Therefore, some authors suggest surgical fixation with percutaneous intramedullary screw placement for zones II and III fractures. In-part due to the vascular watershed characteristics of zone II fractures, the nonunion rate in zones II fractures managed nonoperatively ranges from 20-30%, with a mean time to radiographic union of 15.9 weeks. To help determine optimal treatment, proximal fractures are classified as zone I (tuberosity), zone II (metaphyseal-diaphyseal junction, within 1.5 cm of the tuberosity), and zone III (proximal diaphysis distal to the 4-5th MT articulation). The location and patient characteristics greatly change the treatment recommendation: shaft and distal fractures are often treated nonoperatively while there is significant variability in the treatment of proximal fractures. The majority of these fractures involve the proximal 1/3 of the 5 th MT (70-71%) and 17% involve the shaft. įifth metatarsal (MT) fractures in general are the most common MT fractures experienced by adults and adolescents, affecting both the young athletic population and middle-aged patients, with an average age at injury of 51. Animal models have largely demonstrated that fracture union is impaired by NSAIDs when assessing callus formation, stiffness, and thickness, leading to an increased rate of delayed union and nonunion. Additionally, in-vitro studies have demonstrated the ability of common NSAIDs including Indomethacin to reduce osteoclast activity and mineral deposition in animal cell lines. Specifically, COX-2 is necessary for differentiation of mesenchymal cells to osteoblasts and thus these medications can reversibly suppress osteoblast formation. NSAIDs are known to reduce inflammation by inhibiting cyclooxygenase (COX)-1 and -2, resulting in downregulation of prostaglandins, leading to the theory that these common medications can alter the inflammatory phase of fracture healing. Recent reviews have highlighted this variability and have concluded that no consensus on the effect of NSAIDs on fracture healing can be made. Controversy exists regarding the acute effect of NSAIDs on early fracture healing. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used to treat pain, with over 25% of the population endorsing that they utilize NSAIDs. This is a multifactorial phenomenon requiring investigation to limit modifiable causes including administration of medications which may increase the rate of nonunion. The occurrence of nonunion and delayed union of fractures has significant implications in the care of orthopedic trauma patients. The rate of nonunion/delayed union of 5 th MT fractures was significantly higher in subjects receiving NSAIDs within 60 days of initial diagnosis in patients managed non-operatively. In the 365 subjects who underwent early repair/ORIF (within 60 days), there was no significant difference in the rate of nonunion/delayed union. 16/1,409 (1.14%) subjects who received anti-inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis while 46/9,217 (0.50% P=0.003483) subjects who did not receive anti-inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis. Of the 10,991 subjects with a diagnosis of 5 th MT, 10,626 (96.7%) underwent initial nonoperative treatment, 1,409 of which (13.3%) received prescription NSAIDS within 60 days of diagnosis. Subsequent ORIF or nonunion/malunion repair operative intervention was used as a surrogate for fracture nonunion/delayed union. open reduction and internal fixation (ORIF) or non/malunion repair within 60 days) and sub-grouped by whether they had been prescribed at least one pre-defined NSAID. Patients were grouped by initial management (nonoperative vs. ICD codes were used to identify patients diagnosed with 5 th MT fracture from 2007-2018. Using PearlDiver, a national insurance database was analyzed. We hypothesize that the use of NSAIDs would increase the rate of nonunion/delayed union in 5 th MT fractures. The purpose of this study was to analyze the rate of nonunion or delayed union in patients with fifth metatarsal (5 th MT) fractures. Controversy exists regarding the acute effect of non-steroidal anti-inflammatory drugs (NSAIDs) on early fracture healing.
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