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

• Published in: Clinical orthopaedics and related research 2021-08, Vol.479 (8), p.1740-1751
• Main Authors: YaDeau, Jacques T., Soffin, Ellen M., Tseng, Audrey, Zhong, Haoyan, Dines, David M., Dines, Joshua S., Gordon, Michael A., Lee, Bradley H., Kumar, Kanupriya, Kahn, Richard L., Kirksey, Meghan A., Schweitzer, Aaron A., Gulotta, Lawrence V.
• Format: Article
• Language: English
• Subjects: Acetaminophen; Analgesia; Analgesics; Analgesics, Opioid - therapeutic use; Anesthetics; Arthroscopy - adverse effects; Arthroscopy - rehabilitation; Brachial Plexus Block; Bupivacaine; Bupivacaine - therapeutic use; Clinical Research; Critical Pathways; Dexamethasone; Drowsiness; Enhanced Recovery After Surgery; Female; Gabapentin; Humans; Ketamine; Male; Medical personnel; Middle Aged; Morphine; Narcotics; Nonsteroidal anti-inflammatory drugs; Opioids; Pain; Pain Management - methods; Pain perception; Pain, Postoperative - therapy; Patient education; Patient Reported Outcome Measures; Patients; Prospective Studies; Rotator cuff; Rotator Cuff - surgery; Side effects; Surgeons; Surgery
• ISSN: 0009-921X; 1528-1132
• DOI: 10.1097/CORR.0000000000001684

Patients often have moderate to severe pain after rotator cuff surgery, despite receiving analgesics and nerve blocks. There are many suggested ways to improve pain after rotator cuff surgery, but the effects of adopting a pathway that includes formal patient education, a long-acting nerve block, and extensive multimodal analgesia are unclear. (1) Does adoption of a clinical pathway incorporating patient education, a long-acting nerve block, and preemptive multimodal analgesia reduce the worst pain during the first 48 hours after surgery compared with current standard institutional practices? (2) Does adoption of the pathway reduce opioid use? (3) Does adoption of the pathway reduce side effects and improve patient-oriented outcomes? From September 2018 to January 2020, 281 patients scheduled for arthroscopic ambulatory rotator cuff surgery were identified for this paired sequential prospective cohort study. Among patients in the control group, 177 were identified, 33% (58) were not eligible, for 11% (20) staff was not available, 56% (99) were approached, 16% (29) declined, 40% (70) enrolled, and 40% (70) were analyzed (2% [4] lost to follow-up for secondary outcomes after postoperative day 2). For patients in the pathway cohort, 104 were identified, 17% (18) were not eligible, for 11% (11) staff was not available, 72% (75) were approached, 5% (5) declined, 67% (70) enrolled, and 67% (70) were analyzed (3% [3] lost to follow-up for secondary outcomes after postoperative day 2). No patients were lost to follow-up for primary outcome; for secondary outcomes, four were lost in the control group and three in the pathway group after postoperative day 2 (p = 0.70). The initial 70 patients enrolled received routine care (control group), and in a subsequent cohort, 70 patients received care guided by a pathway (pathway group). Of the 205 eligible patients, 68% (140) were included in the analysis. This was not a study comparing two tightly defined protocols but rather a study to determine whether adoption of a pathway would alter patient outcomes. For this reason, we used a pragmatic (real-world) study design that did not specify how control patients would be treated, and it did not require that all pathway patients receive all components of the pathway. We developed the pathway in coordination with a group of surgeons and anesthesiologists who agreed to apply the pathway as much as was viewed practical for each individual patient. Patients in both groups received