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The Effect of Perioperative Ketorolac Administration on Opioid Use After Hip Arthroscopy.
Cunningham, D, Lewis, B
Orthopedics. 2021;(3):e417-e421
Abstract
Patients undergoing hip arthroscopy often have postoperative pain that is managed in part with opioids. The hypothesis of this study was that administration of ketorolac at the conclusion of the case may improve postoperative pain control and reduce opioid use. This investigation was a retrospective, observational study of opioid use, pain, and time spent in the postanesthesia care unit (PACU) among opioid-naïve patients undergoing primary hip arthroscopy (Current Procedural Terminology code 29914 or 29916) for femoroacetabular impingement syndrome before and after the institution of a surgeon-driven policy to administer ketorolac at the end of the case. Baseline characteristics and perioperative ketorolac administration were recorded. Outcomes included opioids used in the PACU through discharge measured in oral morphine equivalents, time spent in the PACU, and pain reported by the patient in the PACU. Comparative statistics, including multivariable main effects linear regression modeling, were performed to determine the effect of ketorolac administration on outcomes. Patients who did not receive ketorolac consumed a median of 22.5 oral morphine equivalents in the PACU through discharge, whereas patients who received ketorolac consumed a median of 17.5 oral morphine equivalents. No significant difference was found in pain reported or time spent in the PACU through discharge, although the results favored ketorolac administration. This study showed a modest but statistically significant reduction in early postoperative opioid use among patients receiving ketorolac at closure. Ketorolac could be part of a multimodal preemptive pain management strategy to help to reduce postoperative opioid use. [Orthopedics. 2021;44(3):e417-e421.].
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Hydrogen Peroxide Does Not Significantly Reduce Cutibacterium acnes Suture Contamination in Arthroscopic Rotator Cuff Repair.
Yamakado, K
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2021;(4):1134-1140
Abstract
PURPOSE To evaluate the efficacy of application of the 3% hydrogen peroxide (HP)-soaked gauze as an addition to the standard preoperative sterile skin preparation for Cutibacterium acnes suture contamination in arthroscopic rotator cuff repairs. METHODS A prospective randomized study was undertaken to evaluate 151 consecutive patients undergoing arthroscopic rotator cuff repair. Each shoulder was prepared with 1 of the 2 randomly selected protocols: chlorhexidine alcohol (1% chlorhexidine gluconate in 70% isopropyl alcohol)(control group) and chlorhexidine alcohol with 3% HP (HP-treated group). In the HP-treated group, the 3% HP-soaked gauze was applied over the shoulder for 5 minutes before the application of the chlorhexidine-alcohol. The first cut-tails of the anchor suture after cuff fixation were submitted to aerobic and anaerobic cultures. Patients were clinically evaluated for infection 10 days, 28 days, 3 months, 6 months, and 12 months after surgery. RESULTS The rate of C acnes-positive cultures was 13.0% (10 of 77 cases) in the control group and 6.8% (5 of 74 cases) in the HP-treated group. The HP-treated group showed a trend of lower C acnes-positive culture rate, which did not reach statistical significance (relative risk, 0.52; 95% confidence interval, 0.19 and 1.45; number needed to treat, 16.1; P = .20). One case of coagulase-negative Staphylococcus (Staphylococcus intermedius) was isolated in the HP-treated group (1 of 74 cases, 1.3%). No other bacteria were isolated. No infections occurred in any of the patients treated in this study during the minimum 3-month follow-up period. One patient in the HP-treated group complained of skin irritation. CONCLUSIONS The use of a 3% HP-soaked gauze as an addition to the standard preoperative sterile skin preparation for arthroscopic rotator cuff repairs showed only a marginal effect (statistically insignificant) in reducing the C acnes suture contamination rate in the arthroscopic rotator cuff repair patients. LEVEL OF EVIDENCE I, prospective, randomized trial.
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A comparison of ice wrap and subacromial injection for postoperative pain and edema control following arthroscopic rotator cuff repair.
Kara, YS, Hapa, O, Işın, Y, Kılıç, Aİ, Havitçioğlu, H
Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology. 2020;(1):17
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Abstract
BACKGROUND Postoperative pain and edema are the most common problems associated with arthroscopic rotator cuff repair. The purpose of the present study was to compare ice wrap and subacromial injection (SI) as treatments for early postop pain and edema control and to contrast them with a control group. MATERIALS AND METHODS 59 patients treated with arthroscopic rotator cuff repair were randomized into three groups: 23 patients who received an ice wrap, 20 patients who received a SI, and a control group of 16 patients. RESULTS Patient demographics, comorbidities, tear retraction, degree of fatty muscle degeneration, surgical procedures, and amount of irrigation fluid were similar for the three groups, which also showed similar results regarding postoperative pain and edema control as well as analgesic consumption. CONCLUSIONS The present study failed to show any difference in effectiveness between the two most common pain management modalities, or between those modalities and the control group. LEVEL OF EVIDENCE IV, prospective observational study.
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Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodeses Produce Similar Outcomes: A Randomized Prospective Analysis.
Forsythe, B, Zuke, WA, Agarwalla, A, Puzzitiello, RN, Garcia, GH, Cvetanovich, GL, Yanke, AB, Verma, NN, Romeo, AA
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2020;(1):23-32
Abstract
PURPOSE To directly compare subjective and objective outcomes of arthroscopic suprapectoral biceps tenodesis (ASPBT) below the bicipital groove and open subpectoral biceps tenodesis (OSPBT) performed with interference screw fixation. METHODS A total of 77 patients indicated for biceps tenodesis who met the inclusion and exclusion criteria were randomized into the ASPBT and OSPBT groups. All tenodesis procedures implemented PEEK (polyether ether ketone) interference screws. Patients underwent a clinical examination that included range of motion and strength assessment at 3, 6, and 12 months postoperatively. Patients completed the American Shoulder and Elbow Surgeons (ASES) shoulder score, Single Assessment Numeric Evaluation score, and Constant score preoperatively and at 6 and 12 months postoperatively. RESULTS Seventy-five patients were analyzed with a mean age of 50.3 ± 10.4 years and a mean body mass index of 28.9 ± 6.3. All patients had arthroscopic evidence of biceps pathology and underwent either an ASPBT (n = 37) or OSPBT (n = 38). The surgical time was significantly greater for ASPBT than for OSPBT (16.9 ± 8.4 minutes vs 9.8 ± 3.1 minutes, P < .001). One patient underwent conversion from the ASPBT group to the OSPBT group because of shearing of a severely attenuated tendon preventing an ASPBT. No significant difference (P > .05) was found in strength or anterior shoulder pain at 3 months, 6 months, and 1 year, and no significant difference (P > .05) was found in clinical outcome scores (ASES, Constant subjective, and Single Assessment Numeric Evaluation) between the 2 groups at 6 months and 1 year. The improvement in the ASES score exceeded the minimal clinically important difference (12 points) in both groups. CONCLUSIONS No differences in patient-reported outcome measures, functional outcomes, or complication rates were found after ASPBT compared with OSPBT. However, the results of this investigation must be interpreted with caution because this study may be underpowered to detect statistical differences. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Surgical Considerations in Managing Osteoporosis, Osteopenia, and Vitamin D Deficiency During Arthroscopic Rotator Cuff Repair.
Entezari, V, Lazarus, M
The Orthopedic clinics of North America. 2019;(2):233-243
Abstract
Osteopenia and osteoporosis are common in older adults and are associated with increased risk of fragility fractures. Vitamin D deficiency caused by chronic disease, poor nutrition, and inadequate sun exposure affects bone quality. Chronic rotator cuff tears can deteriorate the bone mineral density of the greater tuberosity and have been linked to reduced anchor pullout strength and high re-tear rate after repair especially in older patients with larger tear size. This article summarizes the current evidence on rotator cuff tear and bone quality and provides treatment strategies for rotator cuff repair in patients with poor bone quality.
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Ultrasound-guided adductor canal block after arthroscopic anterior cruciate ligament reconstruction: Effect of adding dexamethasone to bupivacaine, a randomized controlled trial.
Ibrahim, AS, Aly, MG, Farrag, WS, Gad El-Rab, NA, Said, HG, Saad, AH
European journal of pain (London, England). 2019;(1):135-141
Abstract
BACKGROUND Dexamethasone improves the quality and duration of peripheral nerve block when used as an adjuvant to local anaesthetic. We evaluated the effect of adding dexamethasone to bupivacaine on the duration of postoperative analgesia in patients undergoing knee arthroscopy using ultrasound-guided adductor canal block. METHODS The study was a randomized, double-blinded trial. Sixty patients scheduled for arthroscopic anterior cruciate ligament reconstruction were randomly allocated into two groups to receive adductor canal block. The control group received 20 mL bupivacaine 0.5% + 2 mL normal saline, and the dexamethasone group received 20 mL bupivacaine 0.5% + 2 mL dexamethasone (8 mg). Measurements included onset and duration of sensory blockade, visual analog score, time to first analgesic requirement, analgesic consumption, satisfaction score and assessment of quadriceps strength. RESULTS Duration of sensory block was significantly longer in the dexamethasone group (17.42 ± 5.24 h) than the control group (12.52 ± 1.16 h), p < 0.001. The visual analog score was significantly lower (p < 0.05) in the dexamethasone group. Time to first analgesic requirement was significantly longer in the dexamethasone group (13.37 ± 3.68 h) compared with the control group (10.57 ± 0.93 h), p < 0.001. Ketorolac dose as a rescue analgesic was significantly higher in the control group (p < 0.001), whereas patients' satisfaction score was significantly higher in the dexamethasone group (p < 0.001). CONCLUSION The addition of dexamethasone to bupivacaine in adductor canal block provides prolonged postoperative analgesia and less postoperative analgesic consumption than bupivacaine alone in anterior cruciate ligament arthroscopic surgery. SIGNIFICANCE Adding dexamethasone to bupivacaine in adductor canal block significantly increases the duration of sensory block, time to first analgesic requirement and patients' satisfaction score in anterior cruciate ligament arthroscopic surgery.
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Effect of parecoxib sodium pretreatment combined with dexmedetomidine on early postoperative cognitive dysfunction in elderly patients after shoulder arthroscopy: A randomized double blinded controlled trial.
Lu, J, Chen, G, Zhou, H, Zhou, Q, Zhu, Z, Wu, C
Journal of clinical anesthesia. 2017;:30-34
Abstract
STUDY OBJECTIVE To evaluate effect of parecoxib sodium pretreatment combined with dexmedetomidine on early postoperative cognitive dysfunction in elderly patients after shoulder arthroscopy. DESIGN Randomized, double-blind study. SETTING University-affiliated teaching hospital. PATIENTS One hundred and fifty-two elderly patients scheduled for shoulder arthroscopy. INTERVENTIONS At 15min before the induction of anesthesia, 152 patients received intravenously parecoxib sodium 40mg and dexmedetomidine at a dose of 0.5μg/kg over 15min, followed by a continuous infusion at a rate of 0.5μg/kg/h until the end of surgery. Then all patients who received postoperative patient-controlled intravenous analgesia were divided 2 groups: sufentanil(0.04μg/kg/h, S group), sufentanil (0.04μg/kg/h) plus dexmedetomidine(0.06μg/kg/h) (SD group). MEASUREMENTS The mini-mental status examination score in SD group was significantly higher than S group at 1, 2 and 7days after surgery. The incidence of postoperative cognitive dysfunction during 7days after surgery in S and SD groups was respectively 17.1% and 6.7%. Compared with the S group, the visual analogue scale scores at rest and upon movement were significantly lower at 6, 14, 24, 36 and 48h after surgery in SD group; analgesia pump liquid amount during 24h after surgery and number of rescue analgesia during 48h after surgery were significantly lower in SD group. Jugular venous oxygen partial pressure and jugular venous oxygen saturation values in SD group were significantly higher than S group at postoperative 24h. The occurrence of nausea and vomiting within 48h after surgery in SD group were significantly lower than S group. We found no complications including respiratory depression and sinus bradycardia within 48h after surgery in all patients. CONCLUSIONS Parecoxib sodium pretreatment combined with dexmedetomidine could reduce the incidence of early postoperative cognitive dysfunction in elderly patients. This might be related to the improvement of postoperative analgesia effect and cerebral oxygen metabolism in patients.
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Comparison of the postoperative analgesic effects of naproxen sodium and naproxen sodium-codeine phosphate for arthroscopic meniscus surgery.
Bali, C, Ergenoglu, P, Ozmete, O, Akin, S, Ozyilkan, NB, Cok, OY, Aribogan, A
Brazilian journal of anesthesiology (Elsevier). 2016;(2):151-6
Abstract
BACKGROUND AND OBJECTIVES Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used to control arthroscopic pain. Addition of oral effective opioid "codeine" to NSAIDs may be more effective and decrease parenteral opioid consumption in the postoperative period. The aim of this study was to compare the efficacy and side effects of naproxen sodium and a new preparation naproxen sodium-codeine phosphate when administered preemptively for arthroscopic meniscectomy. METHODS Sixty-one patients were randomized into two groups to receive either oral naproxen sodium (Group N) or naproxen sodium-codeine phosphate (Group NC) before surgery. The surgery was carried out under general anesthesia. Intravenous meperidine was initiated by patient-controlled analgesia (PCA) for all patients. The primary outcome measure was pain score at the first postoperative hour assessed by the Visual Analogue Scale (VAS). Sedation assessed by Ramsey Sedation Scale, first demand time of PCA, postoperative meperidine consumption, side effects and hemodynamic data were also recorded. RESULTS The groups were demographically comparable. Median VAS scores both at rest and on movement were significantly lower in Group NC compared with Group N, except 18(th) hour on movement (p<0.05). The median time to the first demand of PCA was shorter in Group N compared with Group NC (p<0.001). Meperidine consumption was higher in Group N compared with Group NC (p<0.001). There was no difference between groups with respect to side effects (p>0.05). CONCLUSIONS The combination of naproxen sodium-codeine phosphate provided more effective analgesia than naproxen sodium and did not increase side effects.
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No difference in long-term development of rotator cuff rupture and muscle volumes in impingement patients with or without decompression.
Ketola, S, Lehtinen, J, Elo, P, Kortelainen, S, Huhtala, H, Arnala, I
Acta orthopaedica. 2016;(4):351-5
Abstract
Background and purpose - Arthroscopic acromioplasty is still commonly used in the treatment of shoulder impingement syndrome, even though its benefits are questioned; randomized controlled studies have not shown any benefits when compared to non-operative treatment. In this randomized study, we investigated whether operative treatment protects from later rotator cuff rupture and whether it has any effect on the development of rotator cuff muscle volume. Patients and methods - 140 stage-II impingement patients were randomized to a structured exercise group (n = 70) or to an operative group (n = 70). In the operative group, arthroscopic acromioplasty was performed, after which a similar structured exercise program was begun. MRI of the shoulder was done at baseline and at 5 years. Results - There were no statistically significant differences in either the amount of perforating ruptures of the supraspinatus tendon or in the changes in muscle volume at 5 years. The grading of muscle fatty degeneration showed worse results in the operative group, but this difference was not statistically significant. Interpretation - In this study, we found that arthroscopic acromioplasty does not have any long-term benefit based on radiological findings of muscle volumes. Also, the frequency of later rotator cuff rupture was similar irrespective of whether or not surgery was performed. Acromioplasty is not justified as a treatment for dynamic shoulder impingement syndrome.
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Compressive cryotherapy versus ice-a prospective, randomized study on postoperative pain in patients undergoing arthroscopic rotator cuff repair or subacromial decompression.
Kraeutler, MJ, Reynolds, KA, Long, C, McCarty, EC
Journal of shoulder and elbow surgery. 2015;(6):854-9
Abstract
BACKGROUND The purpose of this study was to compare the effect of compressive cryotherapy (CC) vs. ice on postoperative pain in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. A commercial device was used for postoperative CC. A standard ice wrap (IW) was used for postoperative cryotherapy alone. METHODS Patients scheduled for rotator cuff repair or subacromial decompression were consented and randomized to 1 of 2 groups; patients were randomized to use either CC or a standard IW for the first postoperative week. All patients were asked to complete a "diary" each day, which included visual analog scale scores based on average daily pain and worst daily pain as well as total pain medication usage. Pain medications were then converted to a morphine equivalent dosage. RESULTS Forty-six patients completed the study and were available for analysis; 25 patients were randomized to CC and 21 patients were randomized to standard IW. No significant differences were found in average pain, worst pain, or morphine equivalent dosage on any day. CONCLUSION There does not appear to be a significant benefit to use of CC over standard IW in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. Further study is needed to determine if CC devices are a cost-effective option for postoperative pain management in this population of patients.