Pain management in shoulder arthroplasty: a systematic review and network meta-analysis of randomized controlled trials

Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum 2-year follow-up

BACKGROUND

Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up.

METHODS

A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, range of motion (ROM), strength, complications, readmissions, and reoperations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up.

RESULTS

A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < .0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different.

CONCLUSION

This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with midterm follow-up.

Effect of the Ultrasound-Guided Interscalene and Supraclavicular Blocks on the C4 Dermatome

Purpose

The C4 dermatome anesthesia holds significance for arthroscopic shoulder surgery. However, the reliability of achieving C4 dermatome anesthesia with the current low-dose ultrasound-guided interscalene block (ISB) and supraclavicular block (SCB) remains uncertain. This prospective, single-center study examined the effects of ultrasound-guided interscalene block (ISB) and supraclavicular block (SCB) on the C4 sensory dermatome in patients undergoing shoulder, hand, or wrist surgery.

Patients and Methods

Patients undergoing outpatient shoulder, hand, or wrist surgeries received ultrasound-guided ISB (for shoulder surgeries) with 12-15 mL of 0.5% bupivacaine or ultrasound-guided SCB (for hand and wrist surgeries) with 20-24 mL of 0.5% bupivacaine. The primary objective of the study was to investigate the sensory effect on the C4 dermatome after ISB and SCB. The secondary outcomes included the sensory effect on the C5 dermatome after performing ISB and SCB, pain scores upon arrival at the post-anesthesia care unit (PACU), and the incidence of adverse effects.

Results

Sixty-one patients were recruited: 30 for ISB and 31 for SCB. C4 dermatome coverage was achieved in 53% and 29% of patients in the ISB and SCB groups, respectively (p=0.0268). Additionally, C5 dermatome coverage was achieved in 97% and 68% of patients in the ISB and SCB groups, respectively (p=0.0034). A moderate correlation coefficient (r=0.47) was observed between C4 sensory scores and postoperative pain scores.

Conclusion

Ultrasound-guided ISB successfully provided C4 coverage in 53% of cases, suggesting that performing an additional C4 block alongside ISB could be advantageous when aiming for complete surgical anesthesia. SCB may not be the primary choice for shoulder surgeries as it often fails to achieve satisfactory sensory blocks at the C4 and C5 levels.

Continuous Catheter Versus Single-Shot Interscalene Block in Shoulder Surgery: A Review and Recommendations for Postoperative Pain Management

Shoulder arthroscopic and arthroplastic surgeries are associated with significant postoperative pain, which can delay recovery and increase opioid consumption. Interscalene blocks (ISBs) are a commonly used method to manage this pain, either as single-shot injections or continuous catheter infusions (CISBs). This review synthesizes findings from studies conducted in the past five years, comparing the efficacy, complications, and outcomes of single-shot ISBs versus CISBs for postoperative pain management in shoulder surgeries. Current literature highlights key differences: single-shot ISBs provide significant immediate postoperative pain relief, whereas CISBs offer prolonged analgesia beyond 48 hours, reduced opioid consumption, and enhanced recovery outcomes. However, CISBs carry a higher risk of complications and procedural complexity compared to single-shot ISBs. Both single-shot ISBs and CISBs present effective options for postoperative pain control in shoulder surgery patients. Single-shot ISBs may be preferable for patients seeking immediate pain relief with fewer complications, while CISBs are beneficial for those requiring prolonged analgesia. The choice of technique should be individualized based on the patient's needs, expected recovery, and potential risk factors.

Novel Techniques for Musculoskeletal Pain Management after Orthopedic Surgical Procedures: A Systematic Review

Effective postoperative pain management is critical for recovery after orthopedic surgery, but often remains inadequate despite multimodal analgesia. This systematic review synthesizes evidence on innovative modalities for enhancing pain control following major orthopedic procedures. Fifteen randomized controlled trials and comparative studies evaluating peripheral nerve blocks, local anesthetic infiltration, cryotherapy, transcutaneous electrical stimulation, adjunct medications, and other techniques are included. Thematic analysis reveals that peripheral nerve blocks and local anesthetic infiltration consistently demonstrate reduced pain scores, opioid consumption, and side effects versus conventional analgesia alone. Oral multimodal medications also show promise as part of opioid-sparing regimens. Adjunctive approaches like cryotherapy, music, and dexmedetomidine require further research to optimize protocols. Despite promising innovations, critical knowledge gaps persist regarding comparative effectiveness, optimal interventions and dosing, combination strategies, cost-effectiveness, and implementation. High-quality randomized controlled trials using standardized protocols are essential to guide the translation of enhanced multimodal regimens into clinical practice. This review provides a framework for pursuing research priorities and advancing evidence-based postoperative pain management across orthopedic surgeries.

Rate of occurrence of respiratory complications in patients who undergo shoulder arthroplasty with a continuous interscalene brachial plexus block and associated risk factors

INTRODUCTION

Continuous interscalene nerve block techniques are an effective form of targeted non-opioid postoperative analgesia for shoulder arthroplasty patients. One of the limiting risks, however, is potential phrenic nerve blockade with resulting hemidiaphragmatic paresis and respiratory compromise. While studies have focused on block-related technical aspects to limit the incidence of phrenic nerve palsy, little is known about other factors associated with increased risk of clinical respiratory complications in this population.

METHODS

A single-institution retrospective cohort study was conducted using electronic health records from adult patients who underwent elective shoulder arthroplasty with continuous interscalene brachial plexus blocks (CISB). Data collected included patient, nerve block, and surgery characteristics. Respiratory complications were categorized into four groups (none, mild, moderate, and severe). Univariate and multivariable analyses were conducted.

RESULTS

Among 1025 adult shoulder arthroplasty cases, 351 (34%) experienced any respiratory complication. These 351 were subdivided into 279 (27%) mild, 61 (6%) moderate, and 11 (1%) severe respiratory complications. In an adjusted analysis, patient-related factors were associated with an increased likelihood of respiratory complication: ASA Physical Status III (OR 1.69, 95% CI 1.21 to 2.36); asthma (OR 1.59, 95% CI 1.07 to 2.37); congestive heart failure (OR 1.99, 95% CI 1.19 to 3.33); body mass index (OR 1.06, 95% CI 1.03 to 1.09); age (OR 1.02, 95% CI 1.00 to 1.04); and preoperative oxygen saturation (SpO2). For every 1% decrease in preoperative SpO2, there was an associated 32% higher likelihood of a respiratory complication (OR 1.32, 95% CI 1.20 to 1.46, p<0.001).

CONCLUSIONS

Patient-related factors that can be measured preoperatively are associated with increased likelihood of respiratory complications after elective shoulder arthroplasty with CISB.

Postoperative Pain Control Following Shoulder Arthroplasty: Rethinking the Need for Opioids

The use of opioid pain medication regimens to control perioperative pain has led to significant patient and societal consequences. There are several alternative, opioid-sparing and opioid-minimizing pain regimens that have been shown to provide equal, if not superior, pain relief with fewer secondary consequences. This article provides an in-depth review of the current evidence regarding efficacy, safety, and feasibility of a perioperative opioid-sparing clinical pathway for patients undergoing shoulder arthroplasty.

No significant difference in risk of prolonged opioid use following outpatient versus inpatient total shoulder arthroplasty: A propensity matched analysis

Background

The purpose of this investigation was to compare rates of filled opioid prescriptions and prolonged opioid use in opioid naïve patients undergoing total shoulder arthroplasty (TSA) in inpatient versus outpatient settings.

Methods

A retrospective cohort study was conducted using a national insurance claims database. Inpatient and outpatient cohorts were created by identifying continuously enrolled, opioid naïve TSA patients. A greedy nearest-neighbor algorithm was used to match baseline demographic characteristics between cohorts with a 1:1 inpatient to outpatient ratio to compare the primary outcomes of filled opioid prescriptions and prolonged opioid use following surgery between cohorts.

Results

A total of 11,703 opioid naïve patients (mean age 72.5 ± 8.5 years, 54.5% female, 87.6% inpatient) were included for analysis. After propensity score matching (n = 1447 inpatients; n = 1447 outpatients), outpatient TSA patients were significantly more likely to fill an opioid prescription in the perioperative window compared to inpatients (82.9% versus 71.5%, p < 0.001). No significant differences in prolonged opioid use were detected (5.74% inpatient versus 6.77% outpatient; p = 0.25).

Conclusions

Outpatient TSA patients were more likely to fill opioid prescriptions compared to inpatient TSA patients. The quantity of opioids prescribed and rates of prolonged opioid use were similar between the cohorts.

Level of evidence

Therapeutic Level III.

Liposomal bupivacaine nerve block provides better pain control post-total shoulder arthroplasty than continuous indwelling catheter

BACKGROUND

Pain control is essential to successful total shoulder arthroplasty (TSA).

MATERIALS AND METHODS

This non-blinded, randomized clinical trial compared shoulder pain, narcotic use, interscalene (IS) block application time, and costs in 76 subjects who were randomly assigned to receive either a single injection IS nerve block of 10 cc (133 mg) liposomal bupivacaine mixed with 10 cc of 0.5% bupivacaine (Group 1), or 20 cc of 0.5% ropivacaine direct injection combined with an indwelling IS nerve block catheter delivering 0.2% ropivacaine at a continual 4 cc/h infusion for the initial 3 post-operative days (Group 2). Surgical time, local anesthesia duration, hospital stay length, morphine milligram equivalents (MME) consumed, worst shoulder pain at 24, 48 and 72 h, and complications were recorded. Patient reported function, pain and activity level surveys were completed before, and 6-week post-TSA (P < 0.05).

RESULTS

Group 1 had less pain 24-h (0.72 ± 0.8 vs. 3.4 ± 2.9, p < 0.0001) and 48-h (2.5 ± 2.2 vs. 4.8 ± 2.6, p = 0.005) post-TSA. At 24-h post-TSA, MME consumption was similar (Group 1 = 4.5 ± 6.4 vs. Group 2 = 3.7 ± 3.8, p = 0.54), but was lower for Group 1 at 48 h (0.0 ± 0.0 vs. 0.64 ± 0.99, p = 0.001). Group 2 had longer IS block application time (10.00 ± 4.6 min vs. 4.84 ± 2.7 min, p < 0.0001). Only group 2 had a strong relationship between MME consumption over the first 24-h post-TSA and pain 24-h post-TSA (r = 0.76, p < 0.0001), a moderate relationship with pain 48-h post-TSA (r = 0.59, P = 0.001), and a weak relationship with pain 72-h post-TSA (r = 0.44, P = 0.02). Significant relationships for these variables were not observed for Group 1 (r ≤ 0.30, p ≥ 0.23). Group 1 IS block costs were less/patient than Group 2 ($190.17 vs. $357.12 USD).

CONCLUSION

A single shot, liposomal bupivacaine interscalene nerve block provided better post-TSA pain control with less narcotic consumption, less time for administration and less healthcare system cost compared to interscalene nerve block using a continuous indwelling catheter.

LEVEL OF EVIDENCE

Level I, Prospective, Randomized.

Patients with limited health literacy have worse preoperative function and pain control and experience prolonged hospitalizations following shoulder arthroplasty

BACKGROUND

Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption.

METHODS

We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables.

RESULTS

Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P = .002), more self-reported allergies (P = .007), and worse American Shoulder and Elbow Surgeons scores (P = .001), visual analog scale pain scores (P = .020), forward elevation (P < .001), and external rotation (P = .022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P > .05). Patients with LHL had a significantly longer LOS (1.84 ± 0.92 days vs. 1.57 ± 0.58 days, P = .012) but did not differ in terms of total hospitalization costs (P = .65) or total inpatient opioid consumption (P = .721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (β, 0.14; 95% confidence interval, 0.02-0.42; P = .035).

CONCLUSION

LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning.

Early reduction in postoperative pain is associated with improved long-term function after shoulder arthroplasty: a retrospective case series

PURPOSE

Mixed modalities are frequently utilized in total shoulder arthroplasty (TSA) to control pain, improve patient satisfaction, reduce narcotics use and facilitate earlier discharge. We investigate the relationship between early postoperative pain control and long-term functional outcomes after shoulder arthroplasty.

METHODS

A retrospective review identified 294 patients (314 shoulders) who underwent anatomic or reverse TSA and received a continuous cervical paravertebral nerve block perioperatively. Opioid and non-opioid analgesics were also available to the patients in an "as needed" capacity to augment perioperative pain control. In addition to demographic and surgical characteristics, the impact on functional outcomes of relative pain (i.e., a patient's subjective pain relative to the entire cohort), pain gradient (i.e., the slope of a patient's subjective pain), and opioid consumption during the first 24 h postoperatively were assessed. Shoulder function was assessed using validated outcome measures collected at 2 year follow-up. Outcomes were measured using American Shoulder and Elbow Surgeons questionnaire (ASES), Shoulder Pain and Disability Index (SPADI), SPADI-130, Raw and Normalized Constant Score, SST-12 and UCLA score.

RESULTS

Patients younger than 65, females, reverse TSA, revisions, and preoperative opioid users had worse functional outcomes. On univariate analysis, increased pain perioperatively (> 50% percentile relative pain) was associated with decreased function at 2 years when analyzed with all seven outcome scores (P < .001 for all), reaching minimal clinically important difference (MCID) using the Constant Score. On multivariate analysis, increased pain in the first 24 h postoperatively (assessed on a continuous scale) was independently associated with worse ASES, SPADI, and SPADI-130 scores. Intraoperative ketamine administration and opioid consumption in the 24 h postoperative period did not influence long-term shoulder function.

CONCLUSION

Patients reporting reduced pain after TSA demonstrated improved shoulder function with the Constant score at 2 years postoperatively in both univariate and multivariate analysis. Larger-scale investigation may be warranted to see if this is true for other functional outcome measures.

LEVEL OF EVIDENCE

III, treatment study.