast. In conclusion, this study highlighted the potential clinical applications of low-dose aspirin in abnormal bone remodeling as well as the risks of high-dose aspirin and other NSAIDs for relieving pain and anti-inflammation in fractures and orthopedic operations.
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Affiliation(s)
- Yong Xie
- 1Department of Orthopedics, Chinese PLA General Hospital, Beijing, 100853 China
| | - Meng Pan
- 2State Key Laboratory of Medical Molecular Biology and Department of Immunology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, 100005 China
| | - Yanpan Gao
- 2State Key Laboratory of Medical Molecular Biology and Department of Immunology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, 100005 China
| | - Licheng Zhang
- 1Department of Orthopedics, Chinese PLA General Hospital, Beijing, 100853 China
| | - Wei Ge
- 2State Key Laboratory of Medical Molecular Biology and Department of Immunology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, 100005 China
| | - Peifu Tang
- 1Department of Orthopedics, Chinese PLA General Hospital, Beijing, 100853 China
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Huss MK, Felt SA, Pacharinsak C. Influence of Pain and Analgesia on Orthopedic and Wound-healing Models in Rats and Mice. Comp Med 2019; 69:535-545. [PMID: 31561753 DOI: 10.30802/aalas-cm-19-000013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The surgical stress response and resulting physiologic changes can lead to postoperative complications and negatively impact animal welfare. Although appropriate pain management is crucial to reduce the pain and stress response to surgery, analgesic choice can significantly affect bone and wound healing. This review aims to summarize data from rat and mouse studies and to provide recommendations for integrating analgesia into orthopedic and wound healing models in these species. Data from other species, such as humans, rabbits and other rodents, is included, where available. From these data, we conclude that for orthopedic surgical models, opioids, local anesthetics and dissociative agents have minimal impact on fracture healing; cyclooxygenase 2 (COX2) selective nonsteroidal antiinflammatory drugs (NSAID) may be used in the shortterm; and steroids should be avoided. For wound healing models, short-term systemic or topical opioids have negligible impact on wound healing; NSAID or local anesthetics may be used short-term; and systemic steroids should be avoided. Alternative analgesics such as tramadol, gabapentin, ketamine, and acetaminophen warrant consideration and further evaluation for both orthopedic and wound healing models. In all cases, researchers and veterinarians should work together to determine the appropriate analgesic plan to minimize pain, as well as to minimize unwanted effects on the orthopedic and wound healing models themselves.
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Affiliation(s)
- Monika K Huss
- Department of Comparative Medicine, Stanford University, Stanford, California;,
| | - Stephen A Felt
- Department of Comparative Medicine, Stanford University, Stanford, California
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Bissinger O, Kreutzer K, Götz C, Hapfelmeier A, Pautke C, Vogt S, Wexel G, Wolff KD, Tischer T, Prodinger PM. A biomechanical, micro-computertomographic and histological analysis of the influence of diclofenac and prednisolone on fracture healing in vivo. BMC Musculoskelet Disord 2016; 17:383. [PMID: 27596101 PMCID: PMC5011804 DOI: 10.1186/s12891-016-1241-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 09/01/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) have long been suspected of negatively affecting fracture healing, although numerous disputes still exist and little data are available regarding diclofenac. Glucocorticoids interfere in this process over a similar and even broader mechanism of action. As many previously conducted studies evaluated either morphological changes or biomechanical properties of treated bones, the conjunction of both structural measures is completely missing. Therefore, it was our aim to evaluate the effects of diclofenac and prednisolone on the fracture callus biomechanically, morphologically and by 3-dimensional (3D) microstructural analysis. METHODS Femura of diclofenac-, prednisolone- or placebo-treated rats were pinned and a closed transverse fracture was generated. After 21 days, biomechanics, micro-CT (μCT) and histology were examined. RESULTS The diclofenac group showed significantly impaired fracture healing compared with the control group by biomechanics and μCT (e.g. stiffness: 57.31 ± 31.11 N/mm vs. 122.44 ± 81.16 N/mm, p = 0.030; callus volume: 47.05 ± 15.67 mm3 vs. 67.19 ± 14.90 mm3, p = 0.037, trabecular thickness: 0.0937 mm ± 0.003 vs. 0.0983 mm ± 0.003, p = 0.023), as confirmed by histology. Biomechanics of the prednisolone group showed obviously lower absolute values than the control group. These alterations were confirmed in conjunction with μCT and histology. CONCLUSIONS The inhibiting effects of both substances were not only mediated by absolute parameters (e.g. breaking load, BV), but we have shown, for the first time, that additional changes occurred in the microstructural bony network. Especially in patients at risk for delayed bone healing (arteriosclerosis, diabetes mellitus, smoking), the administration of these drugs should be weighed carefully.
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Affiliation(s)
- Oliver Bissinger
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Kilian Kreutzer
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Carolin Götz
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Statistics and Epidemiology, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Pautke
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephan Vogt
- Department of Orthopaedics and Orthopaedic Sports Medicine, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany.,Department of Orthopaedic Sports Medicine, Hessing Stiftung Augsburg, Hessingstr. 17, 86199, Augsburg, Germany
| | - Gabriele Wexel
- Department of Orthopaedics and Orthopaedic Sports Medicine, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thomas Tischer
- Department of Orthopaedics and Orthopaedic Sports Medicine, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany.,Department of Orthopaedic Surgery, University of Rostock, Doberanerstr. 142, 18057, Rostock, Germany
| | - Peter Michael Prodinger
- Department of Orthopaedics and Orthopaedic Sports Medicine, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
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Inal S, Kabay S, Cayci MK, Kuru HI, Altikat S, Akkas G, Deger A. Comparison of the effects of dexketoprofen trometamol, meloxicam and diclofenac sodium on fibular fracture healing, kidney and liver: an experimental rat model. Injury 2014; 45:494-500. [PMID: 24246878 DOI: 10.1016/j.injury.2013.10.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 08/08/2013] [Accepted: 10/04/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Nonsteroidal anti-inflammatory drugs (NSAIDs) are particularly used in patients with bone fractures, but there are limited studies on whether one NSAID is superior to another. In this study, we used histopathological and biochemical parameters to determine whether there are differences between the effects of the administration of clinical doses of dexketoprofen trometamol (DEXT), meloxicam (MEL) and diclofenac sodium (DIC) on the healing of closed fibular fractures and the toxicity of both the liver and kidney. METHODS Twenty-eight male Sprague-Dawley rats were randomly divided into four groups of seven each. Closed diaphyseal fractures were formed in the left fibulas of all of the rats. The NSAIDs dexketoprofen trometamol (DEXT) (Arveles(®)), meloxicam (MEL) (Melox(®)) and diclofenac sodium (DIC) (Voltaren(®)) were intramuscularly administered to Groups I, II, and III, respectively, for a period of 10 days after the fibular fractures were performed. No pharmacological agents were administered to Group IV (Control group). Blood samples were collected from all of the rats after the fractures were performed, and the rats were sacrificed on day 28. The histopathological findings were compared, and the blood samples were evaluated to determine any differences between the levels of superoxide dismutase (SOD), catalase (CAT), and malondialdehyde (MDA). RESULTS Our results suggest that DEXT and MEL impair the healing of bone fractures and that DIC does not histopathologically affect the healing process of bone fractures. We also found that DEXT, MEL, and DIC impaired the renal histopathology compared with the control group. However, the liver histopathological analysis showed that DEXT and MEL caused a higher degree of parenchymal necrosis compared with DIC. CONCLUSION Based on our results, DIC can be considered a relatively safe medication in patients with fractures.
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Affiliation(s)
- Sermet Inal
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Dumlupinar University, Kutahya, Turkey.
| | - Sahin Kabay
- Department of Urology, Faculty of Medicine, Dumlupinar University, Kutahya, Turkey.
| | - M Kasim Cayci
- Department of Biology, Faculty of Arts and Science, Dumlupinar University, Kutahya, Turkey.
| | - H Isa Kuru
- Department of Medical Laboratory Techniques, Simav Vocational High School, Dumlupinar University, Turkey.
| | - Sayit Altikat
- Department of Biochemistry, Faculty of Medicine, Dumlupinar University, Kutahya, Turkey.
| | - Gizem Akkas
- Department of Pathology, Faculty of Medicine, Dumlupinar University, Kutahya, Turkey.
| | - Aysenur Deger
- Department of Pathology, Faculty of Medicine, Dumlupinar University, Kutahya, Turkey.
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Li KH, Cheng L, Zhu Y, Deng GB, Long HT. Effects of a selective cyclooxygenase-2 inhibitor (celecoxib) on fracture healing in rats. Indian J Orthop 2013; 47:395-401. [PMID: 23960285 PMCID: PMC3745695 DOI: 10.4103/0019-5413.114930] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Kang-Hua Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Liang Cheng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Yong Zhu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China,Address for correspondence: Dr. Yong Zhu, Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China. E-mail:
| | - Guo-Bing Deng
- Department of Orthopaedics, Chenzhou People's Hospital, Chenzhou, 423000, Hunan, China
| | - Hai-Tao Long
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
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Pountos I, Georgouli T, Calori GM, Giannoudis PV. Do nonsteroidal anti-inflammatory drugs affect bone healing? A critical analysis. ScientificWorldJournal 2012; 2012:606404. [PMID: 22272177 PMCID: PMC3259713 DOI: 10.1100/2012/606404] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 10/18/2011] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Ippokratis Pountos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS1 3EX, UK
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