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Sewpaul Y, Huynh RCT, Hartland AW, Leung B, Teoh KH, Rashid MS. Non-steroidal Anti-inflammatory Drugs and Cyclooxygenase-2 Inhibitors Do Not Affect Healing After Rotator Cuff Repair: A Systematic Review and Meta-analysis. Arthroscopy 2024; 40:930-940.e1. [PMID: 37967731 DOI: 10.1016/j.arthro.2023.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 11/17/2023]
Abstract
PURPOSE To determine whether non-steroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors affect healing rate, functional outcomes, and patient satisfaction after rotator cuff repair. METHODS Medline, EMBASE, PsychINFO and the Cochrane Library were searched for randomized controlled trials (RCTs) investigating the use of NSAIDs and COX-2 inhibitors after arthroscopic rotator cuff repair. Primary outcomes included healing and retear rate, determined by radiological imaging. Secondary outcomes included shoulder-specific outcome measures and the visual analog scale (VAS). Risk of bias was graded using the Cochrane risk-of-bias v2.0 tool. The GRADE framework was used to assess certainty of findings. RESULTS Seven RCTs with a total of 507 patients were included (298 randomized to NSAID/COX-2 vs 209 randomized to control). NSAIDs use did not yield a difference in retear rate (P = .77). NSAIDs were shown to significantly reduce pain in the perioperative period (P = .01); however, no significant difference was present at a minimum of 6 months (P = .11). COX-2 inhibitors did not significantly reduce pain (P = .15). Quantitative analysis of ASES and UCLA scores showed NSAIDs significantly improved functional outcomes versus control (P = .004). COX-2 inhibitors did not significantly improve functional outcomes (P = .15). Two trials were deemed "low" risk of bias, four trials were graded to have "some concerns", and one trial was graded to have "high" risk of bias. Retear rate and functional PROMs were deemed to have "low" certainty. VAS pain scale was graded to have "moderate" certainty. CONCLUSIONS This systematic review and meta-analysis indicates that NSAIDs do not affect healing rate after arthroscopic rotator cuff repair, but they do significantly improve postoperative pain and functional outcomes. No significant difference was seen in pain or functional outcomes with the use of COX-2 inhibitors. LEVEL OF EVIDENCE Level I, meta-analysis of randomized controlled trials.
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Affiliation(s)
- Yash Sewpaul
- Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| | | | | | - Brook Leung
- Royal London Hospital, Whitechapel, London, United Kingdom
| | - Kar Hao Teoh
- Department of Trauma and Orthopaedic Surgery, Princess Alexandra Hospital, Harlow, United Kingdom
| | - Mustafa S Rashid
- Manchester University NHS Foundation Trust, Manchester, United Kingdom.
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Nucci N, Degen R, Ekhtiari S, Gazendam A, Ayeni OR, Horner N, Wong I, Woodmass J, Grant J, Sheehan B, Pickell M, Kopka M, Khan M, Martin R, Tucker A, Sommerfeldt M, Gusnowski E, Rousseau-Saine A, Lebel ME, Karpyshyn J, Matache B, Carroll M, Da Cunha R, Kwapisz A, Martin RK. Arthroscopy Association of Canada Position Statement on Opioid Prescription After Arthroscopic Surgery. Orthop J Sports Med 2023; 11:23259671231214700. [PMID: 38145216 PMCID: PMC10748902 DOI: 10.1177/23259671231214700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/23/2023] [Indexed: 12/26/2023] Open
Abstract
Background Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications. Purpose This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery. Study Design Position statement. Methods The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy, opioids, analgesia, and pain, and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated. Results A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption. Conclusion A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription.
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Affiliation(s)
| | - Ryan Degen
- Western University, London, Ontario, Canada
| | | | | | | | - Nolan Horner
- Genesis Orthopaedics & Sports Medicine, Chicago, Illinois, USA
| | - Ivan Wong
- Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - John Grant
- University of Michigan, Ann Arbor, Michigan, USA
| | | | | | | | - Moin Khan
- Investigation performed at McMaster University, Hamilton, Ontario, Canada
| | - Ryan Martin
- University of Calgary, Calgary Alberta, Canada
| | - Allison Tucker
- Nova Scotia Health Authority, Halifax Nova Scotia, Canada
| | | | - Eva Gusnowski
- Saint John Orthopaedics, Saint John, New Brunswick, Canada
| | | | | | | | | | - Michael Carroll
- Queen Elizabeth Hospital, Charlottetown, Prince Edward Island, Canada
| | | | - Adam Kwapisz
- University of Manitoba, Winnipeg, Manitoba, Canada
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Seah SJS, Yeo MHX, Gatot C, Lie D. Non-selective NSAIDs do not increase retear rates post-arthroscopic rotator cuff repair: A meta-analysis. J ISAKOS 2023; 8:216-226. [PMID: 37085034 DOI: 10.1016/j.jisako.2023.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 03/31/2023] [Accepted: 04/06/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Arthroscopic rotator cuff repairs (RCRs) are known to be associated with substantial pain and post-operative pain management is critical in overall patients' outcomes. Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used oral medications and can reduce opioid usage. However, controversies arise due to its postulated effect on postoperative tendon healing. As the evidence of safety and efficacy of NSAIDs remains unclear, this study aims to investigate the effect of NSAIDs on retear rates and clinical outcomes. METHODS A systematic search of four databases (PubMed, EMBASE, Scopus, and Cochrane Library) was conducted, identifying studies that compared cohorts with post-RCR NSAIDs use versus control groups without NSAID use. Meta-analysis was conducted for retear rate as well as pain and functional outcomes (Visual Analogue Scale and American Shoulder and Elbow Surgeons Shoulder score). Subgroup analysis was conducted for retear rates to determine the overall treatment effect of including selective COX-2 inhibitors. RESULTS Six studies were included in the meta-analysis. The total baseline cohort size was 916, with 443 (48.3%) patients in the NSAID group and 473 (51.6%) patients in the control group. There were no statistically significant differences in the baseline characteristics between the two groups. Meta-analysis between the two groups showed that there were no statistically significant differences in retear rates (p = 0.70), early and late post-operative Visual Analogue Scale score (p = 0.10 and p = 0.10, respectively) and latest American Shoulder and Elbow Surgeons Shoulder score (p = 0.31). However, subgroup analysis of retear rates revealed a statistically significant difference between the subgroup including COX-2 selective inhibitor versus non-selective COX inhibitor (p < 0.01). CONCLUSION NSAID use in post-arthroscopic RCR pain relief does not increase retear rates and can provide similar clinical outcomes compared to a non-NSAID regimen. LEVEL OF EVIDENCE Meta-analysis, level of evidence, 4.
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Affiliation(s)
- Shawn J S Seah
- Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore
| | - Mark H X Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore
| | - Cheryl Gatot
- Department of Orthopedic Surgery, Singapore General Hospital, 169608, Singapore
| | - Denny Lie
- Department of Orthopedic Surgery, Singapore General Hospital, 169608, Singapore.
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Ekhtiari S, Nucci N, Uddin F, Albadran A, Gazendam AM, Bhandari M, Khan M. Opioid-Sparing Strategies in Arthroscopic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. JBJS Rev 2023; 11:01874474-202307000-00005. [PMID: 37459422 DOI: 10.2106/jbjs.rvw.23.00047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Opioid overprescription is a problem in orthopaedic surgery. Arthroscopic surgery, given its minimally invasive nature, represents an opportunity to minimize opioid prescription and consumption by using effective pain management adjuncts. Thus, the primary question posed in this study was which noninvasive pain management modalities can effectively manage pain and reduce opioid intake after arthroscopic surgery. METHODS The databases PubMed, MEDLINE, EMBASE, Scopus, and Web of Science were searched on August 10, 2022. Randomized controlled trials (RCTs) evaluating noninvasive pain management strategies in arthroscopy patients were evaluated. Eligible studies were selected through a systematic screening process. Meta-analysis was performed for pain scores and opioid consumption at time points which had sufficient data available. RESULTS Twenty-one RCTs were included, with a total of 2,148 patients undergoing shoulder, knee, and hip arthroscopy. Meta-analysis comparing nonopioid, oral analgesic regimens, with or without patient education components, with the standard of care or placebo demonstrated no difference in pain scores at 24 hours, 4 to 7 days, or 14 days postoperatively. Nonopioid regimens also resulted in significantly lower opioid consumption in the first 24 hours postoperatively (mean difference, -37.02 mg oral morphine equivalents, 95% confidence interval, -74.01 to -0.03). Transcutaneous electrical nerve stimulation (TENS), cryotherapy, and zolpidem were also found to effectively manage pain and reduce opioid use in a limited number of studies. CONCLUSIONS A range of noninvasive pain management strategies exist to manage pain and reduce opioid use after arthroscopic procedures. The strongest evidence base supports the use of multimodal nonopioid oral analgesics, with some studies incorporating patient education components. Some evidence supports the efficacy of TENS, cryotherapy, and nonbenzodiazepine sleeping aids. Direction from governing bodies is an important next step to incorporate these adjuncts into routine clinical practice to manage pain and reduce the amount of opioids prescribed and consumed after arthroscopic surgery. LEVEL OF EVIDENCE Level II, systematic review and meta-analysis of RCTs. See Instructions for Authors for a complete description of the levels of evidence.
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Affiliation(s)
- Seper Ekhtiari
- Division of Trauma and Orthopaedics, Addenbrooke's Hospital-Cambridge University Hospitals, Cambridge, United Kingdom
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicholas Nucci
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Fares Uddin
- Roth McFarlane Hand & Upper Limb Centre, Western University, London, Ontario, Canada
| | - Adeeba Albadran
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Mohit Bhandari
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Moin Khan
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
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