CORR Insights®: How Does Perioperative Ketorolac Affect Opioid Consumption and Pain Management After Ankle Fracture Surgery?

Abstract

Ankle fractures are one of the most-common fractures of the lower extremity, with a reported incidence of about 190 per 100,000 persons per year. Up to 25% of all patients with ankle fractures undergo surgery (most commonly, open reduction and internal fixation), which may help to avoid post-operative long-term sequelae including post-traumatic ankle osteoarthritis [8]. Post-operative pain is inevitable, and physicians who manage it must be mindful of the opioid epidemic in the United States. Although less than 5% of the world’s population, Americans consume more than 80% of the world’s prescribed opioids [13]. Beyond the serious nature of opioid abuse and dependence, physicians must also consider that postoperative opioid administration may inhibit bone healing. One animal model showed that post-operative use of opioid pain medication resulted in weaker and slower callus formation compared with controls [6]. One study demonstrated that patients with surgical fracture treatment who take more opioids reported greater pain intensity and less satisfaction with pain relief [4]. Another clinical study of 9995 humeral shaft fractures found that post-operative use of opioids was associated with fracture nonunion [3]. In the last two decades, post-operative opioid monotherapy gained prominence both because of aggressive marketing by pharmaceutical companies, and concerns about side effects of non-steroidal anti-inflammatory drugs (NSAIDs), including evidence associating them with delayed union or nonunion [13]. Multimodal analgesia typically includes several classes of analgesics and antiinflammatory drugs (such as NSAIDs, selective cyclooxygenase-2 inhibitors, acetaminophen, paracetamol, neuromodulatorymedications, opioid agonists, glucocorticoids, N-Methyl D-Aspartate antagonists) as well as local anesthetic techniques (wound infiltration and intraarticular injections), and sometimes peripheral nerve blocks [9]. One study found that multimodal analgesia substantially reduced the length of hospitalization in patients who underwent fusion surgery of the ankle and hindfoot [12]. However, this study has several limitations including retrospective character of the study, small number of patients included into this study, and the heavy selections bias as the selection for receiving the pain protocol was solely left to the surgeon’s discretion [12]. Therefore, the results of this study should be interpreted with great caution [10]. In the current study, McDonald and colleagues [11] found that perioperative ketorolac administration may help to reduce the post-operative opioid consumption. This study is important because it demonstrates a simple protocol how to reduce opioid consumption and to improve pain management in patients who had ankle fracture surgery. Surgical treatment of the ankle is one of the most common surgical procedures in foot and ankle as well as in general traumatology. It is our “daily This CORR Insights is a commentary on the article “How Does Perioperative Ketorolac Affect Opioid Consumption and Pain Management After Ankle Fracture Surgery?” by McDonald and colleagues available at: DOI: 10.1097/CORR.0000000000000978. The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. A. Barg MD (✉), Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA, Email: alexej.barg@hsc.utah.edu