Regional Anesthesia Improves Outcome in Patients Undergoing Proximal Humerus Fracture Repair

Transcription

1 Bulletin of the Hospital for Joint Diseases 2014;72(3): Regional Anesthesia Improves Outcome in Patients Undergoing Proximal Humerus Fracture Repair Kenneth A. Egol, M.D., Jordanna Forman, B.S., Crispin Ong, M.D., Andrew Rosenberg, M.D., Raj Karia, M.P.H., and Joseph D. Zuckerman, M.D. Abstract Background: The purpose of this study was to examine functional outcomes following ORIF of displaced proximal humerus fractures in patients who received brachial plexus blocks compared to those who underwent general anesthesia. Methods: We retrospectively reviewed prospectively collected data on 92 patients. Patients were grouped according to anesthesia type: regional interscalene brachial plexus block, with or without general anesthesia, or general anesthesia alone. Patients were asked to complete the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion assessments at a minimum of 6-month follow-up. Plain radiographic films were obtained to assess fracture healing. Results: Forty-five (48.9%) patients with 45 proximal humerus fractures received a regional anesthetic, while 47 (51.1%) patients with 48 proximal humerus fractures had general anesthesia. No significant differences existed in demographic information or fracture type. DASH scores at the most recent follow-up were significantly better in the regional block group (38.6) compared to the general anesthesia group (53.1) (p = 0.003). The regional block group had significantly better passive and active forward elevation and external rotation range and equivalent internal rotation (p = 0.002, 0.005, 0.002, and 0.507, respectively). Kenneth A. Egol, M.D., NYU Hospital for Joint Diseases, Langone Medical Center, New York, NY and The Jamaica Hospital Medical Center, Jamaica, New York. Jordanna Forman, B.S., Crispin Ong, M.D., Andrew Rosenberg, M.D., Raj Karia, M.P.H., and Joseph D. Zuckerman, M.D., NYU Hospital for Joint Diseases, Langone Medical Center, New York, New York. Correspondence: Kenneth A. Egol, M.D., 301 East 17th Street, Suite 1402, New York, New York 10003; Kenneth.Egol@nyumc. org. Conclusion: Patients who received regional anesthetic via a brachial plexus interscalene blocks had better functional outcomes and range of motion at the most recent clinical follow-up. Regional anesthesia provides patients with prolonged postoperative pain relief, which may allow for early mobilization, increasing the likelihood that the patient s function and range of motion will return to baseline. The preferred treatment for fractures of the proximal humerus has evolved as recent innovations have increased the range of fracture types that can be successfully treated with open reduction and internal fixation (ORIF). 1-5 The expanding number of fractures that are being treated with ORIF is partially attributed to the better prognosis of stable internal fixation compared to hemi- or total joint arthroplasty or nonoperative management. 6 Restriction of shoulder range of motion following surgical intervention for proximal humerus fracture is a feared complication and multifactorial in origin. However, early mobilization and physiotherapy have been correlated with improved shoulder function and decreased pain following fracture management. 7 Despite these findings, early mobilization and passive range of motion can be very painful, imposing limitations in the patient s ability to reach their maximum rehabilitation potential. Regional nerve block anesthesia has been found to be potentially beneficial in reducing postoperative pain. Insertion of a catheter adjacent to a nerve plexus has been shown to result in excellent muscle relaxation during operative procedures and can provide lasting analgesic effects, thereby reducing unplanned hospital admission for pain control and the need for continued postoperative use of opioids or nacotics. 8,9 Theoretically, this type of postoperative pain management could allow for more intensive early passive range of motion, thereby producing superior functional results when compared to patients that did not receive a regional nerve block. However, to date there Egol KA, Forman J, Ong C, Rosenberg A, Karia R, Zuckerman JD. Regional anesthesia improves outcome in patients undergoing proximal humerus fracture repair. Bull Hosp Jt Dis. 2014;72(3):231-6.

2 232 Bulletin of the Hospital for Joint Diseases 2014;72(3):231-6 has been no published literature examining the relationship between postoperative range of motion and function with the presence or absence of regional block anesthesia. The purpose of this study was to examine the functional outcome following ORIF of a displaced proximal humerus fracture in patients who received regional block anesthesia via a brachial plexus interscalene block compared to those who had general anesthesia for their surgery. Patients and Methods This study retrospectively reviewed prospectively collected data on 122 patients with 123 displaced, unstable proximal humerus fractures who presented to our affiliated institutions between February 2003 and March All patients included in our study were asked to sign informed consent approved by the Institutional Review Board (IRB) by the appropriate medical center and were subsequently enrolled in our prospective database. Fractures were classified according to the Orthopaedic Trauma Association (OTA) and Neer classification systems. 10,11 Patient demographics of age, gender, mechanism of injury, and comorbidities were collected at the time of presentation. Operative data including patient position, length of procedure, use of bone substitute or graft, number of screws, manufacturer of plate, intraoperative complications, and anesthesia details were recorded from the hospital operative report. All fractures underwent open reduction and internal fixation fracture repair with a locking plate via a standard approach under the supervision of a fellowship trained orthopaedic surgeon. Anesthesia Details Patients were indicated for either general endotracheal anesthesia or regional anesthesia via an interscalene brachial plexus block with or without general anesthesia. The interscalene brachial plexus block was performed in the interscalene groove, between the anterior and middle scalene muscles (Fig. 1) with either the nerve stimulator technique, under ultrasound guidance or a combination of the two. The nerves stimulator technique uses a twitch response, usually 0.3 ma or less, in the distribution of the nerves to be blocked as the endpoint before injection of local anesthetic, while real time visualization is employed to deposit local anesthetic when utilizing ultrasound guided regional anesthesia. Typically, 40 ml of local anesthetic was administered. Surgical Procedure The patient was placed in the beach chair position with the injured upper extremity prepped and draped in the usual sterile fashion. A deltopectoral incision was utilized in all cases. Non-absorbable sutures were placed through the rotator cuff tendons to achieve direct fracture mobilization. In all cases, the humeral head was elevated and reduced through a lateral cortical window; cancellous chips or calcium phosphate cement were used to fill any significant bone defects, if necessary. Once anatomic reduction was achieved, the plate was affixed to the anterolateral aspect of the humerus. Proximal locking screws were placed in a unicortical manner and confirmed to be within the humeral head via intraoperative fluoroscopy. Distal shaft screws were placed bicortically and were a combination of locking and non-locking, depending on the treating surgeon s preference and fracture indications. The number of screws used varied according to surgeon preference. The non-absorbable braided sutures were then tied down to the plate after screw placement to allow for enhanced fixation. Postoperative Protocol Immediately following surgery, all patients were placed in an arm sling with the shoulder held in internal rotation, Figure 1 Scalene muscles. The interscalene brachial plexus block is performed in the interscalene groove, between the anterior and middle scalene muscles.

3 Bulletin of the Hospital for Joint Diseases 2014;72(3): neutral flexion, neutral abduction, and the elbow flexed to 90. Rehabilitation consisted of early passive shoulder range of motion followed by active range at 6 weeks depending upon the status of tuberosity healing. All patients were seen at standard follow-up intervals of 2, 6, 12, 26, and 52 weeks. Range of shoulder motion was assessed at each visit by taking goniometric measurements of active and passive forward elevation, internal rotation, and external rotation by the treating physician. Radiographic evaluation was conducted using the standard shoulder trauma series: anteroposterior (AP) internal and external rotation, axillary Y, and scapular Y. Complications at any point during treatment were recorded. Patients were asked to complete the Disabilities of the Arm, Shoulder and Hand (DASH) functional outcome questionnaire. Patients were only included in this study if they had complete follow-up data at a minimum of 6 months postoperatively. Results A total of 92 patients (75.4%) with 93 proximal humerus fractures met inclusion criteria and had completed followup information; these patients were included in our study cohort. Forty-seven (51.1%) patients with 48 proximal humeral fractures received general anesthesia, and 45 (48.9%) patients with 45 fractures received regional anesthesia for their operative treatment. Anesthesia was selected according to patient and injury factors as well as surgeon and anesthesiologist preference in a non-randomized manner. There were 11 males (24.4%) and 34 females (75.6%) in the block group, with an average age of 61 years old. The average age of the general anesthesia group was 60 years old with 13 males (27.7%) and 34 females (72.3%). The mean length of follow-up of the cohort was 15.4 months (13.2 and 17.0 months for the block and general groups, respectively). No significant differences existed in demographic data, mechanism of injury, OTA, or Neer fracture classification between the two groups (Table 1). DASH scores at the most recent follow-up interval were found to be significantly better (p = 0.003) in the group that received regional block anesthesia (38.6) compared to the general anesthesia group (53.1). The block group had average range of motion measurements of 139, 147, and 50 for active forward elevation, passive forward elevation, and external rotation, respectively. The corresponding measurements for the group that received general anesthesia were as follows: 119, 131, and 40. The range of motion for the block group was found to be significantly improved compared to the general anesthesia group (p = 0.002, 0.005, and 0.002, respectively). Internal rotation was measured by noting the maximal vertebral level reached Table 1 Comparison of Demographic and Clinical Variables Regional vs. General Anesthesia Regional Anesthesia N = 45 (%) General Anesthesia N = 47 (%) p-value Age (SD) 61 (13.3) 60 (15.6) Gender (%) Male 11 (24.4) 13 (27.7) Female 34 (75.6) 34 (72.3) Mechanism of Injury (%) Fall LV 41 (91.1) 37 (78.7) Fall HV 0 (0.0) 3 (6.4) MVA 4 (8.9) 4 (8.5) Ped Struck 0 (0.0) 3 (6.4) Neer Classification (%) (24.4) 12 (25.0) 3 30 (66.7) 27 (56.2) 4 4 (8.9) 9 (18.8) OTA Classification (%) A1 0 (0.0) 0 (0.0) A2 6 (13.3) 4 (8.3) A3 8 (17.8) 8 (16.7) B1 5 (11.1) 5 (10.4) B2 3 (6.7) 4 (8.3) B3 3 (6.7) 1 (2.1) C1 2 (4.4) 9 (18.8) C2 14 (31.1) 11 (22.9) C3 4 (8.9) 6 (12.5)

4 234 Bulletin of the Hospital for Joint Diseases 2014;72(3):231-6 by the patient s thumb when the elbow is flexed and the shoulder is internally rotated behind the back. The range of internal rotation for both groups was the iliac crest (IC) to T12. Internal range of motion was analyzed by grouping six levels along the vertebral column and comparing the two groups: IC-L2, L3-L5, T1-T3, T4-T6, T7-T9, and T10-T12. No significant difference was found in the internal range of motion between the regional and general anesthesia groups (p = 0.507) (Table 2). Five patients (11.1%) within the regional block anesthesia group experienced a postoperative complication. One patient (2.1%) developed a postoperative infection and was brought back to the operating room for multiple irrigation and debridements. Another patient (2.1%) had screw penetration of the articular surface that was treated with shoulder arthroscopy and screw removal 2 years following initial fracture fixation. Two patients (4.3%) had failure of fixation and plate-pull off; both subjects were closely monitored at each subsequent follow-up, and their fractures eventually went on to unite without further intervention. One patient (2.1%) developed osteonecrosis of the humeral head. Radiographically, one patient (2.1%) was noted to have some heterotopic ossification; however, this did not impede with range of motion or functionality, and no further treatment was required. The general anesthesia group reported 17 patients (34.7%) with postoperative complications, significantly more frequent than the regional (block) anesthesia group (p = 0.005). One patient (2.0%) required arthroscopic release and manipulation under anesthesia for arthrofibrosis. Eight patients (16.3%) were noted to have intra-articular screw penetration; four (50%) of these subjects required reoperation and removal of screws, and one (12.5%) was indicated for total shoulder arthroplasty. One patient (2.0%) experienced both screw penetration and osteonecrosis. Two subjects (4.1%) had painful impingement, which was treated with an analgesic injection into the subacromial space. One patient (2.0%) had fracture nonunion requiring exchange of hardware and autologous bone graft; another patient (2.0%) developed osteonecrosis and a superficial infection with malunion of their fracture. Two patients (4.1%) developed a postoperative infection. One patient in this group (2.0%) developed heterotopic ossification as demonstrated radiographically. Discussion This is the first study, to our knowledge, to investigate the relationship between the outcome of patients undergoing ORIF for the treatment of proximal humeral fractures and anesthetic type. We found that patients who received regional anesthesia compared to those who received general endotracheal anesthesia had significantly improved range of motion and functional outcome scores, as determined by goniometric measurements of forward elevation, internal and external rotation, and DASH questionnaire at a mean 15.4 months postoperatively. Regional anesthesia, such as brachial plexus blocks, has been found to provide excellent muscle relaxation during surgery as well as decreasing the incidence of unplanned hospital admission and reducing the requirements for postoperative analgesia. 8,9 It is the belief of the investigators that such blockade effects can assist the patient in progressing with passive range of motion exercises promptly and more vigorously following surgery. This was supported by improved range of motion and functional results at a minimum 6 months following operative intervention in patients who received regional block anesthesia compared to those whom received general anesthesia only. Early range of motion has been previously shown to improve outcomes. In a prospective controlled trial by Hodgson and colleagues, patients who sustained two-part fractures of the proximal humerus were randomized into one of two rehabilitation programs. One group was randomized to receive physiotherapy 1 week following immobilization, while the other group did not begin physiotherapy until 3 weeks following immobilization. The patients who began Table 2 Comparison of Range of Motion and DASH Scores at Most Recent Follow-up Interval Regional Anesthesia N = 45 General Anesthesia N = 47 p-value Forward Elevation (active) in degrees * Forward Elevation (passive) in degrees * External Rotation in degrees * Internal Rotation n (%) IC-L2 13 (28.9) 13 (27) L3-L5 3 (6.7) 7 (14.6) T1-T3 0 (0.0) 3 (6.3) T4-T6 15 (33.3) 12 (25.0) T7-T9 3 (6.7) 4 (8.3) T10-T12 11 (24.4) 9 (18.8) DASH Score *

5 Bulletin of the Hospital for Joint Diseases 2014;72(3): immediate passive range of motion exercises experienced less pain and an increase in shoulder function 52 weeks postoperatively. 7 This finding suggests that early range of motion exercises may result in better functional outcome following fracture of the proximal humerus, which is consistent with the results of our study. In another randomized controlled trial examining conservatively treated proximal humerus fractures, Lefevre-Colau and coworkers compared patients that had early mobilization to those treated with standard protocol of 3 week immobilization followed by physiotherapy. The early mobilization group was found to have significantly better Constant scores, better active mobility in forward elevation, and reduced pain than the conventionally-treated group. 12 Humeral fracture and shoulder replacement surgery can be performed under regional anesthesia, general anesthesia, or a combination of both. Regional anesthesia for shoulder surgery involves a brachial plexus block usually performed in the interscalene area. The nerve block can be accomplished by a paresthesia technique, use of a nerve stimulator, ultrasound guidance, or a combination of the nerve stimulator technique and ultrasound guidance. In this study, the techniques utilized were either the nerve stimulator technique or ultrasound guided regional anesthesia. The nerve stimulator technique involves positioning an insulated needle in close proximity to the brachial plexus by obtaining a twitch response in specific muscles in the distribution of the brachial plexus. Close proximity is obtained by ensuring that a twitch response is obtained at a low milliamperage current (typically 0.3 mamps in our institution). Ultrasound guided regional anesthesia is a technique in which the block is performed under real time visualization of the needle as it is positioned close to the nerves to be blocked and proper spread of local anesthesia is verified on the ultrasound screen as the medication is injected. To date, neither technique is considered superior as far as efficacy and safety. At times, for either patient comfort or safety and depending on the patient s comorbidities, the patient may receive a general anesthetic in addition to the regional nerve block. Although, to date, there have been no studies that specifically examine the effect of regional (block) anesthesia for proximal humerus fractures undergoing ORIF, the results of other upper extremity injuries and surgical procedures as well as anesthetic effect on injuries of the lower extremities have been investigated. Brown and associates divided patients indicated for shoulder arthroscopy into two groups based on the type of anesthesia: Group I consisted of patients who had undergone shoulder arthroscopy under general anesthesia, while Group II consisted of patients who had received interscalene block anesthesia for their shoulder surgery. 8 Postoperative results for patients in Group II demonstrated fewer side effects, fewer hospital re-admissions, an overall shorter hospital stay, and a decreased need for postoperative opioids than Group I; the interscalene block was found to be a safe and effective method with excellent muscle relaxation and intraoperative analgesia. 8 In a similar study, D Allesio and coworkers retrospectively compared patients who received an interscalene block to those receiving general anesthesia for ambulatory shoulder arthroscopy. 13 Their findings demonstrated a significantly decreased postanesthesia care unit stay and fewer unplanned admissions for nausea, vomiting, and therapy for severe pain. 13 Other investigations have evaluated anesthetic type in relation to fracture care in lower extremity fracture surgery. Koval and colleagues examined the effect of regional versus general anesthesia on functional recovery in a cohort of patients following hip fracture. No significant functional differences existed between the two groups at any of the follow-up intervals. 14 This study supports our finding that the clinical benefits of regional anesthesia may be most relevant to patients who have sustained upper extremity injuries. In a similar investigation, Urwin and associates 15 concluded that there were only marginal advantages to regional anesthesia with a decreased incidence of myocardial infarction, confusion, and postoperative hypoxia in patients who had undergone regional anesthesia compared to those who had general anesthesia. No other outcome measures reached statistical significance in this study. 15 However, in a study by Jordan and coworkers, 16 patients who underwent operative fixation following an ankle fracture that received spinal anesthesia were found to have less postoperative pain and better early functional outcome compared to those who were repaired under general anesthesia. At 6 and 12 months postoperatively, the difference in pain scores and functional outcome between the two groups lost significance, indicating that regional anesthesia for repair of ankle fractures may only be clinically significant in the early postoperative period. 16 One possible explanation for the improved functional outcome seen in patients who received a regional is the concomitant blockade of the sympathetic nervous system. The preoperative onset of this sympathetic blockade could be linked to decreasing the rate of complex regional pain syndrome and the development of postoperative pain syndrome. 17,18 Regional anesthesia may also obstruct afferent pain signals from reaching the central nervous system, perhaps then lessening the neurogenic inflammation that is associated with operative intervention following traumatic injury. Limitations of our study include the non-randomized manner in which patients were selected to receive a regional block or general anesthesia. The type of anesthesia administered was based on the preference of the attending anesthesiologist as well as the patient and the comorbidities of the patient. However, the finding that there were no significant differences between the classifications of fracture type between the two groups, suggesting that the severity of the fracture pattern was comparable, strengthens the comparison. Another limitation is the lack of data on patient BMI, which could have influenced the anesthesiologist s choice of type of anesthesia. There were a number of anesthesiolo-

6 236 Bulletin of the Hospital for Joint Diseases 2014;72(3):231-6 gists and 6 different attending orthopaedic surgeons who performed operative procedures on the patients included in this study. Minimum follow-up to meet inclusion criteria was 6 months postoperatively; however, longer follow-up may provide differing results as each patient may experience a more gradual outcome following ORIF. Patients who received regional (block) anesthesia for proximal humerus fracture repair were found to have better functional outcome and range or motion at the most recent clinical follow-up compared to those who received general anesthesia during open reduction internal fixation of proximal humerus fractures. Regional anesthesia via a brachial plexus block provides patients with prolonged postoperative pain relief, management that may allow for early mobilization, and permits the patient to proceed with earlier and more intensive physiotherapy following operative intervention. Early mobilization may increase the likelihood that the patient function and range of motion will return to baseline. Disclosure Statement None of the authors received funding in support of this research. Kenneth A. Egol, M.D., has received support for other works in the form of royalties and consultancy fees from Exactech and research support from Synthes, Omega, and OREF. Joseph D. Zuckerman, M.D., has received support for other works in the form of royalties and consultancy fees from Exactech. Acknowledgments This research was performed at the Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York, and The Jamaica Hospital Medical Center, Jamaica, New York. This paper was selected as Best Poster at the 2013 OTA Annual Meeting. References 1. Robinson CM, Amin AK, Godley KC, et al. Modern perspectives of open reduction and plate fixation of proximal humerus fractures. J Orthop Trauma Oct;25(10): doi: /BOT.0b013e31821c0a2f. 2. Robinson CM, Akhtar A, Mitchell M, Beavis C. Complex posterior fracture-dislocation of the shoulder. Epidemiology, injury patterns, and results of operative treatment. J Bone Joint Surg Am Jul;89(7): doi: /jbjs.f Robinson CM, Khan LAK, Akhtar MA. Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg Br Apr;88(4): doi: / X.88B Robinson CM, Teoh KH, Baker A, Bell L. Fractures of the lesser tuberosity of the humerus. J Bone Joint Surg Am Mar 1;91(3): doi: /jbjs.h Robinson CM, Wylie JR, Ray AG, et al. Proximal humeral fractures with a severe varus deformity treated by fixation with a locking plate. J Bone Joint Surg Br May;92(5): doi: / X.92B Egol KA, Koval KJ, Zuckerman JD. Handbook of Fractures. Philadelphia: Lippincott Williams & Wilkins, Hodgson SA, Mawson SJ, Stanley D. Rehabilitation after twopart fractures of the neck of the humerus. J Bone Joint Surg Br Apr;85(3): doi: / X.85B Brown AR, Weiss R, Greenberg C, et al. Interscalene block for shoulder arthroscopy: comparison with general anesthesia. Arthroscopy. 1993;9(3): Mirza F, Brown AR. Ultrasound-guided regional anesthesia for procedures of the upper extremity. Anesthesiol Res Pract. 2011;2011: doi: /2011/ Anon. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma. 1996;10 Suppl 1:v-ix, Neer CS 2nd. Displaced proximal humeral fractures: part I. Classification and evaluation Clin Orthop Relat Res Jan;442: doi: /01.blo ca 12. Lefevre-Colau MM, Babinet A, Fayad F, et al. Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial. J Bone Joint Surg Am Dec;89(12): doi: /jbjs.f D Alessio JG, Rosenblum M, Shea KP, Freitas DG. A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy. Reg Anesth Jan-Feb;20(1): Koval KJ, Aharonoff GB, Rosenberg AD, et al. Functional outcome after hip fracture. Effect of general versus regional anesthesia. Clin Orthop Relat Res Mar;(348): Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. Br J Anaesth Apr;84(4): Jordan C, Davidovitch RI, Walsh M, et al. Spinal anesthesia mediates improved early function and pain relief following surgical repair of ankle fractures. J Bone Joint Surg Am Feb;92(2): doi: /jbjs.h Reuben SS. Preventing the development of complex regional pain syndrome after surgery. Anesthesiology Nov;101(5): Yoo HS, Nahm FS, Lee PB, Lee CJ. Early thoracic sympathetic block improves the treatment effect for upper extremity neuropathic pain. Anesth Analg Sep;113(3): doi: /ane.0b013e