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Think Again About That Block

Commentary on an article by Surena Namdari, MD, MSc, et al.: “Randomized Controlled Trial of Interscalene Block Compared with Injectable Liposomal Bupivacaine in Shoulder Arthroplasty”

Gupta, Ranjan MD*

doi: 10.2106/JBJS.16.01584
Commentary and Perspective
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University of California Irvine, Irvine, California

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As orthopaedic surgeons are increasingly being evaluated for patient satisfaction scores, managing postoperative pain is critical. Although surgeons are not alone in this undertaking, they are an integral part of the decision-making process of how patient pain is managed. Over recent years, there has been an increased use of image-guided interscalene brachial plexus blockade for managing pain with inpatient shoulder surgical procedures. Although there are certain benefits associated with interscalene brachial plexus blockade, including presumed decreased hospital stay and reduced postoperative use of analgesics, there are also issues associated with its use, including technical issues leading to the failure of the procedure, rebound pain, and potential complications directly caused by the procedure. More importantly, there is an inability to assess the patient’s neurologic function after the surgical procedure.

As an alternative, bupivacaine liposome injectable suspension is a local analgesic that is approved by the U.S. Food and Drug Administration (FDA) for administration into the surgical site. Although there has been some early literature detailing its use in hip and knee joint replacement, this current study, “Randomized Controlled Trial of Interscalene Block Compared with Injectable Liposomal Bupivacaine in Shoulder Arthroplasty,” by Namdari et al. details the results from a prospective, non-blinded, randomized controlled trial with clearly defined end points of in-hospital pain scores and postoperative analgesic consumption within the first 24 hours for specific diagnoses relevant to shoulder arthroplasty while excluding patients with major comorbidities. An equivalent number of patients were randomized to either the interscalene brachial plexus blockade group or the bupivacaine liposome injection group (78 patients each), with the primary outcome variable being morphine equivalent units. Namdari et al. found that patients treated with bupivacaine liposome injectable suspension required an equivalent amount of postoperative narcotics and greater intraoperative narcotics compared with patients treated with interscalene brachial plexus blockade. Moreover, although interscalene brachial plexus blockade provided improved pain scores for the first 8 hours after the surgical procedure, pain scores were worse at 24 hours.

Although the authors did not explore and compare other methods of soft-tissue infiltration, such as non-liposomal injectable bupivacaine or alternative infiltration cocktails, this study does provide clinically relevant data that are timely and relevant to the readership of JBJS. It should be noted that some might consider this technique laborious as intraoperative infiltration of 20 mL of bupivacaine liposome injectable suspension diluted in 20 mL of saline solution in 0.5-mL increments requires that 80 injections are given to deliver the 40 mL into and around the shoulder. Also, although the optimal postoperative pain regimen for shoulder arthroplasty and the cost-effectiveness of analgesic techniques require further investigation, the results from this study actually can impact day-to-day management of patients undergoing shoulder arthroplasty. In my own early clinical experience with this technique, there have been a few patients who had some early increase in narcotic use in the immediate postoperative period, but this was of no clinical importance, especially in light of the satisfaction from patients being immediately able to use the involved extremity. Moreover, both patients and orthopaedic nurses who take care of these patients in the immediate postoperative time period can readily appreciate the lack of rebound pain and the ensuing reduced time in the hospital. As such, orthopaedic surgeons who perform shoulder arthroplasty should seriously consider the use of the local delivery of bupivacaine liposome injectable suspension as a viable alternative to regional interscalene brachial plexus blockade for managing postoperative pain.

*Disclosure: The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (

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