NSAID Use Increases Odds of Nonunion After Subtalar Arthrodesis: A Large Database Study

Research Type Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as part of a multimodal pain regimen in the postoperative setting. While they have demonstrated efficacy in controlling pain and inflammation, there is concern that NSAIDs may lead to increased rates of nonunion in joint arthrodesis procedures by inhibiting the native inflammatory and remodeling cascade of bone. The purpose of this study was to determine whether postoperative NSAID use influences rates of nonunion after subtalar arthrodesis (SA). Additionally, we analyze the incidence of relevant medical and surgical complications in patients taking NSAIDs after SA. Methods Patients undergoing primary SA from 2010 to 2022 were identified in the PearlDiver database (n = 49,159). Patients who were prescribed a minimum two-week course of NSAIDs (meloxicam, naproxen, toradol, celecoxib) within 90 days of index SA procedure (n = 4,852) were propensity score matched 1:1 for age, sex, Elixhauser comorbidity index (ECI) and its components to controls without NSAID use (n = 4,852). The incidence of nonunion within 1 year following SA was compared between the exposed and control cohorts. Logistic regression was used to evaluate the rate of relevant 90-day medical complications in each group. Results 9,874 patients undergoing primary SA were successfully propensity score matched (Table 1). Patients in the NSAID group were significantly more likely to experience nonunion (505/4852, 10.4%) within 1-year postoperatively when compared to their counterparts in the non-NSAID group (387/4852, 7.8%) (OR 1.38; 95% CI 1.20-1.58). Furthermore, patients prescribed NSAIDs were more likely to develop a wound dehiscence (OR 1.27, 95% CI 1.03-1.56) within 90-days following their procedure (Table 2). Patients were at equal risk of venous thromboembolism, gastrointestinal hemorrhage, myocardial infarction, cerebrovascular accident, hematoma formation, blood loss anemia, mortality, emergency department visits, and readmission rate regardless of NSAID use (all p>0.05, Table 3). Conclusion In this large database study, NSAID use after subtalar arthrodesis was an independent risk factor for nonunion at 1-year. Additionally, patients taking NSAIDs had higher rate of wound dehiscence within 90 days postoperatively. Surgeons should consider alternative modalities for pain control in the postoperative setting to optimize subtalar fusion rates.