Perioperative Ketorolac for Supracondylar Humerus Fracture in Children Decreases Postoperative Pain, Opioid Usage, Hospitalization Cost, and Length-of-Stay

Abstract

Supplemental Digital Content is available in the text. Background: There is a need for improved opioid stewardship in orthopedic surgery through multimodal analgesia strategies. Perioperative administration of ketorolac in children undergoing closed reduction and percutaneous pinning (CRPP) for displaced supracondylar humerus (SCH) fracture may decrease pain, reduce opioid requirements, and decrease hospitalization costs. Methods: Retrospective case-control investigation of children (aged, 1 to 14) treated with CRPP for closed, modified Gartland type III extension-type SCH fractures at a single children’s hospital between 2011 and 2017. Patients that received ketorolac perioperatively (cases) were randomly matched 1:2 by sex and age (±1\u2009y) with patients that did not receive ketorolac (controls). Data abstraction included demographic and perioperative details including inpatient Wong-Baker FACES pain ratings and analgesic requirements. Analysis included 2-tailed Mann-Whitney U and χ2 tests. Results: In total, 342 patients were studied including 114 cases and 228 controls. Age (mean, 6.2±2.4\u2009y), sex ratio (M:F, 1.28:1), operative time, and number of pins used were equivalent between groups. Mean pain rating at 0 to 29 minutes postoperatively was lower in the ketorolac group (0.7±1.9) than in controls (1.4±2.6, P=0.017), as well as at 30 to 120 minutes postoperatively (1.1±2.3 and 1.7±2.8, respectively, P=0.036), as seen in Figure 1. Patients in the ketorolac group received a lower number of inpatient oxycodone doses (1.0±0.6) than control patients (1.2±0.5, P=0.003). Mean postoperative length-of-stay (LOS) was 50.0% longer for control patients (20.4±11.3\u2009h) than the ketorolac patients (13.6±8.8\u2009h, P<0.001). Ketorolac administration was associated with 40.4% lower inpatient hospitalization cost compared to control patients, providing a 33.8 times return on investment. There was no difference in the 90-day complication rate between patient groups (P=0.905). Conclusions: The complementary administration of ketorolac reduces postoperative pain and opioid use in children with displaced supracondylar humerus fractures. Perioperative ketorolac is also associated with reduced LOS following CRPP for supracondylar humerus fractures and offers significant cost savings opportunities. Level of Evidence: Level 3—Therapeutic: Case-Control Study.