Acetaminophen’s Role in Pain Management After Arthroscopic Rotator Cuff Repair
Approximately 250,000 rotator cuff repairs are performed in the US each year, and although arthroscopic rotator cuff procedures can reduce long-term pain and improve patients’ quality of life, they can also cause significant postoperative pain – especially in the early postoperative period. [1-3]
Opioids have been considered the gold standard for pain management in these and other orthopaedic surgery patients, but they have significant drawbacks, including serious side effects and the potential for dependence and abuse. 
All of which led Joseph A. Abboud, MD, and his colleagues at The Rothman Orthopaedic Institute to investigate whether acetaminophen could play a more significant role in pain management in patients undergoing arthroscopic rotator cuff repair, potentially reducing their reliance on opioids.
They found that yes, it can: Including acetaminophen for pain management prior to and after arthroscopic rotator cuff repair can significantly reduce opioid consumption and improve patient satisfaction postoperatively. Not only that, but patients who take acetaminophen perioperative can also have better pain control, even while consuming fewer opioids.
Their findings were presented at the 2021 Annual Meeting of the American Academy of Orthopaedic Surgeons in San Diego.
“When thinking about perioperative and postoperative pain management, acetaminophen is not always seriously considered,” said Dr. Abboud, senior author on the study. He is a professor of orthopaedic surgery at the Sidney Kimmel Medical College of Thomas Jefferson University and chief medical officer at The Rothman Orthopaedic Institute in Philadelphia, Pennsylvania.
“[Acetaminophen] is considered as part of the preoperative pain medication cocktail, but not for the regimen during or after surgery to help offset the need for other medications, like opioids,” he continued. “This study shows the benefits of including acetaminophen and highlights the need for it to be part of the education on pain management.”
The study included 57 patients, ages 30 to 80, who underwent arthroscopic rotator cuff repair between June 2019 and March 2020. Patients were randomized to 1 of 3 treatment groups:
- Group 1 (control) received both 5 mg of oxycodone every 6 hours as needed and 1000 mg of acetaminophen orally every 6 hours as needed after surgery. Patients had the option to take either, neither, or both medications.
- Group 2 (control) received 5 mg of oxycodone every 6 hours as needed without any additional acetaminophen after surgery.
- Group 3 received 1000 mg of acetaminophen orally every 6 hours for 1 day prior to and after surgery. The timing of the doses was increased to every 8 hours for POD2 through POD5. Patients were allowed to take 5 mg of oxycodone every 6 hours as needed after surgery.
In addition, all patients received interscalene blocks with liposomal bupivacaine preoperatively.
Patients in Group 3 who did not take the prescribed dose of acetaminophen before and after surgery were excluded from the study. Patients in all groups were instructed not to take any other pain medication.
On POD1 through POD7, patients in all 3 groups were asked to complete a daily survey that included 5 questions:
- Did you take any opioid medication today (yes/no)?
- If yes, how many pills and at what times?
- How would you rate your pain today (0-100)?
- If you experienced any side effects, what were they?
- Are you satisfied with your pain control?
The primary outcome of the study was the total number of 5-mg oxycodone pills patients took in the first week after arthroscopic rotator cuff repair. Secondary outcomes included daily side effects, level of pain experienced, and satisfaction with pain control.
The researchers found that:
- Patients in Group 3 consumed significantly fewer 5-mg oxycodone pills overall compared with the other groups (Group 1: 12.97; Group 2: 18.88; Group 3: 8.06; P=0.017).
- Patients who took acetaminophen before and after surgery consumed approximately 10 fewer opioid pills in the first week after surgery compared with patients who took no acetaminophen, and 4 fewer pills than patients who took acetaminophen only as needed after surgery.
- The average pill consumption in Group 3 was significantly less than in Group 1 and Group 2 on POD1: 2.1 vs 3.0 (P=0.03) and 2.1 vs. 3.2 (P=0.02), respectively.
- Group 3 patients reported significantly better overall pain control on a 0 to 100 scale than patients in the other groups (P=0.040).
“I was pleasantly surprised that acetaminophen made such a significant difference in opioid use with patients,” said Dr. Abboud. “We saw an improvement in pain levels and satisfaction postoperatively, which translates to fewer calls from patients who say their pain medications are not working.
“This [study] provides the evidence we need for when we speak to patients. Every drug has side effects, but of all the drugs available, acetaminophen has been around for a long time, with minimal side effects, making it an important component of the overall pain management process.”
Singh A, Kirsch J, Patel MS, Harper T, Lazarus MD, Horneff JG, Namdari S, Voskeridjian AC, Abboud JA. Effect of Perioperative Acetaminophen on Pain Management in Patients Undergoing Rotator Cuff Repair: A Prospective Randomized Study (Paper 180). Presented at the 2021 Annual Meeting of the American Academy of Orthopaedic Surgeons, August 31-September 3, San Diego, California.
- Weber S, Chahal J. Management of rotator cuff injuries. J Am Acad Orthop Surg. 2020 Mar 1;28(5):e193-e201. doi: 10.5435/JAAOS-D-19-00463.
- Bang Sr, Yu SK, Kim TH. Can gabapentin help reduce postoperative pain in arthroscopic rotator cuff repair? A prospective, randomized, double-blind study. Arthroscopy 2010;26:S106-11.
- Chung SW, Kim JY, Kim MH, Kim SH, Oh JH. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med. 2013 Jul;41(7):1674-83.
- Uquillas CA, Capogna BM, Rossy WH, Mahure SA, Rokito AS. Postoperative pain control after arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2016 Jul;25(7):1204-13.