Abstract
Objectives:
Opioid drug overdose is the leading cause of injury-related death in the US since 2016, prompting calls for reform, especially within surgical prescription practices. The use of Cold Therapy Units (CTU) has been wildly accepted as an adjunct to pharmacologic therapy to treat pain, particularly in the arthroplasty literature. However, these devices are currently not readily reimbursed by insurance companies and have not been tested within arthroscopic shoulder surgery. Building upon a study by Tantiphaiboontana et al, which showed decrease opioid usage after arthroscopic rotator cuff repair (ARCR) with the inclusion of a standardized nonsteroidal anti-inflammatory medication (NSAID) regimen, our group sought to study CTU use as a pain adjunct. The purpose of this study was to evaluate the effect of a standardized CTU protocol on postoperative pain and opioid usage following ARCR as well as longer term effects on shoulder functional outcomes.
Methods:
A prospective cohort trial was performed in adult patients undergoing primary arthroscopic rotator cuff repair by five fellowship-trained sports surgeons at a single institution between 6/16/2023 and 9/1/2024. All patients received the institutional multi-model pain regimen consisting of a postoperative regional nerve block, NSAIDs, narcotic medication and a standardized physical therapy course. This multi-modal pain regimen was originally implemented and studied by Tangtiphaiboontana et al, who’s cohort will serve as the control group. Patients in this study were additionally instructed to use a commercial CTU for a minimum of four times per day in thirty-minute session for at least two weeks. Patients were instructed to keep a daily pain and opioid use diary which was returned at the first postoperative visit. Patient reported outcome measures including the Visual Analog Score (VAS), Disability of Arm, Shoulder and Hand (DASH) and American Shoulder and Elbow Surgeons (ASES) were recorded preoperatively, as well as postoperatively at 6 weeks, 3 months, 6 months and one year.
Results:
A total of 45 patients in the CTU group and 51 patients in the control group were included for analysis. There were no differences in age, race, sex, history of preoperative NSAID use between groups (Table 1). Early VAS scores for postoperative days 1 through 6 are shown in Figure 1. The amount of mean total morphine milligram equivalents (MME) used in the first postoperative week was lower in the CTU group (128.3 ± 64.8 MME vs 168.3 ± 96 MME, p=0.14), although this difference was not statistically different. The CTU group had better postoperative pain control immediately on postoperative day 1 (VAS 2.4 vs 4.1, p <0.01) and worse pain control on postoperative day 2 (4.3 vs 3.1, p<0.01), but no difference was seen starting postoperative day 3. Both the CTU group and control group showed significant improvements in ASES (CTU 36 p<0.01, control 35.6 p<0.01) and DASH (CTU 29.1 p<0.01, control 30.7 p<0.01) scores at one year. As shown in table 2, there was no difference in VAS score, ASES score or DASH score at 6 weeks, 3 months, 6 months or 1 year between the two groups.
Conclusions:
A regimented postoperative CTU regimen reduced opioid requirements following arthroscopic rotator cuff repair, although this difference was not statistically significant. Patients in the CTU group had less pain in the immediate postoperative period, but there were no differences between groups after postoperative day 3. Patient reported functional outcomes were not statistically different between those who used the CTU and those who did not
