Examining the Effectiveness of a Connective Tissue Matrix Implant in Reducing Post-operative Pain and Narcotic After Outpatient Arthroscopic Shoulder Surgery

This document is a protocol for a human research study. This study is to be conducted according to United States standards of Good Clinical Practice in accordance with applicable Federal regulations and institutional research policies and procedures.

Extracellular matrix grafts have been used to help with postoperative inflammation.

Shoulder surgery has evolved over the past decade with many procedures now done on an outpatient basis. Multimodal pain management strategies and regional anesthesia have greatly contributed to this transition and newer strategies continue to evolve. Uncontrolled pain can often lead to readmissions, prolonged hospital or ambulatory stays and an overall negative patient experience. Despite improvements in regional anesthetic technique and newer longer acting medicines such as liposomal bupivacaine, the duration of pain relief is often only over the course of 72 hours postoperatively. Post-operative pain beyond 72 hours is largely inflammatory in nature. As such, biologic approaches to reduce surgical tissue damage-induced inflammation is an attractive therapeutic addition to surgical procedures. These approaches are especially relevant in light of the current opioid epidemic plaguing the United States.

Flowable, placental-derived connective tissue matrix (pECM) is a potential option to supplement damaged tissue prone to inflammation as it introduces nascent, hydrated components of the inflammatory phase, including structural proteins and growth factors, which allow for efficient repair. Derived from relatively immune-privileged tissue, placental-derived pECM elicits little or no immune response in recipients. They have been shown to greatly reduce inflammatory cell influx and inflammatory cytokines present in dermal and mucosal surgical sites post-operatively. Moreover, placental-derived pECM reduces expression of prostaglandin E2, a potent pain mediator, in vitro. In the orthopedic space, ECM has been used effectively to reduce pain following spinal fusion and for treatment of knee arthritis. Taken together, biologic therapies directed at modulating inflammation and associated pain is an increasing area of interest with far reaching implications.

The purpose of the current study is to prospectively analyze two groups of patients treated for arthroscopic shoulder surgery with and without a flowable pECM to determine if a significant reduction in pain and opioid consumption as measured in morphine equivalent units is demonstrated within the first 6 weeks of surgery. Furthermore, patients will be compared in regard to early range of motion and patient reported outcomes to determine if a difference is present when the ECM is utilized within the first 6 months of surgery. This is the first double blinded prospective series in the shoulder literature to date looking at a pECM graft for pain reduction and improved range of motion perioperatively.

Study Objectives

Utilizing a prospective randomized controlled trial, the aim of this study is to assess modulation of post-operative pain and narcotic use when a placental-derived extracellular matrix is injected into the bed of the repair following outpatient arthroscopic shoulder surgery. Furthermore, this study aims to determine if the addition of pECM influences patient reported outcomes and influences early postoperative range of motion.

Primary Aims \& Objective

Aim 1a: To assess post-operative narcotic consumption (measured in morphine equivalent units) between patients treated with flowable placental-derived pECM compared to those patients undergoing arthroscopic shoulder surgery.

Hypothesis: Narcotic consumption (measured in morphine equivalent units) will be reduced in patients treated with an extracullar matrix graft as compared to those patients undergoing rotator cuff surgery without.

Objective: Utilizing a prospective randomized controlled trial, narcotic use will be measured for 24-hour increments for a total of 7 post-operative days (PODs) then once on POD 14, 21, 28, and 42. . Consumption will be measured by the number of tablets ingested and converted to morphine equivalent units and compared between the two treatment groups.

Aim 1b: To determine if flowable placental-derived pECM decreases patient-reported post-operative VAS pain in patients undergoing outpatient rotator cuff surgery

Hypothesis: There will be a decrease in VAS pain for up to 6 weeks post-operatively among participants who receive pECM, as compared to the control group (no pECM).

Objective: Utilizing a prospective randomized controlled trial, post-operative patient-reported VAS pain (on a scale of 0-10) will be collected 1 times per day (every 24 hours) for 7 post-operative days (PODs); then an average score collected on POD 14, POD 21, POD 28, and POD 42. Scores will be averaged and compared between the two treatment groups for the first 7 days, 2 week, 3rd week, 4th week and 6th week postoperatively.

Secondary Aims \& Objectives

Aim 2a: To assess patient-reported outcomes and early range of motion (measured in morphine equivalents) in patients treated with flowable placental-derived pECM compared to patients injected with saline control.

Hypothesis: There will be improved patient reported outcomes and early range of motion measured at 6 weeks and 3 months and 6 months postoperatively in patients receiving and extracellular matrix injection following outpatient arthroscopic shoulder surgery.

Objective: Utilizing a prospective randomized controlled trial, patient reported outcomes as measured by American Shoulder and Elbow Score, Simple Shoulder Test and SANE scores and range of motion (External rotation, internal rotation and forward flexion) will be collected preoperatively and at 2 weeks (external rotation), 6 weeks (all)) , 3 months (all) and 6 months (all) postoperatively. Scores and range of motion measurements will be averaged and compared for differences between the two groups.

Study Design

The study design is a randomized double-blind randomized controlled trial.

Research Design

Patients will be randomly assigned to one of two treatment groups (see Intervention Description). Patients will randomly select one of 70 sealed envelopes the day of surgery. Patients will be blinded to the medication utilized as well as the treating surgeon (PI). A consecutive series of patients will be enrolled to prevent selection bias. A single surgeon will be performing all procedures to minimize variability. Upon completion of the surgery, a spinal needle will be loaded into the substance of the rotator cuff tendon under direct arthroscopic visualization. The surgeon will then leave the room and the envelope will be opened by the circulating operating room nurse. If the patient is in the treatment group, 2cc of an extracellular matrix graft be opened and then injected with a 22g spinal needle already placed into the bed of the repair by the physician assistant. Those patients that are in the control group will have the needle removed and no injection administered. The envelope will be then sealed with the patient's name and treatment group to allow for data analysis upon completion of the study.

Data Collection will occur post-operatively for 6 months. Data will be collected at 13 timepoints, in total for pain and opioid consumption. For the first seven days, data will be collected at 24-hour time intervals beginning the first morning after the surgery (POD1) at 8am then at 24-hour intervals for the next 7 days (POD7). Data will be collected using Oberd, an application that uses text message or email to collect information. The morning after the surgery (POD0) the first email will occur at 8am. Patients will then be notified by email alert 1 times per day (8am) asking to rate their pain on a scale of 0-10 (VAS) beginning on POD 1 thru POD 7. Patients will also respond to the number of pain pills taken in the slotted time span. All patients will be prescribed the same narcotic regimen (oxycodone IR) barring any allergies encountered. Patients who fail to respond to the email alert will be notified by the data collection system and contacted via phone by study personnel. Patients lacking smartphone technology will all be notified via telephone and also asked to keep a personal log to capture the information needed.

Eligibility Criteria:
Inclusion Criteria:

1. Age 18 and older
2. Primary diagnosis of rotator cuff tear, labral tear or SLAP tear
3. Able to provide informed consent
4. Is willing and able to accept text messages

Exclusion Criteria:

1. Older than 55 years old.
2. Pregnancy.
3. Known narcotic or alcohol abuse (\< 3 months)
4. Revision shoulder surgery
5. Current narcotic regimen or contract with pain management specialist