Evaluating the Effects of Perioperative Ketorolac Use on Outcomes After Surgical Treatment of Open Reduction and Internal Fixation of Ankle Fractures

BACKGROUND: Ketorolac is commonly used as part of multimodal analgesia after orthopaedic surgery; however, concerns persist regarding its potential effects on postoperative wound healing and fracture union. While previous studies have evaluated ketorolac use in arthroplasty and long bone fractures, data specific to ankle open reduction and internal fixation (ORIF) remain limited. This study evaluated the association between perioperative ketorolac use and short-term postoperative complications and longer term healing outcomes after ankle ORIF. METHODS: This retrospective cohort study obtained data from a healthcare database platform from January 1, 2015, to January 1, 2025. Adult patients (≥18 years) who underwent ankle ORIF were identified using standardized Current Procedural Terminology (CPT) codes. Patients were stratified based on perioperative ketorolac exposure on the day of surgery and compared with a control cohort without ketorolac exposure within a defined perioperative washout window. Cohorts were balanced using 1:1 propensity score matching. Outcomes were assessed at 90 days and 2 years postoperatively. RESULTS: After propensity score matching, 29,920 patients remained in each cohort. At 90 days, perioperative ketorolac use was associated with higher rates of deep and superficial surgical site infection, wound dehiscence, and implant-related infection. Ketorolac use was also associated with lower transfusion rates, although transfusion was rare in both cohorts, and a modestly lower rate of opioid prescribing, although this reflects prescription documentation rather than analgesic efficacy. No significant differences were observed in pulmonary embolism, acute renal failure, or inpatient readmissions. At 2 years, there were no significant differences between cohorts in rates of nonunion, malunion, revision surgery, or below-knee amputation. CONCLUSIONS: In this retrospective database analysis, perioperative ketorolac use after ankle ORIF was associated with increased early wound-related and infection-related complications but not with adverse long-term fracture healing or limb outcomes. These findings suggest a nuanced risk-benefit profile for ketorolac in ankle fracture fixation and underscore the importance of individualized perioperative analgesic decision making, particularly for patients at higher risk of soft-tissue complications. LEVEL OF EVIDENCE: Level 3, systematic review and meta-analysis.