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…

• 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

• No procedure-specific evidence was found in this literature review.

PROSPECT Recommendations

• Opioids are recommended for rescue postoperative analgesia (Grade D).

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Early versus delayed motion rehabilitation protocols for pain management after rotator cuff repair surgery

Arguments against…

• One study compared early (POD 2–3) versus delayed (POD 28) motion rehabilitation protocols after rotator cuff repair and did not find any difference in pain scores 7–10 days postoperatively (Mazzocca 2017; LoE 2). Opioid consumption was not recorded.

PROSPECT Recommendations

• Specific early or delayed motion protocols are not recommended due to lack of procedure-specific evidence.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Shoulder immobilisation techniques for pain management after rotator cuff repair surgery

• An abduction brace was compared with an antirotation sling as a way to immobilise the shoulder after surgery (Hollman 2017; LoE 2). Neither pain scores nor opioid use after surgery were different between the techniques.

PROSPECT Recommendations

• Specific postoperative shoulder immobilisation devices are not recommended due to limited device-specific evidence.

Rotator Cuff Repair Surgery-Specific Evidence

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

• Postoperative TENS was compared with placebo (Mahure 2017; LoE 2). TENS was associated with lower pain scores at 12 h and on POD 7. Opioid consumption after surgery also favoured TENS.

PROSPECT Recommendations

• TENS is not recommended due to limited procedure-specific evidence.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Compressive cryotherapy for pain management after rotator cuff repair surgery

• Compressive cryotherapy was compared with standard ice wrap (Kraeutler 2015; LoE 1). Neither pain scores nor opioid use after surgery was significantly different.

PROSPECT Recommendations

• Compressive cryotherapy or ice wrapping is not recommended due to lack of procedure-specific evidence.

Rotator Cuff Repair Surgery-Specific Evidence

Data table: Zolpidem (sleep aid) for pain management after rotator cuff repair surgery

• Addition of zolpidem as a sleep aid to multi-modal analgesia was compared with multimodal analgesia only (Cho 2015; LoE 2). Pain scores after surgery were not significantly different; the zolpidem group had lower rescue analgesic requirements.

PROSPECT Recommendations

• Zolpidem as a sleep aid is not recommended due to limited procedure-specific evidence.