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Effect of postoperative NSAID use on opioid consumption after rotator cuff repair
, Rebekah M. Kleinsmithb,c, Adam Hadrob,c, Fernando A. Huyke-Hernandezb,c, Stephen A. Doxeyb,c, Adam Schweitzerd, Jacob Ristowa, Jonathan P. Bramane, Brian P. Cunninghamb,c,
⁎Corresponding author: Brian P. Cunningham. brian.cunningham@parknicollet.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Opioid consumption following rotator cuff repair (RCR) remains a significant concern in post-surgical pain management. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) has been proposed as a multimodal analgesic approach to reduce opioid use and improve recovery. However, the impact of NSAIDs on opioid consumption and clinical outcomes following RCR remains unclear, with conflicting findings from previous studies. The purpose of this study is to compare opioid consumption in patients prescribed a short course of NSAIDs after RCR versus those who were not prescribed NSAIDs.
A retrospective cohort study was conducted including 125 patients who underwent primary arthroscopic RCR between 2012 and 2022. Patients were categorized into two groups based on the surgeon's practice change in May 2017: those who were not prescribed NSAIDs post-surgery and those who were prescribed NSAIDs for six weeks post-surgery. Data on opioid prescription, the need for opioid and NSAID refills, postoperative complications, and patient-reported outcomes (PROs) were collected and analyzed.
No significant differences were observed between the two groups regarding demographic characteristics or preoperative MRI findings. The NSAID group demonstrated a significant reduction in opioid prescription compared to the non-NSAID group, receiving less morphine milligram equivalents (MME) on the day of surgery (306.7 ± 30.2 vs. 1007.4 ± 302.1, p < 0.001). Furthermore, patients in the NSAID group required fewer opioid refills (21.6 % vs. 37.5 %), though this difference did not reach statistical significance (p = 0.085). Both groups showed similar functional outcomes, with no significant differences in postoperative complications or clinical rotator cuff healing failures.
This study demonstrates that a short course of NSAIDs following rotator cuff repair reduces opioid consumption without negatively affecting functional outcomes or tendon healing. These findings support the potential role of NSAIDs in reducing opioid reliance post-surgery and advocate for their inclusion in multimodal pain management protocols for RCR.
Keywords
Rotator cuff repair
Postoperative analgesia
Opioid consumption
NSAIDs
Multimodal pain management
Functional outcomes
1 Introduction
Rotator cuff tears (RCT) are increasingly common among the aging population.1 Rotator cuff pathology remains one of the most frequently encountered surgically treated disease by upper extremity orthopaedic surgeons.2 The majority of RCTs are managed surgically through either an arthroscopic or open approach, with arthroscopic rotator cuff repair (RCR) being the mainstay of RCT management.3 Each technique presents pros and cons; however, both offer comparable long-term structural and clinical success rates.4–6 Postoperative analgesic management with opioids is common following RCR as it is known to be a painful procedure. However, due to the current state of the opioid epidemic across the United States, orthopaedic surgeons are looking for alternative analgesic modalities.7
The increasing use of multimodal analgesia has emerged as a promising strategy to reduce opioid consumption and improve postoperative recovery. Multimodal regimens, including opioids combined with nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and local anesthetics, have been shown to enhance analgesia and reduce opioid use, ultimately decreasing postoperative adverse events.8,9 NSAIDs exert their effects by inhibiting cyclooxygenase (COX) enzymes, thereby reducing prostaglandin production and mitigating pain signaling at both central and peripheral sites.10,11 Despite their therapeutic benefits, NSAIDs' inhibition of COX-1 can result in gastrointestinal complications and impaired renal function, presenting a challenge to their perioperative use.12
Historically, prescription opioids have been the gold standard for pain management following orthopaedic procedures, but the exponential rise in opioid prescriptions and related adverse outcomes has spurred interest in alternative analgesic strategies.13 The adoption of multimodal pain management protocols has shown promise in reducing opioid reliance, but further research is necessary to optimize their use.14–18 In the context of RCR, NSAIDs have been a common post-surgical analgesic; however, concerns persist regarding their potential to impair tendon healing. Animal studies have indicated that NSAID use may reduce tendon healing rates and impair collagen maturation, leading to concerns about their safety following RCR.19–22 Conversely, some studies have suggested that NSAIDs do not significantly affect healing or clinical outcomes after rotator cuff surgery, raising questions about their overall impact on recovery.23
Given the limited evidence and conflicting findings, the optimal role of NSAIDs in pain control for RCR recovery remains unclear. The purpose of this study is to compare opioid consumption in patients prescribed a short course of NSAIDs after RCR versus those who were not prescribed NSAIDs for six weeks post-surgery. We hypothesize that a short course of NSAIDs will significantly reduce narcotic use without adversely affecting clinical outcomes or healing. The primary outcomes include opioid consumption measured in Morphine Milligram Equivalents (MME) and the need for narcotic refills during the six-week postoperative period. This study represents a crucial step in refining post-surgical analgesia protocols for RCR.
2 Methods
2.1 Study design
This was a retrospective cohort study conducted in 2023, which was approved by the Institutional Review Board (IRB). The study was designed to evaluate the opioid consumption following arthroscopic RCR, comparing patients prescribed NSAIDs versus those who were not prescribed NSAIDs.
2.2 Study population
2.2.1 Inclusion and exclusion criteria
Patients who underwent primary arthroscopic RCR performed by the primary surgeon between 2012 and 2022 were identified through review of the electronic surgical log. Patients were excluded from the study if they were younger than 18 years old, had irreparable cuff tears or partial repairs, had a history of prior surgery on the operative shoulder, required open RCR, had less than one year of clinical follow-up, or had incomplete patient-reported outcomes (PROs) pre-operatively or one year postoperatively.
2.2.2 Patient groups
The patient population was divided into two cohorts based on the primary surgeon's change in practice in May 2017. One group consisted of patients who were instructed to avoid NSAIDs for six weeks following surgery (RCRs performed prior to May 2017). The second group included patients who were routinely prescribed ibuprofen 800 mg three times daily (TID) for postoperative pain control following RCR after May 2017. This division allowed for comparison of outcomes between the two practices while standardizing for surgical technique and surgeon-specific practices.
2.2.3 Demographics and data collection
Patient demographic information, including age, sex, body mass index (BMI), smoking status, and workers' compensation status, were obtained from the electronic medical records (EMR). Magnetic resonance imaging was blindly reviewed by a fellowship trained orthopedic surgeon to determine injury characteristics including level of retraction and Goutallier Classification. Surgical data, including injury characteristics such as tendon retraction level (based on the Goutallier Classification), number of tendons involved, retraction distance, number of anchors used for repair, and any concomitant procedures, were collected. Preoperative and postoperative range of motion (ROM) data were also gathered from clinic notes. Preoperative imaging, including MRI, was reviewed by a fellowship-trained orthopaedic surgeon to assess the severity of the rotator cuff injury and to classify tendon retraction.
Between the two groups (no NSAID prescription or with NSAID prescription), initial opioid prescription was compared by collecting if date of surgery (DOS) opioids were prescribed (yes or no) and DOS morphine milligram equivalents (MME) prescribed. For each patient, the type of opioid and number of pills prescribed at discharge was recorded. Opioid dosing was converted to mean Morphine Milligram Equivalents (MME) utilizing the standardized MME conversion equation (National Center for Injury Prevention and Control. CDC compilation of benzodiazepines, muscle relaxants, stimulants, zolpidem, and opioid analgesics with oral morphine milligram equivalent conversion factors, 2017 version. Atlanta, GA: Centers for Disease Control and Prevention; Available at https://www.cdc.gov/drugoverdose/resources/data.html). The number of opioid refills, total MME quantity during episode of care and quantity of prescribed NSAIDs within 6 weeks post-operatively were subsequently collected and compared between the two groups.
2.3 Study outcomes
2.3.1 Primary outcome
The primary outcome of this study was the total opioid prescribed, quantified in MME, over the first six weeks postoperatively. These data were collected through review of the patients’ electronic medical records.
2.3.2 Secondary outcomes
Secondary outcomes included the number of opioid and NSAID prescriptions filled from the DOS to six weeks postoperatively. Secondary outcomes were the rate of postoperative complications occurring within the first year, including repair failures requiring reoperation or revision. Patient-reported outcome measures included the Western Ontario Rotator Cuff (WORC) index and the American Shoulder and Elbow Surgeons (ASES) score. Since the primary surgeon transitioned from the WORC index to the ASES score in 2018, both PROs were collected, with the WORC index predominantly available for the no-NSAID group and ASES for the NSAID group. These were compared based on an improvement of greater than the minimum clinically important difference (MCID) from the pre-operative to one-year post-operative PRO testing. Achievement of MCID was based on previously reported values.24
2.4 Statistical analysis
Statistical analysis was performed using Intellectus statistical software (Clearwater, FL). Descriptive statistics were reported as means ± standard deviations for continuous variables and as counts and percentages for categorical variables. Comparisons between groups were made using Fisher's Exact test, independent t-tests, Mann-Whitney U tests, and one-way Analysis of Variance, as appropriate. Pearson correlations were used to evaluate relationships between variables. Statistical significance was set at an alpha value of p ≤ 0.05.
3 Results
3.1 Cohort overview
A total of 272 patients underwent RCR by the primary surgeon during the study period, with their medical records reviewed for eligibility. Of these, 147 patients were excluded based on predefined exclusion criteria, most notably the absence of one-year follow-up data. 125 patients met the inclusion criteria for the study, consisting of 36 individuals in the non-NSAID group and 89 in the NSAID group.
3.2 Analysis of subgroups
No significant differences were observed in baseline characteristics such as age, sex, BMI, smoking history, diabetes status, or workers' compensation involvement (Table 1). There were no notable disparities in tendon retraction or Goutallier classification on MRI between the two cohorts (Table 2). The NSAID group had a significantly lower average number of tendons involved when analyzing intraoperative findings (No NSAID cohort average: 2.1, NSAID cohort: 1.7, p = 0.022) and required fewer anchors for the repair (No NSAID group average: 3.2, NSAID group: 2.3, p = 0.039). Tendon retraction observed during surgery did not differ significantly between the groups (p = 0.437, Table 3).
| No NSAID | NSAID | P-valuea | |
| Supraspinatus Tendon retraction (cm) | 0.840 | ||
| <1 cm | 28 (31.8 %) | 12 (32.4 %) | |
| 1–2 cm | 16 (18.2 %) | 6 (16.2 %) | |
| >2 cm | 40 (45.5 %) | 13 (35.1 %) | |
| Goutallier Classification | 0.310 | ||
| 0 | 58 (65.9 %) | 19 (51.4 %) | |
| 1 | 18 (20.5 %) | 12 (32.4 %) | |
| 2 | 4 (4.6 %) | 3 (8.1 %) | |
| 3 | 3 (3.4 %) | 0 (0.0 %) | |
| 4 | 1 (1.1 % | 0 (0.0 %) |
| No NSAID | NSAID | P-valuea | |
| # of Tendons involved | 0.022 | ||
| 1 | 21 (23.9 %) | 18 (48.7 %) | |
| 2 | 35 (39.8 %) | 11 (29.7 %) | |
| 3 | 29 (33.0 %) | 6 (16.2 %) | |
| 4 | 1 (1.1 %) | 1 (2.7 %) | |
| Supraspinatus Tendon retraction (cm) | 0.437 | ||
| <1 cm | 22 (25.0 %) | 3 (8.1 %) | |
| 1–2 cm | 11 (12.5 %) | 2 (5.4 %) | |
| >2 cm | 44 (50.0 %) | 14 (37.8 %) | |
| # of anchors required for repair | 0.039 | ||
| 1 | 13 (14.8 %) | 10 (27.0 %) | |
| 2 | 14 (15.9 %) | 11 (29.7 %) | |
| 3 | 22 (25.0 %) | 7 (18.9 %) | |
| 4 | 18 (20.5 %) | 6 (16.2 %) | |
| 5 | 17 (19.3 %) | 1 (2.7 %) | |
| >6 | 2 (2.3 %) | 0 (0.0 %) | |
| Concomitant Procedures | |||
| GH Debridement | 56 (63.6 %) | 24 (64.9 %) | 0.896 |
| LHB Tenotomy | 18 (20.5 %) | 3 (8.1 %) | 0.092 |
| LHB Tenodesis | 49 (55.7 %) | 24 (64.9 %) | 0.342 |
| DCE | 16 (18.2 %) | 9 (24.3 %) | 0.433 |
| SAD | 67 (76.1 %) | 27 (73.0 %) | 0.709 |
The average reported MCID values for the ASES and WORC scores were 15.5 (15 % total difference) and 6 (13 % total difference), respectively.24 The average ASES score in the NSAID group increased from 34.3 preoperatively to 84.6 one year post-operatively, with 83.8 % of patients exceeding the MCID. The non-NSAID group showed an improvement from a pre-operative average of 37.0–82.8 at one-year follow-up, with 73.9 % achieving at least the MCID. The percentage of patients exceeding the MCID did not significantly differ between groups (p = 0.471).
Five postoperative complications were recorded in the non-NSAID group, including three pulmonary emboli (PE) requiring anticoagulation therapy, one transient ulnar nerve palsy, and one case requiring shoulder manipulation to restore range of motion. The NSAID group had two postoperative complications: one superficial femoral vein DVT requiring anticoagulation, and one shoulder requiring manipulation for range of motion improvement. The incidence of complications did not significantly differ between the groups (5.7 % for no-NSAID cohort vs 5.4 % for NSAID cohort, p = 0.827).
Within the non-NSAID cohort, two patients experienced failure of rotator cuff healing necessitating revision surgery within the first year. One patient in the NSAID group required revision RCR due to rotator cuff retear. The incidence of RCR retear requiring revision did not differ significantly between the two groups (2.3 % for no-NSAID cohort vs 2.7 % for NSAID cohort, p = 1.000).
3.3 Opioid consumption and refills
The majority of patients in both the non-NSAID and NSAID groups were prescribed opioids on the day of surgery (90.9 % and 94.6 %, respectively), with no significant difference between the two groups (p = 0.816, Table 4). A notable difference was observed in the total amount of morphine milligram equivalents (MME) prescribed on the day of surgery, with the non-NSAID group receiving a significantly higher MME (1007.4 ± 302.1) compared to the NSAID group (306.7 ± 30.2, p < 0.001) (Fig. 1).
| No NSAID (WORC) | Yes NSAID (ASES) | P-valuea | |
| DOS Opioids (yn) | 80 (90.9 %) | 35 (94.6 %) | 0.816 |
| DOS MME | 1007.4 (302.1) | 306.7 (30.2) | <0.001 |
| <6w Opioid Refills | 33 (37.5 %) | 8 (21.6 %) | 0.085 |
| <6w MME Refilled | 878.8 (1147.2) | 250.0 (106.9) | 0.002 |
| <6w NSAID Refills | 1 (1.1 %) | 5 (13.5 %) | 0.008 |
Within the first six weeks post-operatively, 37.5 % of patients in the non-NSAID group required a refill of opioids, compared to 21.6 % in the NSAID group; however, this difference did not reach statistical significance (p = 0.085). Among those who required refills, the non-NSAID group received significantly higher MME (878.8 ± 1147.2) compared to the NSAID group (250.0 ± 106.9, p = 0.002). There was a significant difference in the number of NSAID refills during the first six weeks, with the NSAID group having a higher rate of refills (13.5 % for NSAID cohort vs 1.1 % in no-NSAID cohort, p = 0.008).
4 Discussion
The optimal role of NSAIDs in pain control for RCR recovery remains unclear. The purpose of this single-center, retrospective cohort study was to compare opioid consumption in patients prescribed a short course of NSAIDs after RCR versus those who were not prescribed NSAIDs for six weeks post-surgery. It was hypothesized that a short course of NSAIDs would significantly reduce narcotic use without adversely affecting clinical outcomes or healing. Prescription NSAIDs following RCR significantly reduced the amount of opioid prescription at day of surgery and within six weeks postoperatively. Additionally, the prescription of NSAIDs did not lead to increased complication rates or worsen postoperative PROs in demographically comparable cohorts following RCR within one year postoperatively.
There was a significant difference in opioid prescription between the two groups. The non-NSAID group was prescribed significantly higher amounts of opioids on the day of surgery (1007.4 MME vs. 306.7 MME), which was reflected in the higher MME required for refills during the first six weeks post-operatively. Although the difference did not reach statistical significance, there was a trend towards significance in patients who were prescribed NSAIDs requiring fewer narcotic refills (37.5 % no-NSAID cohort required a refill of opioids, 21.6 % NSAID cohort required a refill of opioids). These results could turn significant with higher power. Among those who required refills, the non-NSAID group received significantly higher MME (878.8 ± 1147.2) compared to the NSAID group (250.0 ± 106.9, p = 0.002). Previous studies have investigated opioid reduction effects following RCR of education about opioids, reduction of the opioid prescription by providers, concurrent liposomal bupivacaine use, and acetaminophen use.25–29 The reduction in opioid consumption when prescribed NSAIDs compared with no prescription has not been highlighted in past research in the context of RCR to the authors’ knowledge. Our data suggests that patients in the NSAID group consumed significantly less opioid medication, particularly in the early post-operative period, without compromising functional outcomes.
The average ASES score in the NSAID group improved significantly from 34.3 to 84.6, with 83.8 % of patients meeting the minimal clinically important difference (MCID). The non-NSAID group demonstrated a similar improvement in WORC scores (37.0–82.8), with 73.9 % achieving the MCID. The incidence of postoperative complications and rate of rotator cuff failure was also comparable between the two groups while demographic characteristics and preoperative findings by MRI did not differ significantly between the NSAID and no-NSAID cohorts. Previous literature demonstrates potential adverse effects of postoperative NSAID consumption on healing and tendon biology.19–23 This study demonstrated no significant differences in rotator cuff repair failure or revision, suggesting that NSAIDs may not adversely affect tendon healing.
Orthopaedic surgeons have long been criticized for their role in contributing to the opioid epidemic through excessive prescription practices, especially following surgeries like rotator cuff repairs (RCR). While there have been efforts in other fields to reduce opioid reliance through education, adjusted prescribing practices, and the use of alternatives, orthopaedics has been slower to adapt. This study provides an important shift in perspective, suggesting that a short course of NSAIDs can significantly reduce opioid consumption after RCR without negatively impacting clinical outcomes or healing. Previous concerns about NSAIDs impairing recovery have been rebutted by this and other studies, indicating that NSAIDs are a viable option to combat the opioid crisis. The NSAID cohort from this study required fewer opioid refills and showed no increase in complications or tendon failure. Orthopaedic practice must evolve by embracing these insights, reducing reliance on opioids, and contributing positively to the broader effort of curbing the opioid epidemic. This study offers valuable evidence, paving the way for a more responsible, patient-centered approach to post-operative care in orthopaedics.
This study has several strengths and limitations. One of the key strengths of this study is its single-center design, conducted by one primary surgeon, which minimizes variability in surgical techniques. The transition from advising patients to avoid NSAIDs post-surgery to actively prescribing them occurred at a specific time point which helps to reduce selection bias. Prior to the change of practice in 2017, opioid prescription appears to be comparable to the national standards at that time30,31. Another key strength of this study is the inclusion of opioid prescription data alongside patient-reported and clinical outcomes, providing a unique and holistic view of the impact of NSAIDs on post-operative recovery. All patients were prescribed NSAIDs, standardizing the NSAID used and removing the potential confounding effects of different NSAID medications. One limitation of this study is the inability to verify actual opioid and NSAID consumption for each cohort, including the frequency and dosage of use. Each cohort was categorized based on prescription rather than self-reported consumption. This sample is underpowered with low N and limited through the nature of retrospective data collection. Therefore, we cannot confidently draw conclusions regarding differences in retear/revision rates.
5 Conclusion
Further investigation into the optimal dosing and timing of NSAID administration in the postoperative period is required to refine pain management strategies and minimize opioid use. Thoughtful prescription of NSAIDs after RCR may provide an important opportunity to reduce opioid prescription and subsequent consumption. Our findings offer evidence that NSAID use can contribute to effective pain management without compromising recovery, encouraging the continued use of NSAIDs as part of a multimodal approach to pain control in RCR.
CRediT authorship contribution statement
Nicholas F. Banfield: All authors including on this manuscript have made significant contributions to the manuscript. Rebekah M. Kleinsmith: Data curation, Writing – original draft, and, Writing – review & editing, and, Visualization. Adam Hadro: Data curation, Writing – original draft, and, Writing – review & editing, and, Visualization. Fernando A. Huyke-Hernandez: Data curation; Formal analysis; and Writing – review & editing. Stephen A. Doxey: Data curation, Writing – original draft, and, Writing – review & editing, and, Visualization, Supervision, and, Project administration. Adam Schweitzer: Data curation, Writing – original draft, and, Writing – review & editing, and, Visualization. Jacob Ristow: Formal analysis, Data curation, Writing – original draft, and, Writing – review & editing, and, Visualization. Jonathan P. Braman: Conceptualization, Methodology, Validation, Formal analysis, Data curation, Writing – original draft, and, Writing – review & editing. Brian P. Cunningham: Conceptualization, Methodology, Validation, Formal analysis, Data curation, Writing – original draft, and, Writing – review & editing, and, Visualization.
Patient consent
Informed consent was obtained for all patients participating in this study.
Ethical statement
IRB: This retrospective cohort study was deemed exempt from full Institutional Review Board review by the Health Partners IRB in February 2023.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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