A Comprehensive Enhanced Recovery Pathway for Rotator Cuff Surgery Reduces Pain, Opioid Use, and Side Effects

Perioperative Pain Management for Distal Radius Fractures

Distal radius fractures have a high incidence among both young and elderly patients, and in many instances require operative intervention. When operative intervention is employed, adequate pain management is essential to decrease postoperative complications, such as chronic pain and disability, while minimizing the risk of prolonged opioid use and dependence. Strategies to optimize pain management include regional anesthesia, preoperative dosing of medication, multimodal regimens, long-acting selective opioids at the time of surgery, corticosteroids, and non-pharmacologic therapies.

Identifying modifiable and nonmodifiable cost drivers of ambulatory rotator cuff repair: a machine learning analysis

INTRODUCTION

Implementing novel tools that identify contributors to the cost of orthopedic procedures can help hospitals maximize efficiency, minimize waste, improve surgical decision-making, and practice value-based care. The purpose of this study was to develop and internally validate a machine learning algorithm to identify key drivers of total charges after ambulatory arthroscopic rotator cuff repair and compare its performance with a state-of-the-art statistical learning model.

METHODS

A retrospective review of the New York State Ambulatory Surgery and Services Database was performed to identify patients who underwent elective outpatient rotator cuff repair (RCR) from 2015 to 2016. Initial models were constructed using patient characteristics (age, gender, insurance status, patient income, Elixhauser Comorbidity Index) as well as intraoperative variables (concomitant procedures and services, operative time). These were subsequently entered into 5 separate machine learning algorithms and a generalized additive model using natural splines. Global variable importance and partial dependence curves were constructed to identify the greatest contributors to cost.

RESULTS

A total of 33,976 patients undergoing ambulatory RCR were included. Median total charges after ambulatory RCR were $16,017 (interquartile range: $11,009-$22,510). The ensemble model outperformed the generalized additive model and demonstrated the best performance on internal validation (root mean squared error: $7112, 95% confidence interval: 7036-7188; logarithmic root mean squared error: 0.354, 95% confidence interval: 0.336-0.373, R²: 0.53), and identified major drivers of total charges after RCR as increasing operating room time, patient income level, number of anchors used, use of local infiltration anesthesia/peripheral nerve blocks, non-White race/ethnicity, and concurrent distal clavicle excision. The model was integrated into a web-based open-access application capable of providing individual predictions and explanations on a case-by-case basis.

CONCLUSION

This study developed an ensemble supervised machine learning algorithm that outperformed a sophisticated statistical learning model in predicting total charges after ambulatory RCR. Important contributors to total charges included operating room time, duration of care, number of anchors used, type of anesthesia, concomitant distal clavicle excision, community characteristics, and patient demographic factors. Generation of a patient-specific payment schedule based on the Agency for Healthcare Research and Quality risk of mortality highlighted the financial risk assumed by physicians in flat episodic reimbursement schedules given variable patient comorbidities and the importance of an accurate prediction algorithm to appropriately reward high-value care at low costs.

Clinical care pathways for ambulatory total shoulder arthroplasty

PURPOSE OF REVIEW

Total shoulder arthroplasty (TSA) is growing in popularity and is increasingly done on an ambulatory basis. This review examines recent developments in anesthesia and analgesia for ambulatory shoulder surgery. Pathway components are discussed and a sample pathway is described.

RECENT FINDINGS

Adoption of pathways for shoulder surgery improves patient experience by reducing pain, opioid use, and side effects while improving patient satisfaction. Long-acting nerve blockade using adjuvants like dexamethasone provide long-lasting analgesia without rebound pain. Peripheral nerve blockade provides better analgesia than peri-articular injection of local anesthetic. There are multiple approaches to nerve blockade for shoulder surgery to consider, including interscalene, superior trunk, supraclavicular, and anterior suprascapular nerve blocks. Multimodal analgesia should include acetaminophen and nonsteroidal anti-inflammatory drugs, but routine gabapentinoids should not be used.

SUMMARY

Anesthesiologists should lead the way to create and implement pathways for ambulatory total shoulder arthroplasty, incorporating appropriate patient selection, patient education, long-lasting nerve blockade, and multimodal analgesia.

Multimodal Nonopioid Pain Protocol Provides Better or Equivalent Pain Control Compared to Opioid Analgesia Following Arthroscopic Rotator Cuff Surgery: A Prospective Randomized Controlled Trial

PURPOSE

To evaluate the efficacy of a multimodal nonopioid analgesic protocol in controlling postoperative pain compared to opioids following a primary arthroscopic rotator cuff repair.

METHODS

Seventy consecutive patients undergoing a primary rotator cuff repair were assessed for eligibility. An observer-blinded prospective randomized controlled trial was designed in accordance with the Consolidated Standards of Reporting Trials 2010 (CONSORT) statement. The two arms of the study included a multimodal nonopioid pain regimen for the experimental group, and a standard of care narcotics for the control group. The primary outcome was visual analog scale (VAS) pain scores for the first 10 postoperative days. Secondary outcomes included PROMIS-PI (Patient-Reported Outcomes Measurement Information System-Pain Interference) scale, patient satisfaction, and adverse drug events.

RESULTS

Thirty patients declined to participate or were excluded, and 40 patients were included in the final analysis. A total of 23 patients were in the traditional group, and 17 patients were in the nonopioid group. Control patients on opioid pain management reported a significantly higher VAS pain score on postoperative day 1 (opioid: 5.7 ± 2, nonopioid: 3.7 ± 2.2; P = .011) and postoperative day 4 (opioid: 4.4 ± 2.7, nonopioid: 2.4 ± 2.2; P = .023). No significant difference was seen on any other postoperative day. When mixed measured models were used to control for confounding factors, the nonopioid group demonstrated significantly lower VAS and PROMIS-PI scores (P < .01) at every time point. Patients in the traditional analgesia group reported significantly more days with constipation (P = .003) and days with upset stomach (P = .020) than those in the nonopioid group.

CONCUSSION

The present study found that a multimodal nonopioid pain protocol provided equivalent or better pain control compared to traditional opioid analgesics in patients undergoing primary arthroscopic rotator cuff repair. Minimal side effects were noted with some improvement in the multimodal nonopioid pain cohort. All patients reported satisfaction with their pain management.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

Efficacy of intra-articular ketorolac for pain control in arthroscopic surgeries: a systematic review and meta-analysis

BACKGROUND

The current systematic review and meta-analysis aimed to synthesize evidence on the efficacy of intra-articular ketorolac for patients undergoing arthroscopic surgeries.

METHODS

PubMed, Embase, ScienceDirect, and Google Scholar databases were searched for randomized controlled trials assessing the analgesic effect of intra-articular ketorolac for arthroscopic surgery of hip/knee or shoulder joint.

RESULTS

Six studies were included. Two studies were on shoulder arthroscopy, while others were on knee joint. Meta-analysis revealed that patients receiving intra-articular ketorolac had significantly lower pain scores at 2-4 h (MD: - 0.58 95% CI: - 0.88, - 0.19 I2 = 49% p = 0.002), 6-8 h (MD: - 0.77 95% CI: - 1.11, - 0.44 I2 = 31% p < 0.00001), 12 h (MD: - 0.94 95% CI: - 1.21, - 0.67 I2 = 0% p < 0.00001), and 24 h (MD: - 1.28 95% CI: - 1.85, - 0.71 I2 = 84% p < 0.00001) as compared to the control group (Certainty of evidence: low-moderate). Analysis of three studies revealed a tendency of reduced analgesic consumption in patients receiving intra-articular ketorolac, but the difference did not reach statistical significance (MD: - 0.53 95% CI: - 1.07, 0.02 I2 = 55% p = 0.06).

CONCLUSIONS

Preliminary evidence from a limited number of studies indicates that additional intra-articular ketorolac to multimodal analgesia results in reduced pain scores up to 24 h after arthroscopic surgery. The clinical relevance of small changes in pain scores is debatable. Also, scarce data suggest that consumption of analgesics may not be reduced with intra-articular ketorolac. Since pain scores can be influenced by the primary diagnosis and dose of ketorolac, the results should be interpreted with caution. The certainty of the evidence is low-moderate. There is a need for future RCTs to further strengthen current evidence.