Pain after rotator cuff repair - why is it such an issue?

Opioid Requirement After Rotator Cuff Repair is Low With a Multimodal

These authors state that "Perhaps the most common serious complication of arthroscopic rotator cuff repair (ARCR) is persistence of opiate medication intake. Patients still receive upwards of 80 oxycodone 5mg pills, or 600 morphine milligram equivalents (MMEs), leading over 20% of opioid-naïve subjects to continue to fill opioid prescriptions beyond 180 days post-surgery - a higher proportion than subjects undergoing any other elective shoulder surgery."

This is a very interesting observation, in that ARCR would seem to be a much less invasive procedure than, for example, open shoulder arthroplasty. The reasons for pain after ARCR require further investigation.

These authors sought to prospectively determine the requirements for opiate medications following ARCR. They also investigated whether a liposomal bupivacaine (LB) interscalene neve block (ISNB) is of greater value to the patient in the reduction of pain and opiate consumption compared to standard bupivacaine ISNB (control) for ARCR.

77% of all patients required fewer than 15 pills postoperatively. The LB group consumed an average of 1.7 fewer pills (13.0 MMEs) on postoperative day (POD) 1 (P= 0.02) and reported statistically lower pain during PODs 1 and 2 (P=0.01 and P= 0.006), as well ascumulatively throughout the study period (P= 0.03). In addition, LB patients 23 remained opioid free at a higher rate (44% vs. 15% in controls, P= 0.03).

Of note, there was no difference in the opioid intake or pain scores after the second postoperative day

The authors point out that "the use of liposomal bupivacaine ISNB is not without its drawbacks. As with any ISNB,  LB confers a risk of adverse side effects such as hypesthesia, nausea, pyrexia, pruritus, constipation, and vomiting.""An expensive formulation, LB costs around 100 times more than standard bupivacaine per dose". Thus one might ask whether the reduction of 1.7 pills justifies this cost.

The authors' suggested protocol is shown below.

However, the manuscript does not comment on their rates of adverse effects from gabapentin, which can be an issue especially in older patients, and the rate of adverse effects from interscalene blocks.

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