Does the use of periarticular anesthetic cocktail provide adequate pain control following shoulder arthroplasty?

Periarticular injection in addition to interscalene nerve block can decrease opioid consumption and pain following total shoulder arthroplasty: a comparison cohort study

BACKGROUND

Interscalene nerve block (INB) is an effective technique to provide postoperative analgesia for total shoulder arthroplasty (TSA). However, the analgesic effects of the block typically resolve between 8 and 24 hours postadministration, which results in rebound pain and subsequent increased opioid use. The objective of this study was to address this issue by determining how adding an intraoperative periarticular injection (PAI) in combination with INB affects acute postoperative opioid consumption and pain scores in patients undergoing TSA. We hypothesized that compared with INB alone, INB + PAI will significantly reduce opioid consumption and pain scores for the first 24 hours postsurgery.

METHODS

We reviewed 130 consecutive patients who underwent elective primary TSA at a single tertiary institution. The first 65 patients were treated with INB alone, followed by 65 patients treated with INB + PAI. The INB used was 15-20 mL of 0.5% ropivacaine. The PAI used was 50 mL of a combination of ropivacaine (123 mg), epinephrine (0.25 mg), clonidine (40 μg), and ketorolac (15 mg). The PAI was injected using a standardized protocol: 10 mL into the subcutaneous tissues prior to incision, 15 mL into the supraspinatus fossa, 15 mL at the base of the coracoid process, and 10 mL into the deltoid and pectoralis muscles-a protocol analogous with a previously described technique. For all patients, a standardized postoperative oral pain medication protocol was used. The primary outcome was acute postoperative opioid consumption represented by morphine equivalent units (MEUs), whereas the secondary outcome was visual analog scale (VAS) pain scores over the first 24 hours postsurgery, operative time, length of stay, and acute perioperative complications.

RESULTS

No significant differences in demographics existed between patients who received INB alone vs. INB + PAI. Patients who received INB + PAI had a significantly lower 24-hour postoperative opioid consumption compared to the INB alone group (38.6 ± 30.5 MEU vs. 60.5 ± 37.3 MEU, P < .001). Additionally, VAS pain scores for the first 24 hours postsurgery in the INB + PAI group were significantly lower compared to those for the INB alone group (2.9 ± 1.5 vs. 4.3 ± 1.6, P ≤ .001). No differences existed between groups regarding operative time, length of inpatient stay, and acute perioperative complications.

CONCLUSION

Patients undergoing TSA with INB + PAI demonstrated significantly decreased 24-hour postoperative total opioid consumption and 24-hour postoperative pain scores compared to the group treated with INB alone. No increase in acute perioperative complications related to PAI was observed. Thus, compared to an INB, the addition of an intraoperative periarticular cocktail injection appears to be a safe and effective method to reduce acute postoperative pain following TSA.

Evolution of Perioperative Pain Management in Shoulder Arthroplasty

Historically, opioids have been used as a primary conservative treatment for pain related to glenohumeral osteoarthritis (GHOA). However, this practice is concerning as it often leads to overuse, which has contributed to the current epidemic of addiction and overdoses in the United States. Studies have shown that preoperative opioid use is associated with higher complication rates and worse outcomes following surgery, particularly for shoulder arthroplasty. To address these concerns, perioperative pain management for shoulder arthroplasty has evolved over the years to the use of multimodal analgesia.

Safety and short-term outcomes of anatomic vs. reverse total shoulder arthroplasty in an ambulatory surgery center

BACKGROUND

A scarcity of literature exists comparing outcomes of outpatient anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA). This study was performed to compare early outcomes between the 2 procedures in a freestanding ambulatory surgery center (ASC) and to determine if the addition of preoperative interscalene nerve block (ISNB) with periarticular liposomal bupivacaine injection (PAI) in the postanesthesia care unit (PACU) would improve outcomes over PAI alone.

METHODS

Medical charts of all patients undergoing outpatient primary aTSA or rTSA at 2 ASCs from 2012 to 2020 were reviewed. A total of 198 patients were ultimately identified (117 aTSA and 81 rTSA) to make up this retrospective cohort study. Patient demographics, PACU outcomes, complications, readmissions, reoperations, calls to the office, and unplanned clinic visit rates were compared between procedures. PACU outcomes were compared between those receiving ISNB with PAI and those receiving PAI alone.

RESULTS

Patients undergoing rTSA were older (61.1 vs. 55.7 years, P < .001) and more likely to have American Society of Anesthesiologists (ASA) class 3 (51.9% vs. 41.0%, P = .050) compared to patients having aTSA. No patient required an overnight stay. Time in the PACU before discharge (89.1 vs. 95.6 minutes, P = .231) and pain scores at discharge (3.0 vs. 3.0, P = .815) were similar for aTSA and rTSA, respectively. One intraoperative complication occurred in the aTSA group (posterior humeral circumflex artery injury) and 1 in the rTSA group (calcar fracture) (P = .793). Ninety-day postoperative total complication (7.7% vs. 7.4%), shoulder-related complication (6.0% vs. 6.2%), medical-related complication (1.7% vs. 1.2%), admission (0.8% vs. 2.5%), reoperation (2.6% vs. 1.2%), and unplanned clinic visit (6.0% vs. 6.1%) rates were similar between aTSA and rTSA, respectively (P ≥ .361 for all comparisons). At 1 year, there were 8 reoperations and 15 complications in the aTSA group compared with 1 reoperation and 8 complications in the rTSA group (P = .091 and P = .818, respectively). Patients who had ISNB spent less time in PACU (75 vs. 97 minutes, P < .001), had less pain at discharge (0.2 vs. 3.9, P < .001), and consumed less oral morphine equivalents in the PACU (1.2 vs. 16.6 mg, P < .001).

CONCLUSION

Early postoperative outcomes and complication rates were similar between the 2 groups, and all patients were successfully discharged home the day of surgery. The addition of preoperative ISNB led to more efficient discharge from the ASC with less pain in the PACU.

Nerve block with liposomal bupivacaine yields fewer complications and similar pain relief when compared to an interscalene catheter for arthroscopic shoulder surgery: a randomized controlled trial

BACKGROUND

Following orthopedic surgery, patients frequently experience pain and discomfort. Multiple methods of regional anesthesia are available; however, the optimal technique to adequately manage pain while minimizing complications remains under investigation. This study aims to compare the complication rates and pain relief of single-injection, liposomal bupivacaine brachial plexus nerve block to a conventional, indwelling ropivacaine interscalene catheter (ISC) in patients undergoing arthroscopic shoulder surgery. We hypothesize that liposomal bupivacaine will have fewer patient complications with similar pain relief than an indwelling catheter.

METHODS

Patients undergoing arthroscopic shoulder surgery were prospectively assessed after randomization into either ropivacaine ISC or single-injection liposomal bupivacaine brachial plexus nerve block (LB) arms. All patients were discharged with 5 analgesics (acetaminophen, methocarbamol, gabapentin, acetylsalicylic acid, and oxycodone) for as-needed pain relief. Preoperatively, patient demographics and baseline Visual Analog Scale, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and Penn Shoulder Scores were obtained. For the first four days postoperatively, complication rates (nausea, dyspnea, anesthetic site discomfort and/or irritation and/or leakage, and self-reported concerns and complications), pain, medication usage, and sleep data were assessed by phone survey every 12 hours. The primary outcome was overall complication rate. At 12 weeks postoperatively, Visual Analog Scale, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and Penn scores were reassessed. Outcome scores were compared with Mann-Whitney U tests, and demographics were compared with chi-squared tests. Significance was set at P < .05.

RESULTS

A total of 63 individuals were allocated into ISC (N = 35) and in the LB arms (N = 28) for analysis. Demographics and preoperative patient-reported outcomes were not different between the arms. Patients in the LB arm experienced fewer (13.1%) overall complications than those in the ISC arm (29.8%) (P < .001), with patients in the ISC arm specifically reporting more anesthetic site discomfort (36.4% vs. 7.1%, P = .007), leakage (30.3% vs. 7.1%, P = .023), and 'other,' free-response complications (ISC: 21.2%; LB: 3.6%; P = .042). No differences were noted in pain, sleep, opioid use, or satisfaction between arms during the perioperative period. More nonopioid medications were consumed on average in the ISC (1.8 ± 1.4) than in the LB arm (1.4 ± 1.3) (P = .001), with greater reported use of acetylsalicylic acid (40.9% vs. 23.4% P < .001) and acetaminophen (69.5% vs. 59.6% P = .013). Patient-reported outcome scores did not differ between groups preoperatively or at 12 weeks.

DISCUSSION

Patients receiving liposomal bupivacaine experienced fewer complications than traditional ISCs after arthroscopic shoulder surgery. Analgesia, sleep, satisfaction, and functional scores were similar between the 2 groups.

Local Infiltration Analgesia Versus Interscalene Block for Pain Management Following Shoulder Arthroplasty: A Prospective Randomized Clinical Trial

BACKGROUND

While providing effective analgesia following shoulder arthroplasty, an interscalene block has known complications. Local infiltration analgesia (LIA) using ropivacaine has been successfully employed in other joint arthroplasties, but its efficacy in shoulder arthroplasty has not been studied extensively. The purpose of this study was to compare pain and opioid consumption between LIA and an interscalene block following shoulder arthroplasty.

METHODS

Patients undergoing primary shoulder arthroplasty were prospectively randomized into 2 groups: the block group received an interscalene block using liposomal bupivacaine, and the injection group received an LIA injection intraoperatively. The LIA injection included ropivacaine, epinephrine, ketorolac, and normal saline solution. Postoperative visual analog scale pain scores, opioid consumption in morphine milligram equivalents, and complications were compared between the groups. The mean pain scores during the first 24 hours postoperatively were used to test noninferiority of LIA compared with an interscalene block.

RESULTS

The study included 74 patients (52 men and 22 women with a mean age of 69 years; 37 were in the injection group and 37 in the block group). There was no significant difference between the groups with respect to pain scores at any postoperative time points (p > 0.05), except for the 8-hour time point, when the injection group had a significantly higher pain score than the block group (p = 0.01). There was no significant difference in opioid consumption between the groups at any time points postoperatively (p > 0.05). The amount of intraoperative opioid consumption was significantly higher in the injection group (p < 0.001). In noninferiority testing for the mean pain scores during the first 24 hours, the injection group was found to be noninferior to the block group. One patient in the block group developed transient phrenic nerve palsy. One patient in the injection group developed dislocation after reverse arthroplasty related to noncompliance. The mean procedure hospital charge was $1,718 for an interscalene block and $157 for LIA.

CONCLUSIONS

LIA and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty. LIA was associated with worse pain at 8 hours postoperatively and more intraoperative opioid consumption but was also substantially less costly.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.