Thomas Obermeyer, MD
As the evolution of shoulder arthroplasty permits progressively shorter lengths of hospital stay and performance of these procedures in the ambulatory setting, pain management continues to receive increased attention from patients and physicians. Pain management is critical for timing of discharge, patient participation in early physical therapy, and is highly correlated with patient satisfaction. For some time, opioids have been a cornerstone of pain management, despite the opioid problem in the United States having achieved “epidemic” proportions with use, misuse and diversion. As a result, there is increased awareness of the benefits of limiting opioid exposure in the perioperative period surrounding elective orthopedic surgery. The authors of the study, “Opioid-Free Total Shoulder Arthroplasty” by Van Doren et al, reported on a series of properly selected patients undergoing total shoulder arthroplasty (TSA) who had satisfactory pain management using a multimodal pain approach without opioids. The study was an important demonstration that all providers performing shoulder replacement can make even minor modifications to pain protocols to move closer to eliminating the requirement for opioids, making these procedures increasingly safer for patients.
The study was an important demonstration that all providers performing shoulder replacement can make even minor modifications to pain protocols to move closer to eliminating the requirement for opioids…
The study was a prospective nonrandomized look at 65 patients with a mean age of 71 years undergoing a mix of primary and reverse arthroplasty; one group received opioid medications and the other group did not. Important exclusions were history of prior surgery, renal or liver disease (contraindicating NSAIDs), fractures, and inability to undergo regional anesthesia in the form of an interscalene nerve block. The observation group received interscalene block, intraoperative fentanyl and routine postoperative opioid medications with over the counter NSAIDs when recommended as needed. The intervention group received interscalene block, preoperative gabapentin and celecoxib, intraoperative acetaminophen, periarticular injection of liposomal bupivacaine, in-hospital use of ketorolac (Toradol), and post-discharge oral gabapentin and celecoxib prescriptions with oral acetaminophen as needed.
Notably, there were no statistically significant differences in pain control at baseline or at 24 hours postoperatively (VAS of 2 for intervention group and VAS of 3 for observation). No significant post-discharge pain scores were noted, although at-all-time points there were trends of lower reported scores in the intervention (non-opioid) group. As expected, there was significantly more constipation noted in the observation group receiving opioids but no differences in falls, delirium or nausea.
For shoulder specialists, there are important take home messages and confirmation from this study that the multimodal pain management approach is effective and capable in appropriate patients to completely eliminate opioids. Preoperative gabapentin at 300mg and preoperative celecoxib at 200mg, which are continued postoperatively, are quite helpful (I personally use pregabalin (Lyrica) at 75mg instead of gabapentin which has shown effectiveness in my practice). My hospital has not approved intravenous acetaminophen due to cost, but Toradol is an excellent alternative which is continued postoperatively (30mg IV every 6 hours). I also provide patients with a preoperative loading dose of 1000mg of oral acetaminophen as a substitute for intravenous intraoperative acetaminophen. Liposomal bupivacaine injected into the periarticular soft tissues has shown benefit, although the 2018 JBJS study by Namdari et al questioned the effectiveness of this expensive medication. I use a periarticular cocktail of inexpensive analgesics I adopted from my hip and knee colleagues. This cocktail contains clonidine, morphine, ropivacaine, ketorolac and epinephrine. As in this study, my patients are provided postoperative prescriptions of celecoxib (meloxicam if sulfa allergy) and gabapentin (or Lyrica) and a limited hydrocodone prescription for breakthrough pain.
If we can adopt some, or all, of the analgesic modalities adopted by these authors, we will get closer to the goal of minimizing opioid exposure, limiting risk to patients, expediting discharge and promoting patient satisfaction.
Thomas Obermeyer, MD, is a board-certified and fellowship-trained orthopaedic surgeon in Illinois, specializing in shoulder and elbow reconstruction and sports injuries. Dr. Obermeyer received his medical degree from Albany Medical College and completed his residency at Loyola University Medical Center in Chicago. He went on to complete a fellowship in shoulder and elbow at Mount Sinai Medical Center in New York City. Dr. Obermeyer is also an award-winning researcher and published author.
*The content of this post are the opinion of the author and of no affiliation to Exactech or the products it sells.