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    Managing Pain in Shoulder Arthroplasty Patients

    Regional anesthesia – specifically, interscalene blocks – have been advocated as an alternative to intravenous opioids to manage pain in patients undergoing primary shoulder arthroplasty.

    They’ve generally done a good job of providing analgesia. [1-3] The problem, as described by Thomas (Quin) Throckmorton, MD, during a presentation at ICJR’s 7th Annual Shoulder Course, is that interscalene blocks are associated with some pretty serious side effects, including respiratory side effects similar to those associated with opioid use. [4-7]

    RELATED: Register for the 8th Annual Shoulder Course

    Dr. Throckmorton characterized his experience with using interscalene blocks in shoulder arthroplasty patients as “horrible,” citing a 13% rate of major complications, including respiratory depression and pneumonia, among 156 shoulder arthroplasty patients in 1 of his studies. [8]

    So, what is the alternative to something that is already supposed to be the alternative to opioids?

    The answer is evolving as surgeons investigate strategies to minimize pain and opioid use in shoulder procedures, Dr. Throckmorton said. For example, liposomal bupivacaine has been shown to provide pain relief equivalent to that of interscalene blocks in multiple studies, including research conducted by Dr. Throckmorton and his colleagues at Campbell Clinic Orthopaedics in Memphis, Tennessee. [8,9-13]

    Dr. Throckmorton’s study compared pain relief, narcotic use, complication rates, and cost in 214 patients undergoing shoulder arthroplasty who received 1 of the following:

    • Liposomal bupivacaine (n=58), which included liposomal bupivacaine plus 0.5% bupivacaine, ketorolac, and morphine
    • Indwelling interscalene blocks (n=156) that was left in place for 3 or 4 days

    Pain scores were equivalent between groups, and no differences were seen in narcotic use at 2, 6, and 12 weeks. As mentioned above, the rate of major complications was 13% for patients in the interscalene block group, compared with just 3.4% in the liposomal bupivacaine group. Cost was a factor: The liposomal bupivacaine mixture Dr. Throckmorton used in the study cost $304.40 per patient, compared with $1,472.42 for the interscalene block. [8]

    Another strategy that shoulder surgeons are adapting from the literature of other orthopaedic subspecialties is multimodal pain management, which has been shown to: [12,14-16]

    • Offer better pain control than individual pain medications
    • Minimize drug side effects
    • Allow for earlier postoperative mobilization
    • Facilitate earlier hospital discharge

    Dr. Throckmorton shared the multimodal pain management protocol he and his colleagues follow for shoulder arthroplasty and arthroscopy patients:

    Preoperatively

    • 10 mg oxycodone
    • 300 mg gabapentin
    • 1 gram acetaminophen intravenously

    Intraoperatively

    • 20 mL liposomal bupivacaine
    • 40 mL 0.25% bupivacaine
    • 30 mg ketorolac (note: patients undergoing arthroscopy for rotator cuff tears do not receive ketorolac)

    Postoperatively

    • Oxycodone as rescue medication
    • Oral acetaminophen
    • Gabapentin

    Click the image above to watch Dr. Throckmorton’s presentation and learn more about pain management in shoulder arthroplasty patients.

    Disclosures: Dr. Throckmorton has no disclosures relevant to this article.

    References

    1. Swedson JD, Bay N, Loose E, et al. Outpatient management of continuous peripheral nerve catheters placed using ultrasound guidance: an experience in 620 patients. Anesth Analg. 2006 Dec;103(6):1436-43.
    2. Winkler T, Suda AJ, Dumitrescu RV, et al. Interscalene versus subacromial continuous infusion of ropivacaine after arthroscopic acromioplasty: a randomized controlled trial. J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):566-72. doi: 10.1016/j.jse.2008.11.005. Epub 2009 Feb 11.
    3. Kean J, Wigderowitz CA, Coventry DM. Continuous interscalene infusion and single injection using levobupivacaine for analgesia after surgery of the shoulder. A double-blind, randomised controlled trial. J Bone Joint Surg Br. 2006 Sep;88(9):1173-7.
    4. Lenters TR, Davies J, Matsen FA 3rd. The types and severity of complications associated with interscalene brachial plexus block anesthesia: local and national evidence. J Shoulder Elbow Surg. 2007 Jul-Aug;16(4):379-87. Epub 2007 Apr 19.
    5. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001 Oct;95(4):875-80.
    6. Bowens C Jr, Briggs ER, Malchow RJ. Brachial plexus entrapment of interscalene nerve catheter after uncomplicated ultrasound-guided placement. Pain Med. 2011 Jul;12(7):1117-20. doi: 10.1111/j.1526-4637.2011.01177.x. Epub 2011 Jun 23.
    7. Azzam MG, Kimzey GW, Phillips GH, Fernandez J, Azar FM, Throckmorton TW. Shearing of a continuous interscalene catheter with lancinating symptoms after an interscalene block: a case report. JBJS Case Connect. 2013 Aug 28;3(3 Suppl 5):e831-3. doi: 10.2106/JBJS.CC.L.00210.
    8. Weller WJ, Azzam MG, Smith RA, Azar FM, Throckmorton TW. Liposomal bupivacaine mixture has similar pain relief and significantly fewer complications at less cost compared to indwelling interscalene catheter in total shoulder arthroplasty. J Arthroplasty. 2017 Nov;32(11):3557-3562. doi: 10.1016/j.arth.2017.03.017. Epub 2017 Mar 16.
    9. Hannan CV, Albrecht MJ, Petersen SA, Srikumaran U. Liposomal bupivacaine vs interscalene nerve block for pain control after shoulder arthroplasty: a retrospective cohort analysis. Am J Orthop. 2016 November;45(7):424-430
    10. Namdari S, Nicholson T, Abboud J, Lazarus M, Steinberg D, Williams G. Randomized controlled trial of interscalene block compared with injectable liposomal bupivacaine in shoulder arthroplasty. J Bone Joint Surg Am. 2017 Apr 5;99(7):550-556. doi: 10.2106/JBJS.16.00296.Yan Z, Chen Z, Ma C. Liposomal bupivacaine versus interscalene nerve block for pain control after shoulder arthroplasty: A meta-analysis. Medicine (Baltimore). 2017 Jul;96(27):e7226. doi: 10.1097/MD.0000000000007226.
    11. Angerame MR, Ruder JA, Odum SM, Hamid N. Pain and Opioid Use After Total Shoulder Arthroplasty With Injectable Liposomal Bupivacaine Versus Interscalene Block. Orthopedics. 2017 Sep 1;40(5):e806-e811. doi: 10.3928/01477447-20170608-01. Epub 2017 Jun 15.
    12. Routman HD, Israel LR, Moor MA, Boltuch AD. Local injection of liposomal bupivacaine combined with intravenous dexamethasone reduces postoperative pain and hospital stay after shoulder arthroplasty. J Shoulder Elbow Surg. 2017 Apr;26(4):641-647. doi: 10.1016/j.jse.2016.09.033. Epub 2016 Nov 15.
    13. Okoroha KR, Lynch JR, Keller RA, et al. Liposomal bupivacaine versus interscalene nerve block for pain control after shoulder arthroplasty: a prospective randomized trial. J Shoulder Elbow Surg. 2016 Nov;25(11):1742-1748. doi: 10.1016/j.jse.2016.05.007. Epub 2016 Jul 14.
    14. Jiang J, Teng Y, Fan Z, Khan MS, Cui Z, Xia Y. The efficacy of periarticular multimodal drug injection for postoperative pain management in total knee or hip arthroplasty. J Arthroplasty. 2013 Dec;28(10):1882-7. doi: 10.1016/j.arth.2013.06.031. Epub 2013 Aug 1.
    15. Krych AJ, Horlocker TT, Hebl JR, Pagnano MW. Contemporary pain management strategies for minimally invasive total knee arthroplasty. Instr Course Lect. 2010;59:99-109.
    16. Hebl JR, Dilger JA, Byer DE, et al. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med. 2008 Nov-Dec;33(6):510-7.