, Volume 472, Issue 5, pp 1482-1488
Date: 29 Oct 2013

Peripheral Nerve Blocks in Shoulder Arthroplasty: How Do They Influence Complications and Length of Stay?

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Regional anesthesia has proven to be a highly effective technique for pain control after total shoulder arthroplasty. However, concerns have been raised about the safety of upper-extremity nerve blocks, particularly with respect to the incidence of perioperative respiratory and neurologic complications, and little is known about their influence, if any, on length of stay after surgery.


Using a large national cohort, we asked: (1) How frequently are upper-extremity peripheral nerve blocks added to general anesthesia in patients undergoing total shoulder arthroplasty? (2) Are there differences in the incidence of and adjusted risk for major perioperative complications and mortality between patients receiving general anesthesia with and without nerve blocks? And (3) does resource utilization (blood product transfusion, intensive care unit admission, length of stay) differ between groups?


We searched a nationwide discharge database for patients undergoing total shoulder arthroplasty under general anesthesia with or without addition of a nerve block. Groups were compared with regard to demographics, comorbidities, major perioperative complications, and length of stay. Multivariable logistic regressions were performed to measure complications and resource use. A negative binomial regression was fitted to measure length of stay.


We identified 17,157 patients who underwent total shoulder arthroplasty between 2007 and 2011. Of those, approximately 21% received an upper-extremity peripheral nerve block in addition to general anesthesia. Patients receiving combined regional-general anesthesia had similar mean age (68.6 years [95% CI: 68.2–68.9 years] versus 69.1 years [95% CI: 68.9–69.3 years], p < 0.0043), a slightly lower mean Deyo (comorbidity) index (0.87 versus 0.93, p = 0.0052), and similar prevalence of individual comorbidities, compared to those patients receiving general anesthesia only. Addition of regional anesthesia was not associated with different odds ratios for complications, transfusion, and intensive care unit admission. Incident rates for length of stay were also similar between groups (incident rate ratio = 0.99; 95% CI: 0.97–1.02; p = 0.467)


Addition of regional to general anesthesia was not associated with an increased complication profile or increased use of resources. In combination with improved pain control as known from previous research, regional anesthesia may represent a viable management option for shoulder arthroplasty. However, further research is necessary to better clarify the risk of neurologic complications.

Level of Evidence

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Each author certifies that he or she, or a member of his or her immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. The institution of one of the authors (SGM) has received, during the study, funding from the Anna-Maria and Stephen Kellen Physician-Scientist Career Development Award provided by the Hospital for Special Surgery. One or more of the authors (RR, YLC, XS, MM) has received, during the study, funding from the Clinical Translational Science Center (Weill Medical College of Cornell University, New York, NY, USA) (RR, YLC, XS, MM); National Center for Advancing Translational Sciences (Rockville, MD, USA) (Grant UL1-RR024996) (MM); and Center for Education and Research on Therapeutics, Agency for Healthcare Research and Quality (Rockville, MD, USA) (Grant U18 HSO16-75) (MM). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Advancing Translational Sciences and Agency for Healthcare Research and Quality.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
Analysis of Premier database files was performed at Weill Medical College of Cornell University, New York, NY, USA.