Bridging multimodal pain management provides 48-hour pain control in patients undergoing total shoulder replacement.

BACKGROUND: We report our experience with a bridging multimodal pain management program that provides comprehensive 48-hour pain control in patients undergoing total shoulder replacement (TSR). METHODS: The study included all patients undergoing unilateral TSR by 1 surgeon between May 2015 and April 2017. There were 62 patients (23 men, 39 women) with an average age of 68 years (range 38-92 years). Of these, 31 underwent standard nonconstrained TSR and 31 underwent reverse TSR. The bridging multimodal pain management protocol included scalene block regional anesthesia using 0.25% bupivacaine enhanced with 4 mg of dexamethasone, application of 20 mg of liposomal bupivacaine diluted with 40 mL of normal saline in the periarticular soft tissues at time of closure, scheduled 24 hours of intravenous acetaminophen and ketorolac, and immediate cryotherapy. Parameters measured included hospital length of stay, postoperative use of intravenous narcotics, and 30-day hospital readmission. RESULTS: The median length of stay was 1 day (range, 1-6; average, 1.5 days). Overall, 41 patients (66%) were discharged on postoperative day 1. Intravenous narcotics were required postoperatively in 22 patients (35.5%). There were no 30-day readmissions. CONCLUSION: This bridging multimodal pain management protocol resulted in a length of stay of 1 day for 66% of patients, even for higher-risk patients with American Society of Anesthesiologists Physical Status Classification III (63%). Of the 62 patients, 64% (n = 40) did not require postoperative intravenous narcotics. For properly selected patients, this program may be considered for performing TSR as an ambulatory procedure.

Diagnosis and management of massive rotator cuff tears: the surgeon's dilemma.

Several studies have documented high success rates following the surgical treatment of full-thickness rotator cuff tears. Historically, however, less favorable and predictable results have been found in the treatment of massive tears (>5 cm) compared with small and medium sized tears. Determining the most appropriate treatment for a patient with a massive rotator cuff tear can be challenging because of inconsistent outcome results. Some patients function well with nonsurgical treatment of massive tears, some have initially favorable results from surgical débridement of tears without repair that then deteriorate over time, and other patients who are surgically treated continue to maintain good function despite documented retears. Nonsurgical treatment of massive rotator cuff tears may be suitable for elderly patients with chronic tears and limited functional goals below shoulder level. Surgical débridement without repair of the tear may be considered for patients with low physical demands whose predominant symptom is pain. Surgical repair is recommended for patients who require maximal postoperative function, particularly for overhead activities. Open repairs have a lower rate of rerupture than arthroscopic repairs; however, arthroscopic repair offers the benefits of decreased morbidity and decreased risk of postoperative deltoid detachment. Early studies of arthroscopic repairs have shown good functional results; however, there has been a high incidence of retears. Tendon transfers and other reconstruction techniques may offer improvements in certain salvage cases, but results of these procedures are inferior to those for primary repair. Preservation of the coracoacromial arch should be considered in all forms of treatment of massive rotator cuff tears to avoid the devastating complication of superior humeral head escape.