Introduction

The use of opioids for postoperative pain is a significant contributor to the ongoing opioid epidemic, with increasing attention being paid to alternative methods of postoperative pain management. The purpose of this review was to evaluate the effectiveness of interventions aimed at reducing postoperative opioid consumption following knee and shoulder arthroscopy.

Methods

We searched CENTRAL, Embase, and Medline from inception until August 2019 for randomized studies investigating interventions aimed at reducing opioid use after knee and shoulder arthroscopy. Demographic data as well as data on postoperative opioid consumption, pain scores, and adverse events were gathered. Opioid consumption amounts were converted to oral morphine equivalents as a common unit. Data for primary outcomes were pooled using random effects meta-analysis. A risk of bias assessment was performed for all included studies.

Results

Overall, 12 studies of Level I evidence were included with a total of 961 patients analyzed. These patients were 36.1% female (313/868), and had an overall weighted mean age of 44.3 ± 10.2 years. The most common interventions aimed at opioid reduction were gabapentinoids in four studies, COX-2 inhibitors in three studies, and bupivacaine infiltration in two studies. Cumulative postoperative opioid consumption in oral morphine equivalents was significantly reduced in the experimental group at six hours (Mean Difference [MD] -16.51 mg [95% CI -24.31 to -8.71], P<0.00001), 24 hours (MD -13.69 mg [95% CI -22.70 to -4.67], P<0.00001), and 48 hours (MD -67.27 mg [95% CI -131.41 to -3.12], P=0.0002)
postoperatively. Pooled analysis of postoperative pain scores initially (MD -1.22 [95% CI -1.76 to -0.68], P=0.007), at six hours postoperatively (MD -1.27 [95% CI -1.84 to -0.69], P<0.00001), at 12 hours postoperatively (MD -1.21 [95% CI -2.25 to -0.17], P=0.0006), and at 24 hours postoperatively (MD -1.43 [95% CI -2.09 to -0.77], P<0.00001) found significantly lower pain scores in the group receiving the intervention aimed at opioid reduction. Lastly, comparison of the risk of adverse events found no significant difference between the experimental and control groups (Risk Difference [RD] -0.08 [95% CI -0.21 to 0.05], P=0.24).

Discussion And Conclusion

Interventions aimed at reducing opioid consumption after knee and shoulder arthroscopy were not only successful in this, but also lowered postoperative pain scores without altering the frequency of adverse events. Results of this study support the use of multimodal analgesia including COX-2 inhibitors and gabapentinoids, as well as preoperative patient education to reduce postoperative opioid use following knee and shoulder arthroscopy.