Oral Ketorolac as an Adjuvant Agent for Postoperative Pain Control following Arthroscopic Rotator Cuff Repair: A Prospective, Randomized, Controlled Study. (113)
Authors: Sivasundaram Lakshmanan , Strony John , Mengers Sunita , Trivedi Nikunj , Tanenbaum Joseph , Salata Michael , Voos James , Victoroff Brian , Karns Michael , Gillespie Robert 
Published: October 2021

Objectives:

Arthroscopic rotator cuff repairs are associated with substantial postoperative pain. Traditionally, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents are associated with several side effects and a significant potential for abuse. This study evaluates the efficacy of ketorolac, a non-steroidal anti-inflammatory drug with analgesic properties, as an adjunctive agent for postoperative pain control following arthroscopic rotator cuff repair.

Methods:

Adult patients undergoing an arthroscopic rotator cuff repair were prospectively enrolled. Patients who met inclusion and exclusion criteria were randomized into one of two groups. The control group received our standard of care pain protocol, including oxycodone-acetaminophen 5-325 on discharge. Patients in the ketorolac group additionally received a dose of IV ketorolac intraoperatively and were prescribed a scheduled dose of oral ketorolac (10mg by mouth every six hours for three days) along with omeprazole (20mg by mouth every day for three days) for acid reflux. Visual Analogue Scale (VAS), functional outcome scores, and total narcotic utilization were recorded three times per day for the first five days after surgery. Statistically significant differences in patient demographics and comorbidities between groups were determined initially with univariate analysis. Linear mixed-effect models were then fitted for each outcome variable to evaluate the main effects of treatment group and follow-up times.

Results:

In our study, 39 patients were included for final analysis; the mean age of the cohort was 55.7±10.6 years and 66.7% of patients were male. There were no differences in preoperative demographics, comorbidities, cuff tear morphology, and functional scores between the two groups. (Table 1) Patients in the Ketorolac group had lower mean VAS scores and opioid utilization at all time points. (Figure 1, 2) On multivariate analysis that controls for confounding variables, patients in the ketorolac group had a mean 9.67 decrease in VAS scores in comparison to the control group, though these results were not statistically or clinically significant (Coefficient estimate= -9.67, 95% CI -25.13-5.79, p=.2202; MCID 13). (Table 3) Patients in the ketorolac group utilized significantly less narcotics, with a mean of 0.7 fewer pills of oxycodone-acetaminophen per time interval in comparison to the control group (Coefficient estimate=-0.70, 95% CI -1.005 -0.389, p<.001). Over the first five days after surgery, patients in the ketorolac group consumed a mean 10.6 fewer narcotic pills, a consumption reduction of 54.6% (19.42 vs. 8.82, p<.001). There was no difference in functional outcome scores at up to six-weeks postoperative between the two groups, (Table 2) as well as no difference in adverse events between the two groups with no reported cases of gastritis or gastrointestinal bleeding. (Table 4).

Conclusions:

In this prospective, randomized, controlled study, the use of adjunctive intravenous and short-term oral ketorolac substantially reduced narcotic utilization following arthroscopic rotator cuff repair.