Reverse total shoulder arthroplasty for acute proximal humeral fracture has comparable 10-year outcomes to elective indications: results from the New Zealand Joint Registry.

HYPOTHESIS AND BACKGROUND: Recently, the indication of reverse total shoulder arthroplasty (RTSA) has expanded beyond rotator cuff arthropathy to include treatment of complex acute proximal humeral fracture (PHF). Limited previous studies have compared the long-term clinical and functional outcomes of patients undergoing RTSA for PHF vs. elective indications for degenerative conditions. The purpose of this study was to compare implant survivorship, reasons for revision and functional outcomes in patients undergoing RTSA for acute PHF with those undergoing elective RTSA in a population-based cohort study. METHODS: Prospectively collected data from the New Zealand Joint Registry from 1999 to 2021 and identified 6862 patients who underwent RTSA. Patients were categorized by preoperative indication, including PHF (10.8%), rotator cuff arthropathy (RCA) (44.5%), osteoarthritis (OA) (34.1%), rheumatoid arthritis (RA) (5.5%), and old traumatic sequelae (5.1%). Revision-free implant survival and functional outcomes (Oxford Shoulder Scores [OSSs] at the 6-month, 5-year, and 10-year follow-ups) were adjusted by age, sex, American Society of Anesthesiologists class, and surgeon experience and compared. RESULTS: Revision-free implant survival at 10 years for RTSA for PHF was 97.3%, compared with 96.1%, 93.7%, 92.8%, and 91.3% for OA, RCA, RA and traumatic sequelae, respectively. When compared with RTSA for PHF, the adjusted risk of revision was significantly higher for traumatic sequelae (hazard ratio = 2.3, P = .023) but not for other elective indications. The most common reason for revision in the PHF group was dislocation or instability (42.9%), which was similar to the OA (47.6%) and traumatic sequelae (33.3%) groups. At 6 months post-surgery, OSSs were significantly lower for the PHF group compared with the RCA, OA, and RA groups (31.1 vs. 35.6, 37.7, and 36.5, respectively, P < .001), and similar to traumatic sequelae (31.7, P = .431). At 5 years, OSSs were only significantly lower for PHF compared with OA (37.4 vs. 41.0, P < .001) and there was no difference between the PHF and other groups. At 10 years, there were no significant differences between groups. CONCLUSIONS: RTSA for PHF demonstrated reliable long-term survivorship and functional outcomes compared with elective indications. Despite lower functional outcomes in the early postoperative period for the PHF group, implant survivorship was similar in patients undergoing RTSA for the primary indication of acute PHF compared with RCA, OA, and RA and superior compared to the primary indication of traumatic sequelae.

Catheter orifice configuration influences the effectiveness of continuous peripheral nerve blockade.

BACKGROUND AND OBJECTIVES: We investigated perineural catheter threading distance and orifice configuration during continuous interscalene analgesia. METHODS: One hundred fifty-three patients receiving an anterolateral interscalene catheter (catheter needle and nerve/plexus in a similar alignment) for elective shoulder surgery were randomized to 1 of 3 groups: following out-of-plane ultrasound confirmation of the needle tip immediately lateral to the C5/6 roots, a nonstimulating catheter was blindly advanced 0.5 cm (end-hole; n = 50), 2.5 cm (multiorifice; n = 50) or 5 cm (multiorifice; n = 53) beyond the needle tip. Ropivacaine 0.75% + lidocaine 1% (50:50) 20 mL was administered preoperatively via the catheter before surgery under general anesthesia. A ropivacaine 0.2% 2 mL/hr elastomeric infusion with mandatory 6 hourly (and on demand) 5-mL boluses was continued for more than 48 hrs with tramadol available as rescue. Patients were questioned in the recovery room, at 24 and 48 hrs for numerical rating pain score (0-10), ropivacaine bolus, and tramadol consumption. RESULTS: Patients were more frequently pain-free in the recovery room in the multiorifice 2.5 and 5 cm groups compared with the end-hole 0.5 cm group (94%, 91% vs 66%; P < 0.001). During the first 24 hrs, the end-hole group demonstrated an earlier time to first pain (median, 10 vs17, 15 hrs; P < 0.001), higher "average pain" (median, 3 vs 1, 2, P = 0.004), and more ropivacaine bolus (median, 5 vs 3, 3; P < 0.001) and tramadol consumption (P = 0.01). Groups 2.5 and 5 cm did not significantly differ in any outcomes. CONCLUSIONS: These results suggest that multiorifice catheters provide superior intermittent bolus continuous peripheral nerve blockade compared with end-hole catheters. For anterolateral approach interscalene catheter placement, there is minimal benefit, either way, to 2.5- or 5-cm blind catheter advancement.

Posterior versus anterolateral approach interscalene catheter placement: a prospective randomized trial.

BACKGROUND AND OBJECTIVES: Two distinctly different approaches to interscalene catheter placement have been in common use for close to a decade. This prospective randomized study tested the hypothesis that interscalene catheters placed using the posterior approach would provide a more effective analgesia after shoulder surgery compared with catheters placed using the anterolateral approach. METHODS: A total of 110 patients presenting for elective shoulder surgery were randomly assigned to receive an ultrasound-guided posterior (n=54) or anterolateral (n=56) interscalene catheter with 20 mL of ropivacaine 0.375% administered preoperatively via the catheter before surgery under general anesthesia. Ropivacaine 0.2% at 2 mL/hr with on-demand hourly 5-mL boluses was continued for more than 48 hrs with tramadol available as rescue. Patients were questioned in the recovery room, at 24 and 48 hrs after surgery, for pain, ropivacaine bolus, and tramadol consumption. RESULTS: Patients were more frequently free of pain in the recovery room in the anterolateral group compared with the posterior group (mean, 91%; 95% confidence interval [CI], 84%-99% versus mean, 61%; 95% CI, 48%-74%; P=0.005). Rescue tramadol consumption was higher for the posterior group during the first but not during the second 24 hrs after surgery (day 1/day 2: 48%versus 27%, P=0.017 / 35% versus 27%, P=0.27). Postoperative pain, ropivacaine bolus consumption, numbness, weakness, neck discomfort, and satisfaction were similar between groups. Catheter threading difficulty was more common (33% versus 13%, P=0.012), and catheter placement time was longer (median, 9 min; interquartile range, 7.5-10 min versus median, 6.5 min; interquartile range, 6-8 min; P<0.0001) in the posterior group. CONCLUSIONS: Anterolateral interscalene catheters perform more effectively and are procedurally more easily placed compared with catheters placed using the posterior approach.

Analgesic effectiveness of a continuous versus single-injection interscalene block for minor arthroscopic shoulder surgery.

BACKGROUND AND OBJECTIVES: The utility of continuous perineural infusions for lesser painful shoulder procedures is not well established. We hypothesized that the addition of a continuous interscalene ropivacaine infusion to a single-injection interscalene block would improve analgesia after minor arthroscopic shoulder surgery. METHODS: An ultrasound-guided interscalene catheter targeting the C5-C6 roots/superior trunk was placed preoperatively in patients undergoing arthroscopic subacromial decompression, excision lateral clavicle, or stabilization. Ropivacaine 0.5% 30 mL was administered via this catheter before surgery was conducted under general anesthesia. All patients received dexamethasone and ondansetron antiemetic prophylaxis. At surgery conclusion, patients were randomly assigned to catheter removal in the postanesthesia care unit ("SS," n = 30) or to an elastomeric infusion of ropivacaine 0.2% 2 mL/hr with patient-controlled 5-mL boluses every hour ("Continuous," n = 31). Multimodal analgesia (acetaminophen, diclofenac, and rescue tramadol) was administered in both groups. Patients were questioned on postoperative days 1 and 2 for numerical rating pain score (0-10), supplemental tramadol consumption, and adverse effects of treatment. RESULTS: Median (quartiles) worst numerical rating pain score was lower in the Continuous group on day 1 on movement (SS = 4 [3-6], Continuous = 2 [0-4], P = 0.008) and at rest (SS = 2 [2-5], Continuous = 1 [0-3], P = 0.007) but was similar between groups on day 2. Median (quartiles) tramadol tablet consumption was lower in the Continuous group on both day 1 (SS = 1 [0-2], Continuous = 0 [0-0], P < 0.001) and day 2 (SS = 1 [0-2], Continuous = 0 [0-1], P = 0.017). Adverse effects of treatment were similar between groups except for numerically rated arm numbness, which was higher for the Continuous group. One patient in the SS group required 2 nights of hospitalization for intravenous opioid. CONCLUSIONS: After minor arthroscopic shoulder surgery, the addition of a continuous interscalene ropivacaine infusion to a single-shot interscalene block reduces pain, especially with movement, during the first 24 hrs.

A prospective randomized comparison of ultrasound guidance versus neurostimulation for interscalene catheter placement.

BACKGROUND AND OBJECTIVES: Ultrasound (US) imaging facilitates catheter placement adjacent to the most appropriate elements of the brachial plexus, which for shoulder surgery are the C5YC6 roots or superior trunk. Therefore, it was investigated whether such placement would improve catheter effectiveness compared to placement with traditional techniques. METHODS: Needles introduced for catheter insertion were prospectively randomized to either US guidance immediately lateral to the C5-C6 roots/superior middle trunks (n = 43) or neurostimulation (NS) guidance to an appropriate motor response at less than 0.5 mA (n = 40). Ropivacaine 0.5% 30 mL was administered via the catheter before surgery under general anesthesia. After surgery, ropivacaine 0.2% infusion at 2 mL/hr with on-demand 5-mL boluses via an elastomeric pump was continued at home for 2 to 5 days. Patients were questioned regarding the need for ropivacaine boluses, tramadol, and numerical rating pain score (NRPS) on postoperative days 1 and 2. RESULTS: Catheter interventions for an NRPS of greater than 2 (0-10) in recovery were lower in the US group (US = 2/43, NS = 10/39; P = 0.007). Day 1 median ropivacaine bolus consumption (US = 1, NS = 2; P = 0.03) and the proportion of subjects requiring 2 or more tramadol tablets (US = 2/43, NS = 7/39; P = 0.04) were lower in the US group. These differences were not present on day 2. Postoperative pain was similar in both groups. Median (quartiles) needle time under the skin was lower in the US group (49 secs [41-55 secs]) than the NS group (97 secs [80-137 secs]) (P G 0.001) and was associated with a 1-point reduction in procedural NRPS (median [quartiles]: US = 2 [1-4], NS = 3 [2-6]; P = 0.002). CONCLUSIONS: After shoulder surgery, interscalene catheters placed with US demonstrated improved effectiveness during the first 24 hrs compared with those placed with NS. These catheters were also placed with less needling and a very small reduction in procedure-related pain.

A prospective randomized comparison of ultrasound and neurostimulation as needle end points for interscalene catheter placement.

BACKGROUND: In this prospective, randomized study, we tested the hypothesis that interscalene catheters placed for shoulder surgery using an ultrasound needle end point provide postoperative analgesia similar in quality to those placed using a neurostimulation needle end point. Secondary end points included needle time under the skin, procedure-related pain, and the incidence of early neurological complications. METHODS: Patients presenting for shoulder surgery were recruited. Needles introduced for catheter insertion were initially guided with out-of-plane ultrasound imaging but were prospectively randomized to either sonographic placement immediately lateral to the interscalene interface (n = 41) or to an appropriate motor response at <0.5 mA (n = 40). Catheters were then advanced blindly 2-3 cm beyond needle tip. All surgery was conducted under general anesthesia. At the end of surgery, an infusion of ropivacaine 0.2% 2 mL/h with as-required hourly 5 mL boluses was instituted and continued at home for 2-5 days. Needle time under the skin and numerical rating pain score (NRPS) during insertion were recorded. Patients recorded worst NRPS, the need for supplementary ropivacaine boluses and tramadol on postoperative days 1 and 2. All patients were questioned at Day 10 for new neurological symptoms. RESULTS: There was no significant difference in the worst NRPS at rest and on movement and the requirement for supplementary ropivacaine boluses or tramadol during the first 48 postoperative hours. In one patient in group ultrasound, a satisfactory ultrasound image was unobtainable. An appropriate motor response was obtained in all subjects in group neurostimulation. The median (quartiles) needle time under the skin was 78 (65-101) s in group ultrasound and 108 (94-129) s in group neurostimulation (P < 0.001). The median (quartiles) insertion NRPS was 2 (0-4) in group ultrasound and 3 (1-5) in group neurostimulation (P < 0.048). There was no difference in the frequency of neurological complications between groups. CONCLUSIONS: Interscalene catheters placed for shoulder surgery using an ultrasound needle end point provide postoperative analgesia that is of similar quality to that obtained when using a neurostimulation needle end point. The ultrasound end point was associated with a reduction in needle under the skin time and procedure-related pain.

Successful continuous interscalene analgesia for ambulatory shoulder surgery in a private practice setting.

BACKGROUND AND OBJECTIVES: Large prospective studies evaluating continuous interscalene block for shoulder surgery have thus far been limited to inpatient and university teaching practices. Shoulder surgery is increasingly being performed on an outpatient basis. The aim of this case series was to prospectively evaluate a large series of interscalene catheters for ambulatory shoulder surgery in a private practice setting. METHODS: A single operator placed nonstimulating catheters using a combination of ultrasound and nerve stimulation. Following postanesthesia care unit (PACU) discharge, opioid-like analgesic adjuvants other than tramadol were avoided unless patients experienced inadequate pain relief. All patients were assessed in the PACU, on the first postoperative morning, and at 3 weeks for catheter effectiveness and for acute and chronic complications. Pain scores and patient satisfaction were assessed in subgroups of 100 consecutive patients. RESULTS: Three hundred patients were studied. The first attempt catheter success rate was 96%. In all but 1 patient, ineffective catheters in the PACU were effectively reinserted. Thirteen patients experienced inadequate pain relief after leaving the PACU. Of these patients, 5 were rescued with additional ropivacaine, 3 had the catheter effectively reinserted, and 5 were managed with oral opioids. One patient required antibiotic treatment for catheter site infection. Neurological sequelae potentially attributable to the catheter were present in 3 patients at 3 weeks, and remained in 1 patient at 4 weeks. This patient's symptoms resolved at 6 months. CONCLUSIONS: Continuous interscalene block for ambulatory shoulder surgery in a private practice setting had a high success rate, a low complication rate, and enabled the avoidance of the use of potent opioids in 98% of patients.