Why bother with interscalene blocks for shoulder arthroplasty?

Efficacy of local infiltration anesthesia versus interscalene nerve blockade for total shoulder arthroplasty

These authors point out that although regional nerve blockade is commonly used for shoulder arthroplasty, complications and rebound pain (see this link) can create problems for the patient and for the surgeon.

The purpose of their study was to evaluate the effectiveness and complication rate of a low-cost local anesthetic injection mixture for use in total shoulder arthroplasty (TSA) compared with interscalene brachial plexus blockade.

From a shoulder registry, 305 patients who underwent TSA and reverse TSA from 2012-2018 were included in this study. All procedures were performed by the same surgeon, in the same manner with standard implants. Only patients who underwent anatomic, reverse, or revision reverse TSA were included. 

From June 21, 2012, to December 13, 2015 144 patients were administered general anesthesia with regional anesthesia. The interscalene nerve block was performed by anesthesiologists who are facile and skilled in this procedure using ultrasound guidance with nerve stimulation.

From December 14, 2015 to June 25, 2018, 161 patients were administered general anesthesia in addition to a local injection consisting of a weight-based mixture of 0.25% ropivacaine, morphine, epinephrine, and ketorolac. The solution was injected both in and around the joint; this included the glenohumeral joint, deltoid, and subacromial space, as well as the subcutaneous tissue surrounding the incision.

Immediate postoperative pain scores were not significantly different between groups.

The median hospital length of stay was 1 day in the local injection group and 2 days in the interscalene nerve block  group.

Opioid consumption during the first 24 hours following surgery was significantly reduced in the local infiltration group compared with the interscalene block group.

No 90-day postoperative nerve complications occurred in the local infiltration group, whereas 2 patients who received interscalene blocks had nerve complications. Both patients experienced wrist drop as well as persistent pain in the thumb and index finger for 6 months after surgery in one patient and numbness in the index and middle fingers lasting for 13 months in the other patient. 

Ninety-day postoperative cardiopulmonary complications occurred in 5 patients in the local infiltration group compared with 8 patients in the interscalene block group. These included deep venous thrombosis, hematoma, stroke, myocardial infarction, and severe hypoxia with saturation of less than 80% requiring intensive care unit admission.

The cost of the weight-based injection mixed in a hospital pharmacy is approximately $25. In contrast to regional anesthesia, local injections can be performed in minimal time, usually less than a minute.

The cost of regional anesthetic supplies, ultrasound use, and professional fees ranges from $1500-1800. On average, an additional 25.0 minutes was required to administer the regional block in the interscalene block group, whereas no additional time was required in the local infiltration group. 

Comment: Many surgeons seem convinced that interscalene blocks are preferred for shoulder arthroplasty. However, like the authors of this paper, we are aware of the downsides and risks (see this link and link) and, as a result, we have not used plexus blocks in our arthroplasty practice for two decades. 

Our reasons for avoiding interscalene blocks for shoulder arthroplasty include (1) desire for documentation of neurological status immediately after surgery, (2) wanting to avoid having a flail unprotected arm as we start immediate postoperative motion exercises, (3) eliminating the risk of block-related neurologic or pulmonary complications, (4) avoiding phrenic nerve paresis with the attendant respiratory compromise, (5) eliminating the inconvenience of a failed block, (6) reducing the cost associated with two different anesthetics (block + general), (7) avoiding the problem of acute rebound pain in the middle of the first postoperative night, (8) the reluctance of some patients to have a needle placed in their neck

and (9) it isn't necessary when preoperative teaching and oral multimodal drugs (Celebrex, Tylenol, and Gabapentin) are used (see below). 

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Local infiltration instead of nerve block for controlling pain after shoulder arthroplasty

Local infiltration analgesia versus interscalene nerve block for postoperative pain control after shoulder arthroplasty: a prospective, randomized, comparative noninferiority study involving 99 patients

These authors conducted a randomized controlled study to investigate the efficacy of local infiltration analgesia (LIA) and interscalene nerve block (ISB) for early postoperative pain control after total shoulder arthroplasty (TSA).

Patients in the ISB group received a continuous infusion of 0.2% ropivacaine by perineural catheter for 48 hours. 

The surgeon injected 110 mL of 0.2% ropivacaine, 30 mg of ketoprofen, and 0.5 mg of epinephrine before TSA in the LIA group and inserted a catheter into the glenohumeral joint. The next morning, 10 mL of 0.2% ropivacaine, 30 mg of ketoprofen, and epinephrine were injected through the catheter, which was then removed.

The study included 99 patients (50 LIA and 49 ISB patients) with a mean age of 72  years.

No significant difference in the mean pain score was found between the 2 groups for the 48-hour postoperative period.

The  LIA group had significantly less severe pain (P = .003) and less opioid consumption (P = .01) in the recovery room.

Comment: This study suggests that injection of a cocktail of ropivacaine,  ketoprofen, and epinephrine injected before placing the TSA components (50-mL flush in the tissues surrounding the glenoid, 50-mL flush around the humerus into the rotator capsule and cuff, and then 10 mL in the incision) may be as effective as an ISB in controlling pain in the recovery room. 

In our practice, we find that nerve blocks and in-wound catheters are not necessary when a multimodal program of Celebrex, Gabepentin, and Tylenol is used along with patient-controlled analgesia (in the recovery room only). Patients on this program are able to do their own assisted range of motion exercises the night of surgery and usually able to leave the medical center on oral medications the next day.

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Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

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Lack of effectiveness of a subacromial pain pump infusion after arthroscopic cuff repair

Efficacy of continuous subacromial bupivacaine infusion for pain control after arthroscopic rotator cuff repair

While most surgeons are now aware of the dangers of the intra articular infusion of local anesthetics with a pain pump, some still advocate the use of pain pumps in the subacromial space after arthroscopic surgery.

These authors conducted a well done randomized controlled trial in 88 patients undergoing arthroscopic rotator cuff repair. Importantly, "the authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article."

The patients were randomized in a blinded fashion into 1 of 3 groups. Group 1 received no postoperative subacromial infusion catheter. Group 2 received a postoperative subacromial infusion catheter filled with saline solution. Group 3 received a postoperative subacromial infusion catheter filled with 0.5% bupivacaine without epinephrine. Infusion catheters were scheduled to infuse at 4 mL/h for 50 hours. They assessed postoperative pain levels  with visual analog scale scores hourly for the first 6 postoperative hours, every 6 hours for the next 2 days, and then every 12 hours for the next 3 days. Patients recorded daily oxycodone consumption for the first 5 postoperative days.
Results

Immediately postoperative, the group with no catheter had significantly lower visual analog scale scores (P = .04). There were no significant differences in visual analog scale scores among the groups at any other time point. There were no differences found among the groups regarding mean daily oxycodone consumption.

They concluded that the use of continuous bupivacaine subacromial infusion catheters resulted in no detectable pain reduction after arthroscopic rotator cuff repair based on visual analog scale scores and narcotic medication consumption.

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Glenohumeral chondrolysis caused by infusion of local anesthetic with a pain pump

Published Evidence Demonstrating the Causation of Glenohumeral Chondrolysis by Postoperative Infusion of Local Anesthetic Via a Pain Pump

The joint surfaces of the shoulder (glenohumeral) joint are normally covered by smooth articular cartilage.

Glenohumeral chondrolysis is the irreversible destruction of previously normal articular cartilage, occurring most commonly after shoulder surgery in young individuals. 

The reported incidence of this complication has risen rapidly since the early 2000s. As chondrolysis cannot be reversed, its occurrence can only be prevented by establishing and avoiding its causes. 

The authors analyzed all published cases of glenohumeral chondrolysis, including the relevant published laboratory data, to consolidate the available evidence on the causation of this complication by the postoperative intra-articular infusion of local anesthetic via a pain pump.

The published evidence demonstrated a causal relationship between the infusion of local anesthetic and the development of glenohumeral chondrolysis. 

The risk of this complication in shoulders receiving intra-articular infusions via a pain pump was significantly greater with higher doses of local anesthetic: twenty of forty-eight shoulders receiving high-flow infusions developed chondrolysis, whereas only two of twenty-five shoulders receiving low-flow infusions developed this complication (p = 0.0029). Eleven of twenty-two shoulders receiving 0.5% bupivacaine developed chondrolysis, whereas none of six shoulders receiving 0.25% bupivacaine developed this complication (p = 0.05). Of twenty-two shoulders infused with 0.5% bupivacaine, the eleven that developed chondrolysis had a mean pain pump delivery volume of 377 mL, whereas the eleven that did not develop chondrolysis had a mean volume of 187 mL (p = 0.003). Among shoulders in which an intra-articular pain pump was used, the risk of chondrolysis was significantly greater when suture anchors were placed in the glenoid for labral repair (p < 0.001). The effect seen with suture anchors may be due to the fact that they allow the intraarticular local anesthetic otherwise present only at the joint surface (green in the figure below)

 to gain access to the deeper tissue through the hole in the cartilage associated with the suture anchor.

It was concluded from the published evidence indicates that the preponderance of cases of glenohumeral chondrolysis can be prevented by the avoidance of the intra-articular infusion of local anesthetic via a pain pump.

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Chondrolysis - more

We continue to see young individuals with chondrolysis of their glenohumeral joint after a surgical procedure including the infusion of local anesthetics through a pain pump.

Here are the films of a person in their mid 20's having had an instability repair  5 years ago followed by a pain pump infusing Lidocaine for two days post surgery.

The shoulder became stiff and painful and did not respond to a capsular release. The shoulder demonstrated progressive loss of comfort and function. At presentation to us the Simple shoulder test Score was 4/12. The x-rays and MRI's showed global loss of cartilage and medial erosion of the glenoid without substantial bone response (i.e. no osteophytes).

 The patient is seeking a shoulder arthroplasty.

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Toxicity of local anesthetics - relation to chondrolysis

Cytotoxicity of Local Anesthetics on Human Mesenchymal Stem Cells

These authors were, like us, concerned about the risk of local anesthetics when applied to living cells. They note that commonly used drugs lidocaine, ropivacaine, and bupivacaine can be toxic to human chondrocytes causing chondrolysis. This study seeks to determine whether the toxic effects of local anesthetics extends to human mesenchymal stem cells.

Human mesenchymal stem cells from three healthy donors were grown in tissue culture and exposed to the following anesthetic treatments for sixty minutes: (1) 1% lidocaine, (2) 2% lidocaine, (3) 0.25% bupivacaine, (4) 0.5% bupivacaine, (5) 0.2% ropivacaine, and (6) 0.5% ropivacaine. The cells were then allowed to recover for twenty-four hours in regular growth media, and viability was measured with use of fluorescent staining for live cells or a luminescence assay for ATP content.

They found that 2% lidocaine was significantly more toxic than all doses of bupivacaine and ropivacaine.

Ropivacaine and bupivacaine had limited toxicity in this model. However, lidocaine significantly decreased mesenchymal stem cell viability. 

Mesenchymal stem cells may play a key role in healing following surgical procedures such as microfracture and ligament reconstruction. If local anesthetics are used following joint surgery, caution should be taken to avoid compromising tissue healing potential.

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Postoperative chondrolysis after intra-articular pain pump infusion of an anesthetic medication - now in the knee as well as the shoulder. JBJS

Previous posts on this blog from 3/25/11, 4/7/11, 10/1/11, 11/3/11, 11/9/11, 11/10/11, 11/29/11, 12/31/11, 1/23/12, 2/18/12 and 4/11/12 have dealt with the development of postoperative glenohumeral chondrolysis after intra-articular pain pump infusion of an anesthetic medication.

The JBJS recently published an article regarding the same complication of pain pumps when used in the knee: "The Development of Postoperative Knee Chondrolysis After Intra-Articular Pain Pump Infusion of an Anesthetic Medication: A Series of Twenty-One Cases". 

In each of 17 knees in this most recent report, 0.5% bupivacaine was infused and in one 0.25% bupivacaine was infused.

This article provides additional independent evidence supporting the causation of chondrolysis by pain pumps, even though this causational relationship has been termed 'speculative' by some authors.

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Risk Factors for Chondrolysis of the Shoulder: This month's Journal of Bone and Joint Surgery

The April issue of the Journal of Bone and Joint Surgery contains one article related to shoulder arthritis: Risk Factors for Chondrolysis of the Glenohumeral Joint. This is a Level II Study of  "Three Hundred and Seventy-five Shoulder Arthroscopic Procedures in the Practice of an Individual Community Surgeon". Chondrolysis is a condition in which the cartilage normally overlying the humeral head and glenoid is 'lysed' or destroyed as shown in the surgical photographs below.

In the series of patients included in this study, each case of documented chondrolysis was associated with the intra-articular post-arthroscopic infusion of a local anesthetic, either Marcaine or Lidocaine. In an analysis of the group of patients with chondrolysis that had received an intra-articular postoperative infusion of a local anesthetic, the risk of chondrolysis was found to be greater for those with one or more suture anchors placed in the glenoid, for younger patients, and for those who had the surgery near the end of the ten-year study period.

The JBJS has provided a commentary on the importance of this article.

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X-rays in chondrolysis

If we look back at the March 23 post, we see the joint space was lost and bone responded to osteoarthritis by building up new bone (osteophytes), this is can be called a hypertrophic response. By contrast in conditions such as chondrolysis the joint space is lost but the bone does not respond, this can be called an atrophic response.

The image above is the AP X-ray of a recent patient who developed post arthroscopic glenohumeral chondrolysis. In contrast to the X-rays of a patient with degenerative joint disease shown in the March 23 post, there are minimal bone spurs and the density of the bone is reduced. The two white arrows are suture anchors used in the arthroscopic procedure.

The image above is the Axillary X-ray of the same patient showing again the atrophic response of the bone to chondrolysis. Additional examples can be see here.

A recent post on the causation of chondrolysis can be found here

The lack of a hypertrophic response in chondrolysis may be one of the reasons that total shoulder arthroplasty may be the preferred joint replacement in this condition as opposed to procedures that do not replace both the ball and socket aspects of the joint.

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