Secondary Logo

Journal Logo

CLINICAL RESEARCH

CORR Insights®: A Comprehensive Enhanced Recovery Pathway for Rotator Cuff Surgery Reduces Pain, Opioid Use, and Side Effects

Soubeyrand, Marc MD, PhD1

Author Information
Clinical Orthopaedics and Related Research: August 2021 - Volume 479 - Issue 8 - p 1752-1753
doi: 10.1097/CORR.0000000000001746

Where Are We Now?

In the present study, YaDeau et al. [8] propose a comprehensive clinical pathway for improving recovery after ambulatory arthroscopic rotator cuff surgery. In this work, they tackle the important issue of patients’ pain following arthroscopic surgery on rotator cuff tears.

Tears in rotator cuff tendons cause pain and decreased mobility of the shoulder. It is possible to repair most rotator cuff tears, provided that the tendon has not retracted too much and that there is not yet any atrophy [6]. In the short- to medium-term, repairing the cuff may help relieve pain and gain mobility. In the long-term, it can slow the degeneration process in the shoulder, and more specifically, the progression toward irreparable, massive cuff rupture and cuff-tear arthropathy [3].

In the past three decades, surgeons have focused their attention on developing arthroscopic techniques as the best approach to rotator cuff repair, and I believe that future improvements to our surgical techniques are likely to be incremental rather than revolutionary. They’re generally effective enough to offer to most patients who are fit enough to undergo elective surgery, but many patients delay surgery because of well-founded concerns about postoperative pain [7].

Resecting the subacromial bursa and debriding the bone and tendons generate an inflammatory storm in the subacromial, subdeltoid, and glenohumeral compartments. These compartments are richly innervated by the branches of the suprascapular, axillary, and lateral pectoral nerves, explaining the intensity of the postoperative pain [4]. This pain risks the functional recovery of the operated shoulder; if mobility is not regained because of pain, the final functional result will be poorer than it would otherwise be. Some patients may be at particular risk for developing this complication, and I think surgeons try to identify those patients so as to avoid offering them surgery; this is an imperfect approach, to be sure. It would be better if we could decrease the pain that all patients experience.

In the current study, YaDeau et al. [8] found that with their clinical pathway, pain relief was better than in the control group, but only on the first postoperative day. After the first day, there was no difference between the two groups. The results they obtained are encouraging even if in the end we have to admit that the ideal protocol has not yet been found.

Where Do We Need To Go?

One of the greatest challenges in rotator cuff surgery is finding solutions that reduce postoperative pain intensity for as many patients as possible. This would eventually make it possible to “rescue” more shoulders by preventing further degeneration.

Postoperative pain is caused by both surgical trauma and possible exacerbation of preoperative pain. Based on this simple analysis, I believe there are three complementary ways we might try to reduce postoperative pain, focusing on three specific time periods: before surgery, during surgery, and after surgery.

How Do We Get There?

The first way to reduce our patients’ pain is by having a better preoperative understanding of the pathophysiology of rotator cuff–related shoulder pain. Why are some small rotator cuff tears painful while other, larger tears are not? In addition, not all patients with rotator cuff tears complain of the same pain. Some patients have anterior pain, some have posterior pain, others describe paresthesia. My experience treating patients with this problem tells me that the long head of the biceps or the acromioclavicular (AC) joint can be the cause of pain, leading to specific therapeutic procedures such as tenotomy or tenodesis of the long head of the biceps or resection of the distal clavicle. However, the clinical examination remains rather limited when it comes to affirming that the long biceps or the AC joint should be treated surgically at the time of rotator cuff repair. A distal clavicular resection in case of an asymptomatic AC joint unnecessarily increases the severity of the surgical trauma, and therefore the postoperative pain. Conversely, failing to treat symptomatic AC osteoarthritis during rotator cuff surgery may result in persistent rotator cuff–related shoulder pain that may be exacerbated after surgery.

In addition to the pathologies involving the long head of the biceps and AC joint, there are probably other causes of rotator cuff–related shoulder pain that are poorly understood but still possible to treat. This might include nerve compressions (of the brachial plexus in thoracic outlet syndromes, of the suprascapular nerve around the scapula, or of the median nerve in the carpal tunnel, pain from which can radiate to the shoulder and become the focus of clinical attention) or pain from periscapular muscle contractures (dystonia related to dynamic instability of the glenohumeral joint secondary to cuff rupture, for example) [2].

The second way to decrease our patients’ pain is to reduce the aggressiveness of the surgical procedure itself. Some steps of the operation itself are more likely to cause pain than others; these are resection of the subacromial bursa (the bursa is resected to make possible good visualization of both the tendinous rupture and the humerus), the saline overpressure induced by the arthropump, and traction of the limb to distract the gleno-humeral and subacromial spaces. Training shoulder surgeons, in particular through surgical simulation, will certainly play an important role in reducing postoperative pain. Another point to study that could be of interest in reducing rotator cuff–related shoulder pain would be the possibility of performing partial denervation of the shoulder under arthroscopy in some cases [1].

The third step, of course, involves better management of postoperative pain. Initiatives such as those described by YaDeau et al. [8] are important because they seek to get the most out of the drugs already available by combining them and seeking to adapt them to the profile of each patient. Improving the reliability of perinervous and intraarticular catheters, with the possibility of prolonging analgesia through reinjections, is also surely a key to overcoming the acute stage of postoperative inflammation. One of the main problems with these catheters is that they can easily move away from the target nerves and become ineffective. An improvement in catheter design may make them more stable. Implanting on-demand anesthetic drug-releasing capsules at the surgical site [5] may also be a worthwhile approach for extending the duration of analgesia in the future. These small capsules would contain local anesthetics and could gradually degrade, thus continuously releasing the anesthetics into the surgical site for several dozen hours after the operation

References

1. Dellon AL. Partial joint denervation I: wrist, shoulder, and elbow. Plast Reconstr Surg. 2009;123:197-207.
2. Gombera MM, Sekiya JK. Rotator cuff tear and glenohumeral instability: a systematic review. Clin Orthop Relat Res. 2014;472:2448-2456.
3. Herve A, Thomazeau H, Favard L. Clinical and radiological outcomes of osteoarthritis twenty years after rotator cuff repair. Orthop Traumatol Surg Res. 2019;105:813-818.
4. Laumonerie P, Dalmas Y, Tibbo ME. Sensory innervation of the human shoulder joint: the three bridges to break. J Shoulder Elbow Surg. 2020;29:e499-e507.
5. Ordeig O, Chin SY, Kim S, Chitnis PV, Sia SK. An implantable compound-releasing capsule triggered on demand by ultrasound. Sci Rep. 2016;6:22803.
6. Sheean AJ, Hartzler RU, Burkhart SS. Arthroscopic rotator cuff repair in 2019: linked, double row repair for achieving higher healing rates and optimal clinical outcomes. Arthroscopy. 2019;35:2749-2755.
7. Toma O, Persoons B, Pogatzki-Zahn E, Van de Velde M, Joshi GP, collaborators PWG. PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2019;74:1320-1331.
8. YaDeau JT, Soffin EM, Tseng A, et al. A comprehensive enhanced recovery pathway for rotator cuff surgery reduces pain, opioid use, and side effects. Clin Orthop Relat Res. 2021;479:1740-1751.
© 2021 by the Association of Bone and Joint Surgeons