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

Early clinical efficacy analysis of enhanced recovery following surgery combined with interscalene brachial plexus block for arthroscopic rotator cuff repair

To explore the early clinical value of enhanced recovery after surgery (ERAS) with interscalene brachial plexus block (ISB) for arthroscopic rotator cuff repair (ARCR). We enrolled 240 patients who underwent arthroscopic rotator cuff repair, randomly divided into 3 groups (n = 80 each). Groups A, B, and C underwent only surgery, surgery + ERAS, and ISB + surgery + ERAS, respectively. We analyzed the clinical data and postoperative indicators for the 3 patient groups. Group comparisons of clinical data and postoperative indicators revealed no significant differences in clinical characteristics (P > .05). Group C showed superior Visual Analog Scale scores at 0-6 and 6-24 hours postoperatively (P < .05), and the shortest length of hospital stay (LOS) (P < .05). At 6 weeks and 3 months postoperatively, Constant-Murley shoulder score and University of California-Los Angeles scores were better in Groups B and C than in Group A (P < .05). Joint swelling was more common in Group A than in Groups B and C (P < .05) but with no significant difference in the incidence of postoperative stiffness (P > .05). ERAS can relieve postoperative pain, shorten LOS, and help restore shoulder joint mobility, thereby reducing postoperative swelling. ISB + ERAS optimized pain control and allowed a shorter LOS, but had similar effects on early functional recovery and complications.

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.

Network Meta-Analysis of Perioperative Analgesic Effects of Different Interventions on Postoperative Pain After Arthroscopic Shoulder Surgery Based on Randomized Controlled Trials

Background

Shoulder arthroscopic surgery is a common surgical method used in orthopedics. However, severe postoperative pain can significantly limit the early joint movement of patients and adversely affect the impact of the surgery. At present, there is no consistent and effective analgesic scheme for the management of postoperative pain after arthroscopic surgery of the shoulder.

Purpose

The aim of this study was to search for the most effective analgesic scheme to control pain in the perioperative period of arthroscopic surgery of the shoulder.

Study Design

Network meta-analysis.

Methods

We searched 5 different databases (i.e., Medline, PubMed, Embase, Web of Science, and the Cochrane Library) from January 2011 to January 2021 for English literature. Thereafter, we sifted out randomized controlled trials (RCTs), which compared different intervention schemes for pain management after shoulder arthroscopy and selected only 12 h, 24 h, or 48 h after the patient leaves the operating room as an optimal period for administration of analgesic intervention schemes. Only patients with shoulder disease who have undergone arthroscopic shoulder surgery were included in this study. The Cochrane “risk of bias” was used for the quality assessment. Moreover, some additional tests were performed to enhance the credibility of the results.

Results

Twenty-nine RCTs involving 1,885 patients were included in this frequentist network meta-analysis (NMA). These articles mainly were divided into two distinct groups, namely, the nerve block group and the non-nerve block group. Regarding the nerve block group, at postoperative 12 h, the intervention suprascapular nerve block + interscalene nerve block (SSNB + INB) was ranked first, whereas INB + intra-articular injection (INB + IAI) was ranked first at 24 h and 48 h postoperation. In the non-nerve block group, external application (EA) was ranked first at postoperative 12 h, but oral administration (OA) exhibited a better analgesic effect at postoperative 24 h and postoperative 48 h.

Conclusion

We conclude that the analgesic effect of SSNB+INB was the best at postoperative 12 h, and INB+IAI was the best at postoperative 24 h and 48 h in the nerve block group. For the non-nerve block group, the effect of EA was the best at postoperative 12 h, and the analgesic effect of OA at postoperative 24 h and 48 h was significantly better than any other interventions.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021286777.

The effect of single-dose, preoperative intravenous tranexamic acid on early postoperative pain scores after rotator cuff repair: a double-blind, randomized controlled trial

BACKGROUND

Tranexamic acid (TXA) is commonly used in upper and lower limb arthroplasty to limit blood loss and postoperative hematoma formation. The role of TXA in rotator cuff repair (RCR) surgery is less defined. This trial assessed the effect of preoperative TXA on early postoperative pain scores.

METHODS

A randomized double-blind trail was conducted in 89 patients undergoing RCR. Patients were randomized to either 2 g of intravenous TXA or placebo at induction. The primary outcome was visual analog scale (VAS)-pain score at day 3 postoperation, with secondary outcomes including VAS-pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores at 2, 8, 24, and 52 weeks.

RESULTS

There was no significant difference in VAS-pain scores between groups at day 3 postoperation. Pain scores were significantly better in the TXA group at 8 weeks. There was no difference between groups at any time point in the ASES or Constant score. The TXA group had improved motion at 6 months with a reduced rate of secondary adhesive capsulitis.

CONCLUSION

TXA did not improve postoperative pain scores after RCR, however, patients who received the intervention demonstrated greater range of motion at 6 months with lower rates of secondary adhesive capsulitis.

Use of Opioids in the Early Postoperative Period After Arthroscopic Rotator Cuff Repair: A Systematic Review

Background:

Postoperative treatment plans after orthopaedic procedures frequently include opioids for pain relief.

Purpose:

To evaluate opioid use in the early postoperative phase after arthroscopic rotator cuff repair (ARCR) to develop a procedure-specific understanding of the current role of opioids in pain management for this procedure.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A PubMed search was used to identify eligible studies. Data on patient demographics, visual analog scale pain scores, and opioid use patterns (in morphine milligram equivalents [MMEs]) were collected and assessed. Cumulative MMEs were reported on postoperative day (POD) zero, and mean MMEs were reported on subsequent PODs (days 1, 2, 3, 5, 7, and 14). Metaregression, I² indices, and Cochran Q tests were used to evaluate study variation, heterogeneity, and variance.

Results:

A total of 1487 patients in 22 studies were included in the analysis. An estimated 51% (95% CI, 31%-70%) of patients with nerve blocks (NBs) were opioid-free through POD-0 versus 40% (95% CI, 1.2%-97%) of patients without NBs, which increased to 65% (95% CI, 55%-74%) versus 25% (95% CI, 1.7%-86%) by POD-1. Opioid requirements were highest in the first 72 hours after ARCR. NB use reduced opioid requirement on POD-0 compared with no NB use (15.8 vs 45.0 MMEs, respectively; P < .001) but did not reduce requirements after that. In addition, NB use led to a statistically significant increase in opioid requirements on POD-7 (28.6 vs 9.5 MMEs, respectively; P < .001). Using a model that assumes stable opioid requirements between our time points, weighted mean cumulative opioid consumption was 163 MMEs in the first week and 273 MMEs in the first 2 weeks (150 and 287 MMEs in patients with NB; 180 and 261 MMEs in patients without NB, respectively).

Conclusion:

Opioid use is relatively common in the early postoperative period after ARCR. Pain scores and opioid requirements may spike on POD-1; however, patients should be educated and reassured that they will gradually decrease usage over the initial 2-week postoperative period.

Peripheral Nerve Blocks Outperform General Anesthesia for Pain Control in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this review is to compare the effectiveness of different peripheral nerve blocks and general anesthesia (GA) in controlling postoperative pain after arthroscopic rotator cuff repair (ARCR).

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review was conducted for the period of January 1, 2005, to February 16, 2021, by searching the following databases: PubMed, Cochrane, Embase, and Arthroscopyjournal.org. The primary outcomes of interest included 1-hour, 24-hour, and 48-hour pain scores on a numeric rating scale or visual analog scale (VAS). Inclusion criteria were English language studies reporting on adults (≥18 years) undergoing ARCR with peripheral nerve blockade. To synthesize subjective pain score data at each evaluation time point across studies, we performed random-effects network meta-regression analyses accounting for baseline pain score as a covariate.

RESULTS

A total of 14 randomized controlled trials with 851 patients were included in the meta-analysis. Data from six different nerve block interventions, single-shot interscalene brachial plexus nerve block (s-ISB; 37.8% [322/851]), single-shot suprascapular nerve block (s-SSNB; 9.9% [84/851]), continuous ISB (c-ISB; 17.5% [149/851]), continuous SSNB (c-SSNB; 6.9% [59/851]), s-ISB combined with SSNB (s-ISB+SSNB; 5.8% [49/851]), s-SSNB combined with axillary nerve block (s-SSNB+ANB; 4.8% [41/851]), as well as GA (17.3% [147/851]) were included. Our meta-analysis demonstrated that c-ISB block had a significant reduction in pain score relative to GA at 1-hour postoperation (mean difference [MD]: -1.8; 95% credible interval [CrI] = -3.4, -.08). There were no significant differences in VAS pain scores relative to GA at 24 and 48 hours postoperatively. However, s-ISB+SSNB had a significant reduction in 48-hour pain score compared to s-ISB (MD = -1.07; 95% CrI = -1.92, -.22).

CONCLUSIONS

It remains unclear which peripheral nerve block strategy is optimal for ARCR. However, peripheral nerve blocks are highly effective at attenuating postoperative ARCR pain and should be more widely considered as an alternative over general anesthesia alone.

LEVEL OF EVIDENCE

Level II Systematic review and meta-analysis of Level I and II studies.

Predictors of postoperative pain, opioid consumption, and functionality after arthroscopic shoulder surgery: A prospective observational study

PURPOSE

This study aims to identify predictors of postoperative pain and opioid consumption after shoulder surgery to help optimize postoperative pain protocols.

STUDY DESIGN

Observational cohort study.

METHODS

One thirty-four patients undergoing arthroscopic shoulder repair were included. Variables related to the patient, surgery and anesthesia were collected and correlated with postoperative pain intensity, analgesic consumption, and functionality up to 1-month post-surgery. We used mixed-effect linear models to estimate the association of gender, interscalene block (ISB), preoperative shoulder pain, non-steroidal anti-inflammatory drugs (NSAIDs) consumption before surgery, and type of surgery with each of the following outcomes: postoperative pain scores, opioid consumption, and functionality. We further analyzed the data for pain scores and opioid consumption per body weight using the multiple linear regression analysis to demonstrate the aforementioned associations specifically at 1 h, 6 h, 12 h, 24 h, 72 h, 1 week and 1 month after surgery.

RESULTS

Omitting the ISB was associated with higher postoperative pain and cumulative opioid consumption over the first 24 h after surgery. Rotator cuff repair and stabilization surgeries were found to be predictive of higher postoperative pain at 24 h, 72 h, and 1 week and lower functionality at 1 week after surgery. Preoperative shoulder pain and NSAIDs consumption were also predictive of postoperative pain and cumulative opioid consumption.

CONCLUSION

Omitting a single shot ISB is a strong predictor of postoperative pain and opioid consumption in the early postoperative phase, beyond which the type of surgery, particularly rotator cuff repair and stabilization surgery, emerges as the most important predictor of postoperative pain and functionality.

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.

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.

Perioperative anaesthetic considerations for rotator cuff repair surgeries: A current concept review

Surgeries for Rotator Cuff (RC) pathologies are required for either trauma or degenerative related aetiologies. Various surgical techniques from open to arthroscopic repair, are being undertaken by orthopaedic surgeons. Peri-operative anaesthetic management of the patients undergoing rotator cuff repair requires understanding the surgical procedure and patient status for optimal anaesthetic planning. Such management mandates a thorough pre-operative evaluation, including clinical history, examination, and relevant investigations. Patients with acute trauma associated Rotator Cuff (RC) tears should be assessed for visceral injuries using appropriate injury evaluation systems before such repairs. On the other hand, patients with degenerative tears tend to be older with associated comorbidities. Hence pre-operative optimisation is necessary according to risk stratification. Anaesthetic techniques for Rotator Cuff (RC) surgery include general anaesthesia or regional anaesthesia. These are individualised according to patient assessment and surgical procedure planned. Knowledge of relevant surgical anatomy is essential for intra-operative, and post-operative neural blockade techniques since optimal peri-operative analgesia improve overall patient recovery. The occurrence of a peri-operative complication should be recognised as timely management improves the patient-related surgical outcomes. We describe the relevance of surgical anatomy, the effect of patient positioning, irrigating fluids, various anaesthetic techniques and an overview of regional and medical interventions to manage pain in patients undergoing for Rotator Cuff (RC) surgery.

Cost of Arthroscopic Rotator Cuff Repairs Is Primarily Driven by Procedure-Level Factors: A Single-Institution Analysis of an Ambulatory Surgery Center

PURPOSE

To identify intraoperative drivers of cost associated with arthroscopic rotator cuff repairs (RCRs) through analysis of an institutional database.

METHODS

This was a single-institution retrospective review of arthroscopic RCRs performed at an ambulatory surgical center between November 2016 and July 2019. Patient-level factors analyzed included age, sex, insurance type (private, Medicare, Medicaid, self-pay, and other government), American Society of Anesthesiologists grade (I, II, III, and missing), and Charlson comorbidity index (0, 1, 2, and ≥3). Procedure-level factors included use of biologics (decellularized dermal allograft or bioinductive healing implant), anesthesia type (regional block, monitored anesthesia care, or general), number of anchors and sutures, additional procedures (biceps tenodesis, distal clavicle resection, subacromial decompression), and operative time. Multivariate linear regression analysis was used to identify factors significantly associated with higher or lower charges.

RESULTS

A total of 712 arthroscopic RCRs were included. The risk-adjusted operative charges were $19,728 (95% confidence interval $16,543 to $22,913). The above factors predicted nearly 65% of the variability in operative charges. The only patient-level factor significantly associated with lower charges was female sex (- $1,339; P = .002). Procedure-level factors significantly associated with higher charges were use of biologics (+ $17,791; P < .001), concurrent open biceps tenodesis (+ $4,027; P < .001), distal clavicle resection (+ $2,266; P = .039), use of regional block (+ $1,256; P = .004), number of anchors (+ $2,245/anchor; P < .001), and increasing operative time ($26/min). Other factors had no significant association.

CONCLUSIONS

Procedural factors are the most significant drivers of operative cost in arthroscopic RCRs, such as quantity and type of implants; additional procedures such as biceps tenodesis and distal clavicle resection; and perioperative conditions such as type of anesthesia and total operating room time. Overall, patient-level factors were not shown to correlate well with operative costs, other than lower charges with female sex.

LEVEL OF EVIDENCE

IV, economic study.

Suprascapular Nerve Block Is an Effective Pain Control Method in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

Background

Effective pain control in patients who have undergone arthroscopic rotator cuff surgery improves functional recovery and early mobilization. Interscalene blocks (ISBs), a widely used approach, are safe and provide fast pain relief; however, they are associated with complications. Another pain management strategy is the use of a suprascapular nerve block (SSNB).

Hypothesis

We hypothesized that indwelling SSNB catheters are a more effective pain control method than single-shot ISBs. We also hypothesized that indwelling SSNB catheters will reduce the level of rebound pain and the demand for opioid analgesics.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Included in this study were 93 patients who underwent arthroscopic rotator cuff surgery between May 2012 and January 2019. These patients were assigned to either the indwelling SSNB catheter group, the single-shot ISB group, or the control (sham/placebo) group (31 patients per group). Level of pain was measured with a visual analog scale (VAS; 0 to 10 [worst pain]) on the day of the operation. The preoperative VAS score was recorded at 6 AM on the day of operation, and the postoperative scores were recorded at 1, 8, and 16 hours after surgery and then every 8 hours until postoperative day 3.

Results

The VAS pain scores were lower in the SSNB and ISB groups than in the control group up to postoperative hour (POH) 8, with the most significant difference at POH 8. At POH 1 and POH 8, the mean VAS scores for each group were 2.29 and 1.74 (SSNB), 2.59 and 2.50 (ISB), and 3.42 and 4.48 (control), respectively. VAS scores in the SSNB and ISB groups were consistently <3, compared with a mean VAS score of 3.1 ± 1.58 in the control group (P < .001). Compared with the ISB group, the SSNB group had significantly fewer side effects such as rebound pain duration as well as lower VAS scores (P < .001).

Conclusion

VAS scores were the lowest in the indwelling SSNB catheter group, with the most pronounced between-group difference in VAS scores at POH 8. Severity and recurring frequency of pain were lower in the indwelling SSNB catheter group than in the single-shot ISB group.

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.

Editorial Commentary: Postoperative Pain Management After Arthroscopic Rotator Cuff Repair: The Journey to Pain Relief

Presently, interscalene block is the undisputed gold-standard procedure for postoperative pain management after arthroscopic rotator cuff surgery in patients experiencing considerable pain. However, the challenge is to make this short-term total pain relief long-term.

Comparison of Subacromial Injection and Interscalene Block for Immediate Pain Management After Arthroscopic Rotator Cuff Repair

PURPOSE

To compare the efficacy of a subacromial injection (SAI) with a single-shot interscalene block (ISB) for immediate postoperative pain relief after outpatient arthroscopic rotator cuff repair (ARCR).

METHODS

We performed a retrospective chart review of consecutive patients who underwent ARCR. Patients received either an ISB before the procedure or an SAI after the procedure. Preoperative baseline patient characteristics were collected and compared. Visual analog scale (VAS) pain scores were recorded preoperatively, at 15-minute intervals over a 120-minute period in the postanesthesia care unit (PACU), and at discharge. Differences in VAS scores between groups were compared with known values of the minimal clinically important difference, and the percentage of patients with VAS scores below the patient acceptable symptom state was tabulated. Differences between preoperative characteristics were assessed using the Mann-Whitney U, Fisher exact, or χ² test. The Mann-Whitney U test was also used to evaluate VAS scores and total time spent in the PACU between groups.

RESULTS

The median VAS score was significantly lower in the ISB group at PACU admission, at all intervals throughout the PACU stay, and at discharge (P < .0001). The median total time in the PACU was 107 minutes (25th percentile-75th percentile, 90-120 minutes) and 210 minutes (25th percentile-75th percentile, 175-274 minutes) in the ISB and SAI groups, respectively (P < .0001). Between-group differences in VAS scores were greater than the values of the minimal clinically important difference at each measured interval. A total of 98% and 67% of patients in the ISB and SAI groups, respectively, were discharged with VAS scores below the patient acceptable symptom state of 3.

CONCLUSIONS

Patients receiving an ISB experience significantly less pain than those receiving an SAI. In addition, they are discharged home from the PACU in half the time as patients receiving an SAI. On the basis of the comparative efficacy, an SAI cannot replace an ISB after ARCR. The ISB should therefore remain the standard of care as an adjunct to postoperative analgesia for patients who undergo outpatient ARCR.

LEVEL OF EVIDENCE

Level III, retrospective, comparative therapeutic trial.

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.

Effect of interscalene nerve block on the inflammatory response in shoulder surgery: a randomized trial

BACKGROUND

Comparing techniques of general anesthesia and regional anesthesia in arthroscopic shoulder surgery, some studies have shown differences in the intensity of immediate postoperative pain and neuroendocrine response, but the inflammatory response when using balanced general anesthesia (BGA) vs. an ultrasound-guided (USG) single-dose interscalene block (SDIB) has not been compared.

MATERIALS AND METHODS

In a single-center, prospective, randomized clinical trial, the inflammatory response of 2 groups of 10 patients scheduled to undergo arthroscopic shoulder surgery was evaluated through measurement of a panel of cytokines that act on cells of the adaptive immune response to promote or inhibit inflammation, chemokines involved in chemotaxis, the erythrocyte sedimentation rate (ESR), the high-sensitivity C-reactive protein (CRP) level, and the white blood cell (WBC) count in 3 blood samples (before anesthesia, immediately postoperatively, and 24 hours postoperatively) with 2 types of anesthesia (BGA vs. USG SDIB). Postoperative pain intensity (immediately, at 12 hours, and at 24 hours) was also assessed.

RESULTS

The ESR and CRP level increased significantly at 24 hours after surgery; however, the increase in ESR (P < .0001) and CRP level (P < .0001) was lower in the USG SDIB group. Significant increases in the levels of soluble interleukin 2 receptor α (P = .022) and interleukin 12p40 (P = .016) occurred in the immediate postoperative period in the USG SDIB group. Immediate postoperative pain showed a significant increase (P < .001) in the BGA group.

CONCLUSIONS

In arthroscopic shoulder surgery, the use of a USG SDIB compared with the use of BGA is possibly associated with improved pain control in the immediate postoperative period and lower immunosuppression, even at 24 hours after surgery.

Effect of Surgical-Site, Multimodal Drug Injection on Pain and Stress Biomarkers in Patients Undergoing Plate Fixation for Clavicular Fractures

Background

Surgical-site, multimodal drug injection has recently evolved to be a safe and useful method for multimodal pain management even in patients with musculoskeletal trauma.

Methods

Fifty consecutive patients who underwent plating for mid-shaft and distal clavicular fractures were included in the study. To evaluate whether surgical-site injections (SIs) have pain management benefits, the patients were divided into two groups (SI and no-SI groups). The injection was administered between the deep and superficial tissues prior to wound closure. The mixture of anesthetics consisted of epinephrine hydrochloride (HCL), morphine sulfate, ropivacaine HCL, and normal saline. The visual analogue scale (VAS) pain scores were measured at 6-hour intervals until postoperative hour (POH) 72; stress biomarkers (dehydroepiandrosterone sulfate [DHEA-S], insulin, and fibrinogen) were measured preoperatively and at POH 24, 48, and 72. In patients who wanted further pain control or had a VAS pain score of 7 points until POH 72, 75 mg of intravenous tramadol was administered, and the intravenous tramadol requirements were also recorded. Other medications were not used for pain management.

Results

The SI group showed significantly lower VAS pain scores until POH 24, except for POH 18. Tramadol requirement was significantly lower in the SI group until POH 24, except for POH 12 and 18. The mean DHEA-S level significantly decreased in the no-SI group (74.2 ± 47.0 µg/dL) at POH 72 compared to that in the SI group (110.1 ± 87.1 µg/dL; p = 0.046). There was no significant difference in the insulin and fibrinogen levels between the groups. The correlation values between all the biomarkers and VAS pain scores were not significantly different between the two groups (p > 0.05).

Conclusions

After internal fixation of the clavicular fracture, the surgical-site, multimodal drug injection effectively relieved pain on the day of the surgery without any complications. Therefore, we believe that SI is a safe and effective method for pain management after internal fixation of a clavicular fracture.

Editorial Commentary: Pain and Stress Response After Shoulder Arthroscopic Rotator Cuff Repair: Does Interscalene Block Make a Clinically Important Difference?

Pain control after arthroscopic rotator cuff repair will invariably encompass a multimodal approach which will include, in some form, an anesthetic block. The authors of "Effects of a Single-Dose Interscalene Block on Pain and Stress Biomarkers in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial" demonstrate better pain control and a decrease in levels of the stress biomarker insulin with the use of a single-dose interscalene block (SISB) and general anesthesia compared to general anesthesia alone. But a closer look at the minimal clinically important difference (MCID) becomes critically important when interpreting the results as the effect may be less than anticipated and the "rebound effect" plays an important role. The notoriously painful rotator cuff repair may need further evaluation beyond the first several days when looking from the patients' perspectives to impact overall satisfaction and utility.