Pain control after hand surgery is multifactorial, affecting patient outcome and satisfaction and health care costs and potentially leading to opioid overuse or diversion.1–3 Many variables influence postoperative pain, including procedure and anesthesia type, patient demographics, and preoperative opioid consumption.4–6 Of these, selection of anesthesia is particularly complex and one of the few variables that surgeons can control. Although perioperative anesthesia selection has been extensively studied in other surgeries, such as total joint arthroplasties,7–13 there is no evidence that one type of anesthesia is superior to another for arthroplasty procedures of the hand.
Preoperative peripheral nerve blocks, local infiltration of anesthetics into the surgical site, and oral opioids are some of the common modalities used to manage postoperative pain in hand surgery. Moreover, there is increasing concern regarding the over-prescription of opioids.14 Currently, 80% of the global opioid supply is consumed by Americans.15 Optimal peri-operative anesthesia, such as peripheral nerve blocks or local infiltrative anesthesia, may lead to decreased postoperative pain and thereby minimize these issues.
Currently, several short- and long-acting local anesthetics are available, including lidocaine, bupivacaine, and more recently, liposomal bupivacaine. To better understand which perioperative anesthetic results in the best postoperative pain relief following thumb basal joint arthroplasty, a prospective comparison study was undertaken. The authors hypothesized that, regarding opioid pill consumption, no difference exists between long-lasting peripheral nerve blocks and local anesthesia with either standard bupivacaine or liposomal bupivacaine for thumb basal joint arthroplasty.
Materials and Methods
After institutional review board approval was obtained, all patients undergoing thumb basal joint arthroplasty performed by 1 of 7 fellowship-trained, orthopedic hand surgeons from January to December 2015 were invited to participate in this study. All surgeries consisted of a complete trapeziectomy followed by a stabilization procedure. The specific stabilization technique varied by individual surgeon but included either ligament reconstruction with tendon interpositioning or a tight-rope construct. No percutaneous or subcutaneous pins were used. Patients with symptomatic basal joint arthritis, confirmed by radiographs, who had failed a course of nonoperative treatment (activity modification, nonsteroidal anti-inflammatory drugs, splinting, and/or corticosteroid injections) were included. Patients with metacarpophalangeal joint hyperextension instability necessitating an additional procedure such as a metacarpophalangeal capsulodesis or a metacarpophalangeal arthrodesis, having revision thumb basal joint arthroplasty, with chronic and preoperative opioid use, and having known allergies to local anesthetics were excluded.
All enrolled patients received general anesthesia for the surgical procedure and were assigned to 1 of 3 perioperative analgesia protocols according to surgeon preference:
Preoperative supraclavicular nerve blocks with 20 mL of 0.5% bupivacaine administered by the attending anesthesiologist.
Preincision injection of 20 mL of 0.5% bupivacaine at the surgical site.
Preincision injection of 10 mL of 0.5% bupivacaine at the surgical site followed by a postclosure injection of 10 mL of liposomal bupivacaine also at the surgical site.
All injections were performed in a predetermined manner. For group 1, prior to the induction of general anesthesia, supraclavicular blocks were performed with a single injection by a board-certified anesthesiologist using ultrasound guidance. For group 2, after the induction of general anesthesia, the skin, joint capsule, and joint space were infiltrated with bupivacaine prior to incision. For group 3, in addition to the preincision bupivacaine infiltration, after skin closure, liposomal bupivacaine was injected into the trapeziectomy space and the closed incision line. Injection of liposomal bupivacaine after closure and after preoperative injection with bupivacaine is the application recommended by the manufacturer. The quantities of local infiltrations and the supraclavicular block were the same to ensure adequate comparisons between the groups.
Patients were prescribed 1 of 3 opioids according to their individual preference: Percocet (Endo Pharmaceuticals, Malvern, Pennsylvania; 5 mg of oxycodone and 325 mg of acetaminophen), Vicodin (AbbVie Inc, North Chicago, Illinois; 5 mg of hydrocodone and 300 mg of acetaminophen), or Tylenol #3 (Janssen Pharmaceuticals, Titusville, New Jersey; 30 mg of codeine and 325 mg of acetaminophen). During the first 5 postoperative days (PODs), patients were asked to record their daily maximum pain level on the visual analog scale (VAS), their daily opioid consumption, and any adverse reactions.
Analysis of variance was used to detect significant differences between groups, and subsequent pairwise comparisons were performed. Chi-square test was used to detect statistically significant differences between categorical variables. A power analysis indicated that 23 patients per group would be sufficient to detect a 1-pill difference in a pairwise comparison.
Seventy-eight patients were enrolled in this study. A total of 27 patients were assigned to group 1, 23 patients were assigned to group 2, and 28 patients were assigned to group 3. The average age in each cohort was 64, 60, and 62 years, respectively. The female:male ratio for each group was 2.9, 4.8, and 2.5, respectively. Postoperatively, no surgical or anesthetic complications were reported, and no patient required return to the operating room (Table 1).
Patient Group Outcomes Patient Group
Adverse Reactions to Postoperative Opioid Medications
Adverse reactions reported within the first 5 PODs are listed in Table 2. The most common adverse reactions were nausea (n=13), constipation (n=9), and itching (n=8), all of which are common medication-related side effects. By cohort, 8 patients in group 1 reported side effects, compared with 7 patients in group 2 and 8 patients in group 3 (P>.05).
Summary of Adverse Events
Visual Analog Scale Pain Scores
All patients recorded VAS pain scores for the first 5 consecutive PODs. These scores reflected the highest pain experienced during the day. On POD 0, group 2 reported the highest amount of pain (average score, 4.1) followed by group 1 and group 3 (average score of 3.7 and 2.7, respectively) (P>.05). On POD 1, all cohorts reported an increase in pain, with group 1 reporting the highest amount (average score, 6.3) followed by group 2 (bupivacaine) and group 3 (liposomal bupivacaine) (average score of 6.1 and 5.2, respectively). All increases from POD 0 to POD 1 in each group were significant (P<.05). Thereafter, VAS scores uniformly decreased for all cohorts from POD 2 through POD 5 without statistical significance between groups (P>.05). Postoperative pain averaged over 5 days, as measured by the VAS, was also not significantly different between the groups (P>.05) (Table 1, Figure 1).
Patients from each cohort reported pain as a visual analog scale (VAS) score during the first 5 postoperative days. Group 1=peripheral nerve block, group 2=bupivacaine, and group 3=liposomal bupivacaine.
Opioid Pill Consumption
On POD 0, patients in group 2 consumed the most opioid pills (average, 2.7 pills) followed by patients in group 1 (average, 2.3 pills) and patients in group 3 (average, 1.8 pills). These differences were not significant (P>.05) (Figure 2). However, by POD 1, group 1 and group 2 patients had significantly higher opioid pill consumption (average of 4.5 and 5.1 pills, respectively) compared with group 3 patients (average, 2.7 pills) (P<.05). Increases in pill consumption from POD 0 to POD 1 were significant for group 1 and group 2 (P<.05) but not group 3 (P>.05). Thereafter, pill consumption decreased uniformly among all groups.
Patients from each cohort reported opioid pill consumption during the first 5 postoperative days. Group 1=peripheral nerve block, group 2=bupivacaine, and group 3=liposomal bupivacaine.
On evaluation of the difference in total pill consumption during the 5-day study period, group 3 (liposomal bupivacaine) was found to have the lowest pill consumption (average, 11 pills) vs group 1 (peripheral block; average, 17 pills) and group 2 (bupivacaine; average, 19 pills). This difference was not statistically significant (P>.05) (Table 1).
The ambulatory surgical setting presents a unique challenge in postsurgical pain control. Unlike the inpatient setting, patients are tasked with independently managing possibly severe postoperative pain with only oral analgesics. Despite advancements in pain management, such as improved local anesthetic formulations and ultrasound-guided plexus blocks, approximately 30% to 40% of ambulatory surgical patients report moderate or severe pain within the first 2 days of discharge.16 Furthermore, pain is a significant risk factor for unexpected hospital admissions and delayed discharge from ambulatory surgical facilities.17 Orthopedic patients have been found to have the highest incidence of immediate postoperative pain,5 with 37% of orthopedic hand patients reporting moderate to severe pain postoperatively.18 Given that pain negatively impacts patient satisfaction and prolongs return to function, identification of the most effective anesthetic and analgesic protocol is important. Recently, a multimodal anesthetic regimen consisting of peripheral nerve block, local infiltrative anesthesia, and a variety of anti-inflammatory and opioid-based medications has afforded improved patient pain control after upper extremity surgery in the outpatient setting.19,20
The duration of pain relief, route of administration, and type of anesthetic must be considered when forming a postoperative pain management strategy. The duration of a peripheral nerve block using 0.5% bupivacaine is variable and can last between 8 and 24 hours.7,8,21–23 In 2011, the Food and Drug Administration approved a novel anesthetic, liposomal bupivacaine, for wound infiltration use in hemorrhoidectomy and bunionectomy. Since then, clinical studies have shown that liposomal bupivacaine can control postoperative pain for up to 72 hours.24,25 The liposomal formulation has been shown to allow a 4-fold increase in bupivacaine dose without increasing peak plasma concentrations or the risk of systemic toxicity.26 A recent comparison of liposomal bupivacaine with bupivacaine hydrochloride for local infiltration in hemorrhoidectomy found liposomal bupivacaine to be superior regarding cumulative pain scores at POD 3 and total opioid consumption during the first 12 to 72 hours postoperatively.27 A systematic review of prospective studies found liposomal bupivacaine to be well tolerated and to have a favorable safety profile when used in knee arthroplasty, hemorrhoidectomy, augmentation mammoplasty, and bunionectomy.28
Additionally, consideration must be given to whether local infiltration or peripheral nerve block is the optimal route of administration. Several studies have reported that the analgesic effect of local injections is comparable to that of an epidural or femoral nerve block, especially for knee replacement.7,8 Randomized clinical trials found that local anesthesia provided inferior analgesia compared with interscalene blocks for shoulder procedures.29,30 Some of these differences may be explained by the fact that a tourniquet, used in distal procedures, may result in a longer duration of local anesthetic tissue saturation by preventing anesthetic drainage; that the more distal aspect of the extremity is just more effectively anesthetized with local anesthesia; or that a tourniquet may cause a temporary palsy of the peripheral nerves.
The authors hypothesized that patients receiving supraclavicular peripheral nerve blocks, compared with local infiltrative anesthesia, would be afforded greater pain relief in the perioperative setting. They found that postoperative pain, as measured by the VAS, was not significantly different among the groups. All pain scores had significantly increased to a maximum by POD 1 and collectively declined throughout the remaining postoperative course. Although a decreased amount of total opioids were consumed in the liposomal bupivacaine group, this difference was not significant (P>.05). Local infiltrative anesthesia appeared to be as effective as a peripheral nerve block for basal joint arthroplasty. Regarding anesthetic choice, liposomal bupivacaine appears to have an advantage with respect to pill consumption early in the postoperative course but not in overall VAS pain scores.
The surgeons at the authors' institution routinely use peripheral nerve blocks for lengthy and/or complex procedures, such as basal joint arthroplasty. The decision algorithm, however, should not be based merely on precedent. Perioperative pain control must also take into account both complications and costs related to anesthesia and analgesia. Although the rate of peripheral nerve block complications is low, the list of reported complications is serious, including pneumothorax, recurrent laryngeal nerve blockade, phrenic blockade, peripheral neuropathy, spinal cord damage, and sympathetic chain blockade.31 Moreover, the procedural cost of an anesthesiologist's performing a peripheral nerve block is not irrelevant. Although the administration of infiltrative anesthesia into the surgical site is bundled within the procedural reimbursement and therefore incurs no additional procedural cost, the same cannot be said for peripheral nerve blocks, which are billed for separately by the anesthesiologist. Costs for peripheral nerve blocks averaged across multiple surgical centers are approximately $200. These costs are consistent with Centers for Medicare & Medicaid Services reimbursement rates. For comparison purposes, the reimbursement rate for a trapeziectomy (Current Procedural Terminology code 25447) is approximately $900. If, as in the current study, there are no clinical benefits to using peripheral nerve blocks vs local infiltrative anesthesia for procedures of the hand, reconsideration of the risks, costs, and efficiency of routinely administering peripheral nerve blocks may be necessary. Although all of the current patients received general anesthesia, it is not uncommon for ambulatory centers to use regional anesthesia alone. This approach avoids the financial cost and potential morbidity associated with general anesthesia.
Finally, the cost of the anesthetic agent should be considered, as there are profound differences. The current cost of liposomal bupivacaine is approximately 100 times that of bupivacaine. The wholesale cost of standard bupivacaine is approximately $3.00 per 20 mL, whereas that of liposomal bupivacaine exceeds $250.00 per 20 mL. Therefore, the potential benefits of liposomal bupivacaine, as illustrated in this study, must be considered in light of its increased cost, particularly for an ambulatory procedure.
This study had a few limitations. First, although the authors assumed analgesic equivalence, the postoperative opioids were not standardized among the groups. They evaluated pill consumption for 3 different types of opioids based on patient and physician preference. Second, this study relied on self-reporting of opioid consumption, which has the potential to generate recall bias. Although the authors ask patients to use the residuum of pills prescribed to accurately enumerate the pills consumed, the potential exists for a patient to misreport the number. The authors failed to account for the inherent difference in pain severity associated with individual suspension technique (ligament reconstruction with tendon interpositioning vs tight-rope construct) after trapeziectomy. Disproportionate assignment of suspension techniques among analgesic groups has the potential to be confounding. An additional limitation is that this study was not randomized or double blinded. This introduces a selection bias that may affect the results of the study. Finally, although this study was powered to detect a 1-pill difference, it may not have been adequately powered toward the end of the postoperative course because fewer and fewer patients were taking medications further out from surgery. Studies are encouraged to validate these findings for similar surgical procedures and to further evaluate the cost–benefit ratio of liposomal bupivacaine compared with other local anesthetic agents in orthopedic hand surgery.
This study attempted to compare the efficacies of peripheral nerve blocks, local infiltration with bupivacaine, and local infiltration with liposomal bupivacaine in thumb basal joint arthroplasty. The results should be helpful to both surgeons and patients in determining the best perioperative analgesia strategy to optimize the postoperative pain experience. In particular, the authors encourage surgeons to consider the following specific findings relative to the postoperative pain experience for thumb basal joint arthroplasty: (1) Patients should be educated and warned to expect an increase in their pain on POD 1; however, their pain should begin to subside after POD 2. (2) Average opioid consumption was fewer than 20 opioid pills in each group investigated, and surgeons should consider prescribing opioids accordingly to avoid over-prescribing. (3) Liposomal bupivacaine showed lower opioid consumption early on, but its use must be negotiated against its increased cost. (4) Peripheral nerve blocks do not seem to offer superior postoperative pain control compared with local anesthesia for thumb basal joint arthroplasty, and their routine use should be reconsidered relative to their added procedural risks and cost without added clear benefit.
- Bot AG, Bekkers S, Arnstein PM, Smith RM, Ring D. Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief. Clin Orthop Relat Res. 2014; 472(8):2542–2549. doi:10.1007/s11999-014-3660-4 [CrossRef]
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- Pasero C, McCaffery M. Orthopaedic postoperative pain management. J Perianesth Nurs. 2007; 22(3):160–172. doi:10.1016/j.jopan.2007.02.004 [CrossRef]
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- Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes S, Callaghan JJ. Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. J Bone Joint Surg Am. 2013; 95(3):193–199. doi:10.2106/JBJS.K.01682 [CrossRef]
- Jæger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med. 2013; 38(6):526–532. doi:10.1097/AAP.0000000000000015 [CrossRef]
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Patient Group Outcomes Patient Group
|Outcome Variable||Patient Group||P|
|Age, average, y||64||60||62||.55|
|Female:male ratio, No.||2.9||4.8||2.5||.32|
|Side effects, No.||18||20||17||.11|
|Visual analog scale pain score,a average|
| POD 0||3.7||4.1||2.7||.34|
| POD 1||6.3||6.1||5.2||.34|
| POD 2||5.6||5.4||4.7||.89|
| POD 3||4.2||4.5||4.7||.85|
| POD 4||3.6||3.7||3.9||.97|
| POD 5||3.0||3.2||3.0||.98|
|Pill use, average No. of pills|
| POD 0||2.3||2.7||1.8||.35|
| POD 1||4.5||5.1||2.7||<.05|
| POD 2||4.0||4.0||2.7||.15|
| POD 3||2.9||2.9||1.9||.18|
| POD 4||1.9||2.6||1.4||.19|
| POD 5||1.6||1.9||1.0||.50|
Summary of Adverse Events
|Adverse Effect||No. of Patients (%)|
|Group 1 (n=27)||Group 2 (n=23)||Group 3 (n=28)||Total (n=78)|
|Patients with ≥1 adverse event||8 (29.6)||7 (30.4)||8 (28.6)||23 (29.5)|
|Dry mouth||0 (0.0)||2 (8.7)||0 (0.0)||2 (2.6)|
|Nausea||6 (22.2)||4 (17.4)||3 (10.7)||13 (16.7)|
|Vomiting||2 (7.4)||1 (4.3)||0 (0.0)||3 (3.8)|
|Feeling drowsy||1 (3.7)||1 (4.3)||3 (10.7)||5 (6.4)|
|Trouble sleeping||0 (0.0)||2 (8.7)||3 (10.7)||5 (6.4)|
|Shortness of breath||0 (0.0)||0 (0.0)||1 (3.6)||1 (1.3)|
|Feeling bloated||0 (0.0)||0 (0.0)||0 (0.0)||0 (0.0)|
|Constipation||2 (7.4)||3 (13.0)||4 (14.3)||9 (11.5)|
|Trouble urinating||0 (0.0)||0 (0.0)||0 (0.0)||0 (0.0)|
|Itching||2 (7.4)||4 (17.4)||2 (7.1)||8 (10.3)|
|Dizziness||2 (7.4)||1 (4.3)||1 (3.6)||4 (5.1)|
|Sweating||2 (7.4)||1 (4.3)||0 (0.0)||3 (3.8)|
|Coughing||0 (0.0)||0 (0.0)||0 (0.0)||0 (0.0)|
|Lack of energy||2 (7.4)||2 (8.7)||3 (10.7)||7 (9.0)|