Total shoulder arthroplasty - how to manage pain after surgery?

Celecoxib significantly reduces opioid use after shoulder arthroplasty

These authors evaluated the effect of celecoxib on pain control and opioid use after shoulder surgery.

Patients scheduled for either total shoulder replacement (group 1) or rotator cuff repair (group 2) were candidates for the study. Consenting patients were randomized to receive either placebo or celecoxib 1 hour prior to the procedure and for 3 weeks postoperatively. 

Patients received their study medication or placebo at the time of discharge: either celecoxib, 200 mg, or placebo twice daily for 3 weeks. An opioid prescription was given to be used in conjunction with the study medication and included oxycodone-acetaminophen, hydrocodone-acetaminophen, codeine, or tramadol. Patients were instructed to count and record remaining opioids, as well as any opioid refills received. Opioid consumption was calculated as the morphine-equivalent dose (MED) to standardize opioid use among patients.

78 patients were enrolled for arthroplasty (group 1, with 39 receiving celecoxib and 39 receiving placebo) and 79 were enrolled for rotator cuff repair (group 2, with 40 receiving celecoxib and 39 receiving placebo). 

Arthroplasty patients prescribed celecoxib took fewer morphine-equivalent doses than controls at 3 weeks  (–197.7) and at 6 weeks ( –270).

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

Preoperative opioid use was statistically associated with higher levels of opioid use in the arthroplasty group.

The authors point out that potentially serious complications from COX-2 inhibitors can occur, such as cardiovascular issues, thrombosis, and stroke. None of these adverse events were observed in their patient population; however, their population was carefully selected to exclude patients with a history of stroke or cardiovascular events.

They also point out that COX-2 inhibitors may be associated with compromised tendon-to-bone healing. 

Comment: This is an interesting randomized controlled trial showing the effectiveness of celecoxib in reducing narcotic use in selected shoulder arthroplasty patients.  

Our approach to total shoulder arthroplasty can be viewed by clicking here.

To support our research to improve outcomes for patients with shoulder problems, click here.

To subscribe to this blog, enter your email in the box to your right that looks like the below

===
How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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. 

Our approach to total shoulder arthroplasty is shown in this link.

==

To subscribe to this blog, enter your email in the box to your right

=====
How you can support research in shoulder surgery Click on this link.

To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link. Also see the essentials of the ream and run.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery 

Does Celebrex interfere with tendon healing?

Do Selective COX-2 Inhibitors Affect Pain Control and Healing After Arthroscopic Rotator Cuff Repair?

These authors evaluated the efficacy of a selective COX-2 inhibitor in early postoperative pain control, satisfaction with pain management, and incidence of systemic adverse effects in 180 patients undergoing arthroscopic rotator cuff repair.  Patients were randomly allocated in equal numbers (60 each) to receive a selective COX-2 inhibitor (celecoxib, Celebrex 200 mg twice a day), a traditional NSAID (ibuprofen,  385 mg 3 times a day), or an opioid drug (tramadol 50 mg twice a day) for 2 weeks from the first day after surgery.

Magnetic resonance and ultrasonography images of 82 patients were retrospectively reviewed at least 24 months after surgery, along with the range of motion and pain VAS and functional scores.

There were no significant differences among the 3 groups in terms of pain intensity, incidence of adverse effects, or dosage of rescue medication at 3 days or 2 weeks after surgery. Pain VAS and functional scores at the final follow-up were also comparable among the 3 groups. 

However, the retear rate in the celecoxib group (11/30 [37%]) was significantly higher than those in the ibuprofen (2/27 [7%]) and tramadol (1/25 [4%]) groups (P = .009).

The authors conclude that selective COX-2 inhibitors should not be used for postoperative analgesia because they might negatively affect tendon-tobone healing after surgical repair.

Comment: This is an important randomized clinical trial. 

While this study concerns rotator cuff repair, we must be concerned that its conclusion may be applicable to other tendon to bone repairs, such as the subscapularis repair after shoulder arthroplasty. This is especially relevant because of the widespread use of Celebrex as a part of multimodal pain management in a wide range of shoulder procedures. On one hand, celecoxib is known to produce fewer gastrointestinal adverse effects than do traditional NSAIDs and fewer adverse effects, such as nausea, vomiting, and somnolence than opioid drugs, on the other hand these advantages may be offset by drug-related problems with tendon healing.

Non steroidal drugs are believed to have a negative effect on bone and tendon healing, possibly because COX-2 inhibition may lead to reduced prostaglandin synthesis and inhibition of osteoblast function in the early phase of bone formation.  COX-2-specific NSAIDs have been shown to inhibit enthesis formation after tendon repair in animal models with higher rates of healing failure with COX-2 inhibitors in comparison to nonselective COX inhibitors. The pro-inflammatory COX-2/prostaglandin E2 (PGE-2) pathway is thought to be important in stimulating tenocyte proliferation, adhesion, and migration during the early stage of healing. 

Thus while inflammation is associated with pain, it appears to be an important component of tendon to bone healing as well. Balancing the pros and cons of NSAIDs and especially selective COX-2 inhibitors is now a challenge for shoulder surgeons.

=====

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'