Enhanced Recovery After Shoulder Arthroplasty

Effects of ultrasound-guided platelet-rich plasma combined with sodium hyaluronate on shoulder function recovery, pain degree and mental health of patients with rotator cuff injury

Rotator cuff injury is a common condition that affects the shoulder and is characterized by damage to the tendons and muscles in the shoulder area. This type of injury can lead to decreased shoulder function, pain, and decreased quality of life for those affected. As such, finding effective treatments for rotator cuff injury is important for improving patient outcomes and reducing the impact of this condition on patients and society. The purpose of this study was to evaluate the effectiveness of SH (Sodium Hyaluronate) and PRP (Platelet-Rich Plasma) in treating rotator cuff injuries in the shoulder. Patients who were diagnosed with Rotator Cuff Injury (RCI) and received treatment at the hospital were selected as the study subjects and divided into four groups. Various treatments were given to patients in each group. Two-way ANOVA and Mann-Whitney tests were used to analyze the results. The study found that patients who received ultrasound-guided platelet-rich plasma combined with sodium hyaluronate had significantly higher shoulder function recovery rates and better quality of life compared to the other groups. They also reported significantly lower pain scores compared to the other groups. The results suggest that ultrasound-guided platelet-rich plasma combined with sodium hyaluronate can effectively improve the shoulder function of patients with rotator cuff injury, reducing pain and improving their overall well-being. This has implications for improving patient outcomes and reducing the impact of rotator cuff injury on patients and society by providing a promising treatment option for this common condition.

Multimodal pain management and postoperative outcomes in inpatient and outpatient shoulder arthroplasties: a population-based study

INTRODUCTION

Multimodal analgesia has been associated with reduced opioid utilization, opioid-related complications, and improved recovery in various orthopedic surgeries; however, large sample size data is lacking for shoulder surgery.

METHODS

A retrospective review using the Premier Healthcare Database of patients who underwent inpatient or outpatient (reverse, total, partial) shoulder arthroplasty from 2010 to 2019. Opioid-only analgesia was compared with multimodal analgesia, categorized into 1, 2, or >2 additional analgesic modes, with/without a nerve block. Multivariable regression models measured associations between multimodal analgesia and opioid charges (in oral morphine equivalents (OME)), cost and length of stay, and opioid-related adverse effects (approximated by naloxone use). We report % change and 95% CIs.

RESULTS

Among 176 225 procedures, 169 679 (75.7% multimodal analgesia use) and 6546 (37.8% multimodal analgesia use) were inpatient and outpatient shoulder arthroplasties, respectively. Among inpatients, multimodal analgesia (>2 modes) without a nerve block (vs opioid-only analgesia) was associated with adjusted reductions in OMEs on postoperative day 1: -19.4% (95% CI -21.2% to -17.6%/representing unadjusted median OME reductions from 45 to 30 mg). For total hospitalization, this was -6.0% (95% CI -7.2% to -4.9%/representing unadjusted median OME reductions from 173 to 135 mg). Conversely, for outpatients, this was +13.7% change in OMEs (95% CI +4.4% to +23.0%/representing unadjusted median OME increases from 110 to 131 mg). In both settings, addition of a nerve block to multimodal analgesia attenuated effects in terms of opioid charges.

CONCLUSIONS

Multimodal analgesia is associated with reductions in opioid charges-specifically inpatient setting-but not various other outcomes.

Effects of the costoclavicular block versus interscalene block in patients undergoing arthroscopic shoulder surgery under monitored anesthesia care: a randomized, prospective, non-inferiority study

BACKGROUND

Recent studies have reported that costoclavicular blocks (CCBs) can consistently block almost all branches of the brachial plexus while sparing the phrenic nerve and provide effective analgesia after shoulder surgery. We aimed to compare the efficacy of the CCB with that of the interscalene block (ISB) as the sole blocking technique for shoulder surgery.

METHODS

A total of 212 patients undergoing elective arthroscopic shoulder surgery were randomized to receive an ISB or CCB based on a non-inferiority design. All patients received titration sedation with propofol under monitored anesthesia during surgery. The primary outcomes were the proportion of patients with complete motor blockade of the suprascapular nerve (SSN) and incidence of hemidiaphragmatic paralysis (HDP). The secondary outcomes included block-related variables, complications, and postoperative pain scores.

RESULTS

The proportion of patients with complete motor blockade of the SSN at 20 min between the CCB and ISB groups (53% vs. 66%) exceeded the predefined non-inferiority margin of -5%, but was comparable at 30 min (87% vs. 91%). The CCB resulted in a significantly lower incidence of HDP (7.55% vs. 92.45%), Horner's syndrome (0% vs. 18.87%), and dyspnea (0% vs. 10.38%) than the ISB. None of the patients experienced failed blocks or required conversion to general anesthesia. Pain scores were comparable between the groups.

CONCLUSIONS

Ultrasound-guided CCBs may be comparable to ISBs, with fewer unfavorable complications in patients with impaired lung function undergoing arthroscopic shoulder surgery.

Perioperative Intravenous Lidocaine Infusion on Postoperative Recovery in Patients Undergoing Arthroscopic Rotator Cuff Repair Under General Anesthesia - A Randomized Controlled Trial

OBJECTIVE

Arthroscopic rotator cuff repair (ARCR) is known to cause severe postoperative pain which may interfere with recovery. Intravenous (IV) lidocaine has analgesic, anti-inflammatory, and anti-hyperalgesic effects, and is being used in various types of surgeries. However, the effect of IV lidocaine in ARCR is not well known.

MATERIALS AND METHODS

Ninety patients undergoing ARCR were randomly allocated to receive IV lidocaine (1.5▒mg/kg bolus of 1% lidocaine after anesthesia induction followed by a continuous infusion of 2▒mg/kg/h up to 1▒h after surgery) or an equal volume of saline. In both groups, an IV patient-controlled analgesia (PCA) device was used which contained fentanyl 10▒µg/mL, infused at 1▒mL/h with a 1▒mL bolus dose. The primary outcome was fentanyl requirements given via IV PCA during the first 24 hours after surgery. Perioperative pain scores and functional recovery were assessed as secondary outcomes.

RESULTS

The amount of fentanyl administered via IV PCA up to 24 hours after surgery was significantly lower in the Lidocaine group compared to the Control group (329 [256.2-428.3] vs. 394.5 [287.0-473.0], P=0.037) The number of PCA bolus attempts were lower in the Lidocaine group without statistical significance. There were no differences in postoperative pain scores or functional shoulder scores between the two groups.

DISCUSSION

IV lidocaine appears to be helpful in reducing opioid requirements during the acute postoperative period in patients undergoing ARCR. IV lidocaine may be a viable option as a component of multimodal analgesia in ARCR when regional analgesia is not possible.

Biological sex impacts perioperative complications after reverse shoulder arthroplasty for proximal humeral fracture

Background

The purpose of this study was to determine the difference in complication rates between males and females undergoing reverse shoulder arthroplasty for proximal humerus fractures. We hypothesized that (1) females were more likely to undergo reverse shoulder arthroplasty for fracture, and (2) males were more likely to sustain a perioperative complication.

Methods

The National Surgical Quality Improvement Program database was queried to identify patients who underwent reverse shoulder arthroplasty for proximal humerus fracture between 2011 and 2018. Patients were stratified based on biological sex. Patient demographics, comorbidities, and 30-day perioperative complication rates were collected. Univariate analyses and multiple variable logistic regression modeling were performed.

Results

About 905 patients were included in the analysis—175 (19.3%) were male and 730 (80.7%) were female. Males were more likely to sustain perioperative complications (26.3% vs. 14.1%; P < .001)—pneumonia (2.9% vs. 0.5%; P = .016), unplanned intubation (2.3% vs. 0.4%; P = .029), and unplanned reoperation (9.1% vs. 1.1%; P < .001). On multivariate analysis, males were at a 2.4-fold increase risk of developing any complication (OR = 2.38 [95% CI 1.55-3.65]; P < .001) and a 10-fold increase risk of returning to the operating room for an unplanned reoperation (OR = 10.59 [95% CI 4.23-27.49]; P < .001) compared with females.

Conclusion

Females were more likely to undergo reverse shoulder arthroplasty for proximal humerus fracture, but males were at increased risk of sustaining short-term complications. This study provides useful information for clinicians to consider when counseling their patients during the perioperative period.

Defining success in regional anaesthesia

Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.

An enhanced recovery after surgery pathway: association with rapid discharge and minimal complications after anterior cervical spine surgery

OBJECTIVEEnhanced recovery after surgery (ERAS) pathways are associated with improved outcomes, lower morbidity and complications, and higher patient satisfaction in multiple surgical subspecialties. Despite these gains, there are few data to guide the application of ERAS concepts to spine surgery. The authors report the development and implementation of the first ERAS pathway for patients undergoing anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA).METHODSThis was a retrospective cohort study of prospectively collected data. The authors created a multidisciplinary pathway based on best available evidence for interventions that positively influence outcomes after anterior cervical spine surgery. Patients were followed prospectively up to postoperative day 90. Patient data were collected via electronic medical record review and included demographics, comorbidities, baseline and perioperative opioid use, postoperative complications, and length of hospital stay (LOS). ERAS process measures and compliance with pathway elements were also tracked.RESULTSThirty-three patients were cared for under the pathway (n = 25 ACDF; n = 8 CDA). The median LOS was 416 minutes (interquartile range [IQR] 210-1643 minutes). Eight patients required an extended stay-longer than 23 hours. Reasons for extended admission included pain (n = 4), dyspnea (n = 1), hypoxia (n = 1), hypertension (n = 1), and dysphagia (n = 1). The median LOS for the 8 patients who required extended monitoring prior to discharge was 1585 minutes (IQR 1423-1713 minutes). Overall pathway compliance with included process measures was 85.6%. The median number of ERAS process elements delivered to each patient was 18. There was no strong association between LOS and number of ERAS process elements provided (Pearson's r = -0.20). Twelve percent of the cohort was opioid tolerant on the day of surgery. There were no significant differences between total intraoperatively or postanesthesia care unit-administered opioid, or LOS, between opioid-tolerant and opioid-naïve patients. There were no complications requiring readmission.CONCLUSIONSAn ERAS pathway for anterior cervical spine surgery facilitates safe, prompt discharge. The ERAS pathway was associated with minimal complications, and no readmissions within 90 days of surgery. Pain and respiratory compromise were both linked with extended LOS in this cohort. Further prospective studies are needed to confirm the potential benefits of ERAS for anterior cervical spine surgery, including longer-term complications, cost, and functional outcomes.

Regional anaesthesia for surgical repair of proximal humerus fractures: a systematic review and critical appraisal

INTRODUCTION

Regional anaesthesia (RA) is often used in shoulder surgery because it provides adequate postoperative analgesia and may enhance the patient outcome. RA reduces overall opioid consumption and is frequently used in enhanced recovery programs to decrease hospital stay. However, there is very limited literature confirming these advantages in the surgical repair of proximal humerus fractures. This paper reviews the current literature on the use of RA in pain management after surgical repair of these fractures and evaluates the effect of RA on the functional outcome, length of stay in hospital, and health care expenditure.

MATERIALS AND METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to March 1, 2018. Studies investigating the use of RA in the management of proximal humerus fractures were included.

RESULTS

Eleven studies (containing 1872 patients) were eligible for inclusion. The analgesic effect of RA was investigated in eight studies that confirmed its pain-relieving ability. Two studies measured functionality and length of hospitalization and suggested that RA improved function and shortened the stay in hospital. Nine papers mentioned side effects associated with RA while three articles claim that RA decreases the incidence of adverse events associated with general anaesthesia.

CONCLUSIONS

This systematic review suggests that RA is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anaesthesia alone. However, given the limited amount of data available, conclusions need to be made with caution and prospective studies are needed in the future.