Association of Intraoperative Ketorolac Administration with Pediatric Anterior Cruciate Ligament Reconstruction Outcomes: A Retrospective Cohort Study.

BACKGROUND

Pediatric anterior cruciate ligament reconstruction (ACLR) is increasingly common. Optimizing pain management while minimizing opioid exposure is a priority. Intraoperative ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is used for analgesia, but its impact on healing and surgical outcomes remains controversial. This study evaluates the effects of intraoperative ketorolac on postoperative outcomes in pediatric ACLR patients (< 18 years).

METHODS

We conducted a retrospective cohort study using the TriNetX national clinical database (102 healthcare organizations). We identified pediatric patients who underwent arthroscopic ACLR (Current Procedural Terminology [CPT] 29888) between 2005 and 2025. Two groups were defined: those who received intraoperative ketorolac (15 or 30 mg intravenous [IV]) and those who did not. Propensity score matching (1 : 1) was performed on baseline covariates (age, sex, race/ethnicity, and comorbidities) to balance the cohorts. Outcomes were assessed at 90 days (opioid utilization and complications) and at 2 years (ACL revision surgery, knee stiffness, and mechanical complications).

RESULTS

A total of 3,409 patients met inclusion criteria; 1,443 pairs were successfully matched. At 90 days, the ketorolac group had a slightly lower mean number of opioid prescriptions (1.20 ± 0.44 vs. 1.43 ± 1.26, p = 0.039). Rates of muscle atrophy, wound disruption, and infection were similar (~0.8% in both groups, p = 1.0). The incidence of an opioid dependence diagnosis was low but significantly higher in the ketorolac group (1.0% vs. 0.3%; risk ratio [RR], 4.0; p < 0.001). At 2-year follow-up, most complication rates were similar between groups (e.g., mechanical complications 0.7% each; knee stiffness 12.5% vs. 10.9%, p = 0.18). However, the ketorolac cohort had a significantly higher rate of repeat ACLR (6.0% vs. 2.6%; RR, 2.29; 95% CI, 1.58-3.33; p < 0.001).

CONCLUSIONS

Intraoperative ketorolac administration was associated with reduced postoperative opioid requirements and no increase in short-term complications. However, a higher incidence of ACL revision surgery was observed at 2 years, representing an association that does not establish causation.