Perspective

Increased narcotic use seen after shoulder arthroplasty with interscalene block plus Exparel

Patients who received interscalene brachial plexus block plus soft tissue infiltration with Exparel when undergoing primary shoulder arthroplasty used significantly more narcotics postoperatively and had no significant reduction in pain scores in the early postoperative period compared with patients who received interscalene brachial plexus block alone, according to results published in The Journal of Bone and Joint Surgery.

“If your hospital already has a protocol where you use interscalene nerve blocks as a form of pain management after shoulder arthroplasty, then there is no value in adding liposomal bupivacaine injection during surgery to that strategy,” Surena Namdari, MD, MSc, of Rothman Orthopaedic Institute and co-author of the study, told Orthopedics Today.

Narcotic use

Namdari and his colleagues randomly assigned 78 patients undergoing primary shoulder arthroplasty to receive an interscalene brachial plexus block either alone (n=39) or with Exparel (bupivacaine liposome injectable suspension, Pacira Pharmaceuticals Inc.). Morphine equivalent units consumed over the first 24 hours after surgery was the primary outcome variable used. Intraoperative narcotic administration and VAS scale for pain were the secondary outcomes.

Surena Namdari, MD, MSc
Surena Namdari

Results showed the interscalene brachial plexus block alone and interscalene brachial plexus block plus bupivacaine liposome injectable suspension groups had no significant demographic differences. When reviewing results during the first 24 hours after surgery, results showed patients who received interscalene brachial plexus block plus bupivacaine liposome injectable suspension used more narcotics than patients who received interscalene brachial plexus block alone.

“The second key finding is that, if you look at their pain scores over the first 72 hours after surgery, they were no different,” Namdari said. “Both groups had the same pain scores, but one group used more narcotics. It is likely because they are using more narcotics to get to that same pain score.”

According to Namdari, the negative effect seen when bupivacaine liposome injection suspension was added to the blocks was surprising.

“Because the liposomal bupivacaine theoretically can last for 24 to 72 hours, we thought that we would see less narcotic utilization in that group, but we saw the opposite,” he said.

Consider other strategies

Since this study focused on the use of bupivacaine liposomal injectable suspension in shoulder replacement, Namdari noted the results are not applicable to other types of surgery.

Researchers should investigate some pain management strategies that are associated with better results after shoulder replacement, such as using an interscalene catheter, he said.

“One potential role which has recently obtained FDA approval is to use the liposomal bupivacaine as the medication that is being placed into the interscalene nerve block,” Namdari said. “It will be interesting to see whether using it in that manner will have a more beneficial impact.” – by Casey Tingle

Disclosure: Namdari reports he receives research funding from DePuy Synthes, Zimmer Biomet, Arthrex, Tornier and Integra Life Sciences; is a paid consultant for Don Joy Orthopaedics, Miami Device Solutions and DePuy Synthes; and receives royalties from Don Joy Orthopaedics, Miami Device Solutions and Elsevier.

Patients who received interscalene brachial plexus block plus soft tissue infiltration with Exparel when undergoing primary shoulder arthroplasty used significantly more narcotics postoperatively and had no significant reduction in pain scores in the early postoperative period compared with patients who received interscalene brachial plexus block alone, according to results published in The Journal of Bone and Joint Surgery.

“If your hospital already has a protocol where you use interscalene nerve blocks as a form of pain management after shoulder arthroplasty, then there is no value in adding liposomal bupivacaine injection during surgery to that strategy,” Surena Namdari, MD, MSc, of Rothman Orthopaedic Institute and co-author of the study, told Orthopedics Today.

Narcotic use

Namdari and his colleagues randomly assigned 78 patients undergoing primary shoulder arthroplasty to receive an interscalene brachial plexus block either alone (n=39) or with Exparel (bupivacaine liposome injectable suspension, Pacira Pharmaceuticals Inc.). Morphine equivalent units consumed over the first 24 hours after surgery was the primary outcome variable used. Intraoperative narcotic administration and VAS scale for pain were the secondary outcomes.

Surena Namdari, MD, MSc
Surena Namdari

Results showed the interscalene brachial plexus block alone and interscalene brachial plexus block plus bupivacaine liposome injectable suspension groups had no significant demographic differences. When reviewing results during the first 24 hours after surgery, results showed patients who received interscalene brachial plexus block plus bupivacaine liposome injectable suspension used more narcotics than patients who received interscalene brachial plexus block alone.

“The second key finding is that, if you look at their pain scores over the first 72 hours after surgery, they were no different,” Namdari said. “Both groups had the same pain scores, but one group used more narcotics. It is likely because they are using more narcotics to get to that same pain score.”

According to Namdari, the negative effect seen when bupivacaine liposome injection suspension was added to the blocks was surprising.

“Because the liposomal bupivacaine theoretically can last for 24 to 72 hours, we thought that we would see less narcotic utilization in that group, but we saw the opposite,” he said.

Consider other strategies

Since this study focused on the use of bupivacaine liposomal injectable suspension in shoulder replacement, Namdari noted the results are not applicable to other types of surgery.

Researchers should investigate some pain management strategies that are associated with better results after shoulder replacement, such as using an interscalene catheter, he said.

“One potential role which has recently obtained FDA approval is to use the liposomal bupivacaine as the medication that is being placed into the interscalene nerve block,” Namdari said. “It will be interesting to see whether using it in that manner will have a more beneficial impact.” – by Casey Tingle

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Disclosure: Namdari reports he receives research funding from DePuy Synthes, Zimmer Biomet, Arthrex, Tornier and Integra Life Sciences; is a paid consultant for Don Joy Orthopaedics, Miami Device Solutions and DePuy Synthes; and receives royalties from Don Joy Orthopaedics, Miami Device Solutions and Elsevier.

    Perspective
    Nady Hamid

    Nady Hamid

    Namdari and colleagues at Rothman Orthopaedic Institute, once again, have produced high-quality research on a relevant topic in shoulder surgery. This was a well-executed, prospective, randomized controlled trial that compared interscalene block alone with a combination of interscalene block with the use of intraoperative local liposomal bupivacaine in patients undergoing elective shoulder arthroplasty. The primary outcome variable was morphine equivalent units consumed during the first 24 hours. The authors found randomized to the interscalene block with interoperative use of liposomal bupivacaine had a significantly higher morphine equivalent usage than the group treated with interscalene block alone. The results of this study were quite surprising. The authors hypothesize there may have been a double rebound pain phenomenon in these patients. It may be quite likely that the small difference in morphine equivalent usage is not clinically significant. It would have been interesting to see if there was any difference in the usage of opioids past the 24-hour period. This study certainly leaves some unanswered questions on the optimal treatment protocol for patients undergoing shoulder arthroplasty and calls into question the efficacy of liposomal bupivacaine.

    • Nady Hamid, MD
    • Assistant professor; OrthoCarolina Shoulder and Elbow Center; Charlotte, North Carolina

    Disclosures: Hamid reports he is a consultant for Zimmer Biomet.