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It is associated with an increased rate of femoral shaft nonunion
43%
881/2068
It has no effect on the healing time of the posterior wall fracture
32%
668/2068
It is associated with a faster time to union
1%
18/2068
Indomethacin is superior to radiation treatment in the prevention of heterotopic ossification
5%
106/2068
There is a decreased rate of revision surgery needed when indomethacin is administered post-operatively
19%
383/2068
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Heterotopic ossification (HO) prophylaxis with indomethacin has been shown to increase the risk of long-bone nonunion. Indomethacin therapy has been shown to be an effective means of preventing HO formation, however literature has shown that it increases the risk of long bone and acetabular nonunion. Indomethacin works primarily by inhibiting IGF-1, which is a different mechanism from other NSAID's which typically inhibit the COX enzymes. IGF-1 is important for bone healing, and its inhibition may be a risk factor for delayed bone healing. Burd et al performed a study to determine if patients with an acetabular fracture, who received indomethacin for prophylaxis against HO, were at risk of delayed healing or nonunion of any associated fractures of long bones. The study group consisted of 112 patients who had sustained at least one concomitant fracture of a long bone; of which 36 needed no prophylaxis, 38 received focal radiation and 38 received indomethacin. When comparing patients who received indomethacin with those who did not, a significant difference was noted in the rate of long bone nonunion (26% vs 7%). Jordan et al performed a study to document the efficacy of variable treatment durations with indomethacin prophylaxis for HO and its effect on union of the posterior wall (PW) in operatively treated acetabular fractures. Patients were randomly assigned to one of four treatment groups: (1) placebo for 6 weeks, (2) 3 days of indomethacin followed by placebo for a total of 6 weeks, (3) 1 week of indomethacin followed by 5 weeks of placebo, and (4) 6 weeks of indomethacin and followed for 1 year. The authors concluded that the use of prophylactic postoperative indomethacin increases the incidence of symptomatic nonunion of the PW as assessed by CT scan and pain VAS. Incorrect Answers: 2-Based on the Jordan et al reference, indomethacin increases the risk of posterior wall nonunion 3-There is no evidence that treatment with indomethacin decreases time to union 4-There is no definitive evidence that indomethacin is superior to radiation in the prevention of HO. Recent data actually is in favor of radiation treatment both to prevent nonunion, and its superiority in preventing HO formation. 5-Indomethacin increases the risk of nonunion, which would therefore increase the need for re-operation.
4.2
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