PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure‐specific postoperative pain management recommendations

Overview

PROSPECT (Procedure-Specific Postoperative Pain Management) is an initiative of the European Society of Regional Anaesthesia and Pain Therapy. It develops evidence-based analgesic recommendations for individual operations rather than for surgery in general. This guideline covers arthroscopic rotator cuff repair, a shoulder procedure known for intense early postoperative pain that can delay rehabilitation and disturb sleep. The working group systematically reviewed randomised controlled trials. It judged each intervention on four questions: whether the effect is statistically significant, whether it matters clinically, whether its benefits outweigh its risks and invasiveness, and whether it adds value on top of basic analgesia.

Key recommendations

The foundation is regular non-opioid systemic analgesia, started before or during surgery and continued afterwards. Opioids are reserved for rescue. Regional anaesthesia is central to the approach: a brachial plexus block is recommended for early pain control. Where that block is unsuitable, for example in patients at respiratory risk, an alternative shoulder block that spares diaphragmatic function can be used. Selected systemic adjuncts may be added to improve and prolong analgesia. The group also lists interventions it does not recommend, because the evidence is limited or inconsistent, or because the risk outweighs the benefit. These include several infiltration and intra-articular techniques when an effective block is already in place.

Clinical implications

For anaesthetists and orthopaedic surgeons, the guideline offers a pragmatic, procedure-tailored protocol that fits into enhanced recovery pathways. It stresses planning for rebound pain as the block wears off, educating patients before discharge, and a smooth transition to oral analgesia at home. It also points to research gaps, such as the need for trials that compare newer block techniques against established approaches using patient-centred outcomes.