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 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.
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.
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).
To see a YouTube of our technique for total shoulder arthroplasty, click on this link.
To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.
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