Randomized, controlled trial of multimodal shoulder injection or intravenous patient-controlled analgesia after arthroscopic rotator cuff repair

Rebound Pain After Arthroscopic Cuff Repair With Interscalene Brachial Plexus Block Anesthesia Is Reduced by Surgeon-Administered Multimodal Shoulder Injections: A Prospective Randomized Controlled Trial

PURPOSE

To compare the effects of additional multimodal shoulder injections on postoperative rebound pain in patients undergoing arthroscopic rotator cuff repair (ASRCR) under interscalene brachial plexus block (ISBPB) anesthesia.

METHODS

A single-blind randomized controlled trial was conducted with 67 patients between April and December 2023. Patients undergoing ASRCR who received ISBPB anesthesia, rather than general anesthesia, with a minimum follow-up period of 48 hours were included. The injection group received 40 mL of 0.75% ropivacaine, 20 mg morphine, 1:200,000 epinephrine, and saline solution, totaling 100 mL. After surgery, the injection was administered to the subacromial space (50 mL) with blind suprascapular nerve block (25 mL) and blind axillary nerve block (25 mL). Control subjects received 100 mL of saline solution. Intravenous patient-controlled analgesia (IV-PCA) was used as adjuvant analgesia for all patients. The primary outcome was evaluated using the visual analog scale (VAS) pain score at 12 hours after surgery, with secondary outcomes of the incidence of rebound pain and VAS pain scores at 0, 2, 4, 8, 24, 36, and 48 hours postoperatively. Fentanyl in the IV-PCA and rescue analgesic amounts, complications, and patient satisfaction were recorded.

RESULTS

Sixty-seven patients (32 in the injection group, 35 in the control group) with a mean age of 61.1 ± 9.0 years were included. The primary outcome assessment, VAS pain score at 12 hours, significantly favored the injection group (2.7 ± 0.93 vs 4.1 ± 1.70, P < .001). The incidence of rebound pain was 18.8% and 65.7% in the injection and control groups, respectively (18.8% vs 65.7%, P < .001). The injection group reported better VAS pain scores at 24, 36, and 48 hours and lower fentanyl use over the 48-hour postoperative period (P = .014). The use of rescue analgesics was similar between groups, and no complications were associated with multimodal shoulder injections. Satisfaction levels were similar in both groups.

CONCLUSIONS

The present study found that patients who underwent multimodal shoulder injections during ASRCR under ISBPB anesthesia had significantly lower VAS pain scores at 12 hours postoperatively and reduced incidence of rebound pain compared with the control group. Pain levels were consistently lower from 12 to 48 hours postoperatively. Additionally, the injection group had reduced opioid consumption within the first 48 hours postoperatively, with no complications observed.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Comparison of Analgesia Treatment Methods After Arthroscopic Rotator Cuff Repair: A Network Meta-analysis of 42 Randomized Controlled Trials

Background

The optimal method for postoperative analgesia after arthroscopic rotator cuff repair (ARCR) is still unclear.

Purpose

To compare the efficacy of postoperative analgesic methods after ARCR through network meta-analysis of randomized controlled trials and prospective controlled trials.

Study Design

Systematic review; Level of evidence, 2.

Methods

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched PubMed, Embase, and Web of Science from inception until April 12, 2022, for randomized controlled trials and prospective controlled trials evaluating neuraxial analgesia, peripheral nerve block, periarticular local anesthetic infiltration, intravenous patient-controlled analgesia, oral analgesia, or any combination of these methods for pain management after ARCR. Outcomes included pain scores at rest, morphine consumption, and complications (nausea and vomiting). Study quality was assessed using the Cochrane risk-of-bias tool. Network meta-analysis was used to assess the relative efficacy of the methods for postoperative analgesia. The best choice for postoperative analgesia was defined as the one with significant differences in pain scores and morphine consumption compared with placebo, with no significant difference in complications, during the initial 48 hours postoperatively.

Results

Included were 42 studies with 3110 patients. Only suprascapular nerve block (SSNB) was significantly superior to placebo in pain scores (mean difference [MD], -0.93 [95% CI, -1.31 to -0.54] at 6 hours; MD, -2.34 [95% CI, -3.49 to -1.19] at 12 hours) and morphine consumption (MD, -17.70 [95% CI, -32.98 to -2.42] at 24 hours) (P < .05 for all), with no difference in complications (odds ratio, 0.96 [95% CI, 0.21 to 4.32]; P > .05). Pain scores were significantly lower with interscalene nerve block compared with SSNB (MD, -0.69 [95% CI, -1.17 to -0.20] at 6 hours; MD, -1.44 [95% CI, -2.21 to -0.67] at 12 hours) and with SSNB + axillary nerve block compared with SSNB (MD, -3.09 [95% CI, -4.18 to -1.99] at 6 hours; MD, -0.87 [95% CI, -1.71 to -0.03] at 12 hours) (P < .05 for all).

Conclusion

Based on the current evidence, most analgesic methods lowered pain and morphine consumption compared with placebo. There were significant differences in pain scores between interscalene nerve block and SSNB during the first 12 hours postoperatively, and adding axillary nerve block to SSNB enhanced the analgesic effect.

The AAOS 2019 Clinical Practice Guidelines for the Management of Rotator Cuff Injuries Are Unbiased and Incorporate a Diverse Body of Literature

Purpose

To analyze the scientific research that formed the basis of the 2019 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for the management of rotator cuff injuries.

Methods

All studies cited in the 2019 AAOS clinical practice guidelines for the management of rotator cuff injuries were extracted and categorized. Extracted data included type of study, number of patients, level of evidence, journal of publication, impact factor, year of publication, country of origin, contributing authors, affiliated institutions, and significant findings. Data were analyzed to determine time from publication to implementation, level of evidence, and frequency of cited journals and authors.

Results

The studies cited in the guideline included 15,130 patients from 140 studies published between 1994 and 2018. The overall mean time from article publication to 2019 AAOS clinical practice guidelines was 4.76 ± 2.23 years. Of articles published in 2010 to 2019, 64 studies were cited in the strong recommendation strength subcategory, and 57 articles were cited in the moderate recommendation strength subcategory. Articles published in Journal of Shoulder & Elbow Surgery and Arthroscopy were cited most frequently. The most frequent authors were J. H. Oh, R. Z. Tashjian, S. H. Kim, N. Maffulli, and J. C. Yoo.

Conclusions

The 2019 AAOS CPG reference a diverse number of journals and authors, appearing to be impartial. Furthermore, prompt time from publication to implementation in the Guidelines indicates that it is possible to influence clinical guidelines with recent work.

Clinical Relevance

An analysis of the scientific research that forms the basis of the AAOS Clinical Practice Guidelines for the Management of Rotator Cuff Injuries can provide valuable information about the quality of the Guidelines.

A Historical Analysis of Randomized Controlled Trials in the Management of Pain in Rotator Cuff Tears

The aim of this analysis was to assess the quality of reporting of randomized controlled trials (RCTs) relating to pain management in rotator cuff (RC) tears. This review evaluated the quality of the studies in the literature regarding this topic through the use of some factors and trends. The online databases used to search all RCTs on the topic of RC surgery were Medline, Scopus, CINAHL, EMBASE, and CENTRAL. This research was completed in September 2020. To assess the quality of reports, the Consolidated Standards of Reporting Trials (CONSORT) and the modified Coleman methodology score (MCMS) were used. From the research, 262 articles emerged. Finally, 79 studies were included in this historical analysis. There were no statistically significant changes in MCMS across trials that included or did not include a CONSORT diagram (p = 0.10). A statistically significant difference in MCMS was discovered between papers produced prior to 2009 and publications produced after 2015 (p = 0.03). There was no association between the number of checklist items for each article and the Coleman score. During the years there has been a significant increase in both quantity and quality of RCTs relating to pain in RC tears.

Opioid-Free Arthroscopic Rotator Cuff Repair

Rotator cuff repair is known to cause significant pain, and therefore opioids are often prescribed postoperatively. The United States is currently experiencing an opioid epidemic, and prescription opioids are considered a gateway drug to opioid abuse and addiction. Orthopedic surgeons are looking for alternative means to control pain. The purpose of this study was to evaluate the efficacy of an opioid-free postoperative pain protocol in patients following an arthroscopic rotator cuff repair. A prospective study of 36 consecutive patients was performed. Patient demographics, prior narcotic consumption, past medical history, and visual analog scale (VAS) pain score were collected. All patients received an opioid-free postoperative pain protocol, including education, premedication, interscalene nerve blockade, and intraoperative injection, and were discharged with ketorolac, zolpidem, and acetaminophen. A sealed envelope containing an oxycodone prescription was also received at discharge. Patients were instructed only to fill the oxycodone prescription if they had uncontrolled pain. The primary outcomes were filling of the oxycodone prescription and use. Secondary outcomes were VAS pain scores and patient satisfaction scores. Sixty-seven percent of patients successfully completed opioid-free arthroscopic rotator cuff repair. Patients who did not use oxycodone had lower pain scores overall when comparing each postoperative day. By the first postoperative visit, patients who did not take oxycodone also demonstrated higher satisfaction with their pain management. This study demonstrates that with appropriate multimodal pain management, the majority of willing patients can undergo rotator cuff repair without use of opioids. [Orthopedics. 2021;44(2):e301-e305.].

Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis

BACKGROUND

Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures used to treat a variety of conditions, with >500,000 procedures performed each year.

PURPOSE

To systematically review the randomized controlled trials (RCTs) on pain control after shoulder arthroscopy in the acute postoperative setting and to ascertain the best available evidence in managing pain after shoulder arthroscopy to optimize patient outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies were included if they were RCTs evaluating interventions to reduce postoperative pain after shoulder arthroscopy: nerve blocks, nerve block adjuncts, subacromial injections, patient-controlled analgesia, oral medications, or other modalities. Meta-analyses and network meta-analyses were performed where appropriate.

RESULTS

Our study included 83 RCTs. Across 40 studies, peripheral nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the variable nerve blocks in the network meta-analysis. However, continuous interscalene block did have the highest P-score at most time points. Nerve block adjuncts were consistently shown across 18 studies to prolong the nerve block time and reduce pain. Preoperative administration was shown to significantly reduce postoperative pain scores (P < .05). No benefit was found in any of the studies evaluating subacromial infusions.

CONCLUSION

Continuous interscalene block resulted in the lowest pain levels at most time points, although this was not significantly different when compared with the other nerve blocks. Additionally, nerve block adjuncts may prolong the postoperative block time and improve pain control. There is promising evidence for some oral medications and newer modalities to control pain and reduce opioid use. However, we found no evidence to support the use of subacromial infusions or patient-controlled analgesia.

How effective is periarticular multimodal drug injection in open elbow arthrolysis? A prospective double-blind randomized controlled trial

BACKGROUND

Evidence on the efficacy and safety of periarticular multimodal drug injection (PMDI) in open elbow arthrolysis (OEA) is limited. This study aimed to investigate differences in postoperative pain, blood loss, and range of motion (ROM) between PMDI vs. no injection among patients undergoing OEA, and the presence of PMDI-related complications.

METHODS

This prospective, double-blind randomized controlled trial included 59 patients who underwent OEA. Patients randomly received PMDI (ropivacaine, epinephrine, ketoprofen) before wound closure or no injection. The primary outcomes were elbow pain over the first postoperative week at rest and during motion, measured using the visual analog scale (VAS). VAS scores were compared to attain the 20-mm threshold values for a minimum clinically important difference. Parecoxib consumption on OEA night and postoperative days (PODs) 1-3 and total consumption during the first postoperative week were recorded. Blood loss was recorded every 24 hours until POD 3. ROM during rehabilitation was measured daily from day 1 to day 7 after surgery, as well as at 3-month follow-up. Medication-related side effects were recorded prospectively.

RESULTS

The mean VAS score showed clinically important differences between PMDI and control groups at rest on OEA night (mean difference [MD], 25 mm; P < .001) and first 3 PODs with motion (POD 1: MD, 28 mm, P < .001; POD 2: MD, 21 mm, P < .001; POD 3: MD, 21 mm, P < .001) but not in other postoperative assessments. Parecoxib consumption was lower in the PMDI group on OEA night and PODs 1-3. Total parecoxib consumption during the first postoperative week was lower in the PMDI group vs. the control group (MD, 148 mg; P < .001). Blood drainage was less in the PMDI group vs. the control group on POD 1 (MD, 38 mL; P = .016) but not on POD 2 (P = .950), POD 3 (P = .259), or total (P = .184). The PMDI group exhibited significantly better ROM during the first 4 PODs than the control group, whereas there was no difference at 3-month follow-up. No medication-related side effects were noted in the PMDI group.

CONCLUSION

PMDI effectively relieves pain and reduces analgesic consumption for OEA patients, without an apparent increase in risks.

How periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair

INTRODUCTION

Multimodal analgesic (MMA) injections combined with corticosteroids have recently been shown to be effective for managing pain after arthroscopic rotator cuff repair.

HYPOTHESIS

The goal of this study was to analyze the effects of corticosteroid injections on the integrity of tendon repairs using magnetic resonance imaging (MRI). The hypothesis was that MMA injections combined with corticosteroids have no deleterious effects on functional outcomes and tendon healing 1 year after surgical rotator cuff repair.

METHODS

This was a prospective, double-blind study of 50 patients undergoing arthroscopic rotator cuff repair who were randomized into two groups. The study group (n=25) received a periarticular injection of a mixture of ropivacaine, morphine and methylprednisolone at the end of the procedure. The control group (n=25) received a placebo injection. The clinical outcomes were the pain level and complications, while the functional outcomes consisted of the Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons Shoulder (ASES) score and Simple Shoulder Test (SST). The structural integrity of the operated tendons was analyzed on MRI at a mean follow-up of 15.1±1.3 months for the study group and 15.2±1.1 for the control group (p=0.848).

RESULTS

Pain on a visual analog scale was significantly reduced in both groups after the surgery. Nevertheless, there was no significant difference between groups at the final follow-up visit (p=0.803). Compared to the preoperative values, the CMS, ASES and SST significantly improved in both groups after surgery but were not significantly different between groups at the final assessment (p=0.801, 0.869 and 0.769, respectively). MRI revealed supraspinatus tendon retears in 16% of patients in the study group and 36% in the control group (p=0.107). There were no infections in the study group as of the final assessment. Advanced age (p=0.049), diabetes (p<0.01) and posterior extension of the tear (p=0.039) negatively impact healing. Corticosteroid injection did not negatively impact healing (p=0.197).

CONCLUSION

This study shows that MMA injection combined with corticosteroids does not alter the tendon healing, clinical outcomes, or functional outcomes 1 year after arthroscopic rotator cuff repair. It remains a safe and effective analgesia method during rotator cuff repair surgery.

LEVEL OF EVIDENCE

II, low-powered placebo-controlled, randomized study.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Nerve Block for Pain Relief During Arthroscopic Rotator Cuff Repair

BACKGROUND

Although arthroscopic rotator cuff repair (ARCR) often results in good outcomes, some patients have severe pain postoperatively. This study investigated the efficacy of nerve block for ARCR.

METHODS

This study was retrospective, and consent was obtained from all patients. We divided 50 patients who had undergone ARCR into 4 groups: continuous interscalene nerve block was performed for 11 patients (continuous-injection group), single interscalene nerve block for 10 (single-injection group), suprascapular nerve block for 8 (suprascapular group), and intravenous analgesic administration for 10 (intravenous group). Eleven patients received no nerve block (control group). We evaluated diclofenac sodium and pentazocine dosing, visual analog scale (VAS) scores, and perioperative complications in each group. VAS scoring was done immediately after surgery and 1 and 6 hours and 1, 2, 3, 7, and 14 days postoperatively.

RESULTS

The doses of diclofenac sodium and pentazocine did not differ between groups. VAS scores immediately after surgery and at 1 and 6 hours after surgery were significantly lower in the single-injection and continuous-injection groups than in the suprascapular, intravenous, and control groups. VAS score at 1 day postoperatively was significantly lower in the continuous-injection group than in the other groups. One patient in the continuous group reported temporary paralysis of the fingers and drug solution leakage.

CONCLUSION

Interscalene nerve blocks yielded good pain relief for ARCR. Although continuous interscalene nerve block produced continuous pain relief, complications are a concern.

Periarticular multimodal drug injection does not improves early postoperative analgesia compared with continuous interscalene brachial plexus block after arthroscopic rotator cuff repair: A retrospective single-center comparative study

BACKGROUND

Although continuous interscalene brachial plexus block (CISBPB) is common method in pain management following arthroscopic rotator cuff repair (ARCR), little is known about the analgesic effects of periarticular multimodal drug injection (PMDI) for ARCR. This retrospective study sought to clarify which technique could provide the best analgesic effect after ARCR.

METHODS

We retrospectively reviewed consecutive patients who underwent ARCR performed by the same surgeon at our institution between June 2016 and November 2017. Patients who underwent surgery before January 2017 received CISBPB and those who underwent surgery after February 2017 received PMDI for postoperative pain control. Both treatment groups also received fentanyl by intravenous patient-controlled analgesia (IV-PCA). Postoperative pain was evaluated by visual analog scale (VAS) pain scores at 3, 6, 12, 24, and 48 h and need for IV-PCA at 8, 16, and 24 h.

RESULTS

Twenty-eight patients received CISBPB and 21 received PMDI. According to the VAS scores, the postoperative analgesic effect was significantly better in the CISBPB group during the first 6 h (p < 0.05). Total fentanyl consumption by IV-PCA during the first 8 postoperative h was significantly greater in the PMDI group than in the CISBPB group.

CONCLUSIONS

PMDI does not improve early postoperative analgesia after ARCR compared with CISBPB. CISBPB had a significantly better analgesic effect in the first 8 h postoperatively.

LEVEL OF EVIDENCE

Level III.

A Systematic Comparison on Postoperative Analgesia Effect Between Subacromial and Intravenous Analgesia Pumps for Arthroscopic Rotator Cuff Repair

PURPOSE

Arthroscopic rotator cuff repair is often associated with severe postoperative pain. Various agents, routes, and modes are used for the treatment of postoperative pain with a minimum of side effects. This systematic work was conducted to compare the postoperative effect of subacromial patient-controlled analgesia with intravenous patient-controlled analgesia after an arthroscopic rotator cuff repair surgery.

DESIGN

A systematic review of relevant studies were retrieved from electronic databases and included based on criteria and eligibility.

METHODS

The articles were retrieved from 1997 to 2018 by computerized searches of Scopus, PubMed, and EMBASE using different combinations of search terms, such as shoulder, rotator cuff, analgesic, analgesia, arthroscopic, pain, cuff repair, rotator cuff repair, acromion, and intravenous.

FINDINGS

A total of 10 articles were included in this study from the initial search of 778 records. Compared with subacromial procedure, the intravenous procedure helps in reducing the postoperative pain but with more side effects.

CONCLUSIONS

This study described that the direct continuous infusion of anesthetic under subacromial analgesic pump showed a greater pain relief with less side effects compared with intravenous infusion for arthroscopic rotator cuff repair.

Peri-articular infiltration analgesia for shoulder surgery: a systematic review and meta-analysis

Effective analgesic alternatives to interscalene brachial plexus block are sought for shoulder surgery. Peri-articular infiltration analgesia is a novel, less invasive technique, but evidence surrounding its use is unclear. This systematic review and meta-analysis aims to evaluate the utility of peri-articular infiltration analgesia in shoulder surgery. We searched literature for trials comparing peri-articular infiltration analgesia with control or with interscalene brachial plexus block. Control groups received no intervention, placebo or systemic opioids. The primary outcome was cumulative oral morphine equivalent consumption during the first 24 h postoperatively. Secondary outcomes included: rest pain scores up to 48 h; risk of side-effects; and durations of post-anaesthetic care unit and hospital stay. Data were pooled with random-effects modelling. Seven trials (383 patients) were included. Compared with control, peri-articular infiltration analgesia reduced 24-h oral morphine consumption by a mean difference (95%CI) of -38.0 mg (-65.5 to -10.5; p = 0.007). It also improved pain scores up to 6 h, 36 h and 48 h, with the greatest improvement observed at 0 h (-2.4 (-2.7 to -1.6); p < 0.001). Peri-articular infiltration analgesia decreased postoperative nausea and vomiting by an odds ratio (95%CI) of 0.3 (0.1-0.7; p = 0.006). In contrast, peri-articular infiltration analgesia was not different from interscalene brachial plexus block for analgesic consumption, pain scores or side-effects. This review provides moderate evidence supporting peri-articular infiltration for postoperative analgesia following shoulder surgery. The absence of difference between peri-articular infiltration analgesia and interscalene brachial plexus block for analgesic outcomes suggests that these interventions are comparable, but further trials are needed to support this conclusion and identify the optimal peri-articular infiltration technique.

PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure-specific postoperative pain management recommendations

Rotator cuff repair can be associated with significant and difficult to treat postoperative pain. We aimed to evaluate the available literature and develop recommendations for optimal pain management after rotator cuff repair. A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in English from 1 January 2006 to 15 April 2019 assessing postoperative pain after rotator cuff repair using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. Out of 322 eligible studies identified, 59 randomised controlled trials and one systematic review met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase-2 inhibitors, intravenous dexamethasone, regional analgesia techniques including interscalene block or suprascapular nerve block (with or without axillary nerve block) and arthroscopic surgical technique. Limited evidence was found for pre-operative gabapentin, perineural adjuncts (opioids, glucocorticoids, or α-2-adrenoceptor agonists added to the local anaesthetic solution) or postoperative transcutaneous electrical nerve stimulation. Inconsistent evidence was found for subacromial/intra-articular injection, and for surgical technique-linked interventions, such as platelet-rich plasma. No evidence was found for stellate ganglion block, cervical epidural block, specific postoperative rehabilitation protocols or postoperative compressive cryotherapy. The analgesic regimen for rotator cuff repair should include an arthroscopic approach, paracetamol, non-steroidal anti-inflammatory drugs, dexamethasone and a regional analgesic technique (either interscalene block or suprascapular nerve block with or without axillary nerve block), with opioids as rescue analgesics. Further randomised controlled trials are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.

Outcomes After Limited or Extensive Bursectomy During Rotator Cuff Repair: Randomized Controlled Trial

PURPOSE

To evaluate the effects of extensive bursectomy (EB) and limited bursectomy (LB) during arthroscopic rotator cuff repair.

METHODS

In the EB group (n = 39), subacromial bursae were thoroughly removed from anterior to posterior and lateral to medial. In the LB group (n = 39), bursectomy was minimized to allow torn cuff visualization and tendon repair. Visual analog scale pain scores, passive forward flexion, external rotation at the side (ER), and internal rotation at the back were measured at 5 weeks and 3, 6, and 12 months after surgery. At each time point, bursal thickness was measured and repair integrity was assessed by sonography or magnetic resonance imaging.

RESULTS

The analysis included 36 patients in the LB group and 35 in the EB group. Group visual analog scale pain scores were not significantly different at any time (P > .05 for all). Forward flexion and internal rotation at the back showed no intergroup difference during follow-up. However, ER was significantly better in the LB group at 6 months and 1 year postoperatively (31° ± 15° vs 22° ± 16° [P = .020] and 40° ± 19° vs 27° ± 20° [P = .009], respectively). Integrity failures were not significantly different at 5 weeks and at 3, 6, and 12 months (P > .05 for all). Marked bursal thickening (>2 mm) was more frequently observed in the EB group (18 of 32 in the LB group and 27 of 32 in the EB group) at 6 months (P = .014).

CONCLUSIONS

EB during arthroscopic rotator cuff repair appears to have no benefit in terms of reducing pain. More adhesions in the subacromial space after EB may result in slower motion recovery, especially in terms of ER. The extent of bursectomy did not affect tendon integrity. However, marked bursal thickening was more frequently observed in the EB group.

LEVEL OF EVIDENCE

Level I, randomized controlled study.

Acute postoperative pain after arthroscopic rotator cuff surgery: A review of methods of pain assessment

INTRODUCTION

Pain can be severe during the first days after arthroscopic surgery, and acute pain is an important outcome in clinical trials of surgical technique or anaesthetic strategy. A standardized, validated method of assessing acute postoperative pain would improve the quality of clinical studies, and facilitate systematic reviews and meta-analyses. A step on the way towards this standard is to investigate the methods most commonly used in recent literature.

METHODS

PubMed and CINAHL databases were searched, including studies of arthroscopic rotator cuff surgery with a primary pain-related outcome during the first postoperative week, published in English from 2012 to 2017.

RESULTS

A total of 47 studies were included, all measuring pain intensity using a pain rating scale. Most frequently used was the visual analogue scale using the anchors "no pain" and "worst pain imaginable", with recordings at 1, 2, 4, 6, 8, 12, and 24 hours postoperatively. A total of 34 studies recorded analgesic consumption, usually as average cumulated consumption in mg. Time to first analgesic request or first pain were recorded in 11 studies, and 4 different starting points were used.

DISCUSSION

This review describes the currently most common methods of assessing acute postoperative pain in clinical trials of arthroscopic shoulder surgery involving rotator cuff repair, and the large variety of methods applied. Based on this study and international guidelines, several recommendations on how to measure and report postoperative pain outcomes in future trials are proposed.

Subacromial Local Anesthetics Do Not Interfere With Rotator Cuff Healing After Arthroscopic Repair

BACKGROUND

Subacromial pain pumps are used for analgesia after arthroscopic rotator cuff surgery. However, there is controversy about myotoxic or tendinotoxic effects of local anesthetics.

HYPOTHESIS

Ropivacaine administered via a subacromial pain pump would have no adverse effect on rotator cuff tendon healing, fatty degeneration, strength, or functional outcomes after arthroscopic repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study continues follow-up of patients enrolled in the authors' 3 published prospective studies regarding pain control after arthroscopic rotator cuff repair. In total, 118 patients who underwent rotator cuff repair and returned for evaluation at least 1 year postoperatively were divided into 3 groups: patients who received continuous subacromial ropivacaine infusion (group 1, n = 33), those who received patient-controlled subacromial ropivacaine infusion (group 2, n = 30), and those who received other pain control modalities (intravenous patient-controlled analgesia and/or interscalene block; group 3, n = 55). At least 1 year postoperatively, tendon healing and changes in global fatty degeneration index (GFDI) were estimated through computed tomographic arthrography, magnetic resonance imaging, or ultrasonography. Changes in isokinetic muscle performance test (IMPT) were calculated and functional outcomes evaluated, including visual analog scales (VASs) for pain and satisfaction, American Shoulder and Elbow Surgeons score, and Constant score.

RESULTS

At final follow-up, there were no differences in pain VAS (group 1, 1.1 ± 2.3; group 2, 1.3 ± 1.9; group 3, 0.9 ± 1.7; P = .88), satisfaction VAS (group 1, 8.3 ± 2.4; group 2, 8.7 ± 1.5; group 3, 8.0 ± 2.1; P = .64), American Shoulder and Elbow Surgeons score (group 1, 79.5 ± 10.5; group 2, 81.1 ± 6.9; group 3, 75.7 ± 7.6; P = .34), or Constant score (group 1, 81.8 ± 8.7; group 2, 77.6 ± 9.3; group 3, 78.2 ± 8.4; P = .31). Among the 3 groups, there were no significant differences in healing rates (group 1, 72.7%; group 2, 73.3%; group 3, 70.9%; P = .83) and no differences in changes of GFDI (group 1, 0.45; group 2, 0.62; group 3, 0.41; P = .79), and IMPT (abduction: group 1, 113.0%; group 2, 121.5%; group 3, 120.1%; P = .73; external rotation: group 1, 112.1%; group 2, 121.6%; group 3, 111.7%; P = .71; internal rotation: group 1, 118.2%; group 2, 118.0%; group 3, 118.1%; P = .95). When data were reanalyzed with 2 groups (group 1 + 2 vs group 3), there were no significant differences in functional scores, healing rates, or changes in GFDI and IMPT ( P > .05).

CONCLUSION

Current data suggest that myotoxicity of subacromial ropivacaine administered via pain pump may be reversible or may not be so severe as to interfere with tendon healing and cause muscle degeneration and thus may not affect postoperative function.

Recovery after shoulder arthroscopy: Inpatient versus outpatient management

INTRODUCTION

Shoulder arthroscopy is particularly suited to outpatient surgery, thanks to advances in anesthetic and analgesic techniques. The main goal of this study was to compare postoperative recovery after shoulder arthroscopy between outpatient and inpatient management.

HYPOTHESIS

There is no difference in functional recovery between inpatient and outpatient management.

MATERIALS AND METHOD

A single-center, single-operator prospective study was conducted. Both groups received patient-controlled analgesia via an interscalene catheter. The inclusion criterion was shoulder arthroscopy for rotator cuff tendinopathy. The choice between inpatient and outpatient management was left to the patient. The study endpoint was postoperative recovery assessed on QOR-15 at days 1, 2, 3, 4 and 7 and on Quick-DASH at 6 weeks.

RESULTS

Forty-nine patients were included, divided into 2 groups. The outpatient (OP) and inpatient (IP) groups were comparable. Reconstructive surgery accounted for 54% of cases in OP versus 62% in IP. There was no significant difference in recovery in the first postoperative days (QOR-15) or at 6 weeks (Quick-DASH) (p>0.05). Pain on visual analog scale (VAS) was significantly greater in OP after discharge home.

DISCUSSION

No significant difference in postoperative recovery was observed between groups. Nevertheless, pain management and patient information for outpatients need improving.

LEVEL OF EVIDENCE

II, comparative study.

Anesthesia and Analgesia in the Patient with an Unstable Shoulder

Introduction:

The patient with an unstable shoulder represents a challenge for the anesthesiologist. Most patients will be young individuals in good health but both shoulder dislocation reduction, a procedure that is usually performed under specific analgesia in an urgent setting, and instability surgery anesthesia and postoperative management present certain peculiarities.

Material and Methods:

For the purpose of the article, 78 references including clinical trials and reviews were included. The review was organized considering the patient that presents an acute shoulder dislocation and the patient with chronic shoulder instability that requires surgery. In both cases the aspects like general or regional anesthesia, surgical positions and postoperative pain management were analyzed.

Conclusion:

The patient with an acutely dislocated shoulder is usually managed in the emergency room. Although reduction without analgesia is often performed in non-medical settings, an appropriate level of analgesia will ease the reduction procedure avoiding further complications. Intravenous analgesia and sedation is considered the gold standard but requires appropriate monitorization and airway control. Intraarticular local analgesic injection is considered also a safe and effective procedure. General anesthesia or nerve blocks can also be considered. The surgical management of the patient with shoulder instability requires a proper anesthetic management. This should start with an exhaustive preoperative evaluation that should be focused in identifying potential respiratory problems that might be complicated by local nerve blocks. Intraoperative management can be challenging, especially for patients operated in beach chair position, for the relationship with problems related to cerebral hypoperfusion, a situation related to hypotension events directly linked to patient positioning. Different nerve blocks will help attaining excellent analgesia both during and after the surgical procedure. An interescalene nerve block should be considered the best technique, but in certain cases, other blocks can be considered.

Effects of a Single-Dose Interscalene Block on Pain and Stress Biomarkers in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

PURPOSE

To compare the effects of a single-dose interscalene block and general anesthesia (SISB/GA) with the effects of GA only in the early postoperative period after arthroscopic rotator cuff repair by evaluating subjective pain visual analog scale scores and objective pain-related stress biomarkers.

METHODS

Patients refractory to conservative treatment of the affected shoulder were enrolled in this prospective, randomized endpoint study. Patients diagnosed with a rotator cuff tear (1-4 cm) based on magnetic resonance imaging were included. Exclusion criteria were small (<1 cm) and massive (>4 cm) rotator cuff tears. Thirty-one patients each were randomized into the SISB/GA and GA treatment groups. Preoperative pain scores were measured at 6:00 AM on the day of surgery, measured again at 1 and 6 hours postoperatively, and then every 6 hours until 3 days postoperatively. Blood sampling was performed to evaluate the stress biomarkers insulin, dehydroepiandrosterone sulfate, and fibrinogen preoperatively at 6:00 AM on the day of surgery and postoperatively at 18, 42, and 66 hours (6:00 AM on postoperative days 1-3).

RESULTS

Pain scores were significantly decreased in the SISB/GA group (2.50 ± 0.94) versus the GA group (3.82 ± 1.31) on the day of surgery (P < .001), and especially at 6 hours postoperatively (SISB/GA: 2.42 ± 1.43; GA: 4.23 ± 2.17; P < .001). Insulin was decreased significantly in the SISB/GA group (10.55 ± 7.92 μU/mL) versus the GA group (20.39 ± 25.60 μU/mL) at 42 hours postoperatively (P = .048). There was no significant change in dehydroepiandrosterone sulfate or fibrinogen over time (P > .05).

CONCLUSIONS

After arthroscopic rotator cuff repair, an SISB effectively relieved pain on the day of surgery without any complications. In addition, insulin levels were significantly reduced at 42 hours postoperatively.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

Blind suprascapular and axillary nerve block for post-operative pain in arthroscopic rotator cuff surgery

PURPOSE

The goal of the study was to evaluate the efficacy of additional axillary nerve block (ANB) with suprascapular nerve block (SSNB) and patient-controlled anaesthesia (PCA) with no device assistance after arthroscopic rotator cuff repair. The hypothesis is that patients with intravenous (IV) PCA and the blockade of the two main nerves (SSNB + ANB) experienced lesser pain than patients with IV PCA or IV PCA + SSNB.

METHODS

The 114 patients undergoing arthroscopic rotator cuff repair were allocated randomly to three groups as follows: group I, intravenous PCA pumps (only PCA); group II, IV PCA + SSNB using a blind technique (PCA + SSNB); and group III, IV PCA + SSNB + ANB using a blind technique (PCA + SSNB + ANB). Pain visual analogue scale (VAS) scores were evaluated at 1, 6, 12, 24, 36, and 48 post-operative hours. Furthermore, the degree of pain was compared according to cuff tear size.

RESULTS

The pain VAS score of group III was lower than that of the other two groups and was significantly lower at post-operative hours 1, 6, and 12. In addition, the larger cuff tear tended to be indicative of greater pain. However, all groups experienced rebound pain.

CONCLUSION

PCA + SSNB + ANB using a blind technique is a better pain control method than PCA + SSNB and only PCA during the initial 12 post-operative hours. PCA + SSNB + ANB is a cost-effective, time-saving, and easily performed method for post-operative pain control as an axis of multimodal pain control strategy.

LEVEL OF EVIDENCE

II.

Postoperative pain control after arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair (ARCR) can provide excellent clinical results for patients who fail to respond to conservative management of symptomatic rotator cuff tears. ARCR, however, can be associated with severe postoperative pain and discomfort that requires adequate analgesia. As ARCR continues to shift toward being performed as an outpatient procedure, it is incumbent on physicians and ambulatory surgical centers to provide appropriate pain relief with minimal side effects to ensure rapid recovery and safe discharge. Although intravenous and oral opioids are the cornerstone of pain management after orthopedic procedures, they are associated with drowsiness, nausea, vomiting, and increased length of hospital stay. As health care reimbursements continue to become more intimately focused on quality, patient satisfaction, and minimizing of complications, the need for adequate pain control with minimal complications will continue to be a principal focus for providers and institutions alike. We present a review of alternative modalities for pain relief after ARCR, including cryotherapy, intralesional anesthesia, nerve blockade, indwelling continuous nerve block catheters, and multimodal anesthesia. In choosing among these modalities, physicians should consider patient- and system-based factors to allow the efficient delivery of analgesia that optimizes recovery and improves patient satisfaction.

Tibial component rotation in total knee arthroplasty

Background

Both the range of motion (ROM) technique and the tibial tubercle landmark (TTL) technique are frequently used to align the tibial component into proper rotational position during total knee arthroplasty (TKA).

The aim of the study was to assess the intra-operative differences in tibial rotation position during computer-navigated primary TKA using either the TTL or ROM techniques. The ROM technique was hypothesized to be a repeatable method and to produce different tibial rotation positions compared to the TTL technique.

Methods

A prospective, observational study was performed to evaluate the antero-posterior axis of the cut proximal tibia using both the ROM and the TTL technique during primary TKA without postoperative clinical assessment. Computer navigation was used to measure this difference in 20 consecutive knees of 20 patients who underwent a posterior stabilized total knee arthroplasty with a fixed-bearing polyethylene insert and a patella resurfacing.

Results

The ROM technique is a repeatable method with an interclass correlation coefficient (ICC2) of 0.84 (p < 0.001). The trial tibial baseplate was on average 4.56 degrees externally rotated compared to the tubercle landmark. This difference was statistically significant (p = 0.028). The amount of maximum intra-operative flexion and the pre-operative mechanical axis were positively correlated with the magnitude of difference between the two methods.

Conclusions

It is important for the orthopaedic surgeon to realise that there is a significant difference between the TTL technique and ROM technique when positioning the tibial component in a rotational position. This difference is correlated with high maximum flexion and mechanical axis deviations.

Efficacy of multimodal analgesia injection combined with corticosteroids after arthroscopic rotator cuff repair

INTRODUCTION

Although arthroscopic rotator cuff repair is minimally invasive, there is still considerable postoperative pain, especially during the first 48 hours. The present study assessed the short-term efficacy and safety of multimodal analgesic (MMA) injection associated to corticosteroids in arthroscopic rotator cuff tear surgery.

MATERIAL AND METHOD

A single-center prospective randomized study included 50 patients undergoing arthroscopic rotator cuff tear surgery. The study group received subacromial injection of a mixture of morphine, ropivacaine and methylprednisolone associated to intra-articular injection of morphine plus methylprednisolone; the control group received only isotonic saline. All patients had had 24 hours self-administered morphine associated to standard analgesia. Postoperative data were recorded at 30 minutes and 1, 2, 4, 6, 12, 18 and 24 hours: pain intensity, morphine intake and side effects, and also time to first morphine bolus and additional analgesic intake. Constant, ASES and SST functional scores were recorded at 3 months.

RESULTS

Postoperative pain was significantly less intense in the MMA group than in controls at 30 min, H1, H4, H6, H12, H18 and H24 (P<0.05). A rebound at D10 occurred in both groups. During the first 24 hours, MMA significantly reduced cumulative resort to morphine (P<0.05 at H1/2, P<0.001 at H1-24). Mean time to first bolus was significantly longer in the MMA group (71.6 vs. 33 min; P<0.05). The rate of opioid-related side effects was similar between groups. At last follow-up, functional scores were similar between groups. There were no cases of infection or delayed skin healing.

CONCLUSION

MMA associated to corticosteroids after arthroscopic rotator cuff tear surgery provided immediate benefit in terms of analgesia and morphine sparing, without apparent risk of infection. The practice is presently little known in France and deserves longer-term assessment, especially as regards functional rehabilitation and tendon healing.

LEVEL OF EVIDENCE

2.

Efficacy of periarticular multimodal drug injection after medial opening-wedge high tibial osteotomy: a randomized, controlled study

PURPOSE

The purpose of this study was to evaluate the efficacy of periarticular multimodal drug injection after medial opening-wedge high tibial osteotomy regarding the postoperative pain level.

METHODS

From January 2011 to January 2012, 70 patients underwent medial opening-wedge high tibial osteotomy. Thirty-five patients were randomly assigned to receive no injection (group I), and 35 patients were assigned to receive periarticular multimodal drug injection (group II). These 2 groups were compared regarding the postoperative pain level, frequency of additional nonsteroidal anti-inflammatory drug injections, total amount of patient-controlled analgesia, and number of times that patients pushed the patient-controlled analgesia button at each time interval. Statistical results were based on multivariate analysis of variance and repeated-measures analyses.

RESULTS

Multivariate analysis of variance of mean visual analog scale (VAS) scores over the 2-week postoperative period showed statistical significance (P < .001). Repeated-measures analysis yielded a statistically significant difference (P = .001) for the time-by-treatment interaction, showing a clear periarticular multimodal drug injection benefit over time based on VAS scores. In addition, the mean number of times that patients pushed the patient-controlled analgesia button differed significantly between groups over time (P = .01). The VAS scores, frequency of additional nonsteroidal anti-inflammatory drug injections, mean number of times that patients pushed the patient-controlled analgesia button, and mean total amount of fentanyl consumption differed significantly within each group over time (P < .001 for all variables). However, the frequency of additional nonsteroidal anti-inflammatory drug injections and mean total amount of fentanyl consumption did not differ significantly between groups over time (P = .822, P = .529, and P = .282). Opioid- and injection-related complications were not found.

CONCLUSIONS

This prospective randomized study shows that intraoperative periarticular multimodal drug injections in patients undergoing medial opening-wedge high tibial osteotomy for unicompartmental osteoarthritis of the knee could result in significant reductions in VAS scores at 2 weeks postoperatively.

LEVEL OF EVIDENCE

Level I, high-quality randomized controlled trial with statistically significant differences.