Rotator Cuff Repair Surgery 2019

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Paracetamol and NSAIDs/COX-2-selective inhibitors for pain management after rotator cuff repair surgery

Arguments for…

• Pre-operative single-dose IV flurbiprofen 1 mg/kg was compared with placebo in patients receiving intra-articular ropivacaine at the end of the procedure (Takada 2009; LoE 2). Pain scores were significantly lower at 0.5 h, 1 h, 2 h, 4 h and 6 h post-surgery and buprenorphine consumption was lower within the first 2 h post-surgery for flurbiprofen vs placebo.
• In patients receiving PCA for the first 48 postoperative hours, celecoxib, ibuprofen or tramadol were compared for 2 weeks after surgery (Oh 2018; LoE 2). Pain scores and rescue opioids were similar in the three groups at 3 days and 2 weeks after surgery. However, the ‘tear’ rates were higher in the celecoxib group, 24 months after surgery.
• A multimodal pain regimen including pre-operative oral oxycodone, acetaminophen, intra-operative intra-articular morphine, methylprednisolone acetate, ropivacaine 0.75%, and postoperative oral oxycodone, acetaminophen and celecoxib was compared with postoperative oral celecoxib added to IV PCA with fentanyl and ketorolac (Cho 2011; LoE 2). The multimodal pain regimen reduced pain scores immediately after surgery on POD 3, 4 and 5. The multimodal protocol also reduced the likelihood for supplementary IM diclofenac.

PROSPECT Recommendations

• Paracetamol and NSAID or COX-2-specific inhibitor are recommended, administered pre-operatively or intra-operatively and continued postoperatively, unless there are contra-indications (Grade D).
• The analgesic benefits and opioid-sparing effects of these simple analgesics are well described (Joshi 2014, Martinez 2017, Ong 2010, Nir 2016, Apfel 2013).

Rotator Cuff Repair Surgery-Specific Evidence

Data table: IV dexamethasone for pain management after rotator cuff repair surgery

Arguments for…

• The effect of three different doses of IV dexamethasone on the duration of interscalene blockade was compared with placebo (Desmet 2015; LoE 1). Postoperative pain scores and analgesic consumption were not significantly different between the dexamethasone groups, but dexamethasone 2.5 mg and 10 mg produced a significantly longer duration of analgesia.

PROSPECT Recommendations

• Although there is limited procedure-specific evidence, IV dexamethasone is recommended (Grade B) for its ability to increase the analgesic duration of interscalene block and decrease supplemental analgesia use, as well as for its antiemetic effects.
• The analgesic benefits and antiemetic effects of dexamethasone are well described (Waldron 2013, Henzi 2000).

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Gabapentinoids for pain management after rotator cuff repair surgery

Arguments for…

• Oral gabapentin 300 mg administered 2 h pre-operatively was compared with placebo (Bang 2010; LoE 2). Pain scores were significantly lower at 2 h, 6 h and 12 h after surgery, although fentanyl consumption did not differ between the gabapentin and placebo groups.

PROSPECT Recommendations

• Gapabentinoids are not recommended due to limited procedure-specific evidence.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Interscalene brachial plexus block (ISB) for pain management after rotator cuff repair surgery

Arguments for…

• A single-shot interscalene brachial plexus block was compared with placebo (Liu 2017; LoE 1). Pain scores were lower at 1 h, 6 h and 12 h after surgery in the block group, and postoperative opioid use was lower at 6 h after surgery.
• Six studies found that continuous interscalene brachial plexus block provided analgesic benefit compared with no block or single-shot interscalene brachial plexus block:
  • Three groups were compared: continuous interscalene block; single-shot interscalene block; and general anaesthesia with no block (Salviz 2013; LoE 1). The continuous interscalene block group had lower pain scores on POD 1, 2 and 7, and lower opioid consumption on POD 1 and 2.
  • Three groups were compared: single-shot interscalene block, continuous interscalene block and no block (IV meperidine as needed) (Kim 2018; LoE 1). Lower pain scores were found for continuous interscalene block 24 h postoperatively, whereas the use of single-shot interscalene block was associated with higher pain scores 24 h postoperatively.
  • Compared with IV PCA piritramide, continuous interscalene block reduced resting pain scores at 6 h, 24 h and 72 h as well as pain scores during physiotherapy on POD 2 and intra-operative opioid consumption (Hofmann-Kiefer 2008; LoE 2).
  • Three groups were compared: one group with continuous interscalene block with a fixed-rate infusion; another with patient-administered bolus; and a third group with no block, but with IV morphine PCA and ketorolac (Shin 2014; LoE 2). Compared with IV PCA, both continuous interscalene block groups had lower pain scores at 1 h, 4 h, 8 h, 16 h, 24 h, 32 h and 40 h after surgery and needed less supplementary opioid analgesia.
  • Continuous interscalene block was compared with single-shot interscalene block (Malik 2016; LoE 1). The continuous interscalene block group had lower pain scores as well as opioid consumption on POD 1, 2 and 3.
  • Continuous interscalene block was compared with single-shot interscalene block (Gomide 2018; LoE 2). The continuous interscalene block group had significantly lower pain scores and rescue analgesic consumption on POD 1, 2 and 3.
• Three studies found that interscalene block provided more effective analgesia than other block techniques:
  • Three groups with continuous blocks were compared: interscalene brachial plexus block; supraclavicular brachial plexus block; and suprascapular nerve block (Auyong 2018; LoE 1). Pain scores were lower in the continuous interscalene block group without a significant reduction in opioid use.
  • Compared with suprascapular nerve block, interscalene block provided lower pain scores and opioid consumption at 2 h after surgery (Desroches 2016; LoE 2) (see Suprascapular nerve block (SSNB) ± axillary nerve block (ANB) for pain management after rotator cuff repair surgery).
  • Three groups were compared: two groups with continuous interscalene block (initial injection ropivacaine 0.75% or 0.2%, but both groups receiving continuous ropivacaine 0.2% postoperatively), and one group with cervical epidural block (Kim 2016; LoE 1). The groups with continuous interscalene block had lower pain scores at all recorded time-points compared with the cervical epidural group. Pain scores between the two continuous interscalene block groups were similar. Postoperative opioid consumption was not reported.
• Two different concentrations of ropivacaine (0.2% vs. 0.1%) were compared for single-shot interscalene block (Wong 2016; LoE 1). Although pain scores were similar, postoperative opioid consumption was reduced for the first 72 h after surgery by ropivacaine 0.2%.
• Different volumes of ropivacaine 0.75% (5 ml vs. 10 ml) were compared for a single-shot interscalene block (Lee 2011; LoE 2). No differences were found either for pain scores or for opioid consumption.
• Ropivacaine 0.2% vs. ropivacaine 0.3% were compared for continuous interscalene block (Borgeat 2010; LoE 2). No differences were found in pain scores, with lower opioid consumption in the 0.3% group at all time-points during the first 48 h after surgery.
• Bupivacaine 0.125% and 0.25% were compared for continuous interscalene block (Thackeray 2013; LoE 1). Pain scores were lower in the 0.25% group without a significant reduction in opioid use.
• For continuous interscalene block, two locations for catheter placement using neurostimulation were compared: posterior to the superior trunk of the brachial plexus versus anterior to the superior trunk of the brachial plexus (Borgeat 2012; LoE 2). Pain scores were not reported but opioid consumption after surgery was not significantly different.
• Two different settings for continuous interscalene block were compared: 2 ml/h ropivacaine 0.2% with mandatory 5-ml boluses 6-hourly versus 5 ml/h ropivacaine 0.2% plus patient-controlled 5-ml boluses (Fredrickson 2011; LoE 1). Both postoperative pain scores and opioid consumption were similar between groups.

Supporting evidence from shoulder surgery including rotator cuff repair

• A systematic review with meta-analysis of RCTs assessing analgesic effects of single-shot interscalene block in patients undergoing shoulder surgery including rotator cuff repair found that interscalene block was more effective compared with placebo or systemic analgesia (Abdallah 2015). However, the duration of analgesia was short (6 h and 8 h with motion and at rest, respectively) and there was rebound pain at 24 h.

PROSPECT Recommendations

• Interscalene brachial plexus blockade is recommended as the first-choice regional analgesic technique.
• Continuous interscalene brachial plexus block is recommended (Grade A).
• Single-shot interscalene brachial plexus block is recommended (Grade A).
• A continuous interscalene block is favoured over a single-shot interscalene block.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Suprascapular nerve block (SSNB) ± axillary nerve block (ANB) for pain management after rotator cuff repair surgery

Arguments for…

• Two studies found an analgesic benefit of suprascapular nerve block compared with placebo/no block:
  • Compared with placebo, arthroscopic suprascapular nerve block reduced IV fentanyl PCA consumption (Lee 2015; LoE 1). Pain scores were not significantly different.
  • Three groups were compared: combined axillary nerve block and suprascapular nerve block versus suprascapular nerve block only versus no block (Park 2016; LoE 2). Treatment groups had lower pain scores compared with no block at 1 h, 6 h, 12 h and 36 h after surgery. Lower pain scores were also identified up to 48 h after surgery for the combined group versus suprascapular nerve block-only group.
• Addition of a suprascapular nerve block to an interscalene block was investigated in a placebo-controlled study (Lee 2017; LoE 1). Addition of suprascapular nerve block was associated with lower pain scores at 3 h, 6 h, 12 h, 18 h and 24 h after surgery. Opioid consumption was not reported.
• Two studies showed analgesic benefit of addition of an axillary nerve block to a suprascapular nerve block:
  • In a placebo-controlled study, addition of an axillary nerve block to a suprascapular nerve block was investigated (Lee 2014; LoE 2). Pain scores were lower at 1 h, 3 h, 6 h, 12 h, 18 h and 24 h after surgery when ropivacaine 0.75% was used for the axillary nerve block compared with saline. Opioid consumption was not reported.
  • Three groups were compared: combined axillary nerve block and suprascapular nerve block versus suprascapular nerve block only versus no block (Park 2016; LoE 2). Treatment groups had lower pain scores compared with no block at 1 h, 6 h, 12 h and 36 h after surgery. Lower pain scores were also identified up to 48 h after surgery for the combined group versus suprascapular nerve block-only group.

Arguments against…

• Two studies found that interscalene block provided more effective analgesia than suprascapular nerve block:
  • Three groups with continuous blocks were compared: interscalene brachial plexus block; supraclavicular brachial plexus block; and suprascapular nerve block (Auyong 2018; LoE 1). Pain scores were lower in the continuous interscalene block group without a significant reduction in opioid use.
  • Compared with suprascapular nerve block, interscalene block provided lower pain scores and opioid consumption at 2 h after surgery (Desroches 2016; LoE 2).

PROSPECT Recommendations

• Suprascapular nerve block with or without axillary nerve block is recommended (Grade B) as an alternative to interscalene block, but not as the first choice.
• A suprascapular nerve block reduces pain scores and/or opioid use after surgery but does not seem to have analgesic advantages over interscalene block.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Stellate ganglion block for pain management after rotator cuff repair surgery

Arguments against…

• Stellate ganglion block was compared with no block (Choi 2015; LoE 2). Neither postoperative pain scores nor opioid consumption was significantly different between the groups.

PROSPECT Recommendations

• Stellate ganglion block is not recommended due to lack of procedure-specific evidence and increased risk of complications.

Rotator Cuff Repair Surgery-Specific Evidence 

Data table: Cervical epidural block for pain management after rotator cuff repair surgery 

Arguments against…

• Three groups were compared: two groups with continuous interscalene block (initial injection ropivacaine 0.75% or 0.2%, but both groups receiving continuous ropivacaine 0.2% postoperatively), and one group with cervical epidural block (Kim 2016; LoE 1). The groups with continuous interscalene block had lower pain scores at all recorded time-points compared with the cervical epidural group. Pain scores between the two continuous interscalene block groups were similar. Postoperative opioid consumption was not reported.

PROSPECT Recommendations

• Cervical epidural block is not recommended due to lack of procedure-specific evidence and increased risks.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Peri-neural adjuncts for pain management after rotator cuff repair surgery

Perineural glucocorticoids

Arguments for…

• Betamethasone 4 mg added perineurally to ropivacaine 0.375% reduced pain scores at 12 h after surgery and on POD 1 and 7, and also reduced opioid consumption, compared with placebo (Watanabe 2016; LoE 2).
• Perineural placebo, perineural dexamethasone 10 mg and IV dexamethasone 10 mg were compared in patients receiving single-shot interscalene block with ropivacaine 0.5%. Both dexamethasone groups had lower pain scores compared with perineural placebo as well as lower paracetamol and diclofenac use for the first 48 h after surgery (p = 0.03) (Desmet 2013; LoE 1). There were no differences in pain scores or opioid consumption between perineural and IV dexamethasone.

Perineural opioids

Arguments for…

• Perineural buprenorphine 150 μg and IM buprenorphine 150 μg were compared with placebo (Behr 2012; LoE 2). Compared with placebo, both perineural and IM buprenorphine increased the duration of analgesia and reduced opioid consumption. Perineural buprenorphine provided a longer duration of analgesia compared with IM buprenorphine.
• Perineural tramadol 1.5 mg/kg and IM tramadol 1.5 mg/kg were compared with placebo (Alemanno 2012; LoE 2). Perineural and IM tramadol increased the duration of analgesia when compared with placebo. Also, perineural tramadol was more effective in increasing the duration of analgesia when compared with IM tramadol.

Perineural magnesium sulphate

Arguments for…

• 2 ml of perineural magnesium sulphate 10% added to interscalene block reduced pain scores at 12 h postoperatively compared with placebo, but did not reduce opioid consumption (Lee 2012; LoE 1).

Perineural α-2-adrenoceptor agonists

Arguments against…

• Perineural clonidine 150 μg did not influence pain scores or opioid consumption compared with placebo (Faria-Silva 2016; LoE 2).

PROSPECT Recommendations

• Perineural adjuncts including opioid (buprenorphine or tramadol), glucocorticoid (betamethasone or dexamethasone), magnesium sulphate, or α-2-adrenoceptor agonist (clonidine), added to the local anaesthetic solution, are not recommended due to limited procedure-specific evidence.
• IV dexamethasone is recommended over perineural administration.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Subacromial or intra-articular injection/infusion for pain management after rotator cuff repair surgery

Arguments for…

• Subacromial and intra-articular injection of ropivacaine and morphine was associated with lower pain scores at 5 h after surgery and on POD 4 and a reduction in 24-h opioid consumption compared with saline injection (Jo 2014; LoE 1).
• Intra-articular injection of a mixture of bupivacaine and lidocaine was compared with subacromial injection and with a combination of intra-articular and subacromial injections (Lee 2015; LoE 1). There were no significant differences between the three groups with regard to pain scores or opioid consumption.
• Two of three studies found analgesic benefit of subacromial injection/infusion compared with interscalene block:
  • Intra-operative injections of liposomal bupivacaine into the surgical site (with a 10 ml bolus injection as a suprascapular nerve block) were compared to an interscalene block performed with bupivacaine 0.5% (Sethi 2019; LoE 2). Significantly lower pain scores on POD 1 and 2 and significantly lower postoperative opioid consumption on POD 0–5 were found in the liposomal bupivacaine group.
  • Subacromial ropivacaine 0.5% infusion was compared with interscalene ropivacaine 0.125% infusion (Oh 2009; LoE 2). Lower pain scores were found in the subacromial group but there was no significant difference in opioid consumption.
  • After interscalene block with levobupivacaine 0.5%, subacromial continuous postoperative levobupivacaine 0.125% infusion was compared with interscalene continuous postoperative levobupivacaine 0.125% infusion (Koltka 2011; LoE 2). Better pain scores and less opioid consumption were found in the interscalene group.

Arguments against…

• Five of nine studies found no overall analgesic benefit of subacromial injection/infusion compared with placebo/IV analgesia:
  • Subacromial bupivacaine and placebo patch were compared with subacromial saline and fentanyl patch (Merivirta 2013; LoE 1). No significant differences in pain scores or opioid consumption were found between the two groups.
  • Subacromial injection of ropivacaine and morphine was compared with IV fentanyl PCA and ketorolac (Han 2012; LoE 2). Pain scores were lower at 2 h postoperatively in the subacromial group, but opioid consumption was lower in the IV PCA group at 12–48 h postoperatively.
  • No subacromial catheter (control group) was associated with lower pain scores than subacromial infusion with bupivacaine in the immediate postoperative period, and there was no difference in opioid consumption (Schwartzberg 2013; LoE 1).
  • There was no difference in pain scores or opioid consumption between subacromial bupivacaine 0.25% infusion at a rate of 2 ml/h, 5 ml/h or saline infusion (Banerjee 2008; LoE 1).
  • Subacromial infusion with bupivacaine 0.5% was compared with IV PCA with fentanyl and ketorolac (Cho 2007; LoE 2). No significant differences were found in pain scores or opioid consumption between the two groups.
  • Subacromial injection of morphine, ropivacaine and methylprednisolone reduced both pain scores and opioid consumption at 0.5 h, 1 h, 4 h, 6 h, 12 h, 18 h and 24 h after surgery compared with placebo (Perdreau 2015; LoE 2).
  • Patient-controlled subacromial ropivacaine administration was compared with IV PCA comprising fentanyl, ketorolac and ondansetron (Yun 2012; LoE 1). Lower pain scores were found for subacromial infusion at 1 h after surgery, with no difference in opioid consumption.
  • Subacromial bupivacaine 0.5% infusion was associated with lower pain scores at 18 h postoperatively and lower opioid consumption on POD 0, 1 and 2 compared with saline infusion (Merivirta 2012; LoE 1).
  • Subacromial infusion with ropivacaine 0.75% provided lower pain scores for the first 12 h, but no difference in opioid consumption, compared with saline infustion (Coghlan 2009; LoE 1).
• Three different intra-articular injections were compared: morphine 20 mg; morphine 10 mg plus ketamine 50 mg; or saline (Khashan 2016; LoE 1). There was no difference in postoperative pain scores and opioid consumption between the three groups.

PROSPECT Recommendations

• Subacromial/intra-articular injection is not recommended due to inconsistent procedure-specific evidence.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Controlled intra-operative hypotension for pain management after rotator cuff repair surgery

• One study investigated the effects of intra-operative hypotension, induced by either remifentanil, nicardipine or their combination, on pain after rotator cuff repair (Kim 2017; LoE 2). Pain scores after surgery were lower for nicardipine only and nicardipine plus remifentanil as compared with remifentanil only. Opioid use after surgery was not recorded.

PROSPECT Recommendations

• Intra-operative controlled hypotension is not recommended as there is insufficient procedure-specific evidence regarding its analgesic benefits. Moreover, there is a concern that hypotension may increase the risk of a reduction in cerebral perfusion and oxygenation (Bijker 2012, Cox 2018)

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Arthroscopy versus mini-incision for pain management after rotator cuff repair surgery

• Two studies showed an analgesic benefit of an arthroscopic versus a mini-incision approach:
  • An arthroscopic approach was associated with lower pain scores on POD 1 than a mini-incision (Liu 2017; LoE 1).
  • An arthroscopic approach provided lower pain scores on POD 1 and 2 with a reduction in postoperative analgesic consumption compared with mini-incision (Cho 2012; LoE 2).

PROSPECT Recommendations

• An arthroscopic technique is recommended whenever possible as it reduces postoperative pain (Grade B).

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Irrigation for pain management after rotator cuff repair surgery

• Isotonic and hyperosmolar irrigation arthroscopy were compared, with lower pain scores reported after hyperosmolar irrigation at the end of surgery (Capito 2017; LoE 1). Opioid use was not reported.

PROSPECT Recommendations

• Hyperosmotic irrigation arthroscopy is not recommended due to limited procedure-specific evidence.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Fixation/suture technique for pain management after rotator cuff repair surgery

• Single-row anchor fixation was compared with transosseous hardware-free suture repair (Randelli 2017; LoE 1). The transosseous technique provided lower pain scores on week 3 and 4 after surgery. Opioid consumption was not reported.

PROSPECT Recommendations

• Single-row anchor fixation as compared with transosseous hardware-free suture repair is not recommended due to limited procedure-specific evidence.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Platelet-rich plasma for pain management after rotator cuff repair surgery

• Use of platelet-rich plasma was compared with standard arthroscopic rotator cuff repair (D’Ambrosi 2016; LoE 1). Lower pain scores were found with platelet-rich plasma in the first week after surgery. Opioid consumption was not recorded.
• Platelet-rich plasma injection at the supraspinatus attachment was compared with subacromial injection of ropivacaine 1% (Flury 2016; LoE 1). No significant differences were found in pain scores and opioid use after surgery.
• Use of platelet-rich fibrin matrix was compared with standard arthroscopic rotator cuff repair (Weber 2013; LoE 2). No significant differences were found in pain scores or opioid use after surgery.
• A meta-analysis of RCTs found that platelet-rich plasma reduced pain scores 7 days after surgery (Yang 2016; LoE 1). Opioid consumption after surgery was not reported.

PROSPECT Recommendations

• Platelet-rich plasma supplementation is not recommended due to limited and inconsistent procedure-specific evidence.