Abstract
Introduction
Regional anaesthesia (RA) is often used in shoulder surgery because it provides adequate postoperative analgesia and may enhance the patient outcome. RA reduces overall opioid consumption and is frequently used in enhanced recovery programs to decrease hospital stay. However, there is very limited literature confirming these advantages in the surgical repair of proximal humerus fractures. This paper reviews the current literature on the use of RA in pain management after surgical repair of these fractures and evaluates the effect of RA on the functional outcome, length of stay in hospital, and health care expenditure.
Materials and methods
The PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to March 1, 2018. Studies investigating the use of RA in the management of proximal humerus fractures were included.
Results
Eleven studies (containing 1872 patients) were eligible for inclusion. The analgesic effect of RA was investigated in eight studies that confirmed its pain-relieving ability. Two studies measured functionality and length of hospitalization and suggested that RA improved function and shortened the stay in hospital. Nine papers mentioned side effects associated with RA while three articles claim that RA decreases the incidence of adverse events associated with general anaesthesia.
Conclusions
This systematic review suggests that RA is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anaesthesia alone. However, given the limited amount of data available, conclusions need to be made with caution and prospective studies are needed in the future.
Similar content being viewed by others
Abbreviations
- RA:
-
Regional anaesthesia
- ISB:
-
Interscalene nerve block
- ERPs:
-
Enhanced recovery programs
- LOS:
-
Length of stay
- RCTs:
-
Randomized controlled trials
- GA:
-
General anaesthesia
- PONV:
-
Postoperative nausea and vomiting
- DASH:
-
Disabilities of the arm, shoulder, and hand
- PACU:
-
Post-anaesthesia care unit
References
Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH, Groenwold RHH, Houwert RM (2018) Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elb Surg 27:1526–1534. https://doi.org/10.1016/j.jse.2018.03.009
Schumaier A, Grawe B (2018) Proximal humerus fractures: evaluation and management in the elderly patient. Geriatr Orthop Surg Rehabil 9:1–11. https://doi.org/10.1177/2151458517750516
Handoll H, Brorson S (2015) Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 11:1. https://doi.org/10.1002/14651858.CD000434.pub4
Palvanen M, Kannus P, Niemi S, Parkkari J (2006) Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 442:87–92. https://doi.org/10.1097/01.blo.0000194672.79634.78
Cvetanovich GL, Frank RM, Chalmers PN, Verma NN, Nicholson GP, Romeo AA (2016) Surgical management of proximal humeral fractures: the emerging role of reverse total shoulder arthroplasty. Orthopedics 39:e465–473. https://doi.org/10.3928/01477447-20160324-02
Beaudet V, Williams SR, Tetreault P, Perrault M-A (2008) Perioperative interscalene block versus intra-articular injection of local anesthetics for postoperative analgesia in shoulder surgery. Reg Anesth Pain Med 33:134–138. https://doi.org/10.1016/j.rapm.2007.10.005
Egol KA, Forman J, Ong C, Rosenberg A, Karia R, Zuckerman JD (2014) Regional anesthesia improves outcome in patients undergoing proximal humerus fracture repair. Bull Hosp Joint Dis 72:231–236
Misamore G, Webb B, McMurray S, Sallay P (2011) A prospective analysis of interscalene brachial plexus blocks performed under general anesthesia. J Shoulder Elb Surg 20:308–314. https://doi.org/10.1016/j.jse.2010.04.043
Nallam SR (2014) Interscalene brachial plexus block: comparison of efficacy of varying doses of dexamethasone combined with levobupivacaine: a double-blind randomised trial. J Evol Med Dent Sci 3:6900–6908. https://doi.org/10.14260/jemds/2014/2836
Gharabawy R, Abd-Elsayed A, Elsharkawy H, Farag E, Cummings K, Eid G, Mendoza M, Mounir-Soliman L, Rosenquist R, Ali Sakr Esa W (2014) The Cleveland clinic experience with supraclavicular and popliteal ambulatory nerve catheters. Sci World J 5:5. https://doi.org/10.1155/2014/572507
Yuan L, Tang W, Fu G, Wang J, Guo J, Chen WT (2014) Combining interscalene brachial plexus block with intravenous-inhalation combined anesthesia for upper extremity fractures surgery: a randomized controlled trial. Int J Surg 12:1484–1488. https://doi.org/10.1016/j.ijsu.2014.10.011
Nielsen KC, Steele SM (2002) Outcome after regional anaesthesia in the ambulatory setting—Is it really worth it? Best Pract Res Clin Anaesthesiol 16:145–157. https://doi.org/10.1053/bean.2002.0244
Grosh T, Elkassabany NM (2018) Enhanced recovery after shoulder arthroplasty. Anesthesiol Clin 36:417–430. https://doi.org/10.1016/j.anclin.2018.04.006
Tayrose G, Newman D, Slover J, Jaffe F, Hunter T, Bosco J 3rd (2013) Rapid mobilization decreases length-of-stay in joint replacement patients. Bull NYU Hosp Jt Dis 71:222–226. https://doi.org/10.1308/003588413X13629960046435
Alimohammadi H, Azizi MR, Safari S, Amini A, Kariman H, Hatamabadi HR (2014) Axillary nerve block in comparison with intravenous midazolam/fentanyl for painless reduction of upper extremity fractures. Acta Med Iran 52:122–124
Weber SC, Jain R (2002) Scalene regional anesthesia for shoulder surgery in a community setting: an assessment of risk. J Bone Joint Surg Am 84:775–779
Oxlund J, Clausen AH, Venø S, Nielsen MD, Pall M, Strøm T, Toft P (2018) A randomized trial of automated intermittent ropivacaine administration vs. continuous infusion in an interscalene catheter. Acta Anaesthesiol Scand 62:85–93. https://doi.org/10.1111/aas.13011
Schwenk ES, Gandhi K, Baratta JL Torjman M, Epstein RH, Chung J, Vaghari BA, Beausang D, Bojaxhi E, Grady B (2015) Ultrasound-guided out-of-plane vs. in-plane interscalene catheters: a randomized, prospective study. Anesthesiol Pain Med 5:31111. Doi:10.5812/aapm.31111.
Flory N, Vangessel E, Donald F, Hoffmeyer P, Gamulin Z (1995) Does the addition of morphine to brachial-plexus block improve analgesia after shoulder surgery. Br J Anaesth 75:23–26. https://doi.org/10.1093/bja/75.1.23
Huang Y, Chiu F, Webb CA, Weyker PD (2017) Review of the evidence: best analgesic regimen for shoulder surgery. Pain Manag 7:405–418. https://doi.org/10.2217/pmt-2017-0013
Kessler J, Marhofer P, Hopkins PM, Hollmann MW (2015) Peripheral regional anaesthesia and outcome: lessons learned from the last 10 years. Br J Anaesth 114:728–745. https://doi.org/10.1093/bja/aeu559
Abdallah FW, Halpern SH, Aoyama K, Brull R (2015) Will the real benefits of single-shot interscalene block please stand up? A systematic review and meta-analysis. Anesth Analg 120:1114–1129. https://doi.org/10.1213/ANE.0000000000000688
Vorobeichik L, Brull R, Bowry R, Laffey JG, Abdallah FW (2018) Should continuous rather than single-injection interscalene block be routinely offered for major shoulder surgery? A meta-analysis of the analgesic and side-effects profiles. Br J Anaesth 120:679–692. https://doi.org/10.1016/j.bja.2017.11.104
Baeriswyl M, Kirkham KR, Jacot-Guillarmod A, Albrecht E (2017) Efficacy of perineural vs systemic dexamethasone to prolong analgesia after peripheral nerve block: a systematic review and meta-analysis. Br J Anaesth 119:183–191. https://doi.org/10.1093/bja/aex191
Ilfeld BM (2017) Continuous peripheral nerve blocks: an update of the published evidence and comparison with novel, alternative analgesic modalities. Anesth Analg 124:308–335. https://doi.org/10.1213/ANE.0000000000001581
Charous M, Ilfeld BM (2015) Liposome bupivacaine for postoperative analgesia: one formulation approved for clinical use within the United States. Curr Anaesthesiol Rep 5:235–242. https://doi.org/10.1007/s40140-015-0105-x
Chahar P, Cummings KC 3rd (2012) Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res 5:257–264. https://doi.org/10.2147/JPR.S27894
Nadeau M-J, Levesque S, Dion N (2013) Ultrasound-guided regional anesthesia for upper limb surgery. Can J Anesth 60:304–320. https://doi.org/10.1007/s12630-012-9874-6
Arciero RA, Taylor DC, Harrison SA, Snyder RJ, Leahy KE, Uhorchak JM (1996) Interscalene anesthesia for shoulder arthroscopy in a community-sized military hospital. Arthroscopy 12:715–719. https://doi.org/10.1016/S0749-8063(96)90176-0
Borgeat A, Ekatodramis G, Kalberer F, Benz C (2001) Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology 95:875–880
Urmey WF, Gloeggler PJ (1993) Pulmonary function changes during interscalene brachial plexus block: effects of decreasing local anesthetic injection volume. Reg Anesth 18:244–249
Borgeat A, Dullenkopf A, Ekatodramis G, Nagy L (2003) Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery. Anesthesiology 99:436–442
Borgeat A, Ekatodramis G (2002) Anaesthesia for shoulder surgery. Best Pract Res Clin Anaesthesiol 16:211–225. https://doi.org/10.1053/bean.2002.0234
Gohl MR, Moeller RK, Olson RL, Vacchiano CA (2001) The addition of interscalene block to general anesthesia for patients undergoing open shoulder procedures. J Am Assoc Nurse Anesth 69:105–109
Kettner SC, Willschke H, Marhofer P (2011) Does regional anaesthesia really improve outcome? Br J Anaesth 107:90–95. https://doi.org/10.1093/bja/aer340
Cohen MM, Duncan PG, Deboer DP, Tweed WA (1994) The postoperative interview: assessing risk factors for nausea and vomiting. Anesth Analg 78:7–16
D’Alessio J, Rosenblum M, Shea K, Freitas D (1995) A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy. Reg Anesth Pain Med 20:62–68
Flanagan C, Wysong E, Ramey JS, Vallier H (2018) Understanding the opioid epidemic: factors predictive of inpatient and postdischarge prescription opioid use after orthopaedic trauma. J Orthop Trauma 32:e408–e414. https://doi.org/10.1097/BOT.0000000000001256
Laurila PA, Lopponen A, Kanga-Saarela T, Flinkkilä T, Salomäki TE (2002) Interscalene brachial plexus block is superior to subacromial bursa block after arthroscopic shoulder surgery. Acta Anaesthesiol Scand 46:1031–1036
Borgeat A, Schappi B, Biasca N, Gerber C (1997) Patient-controlled analgesia after major shoulder surgery: patient-controlled interscalene analgesia versus patient-controlled analgesia. Anesthesiology 87:1343–1347. https://doi.org/10.1097/00000542-199712000-00013
Janssen H, von Stosch R, Poeschl R, Büttner B, Bauer M, Hinz JM, Bergmann I (2014) Blood pressure response to combined general anaesthesia/interscalene brachial plexus block for outpatient shoulder arthroscopy. BMC Anesthesiol 14:50. https://doi.org/10.1186/1471-2253-14-50
Ozzeybek D, Oztekin S, Mavioğlu O, Karaege G, Ozkardeşler S, Ozkan M, Canyilmaz M, Elar Z (2003) Comparison of the haemodynamic effects of interscalene block combined with general anaesthesia and interscalene block alone for shoulder surgery. J Int Med Res 31:428–433. https://doi.org/10.1177/147323000303100512
YaDeau JT, Liu SS, Bang H, Shaw PM, Wilfred SE, Shetty T, Gordon M (2011) Cerebral oximetry desaturation during shoulder surgery performed in a sitting position under regional anesthesia. Can J Anesth 58:986–992. https://doi.org/10.1007/s12630-011-9574-7
Ilfeld B, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Chmielewski TL, Spadoni EH, Wright TW (2006) Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology 105:999–1007
Chona D, Lakomkin N, Bulka C, Mousavi I, Kothari P, Dodd AC, Shen MS, Obremskey WT, Sethi MK (2017) Predicting the post-operative length of stay for the orthopaedic trauma patient. Int Orthop 41:859–868. https://doi.org/10.1007/s00264-017-3425-2
Ilfeld BM, Enneking FK (2005) Continuous peripheral nerve blocks at home: a review. Anesth Analg 100:1822–1833. https://doi.org/10.1213/01.ANE.0000151719.26785.86
Polanczyk CA, Marcantonio E, Goldman L, Rohde LE, Orav J, Mangione CM, Lee TH (2001) Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med 134:637–643
Ljungqvist O, Hubner M (2018) Enhanced recovery after surgery –ERAS-principles, practice and feasibility in the elderly. Aging Clin Exp Res 30:249–252
Padarura M, Ponchietti L, Casas IM, Svenningsen P, Pereira J, Landaluce-Olavarria A, Font RF, Miguel IP, Ugarte-Sierra B (2017) Enhanced Recovery After Surgery (ERAS) – The evidence in geriatric emergency surgery: A systematic review. Chirurgia 112(5):546–557
Hoekstra H, Smeets B, Metsemakers WJ, Spitz A-C, Nijs S (2017) Economics of open tibial fractures: the pivotal role of length-of-stay and infection. Health Econ Rev 7:32. https://doi.org/10.1186/s13561-017-0168-0
Menendez ME, Baker DK, Fryberger CT, Ponce BA (2015) Predictors of extended length of stay after elective shoulder arthroplasty. J Shoulder Elb Surg 24:1527–1533. https://doi.org/10.1016/j.jse.2015.02.014
Neuhaus V, Swellengrebel CHJ, Bossen JKJ, Ring D (2013) What are the factors influencing outcome among patients admitted to a hospital with a proximal humeral fracture? Clin Orthop Relat Res 471:1698–1706. https://doi.org/10.1007/s11999-013-2876-z
Acknowledgements
The authors thank Mr. Thomas Vandendriessche, biomedical information specialist (KU Leuven Libraries-2 Bergen-Learning Centre Désiré Collen, Leuven, Belgium), for his help in conducting the systematic literature search.
Funding
No funding was received.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
Prof. Dr. An Sermon is a consultant for DepuySynthes. Prof. Dr. Willem-Jan Metsemakers is a consultant for DepuySynthes and BoneSupport. Furthermore, he is a member of the lecture bureau of Zimmer Biomet. Prof. Dr. Stefaan Nijs is consultant for DepuySynthes, Zimmer Biomet and Mathys Medical. Prof. Dr. Harm Hoekstra is a member of the lecture bureau of DepuySynthes and 7Smedical. All authors hereby disclose any financial and personal relationships with other people or organisations that could inappropriately influence this work.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Iliaens, J., Metsemakers, WJ., Coppens, S. et al. Regional anaesthesia for surgical repair of proximal humerus fractures: a systematic review and critical appraisal. Arch Orthop Trauma Surg 139, 1731–1741 (2019). https://doi.org/10.1007/s00402-019-03253-0
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00402-019-03253-0