Postoperative Multimodal Pain Management and Opioid Consumption in Arthroscopy Clinical Trials: A Systematic Review

Abstract

Purpose: To provide an updated review of multimodal pain management in arthroscopic surgery by evaluating pain and opioid consumption after shoulder, knee, and hip arthroscopy. Methods: A comprehensive literature search was performed to identify randomized controlled trials (RCTs) investigating multimodal pain management after shoulder, knee, and hip arthroscopy. Articles were identified from January 2011 through December 2020 using various databases. As the primary outcome variables of this study, differences in postoperative pain and opioid consumption volumes were summarized from all reported postoperative time points. Results: 37 shoulder, 28 knee, and 8 hip arthroscopy RCTs were included in the study. The most frequent bias present in the included RCTs was incomplete outcome data (58%), while group allocation concealment was the least frequent bias (15%). Qualitative analysis of rotator cuff repair (n ¼ 12), anterior cruciate ligament reconstruction (n ¼ 11), meniscectomy (n ¼ 5), femoroacetabular impingement (n ¼ 2), oral medications (n ¼ 8), postoperative interventions (n ¼ 10), and nonpharmacological interventions (n ¼ 6) was performed. Conclusions: Many multimodal pain management protocols offer improved pain control and decreased opioid consumption after arthroscopic surgery. On the basis of the current literature, the evidence supports an interscalene nerve block with a dexamethasone-dexmedetomidine combination for rotator cuff repair, a proximal continuous adductor canal block for anterior cruciate ligament reconstruction, and local infiltration analgesia (e.g., periacetabular injection with 20 mL of .5% bupivacaine) for hip arthroscopy. When evaluating oral medication, the evidence supports 150 mg Pregabalin for shoulder arthroscopy, 400 mg Celecoxib for knee arthroscopy, and 200 mg Celecoxib for hip arthroscopy, all taken preoperatively. There is promising evidence for the use of various nonpharmacological modalities, specifically preoperative opioid education for rotator cuff repair patients; however, more clinical trials that evaluate nonpharmacological interventions should be performed.

Multimodal analgesia did not improve post-operative pain scores, reduce opioid consumption or reduce length of stay following hip arthroscopy

“…Third, this study only included the use of adjunctive oral medications and did not include the use of regional anesthesia (aside from peri‐incisional local anesthetic infiltration). However, prior systematic reviews have only reported a significant improvement in pain and reduction in opioid use in a single included clinical trial evaluating the efficacy of femoral nerve blocks in hip arthroscopy; however, this does carry an associated risk of falls [21, 31]. Further study is required of adjunctive regional anesthesia techniques to determine if alternative blocks may provide improved pain control without added perioperative risk.…”

“…While reducing opioid prescriptions is essential, effective pain management is important to improve patient satisfaction and clinical outcomes, particularly when considering ambulatory surgical procedures where successful discharge and avoidable readmissions are tied to the adequacy of postoperative analgesia [1]. The use of multimodal analgesia to improve pain control is gaining significant attention, particularly in sports medicine, with recent publications demonstrating efficacy in shoulder and knee surgery [10, 16, 21]. However, its use and efficacy in hip arthroscopy are incompletely understood.…”

How Patients Dispose of Unused Prescription Opioids: A Survey of over 300 Postoperative Patients

“…Patients returning to pharmacies for prescription renewal or acquisition of step-down medication may be targets for these interventions. Importantly, multimodal pain management strategies are proving effective in reducing postoperative opioid consumption in the orthopedic setting [16]. When combined with a multimodal strategy, point-of-service disposal interventions may further mitigate the risk of diversion of unused opioids.…”

Acute Perioperative Pain Management of the Orthopaedic Patient

“…In a subset of patients who had undergone TKA, nonpharmacological interventions were associated with moderate improvement in pain (Komann et al, 2019). Despite limited outcome data, the promotion of postoperative care that includes both passive and active interventions have demonstrated value (Cheah et al, 2022; Fan & Chen, 2020; Komann et al, 2019; Paul et al, 2021; Tedesco et al, 2017).…”