NSAIDs need not usually be withheld after orthopaedic surgery

Editor—We cannot let Varghese et al’s letter go unchallenged. After extrapolation of rodent data they say that non-steroidal anti-inflammatory drugs should not be used after orthopaedic surgery.¹ Prompted by similar views from some of our surgical colleagues, we recently undertook a comprehensive electronic literature search of the effects of non-steroidal anti-inflammatory drugs in orthopaedics, trauma, and bone metabolism. We also asked consultant members of our trauma team for any human data to substantiate their concerns. We presented and discussed the findings at one of our main departmental meetings.

Although many studies in diverse rodent models have indeed suggested that non-steroidal anti-inflammatory drugs inhibit bone healing, many animal studies have shown no effect. In humans the published evidence seems to be limited to one non-peer reviewed abstract that reported delayed union associated with a variety of non-steroidal anti-inflammatory drugs² and one study that showed no adverse effect on new bone formation associated with the use of diclofenac.³

Unrelieved pain is dangerous and should be treated as effectively as possible in all patients for pathophysiological as well as humanitarian reasons. Drug treatment in any patient entails multiple risk-benefit analyses and all forms of pain relief have potentially deleterious effects. An evidence based overview has highlighted the need for improved management of acute pain and given guidelines on how it may best be achieved.⁴ More recently the particular role of non-steroidal anti-inflammatory drugs has been clarified and promoted.⁵ We recommend these documents to all staff who care for postoperative patients.

In the absence of well designed human trials showing clinically important effects on bone healing, non-steroidal anti-inflammatory drugs should not be withheld unless there are specific, proved contraindications. A more cautious approach would curtail their use only in those fractures with the highest risk of non-union, for reasons of anatomy, blood supply, or the nature of the injury.