Continuous interscalene brachial plexus blockade is associated with reduced length of stay after shoulder arthroplasty

Complication rates and efficacy of single-injection vs. continuous interscalene nerve block: a prospective evaluation following arthroscopic primary rotator cuff repair without a concomitant open procedure

Background

To compare the complications and efficacy of pain relief of the interscalene anesthetic block using either a single-injection (SI) vs. a continuous, indwelling catheter (CIC) for arthroscopic rotator cuff repair surgery.

Methods

Patients undergoing primary, arthroscopic rotator cuff repair without concomitant open procedure or biceps tenodesis were prospectively enrolled by 4 fellowship-trained sports medicine and shoulder surgeons. Patients received either a SI or CIC preoperatively based on surgeon preference. Patients were contacted by phone to complete a standard questionnaire on postoperative days (PODs) 1, 3, 7, 14, and 28. Patients were asked to rate the efficacy of their subjective pain relief (scale of 0-10), document issues with the catheter, describe analgesic usage, and report pharmacological and medical complications. The primary outcome was measured as complication rate. Postoperative narcotic use, patient satisfaction, and visual analog scale pain scores were measured as secondary outcomes.

Results

Seventy patients were enrolled, 33 CIC patients (13 male, 20 female, mean age 61 ± 8 years) and 37 SI patients (20 male, 17 female, mean age 59 ± 10 years). There were significantly more injection/insertion site complications in the CIC group (48%) vs. the SI group (11%, P = .001). The incidence of motor weakness was higher in the CIC group on POD 1 (P = .034), but not at any subsequent time points. On POD 1, CIC patients had a clinically significantly lower pain score compared to SI (3.2 vs. 5.4; P = .020). Similar scores were observed at subsequent time points until POD 28, when CIC again had a lower pain score (0.8 vs. 2.7; P = .005). However, this did not reach clinical significance. All patients in both groups rated a satisfaction of 9 or 10 (scale 0-10) with the anesthesia provided by their nerve block.

Conclusion

CIC interscalene nerve blocks had an increased risk for injection site complications and minor complications in the immediate postoperative period when using the CIC for arthroscopic rotator cuff repair without any concomitant open procedures. CIC blocks demonstrated clinically significant superior pain relief on POD 1 but were equal to SI blocks at every time point thereafter. Superior pain relief of CIC at POD 28 was not clinically significant. CIC catheters do not appear to markedly decrease the use of postoperative narcotics. Despite this trend in complication rates and pain scores, all patients in both groups were satisfied with their nerve block.

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.

Wide Geographic Variation in Resource Utilization after Shoulder Arthroplasty

Background

There is growing interest in optimizing cost and resource utilization after shoulder arthroplasty, but little data to guide improvement efforts.

Objective

The purpose of this study was to evaluate geographic variation in length of stay and home discharge disposition after shoulder arthroplasty across the United States.

Methods

The Centers for Medicare and Medicaid Services database was used to identify Medicare discharges following shoulder arthroplasties performed from April 2019 through March 2020. National, regional (Northeast, Midwest, South, West), and state-level variation in length of stay and home discharge disposition rates were examined. The degree of variation was assessed using the coefficient of variation, with a value greater than 0.15 being considered as "substantial" variation. Geographic maps were created for visual representation of the data.

Results

There was substantial state-level variation in home discharge disposition rates (64% in Connecticut to 96% in West Virginia) and length of stay (1.01 days in Delaware to 1.86 days in Kansas). There was wide regional variation in length of stay (1.35 days in the West to 1.50 days in the Northeast) and home discharge disposition rates (73% in the Northeast to 85% in the West).

Conclusions

There is wide variation in resource utilization after shoulder arthroplasty across the United States. Certain patterns emerge from our data; for instance, the Northeast has the longest hospital stays with the lowest home discharge rates. This study provides important information for the implementation of targeted strategies to effectively reduce geographic variation in healthcare resource utilization.

Interscalene block with liposomal bupivacaine versus continuous interscalene catheter in primary total shoulder arthroplasty

BACKGROUND

Multimodal pain regimens in total shoulder arthroplasty (TSA) now include regional anesthetic techniques. Historically, regional anesthesia for extended postoperative pain control in TSA was administered using a continuous interscalene catheter (CIC). Liposomal bupivacaine (LB) is used for its potential for similar pain control and fewer complications compared with indwelling catheters. We evaluated the efficacy of interscalene LB compared with a CIC in postoperative pain control for patients undergoing TSA.

METHODS

This was a retrospective cohort study at a tertiary-care academic medical center including consecutive patients undergoing primary anatomic or reverse TSA from 2016 to 2020 who received either single-shot LB or a CIC for perioperative pain control. Perioperative and outcome variables were collected. The primary outcome was postoperative pain control, whereas the secondary outcome was health care utilization.

RESULTS

The study included 565 patients, with 242 in the CIC cohort and 323 in the LB cohort. Demographic characteristics including sex (P = .99) and race (P = .81) were similar between the cohorts. The LB cohort had significantly lower mean pain scores at 24 hours (3 vs. 2, P < .001) and 36 hours (3 vs. 2, P < .001) postoperatively. The CIC cohort showed a higher percentage of patients experiencing a pain score of 9 or 10 postoperatively (29% vs. 17%, P = .001), whereas the LB cohort had a significantly greater proportion of opioid-free patients (32% vs. 10%, P < .001). Additionally, a greater proportion of CIC patients required opioid escalation to patient-controlled analgesia (7% vs. 2%, P = .002). The CIC cohort experienced a greater length of stay (2.3 days vs. 2.1 days, P = .01) and more 30-day emergency department visits (5% vs. 2%, P = .038).

CONCLUSIONS

LB demonstrated lower mean pain scores at 24 and 36 hours postoperatively and lower rates of severe postoperative pain. Additionally, LB patients showed significantly higher rates of opioid-free pain regimens. These results suggest that as part of a multimodal pain regimen in primary shoulder arthroplasty, LB may provide greater reductions in pain and opioid use when compared with CICs.

Single shot interscalene regional anesthesia provides noninferior analgesia and decreased complications compared with an indwelling catheter for arthroscopic and reconstructive shoulder surgery

BACKGROUND

There is an abundance of literature comparing the efficacy, safety, and complication rates of regional anesthesia in shoulder surgery. The purpose of this study was to compare analgesia efficacy, and complication rates between single shot and continuous catheters in patients undergoing arthroscopic or reconstructive shoulder surgery in a large cohort.

METHODS

Consecutive patients (n = 1888) who underwent shoulder arthroplasty or arthroscopic shoulder surgery and had regional anesthesia were included. Patients had either a single-shot interscalene block (SSIB) or an SSIB with a continuous interscalene nerve block with a catheter (CIB). The decision for SSIB or CIB was selected based on patient risk factors and surgeon preference. Patients received phone calls on postoperative days 1, 2, 7, and 14 to assess for pain levels (numeric rating scale [NRS]) and complications.

RESULTS

One hundred sixty patients received SSIB, and 1728 patients received CIB. The postoperative NRS scores at day 1 were also similar. There were 3 complications (2%) in the SSIB group and 172 complications (10%) in the CIB group. Ten patients in the CIB group required emergency department (ED) visits secondary to block complications compared with no ED visits in the SSIB group.

CONCLUSION

In 1888 consecutive patients, SSIB and CIB provided similar pain relief following shoulder surgery. However, patients who received CIB had significantly more complications and ED visits than patients who received SSIB. The potential benefits of longer pain relief may not outweigh the risks of CIB vs. SSIB in common shoulder procedures.

Interscalene Block for Analgesia in Orthopedic Treatment of Shoulder Trauma: Single-Dose Liposomal Bupivacaine versus Perineural Catheter

Background

Interscalene brachial plexus block is frequently utilized to provide perioperative analgesia to patients undergoing shoulder surgery to optimize recovery, minimize opioid consumption, and decrease overall hospital length of stay. The use of an indwelling perineural interscalene catheter provides extended analgesia and is efficacious in managing severe postoperative pain following major shoulder surgery. Currently, the only alternative to perineural catheters for extended analgesia with interscalene block involves the perineural infiltration of liposomal bupivacaine. However, there is limited published data regarding the overall analgesic effectiveness of using interscalene liposomal bupivacaine in the setting of shoulder surgery.

Methods

We performed a retrospective review of 43 patients in the acute trauma setting who underwent major shoulder surgery and received extended analgesia via perioperative interscalene brachial plexus block with either an indwelling continuous catheter or single-dose liposomal bupivacaine to determine if comparable analgesia can be achieved. The primary outcomes of interest were postoperative pain scores and opioid consumption. Due to the ability to titrate and bolus local anesthetic infusions to a desired clinical effect, we hypothesized that opioid consumption and pain scores would be lower when using the continuous catheter technique.

Results

After statistical analysis, our results demonstrated no significant difference between the two techniques in regards to opioid consumption as well as numeric pain scores during the 48-hour postoperative period, but did note a higher rate of complications with patients who received perineural interscalene continuous catheters. Secondary outcomes showed an increase in time required to complete the regional block procedure with the use of indwelling catheters.

Conclusion

Interscalene brachial plexus block with liposomal bupivacaine may be a viable alternative to indwelling continuous catheters for providing extended analgesia in patients undergoing major shoulder surgery.

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

BACKGROUND

Interscalene nerve block and liposomal bupivacaine have been found to provide adequate pain control following shoulder arthroplasty. We hypothesized that local infiltration of a periarticular cocktail would provide equivalent pain control compared to interscalene nerve block and liposomal bupivacaine.

METHODS

Eighty-seven patients undergoing primary shoulder arthroplasty were treated with local infiltration of a periarticular cocktail (200 mg of 0.5% ropivacaine, 1 mg epinephrine, and 30 mg ketorolac), local infiltration of liposomal bupivacaine, or preoperative interscalene nerve block. The outcomes of the study were postoperative visual analog scale scores, opioid consumption, length of stay, and complications.

RESULTS

A total of 30 patients receiving local infiltration of a periarticular cocktail, 26 receiving liposomal bupivacaine, and 31 receiving interscalene nerve block were included in the study. Patients who received local infiltration of a periarticular cocktail had a significantly lower mean visual analog scale when compared to interscalene nerve block and liposomal bupivacaine on postoperative day 0 (2.5 versus 4.0 versus 4.8, P = 0.001 and P < 0.001). Pain scores between postoperative day 0-3 were lower in patients who received local infiltration of a periarticular cocktail, but not significantly. Patients who received local infiltration of a periarticular cocktail required significantly less opioids than the interscalene nerve block group on postoperative day 0 (P < 0.001).

DISCUSSION

A decrease in early postoperative pain and opioid consumption was found with local infiltration of a periarticular cocktail when compared with interscalene nerve block and liposomal bupivacaine after shoulder arthroplasty.Level of evidence: Level II.

The Feasibility of Outpatient Shoulder Arthroplasty: Risk Stratification and Predictive Probability Modeling

Whether shoulder arthroplasty can be performed on an outpatient basis depends on appropriate patient selection. The purpose of this study was to identify risk factors for adverse events (AEs) following shoulder arthroplasty and to generate predictive models to improve patient selection. This was a retrospective review of prospectively collected data using a single institution shoulder arthroplasty registry as well as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including subjects undergoing hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse TSA. Predicted probability of suitability for same-day discharge was calculated from multivariable logistic models for different patient subgroups based on age, comorbidities, and Charlson/Deyo Index scores. A total of 2314 shoulders (2079 subjects) in the institutional registry met inclusion criteria for this study. Younger age, higher body mass index (BMI), male sex, and prior steroid injection were all significantly associated with suitability for discharge, whereas preoperative narcotic use, comorbidities (heart disease and anemia/other blood disease), and Charlson/Deyo Index score of 2 were associated with AEs that might prevent same-day discharge. Compared with TSA, reverse TSA was associated with less suitability for discharge (P=.01). On querying the ACS-NSQIP database, 15,254 patients were identified. Female sex, BMI less than 35 kg/m², American Society of Anesthesiologists class III/IV, preoperative anemia, functional dependence, low pre-operative albumin, and hemiarthroplasty were associated with unsuitability for discharge. Males 55 to 59 years old with no comorbidities nor history of narcotic use formed the lowest risk subgroup. Transfusion is the primary driver of AEs. Strategies to avoid this complication should be explored. Risk stratification will improve the ability to identify patients who can safely undergo outpatient shoulder arthroplasty. [Orthopedics. 2021;44(2):e215-e222.].

Perioperative pain management for shoulder surgery: evolving techniques

Improving management of postoperative pain following shoulder surgery is vital for optimizing patient outcomes, length of stay, and decreasing addiction to narcotic medications. Multimodal analgesia (ie, controlling pain via multiple different analgesic methods with differing mechanisms) is an ever-evolving approach to enhancing pain control perioperatively after shoulder surgery. With a variety of options for the shoulder surgeon to turn to, this article succinctly reviews the pros and cons of each approach and proposes a potential pain management algorithm.

Reverse shoulder replacement: a day-case procedure

Background and hypothesis

Reverse shoulder arthroplasty (RSA) is an increasingly popular treatment modality for glenohumeral joint arthritis in association with rotator cuff arthropathy. A prolonged hospital stay following joint arthroplasty risks increased complications for patients plus financial implications for institutions. We hypothesized that RSA could be safely and effectively carried out as an outpatient procedure with reduced risks to patients and institutional costs.

Methods

Patients attending our institution for RSA during March 2015 to August 2018 were reviewed preoperatively for consideration for RSA as an outpatient procedure. The inclusion criteria were arthritis of the shoulder having failed conservative management, age older than 50 years, and intact deltoid muscle function. Patients were excluded if they underwent RSA for trauma or for revision following previous total shoulder replacement or hemiarthroplasty. Overall health, social circumstances, and individual wishes were considered.

Results

A total of 21 patients underwent RSA as an outpatient procedure. The mean age was 74 years (range, 59-84 years). There were 8 male and 13 female patients. No overnight stays were required in patients in whom outpatient surgery was planned. The Oxford Shoulder Score increased from a mean of 16 (range, 4-30) preoperatively to a mean of 31 (range, 7-35) at 6 months postoperatively; it was a mean of 36 (range, 7-48) at 12 months postoperatively. Of the patients, 88% were “very satisfied” or “satisfied” with the service and 81% would undergo the surgical procedure again as a day-case procedure.

Conclusion

RSA as an outpatient procedure can be carried out effectively with high patient satisfaction rates in carefully selected patients.

Enhanced Recovery After Surgery: Concepts and Application to Total Shoulder Replacement

BACKGROUND

Enhanced Recovery After Surgery (ERAS) focuses on optimizing each element on a treatment pathway and encouraging the patient to actively engage in his or her recovery and rehabilitation. It requires collaboration across a multidisciplinary team and has been successful in improving patient outcomes, length of stay (LOS), and costs for a wide range of surgical procedures, including musculoskeletal surgeries such as total hip and total knee replacement.

PURPOSE

To examine the application of ERAS concepts to total shoulder replacement (TSR) surgery.

METHODS

Hospital Episode Statistics (HES) in England on LOS for TSR surgery were examined, and a review of literature on the use of ERAS concepts in TSR was undertaken.

RESULTS

Analysis of HES data suggested scope for improvement in reducing LOS. A review of the literature found some evidence of the use of ERAS concepts, particularly in multimodal pain management.

CONCLUSIONS

Future research is now required for ERAS procedure-specific components for TSR surgery.

Predictors of Length of Stay and Discharge Disposition After Shoulder Arthroplasty: A Systematic Review

INTRODUCTION

Identifying patient factors that affect length of stay (LOS) and discharge disposition after shoulder arthroplasty is key in managing patient expectations. In this systematic review, we identify patient-specific covariates that correlate with increased LOS and need for discharge to a facility.

METHODS

We searched biomedical databases to identify associations between patient-specific factors and LOS and discharge disposition after shoulder arthroplasty. We included all studies involving hemiarthroplasty, anatomic shoulder arthroplasty, and reverse shoulder arthroplasty. Reported patient and provider factors were evaluated for their association with increased LOS and discharge to a facility.

RESULTS

Twenty-two studies were identified. Age >65 years, female sex, obesity, and reverse shoulder arthroplasty were associated with extended LOS and correlated with discharge to a facility. Greater hospital and surgeon volume were associated with decreased LOS and decreased risk of discharge to a facility. Local injection of liposomal bupivacaine combined with intravenous dexamethasone was associated with reduced LOS.

DISCUSSION

Patient factors affecting LOS and likelihood of discharge to a facility include age >65 years, female sex, diabetes, obesity, and reverse shoulder arthroplasty. These factors can be used to develop studies to preoperatively predict outcomes after shoulder arthroplasty and to help identify patients who may be at risk of prolonged postoperative admission.

LEVEL OF EVIDENCE

Prognostic level IV.

Outpatient shoulder arthroplasty: outcomes, complications, and readmissions in 2 outpatient settings

BACKGROUND

There is currently a paucity of non-database studies looking at safety and outcomes after outpatient shoulder arthroplasty. The purpose of this study was to report our initial safety experience with outpatient shoulder arthroplasty including 90-day complications and readmissions. Our hypothesis was that the rate of early complications after outpatient shoulder arthroplasty would be low and similar to that of inpatient procedures regardless of outpatient setting.

METHODS

We analyzed 50 consecutive patients who underwent outpatient shoulder arthroplasties (44 anatomic total shoulder arthroplasties, 4 reverse total shoulder arthroplasties, and 2 hemiarthroplasties) from 2014-2017. The readmission rate and complications were recorded. All patients were available for minimum 3-month follow-up. Preoperative and postoperative Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and visual analog scale scores were recorded.

RESULTS

The average age was 56.9 ± 6.9 years; average body mass index, 29.75 ± 5.9; and average Charleston Comorbidity Index, 1.6 ± 1.2. There were 6 complications (12%) (hematoma, deep venous thrombosis, axillary nerve injury, acute infection, and 2 subscapularis failures). Only 4 occurred within the 90-day global period, and only 1 patient required readmission. Our subscapularis failures occurred after 3 months postoperatively and required additional surgery (arthroscopic repair and revision to reverse total shoulder arthroplasty). At last follow-up, all had significant improvements (P < .001) in range of motion and functional scores (American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and visual analog scale scores). No difference in the complications and functional outcomes was found between the patients based on their surgical setting.

CONCLUSION

Outpatient shoulder arthroplasty is a safe option for appropriately selected patients. No difference in complications and outcomes occurs regardless of outpatient setting.