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A prospective randomized trial to identify the optimal postoperative pain management in shoulder arthroplasty: liposomal bupivacaine vs. continuous peripheral nerve block
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placement. The screw length used for both placement locations was measured. The distal humerus and proximal radius were then potted in PVC pipe with plater. The proximal radius was attached to the load cell and crosshead of an Instron testing machine. The distal humerus was attached to the baseplate of the testing machine such that the elbow was in 20° flexion. Cyclic axial load was applied to the fixed lateral condylar fragment through the radial head in 20N increments for 10 cycles up until 200N followed by load to failure. Biomechanical variables were compared between posterior and lateral screw placement using paired t-test with P < .05. Results: Longer screws could be inserted with posterior screw placement than lateral screw placement 40.2 vs. 27.0 mm (P = .0001). There were no significant differences in stiffness and displacement for each cyclic load applied between posterior and lateral screw placement (P > .05). Posterior screw placement had significantly higher linear stiffness (283.0 N/mm vs. 259.8N/mm, P = 0 < 0001), yield load (228.4N vs. 175.0N, P = .015), energy to yield load (101.1Nmm vs. 77.4 Nmm P = .001), ultimate load (547.1N vs. 360.6N, P = .0128) and energy to ultimate load (1769.3Nmm vs. 715.3 P = .003) compared to lateral screw placement. Conclusion: Posterior screw placement with small lateral condylar fragments in intra-articular distal humerus fractures demonstrates superior biomechanical properties compared to lateral screw placement, and may be preferable for fixation of these fragments.
Paper #13 HEMIARTHROPLASTY FOR THE TREATMENT OF DISTAL HUMERUS FRACTURES: MID-TERM CLINICAL RESULTS
Mark Schultzel, MD1, Karl B. Scheidt, MD2, Steven J. Narvy, MD3, Christopher Klein, BS1, Brian K. Lee, MD1, Evan H. Argintar, MD4, John M. Itamura, MD1, 1Kerlan Jobe Orthopaedic Clinic, Los Angeles, California, USA; 2Clement J. Zablocki VA Medical Center, Milwaukee, WI, USA; 3Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; 4MedStar Washington Hospital Center, Washington, DC, USA Introduction: Total elbow arthroplasty is the current gold standard of treatment for unreconstructable distal humerus fractures; however, longevity of the implant remains a concern in younger, more active patients. Distal humerus hemiarthroplasty offers an alternative and may allow for more durable results. Materials and Methods: This is a retrospective study of 10 patients who underwent elbow hemiarthroplasty for distal humerus fractures over a fouryear period (2008-2012) by a single surgeon. Patients were followed clinically with testing of range of motion, Mayo Elbow, DASH, VAS, SANE, and ASES scores. The average patent age at surgery was 71.9 years (range 56-81 years) with the average follow-up of 73.2 months (range 36-96 mo.). Results: At final follow-up, the patients maintained improvements in Mayo Elbow scores (mean 89.23, range 75100) and DASH scores (mean 33.71, range 11.2-55.1), along with no significant decrease in range of motion in comparison to testing done at 1 year after surgery. Mean VAS score was 2.43 (range 0-5), SANE score 74.14 (range 50-100), and ASES score 72.14 (range 48.33-100). Participants had an average flexion of 128.7° (range: 95-142°), extension of 44.2° (range: 0-90°), supination of 79.1° (range: 45-90°), and pronation of 73.3° (range: 50-90°). All patients were nonsmokers and all patients except for one stated that they would have the surgery again in hindsight. No post-operative elbow dislocations or subluxations were observed. No cases of heterotopic ossification were observed. Complications included one fracture and one complaint of prominent hardware. Two patients were deceased and one other patient in the study was lost to follow-up. Conclusion: This mid-term review suggests that distal humerus hemiarthroplasty may be an effective treatment for certain distal humerus fractures. The data suggest that elbow range of motion and functional use of the elbow are maintained from comparison with shortterm studies. Additional studies must be conducted to further define
J Shoulder Elbow Surg 2017
the role of elbow hemiarthroplasty for the treatment of complex fractures of the distal humerus.
Paper #14 A PROSPECTIVE RANDOMIZED TRIAL TO IDENTIFY THE OPTIMAL POSTOPERATIVE PAIN MANAGEMENT IN SHOULDER ARTHROPLASTY: LIPOSOMAL BUPIVACAINE VS. CONTINUOUS PERIPHERAL NERVE BLOCK
Vani J. Sabesan, MD, Rajin Shahriar, MD, Graysen Petersen-Fitts, MD, Therese Bou-Akl, PhD, Beaumont Health, Wayne State University School of Medicine, Taylor, Michigan, USA Background: Shoulder arthroplasty is the fastest growing joint replacement surgery in the U.S therefore optimal postoperative pain management is critical. Effective postoperative pain management have been correlated with early mobilization and rehabilitation which are proven factors that lead to better patient satisfaction and clinical outcomes. Because current pain management schemes are suboptimal for shoulder arthroplasty Liposomal bupivacaine (Exparel) may be considered a promising new agent that has yet been untested in shoulder. The purpose of this study was assess the impact of liposomal Bupivacaine compared to standard of care continuous peripheral nerve catheter in terms of postoperative pain control and outcomes after shoulder arthroplasty surgery. We will evaluate the potential promises of liposomal bupivacaine to address many of the shortcomings associated with interscalene blocks, including a favorable safety profile, decreased cost, increased duration of effect, and a potential improvement in functional outcomes and faster return to activities of daily living. Methods: A prospective randomized controlled clinical trial compared 65 consecutive patients undergoing shoulder arthroplasty treated with peripheral catheter versus Exparel. All patients received multimodal standard of care preoperative and postoperative anesthesia including celecoxib and tylenol. Patients in Group 1 received a continuous interscalane peripheral nerve block (CISB) with 0.125% bupivacaine at a rate of 6 ml/hour postoperatively. Patients in Group 2 received a single shot peripheral nerve block with Exparel. Patients in Group 2 also received local tissue infiltration with liposomal bupivacaine intra-operatively. The primary outcome measures included pain assessment every 2 hours after surgery using the Numeric Ranking Scale (NRS) for pain (0 = nopain, 10 = worst pain) for up to 48 hours after surgery or until discharge; in addition, all doses and times of narcotics administered during the inpatient stay were recorded. Following discharge, telephone surveys were conducted at 2 and 7 days to assess pain and narcotic usage. Follow up postoperative assessments included patient reported functional outcome scores (PENN, ASES, and SSV scores) at 6 weeks, 3 months, and 6 months postoperatively. Results: A total of 65 consecutive patients who underwent shoulder arthroplasty were included in the study with 33 patients in Group 1and 32 patients in Group 2 with an average age of 62.7 years old. Demographic variables were similar between the two groups (16 females in Group 1 vs. 15 males; 10 females in Group 2 vs. 21 males; average age 66.6 years in Group 1 and 62.5 years in Group 2). The exparel group had equivalent narcotic usage, pain scores and time to first narcotic rescue does compared to CISB group P > .05. In addition there was no significant difference in postoperative ASES, PENN, and SSV outcome scores between groups (P > .05). There was no significant difference in length of stay between groups and a significant increased number of complications and cost for the CISB group compared to the Exparel group (P > .05). Conclusion: Liposomal bupivacaine appears to be equivalent to gold standard continuous interscalene peripheral catheter in terms of postoperative pain relief, narcotic usage, length of stay and time to rescue narcotic for shoulder arthroplasty patients. Our results demonstrated a lower complication rate and decreased cost for liposomal bupivacaine over CISB for postoperative pain relief after shoulder arthroplasty. Future studies should focus on benefits of optimal pain relief in terms of postoperative rehabilitation and long term outcomes for patients undergoing shoulder arthroplasty surgery.
placement. The screw length used for both placement locations was measured. The distal humerus and proximal radius were then potted in PVC pipe with plater. The proximal radius was attached to the load cell and crosshead of an Instron testing machine. The distal humerus was attached to the baseplate of the testing machine such that the elbow was in 20° flexion. Cyclic axial load was applied to the fixed lateral condylar fragment through the radial head in 20N increments for 10 cycles up until 200N followed by load to failure. Biomechanical variables were compared between posterior and lateral screw placement using paired t-test with P < .05. Results: Longer screws could be inserted with posterior screw placement than lateral screw placement 40.2 vs. 27.0 mm (P = .0001). There were no significant differences in stiffness and displacement for each cyclic load applied between posterior and lateral screw placement (P > .05). Posterior screw placement had significantly higher linear stiffness (283.0 N/mm vs. 259.8N/mm, P = 0 < 0001), yield load (228.4N vs. 175.0N, P = .015), energy to yield load (101.1Nmm vs. 77.4 Nmm P = .001), ultimate load (547.1N vs. 360.6N, P = .0128) and energy to ultimate load (1769.3Nmm vs. 715.3 P = .003) compared to lateral screw placement. Conclusion: Posterior screw placement with small lateral condylar fragments in intra-articular distal humerus fractures demonstrates superior biomechanical properties compared to lateral screw placement, and may be preferable for fixation of these fragments.
Paper #13 HEMIARTHROPLASTY FOR THE TREATMENT OF DISTAL HUMERUS FRACTURES: MID-TERM CLINICAL RESULTS
Mark Schultzel, MD1, Karl B. Scheidt, MD2, Steven J. Narvy, MD3, Christopher Klein, BS1, Brian K. Lee, MD1, Evan H. Argintar, MD4, John M. Itamura, MD1, 1Kerlan Jobe Orthopaedic Clinic, Los Angeles, California, USA; 2Clement J. Zablocki VA Medical Center, Milwaukee, WI, USA; 3Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; 4MedStar Washington Hospital Center, Washington, DC, USA Introduction: Total elbow arthroplasty is the current gold standard of treatment for unreconstructable distal humerus fractures; however, longevity of the implant remains a concern in younger, more active patients. Distal humerus hemiarthroplasty offers an alternative and may allow for more durable results. Materials and Methods: This is a retrospective study of 10 patients who underwent elbow hemiarthroplasty for distal humerus fractures over a fouryear period (2008-2012) by a single surgeon. Patients were followed clinically with testing of range of motion, Mayo Elbow, DASH, VAS, SANE, and ASES scores. The average patent age at surgery was 71.9 years (range 56-81 years) with the average follow-up of 73.2 months (range 36-96 mo.). Results: At final follow-up, the patients maintained improvements in Mayo Elbow scores (mean 89.23, range 75100) and DASH scores (mean 33.71, range 11.2-55.1), along with no significant decrease in range of motion in comparison to testing done at 1 year after surgery. Mean VAS score was 2.43 (range 0-5), SANE score 74.14 (range 50-100), and ASES score 72.14 (range 48.33-100). Participants had an average flexion of 128.7° (range: 95-142°), extension of 44.2° (range: 0-90°), supination of 79.1° (range: 45-90°), and pronation of 73.3° (range: 50-90°). All patients were nonsmokers and all patients except for one stated that they would have the surgery again in hindsight. No post-operative elbow dislocations or subluxations were observed. No cases of heterotopic ossification were observed. Complications included one fracture and one complaint of prominent hardware. Two patients were deceased and one other patient in the study was lost to follow-up. Conclusion: This mid-term review suggests that distal humerus hemiarthroplasty may be an effective treatment for certain distal humerus fractures. The data suggest that elbow range of motion and functional use of the elbow are maintained from comparison with shortterm studies. Additional studies must be conducted to further define
J Shoulder Elbow Surg 2017
the role of elbow hemiarthroplasty for the treatment of complex fractures of the distal humerus.
Paper #14 A PROSPECTIVE RANDOMIZED TRIAL TO IDENTIFY THE OPTIMAL POSTOPERATIVE PAIN MANAGEMENT IN SHOULDER ARTHROPLASTY: LIPOSOMAL BUPIVACAINE VS. CONTINUOUS PERIPHERAL NERVE BLOCK
Vani J. Sabesan, MD, Rajin Shahriar, MD, Graysen Petersen-Fitts, MD, Therese Bou-Akl, PhD, Beaumont Health, Wayne State University School of Medicine, Taylor, Michigan, USA Background: Shoulder arthroplasty is the fastest growing joint replacement surgery in the U.S therefore optimal postoperative pain management is critical. Effective postoperative pain management have been correlated with early mobilization and rehabilitation which are proven factors that lead to better patient satisfaction and clinical outcomes. Because current pain management schemes are suboptimal for shoulder arthroplasty Liposomal bupivacaine (Exparel) may be considered a promising new agent that has yet been untested in shoulder. The purpose of this study was assess the impact of liposomal Bupivacaine compared to standard of care continuous peripheral nerve catheter in terms of postoperative pain control and outcomes after shoulder arthroplasty surgery. We will evaluate the potential promises of liposomal bupivacaine to address many of the shortcomings associated with interscalene blocks, including a favorable safety profile, decreased cost, increased duration of effect, and a potential improvement in functional outcomes and faster return to activities of daily living. Methods: A prospective randomized controlled clinical trial compared 65 consecutive patients undergoing shoulder arthroplasty treated with peripheral catheter versus Exparel. All patients received multimodal standard of care preoperative and postoperative anesthesia including celecoxib and tylenol. Patients in Group 1 received a continuous interscalane peripheral nerve block (CISB) with 0.125% bupivacaine at a rate of 6 ml/hour postoperatively. Patients in Group 2 received a single shot peripheral nerve block with Exparel. Patients in Group 2 also received local tissue infiltration with liposomal bupivacaine intra-operatively. The primary outcome measures included pain assessment every 2 hours after surgery using the Numeric Ranking Scale (NRS) for pain (0 = nopain, 10 = worst pain) for up to 48 hours after surgery or until discharge; in addition, all doses and times of narcotics administered during the inpatient stay were recorded. Following discharge, telephone surveys were conducted at 2 and 7 days to assess pain and narcotic usage. Follow up postoperative assessments included patient reported functional outcome scores (PENN, ASES, and SSV scores) at 6 weeks, 3 months, and 6 months postoperatively. Results: A total of 65 consecutive patients who underwent shoulder arthroplasty were included in the study with 33 patients in Group 1and 32 patients in Group 2 with an average age of 62.7 years old. Demographic variables were similar between the two groups (16 females in Group 1 vs. 15 males; 10 females in Group 2 vs. 21 males; average age 66.6 years in Group 1 and 62.5 years in Group 2). The exparel group had equivalent narcotic usage, pain scores and time to first narcotic rescue does compared to CISB group P > .05. In addition there was no significant difference in postoperative ASES, PENN, and SSV outcome scores between groups (P > .05). There was no significant difference in length of stay between groups and a significant increased number of complications and cost for the CISB group compared to the Exparel group (P > .05). Conclusion: Liposomal bupivacaine appears to be equivalent to gold standard continuous interscalene peripheral catheter in terms of postoperative pain relief, narcotic usage, length of stay and time to rescue narcotic for shoulder arthroplasty patients. Our results demonstrated a lower complication rate and decreased cost for liposomal bupivacaine over CISB for postoperative pain relief after shoulder arthroplasty. Future studies should focus on benefits of optimal pain relief in terms of postoperative rehabilitation and long term outcomes for patients undergoing shoulder arthroplasty surgery.