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Nwankpa C, Razi A, Ring D, Ramtin S. Inordinate attention to minor pathophysiology variations in musculoskeletal research: example of rotator cuff tendinopathy. J Shoulder Elbow Surg 2024; 33:e302-e307. [PMID: 38000730 DOI: 10.1016/j.jse.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/22/2023] [Accepted: 10/18/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Evidence suggests variation in pathophysiology is less relevant to musculoskeletal illness than variation in mental health factors. For diseases such as rotator cuff tendinopathy, attention may be placed on aspects of tendon thinning and suture techniques when studies show that variations in muscle quality and defect size have limited association with comfort and capability compared with variations in thoughts and feelings regarding symptoms. Using rotator cuff tendinopathy as an example, we studied the degree to which research addresses relatively minor degrees of variation in pathophysiology and relatively minor differences in treatments to better understand the relative emphasis on pathophysiology. We asked the following questions: What factors are associated with relative pathophysiology severity in comparative therapeutic studies of musculoskeletal conditions? What factors are associated with relative differences in interventions in comparative therapeutic studies of musculoskeletal conditions? METHODS We systematically reviewed clinical trials of patients with rotator cuff tendinopathy for the relative severity of pathophysiology (low, moderate, or high) and variation in interventions (minimal, moderate, or large). An example of a relatively minor variation in rotator cuff tendon pathophysiology is bursal- vs. articular-sided thinning of the tendon. An example of a relatively minor variation in treatment is single- vs. double-row defect closure. RESULTS Most studies of rotator cuff tendinopathy treatment addressed low (39%) or medium (50%) levels of pathophysiology. Greater relative pathology severity was independently associated with operative treatment (odds ratio, 12 [95% confidence interval, 3.2-45]; P < .001). Of 127 studies, 113 (89%) were rated as comparing treatments with minimal difference. CONCLUSION Despite the evidence of limited variation in comfort and capability due to pathophysiological variations, a large percentage of research on rotator cuff tendinopathy addresses relatively limited severity of pathophysiology and relatively minor variations in treatment. This may be typical of musculoskeletal research and suggests a possibility of focusing, on the one hand, on more impactful interventions such as treatments that can delay or avoid rotator cuff arthropathy and, on the other hand, on management strategies that optimize accommodation of common age-related changes in the rotator cuff tendons.
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Affiliation(s)
- Christina Nwankpa
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Amin Razi
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA.
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Kim E, Choi CH, Lim JA, Lee SY, Choi E, Kim J. Eighth Cervical Nerve Root Block During Interscalene Brachial Plexus Block Decreases Pain Caused by Posterior Portal Placement but Increases Horner Syndrome in Patients Undergoing Arthroscopic Shoulder Surgery: A Randomized Controlled Trial. Arthroscopy 2024; 40:217-228.e4. [PMID: 37355189 DOI: 10.1016/j.arthro.2023.06.022] [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: 10/07/2022] [Revised: 03/07/2023] [Accepted: 06/05/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To compare the intensity of pain on posterior portal placement between a C5-C7 root block (conventional interscalene brachial plexus block [ISBPB]) and a C5-C8 root block in patients undergoing arthroscopic shoulder surgery. METHODS In this prospective, single-blinded, parallel-group randomized controlled trial, patients were randomized to receive either a C5-C7 root block (C5-C7 group, n = 37) or a C5-C8 root block (C5-C8 group, n = 36) with 25 mL of 0.75% ropivacaine. The primary outcome was the pain intensity on posterior portal placement, which was graded as 0 (no pain), 1 (mild pain), or 2 (severe pain). The secondary outcomes were the bilateral pupil diameters measured 30 minutes after ISBPB placement; the incidence of Horner syndrome, defined as a difference in pupil diameter (ipsilateral - contralateral) of less than -0.5 mm; the onset of postoperative pain; and the postoperative numerical rating pain score, where 0 and 10 represent no pain and the worst pain imaginable, respectively. RESULTS Fewer patients reported mild or severe pain on posterior portal placement in the C5-C8 group than in the C5-C7 group (9 of 36 [25.0%] vs 24 of 37 [64.9%], P = .003). Less pain on posterior portal placement was reported in the C5-C8 group than in the C5-C7 group (median [interquartile range], 0 [0-0.75] vs 1 [0-1]; median difference [95% confidence interval], 1 [0-1]; P = .001). The incidence of Horner syndrome was higher in the C5-C8 group than in the C5-C7 group (33 of 36 [91.7%] vs 22 of 37 [59.5%], P = .001). No significant differences in postoperative numerical rating pain scores and onset of postoperative pain were found between the 2 groups. CONCLUSIONS A C5-C8 root block during an ISBPB reduces the pain intensity on posterior portal placement. However, it increases the incidence of Horner syndrome with no improvement in postoperative pain compared with the conventional ISBPB (C5-C7 root block). LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Eugene Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Chang Hyuk Choi
- Department of Orthopedic Surgery, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Jung A Lim
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - So Young Lee
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Eunjoo Choi
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Jonghae Kim
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, Republic of Korea.
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Chillemi C, Damo M, Proietti R, Polizzotti G, Ferrari S, Idone F, Palliccia A, Di Rosa S, Carli S, Zimbalatti B. Shoulder pain management strategies and early functional outcome after arthroscopic rotator cuff tear repair. A randomized controlled study. J Bodyw Mov Ther 2024; 37:156-163. [PMID: 38432799 DOI: 10.1016/j.jbmt.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 07/26/2023] [Accepted: 11/06/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND The management of acute postoperative pain after rotator cuff surgery can be challenging. To our knowledge, there are no data available in the literature correlating satisfactory pain control with improvement in terms of function. The purposes of the present study were to evaluate: 1) pain pattern after arthroscopic rotator cuff repair in patients operated with two different techniques (transosseous vs transosseous equivalent); 2) safety/efficacy of three different pharmacological pain control strategies; 3) possible relationship between a correct shoulder pain management protocol in the early post-operative period and patients' functional improvement. METHODS 114 patients underwent rotator cuff tear repair, either with a Transosseus or a Transosseus equivalent technique. 62 (54%) were male and 52 (46%) were female. The average age was 59 ± 9 years. They were randomly assigned into three different pain management protocols: Paracetamol as needed (max 3 tablets/day) for 1 week (Protocol A), Paracetamol + Codein 1 tablet three times per day for 7 days (Protocol B), or Paracetamol + Ibuprofen 1 tablet two times per day for 7 days (Protocol C). Immediate passive mobilization of the operated shoulder was allowed. VAS and Passive Flexion values were recorded at 7 (T1), 15 (T2) and 30 (T3) days post-surgery. DASH values were recorded at 90 days post-surgery. All patients were asked to register any kind of signs/symptoms that may appear during drug assumption according to each pain management protocols. RESULTS All the pain management protocols administered were well tolerated by all the study population, and no adverse signs/symptoms were highlighted during drug assumption. Pain pattern: in both surgical techniques, patients within Protocol A were associated with worst results in terms of mean VAS at each time point examined when compared to Protocol B and C (p < 0,05). In patients within Protocol A, no statistically significant differences were found at each point time examined comparing the two surgical techniques, with the exception of T2, where the TO was associated with an higher VAS value than TOE (p < 0.05). No differences were highlighted in Protocol B and C when comparing the values between two surgical techniques. ROM: in both surgical techniques, patients within Protocol A were associated with worst results in terms of mean PROM at each time point examined when compared to Protocol B and C (p < 0,05). In the TO group, patients within Protocol B had better PROM values at T1 (p < 0,05) and T2 (p < 0,05) compared to Protocol C, but no differences were highlighted at T3. In the TOE group, no statistically significant differences were found between patients within Protocol B and C at each time point examined. DASH: In the TO group, no statistically significant differences were found regarding the DASH values comparing Protocol B vs Protocol C, but they were highlighted comparing the values between Protocol A and Protocol B (p < 0,05), and between Protocol A and Protocol C (p < 0,05). Similar results were recorded in the TOE group. CONCLUSION Post-operative pain is influenced by the surgical technique used being transosseous more painful in the first 15 days after surgery. Oral anti-inflammatory drugs are a feasible strategy to appropriately control post-operative pain. An association between Paracetamol and either Codein or Ibuprofen can lead to better outcomes in terms of VAS reduction and early recovery of passive ROM.
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Affiliation(s)
- Claudio Chillemi
- Department of Orthopaedic Surgery, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy.
| | - Marco Damo
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy
| | - Riccardo Proietti
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy
| | - Giuseppe Polizzotti
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy
| | - Stefano Ferrari
- Department of Anesthesiology, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy
| | - Francesco Idone
- Department of Anesthesiology, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy
| | - Annamaria Palliccia
- Department of Anesthesiology, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy
| | - Sara Di Rosa
- Department of Medicine Physical and Functional Rehabilitation, Sapienza University of Rome, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy
| | - Stefano Carli
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, Istituto Chirurgico Ortopedico Traumatologico (ICOT), Latina, Italy
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Su P, Liu Y, Zhang L, Bai LB. Comparison of Analgesia Treatment Methods After Arthroscopic Rotator Cuff Repair: A Network Meta-analysis of 42 Randomized Controlled Trials. Orthop J Sports Med 2023; 11:23259671231167128. [PMID: 37346775 PMCID: PMC10280546 DOI: 10.1177/23259671231167128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 06/23/2023] Open
Abstract
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.
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Affiliation(s)
- Peng Su
- Department of Hand and Foot Surgery,
Shandong Provincial Hospital, Shandong First Medical University, Jinan, China
| | - Yijia Liu
- Department of Orthopedic Surgery, West
China Hospital, Sichuan University, Chengdu, China
| | - Lu Zhang
- School of Finance, Qilu University of
Technology (Shandong Academy of Sciences), Jinan, China
| | - Long-bin Bai
- Department of Hand and Foot Surgery,
Shandong Provincial Hospital, Shandong First Medical University, Jinan, China
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Paul RW, Szukics PF, Brutico J, Tjoumakaris FP, Freedman KB. Postoperative Multimodal Pain Management and Opioid Consumption in Arthroscopy Clinical Trials: A Systematic Review. Arthrosc Sports Med Rehabil 2022; 4:e721-e746. [PMID: 35494281 PMCID: PMC9042766 DOI: 10.1016/j.asmr.2021.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/17/2021] [Indexed: 01/01/2023] Open
Affiliation(s)
- Ryan W. Paul
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Patrick F. Szukics
- Rowan University School of Osteopathic Medicine, Department of Orthopaedic Surgery, Stratford, New Jersey, U.S.A
| | - Joseph Brutico
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | | | - Kevin B. Freedman
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
- Address correspondence to Kevin B. Freedman, M.D., Rothman Orthopaedic Institute, Thomas Jefferson University, 825 Old Lancaster Rd., Suite 200, Bryn Mawr, PA, 19010, U.S.A.
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Berton A, Longo UG, De Salvatore S, Sciotti G, Santamaria G, Piergentili I, De Marinis MG, Denaro V. A Historical Analysis of Randomized Controlled Trials in the Management of Pain in Rotator Cuff Tears. J Clin Med 2021; 10:jcm10184072. [PMID: 34575180 PMCID: PMC8470804 DOI: 10.3390/jcm10184072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Alessandra Berton
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico di Roma University, Via Alvaro del Portillo, 200, Trigoria, 00128 Rome, Italy; (A.B.); (S.D.S.); (I.P.); (V.D.)
| | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico di Roma University, Via Alvaro del Portillo, 200, Trigoria, 00128 Rome, Italy; (A.B.); (S.D.S.); (I.P.); (V.D.)
- Correspondence: ; Tel.: +39-062-2541-1613
| | - Sergio De Salvatore
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico di Roma University, Via Alvaro del Portillo, 200, Trigoria, 00128 Rome, Italy; (A.B.); (S.D.S.); (I.P.); (V.D.)
| | - Gaia Sciotti
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, 00128 Rome, Italy; (G.S.); (G.S.); (M.G.D.M.)
| | - Giulia Santamaria
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, 00128 Rome, Italy; (G.S.); (G.S.); (M.G.D.M.)
| | - Ilaria Piergentili
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico di Roma University, Via Alvaro del Portillo, 200, Trigoria, 00128 Rome, Italy; (A.B.); (S.D.S.); (I.P.); (V.D.)
| | - Maria Grazia De Marinis
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, 00128 Rome, Italy; (G.S.); (G.S.); (M.G.D.M.)
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico di Roma University, Via Alvaro del Portillo, 200, Trigoria, 00128 Rome, Italy; (A.B.); (S.D.S.); (I.P.); (V.D.)
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Mallama CA, Greene C, Alexandridis AA, McAninch J, Dal Pan G, Meyer T. Patient-reported opioid analgesic use after discharge from surgical procedures: a systematic review. PAIN MEDICINE 2021; 23:29-44. [PMID: 34347101 DOI: 10.1093/pm/pnab244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This systematic review synthesizes evidence on patient-reported outpatient opioid analgesic use post-surgery. METHODS We searched Pubmed (February 2019), Web of Science and Embase (June 2019) for U.S. studies describing patient-reported outpatient opioid analgesic use. Two reviewers extracted data on opioid analgesic use, standardized use, and performed independent quality appraisals based on the Cochrane Risk of Bias Tool and an adapted Newcastle-Ottawa scale. RESULTS Ninety-six studies met eligibility criteria; 56 had sufficient information to standardize use in oxycodone 5 mg tablets. Patient-reported opioid analgesic use varied widely by procedure type; knee and hip arthroplasty had the highest postoperative opioid use, and use after many procedures was reported as < 5 tablets. In studies that examined excess tablets, 25%-98% of the total tablets prescribed were reported to be excess, with most studies reporting that 50%-70% of tablets went unused. Factors commonly associated with higher opioid analgesic use included preoperative opioid analgesic use, higher inpatient opioid analgesic use, higher postoperative pain scores, and chronic medical conditions, among others. Estimates also varied across studies due to heterogeneity in study design, including length of follow-up and inclusion/exclusion criteria. CONCLUSION Self-reported post-surgery outpatient opioid analgesic use varies widely both across procedures and within a given procedure type. Contributors to within-procedure variation included patient characteristics, prior opioid use, intraoperative and perioperative factors, and differences in timing of opioid use data collection. We provide recommendations to help minimize variation caused by study design factors and maximize interpretability of forthcoming studies for use in clinical guidelines and decision-making.
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Affiliation(s)
- Celeste A Mallama
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Christina Greene
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Apostolos A Alexandridis
- Office of Science, Center for Tobacco Products, United States Food and Drug Administration, Silver Spring MD, USA. The work presented here was conducted while an ORISE fellow with the Center for Drug Evaluation and Research
| | - Jana McAninch
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Gerald Dal Pan
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
| | - Tamra Meyer
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, USA
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Hurley ET, Maye AB, Thompson K, Anil U, Resad S, Virk M, Strauss EJ, Alaia MJ, Campbell KA. Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis. Am J Sports Med 2021; 49:2262-2271. [PMID: 33321046 DOI: 10.1177/0363546520971757] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
| | - Andrew B Maye
- New York University Langone Health, New York, New York, USA
| | | | - Utkarsh Anil
- New York University Langone Health, New York, New York, USA
| | - Sehar Resad
- New York University Langone Health, New York, New York, USA
| | - Mandeep Virk
- New York University Langone Health, New York, New York, USA
| | - Eric J Strauss
- New York University Langone Health, New York, New York, USA
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A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186863. [PMID: 32962199 PMCID: PMC7558823 DOI: 10.3390/ijerph17186863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 12/16/2022]
Abstract
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.
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10
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Chen C, Zuo J, Zhang W. A Systematic Comparison on Postoperative Analgesia Effect Between Subacromial and Intravenous Analgesia Pumps for Arthroscopic Rotator Cuff Repair. J Perianesth Nurs 2020; 35:265-268. [PMID: 32147277 DOI: 10.1016/j.jopan.2019.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/03/2019] [Accepted: 11/25/2019] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Chen Chen
- Department of Anesthesiology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Jianwei Zuo
- Department of Sports Medicine, Peking University Shenzhen Hospital, Shenzhen, China
| | - Wentao Zhang
- Department of Sports Medicine, Peking University Shenzhen Hospital, Shenzhen, China.
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11
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An VVG, Farey JE, Karunaratne S, Smithers CJ, Petchell JF. Subacromial analgesia via continuous infusion catheter vs. placebo following arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized trials. J Shoulder Elbow Surg 2020; 29:471-482. [PMID: 32067710 DOI: 10.1016/j.jse.2019.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 11/21/2019] [Accepted: 11/23/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Subacromial analgesia (SAA) is hypothesized to reduce pain after arthroscopic shoulder surgery by delivering a continuous infusion of local anesthetic directly to the surgical site. The purpose of this systematic review and meta-analysis was to evaluate the efficacy of SAA vs. placebo for pain relief after arthroscopic subacromial shoulder procedures. METHODS MEDLINE, Embase, PubMed, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials comparing SAA with placebo after arthroscopic shoulder surgery. Outcomes collected included pain scores (converted to equivalent ordinal visual analog scores; minimal clinically important difference 1.4 cm), oral morphine equivalents used postoperatively, and catheter-related complications. Meta-analysis was performed via a random-effects model. Included trials underwent a risk of bias and quality of evidence assessment. RESULTS Nine studies involving 459 participants were included. There were no clinically significant changes for pain scores in SAA at 6-, 12-, 24-, and 48-hour postoperative timepoints. Patients receiving SAA used less morphine equivalents of pain medication at 12 hours only (-0.37 mg, 95% confidence interval: -0.63 to -0.11), but there was no significant difference at 24 and 48 hours. There were no major complications (infection or reoperation). Included trials demonstrated a moderate risk-of-bias, and low to very low quality of evidence for primary outcomes. CONCLUSION Subacromial continuous infusion of local anesthetic does not provide a clinically significant benefit compared with placebo as part of a multimodal analgesia regime after arthroscopic subacromial surgical procedures. Future, high-quality trials are required to further assess the efficacy of SAA against placebo.
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Affiliation(s)
- Vincent V G An
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
| | - John E Farey
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Sascha Karunaratne
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Christopher J Smithers
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Jeffrey F Petchell
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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12
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Paladini G, Di Carlo S, Musella G, Petrucci E, Scimia P, Ambrosoli A, Cofini V, Fusco P. Continuous Wound Infiltration of Local Anesthetics in Postoperative Pain Management: Safety, Efficacy and Current Perspectives. J Pain Res 2020; 13:285-294. [PMID: 32099452 PMCID: PMC6999584 DOI: 10.2147/jpr.s211234] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/14/2020] [Indexed: 12/18/2022] Open
Abstract
Local infiltration and continuous infusion of surgical wound with anesthetics are parts of multimodal analgesia for postoperative pain control. The techniques, given the simplicity of execution that does not increase the timing of the intervention and does not require additional technical skills, are applied in several kinds of surgeries. The continuous wound infiltration can be used for days and a variety of continuous delivery methods can be chosen, including patient-controlled analgesia, continuous infusion or intermittent bolus. The purpose of this narrative review is to analyze the literature, in particular by researching the safety, efficacy and current perspectives of continuous wound infiltration for postoperative pain management in different surgical settings. We have identified 203 articles and 95 of these have been taken into consideration: 17 for the lower limb surgery; 7 for the upper limb surgery, 51 for the laparotomy/laparoscopic surgery of the abdominopelvic area, 13 studies regarding breast surgery and 7 for cardiothoracic surgery. The analysis of these studies reveals that the technique has a variable effectiveness based on the type of structure involved: it is better in structures rich in subcutaneous and connective tissue, while the effectiveness is limited in anatomic districts with a greater variability of innervation. However, regardless the heterogeneity of results, a general reduction in pain intensity and in opioid consumption has been observed with continuous wound infiltration: it is an excellent analgesic technique that can be included in the multimodal treatment of postoperative pain or represents a valid alternative when other options are contraindicated.
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Affiliation(s)
- Giuseppe Paladini
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Stefano Di Carlo
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti, Chieti, Italy
| | - Giuseppe Musella
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Emiliano Petrucci
- Department of Anesthesia and Intensive Care, San Salvatore Academic Hospital of L'Aquila, L'Aquila, Italy
| | - Paolo Scimia
- Department of Anesthesia and Intensive Care, ASUR Marche AV5, San Benedetto Del Tronto, Italy
| | - Andrea Ambrosoli
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Vincenza Cofini
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Pierfrancesco Fusco
- Department of Anesthesia and Intensive Care, San Salvatore Academic Hospital of L'Aquila, L'Aquila, Italy
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13
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Hajewski CJ, Westermann RW, Holte A, Shamrock A, Bollier M, Wolf BR. Impact of a Standardized Multimodal Analgesia Protocol on Opioid Prescriptions After Common Arthroscopic Procedures. Orthop J Sports Med 2019; 7:2325967119870753. [PMID: 31598527 PMCID: PMC6764056 DOI: 10.1177/2325967119870753] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Excessive prescription of opioids has become a national problem. Providers
must attempt to decrease the amount of opioids prescribed while still
providing patients with adequate pain relief after surgery. Hypothesis: Implementing a standardized multimodal analgesic protocol will decrease the
amount of opioids prescribed at the time of surgery as well as the total
amount of opioids dispensed postoperatively. Study Design: Case series; Level of evidence, 4. Methods: Patients who had undergone meniscectomy, rotator cuff repair (RCR), or
anterior cruciate ligament (ACL) reconstruction at our institution were
identified by Current Procedural Terminology code 12 months prior to and 6
months after the initiation of a standardized multimodal postoperative pain
protocol. Records were reviewed to extract demographic data, amount of
opioids prescribed at the time of surgery, amount and frequency of opioid
refills, and call-ins regarding pain medication or its side effects. A
Wilcoxon rank-sum test was used to evaluate differences in opioid
prescriptions between pre- and postprotocol, and significance was set to
P < .05. Results: The mean amount of opioids prescribed at the time of surgery decreased from
63.5 to 22.3 pills (P < .0001) for meniscectomy, from
73.3 to 39.7 (P < .0001) for ACL reconstruction, and
from 75.6 to 39.8 (P < .0001) for RCR. The percentage of
patients receiving a refill of opioids during the postoperative period also
decreased for all groups: from 13% to 4% (P = .0051) for
meniscectomy, 29.2% to 11.4% (P = .0005) for ACL
reconstruction, and 47.3% to 24.4% (P < .0001) for RCR.
There was no significant difference in patient calls regarding pain
medication or its side effects. Conclusion: Institution of a standardized multimodal analgesia protocol significantly
decreased the amount of opioids dispensed after common arthroscopic
procedures. This reduction in the amount of opioids given on the day of
surgery did not result in an increased demand for refills. Our study also
demonstrated that 20 opioid pills were adequate for patients undergoing
meniscectomy and 40 pills were adequate for ACL reconstruction and RCR in
the majority of cases. This protocol serves as a way for providers to
decrease the amount of opioids dispensed after surgery while providing
patients with alternatives for pain relief.
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Affiliation(s)
| | | | - Andrew Holte
- University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Alan Shamrock
- University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Matthew Bollier
- University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Brian R Wolf
- University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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14
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Toma O, Persoons B, Pogatzki-Zahn E, Van de Velde M, Joshi GP. PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2019; 74:1320-1331. [PMID: 31392721 PMCID: PMC6771830 DOI: 10.1111/anae.14796] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2019] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- O Toma
- Institute for Anaesthesiology, Spital STS AG, Thun, Switzerland.,University of East Anglia, Norwich, UK
| | - B Persoons
- Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and University Hospital Leuven, Belgium
| | - E Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care, and Pain Medicine, University Hospital Münster, Germany
| | - M Van de Velde
- Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and University Hospital Leuven, Belgium
| | - G P Joshi
- Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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15
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Rasmussen JK, Nikolajsen L, Bjørnholdt KT. Acute postoperative pain after arthroscopic rotator cuff surgery: A review of methods of pain assessment. SICOT J 2018; 4:49. [PMID: 30465647 PMCID: PMC6250077 DOI: 10.1051/sicotj/2018042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/10/2018] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
| | - Lone Nikolajsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Research, C319, Palle Juul Jensens Boulevard 99, Aarhus, Denmark
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16
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Lovecchio F, Derman P, Stepan J, Iyer S, Christ A, Grimaldi P, Kumar K, Ranawat A, Taylor SA. Support for Safer Opioid Prescribing Practices: A Catalog of Published Use After Orthopaedic Surgery. J Bone Joint Surg Am 2017; 99:1945-1955. [PMID: 29135671 DOI: 10.2106/jbjs.17.00124] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Francis Lovecchio
- 1Departments of Orthopaedic Surgery (F.L., P.D., J.S., S.I., A.C., P.G., A.R., and S.A.T.) and Anesthesiology (K.K.), Hospital for Special Surgery, New York, NY
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17
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Ko SH, Cho SD, Lee CC, Choi JK, Kim HW, Park SJ, Bae MH, Cha JR. Comparison of Arthroscopically Guided Suprascapular Nerve Block and Blinded Axillary Nerve Block vs. Blinded Suprascapular Nerve Block in Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial. Clin Orthop Surg 2017; 9:340-347. [PMID: 28861202 PMCID: PMC5567030 DOI: 10.4055/cios.2017.9.3.340] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 05/05/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The purpose of this study was to compare the results of arthroscopically guided suprascapular nerve block (SSNB) and blinded axillary nerve block with those of blinded SSNB in terms of postoperative pain and satisfaction within the first 48 hours after arthroscopic rotator cuff repair. METHODS Forty patients who underwent arthroscopic rotator cuff repair for medium-sized full thickness rotator cuff tears were included in this study. Among them, 20 patients were randomly assigned to group 1 and preemptively underwent blinded SSNB and axillary nerve block of 10 mL 0.25% ropivacaine and received arthroscopically guided SSNB with 10 mL of 0.25% ropivacaine. The other 20 patients were assigned to group 2 and received blinded SSNB with 10 mL of 0.25% ropivacaine. Visual analog scale (VAS) score for pain and patient satisfaction score were assessed 4, 8, 12, 24, 36, and 48 hours postoperatively. RESULTS The mean VAS score for pain was significantly lower 4, 8, 12, 24, 36, and 48 hours postoperatively in group 1 (group 1 vs. group 2; 5.2 vs. 7.4, 4.1 vs. 6.1, 3.0 vs. 5.1, 2.1 vs. 4.2, 0.9 vs. 3.9, and 1.3 vs. 3.3, respectively). The mean patient satisfaction score was significantly higher at postoperative 4, 8, 12, 24, 36, and 48 hours in group 1 (group 1 vs. group 2; 6.7 vs. 3.9, 7.4 vs. 5.1, 8.8 vs. 5.9, 9.2 vs. 6.7, 9.5 vs. 6.9, and 9.0 vs. 7.2, respectively). CONCLUSIONS Arthroscopically guided SSNB and blinded axillary nerve block in arthroscopic rotator cuff repair for medium-sized rotator cuff tears provided more improvement in VAS for pain and greater patient satisfaction in the first 48 postoperative hours than blinded SSNB.
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Affiliation(s)
- Sang Hun Ko
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Sung Do Cho
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Chae Chil Lee
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jang Kyu Choi
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Han Wook Kim
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seon Jae Park
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Mun Hee Bae
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jae Ryong Cha
- Department of Orthopedics Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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18
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Warrender WJ, Syed UAM, Hammoud S, Emper W, Ciccotti MG, Abboud JA, Freedman KB. Pain Management After Outpatient Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials. Am J Sports Med 2017; 45:1676-1686. [PMID: 27729319 DOI: 10.1177/0363546516667906] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Effective postoperative pain management after shoulder arthroscopy is a critical component to recovery, rehabilitation, and patient satisfaction. PURPOSE This systematic review provides a comprehensive overview of level 1 and level 2 evidence regarding postoperative pain management for outpatient arthroscopic shoulder surgery. STUDY DESIGN Systematic review. METHODS We performed a systematic review of the various modalities reported in the literature for postoperative pain control after outpatient shoulder arthroscopy and analyzed their outcomes. Analgesic regimens reviewed include regional nerve blocks/infusions, subacromial/intra-articular injections or infusions, cryotherapy, and oral medications. Only randomized control trials with level 1 or level 2 evidence that compared 2 or more pain management modalities or placebo were included. We excluded studies without objective measures to quantify postoperative pain within the first postoperative month, subjective pain scale measurements, or narcotic consumption as outcome measures. RESULTS A combined total of 40 randomized control trials met our inclusion criteria. Of the 40 included studies, 15 examined nerve blocks, 4 studied oral medication regimens, 12 studied subacromial infusion, 8 compared multiple modalities, and 1 evaluated cryotherapy. Interscalene nerve blocks (ISBs) were found to be the most effective method to control postoperative pain after shoulder arthroscopy. Increasing concentrations, continuous infusions, and patient-controlled methods can be effective for more aggressively controlling pain. Dexamethasone, clonidine, intrabursal oxycodone, and magnesium have all been shown to successfully improve the duration and adequacy of ISBs when used as adjuvants. Oral pregabalin and etoricoxib administered preoperatively have evidence supporting decreased postoperative pain and increased patient satisfaction. CONCLUSION On the basis of the evidence in this review, we recommend the use of ISBs as the most effective analgesic for outpatient arthroscopic shoulder surgery.
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Affiliation(s)
| | - Usman Ali M Syed
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sommer Hammoud
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - William Emper
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael G Ciccotti
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph A Abboud
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kevin B Freedman
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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19
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Cuff DJ, O'Brien KC, Pupello DR, Santoni BG. Evaluation of Factors Affecting Acute Postoperative Pain Levels After Arthroscopic Rotator Cuff Repair. Arthroscopy 2016; 32:1231-6. [PMID: 26895783 DOI: 10.1016/j.arthro.2015.12.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate multiple preoperative and operative factors that may be predictive of and correlate with acute postoperative pain levels after arthroscopic rotator cuff repair. METHODS One hundred eighty-one patients underwent arthroscopic rotator cuff surgery along with subacromial decompression and met the inclusion criteria for this study. Postoperative visual analog scale (VAS) scores were obtained on postoperative days 1, 7, and 90. Multivariate linear regression analysis was used to correlate postoperative VAS scores with multiple independent factors, including preoperative subjective pain tolerance, preoperative VAS score, preoperative narcotic use, sex, smoking status, number of suture anchors used, tear size, single- or double-row repair, and patient age. RESULTS Preoperative subjective pain tolerance, notably those patients rating themselves as having an extremely high pain tolerance, was the most significant predictor of high VAS pain scores on both postoperative day 1 (P = .0001) and postoperative day 7 (P < .0001). Preoperative narcotic use was also significantly predictive (P = .010) of high pain scores on postoperative day 1 and day 7 (P = .019), along with nonsmokers (P = .008) and younger patients (P = .006) being predictive on day 7. There were no patient factors that were predictive of VAS scores 3 months postoperatively (P = .567). CONCLUSIONS Preoperative subjective pain tolerance, notably those patients rating themselves as having an extremely high pain tolerance, was the strongest factor predicting high acute pain levels after arthroscopic rotator cuff surgery. Preoperative narcotic use, smokers, and younger patients were also predictive of higher pain levels during the first postoperative week. LEVEL OF EVIDENCE Level IV, prognostic case series.
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Affiliation(s)
- Derek J Cuff
- Suncoast Orthopaedic Surgery and Sports Medicine, Venice, Florida, U.S.A..
| | | | - Derek R Pupello
- Foundation for Orthopaedic Research & Education, Tampa, Florida, U.S.A
| | - Brandon G Santoni
- Foundation for Orthopaedic Research & Education, Tampa, Florida, U.S.A
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20
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Local infiltration analgesia versus continuous interscalene brachial plexus block for shoulder replacement pain: a randomized clinical trial. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1245-52. [DOI: 10.1007/s00590-015-1678-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/29/2015] [Indexed: 01/01/2023]
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21
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Lee HJ, Kim YS, Park I, Ha DH, Lee JH. Administration of analgesics after rotator cuff repair: a prospective clinical trial comparing glenohumeral, subacromial, and a combination of glenohumeral and subacromial injections. J Shoulder Elbow Surg 2015; 24:663-8. [PMID: 25648969 DOI: 10.1016/j.jse.2014.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 11/25/2014] [Accepted: 12/06/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Local analgesic injections are commonly used for pain relief after shoulder surgery. The aim of this study was to compare the efficacy of local injections administered in the glenohumeral joint, the subacromial space, or both locations after arthroscopic rotator cuff repair. METHODS Between March 2011 and December 2011, 121 consecutive patients who had undergone arthroscopic rotator cuff repair surgery were enrolled in the study and all patients were randomly allocated to 3 groups. In group 1, 40 patients received a postoperative glenohumeral injection of bupivacaine (20 mL) and lidocaine (10 mL). In group 2, 42 patients received the same postoperative injection, but it was administered in the subacromial space. In group 3, 39 patients received the same amount of local anesthesia but with half injected in the glenohumeral joint and half in the subacromial space. The visual analog scale was used to assess pain intensity before surgery and at postoperative hours 1, 2, 6, 12, and 24. Demerol was used as a postinjection rescue analgesic, and the total number of administrations was recorded at each time point. RESULTS There were no significant differences between groups in patient age, sex, or rotator cuff tear size (P > .05). The visual analog scale scores for pain between each group were not significantly different at any time point, including before surgery (P > .05). In addition, the amount of supplementary analgesic administered was not significantly different between the groups (P > .05). CONCLUSION Injection of local analgesics after arthroscopic rotator cuff repair relieves postoperative pain regardless of the injection location.
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Affiliation(s)
- Hyo-Jin Lee
- Department of Orthopaedic Surgery, Wonkwang University Sanbon Hospital, Wonkwang University of School of Medicine, Gunpo, Gyeonggi-do, South Korea
| | - Yang-Soo Kim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - In Park
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Dae-Ho Ha
- Department of Orthopaedic Surgery, Wonkwang University Sanbon Hospital, Wonkwang University of School of Medicine, Gunpo, Gyeonggi-do, South Korea
| | - Jun-Hyung Lee
- Department of Orthopaedic Surgery, Wonkwang University Sanbon Hospital, Wonkwang University of School of Medicine, Gunpo, Gyeonggi-do, South Korea
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Marcheggiani Muccioli GM, Wykes P, Hundle B, Grassi A, Roatti G, Funk L. Effects of a synovial fluid substitute on early recovery after arthroscopic subacromial decompression of the shoulder. Musculoskelet Surg 2014; 99:121-6. [PMID: 25346096 DOI: 10.1007/s12306-014-0341-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 10/10/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this pilot study was to determine whether the use of a synovial fluid substitute (Viscoseal) after arthroscopic subacromial decompression (ASD) of the shoulder was safe (primary outcome) and effective in reducing the postsurgical pain on the day of surgery and the time from surgery to discharge (secondary outcomes), compared with patients undergoing standard ASD alone. METHODS Forty-six patients with primary isolated shoulder subacromial impingement were randomly assigned to either undergo SAD alone (control group: n = 21) or to receive 10 ml Viscoseal into the subacromial space at the end of the procedure (treatment group: n = 25). RESULTS No adverse events were reported in either group. All clinical scores improved significantly in each group from preoperative to 12-week follow-up (p < 0.01). The Viscoseal group experienced significantly (p = 0.001) less severe pain 4 h after the surgery {mean 54.0 ± 43.1, median 50 [interquartile range (IQR) 0-100]} and shorter time from surgery to discharge [mean 5.2 ± 1.4, median 5 (IQR 4-6)] than the control group [mean 102.4 ± 40.2, median 100 (IQR 50-150) and mean 11.0 ± 5.3, median 12 (IQR 6-16), respectively]. The Viscoseal group also required less analgesia postoperatively than the control group in the first 8 h: 24% of the Viscoseal required no analgesia, while all patients in the control group required analgesia; 24% of the control group required opiates compared with 4% in the Viscoseal group. CONCLUSION Viscoseal was safe and well tolerated after shoulder arthroscopy. It provided excellent pain relief and a faster discharge time after ASD of the shoulder. The use of Viscoseal should be investigated in larger randomized controlled trials and for other shoulder arthroscopy procedures. LEVEL OF EVIDENCE Level II, Pilot Prospective Comparative Study.
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Affiliation(s)
- G M Marcheggiani Muccioli
- Laboratorio di Biomeccanica ed Innovazione Tecnologica - Istituto Ortopedico Rizzoli, University of Bologna, via di Barbiano, 1/10, 40100, Bologna, Italy,
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