Local Analgesia Infiltration Techniques for Shoulder Arthroplasty

Key Points

  • The demand for shoulder arthroplasty in the United States will continue to grow.1-3
  • The success of accelerated care pathways, including outpatient surgery4 and shorter hospital stays, depends on providing dynamic pain relief, which, in turn, facilitates ambulation and rehabilitation.5-7
  • Even with opioids, postoperative pain management can be poor and lead to persistent pain and other significant complications.8
  • Opioid-sparing, multimodal analgesia should be used to provide optimal postoperative pain management, and local/regional analgesia should be its principal component, as it provides excellent dynamic pain relief.5-7,9
  • The “gold standard” for pain relief after shoulder surgery is brachial plexus block via the interscalene approach,10 which was found to significantly reduce pain scores in a systematic review of 10 studies.11
  • Other techniques for administering pain medication after shoulder surgery include the suprascapular6,10 and supra- and infra-clavicular6,7 approaches.
  • In another recent systematic review, single-injection interscalene block provided effective dynamic pain relief and pain relief at rest for up to 6 and 8 hours, respectively.12
  • Although the duration of analgesia can be prolonged by using continuous catheters,6,13-15 it can be technically challenging and logistically problematic to administer therapy using this method.10,16
  • More importantly, use of continuous catheters has been associated with serious complications (eg, central neuraxial needle placement, cervical spinal cord damage, permanent paralysis).10
  • Likewise, the use of infusion pump systems can lead to wound infection, cellulitis, and skin necrosis.17
  • Periarticular infiltration (PAI) is now being used as a principal component of multimodal analgesia,18 which has been studied extensively for knee and hip replacement surgery.9,19,20
  • Overall, PAI provides excellent pain relief; however, the technique must be properly administered to obtain maximum benefits.
  • It is essential to combine PAI with nonopioid analgesics and opioids available for rescue use.9 Moreover, an optimal multimodal pain management approach begins in the preoperative period, during which patients can be prepared, expectations can be managed, and risk factors can be identified.9
  • Based on the neuroanatomy of the shoulder, effective control of postoperative pain requires blockade of nerves innervating the synovium, capsule, articular surfaces, periosteum, ligaments, and muscles.21
  • Further research is warranted to identify optimal combinations of analgesics, as well as routes and durations of administration, to improve pain relief while minimizing adverse effects and recovery time.

Technical Notes

  • Always inject local analgesics slowly into the soft tissues of the surgical site.
    • Aspirating the site while inserting the needle and injecting the analgesic while withdrawing the needle will reduce the risk of intravascular injection.
  • Use a 20- to 30-mL syringe with a 22-gauge, 3.8- to 7.6-inch needle, which is inserted approximately 1 cm into the tissue plane (eg, capsule).
  • Use a fanning technique (ie, moving needle technique) for proper infiltration.
    • Typical injection volume for surgical site infiltration is 1–1.5 mL for every 1–1.5 cm of surgical incision per layer, or more as needed.
  • Infiltration should be meticulous and extensive, using direct visualization to perform deep (humeral insertion), mid-layer (muscle), and superficial (subcutaneous tissue, fat, skin) injections.

Recommended Injection Solutions

  • Bupivacaine liposome injectable suspension (EXPAREL®) is intended for single-dose administration only.22
    • Recommended dose will depend on the size of the surgical site, volume required to cover the area, and patient-based factors that may affect the safety of an amide local anesthetic.
  • Recommended injection solution for liposomal bupivacaine is 20 mL (266 mg) combined with bupivacaine HCl 0.25%, 30 mL (75 mg) with epinephrine and 40 mL of saline. 
    • Expected onset of analgesia is <10 minutes; expected duration of effect is up to 72 hours.22, 23

Infiltration Technique Descriptions

In a single container, mix 20 mL of bupivacaine liposome injectable suspension (EXPAREL®), 30 mL of 0.25% bupivacaine HCl with epinephrine, and 40 mL of saline, for a total volume of 90 mL.

Step 1: Deep Injections
Infiltration Technique
(Combination standard total and reverse total shoulder replacement)
Local Analgesic Volume
After preparation of the shoulder joint following glenoid insertion, but before humeral insertion, inject 30 mL (generally in 1-2 mL increments) of the solution throughout the deep structures, including soft tissue and periosteum all around the glenoid, posterior capsule, and anterior capsule, under the subscapularis muscle, and in the periosteum around the humeral side (Figure 1).30 mL
Step 2: Midlayer Injections
After insertion of the humeral component, inject 30 mL of the solution into the subscapularis muscle tendon. With standard total shoulder replacement, the subscapularis muscle requires injection. The subscapularis also requires injection with reverse total shoulder replacement, but sometimes this muscle is not repaired; in this case, the solution should be injected around the remaining tendon. Also, inject into the deltoid and pectoralis muscle bellies at the deltopectoral interval (Figure 2).30 mL
Step 3: Superficial Injections
Inject the remaining 30 mL of the solution into the subcutaneous tissue along the common anterior incision (Figure 3).30 mL

Figure 1. View of deep, humeral infiltrations (Step 1)


Figure 2. View of mid-layer, muscle/fascia infiltrations (Step 2)

Figure 3. View of superficial infiltrations (Step 3)


References

1.     Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg. 2010;19(8):1115-1120.

2.     Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254.

3.     Padegimas EM, Maltenfort M, Lazarus MD, Ramsey ML, Williams GR, Namdari S. Future patient demand for shoulder arthroplasty by younger patients: national projections. Clin Orthop Relat Res. 2015;473(6):1860-1867.

4.     Memtsoudis SG, Kuo C, Ma Y, Edwards A, Mazumdar M, Liguori G. Changes in anesthesia-related factors in ambulatory knee and shoulder surgery: United States 1996-2006. Reg Anesth Pain Med. 2011;36(4):327-331.

5.     Joshi GP, Schug SA, Kehlet H. Procedure-specific pain management and outcome strategies. Best Pract Res Clin Anaesthesiol. 2014;28(2):191-201.

6.     Lin E, Choi J, Hadzic A. Peripheral nerve blocks for outpatient surgery: evidence-based indications. Curr Opin Anaesthesiol. 2013;26(4):467-474.

7.     Salinas FV, Joseph RS. Peripheral nerve blocks for ambulatory surgery. Anesthesiol Clin. 2014;32(2):341-355.

8.     Bjornholdt KT, Brandsborg B, Soballe K, Nikolajsen L. Persistent pain is common 1-2 years after shoulder replacement. Acta Orthop. 2015;86(1):71-77.

9.     Joshi GP, Cushner FD, Barrington JW, et al. Techniques for periarticular infiltration with liposomal bupivacaine for the management of pain after hip and knee arthroplasty: a consensus recommendation. J Surg Orthop Adv. 2015;24(1):27-35.

10.  Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anaesthesia. 2010;65(6):608-624.

11.  Hughes MS, Matava MJ, Wright RW, Brophy RH, Smith MV. Interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review. J Bone Joint Surg Am. 2013;95(14):1318-1324.

12.  Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the real benefits of single-shot interscalene block please stand up? A systematic review and meta-analysis. Anesth Analg. 2015;120(5):1114-1129.

13.  Bingham AE, Fu R, Horn JL, Abrahams MS. Continuous peripheral nerve block compared with single-injection peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med. 2012;37(6):583-594.

14.  Fredrickson MJ, Ball CM, Dalgleish AJ. Analgesic effectiveness of a continuous versus single-injection interscalene block for minor arthroscopic shoulder surgery. Reg Anesth Pain Med. 2010;35(1):28-33.

15.  Salviz EA, Xu D, Frulla A, et al. Continuous interscalene block in patients having outpatient rotator cuff repair surgery: a prospective randomized trial. Anesth Analg. 2013;117(6):1485-1492.

16.  Marhofer P, Anderl W, Heuberer P, et al. A retrospective analysis of 509 consecutive interscalene catheter insertions for ambulatory surgery. Anaesthesia. 2015;70(1):41-46.

17.  Brown SL, Morrison AE. Local anesthetic infusion pump systems adverse events reported to the Food and Drug Administration. Anesthesiology. 2004;100(5):1305-1307.

18.  Ramirez MA, Ramirez JM, Murthi AM. Multimodal local infiltration analgesia in total shoulder replacement. Pain Manag. 2013;3(4):253-255.

19.  Lombardi AV, Jr. Recent advances in incorporation of local analgesics in postsurgical pain pathways. Am J Orthop (Belle Mead NJ). 2014;43 (10 Suppl):S2-S5.

20.  Vendittoli PA, Makinen P, Drolet P, et al. A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study. J Bone Joint Surg Am. 2006;88(2):282-289.

21.  Bowens C, Jr., Sripada R. Regional blockade of the shoulder: approaches and outcomes. Anesthesiol Res Pract. 2012;2012:971963.

22.  Pacira Pharmaceuticals Inc. EXPAREL (bupivacaine liposome injectable suspension) [package insert]. San Diego, CA; Pacira Pharmaceuticals, Inc.; 2015.

23.  The Management of Postoperative Pain Working Group. VHA/DoD clinical practice guideline for the management of postoperative pain. Washington, DC: U.S. Department of Veterans Affairs; 2002.

Local Analgesia Infiltration Techniques for Carpometacarpal (CMC) Joint Arthroscopy

CMC Key Points

  • In the face of ever-increasing healthcare costs, improved efficiency and shorter hospital stays are of paramount importance. In orthopaedic surgery, this corresponds to performing more procedures on an outpatient basis1 and providing optimal dynamic postoperative pain relief.2-4
  • Even with opioids, postoperative pain management can be poor and lead to persistent pain, significant complications, and decreased patient satisfaction.5,6
  • Opioid-sparing, multimodal analgesia should be used to provide optimal postoperative pain management, and local/regional analgesia should be its principal component, as it provides excellent dynamic pain relief.2-4,7
  • There is no “gold standard” for the management of acute pain after wrist/hand surgery. Indeed, in a recent systematic review on the topic, the 10 studies identified were sufficiently heterogeneous to preclude direct comparisons or statistical analysis.6
  • Periarticular infiltration (PAI) is now being used as a principal component of multimodal analgesia after shoulder8 and knee/hip2,9,10 arthroscopy.
  • In general, PAI provides excellent pain relief; however, the technique must be administered properly to produce maximum benefits.
  • It is important to combine PAI with nonopioid analgesics and to have opioids available for rescue use.2 An optimal multimodal pain management approach begins preoperatively, when patients can be prepared, expectations can be managed, and risk factors can be identified.2,7
  • In the wrist, local analgesia involves blocking three major nerves. The median nerve arises from the lateral and medial cords of the brachial plexus.11 It is the only nerve that passes through the wrist via the carpal tunnel. The ulnar nerve arises from the medial cord of the brachial plexus and passes through the wrist via Guyon’s canal.12 The radial nerve arises from the posterior cord of the brachial plexus.13
  • Based on the neuroanatomy of the wrist/hand, and owing to the lack of sufficient clinical research, the PAI technique for managing acute postoperative pain likely will undergo further development and refinement. 

CMC Technical Notes

  • Always inject local analgesics slowly into the soft tissues of the surgical site.
    • Aspirating the site while inserting the needle and injecting the analgesic while withdrawing the needle will reduce the risk of intravascular injection.
  • Use a 20- to 30-mL syringe with a 22-gauge, 3.8- to 7.6-inch needle, which is inserted approximately 1 cm into the tissue plane (eg, capsule).
  • Use a fanning technique (ie, moving needle technique) for proper infiltration.
    • Typical injection volume for surgical site infiltration is 1–1.5 mL for every 1–1.5 cm of surgical incision per layer, with more as needed.
  • Infiltration should be meticulous and extensive, using direct visualization to perform deep (humeral insertion), midlayer (muscles), and superficial (subcutaneous tissue, fat, skin) injections.

CMC Recommended Injection Solutions

  • Bupivacaine liposome injectable suspension (EXPAREL®; Pacira Pharmaceuticals, Inc., San Diego, CA) is intended for single-dose administration only.14
    • Recommended dose will depend on the size of the surgical site, volume required to cover the area, and patient-based factors that may affect the safety of an amide local anesthetic.
  • Recommended injection solutions include 20 mL of 0.5% marcaine and 20 mL of EXPAREL. 

CMC Infiltration Technique Descriptions

Pre-emptive use of 0.5% marcaine is essential 3–5 minutes before incision. The goal is to eliminate incisional pain stimulation and allow for the closing infiltration of EXPAREL®-encapsulated marcaine to have time to begin its release during the patient’s stay in the postanesthesia care unit.

Step 1 Preincision: after induction of general anesthesia, prep and drape the affected area and inject 20 mL of 0.5% marcaine into the areas listed below as follows:

Infiltration Technique

Local Analgesic Volume

Carpal tunnel (Figure 1a)5 mL
SC ring block from midline of volar wrist flexion crease to midline of dorsal wrist crease (Figure 1b)5 mL
Trapeziometacarpal joint (Figure 2a)1 mL
Scaphotrapezial joint (Figure 2a)1 mL
Volar CMC capsule and thenar muscle origin (Figure 2b)3 mL
PIN and AIN: single, dorsal needle puncture 4 cm proximal to wrist dorsal to radiocarpal joint, just ulnar to the ulnar border of the radial shaft5 mL
  • Dorsal to interosseous membrane
2.5 mL
  • Volar to interosseous membrane
2.5 mL
Step 2 Closing: after closing the volar capsule and before skin closure, inject 20 mL of undiluted/unexpanded EXPAREL as follows:
Former trapezial space (Figure 3)1 mL
Volar CMC capsule and thenar muscle origin2 mL
SC circumferentially along incisional margins2 mL
Carpal tunnel5 mL
SC ring block from midline of volar wrist flexion crease to midline of dorsal wrist crease5 mL
PIN and AIN: single, dorsal needle puncture 4 cm proximal to wrist dorsal to radiocarpal joint, just ulnar to the ulnar border of the radial shaft
  • Dorsal to interosseous membrane
2.5 mL
  • Volar to interosseous membrane
2.5 mL

AIN = anterior interosseous nerve;
CMC = carpometacarpal;
PIN = posterior interosseous nerve;
SC = subcutaneous.

Figure 1. Preincision superficial blocking with 0.5% marcaine (Step 1)


Figure 2. Preincision blocking of interosseous membrane (Step 2)