Orthopedics

Feature Article 

Improvement in Postoperative Pain Control and Length of Stay With Peripheral Nerve Block Prior to Distal Radius Repair

Pierce Johnson, MD; Joshua Hustedt, MD; Thomas Matiski, MD; Robert Childers, BSE, MS; Evan Lederman, MD

Abstract

Distal radius repair is a common orthopedic surgery often performed at outpatient surgical centers. To date, little is known regarding optimal pain control in this setting. In this study, the authors evaluated patients who underwent distal radius open reduction and internal fixation (ORIF) in an outpatient surgery center setting. Comparisons between 2 surgical groups, peripheral nerve block without general anesthesia vs general anesthesia only, were recorded in terms of postoperative length of stay (LOS) in phase I, total LOS, and patient-reported pain level at discharge. The authors identified 80 patients undergoing distal radius ORIF from March to August 2016. A total of 37 (46.3%) patients received general anesthesia only and 43 (53.8%) patients received peripheral nerve block without general anesthesia. Overall, patients in the nerve block only group showed a statistically significant decrease in pain at discharge, as well as decreased phase I and total LOS. Although the power of the data is low relative to the number of distal radius procedures performed every year, there is a trend of better pain control and decreased LOS when using nerve blocks instead of general anesthesia. [Orthopedics. 2020;43(6):e549–e552.]

Abstract

Distal radius repair is a common orthopedic surgery often performed at outpatient surgical centers. To date, little is known regarding optimal pain control in this setting. In this study, the authors evaluated patients who underwent distal radius open reduction and internal fixation (ORIF) in an outpatient surgery center setting. Comparisons between 2 surgical groups, peripheral nerve block without general anesthesia vs general anesthesia only, were recorded in terms of postoperative length of stay (LOS) in phase I, total LOS, and patient-reported pain level at discharge. The authors identified 80 patients undergoing distal radius ORIF from March to August 2016. A total of 37 (46.3%) patients received general anesthesia only and 43 (53.8%) patients received peripheral nerve block without general anesthesia. Overall, patients in the nerve block only group showed a statistically significant decrease in pain at discharge, as well as decreased phase I and total LOS. Although the power of the data is low relative to the number of distal radius procedures performed every year, there is a trend of better pain control and decreased LOS when using nerve blocks instead of general anesthesia. [Orthopedics. 2020;43(6):e549–e552.]

Distal radius fractures are one of the most common orthopedic injuries that frequently require surgical fixation. Improvements in postoperative pain control following distal radius repair provide the potential to not only increase patient satisfaction but also to decrease length of stay (LOS) and thus lower health care costs.1 Several studies have shown the benefit of using localized nerve blocks over general anesthesia when examining postoperative complications, especially for older patients.2 However, few studies have looked at the benefits of postoperative pain control with regional nerve blocks prior to distal radius repair.

Another important aspect of postoperative pain control is the amount of pain medication needed, especially its relation to cost. One study showed there was a higher need for pain medications after surgery for general anesthesia patients than for plexus blockade patients.3 However, some blockade patients experienced rebound pain, resulting in higher pain scores longer after their surgery when compared with the general anesthesia group. In addition to pain management after surgery, several studies have shown increased drug costs from general anesthesia patients vs regional anesthesia or plexus blockade patients.1 Although pain management is of utmost importance to ensure patient satisfaction and recovery, the cost should be considered when functional differences are negligible, especially in a busy outpatient setting. Length of stay can be affected not only by additional pain medications needed in the postanesthesia care unit, but the effects of general anesthesia or other drugs on a patient.

In this study, the authors attempted to evaluate pain control differences and LOS after distal radius repair in patients receiving regional nerve blocks vs those receiving general anesthesia only, specifically in the same-day surgery setting. They hypothesized that providing regional nerve blocks will improve both postoperative pain control and decrease LOS when compared with general anesthesia in patients undergoing distal radius repair.

Materials and Methods

The authors performed a nonrandomized, consecutive review in which 82 patients undergoing distal radius open reduction and internal fixation from March through August 2016 were placed into 1 of 2 groups: peripheral nerve block without general anesthesia vs general anesthesia only. Two patients were excluded from the study, 1 in each group. The first was excluded from the no–nerve block group due to hospital transfer for unrelated medical reasons. The second patient was excluded from the nerve block group due to patient’s request to rest in phase II. This left a total of 80 participating patients, 37 in the no–nerve block group and 43 in the block group.

All surgeries were performed by 1 of 16 different board-certified hand surgeons in an outpatient surgery center setting. The decision of whether to place a nerve block was based solely on surgeon preference. The nerve blocks were performed by 25 different anesthesiologists using either 0.5% bupivacaine with or without epinephrine or 0.5% ropivacaine with or without epinephrine. Two patients received axillary nerve blocks, 2 patients received interscalene, and 39 patients received supraclavicular blocks. The type and location of the anesthetic administration was based on anesthesiologist preference. The authors measured postoperative LOS in phase I, total LOS, block-related complications, and patient-reported pain level at discharge. Also recorded was the type and amount of pain medication given postoperatively in the postanesthesia care unit. Recovery phases were defined by the American Society of PeriAnesthesia Nurses criteria, which include adequacy of airway and ventilatory status, cardiac and hemodynamic stability, normothermia, management of pain and comfort, integrity of surgical wound and dressings, and fluid balance.4 After surgery, patients were admitted to the postanesthesia care unit for a minimum of 30 minutes and discharged from the day surgery unit using the postanesthesia discharge criteria.5 Pain levels at discharge were reported on a scale of 0 to 10. The 2 groups’ mean phase I LOS times, total LOS times, and pain levels at discharge were then compared using standard t test analysis. P<.05 was considered statistically significant.

Results

A total of 80 patients were part of the study, 37 (46.3%) in the no–nerve block group and 43 (53.8%) in the nerve block group. Patients in the nerve block group showed a statistically significant decrease in postoperative pain at discharge as well as decreased phase I and total LOS. Mean postoperative pain score was 0.932±1.981 in the block group vs 3.93±2.780 in the general anesthesia group, with a mean difference of 3.0024 (P<.0001) (Figure 1). Mean phase I LOS was 37.27±12.79 minutes in the block group vs 71.21±33.12 minutes in the no–nerve block group, with a mean difference of 33.938 minutes (P<.0001) (Figure 2). Total LOS differed between the 2 groups as well, with a mean of 72.12±23.45 minutes in the nerve block group vs 109.18±59.48 minutes in the no–nerve block group, with a mean difference of 37.068 minutes (P<.0001) (Tables 12). There was 1 minor complication to the nerve block: short-lasting skin irritation at the site of injection. This resolved prior to hospital discharge. No other nerve block–related complications were noted.

Patient-reported pain at discharge based on numerical analog scale score from 0 to 10, with 10 being most severe.

Figure 1:

Patient-reported pain at discharge based on numerical analog scale score from 0 to 10, with 10 being most severe.

Total length of stay (LOS) for patients receiving nerve block vs those who did not.

Figure 2:

Total length of stay (LOS) for patients receiving nerve block vs those who did not.

95% Confidence Intervals for Phase I Length of Stay, Total Length of Stay, and Pain Level at Discharge for Nerve Block Versus No–Nerve Block Groups

Table 1:

95% Confidence Intervals for Phase I Length of Stay, Total Length of Stay, and Pain Level at Discharge for Nerve Block Versus No–Nerve Block Groups

Phase I Length of Stay, Total Length of Stay, and Pain Level at Discharge for Nerve Block Versus No–Nerve Block Groups

Table 2:

Phase I Length of Stay, Total Length of Stay, and Pain Level at Discharge for Nerve Block Versus No–Nerve Block Groups

Discussion

Distal radius repair is one of the most commonly performed surgeries in orthopedics. Yet, there is still debate over the optimal pain management strategy for postoperative pain control. The aim of this study was to evaluate postoperative pain control and LOS following distal radius repair. This was compared with the outcomes with previous literature while being done in the setting of a busy same-day surgical center.

Several studies have evaluated the benefit of regional pain block modalities for the treatment postoperative pain control following upper extremity surgery. Hustedt et al2 recently showed that avoiding general anesthesia with the use of regional nerve block prior to hand surgery significantly reduced postoperative complications, especially for those patients older than 65 years. In another study, Galos et al3 compared general vs regional anesthesia for distal radius fracture repair. They also found that immediate postoperative pain was reduced in patients treated with regional anesthesia when compared with general anesthesia. However, they found an increase in pain in the block group at 12 hours postoperatively when compared with the general anesthesia group, highlighting the significance of rebound pain. This is an important issue when using peripheral nerve blocks and, although not specifically highlighted in the current study, should remain an important aspect of the preoperative discussion with the patient. Rebound pain should be anticipated and the proper arrangements should be made to help control this. These include patient education and additional pain management modalities such as sufficient oral pain medications.

Chan et al1 evaluated postoperative pain control with the use of 3 different modalities, including general anesthesia, brachial plexus block, and intravenous regional anesthesia. They reported improved postoperative pain scores in both the intravenous regional anesthesia and brachial plexus block groups when compared with general anesthesia. In addition, they also reported less nausea and vomiting postoperatively in the intravenous regional anesthesia and brachial plexus block groups when compared with the general anesthesia group.

Postoperative LOS remains an important factor with the current environment of closely monitored surgical quality metrics. One can argue this is especially true in the same-day surgery setting. The current results show a significant improvement in phase I and total LOS in patients receiving nerve blocks. Galos et al3 showed similar results in their study evaluating LOS. They found a decreased recovery time in the nerve block group without differences in operative suite time.5 However, the operative suite time likely depends on the individual hospital setting, hospital system, and the anesthesia team performing the blocks. This was highlighted by the study by Chan et al,1 in which they found increased operative suite times by nearly 18 minutes. They also found no improvement in LOS times with the block group, but attributed this to the lack of a fast-track system at their facility in which patients would have the ability to bypass the postanesthesia care unit, thus reducing postoperative times. This is a key point when evaluating operative suite and LOS times and highlights the importance of preoperative anesthesia coordination and planning.

This study had several limitations, the first of which is the inherent limitations of the retrospective nature of the study. Second, the type of peripheral nerve block (ie, mixture of anesthetic) and locations (supraclavicular, axillary, or interscalene) of the blocks was left up to the discretion of the attending anesthesiologist and was not standardized to 1 location or mixture, thus leading to possible confounding results. The average time needed for performing the nerve blocks was not recorded. This would likely increase the total LOS in the nerve block group. Finally, based on the large number of anesthesiologists included in the study, one can assume a variation of experience and skill when it comes to performing the nerve blocks. However, if anything, this would more likely favor the general anesthesia group, leading to an even larger actual difference between groups.

Conclusion

The results of this study showed that peripheral nerve blocks prior to distal radius repair significantly lower pain scores at discharge and decrease LOS. On the basis of these results, the authors recommend the use of peripheral nerve block prior to distal radius repair in the outpatient surgery center setting to improve postoperative pain and decrease LOS.

References

  1. Chan VW, Peng PW, Kaszas Z, et al. A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis. Anesth Analg. 2001;93(5):1181–e1184. doi:10.1097/00000539-200111000-00025 [CrossRef]
  2. Hustedt JW, Chung A, Bohl DD, Olmschied N, Edwards SG. Comparison of postoperative complications associated with anesthetic choice for surgery of the hand. J Hand Surg Am. 2017;42(1):1–8. doi:10.1016/j.jhsa.2016.10.007 [CrossRef] PMID:27856100
  3. Galos DK, Taormina DP, Crespo A, et al. Does brachial plexus blockade result in improved pain scores after distal radius fracture fixation? A randomized trial. Clin Orthop. 2016;474(5):1247–1254.
  4. American Society of PeriAnesthesia Nurses. (2015). 2015–2017 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses.
  5. Chung F. Recovery pattern and home-readiness after ambulatory surgery. Anesth Analg. 1995;80(5):896–902. PMID:7726431

95% Confidence Intervals for Phase I Length of Stay, Total Length of Stay, and Pain Level at Discharge for Nerve Block Versus No–Nerve Block Groups

Parameter95% Confidence Interval
Length of stay phase I, min
  Nerve block33.81–41.58
  No nerve block60.32–82.10
Total length of stay, min
  Nerve block64.90–79.33
  No nerve block89.64–128.73
Pain level at discharge
  Nerve block0.338–1.569
  No nerve block3.020–4.848

Phase I Length of Stay, Total Length of Stay, and Pain Level at Discharge for Nerve Block Versus No–Nerve Block Groups

ParameterNo.MeanSDStandard Error of the Mean
Phase I length of stay, min
  No nerve block3871.2133.1285.374
  Nerve block4437.2712.7891.928
Total length of stay, min
  No nerve block38109.1859.4759.648
  Nerve block4372.1223.4533.577
Pain level at discharge
  No nerve block383.9342.78070.4511
  Nerve block440.9321.98130.2987
Authors

The authors are from the Department of Orthopedics (PJ, JH, RC), University of Arizona College of Medicine; Gateway Surgical Center (TM); and TOCA Orthopedics (EL), Phoenix, Arizona.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Pierce Johnson, MD, Department of Orthopedics, University of Arizona College of Medicine, 1320 N 10th St, Ste A, Phoenix, AZ 85006 ( Pierce.johnson@bannerhealth.com).

Received: April 25, 2019
Accepted: July 29, 2019
Posted Online: August 06, 2020

10.3928/01477447-20200721-14

Sign up to receive

Journal E-contents