Sunday, September 13, 2020

Shoulder arthroplasty and cuff repair - pain management

 Celecoxib Significantly Reduces Opioid Use After Shoulder Arthroplasty

These authors assessed the effect of celecoxib (Celebrex) on pain control and opioid use after either total shoulder replacement (group 1, 78 patients) or rotator cuff repair (RCR, group 2, 79 patients).

Consenting patients were randomized by type of procedure using block randomization to receive either placebo or celecoxib one hour prior to the procedure and for 3 weeks postoperatively. Patients received their study medication or placebo at the time of discharge according to the medication schedule (either celecoxib 200 mg or placebo twice daily for three weeks). Opioid prescription was given to be used in conjunction with the study medication and included oxycodone/acetaminophen, hydrocodone/acetaminophen, codeine, or tramadol.

The primary outcome measure was opioid utilization as measured by morphine equivalent dose (MED).

Compared to the placebo arm, patients prescribed celecoxib took less MED by -168 at 3 weeks in the total population and by -197.7 in the arthroplasty group. 

Similarly, at 6 weeks, total MED used was -199 units for the total population, and -270  in the arthroplasty group. 

No statistically significant differences in opioid consumption were found between study arms in the cuff repair group, either at 3 or 6 weeks. 

Preoperative opioid use was statistically associated with higher levels of opioid use in the total population and group 1 at 3 and 6 weeks,  but not in group 2.

Comment: This article nicely points out the potential advantage of celecoxib, but their discussion also highlights the potential downsides of  COX-2 inhibitors, including potentially serious cardiovascular issues, thrombosis, and stroke. Another potential concern is that COX 2 inhibitors have been shown to have a deleterious effect on tendon to bone healing. For example patients on anti-inflammatory medications are reported to have significantly higher re-tear rate after cuff repair. In shoulder arthroplasty, healing of the subscapularis repair in anatomic shoulder arthroplasty is essential for good long term results after anatomic shoulder arthroplasty. 

Thus the observed benefits of celecoxib must be weighed off against the potential risk of subscapularis failure. 

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