SSM Health Orthopedics, SSM Health DePaul Hospital, St. Louis, MO, USA.
SSM Health Orthopedics, SSM Health DePaul Hospital, St. Louis, MO, USA.
J Shoulder Elbow Surg. 2021 Jan;30(1):1-8. doi: 10.1016/j.jse.2020.08.025. Epub 2020 Sep 9.
The opioid crisis has illuminated the risks of opioid use for pain management, with renewed interest in reducing opioid consumption after common orthopedic procedures. Anti-inflammatory medication is an important component of multimodal pain management for patients undergoing orthopedic surgery. The purpose of this study was to evaluate the effect of celecoxib on pain control and opioid use after shoulder surgery.
Patients scheduled for either total shoulder replacement (group 1) or rotator cuff repair (group 2) were candidates for the study. The exclusion criteria included allergy to celecoxib, coagulopathy, use of anticoagulants, baseline use of long-acting opioids, and a history of medical conditions such as myocardial infarction or stroke. Consenting patients were randomized by type of procedure using block randomization to receive either placebo or celecoxib 1 hour prior to the procedure and for 3 weeks postoperatively. The primary outcome measure assessed was opioid utilization as measured by morphine-equivalent dose (MED). Secondary outcome measures included pain scores at 3 and 6 weeks postoperatively. Data were analyzed using multiple linear regression.
Of 1081 patients scheduled for either total shoulder replacement or rotator cuff repair from February 2014 to February 2018, 78 were enrolled for arthroplasty (group 1, with 39 receiving celecoxib and 39 receiving placebo) and 79 were enrolled for rotator cuff repair (group 2, with 40 receiving celecoxib and 39 receiving placebo). Compared with the placebo arm, patients prescribed celecoxib took fewer MEDs by -168 (95% confidence interval [CI], -272 to -64; P < .01) at 3 weeks in the total population and by -197.7 (95% CI, -358 to -38; P = .02) in the arthroplasty group. Similarly, at 6 weeks, total MEDs used was -199 (95% CI, -356 to -42; P < .01) in the total population and -270 (95% CI, -524 to -16; P = .04) in the arthroplasty group. No statistically significant differences in opioid consumption were found between study arms in the cuff repair group, at either 3 or 6 weeks. Of note, preoperative opioid use was statistically associated with higher levels of opioid use in the total population and group 1 at 3 and 6 weeks (P < .01 for all) but not in group 2 (P > .05 for both).
Use of morphine equivalents was statistically significantly less at 3 and 6 weeks in patients who took celecoxib in the total population and in the arthroplasty group. Patients prescribed celecoxib for 3 weeks after shoulder surgery took less opioid medication for pain at 3 and 6 weeks. Multimodal pain control using celecoxib is an effective way to reduce postoperative opioid use in shoulder arthroplasty patients. Preoperative opioid use is associated with higher levels of opioid use after shoulder arthroplasty.
阿片类药物危机凸显了阿片类药物在疼痛管理方面的风险，人们对减少常见骨科手术后阿片类药物的使用重新产生了兴趣。抗炎药物是骨科手术后患者多模式疼痛管理的重要组成部分。本研究的目的是评估塞来昔布对肩部手术后疼痛控制和阿片类药物使用的影响。
计划接受全肩关节置换术（第 1 组）或肩袖修复术（第 2 组）的患者有资格参加本研究。排除标准包括对塞来昔布过敏、凝血障碍、使用抗凝剂、基线使用长效阿片类药物以及心肌梗死或中风等病史。同意参加的患者根据手术类型通过块随机化接受安慰剂或塞来昔布 1 小时术前和术后 3 周。主要结局测量指标是通过吗啡等效剂量（MED）评估的阿片类药物使用情况。次要结局测量指标包括术后 3 周和 6 周的疼痛评分。数据使用多元线性回归进行分析。
2014 年 2 月至 2018 年 2 月期间，计划接受全肩关节置换术或肩袖修复术的 1081 名患者中，78 名患者被纳入关节置换术（第 1 组，其中 39 名接受塞来昔布，39 名接受安慰剂），79 名患者被纳入肩袖修复术（第 2 组，其中 40 名接受塞来昔布，39 名接受安慰剂）。与安慰剂组相比，全人群中接受塞来昔布治疗的患者在第 3 周时使用的 MED 减少了 168（95%置信区间[CI]，-272 至-64；P<.01），在关节置换组中减少了 197.7（95%CI，-358 至-38；P=.02）。同样，在第 6 周时，全人群中使用的总 MED 减少了 199（95%CI，-356 至-42；P<.01），在关节置换组中减少了 270（95%CI，-524 至-16；P=.04）。在肩袖修复组中，在第 3 周和第 6 周时，研究组之间在阿片类药物的消耗方面均未发现统计学显著差异。值得注意的是，术前阿片类药物的使用与全人群和第 1 组在第 3 周和第 6 周的阿片类药物使用水平呈统计学显著相关（所有 P<.01），但在第 2 组中无统计学显著相关（所有 P>.05）。
在全人群和关节置换组中，接受塞来昔布治疗的患者在第 3 周和第 6 周时吗啡等效剂量的使用统计学上显著减少。在肩部手术后接受塞来昔布治疗 3 周的患者，在第 3 周和第 6 周时使用的阿片类药物用于缓解疼痛的剂量较少。在肩部关节置换术后患者中，使用塞来昔布进行多模式疼痛控制是减少术后阿片类药物使用的有效方法。术前阿片类药物的使用与肩部关节置换术后的阿片类药物使用水平相关。
