The impact of peripheral nerve blocks on perioperative outcome in hip and knee arthroplasty-a population-based study

Comprehensive Pain Management in Total Joint Arthroplasty: A Review of Contemporary Approaches

Background: Total hip and knee arthroplasties are among the most effective and widely performed procedures in modern medicine, providing substantial benefits to patients with end-stage osteoarthritis. These surgeries have transformed the treatment of degenerative joint disease, significantly enhancing functionality and quality of life for patients. Despite considerable advancements in surgical techniques and postoperative care, managing postoperative pain remains a major challenge, impacting both clinical recovery and patient satisfaction. The persistence of postoperative pain as a barrier to recovery underscores the need for improved pain management strategies. Methods: A comprehensive narrative review of the literature was conducted, focusing on the physiological mechanisms underlying surgical pain, the role of anesthesia techniques, and the development of multimodal pain management approaches used in total joint arthroplasty. This review emphasizes the components of modern multimodal strategies, which combine multiple pharmacologic and non-pharmacologic methods to address the various mechanisms of postoperative pain. Results: Current pain management strategies employ a dynamic, multimodal approach that covers the perioperative period. These strategies aim to optimize pain control while minimizing side effects. They incorporate a range of methods, including nerve blocks, non-opioid analgesics, opioids, and non-pharmacologic techniques such as physical therapy. However, evidence regarding the efficacy and optimal combinations of these interventions varies widely across studies. Conclusions: This variation has led to inconsistent pain management practices across institutions. To standardize and improve care, this paper presents the authors' institutional pain management model, offering a potential framework for broader application and adaptation in the field of joint arthroplasty.

The addition of peripheral nerve blocks to routine spinal or general anesthesia was associated with decreased risks of major adverse events after total hip or knee arthroplasty: A retrospective, propensity score-matched cohort study

Background

Although total joint arthroplasty is the most effective procedures for end-stage arthritis, the incidence of postoperative death and complications remains high. The association of additional peripheral nerve blocks (PNBs) to routine spinal or general anesthesia with major adverse events (including mortality and complication rates) in elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) has been subject to inconclusive findings.

Methods

This retrospective observational single institution study included all patients ≧ 18 years undergoing their first elective THA or TKA from January 1, 2012 to December 31, 2021. A 1:2 propensity score matching (PSM) was performed to account for the baseline differences between two groups that were accepted to PNB or not. Kaplan-Meier curves were employed to estimate the effects of PNB on mortality. The associations of PNB and the complications were assessed by logistic regression models.

Results

We identified 1328 patients, among whom 197 had PNB and 1131 had not. The 90-day all-cause mortality was significantly reduced in patients with PNBs (0 % vs 2.79 %, P = 0.041) after THA or TKA, when compared to the non-PNB group. PNB was also associated with a lower risk of pulmonary complications (odds ratio [OR], 0.430; 95%confidence interval [CI],0.216-0.857) and deep vein thrombosis (OR, 0.103; 95%CI, 0.011-0.954).

Interpretation

The results of this observational, propensity score-matched cohort study suggested a strong association between the addition of PNBs to routine spinal or general anesthesia and decreased risks of major adverse events.

Pain Control and Satisfaction With Peripheral Nerve Blocks for Upper Extremity Surgery

BACKGROUND

Regional anesthesia ("block") is an important component of upper extremity (UE) surgery pain control. However, little is known about patient experience related to perioperative opioid use. This study assessed patient-reported pain control and satisfaction with UE blocks and evaluated how opioid consumption impacted these outcomes before the block "wore off."

METHODS

A postoperative phone survey was administered to patients who underwent outpatient UE surgery at a surgery center for more than 16 months. It assessed pain scores (scale 1-10), satisfaction with block duration (scale 1-5), duration until return of UE function, and opioid consumption. Analyses used Mann-Whitney U tests, Fisher exact tests, and bivariate and multivariable linear and ordered logistic regressions to understand relationships between opioid use and outcomes.

RESULTS

A total of 509 patients (61%) completed the survey, and 441 (88%) were satisfied with block duration. Initial and final pain scores were significantly higher in patients who took opioids prior to the block wearing off (6 and 4.5, P = .04 and 3.5 and 2, P = .002, respectively). Although satisfaction with block duration was not different in group comparisons (ie, patients who premedicated vs those who did not), in a multivariable analysis, patients who premedicated with opioids had 78% increased odds of reporting the highest level of satisfaction compared with the lower 4 levels (P = .03).

CONCLUSIONS

Upper extremity blocks are associated with high overall patient satisfaction and postsurgical pain control. Premedicating before the block wears off may increase patient satisfaction with block duration even if pain is not notably impacted.

Does the impact of peripheral nerve blocks vary by age and comorbidity subgroups? A nationwide population-based study

INTRODUCTION

A large body of literature suggests that peripheral nerve blockade (PNB) is associated with improved perioperative outcomes in total hip and knee joint arthroplasty patients. However, it is unclear to what extent this association exists across patient subgroups based on age and health status.

METHODS

Patients who underwent total joint arthroplasty were identified from the Premier Healthcare database (2006-2019). Mixed-effects models were applied to assess the relationship between exposure of interest (PNB use on the day of surgery) and various outcomes (postoperative respiratory complications, acute renal failure, delirium, intensive care unit admission, prolonged length of stay, and high opioid consumption) across multiple subgroups stratified by patient age and pre-existing comorbidities.

RESULTS

PNB use and outcome association varies based on the patient's health and age characteristics. For adults and older adults with excellent or fair, there was a decrease in the likelihood of respiratory complication with the use of PNB (OR: 0.92, 95% CI 0.86 to 0.98; OR: 0.88, 95% CI 0.81 to 0.95; OR: 0.94, 95% CI 0.89 to 0.99, respectively). Peripheral nerve blocks were also associated with a reduction in the odds of high opioid consumption across all categories except adult patients in poor health.

CONCLUSION

PNB use is associated with beneficial effects more commonly observed among patients with a lower comorbidity burden, without a clear pattern of association with patient age.

Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.

Effectiveness of an online management platform (Joint Cloud) versus standard process for patients undergoing total knee arthroplasty: study protocol for a prospective randomised controlled trial

INTRODUCTION

Osteoarthritis (OA) is one of the main causes of mobility impairment in the elderly worldwide. Therefore, total knee arthroplasty (TKA) is often performed and is one of the most successful surgery and has resulted in substantial quality-of-life gains for people with end-stage arthritis. There is still room for improvement in the standard treatment process in the preoperative, intraoperative and postoperative period of TKA. Telerehabilitation has the potential to become a positive alternative to face-to-face rehabilitation nowadays. But it remains unclear how well telemedicine interventions cover the entire surgical pathway (preoperation, intraoperation, postoperation). This study aims to explore the effectiveness of Joint Cloud (JC, an online management platform) compared with existing standard process in regulating functional recovery, pain management, muscle strength changes and other health-related outcomes in patients undergoing total knee arthroplasty preoperation, intraoperation and postoperation.

METHODS AND ANALYSIS

A randomised controlled trial was designed to compare the online management platform (JC) with standard process (SP) in patients undergoing TKA. A total of 186 TKA patients will be randomly assigned to the intervention (n=93) or control (n=93) group. Patients in the intervention group will receive access to the 'JC' mini-program. This mini-program provides popular science information (eg, information about OA and TKA), functional exercise information and communication channels. Patients evaluate their condition and functional level through standardised digital questionnaires. The control group of patients will not accept any functions of this mini-program. The primary outcome is knee functional recovery, and the secondary outcomes are pain management, isometric knee extensor muscle strength, patient satisfaction and cost-benefit analysis. Assessments will be performed 1 month and 3 days before surgery (T0) and 1 month and 3 months after surgery. Data analysis will be performed according to the intent-to-treat (ITT) principle. Repeated measures of linear mixed models and parametric and non-parametric testing will be used for statistical analysis.

ETHICS AND DISSEMINATION

The study was reviewed and approved by the Tianjin Hospital Medical Ethics Review Committee on 10 February 2023 (2022YLS155). Test data are considered highly sensitive but are available upon request. The findings will be disseminated in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ChiCTR2300068486.

Regional Anesthesia Is Safe and Effective for Low-Energy Tibial Plateau Fractures

The purpose of this study was to determine if the use of peripheral nerve blocks in the operative management of tibial plateau fractures is associated with improved outcomes when compared with the use of spinal and general anesthesia. Over a period of 16 years, 132 patients who underwent operative repair for a low-energy tibial plateau fracture and had at least 12 months of follow-up met the inclusion criteria and formed the basis of this study. Patients were grouped into cohorts based on the anesthetic method used during surgery: peripheral nerve block in combination with conscious sedation or general anesthesia (BA), general anesthesia alone (GA), or spinal anesthesia alone (SA). Outcomes were assessed at 3 months, 6 months, and 12 months. Length of stay was greatest in the GA cohort (P<.05), and more patients in the BA cohort were discharged to home (P<.05). Patients in the GA cohort had the highest pain scores at 3 months and 6 months (P<.05). Patients in both the SA and BA cohorts had better Short Musculoskeletal Function Assessment scores at 6 and 12 months when compared with the GA cohort (P<.05). Although knee range of motion did not differ among the three cohorts at 3 months, it did differ at 6 months and 12 months postoperatively, with those who had a preoperative nerve blockade (SA and BA) having the greatest knee range of motion (P<.05). Regional anesthesia was safe and was associated with lower pain scores in the early postoperative period and greater knee range of motion and functional outcome scores in the late postoperative period. [Orthopedics. 2023;46(6):358-364.].

A Systematic Review on Long-Term Postsurgical Pain Outcomes; What Is the Effect of Upper Extremity Regional Anesthesia?

BACKGROUND

Chronic pain is a recognized complication of surgery, and it has been hypothesized that regional anesthesia might reduce the risk of development of chronic pain after upper extremity surgery.

METHODS

A systematic literature review was performed to assess whether in patients undergoing elective upper extremity surgery (P), regional anesthesia (I), compared to general anesthesia (C), would result in lower long-term (>3 months) postoperative pain intensity (O). We included randomized and nonrandomized controlled trials (RCTs). Our primary outcome was numerical rating score or visual analogue scale for pain, at >3 months postoperatively. The Embase, Medline ALL, Web of Science Core Collections, Cochrane Central Register of Controlled Trials, and Google Scholar databases were searched for all reports assessing pain at >3 months after upper extremity surgery under general versus regional anesthesia. Secondary outcomes were: opioid prescription filling, complex regional pain syndrome (CRPS) incidence, the Mayo Wrist Score (MWS), and scores on the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Quality (or certainty) of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Risk-of-bias was assessed using the Cochrane tool for randomized trials (RoB 2.0) and nonrandomized trials (ROBINS-I).

RESULTS

This review included 14 studies, comprising 7 RCTs and 7 nonrandomized studies. Six of the 7 studies (4 RCTs, N = 273; 2 nonrandomized studies, N = 305) using a pain score, our primary outcome, report comparable long-term postoperative pain scores after regional and general anesthesia. Six of the 7 studies using our secondary outcomes report comparable long-term outcomes in terms of opioid prescription filling (2 retrospective cohort studies [RCSs], N = 89,256), CRPS incidence (1 RCT, N = 301), MWS (1 RCT and 1 RCS, N = 215), and DASH score (1 RCT, N = 36). Comparable outcomes were reported in all 7 RCTs (N = 778) and in 5 of the 7 nonrandomized studies, comprising 5 RCSs (N = 89,608). Two prospective observational studies (POSTs), comprising 279 patients, report a statistically significant difference in outcomes, with less pain and better DASH scores after brachial plexus anesthesia. All 14 studies provided moderate to very low certainty evidence, and there was a serious risk of bias due to confounding bias in 5 of the 7 nonrandomized studies (N = 631).

CONCLUSIONS

The results of this review indicate that upper extremity regional anesthesia, compared to general anesthesia, is unlikely to change pain intensity at >3 months postoperatively.

Regional anesthesia for transplantation surgery - A white paper part 1: Thoracic transplantation surgery

Transplantation surgery continues to evolve and improve through advancements in transplant technique and technology. With the increased availability of ultrasound machines as well as the continued development of enhanced recovery after surgery (ERAS) protocols, regional anesthesia has become an essential component of providing analgesia and minimizing opioid use perioperatively. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures. To date, no formal guidelines or recommendations exist which address the use of regional anesthesia in transplantation surgery. In response, the Society for the Advancement of Transplant Anesthesia (SATA) identified experts in both transplantation surgery and regional anesthesia to review available literature concerning these topics. The goal of this task force was to provide an overview of these publications to help guide transplantation anesthesiologists in utilizing regional anesthesia. The literature search encompassed most transplantation surgeries currently performed and the multitude of associated regional anesthetic techniques. Outcomes analyzed included analgesic effectiveness of the blocks, reduction in other analgesic modalities-particularly opioid use, improvement in patient hemodynamics, as well as associated complications. The findings summarized in this systemic review support the use of regional anesthesia for postoperative pain control after transplantation surgeries. Part 1 of the manuscript focuses on regional anesthesia performed in thoracic transplantation surgeries, and part 2 in abdominal transplantations.

Peripheral Nerve Block Utilization is Associated With Decreased Postoperative Opioid Consumption and Shorter Length of Stay Following Total Knee Arthroplasty

Background

This study aims to examine differences in postoperative complications and opioid consumption associated with perioperative peripheral nerve block (PNB) utilization during primary total knee arthroplasty (TKA).

Methods

The Premier Healthcare Database was queried for adult patients who underwent primary, elective TKA from 2015 to 2020. Patients who received a femoral or adductor canal PNB were compared to patients who did not. PNB utilization was trended from 2015 to 2020. Univariate and multivariate regression analyses were performed to assess differences in the 90-day risk of postoperative complications between groups. The average inpatient opioid consumption in morphine milligram equivalents was assessed as a function of length of stay.

Results

Overall, 609,991 patients were included. PNB utilization increased from 9.29% in 2015 to 30.3% in 2020. After controlling for confounders, the PNB cohort was more likely to have same-day discharge (adjusted odds ratio [aOR] 1.88) and had a decreased risk of periprosthetic joint infection (aOR 0.87), pulmonary embolism (aOR 0.81), and respiratory failure (aOR 0.78). However, there was an increased risk of seroma (aOR 1.75) and hematoma (aOR 1.22) associated with PNB utilization. Lower average overall opioid exposure was seen in the PNB cohort vs no-PNB cohort (82.1 ± 194.7 vs 89.4 ± 214.1 morphine milligram equivalents, P < .001).

Conclusions

PNB utilization during primary TKA is associated with a shorter length of stay and decreased risk of multiple postoperative complications, as well as reduced postoperative opioid consumption. These data provide evidence in support of the safety and efficacy of this emerging practice. However, the clinical relevance of an increased risk of seroma and hematoma formation may warrant further investigation.

Continuous peripheral nerve blocks for analgesia of ventilated critically ill patients with multiple trauma: a prospective randomized study

BACKGROUND

Sedation of ventilated critically ill trauma patients requires high doses of opioids and hypnotics. We aimed to compare the consumption of opioids and hypnotics, and patient outcomes using sedation with or without continuous regional analgesia (CRA).

METHODS

Multiple trauma-ventilated patients were included. The patients were randomized to receive an intravenous analgesia (control group) or an addition of CRA within 24h of admission. A traumatic brain injury (TBI) patients group was analyzed. The primary endpoint was the cumulative consumption of sufentanil at 2 days of admission. Secondary endpoints were cumulative and daily consumption of sufentanil and midazolam, duration of mechanical ventilation, intensive care unit (ICU) stay, and safety of CRA management.

RESULTS

Seventy six patients were analyzed: 40 (67.5% males) in the control group and 36 (72% males) in the CRA group, respectively. The median [IQR] Injury Severity Score was 30.5 [23.5-38.5] and 26.0 [22.0-41.0]. The consumption of sufentanil at 48h was 725 [465-960] μg/48h versus 670 [510-940] μg/48h (p = 0.16). Daily consumption did not differ between the groups except on day 1 when consumption of sufentanil was 360 [270-480] μg vs. 480 [352-535] μg (p = 0.03). Consumptions of midazolam did not differ between the groups. No difference was noted between the groups according to the secondary endpoints.

CONCLUSIONS

CRA does not decrease significantly sufentanil and midazolam consumption within the first 5 days after ICU admission in multiple trauma-ventilated patients. The use of peripheral nerve blocks in heavily sedated and ventilated trauma patients in the ICU seems safe.

Does the Addition of iPACK Block to Adductor Canal Block Provide Improved Analgesic Effect in Total Knee Arthroplasty? A Systematic Review and Meta-Analysis

The interspace between popliteal artery and the capsule of posterior knee (iPACK) block was proposed in recent years to relieve posterior knee pain. Since adductor canal block (ACB) and iPACK involve different branches of the sensory nerves, it is theoretically feasible to combine iPACK block and ACB to relief pain after total knee arthroplasty (TKA). We aim to validate the efficacy of adding iPACK block to ACB in the setting of a multimodal pain management protocol following TKA. A comprehensive literature review on Web of Science, Embase, the Cochrane Library, and PubMed was performed. Eight studies (N = 1,056) that compared the efficacy of iPACK block + ACB with ACB alone were included. Primary outcomes consisted of Visual Analogue Scale (VAS) score at rest or during activity at various time points. Secondary outcomes include opioids consumption, walking distance, and length of hospital stay (LOS). Compared to ACB alone, VAS scores at rest (standardized mean difference [SMD]: -1.18; 95% confidence interval [CI]: -2.05 to -0.30) and during activity (SMD: -0.26; 95% CI: -0.49 to -0.03) on the day of surgery were lower in the iPACK block + ACB group. However, the difference did not reach the minimal clinically important difference. Opioids consumption at postoperative 24 hours was lower in the iPACK + ACB group (SMD: -0.295; 95% CI: -0.543 to -0.048). VAS score on postoperative day (POD) 1 and POD2, opioids consumption from 24 to 48 hours, walking distance, and LOS were not different. In conclusion, the addition of iPACK block to ACB in a multimodal pain management protocol can effectively reduce opioids consumption in the early postoperative period. This is a level III, meta-analysis study.

The impact of regional anesthesia on opioid demand in distal radius fracture surgery

PURPOSE

Regional anesthesia (RA) is commonly used in distal radius fracture surgery to reduce pain and opioid consumption. The purpose of this study was to evaluate the real-world impact of RA on inpatient and outpatient opioid consumption and demand in patients undergoing distal radius fracture surgery.

METHODS

All patients ages 18 and older undergoing distal radius fracture surgery between 7/2013 and 7/2018 at a single institution (n = 969) were identified. Inpatient opioid consumption and outpatient opioid prescribing in oxycodone 5-mg equivalents (OE's) up to 90-d post-operative were recorded for patients with and without RA. Adjusted models were used to evaluate the impact of RA on opioid outcomes.

RESULTS

Adjusted models demonstrated decreases in inpatient opioid consumption in patients with RA (10.7 estimated OE's without RA vs. 7.6 OE's with RA from 0 to 24 h post-op, 10.2 vs. 5.3 from 24 to 48 h post-op and 7.5 vs. 5.0 from 48 to 72 h post-op, p<.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA (65.3 OE's without RA vs. 81.0 with RA from 1-month pre-op to 2-week post-discharge, 76.1 vs. 87.7 OE's to 6-weeks, and 80.8 vs. 93.5 OE's to 90-d, all p values for RA <.05) though rates of refill were significantly lower in patients with RA from 2-week to 6-week post-op compared to patients without RA.

CONCLUSIONS

Patients undergoing RA in distal radius fracture surgery had decreased inpatient opioid consumption but increased outpatient demand after adjustment for patient and operative characteristics.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

Peripheral nerve-blocks and associations with length of stay and readmissions in fast-track total hip and knee arthroplasty

BACKGROUND

Peripheral nerve blocks (PNB) have recently been recommended in total hip (THA) and knee (TKA) arthroplasty as they may reduce pain, morphine consumption, length of stay (LOS) and complications. However, whether PNBs are associated with early discharge within an enhanced recovery protocol including multimodal analgesia is uncertain.

METHODS

An observational multicenter study from January to August 2017 in six Danish Arthroplasty Centers with established fast-track protocols. Prospective recording of preoperative characteristics and information on PNB, LOS and readmissions through the Danish National Patient Registry and medical records. Multiple logistic regression was used to investigate associations between PNB and a LOS >1 day, LOS >4 days, and 30-days readmissions. We also reported on mobilization, pain, opioid and fall-related complications leading to LOS >4 days or readmissions.

RESULTS

A total of 2027 (58.6%) THA and 1432 (41.4%) TKAs with a median LOS of 1 day (IQR 1-2) and 5.3% (CI:4.6-6.1) 30-days readmission rate were identified. PNB was used in 40.7% (CI:38.2-43.3) of TKA and 2.7% (CI:2.0-3.5) of THA, but with considerable interdepartmental variation (0.0-89.0% for TKA). There was no association between PNB and LOS >1 day (OR:1.19 CI:0.82-1.72; p = .354), LOS >4 days (OR:1.4 CI:0.68-2.89; p = .359) or 30-days readmissions (OR:1.02 CI:0.63-1.65; p = .935) in TKA. Logistic regression in THA was not possible due to limited use of PNB. In TKA there were 12 (2.1% CI:1.2-3.6) with and 1 (0.1% CI:0.02-0.7) without a PNB, who had mobilization, pain or opioid-related complications, and 5 (0.9% CI:0.4-2.0) versus 4 (0.5% CI:0.2-1.2) who fell. Correspondingly, 2 (3.7% CI:1.0-12.6) and 11 (0.6% CI:0.3-1.0) of THA patients had these complications, while 0 (0.0% CI:0.0-6.6) and 17 (0.8% CI:0.5-1.3) fell.

CONCLUSION

Routine use of peripheral nerve blocks was not associated with early discharge or 30-days readmissions in fast-track THA and TKA. Future studies should focus on benefits of PNB in high-risk patients.

Efficacy of Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined With Local Infiltration Analgesia on Postoperative Pain After Total Hip Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial

BACKGROUND

This study examined whether pericapsular nerve group (PENG) block combined with local infiltration analgesia (LIA) could improve pain management and functional recovery after total hip arthroplasty.

METHODS

All patients were randomly assigned to receive PENG block combined with LIA (PENG group) or sham PENG block and LIA (Sham group). The primary outcome was cumulative morphine consumption within 24 hours after surgery. Secondary outcomes were pain scores on a visual analog scale (VAS); time to first rescue analgesia; cumulative morphine consumption during hospitalization; intraoperative consumption of opioids; postoperative recovery; and postoperative complications.

RESULTS

PENG patients consumed significantly less morphine within the first 24 hours and throughout hospitalization and smaller amounts of intraoperative opioids. There were significantly lower pain scores at rest and during motion within 24 hours in PENG patients. PENG patients took significantly longer until the first rescue analgesia and showed significantly better postoperative rehabilitation. However, the absolute change in morphine consumption and VAS scores did not exceed the reported minimal clinically important differences (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement). The two groups showed no difference in quadriceps muscle strength and postoperative complications.

CONCLUSION

PENG block combined with LIA could improve postoperative pain relief, reduce opioid use, and enhance recovery in total hip arthroplasty patients, without weakening the quadriceps muscle strength. This work justifies further trials to examine the safety and efficacy of this block and to explore maximal effective volume of local anesthetic for motor-sparing PENG block.

Beware the rebound effect: regional anesthesia increases opioid utilization after humerus fracture surgery

Introduction

Regional anesthesia (RA) is used reduce pain in proximal humerus and humeral shaft fracture surgery. The study hypothesis was that RA would decrease opioid demand in patients undergoing fracture surgery.

Materials and methods

Opioid demand was recorded in all patients ages 18 and older undergoing proximal humerus or humeral shaft fracture surgery at a single, Level I trauma center from 7/2013 - 7/2018 (n = 380 patients). Inpatient opioid consumption from 0-24, 24-48, and 48-72 h and outpatient opioid demand from 1-month pre-operative to 90-days post-operative were converted to oxycodone 5-mg equivalents (OE's). Unadjusted and adjusted models were constructed to evaluate the impact of RA and other factors on opioid utilization.

Results

Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (6.8 estimated OE's without RA vs 8.8 estimated OE's with RA from 0-24 h post-op; 10 vs 13.7 from 24-48 h post-op; and 8.7 vs 11.6 from 48-72 h post-op; all p < 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA at all timepoints.

Discussion

In proximal humerus and humeral shaft fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics.

Regional anesthesia does not decrease inpatient or outpatient opioid demand in distal femur fracture surgery

INTRODUCTION

Regional anesthesia (RA) is sometimes used to decrease pain and opioid consumption in distal femur fractures. However, the real-world impact of RA on inpatient opioid consumption and outpatient opioid demand is not well known. The hypothesis of this study is that RA would be associated with decreased inpatient opioid consumption and outpatient opioid demand.

METHODS

This study evaluated inpatient post-operative opioid consumption (0-24 h, 24-48 h, 48-72 h) and outpatient opioid demand (discharge to 2 weeks, 6 weeks, and 90 days) in all patients ages 18 and older undergoing operative treatment of distal femur fractures at a single institution from 7/2013 to 7/2018 (n = 230). Unadjusted and adjusted multivariable models were used to evaluate the impact of RA and other baseline patient and operative characteristics on inpatient opioid consumption and outpatient opioid demand.

RESULTS

Adjusted models demonstrated a small, significant increase in inpatient opioid consumption in patients with RA compared to no RA (4.7 estimated OE's without RA vs 6.2 OE's with RA from 24- to 48-h post-op, p < 0.05) but otherwise no significant differences at other timepoints (6.7 estimated OE's without RA vs 6.9 OE's with RA from 0- to 24-h post-op and 4.5 vs 4.4 from 48- to 72-h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA from discharge to 6 weeks and to 90 days (55.8 OE's without RA vs 63.9 with RA from discharge to 2 weeks, p > 0.05; 74.9 vs 95.1 OE's to 6 weeks, and 85 vs 113.1 OE's to 90 days, p < 0.05).

DISCUSSION

In distal femur fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results call into question the routine use of RA in distal femur fractures.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

Perineural Administration of Dexmedetomidine in Axillary Brachial Plexus Block Provides Safe and Comfortable Sedation: A Randomized Clinical Trial

Dexmedetomidine prolongs the duration of regional block while its systemic sedative effect when administered perineurally is unknown. We aimed to evaluate the systemic sedative effect of perineural dexmedetomidine in patients after axillary brachial plexus block (ABPB). This single-blinded prospective randomized control trial included 80 patients undergoing wrist surgery receiving ABPB. Patients were randomized into two groups – Control group (CG, N = 40) and dexmedetomidine group (DG, N = 40). Both groups received ABPB with 20 ml of 0.5% Bupivacaine and 10 ml of 2% Lidocaine. Additionally, patients in DG received 100 mcg of dexmedetomidine perineurally. Depth of sedation was evaluated using Narcontrend Index (NI) and Ramsay Sedation Scale (RSS) immediately after ABPB and in several time points up to 120 min. Duration of block as well as patient satisfaction with sedation was evaluated using a postoperative survey. Our results showed that NI and RSS statistically differed between groups, presenting a deeper level of sedation during the first 90 min in DG compared to controls, P < 0.001. In the first 10 to 60 min after ABPB the median RSS was 4 (IQR within median) and median NI was 60 (IQR 44–80) in DG group, in contrast to CG patients where median RSS was 2 (IQR within median) and median NI was 97 (IQR 96–98) throughout surgery. The level of sedation became equal in both groups 90 and 120 min after ABPB when the median NI value was 98 (97–99) in DG and 97.5 (97–98) in CG, P = 0.276, and the median RSS was 2 (IQR within median) in both groups, P = 0.128. No significant intergroup differences in hemodynamic or respiratory parameters were found. Patients in DG expressed satisfaction with sedation and 86.5% noted that the sensation was similar to ordinary sleep. In DG mean duration of motor block was 13.5 ± 2.1 h and sensory block was 12.7 ± 2.8 h which was significantly longer compared to CG 6.3 ± 1.5 h, P < 0.001 and 6.4 ± 1.8 h, P < 0.001. We found that beside prolongation of analgesia, perineural administration of dexmedetomidine might provide rather safe and comfortable sedation with no significant effect on hemodynamic or respiratory stability and yields a high level of patient satisfaction.

Comparison Between Ultrasound-Guided Suprainguinal Fascia Iliaca Block and Anterior Quadratus Lumborum Block for Total Hip Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial

BACKGROUND

Nerve block is a key technique in postoperative analgesia for total hip arthroplasty (THA). This study aimed to compare ultrasound-guided suprainguinal fascia iliaca block (SFIB) and anterior quadratus lumborum block (AQLB) in patients undergoing primary THA.

METHODS

In this prospective, double-blind, randomized controlled trial, 100 patients undergoing primary THA under general anesthesia were randomly allocated to receive an ultrasound-guided SFIB + sham AQLB (SFIB group), or an ultrasound-guided AQLB + sham SFIB (AQLB group). Before wound suture, all patients received periarticular infiltration analgesia which the local anesthetic was injected into joint capsule, exposed gluteal and abductor muscles, peritrochanteric zone, and subcutaneous tissue under the incision as multiple sites. The primary outcome was postoperative morphine consumption within 24 hours after surgery. Secondary outcomes were the time to first rescue analgesia, postoperative pain assessed on the visual analog scale, postoperative quadriceps strength, the time to hospital discharge, and the incidence of postoperative complications.

RESULTS

There were no significant differences between the 2 groups concerning morphine consumption within 24 hours after surgery (P = .774), the time to first rescue analgesia (P = .890), the time to hospital discharge (P = .532), and the incidence of postoperative complications (P > .05). The visual analog scale pain scores at rest and during motion also were similar at all time points (P > .05). Significantly more patients in the SFIB group experienced quadriceps muscle weakness at 2 hours (P = .008) and 6 hours (P = .009) after surgery.

CONCLUSION

Under the circumstances of this study, when combined with periarticular infiltration analgesia, the SFIB provided similar pain relief compared with AQLB in patients undergoing THA, but was associated with muscle weakness within 6 hours after surgery.

Regional anesthesia reduces inpatient and outpatient perioperative opioid demand in periarticular elbow surgery

HYPOTHESIS

Regional anesthesia (RA) can be used to manage perioperative pain in the treatment of periarticular elbow fracture fixation. However, the opioid-sparing benefit is not well-characterized. The hypothesis of this study was that RA had reduced inpatient opioid consumption and outpatient opioid demand in patients who had undergone periarticular elbow fracture surgery.

METHODS

This study retrospectively reviews inpatient opioid consumption and outpatient opioid demand in all patients aged ≥18 years at a single Level I trauma center undergoing fixation of periarticular elbow (distal humerus and proximal forearm) fracture surgery (n=418 patients). In addition to RA vs. no RA, additional patient and operative characteristics were recorded. Unadjusted and adjusted models were constructed to evaluate the impact of RA and other factors on inpatient opioid consumption and outpatient opioid demand.

RESULTS

Adjusted models demonstrated decreases in inpatient opioid consumption postoperation in patients with RA (13.7 estimated oxycodone 5-mg equivalents or OEs without RA vs. 10.4 OEs with RA from 0 to 24 hours postoperation, P = .003; 12.3 vs. 9.2 OEs from 24 to 48 hours postoperation, P = .045). Estimated cumulative outpatient opioid demand differed significantly in patients with RA (166.1 vs. 132.1 OEs to 6 weeks, P = .002; and 181 vs. 138.6 OEs to 90 days, P < .001).

DISCUSSION

In proximal forearm and distal humerus fracture surgery, RA was associated with decreased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results encourage utilization of perioperative RA to reduce opioid use.

Regional anesthesia does not decrease inpatient or outpatient opioid demand in femoral shaft fracture surgery

INTRODUCTION

Regional anesthesia (RA) may be used in femoral shaft fracture surgery to decrease pain and opioid consumption. However, the impact of RA on inpatient and outpatient opioid demand in patients undergoing femoral shaft fracture surgery is largely unknown. The aim of this study was to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand in patients undergoing femoral shaft fracture surgery.

METHODS

Inpatient opioid consumption and outpatient opioid demand in all patients undergoing femoral shaft fracture surgery was recorded at a single, Level I trauma center from 7/2013 - 7/2018 (n=436). In addition to RA, baseline and treatment factors including age, sex, race, body mass index (BMI), smoking, chronic opioid use, American Society of Anesthesiologists (ASA) score, injury mechanism, additional injuries, open injury, and additional inpatient surgery were recorded. Unadjusted and adjusted multivariable models were used to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand.

RESULTS

Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (6.9 estimated OE's without RA vs 8.8 OE's with RA from 48-72 hours post-op, p<0.05) but no significant differences at other timepoints (10.3 estimated OE's without RA vs 9.2 OE's with RA from 0-24 hours post-op, 8.2 vs 8.8 from 24-48 hours post-op, p>0.05). Estimated cumulative outpatient opioid demand did not differ significantly in patients with RA (82.3 OE's without RA vs 94.8 with RA from discharge to two-weeks, 105.4 vs 116.3 OE's to 6-weeks, and 124.5 vs 137.9 OE's to 90-days, all p>0.05). Late opioid refills were significantly more common in patients with RA (1.57 odds at 2-weeks to 6-weeks, 1.69 odds at 6-weeks to 90-days, p<0.05) DISCUSSION: In femoral shaft fracture surgery, RA was not associated with decreased opioid demand after adjusting for baseline patient and treatment characteristics. These results provide a real-world estimate of the impact of RA on opioid demand in femoral shaft fracture surgery and encourage providers to seek alternative analgesic modalities.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

Peripheral nerve block use in ankle arthroplasty and ankle arthrodesis: utilization patterns and impact on outcomes

PURPOSE

Ankle arthrodesis and total ankle arthroplasty (TAA) are often associated with significant postoperative pain. While this may be mitigated by the use of peripheral nerve blocks (PNB), large-scale data are lacking. Using national data, we aimed to evaluate PNB utilization pattern and its impact on outcomes.

METHODS

This retrospective cohort study utilized data from the nationwide database (2006-2016) on TAA (n = 5,290) and ankle arthrodesis (n = 14,709) procedures. PNB use was defined from billing; outcomes included opioid utilization, length and cost of stay, discharge to a skilled nurse facility, and opioid-related complications. Mixed-effects models estimated the association between PNB use and outcomes, separate by procedure type and inpatient/outpatient setting. We report odds ratios and 95% confidence intervals (CI).

RESULTS

Overall, PNB was utilized in 8.7% of TAA and 9.9% of ankle arthrodesis procedures, with increased utilization from 2006 to 2016 of 2.6% to 11.3% and 5.2% to 12.0%, respectively. After adjustment for relevant covariates, PNB use was significantly associated with decreased total opioid utilization specifically in the inpatient setting in TAA ( - 16.9% CI  - 23.9%;  - 9.1%) and ankle arthrodesis procedures ( - 18.9% CI  - 24.4;  - 13.0%), this was particularly driven by a decrease in opioid utilization on the day of surgery. No clinically relevant effects were observed for other outcomes.

CONCLUSION

PNB utilization is associated with substantial reductions in opioid utilization, particularly in the inpatient setting. Our study is in support of a wider use of this analgesic technique, which may translate into more benefits in terms of clinical outcomes and resource utilization.

LEVEL OF EVIDENCE

III.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature

BACKGROUND

Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.

METHODS

A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.

RESULTS

Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).

CONCLUSIONS

Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.

RECOMMENDATION

PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Effectiveness of Liposomal Bupivacaine Compared With Standard- of-Care Measures in Pediatric Cardiothoracic Surgery: A Retrospective Cohort Study

OBJECTIVE

Effective postsurgical pain management is important for pediatric patients to improve outcomes while reducing resource use and waste. The authors examined opioid consumption and economic outcomes associated with liposomal bupivacaine (LB) or non-LB analgesia use in pediatric patients undergoing cardiothoracic surgery.

DESIGN

The authors retrospectively analyzed Premier Healthcare Database records.

SETTING

The data extracted from the database included patient records from hospitals across the United States in both rural and urban locations.

PARTICIPANTS

The records included data from patients aged 12-to-<18 years.

INTERVENTIONS

The records belonged to patients undergoing video-assisted thoracoscopic procedures (VATS) who received LB or non-LB analgesia after surgery.

MEASUREMENTS AND MAIN RESULTS

Outcomes included in-hospital postsurgical opioid consumption in morphine milligram equivalents (MMEs), hospital length of stay (LOS), and total hospital costs; the LB and non-LB cohorts were compared using a generalized linear model with inverse probability of treatment weighting to balance the cohorts. For VATS procedures, pediatric patients receiving LB had significant reductions in in-hospital opioid consumption (632 v 991 MMEs; p < 0.0001), shorter LOS (5.1 v 5.6 days; p = 0.0023), and lower total hospital costs ($18,084 v $21,962; p < 0.0001) compared with those receiving non-LB analgesia.

CONCLUSIONS

These results support use of LB in multimodal analgesia regimens for managing pain in pediatric patients after cardiothoracic surgery.

Practice Patterns in Perioperative Nonopioid Analgesic Administration by Anesthesiologists in a Veterans Affairs Hospital

OBJECTIVE

Although multimodal analgesia (MMA) is recommended for perioperative pain management, previous studies have found substantial variability in its utilization. To better understand the factors that influence anesthesiologists' choices, we assessed the associations between patient or surgical characteristics and number of nonopioid analgesic modes received intraoperatively across a variety of surgeries in a university-affiliated Veteran Affairs hospital.

METHODS

We included elective inpatient surgeries (orthopedic, thoracic, spine, abdominal, and pelvic procedures) that used at least one nonopioid analgesic within a one-year period. Multivariable multinomial logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals (CIs). We also described the combinations of analgesia used in each surgical subtype and conducted exploratory analyses to test the associations between the number of modes used and postoperative outcomes.

RESULTS

Of the 1,087 procedures identified, 33%, 53%, and 14% were managed with one, two, and three or more modes, respectively. Older patients had lower odds of receiving three or more modes (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.15-0.52), as were patients with more comorbidities (two modes: aOR = 0.87, 95% CI = 0.79-0.96; three or more modes: aOR = 0.81, 95% CI = 0.71-0.94). Utilization varied across surgical subtypes P < 0.0001). Increasing the number of modes, particularly use of regional anesthesia, was associated with shorter length of stay.

CONCLUSIONS

Our study suggests that age, comorbidities, and surgical type contribute to variability in MMA utilization. Risks and benefits of multiple modes should be carefully considered for older and sicker patients. Future directions include developing patient- and procedure-specific perioperative MMA recommendations.

The Impact of Femoral Nerve Anesthesia on Short-Term Clinical Outcomes and Opioid Claims After Total Knee Arthroplasty

Background

The impact of femoral nerve blocks (FNBs) during primary total knee arthroplasty (TKA) on clinical outcomes and pain management remains unclear. The present research investigates the impact that continuous and single-shot FNBs during TKA have on postoperative opioid claims and short-term clinical outcomes.

Methods

An administrative claims database was queried to identify patients who underwent primary TKA with a continuous FNB, single-shot FNB, or no FNB. More than 300,000 patients were analyzed from the database. Rates of opioid claims were compared via achi-square analysis. Incidence of postoperative complications was compared with multivariable logistic regression.

Results

Patients receiving a FNB had a significantly higher risk of falls both at 6 months (odds ratio [OR], 1.30) and 1 year postoperatively (OR, 1.25), as well as readmissions within 90 days (OR, 1.18) compared with patients without FNBs. The FNB cohort exhibited a higher risk of deep vein thrombosis (OR, 1.57), myocardial infarction (OR, 1.79), and cerebrovascular accident (OR, 1.20) during the inpatient stay. Relative to single-shot FNBs, continuous FNBs were associated with a higher risk of readmissions within 90 days and systemic complications, although the risk varied by age, sex, and Charlson Comorbidity Index score. More patients without FNBs filed opioid claims within 1 year postoperatively, but the average total morphine milligram equivalents prescribed was comparable to patients who received FNBs.

Conclusions

FNBs during TKA place patients at a significantly higher risk of falls, readmissions, and systemic complications in the short term. The risk of readmission and systemic complications was higher for continuous FNBs. More patients without FNBs filed opioid claims postoperatively than patients who received FNBs.

Total knee arthroplasty under quadruple nerve block with ropivacaine 0.32%: effect of addition of intravenous dexmedetomidine to intravenous dexamethasone on analgesic duration

BACKGROUND AND OBJECTIVES

Peripheral nerve blocks reduce postoperative pain and enhance recovery after total knee arthroplasty (TKA). This study aims to assess the benefits of addition of intravenous dexmedetomidine (DexM) to intravenous dexamethasone on the analgesic duration of quadruple nerve blocks.

METHODS

This double-blind, randomized, controlled trial prospectively enrolled 90 patients scheduled for TKA under quadruple nerve blocks (sciatic, femoral, obturator, and lateral femoral cutaneous nerves blocks) with 70 mL, 0.32% ropivacaine. All patients received systemic dexamethasone 10 mg. Patients were randomized to receive DexM (2 µg/kg, intravenous) or placebo (1:1 ratio). The primary endpoint was the duration of analgesia defined as the time to first request for rescue analgesia (oxycodone).

RESULTS

Kaplan-Meier curves for the first analgesic request were similar between groups (log-rank test; p=0.27). Median (IQR) duration of analgesia was similar between placebo (1575 min (1211-1952)) and DexM (1470 min (1263-1700)) groups (p=0.56). Cumulative consumption of oxycodone at the 48th hour was 20 mg (10-30) and 30 mg (20-40) in placebo and DexM groups, respectively (p=0.14). The day after surgery, 93% and 89% of patients were able to walk in placebo and DexM groups, respectively (p=0.46). Intravenous DexM was associated with bradycardia, hypotension and longer recovery room stay (p<0.05 for all comparisons).

CONCLUSIONS

In a multimodal analgesic regimen, addition of systemic DexM (2 µg/kg) to systemic dexamethasone does not prolong the analgesic duration of quadruple nerve block with ropivacaine 0.32% after TKA.

TRIAL REGISTRATION NUMBER

NCT03834129.

Modifiable Analgesia-/Anesthesia-Related Factors and Risk of Severe Gastrointestinal Complications After Lower Extremity Total Joint Arthroplasty: A Nationwide Analysis

BACKGROUND

Severe gastrointestinal (GI) complications after elective hip and knee arthroplasty (THA/TKA) are rare. Some of them can be life-threatening and/or require emergency abdominal surgery. We studied the epidemiology of severe GI complications after THA/TKA and associations with anesthesia- and/or analgesia-related factors.

METHODS

We included 591,865 THA and 1,139,616 TKA cases (Premier Healthcare claims database; 2006-2016). Main outcomes were GI complications and related emergency surgeries within 30 days after THA/TKA. Anesthesia- and analgesia-related factors were anesthesia type (neuraxial, general), use of peripheral nerve block, patient-controlled analgesia, nonopioid analgesics (acetaminophen, gabapentin/pregabalin, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, ketamine), and opioids (in oral morphine equivalents, categorized into low, medium, and high use based on the interquartile range). Mixed-effects models measured associations between anesthesia- and analgesia-related factors and outcomes, which were reported using odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Among THA patients, GI complications were observed in 1.03% (n = 6103), with 0.08% (n = 450) requiring emergency surgery; this was 0.79% (n = 8971) and 0.05% (n = 540), respectively, for TKA patients. After adjustment for relevant covariates (including opioid use), almost all anesthesia-/analgesia-related factors were associated with significantly decreased odds of GI complications, specifically use of cyclooxygenase-2 inhibitors (OR 0.72 CI 0.67-0.76/OR 0.82 CI 0.78-0.86), nonsteroidal anti-inflammatory drugs (OR 0.81 CI 0.77-0.85/OR 0.90 CI 0.86-0.94), and peripheral nerve blocks (OR 0.77 CI 0.69-0.87/OR 0.91 CI 0.85-0.97); all for THA and TKA, respectively (all P < .01).

CONCLUSION

Rare, but devastating, acute GI complications (requiring surgery) after THA/TKA may be positively impacted by a variety of modifiable anesthesia-/analgesia-related interventions.

Peripheral nerve block use in inpatient and outpatient shoulder arthroplasty: a population-based study evaluating utilization and outcomes

Background

Peripheral nerve block (PNB) is an effective pain management option after shoulder arthroplasty with increasing popularity over the past decade. Large-scale US data in shoulder arthroplasties are lacking, especially regarding impacts on opioid utilization. This population-based study aimed to evaluate PNB utilization patterns and their effect on outcomes after inpatient and outpatient shoulder arthroplasty.

Methods

This retrospective cohort study used data from the nationwide Premier Healthcare claims database (2006–2016). This study includes n=94 787 and n=3293 inpatient and outpatient (total, reverse and partial) shoulder arthroplasty procedures. Multivariable mixed-effects models estimated associations between PNB use and opioid utilization in oral morphine equivalents and cost of hospitalization/stay. For the inpatient group, additional outcome measures were length of stay (LOS), admission to a skilled nurse facility, 30-day readmission, combined complications and naloxone use (as a proxy for opioid-related complications). We report OR (or % change for continuous variables) and 95% CIs.

Results

Overall, PNB was used in 19.1% (n=18 144) and 20.8% (n=685) of inpatient and outpatient shoulder arthroplasties, respectively, with an increasing trend for inpatient procedures. PNB utilization was consistently associated with lower (up to −14.0%, 95% CI −15.4% to −12.5% decrease, with median 100 and 90 oral morphine equivalents for inpatient and outpatient procedures) opioid utilization on the day of surgery with more potent effects seen for inpatient shoulder arthroplasties. Other outcomes were minimally impacted.

Discussion

In this first national study on PNB use in shoulder arthroplasty, we found increasing PNB use among specifically, inpatient procedures, resulting in particularly reduced opioid use on the day of surgery. While our findings may support PNB use in shoulder arthroplasty, its current low utilization and trends towards more outpatient procedures necessitate continuous monitoring of more extensive benefits.

Enhanced recovery after surgery (ERAS) in hip and knee replacement surgery: description of a multidisciplinary program to improve management of the patients undergoing major orthopedic surgery

PURPOSE

Enhanced recovery after surgery (ERAS) protocols aim to develop peri-operative multidisciplinary programs to shorten length of hospital stay (LOS) and reduce complications, readmissions and costs for patients undergoing major surgery. The aim of this study is to evaluate the effects of an ERAS pathway for total hip (THR) and knee (TKR) replacement surgery in terms of length of stay, incidence of complications and patient satisfaction.

METHODS

Patients scheduled for hip and knee replacement were included in the study. The main aspects of this program were preoperative education/physical therapy, rational choice of the anesthetic technique, optimization of multimodal analgesia, reduction of incidence of urinary retention and catheterization, active management of risk for blood loss and deep vein thrombosis, and early mobilization of the patients. All patients had 6 months predicted and planned follow-up appointments. Primary outcomes of the study were the mean LOS, readmission and complication rates. Secondary Outcomes were percentage of Knee Injury & Osteoarthritis Outcome Score (KOOS) and Hip disability and Osteoarthritis Outcome Score (HOOS) increase and patient's satisfaction.

RESULTS

We consecutively enrolled 207 patients who underwent total joint arthroplasty, 78 hip and 129 knee joint replacements. The mean length of stay (LOS) for patients of the two groups was 4.3 days for ASA 3-4 patients subjected to TKR and THR, in ASA 1-2 patients 3.6 days for TKR and 3.9 days for THR respectively. Postoperative satisfaction level was higher than 7 (very satisfied) in 94.4% of the cases. All patients were discharged home: 61.8% continued physical therapy in complete autonomy, 23.7% supported by a home-physiotherapist and only 14.5% needed the attendance to a physiotherapy center on a daily basis. The overall incidence of major complications was 3.4%.

CONCLUSIONS

The implementation of an ERAS program for hip and knee replacement surgery allows early patient's discharge and a quick return to independency in the daily activities.

LEVEL OF EVIDENCE

IV.

Lack of July effect in the utilization of neuraxial and peripheral nerve block in US teaching hospitals: a retrospective analysis

BACKGROUND

Given the steep learning curve for neuraxial and peripheral nerve blocks, utilization of general anesthesia may increase as new house staff begin their residency programs. We sought to determine whether "July effect" affects the utilization of neuraxial anesthesia, peripheral nerve blocks, and opioid prescribing for lower extremity total joint arthroplasties (TJA) in July compared with June in teaching and non-teaching hospitals.

METHODS

Neuraxial anesthesia, peripheral nerve block use, and opioid prescribing trends were assessed using the Premier database (2006-2016). Analyses were conducted separately for teaching and non-teaching hospitals. Differences in proportions were evaluated via χ² test, while differences in opioid prescribing were analyzed via Wilcoxon rank-sum tests.

RESULTS

A total of 1 723 256 TJA procedures were identified. The overall proportion of neuraxial anesthesia use in teaching hospitals was 14.4% in both June and July (p=0.940). No significant changes in neuraxial use were seen in non-teaching hospitals (24.5% vs 24.9%; p=0.052). Peripheral nerve block utilization rates did not differ in both teaching (15.4% vs 15.3%; p=0.714) and non-teaching hospitals (10.7% vs 10.5%; p=0.323). Overall median opioid prescribing at teaching hospitals changed modestly from 262.5 oral morphine equivalents (OME) in June to 260 in July (p=0.026) while median opioid prescribing remained at a constant value of 255 OME at non-teaching hospitals (p=0.893).

CONCLUSION

Utilization of neuraxial and regional anesthesia techniques was not affected during the initial transition period of new house staff in US teaching institutions. It is feasible that enough resources are available in the system to accommodate periods of turnover and maintain levels of regional anesthetic care including additional attending anesthesiologist oversight.

Nerve Block Use after Hip Fracture Versus Elective Hip or Knee Arthroplasty: Retrospective Analysis

OBJECTIVES

Although peripheral nerve blocks are associated with improved pain control and end outcomes among older adults with hip fracture, their current utilization among US hip fracture patients is not well understood. We characterized contemporary use of peripheral nerve blocks after hip fracture over time and identified predictors of nerve block receipt.

DESIGN

Retrospective cohort study of claims data from one large national private US insurer.

SETTING

US acute care hospitals.

PARTICIPANTS

A total of 94 985 adults aged 50 years and older hospitalized for a femoral neck, intertrochanteric, or subtrochanteric fracture; 409 263 adults aged 50 years and older hospitalized for elective hip or knee arthroplasty between 2004 and 2016.

MEASUREMENTS

Receipt of a peripheral nerve block for pain control, based on Current Procedural Terminology codes in physician service claims.

RESULTS

Overall, 2874 hip fracture patients (3.0%; 95% confidence interval [CI] = 2.9-3.1) received a nerve block for pain control, and the percentage receiving a block increased from .4% in 2004-2006 (95% CI = .3%-.6%) to 4.6% in 2013-2016 (95% CI = 4.4%-4.8%; P < .001). The adjusted odds of receiving a nerve block was lower for patients with vs without dementia (odds ratio [OR] = .88; 95% CI = .80-.98; P = .02) and among patients aged 75 to 84 vs 64 years or younger (OR = .86; 95% CI = .74-1.00; P = .02). The odds of nerve block receipt did not vary according to race, ethnicity, fracture location, or most other common comorbidities. Compared with patients with hip fracture, the adjusted odds of nerve block receipt were 2 times higher among patients undergoing elective hip replacement and more than 30 times higher among patients undergoing elective knee replacement.

CONCLUSION

Although use of peripheral nerve blocks for pain control after hip fracture has increased over time, fewer than 5 of every 100 patients hospitalized with hip fracture currently receive a peripheral nerve block, suggesting possible underuse. J Am Geriatr Soc 68:835-840, 2020.

Catheter use in regional anesthesia: pros and cons

Continuous peripheral nerve blocks refer to a local anesthetic solution administered via perineurally placed catheters in an effort to extend the benefits of a single-shot peripheral nerve block. They offer several advantages in the postoperative period including excellent analgesia, reduced opioid consumption and associated side effects, enhanced rehabilitation and improved patient satisfaction. The current trend towards less invasive, one-day surgery and enhanced recovery programs may decrease the requirement of catheter use. Prolonged motor block in particular is associated with undesirable outcomes. Should we routinely use continuous peripheral nerve blocks in our daily practice? This PRO-CON debate aims at answering the question from the experts' perspectives. Fascial compartment and wound catheters are outside the scope of this debate.

Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps

Objective

In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below.

Setting

Expert commentary.

Methods

Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management.

Conclusions

Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.

Are Histological Examinations of Arthroplasty Specimens Performed Consistently Across the Country? A Large Database Study

BACKGROUND

It is currently unknown to what extent routine histological examination of joint arthroplasty specimens occurs across hospitals nationwide. Although this practice is neither supported nor refuted by the available evidence, given the increasing demand for joint arthroplasties, it is crucial to study overall utilization as well as its main drivers.

QUESTIONS/PURPOSES

Using national data on joint replacements, we aimed to evaluate: (1) What is the current use of routine histological examination of joint arthroplasty specimens? (2) Does the use vary by geographic location and hospital characteristics? (3) Has use changed over time?

METHODS

From the Premier Healthcare database (2006-2016) we included claims data from 87,667 shoulder (595 hospitals, median age 70 years, 16% nonwhite), 564,577 hip (629 hospitals, median age 65 years, 21% nonwhite), and 1,131,323 (630 hospitals, median age 66 years, 24% nonwhite) knee arthroplasties (all elective). Our study group has extensive experience with this data set, which contains information on 20% to 25% of all US hospitalizations. Included hospitals are mainly concentrated in the South (approximately 40%) with equal distributions among the Northeast, West, and Midwest (approximately 20% each). Moreover, the Premier data set has detailed billing information, which allows for evaluations of real-world clinical practice. There was no missing information on the main variables of interest for this specific study. We assessed frequency of histology examination (defined by Current Procedural Terminology codes) overall as well as by hospital characteristics (urban/rural, bed size, teaching status, arthroplasty volume), geographic region (Northeast, South, Midwest, West), and year. Given the large sample size, instead of p values, standardized differences were applied in assessing group differences where a standardized difference of > 0.1 (or 10%) was assumed to represent a meaningful difference between groups. For significance of trends, p values were applied. Percentages provided represent proportions of individual procedures.

RESULTS

In most hospitals, histology testing was either rare (1%-10%, used in 187 of 595, 189 of 629, and 254 of 630 hospitals) or ubiquitous (91%-100%, used in 121 of 595, 220 of 629, and 195 of 630 hospitals) for shoulder, hip, and knee arthroplasties, respectively. Overall, histology testing occurred more often in smaller hospitals (37%-53% compared with 26%-45% in larger hospitals) and those located in the Northeast (59%-68% compared with 22%-44% in other regions) and urban areas (32%-49% compared with 20%-31% in rural areas), all with standardized differences > 10%. Histologic examination is slowly decreasing over time: from 2006 to 2016, it decreased from 34% to 30% for shoulder arthroplasty, from 50% to 45% for THAs, and from 43% to 38% for TKAs (all p < 0.001).

CONCLUSIONS

Although overall use is decreasing, a substantial number of hospitals still routinely perform histology testing of arthroplasty specimens. Moreover, variation between regions and hospital types suggests that this practice is driven by a variety of factors. This is the first study addressing national utilization, which will be helpful for individual hospitals to assess how they compare with national utilization patterns. Moreover, the findings have clear implications for followup studies, which may be necessary given the exponentially growing demand for arthroplasties.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review

BACKGROUND

Elective total joint arthroplasty may be a gateway to long-term opioid use.

QUESTIONS/PURPOSE

We sought to review the literature on multimodal and regional analgesia as a strategy to minimize perioperative opioid use and control pain in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

We conducted a narrative review to assess the state of the evidence informing opioid-sparing analgesics for THA and TKA. A PubMed search was conducted for English-language articles published before April 2018. We preferentially included well-designed randomized controlled trials, systematic reviews, and meta-analyses. Where the highest levels of evidence were not yet apparent, we evaluated retrospective and/or observational studies.

RESULTS

Multimodal analgesia emphasizing nonsteroidal anti-inflammatory agents and acetaminophen is associated with decreases in perioperative opioid use for THA and TKA. Regional analgesia, including peripheral nerve blocks and local infiltration analgesia, is also associated with decreased perioperative opioid use for THA and TKA. Emerging topics in post-arthroplasty analgesia include (1) the value of nonsteroidal anti-inflammatory drugs, (2) the use of peripheral nerve catheters and extended-release local anesthetics to prolong the duration of opioid-free analgesia, and (3) novel peripheral nerve blocks, exemplified by the IPACK (interspace between the popliteal artery and posterior capsule of the knee) block for TKA.

CONCLUSIONS

The use of multimodal analgesia with regional techniques may decrease perioperative opioid use for patients undergoing THA and TKA. These techniques should be part of a comprehensive perioperative plan to promote adequate analgesia while minimizing overall opioid exposure.

Patient education and engagement in postoperative pain management decreases opioid use following knee replacement surgery

OBJECTIVE

Effects of patient education on perioperative analgesic utilization are not well defined. We designed a simple pain management educational card for total knee arthroplasty (TKA) patients and retrospectively reviewed clinical data before and after implementation to test the hypothesis that more informed patients will use less opioid.

METHODS

With IRB approval, we analyzed clinical data collected perioperatively on all TKA patients one month before (PRE) and one month after (POST) card implementation. The card was designed using a modified Delphi method; the front explained all analgesic medications and the Defense and Veterans Pain Rating Scale was on the back. The primary outcome was total opioid dosage in morphine milligram equivalents (MME) for the first two postoperative days. Secondary outcomes included daily opioid usage, pain scores, ambulation distance, hospital length of stay and use of antiemetics.

RESULTS

There were 20 patients in each group with no differences in baseline characteristics. Total two-day MME [median (10th-90th percentiles)] was 71 (32-285) for PRE and 38 (1-117) for POST (p = 0.001). There were no other differences.

CONCLUSION

Educating TKA patients in multimodal pain management using a simple tool decreases opioid usage.

PRACTICE IMPLICATIONS

Empowering TKA patients with education can reduce opioid use perioperatively.

Acute Pain Is Associated With Chronic Opioid Use After Total Knee Arthroplasty

BACKGROUND AND OBJECTIVES

Pain scores are routinely reported in clinical practice, and we wanted to examine whether this routinely measured, patient-reported variable provides prognostic information, especially with regard to chronic opioid use, after taking preoperative and perioperative variables into account in a preoperative opioid user population.

METHODS

In 32,874 preoperative opioid users undergoing primary total knee arthroplasty at Veterans Affairs hospitals between 2010 and 2015, we compared preoperative and perioperative characteristics in patients reporting lower versus higher acute pain (scores ≤4/10 vs >4/10 averaged over days 1-3). We calculated the propensity for lower acute pain based on all available data. After 1:1 propensity score matching, to identify similar patients differing only in acute pain, we contrasted rates of chronic significant opioid use (mean >30 mg/d in morphine equivalents) beyond postoperative month 3, discharge prescriptions, and changes in postoperative versus preoperative dose categories. Sensitivity analysis examined associations with dose escalation.

RESULTS

Rates of chronic significant opioid use (21% overall) differed in patients with lower versus higher acute pain (36% vs 64% of the overall cohort). After propensity matching (total n = 20,926 patients) and adjusting for all significant factors, lower acute pain was associated with less chronic significant opioid use (rates 12% vs 16%), smaller discharge prescriptions (ie, supply <30 days and daily oral morphine equivalent <30 mg/d), and more reduction in dose, all P < 0.001. In sensitivity analysis, dose escalation was 15% less likely with lower acute pain (odds ratio, 0.85; 95% confidence interval, 0.80-0.91).

CONCLUSIONS

Acute pain predicts chronic opioid use. Prospective studies of efforts to reduce acute pain, in terms of long-term effects, are needed.

Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study

BACKGROUND

Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA).

OBJECTIVES

Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA.

DESIGN

A web-based prospective observational registry.

SETTING

Five Italian Private and University Hospitals from 2012 to 2015.

PATIENTS

Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery.

INTERVENTION(S)

Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability.

MAIN OUTCOME MEASURES

Experience of PPSP according to the type of peri-operative analgesia.

RESULTS

Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months.

CONCLUSION

Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02147730.

Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study

BACKGROUND

Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA).

OBJECTIVES

Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA.

DESIGN

A web-based prospective observational registry.

SETTING

Five Italian Private and University Hospitals from 2012 to 2015.

PATIENTS

Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery.

INTERVENTION(S)

Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability.

MAIN OUTCOME MEASURES

Experience of PPSP according to the type of peri-operative analgesia.

RESULTS

Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months.

CONCLUSION

Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02147730

Liposomal Bupivacaine Does Not Reduce Inpatient Opioid Prescription or Related Complications after Knee Arthroplasty: A Database Analysis

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS MANUSCRIPT TELLS US THAT IS NEW: BACKGROUND:: Although some trials suggest benefits of liposomal bupivacaine, data on real-world use and effectiveness is lacking. This study analyzed the impact of liposomal bupivacaine use (regardless of administration route) on inpatient opioid prescription, resource utilization, and opioid-related complications among patients undergoing total knee arthroplasties with a peripheral nerve block. It was hypothesized that liposomal bupivacaine has limited clinical influence on the studied outcomes.

METHODS

The study included data on 88,830 total knee arthroplasties performed with a peripheral nerve block (Premier Healthcare Database 2013 to 2016). Multilevel multivariable regressions measured associations between use of liposomal bupivacaine and (1) inpatient opioid prescription (extracted from billing) and (2) length of stay, cost of hospitalization, as well as opioid-related complications. To reflect the difference between statistical and clinical significance, a relative change of -15% in outcomes was assumed to be clinically important.

RESULTS

Overall, liposomal bupivacaine was used in 21.2% (n = 18,817) of patients that underwent a total knee arthroplasty with a peripheral nerve block. Liposomal bupivacaine use was not associated with a clinically meaningful reduction in inpatient opioid prescription (group median, 253 mg of oral morphine equivalents, adjusted effect -9.3% CI -11.1%, -7.5%; P < 0.0001) and length of stay (group median, 3 days, adjusted effect -8.8% CI -10.1%, -7.5%; P < 0.0001) with no effect on cost of hospitalization. Most importantly, liposomal bupivacaine use was not associated with decreased odds for opioid-related complications.

CONCLUSIONS

Liposomal bupivacaine was not associated with a clinically relevant improvement in inpatient opioid prescription, resource utilization, or opioid-related complications in patients who received modern pain management including a peripheral nerve block.