1. EFFECTS OF NONSTEROIDAL ANTI- INFLAMMATORY DRUGS ON BONE FORMATION AND SOFT- TISSUE HEALING Literature review By : Bashar Reda Orthopedic demonstrator

2. objectives 1- introduction 2- NSAIDs and their mechanism of action 3- heterotopic ossification 4- bone ingrowth 5-bone healing 6- soft tissue healing 7- COX-2 inhibitors

3. NSAIDs

4. Introduction  NSAIDs continue to be prescribed as analgesics for patients with healing fractures even though these drugs diminish bone formation,healing, and remodeling.  Inhibition of bone formation can be clinically useful in preventing (H.O.)in selected clinical situations.  Naproxen may be more efficacious than the traditional indomethacin, and short-term administration is as effective as long-term.

5. introduction  NSAIDs may have positive effect on soft tissue healing  COX-2 inhibitors have negative effect on both bone and soft tissue healing

6. NSAIDs  (NSAIDs) are among the most commonly prescribed medications.  These drugs function by blocking cyclooxygenase (COX), an enzyme involved in making prostaglandins from arachidonic acid.  COX-1 is considered to be important in the production of prostaglandins during normal physiologic processes in various tissues.  COX-2 is thought to be an“inducible” form of COX, responsible for the inflammatory response in various tissues.

8. NSAIDs  Therefore the COX-2 enzyme has been the target of the coxibs, which may reduce inflammation without producing as many gastrointestinal side effects as COX-1.  Several prostaglandins are important for bone formation specially PG-E2.

9. NSAIDs  Side effects : - Nausea - diarrhea -constipation - Renal failure -liver failure - GI bleeding - Fluid retention - rash - headache - Prolonged bleeding time after surgery

11. Heterotopic ossification  Heterotopic ossification (HO) is a process by which the soft tissues becomes pathologically ossified.  HO typically occurs when primitive mesenchymal cells in the surrounding soft tissues are transformed into osteoblastic tissue. This tissue then forms mature lamellar bone.

12. Heterotopic ossification  Risk factors : 1- for general HO - Certain type surgery - head or spinal trauma - burn patients - blunt muscle trauma (specially quadriceps). - pagets disease

13. Heterotopic ossification - diffuse idiopathic skeletal hyperostosis (DISH) 2- HO in hip surgery - Male > female - Pt with hypertrophic OA - Pt with post-traumatic arthritis - Pt with previous history of HO in other hip - Lateral approach to the hip

14. Heterotopic ossification  Clinically : -pain - stiffness - erythema -swelling - Fever - tenderness - this presentation may suggest wound or prosthetic joint infection.

15. Heterotopic ossification  investigation : - HO is typically evaluated radiographically but at least 2 weeks after surgery - Other options include bone scan, CT scan, MRI. - Typically associated with high ESR and ALP.

16. Heterotopic ossification  Classification : HO is typically evaluated radiographically. The most widely accepted classification system is Brooker classification - Grade I represents islands of bone within soft tissues about the hip. - Grade II includes bone spurs adjacent to the pelvis or proximal end of the femur leaving at least 1 cm between opposing bone surfaces.

17. Heterotopic ossification - Grade III represents bone spurs adjacent to the pelvis or proximal end of the femur leaving less than 1 cm between opposing bone surfaces. - Grade IV represents radiographic ankylosis of the hip.

20. Heterotopic ossification  Prevention either with – radiation - NSAIDs  Studies have shown that NSAID are effective in preventing HO  indomethacin traditionally has been used for this purpose, but recent literature shown better effect of other agents  In a randomized prospective double-blind study(vilpaeu et al) 63 patients completed treatment in one of three groups: naproxen 750 mg/day, indomethacin 75 mg/day, or placebo.

21. Heterotopic ossification  Treatment was started on postoperative day 1 and continued for 6 weeks  At 6 months, naproxen was significantly more effective than placebo (P < 0.001) and indomethacin (P = 0.02) in preventing HO (as defined by the Brooker classification).  Persson et al also showed that 1 week of treatment with NSAIDs is as effective as 3 weeks’ in preventing HO.

22. Heterotopic ossification  In this double blind prospective study the author randomized 144 pt into three groups : - One received ibuprofen 400 mg TID for 7 days followed by placebo for 14 days. - Other group received ibuprofen 400 mg TID for 21 days. - The last group received placebo for 21 days.  patients were followed for at least 1 year, with HO outcomes determined radiographically by the Brooker classification.

23. Heterotopic ossification  Significant (P = 0.005) reduction in HO was seen in the patients who had received 1 week of ibuprofen compared with those who had received only placebo.No difference was seen in the rate of HO between the 1-week and 3-week ibuprofen groups (P = 0.8).

24. Heterotopic ossification  A retrospective study by van der Heide et al in which the author compared three groups - One group received indomethacin for 3 days - Other group had no prophylaxis. - Last group received indomethacin for 7 days  The study concluded that indomethacin for 3 days showed similar outcome with no prophylaxis group and that short course of NSAID is ineffective.

25. Heterotopic ossification  Long-term administration may add to the complication rate without extending the benefit, specially the adverse effect this regimen may have on bone ingrowth if an ingrowth prosthesis is to be used

26. Bone ingrowth

27.  The effects of NSAIDs on biologic fixation in porous ingrowth implants have been evaluated in several studies. Indomethacin, aspirin,and ibuprofen all diminished the amount of bone ingrowth in a dose related fashion in porous implants in both human and animals

28. Bone ingrowth  although NSAIDs diminish early bone ingrowth, it may well be that, even in their presence, bone ingrowth eventually occurs and therefore that the use of NSAIDs to control HO is a reasonable choice. However, the data on this issue are limited.

29. Bone healing

30.  The majority of studies have demonstrated slower healing, more nonunions, and weaker union in animals treated with NSAIDs.  This effect seems to be dose-dependent.  Even aspirin at a sufficiently high dosage has been found to impede healing

31. Bone healing  A retrospective study by Giannoudis et al compared 32 patients who developed nonunion of the femoral diaphysis with 67 comparable control patients whose fractures had united

32. Bone healing  Author found no significant effect of factors such as smoking, type of implant, reaming, fraction distraction which were attributed before on the nonunion.  However, they did find a statistically significant (P = 0.000001) association between nonunion and the use of NSAIDs after injury. Sixty-three percent of the patients who developed nonunions admitted to taking NSAIDs versus 13% in the control group.

33. Soft tissue healing

34.  The effects of NSAIDs on soft-tissue healing are not so clear-cut as those on bone healing. Tissue culture studies show increased collagen synthesis in skin, tendons, muscles and physeal cartilage.

35. Soft tissue healing  Eight prospective randomized placebo-controlled double-blind studies have concluded That NSAIDs are beneficial after various sprains and strains, but three studies found no effect.

36. Soft tissue healing  McLatchie et al reported that patients treated with ibuprofen (2,400 mg/day) after grade 1 or 2 ankle inversion injuries had less tenderness 7 days after injury and were able to achieve a higher level of training than those who received placebo.

37. COX-2 inhibitors  COX-2 presumably would be induced after injury and therefore would be important in the body’s response to injury.  It was found that these drugs has negative effect on both bone and soft tissue healing.  In one study rofecoxib has been shown to significantly (P < 0.05) inhibit fracture healing in rats  With regard to soft tissue, a study of injured ligaments in the rat has shown a 32% lower load to failure in a group treated with celecoxib.

38. conclusion  Generally, NSAIDs, including COX-2 inhibitors, diminish bone formation and therefore should be used as needed to decrease bone formation when desired but avoided when bone formation is the preferred outcome.  NSAIDs appear to be beneficial for soft-tissue healing.

39. conclusion  A COX-2 inhibitor has shown a negative effect on both bone and soft tissue healing.  Use but don’t abuse.

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