Intra‐articular infiltration analgesia for arthroscopic shoulder surgery: a systematic review and meta‐analysis

Abstract

Summary Phrenic‐sparing analgesic techniques for shoulder surgery are desirable. Intra‐articular infiltration analgesia is one promising phrenic‐sparing modality, but its role remains unclear because of conflicting evidence of analgesic efficacy and theoretical concerns regarding chondrotoxicity. This systematic review and meta‐analysis evaluated the benefits and risks of intra‐articular infiltration in arthroscopic shoulder surgery compared with systemic analgesia or interscalene brachial plexus block. We sought randomised controlled trials comparing intra‐articular infiltration with interscalene brachial plexus block or systemic analgesia (control). Cumulative 24‐h postoperative oral morphine equivalent consumption was designated as the primary outcome. Secondary outcomes included visual analogue scale pain scores during the first 24 h postoperatively; time‐to‐first analgesic request; patient satisfaction; opioid‐related side‐effects; block‐related adverse events; and any indicators of chondrotoxicity. Fifteen trials (863 patients) were included. Compared with control, intra‐articular infiltration reduced 24‐h postoperative analgesic consumption by a weighted mean difference (95%CI) of −30.9 ([−38.9 to −22.9]; p < 0.001). Intra‐articular infiltration also reduced the weighted mean difference (95%CI) pain scores up to 12 h postoperatively, with the greatest reduction at 4 h (−2.2 cm [(−4.4 to −0.04]); p < 0.05). Compared with interscalene brachial plexus block, there was no difference in opioid consumption, but patients receiving interscalene brachial plexus block had better pain scores at 2, 4 and 24 h postoperatively. There was no difference in opioid‐ or block‐related adverse events, and none of the trials reported chondrotoxic effects. Compared with systemic analgesia, intra‐articular infiltration provides superior pain control, reduces opioid consumption and enhances patient satisfaction, but it may be inferior to interscalene brachial plexus block patients having arthroscopic shoulder surgery.

Erector spinae plane block vs. peri‐articular injection for pain control after arthroscopic shoulder surgery: a randomised controlled trial

“…Although there are some variations in the approach of shoulder PAI and structures injected, it is likely that PAI results in analgesic effects inferior to interscalene brachial plexus block but superior to systemic analgesia alone [2, 8]. In this study, PAI was performed by injections inside and around the joint space, and our results suggest that PAI in this approach is at least equally effective, if not more effective, than ESP block.…”

“…Although there are some variations in the approach of shoulder PAI and structures injected, it is likely that PAI results in analgesic effects inferior to interscalene brachial plexus block but superior to systemic analgesia alone [2,8].…”

“…Other proposed alternatives include suprascapular nerve block; superior trunk block; intra-articular injection; and peri-articular injection (PAI). Of note, there are concerns of chondrotoxicity with intra-articular injections [8]. However, PAI involves the injection of local anaesthetic around the joint space and surrounding structures [9,10].…”

The Impact of Regional Anesthesia in Masking Acute Compartment Syndrome after Limb Trauma

“…Continuous wound (articular) infusion (CWI) or peri-articular infiltration (local infiltration analgesia [LIA]) are effective regional analgesia techniques but have no impact on motor or major sensory block due to the lack of effect on major nerves [ 63 , 64 ]. The surgery most profiting from these techniques is total knee arthroplasty, whereas hip surgery and upper extremity trauma are controversially discussed [ 65 ]. Fascial plane blocks represent a modern regional analgesia approach, where high volumes of low-concentration local anesthetics are injected for analgesia, therefore avoiding central blocks or PNBs.…”

Clinical care pathways for ambulatory total shoulder arthroplasty

“…A retrospective study found that periarticular local anesthetic injection provided similar analgesia to peripheral nerve blockade for TSA [36]. However, meta-analysis of intra-articular infiltration analgesia for arthroscopic shoulder surgery showed that ISB provided better analgesia [37 ▪▪ ], a finding that probably also applies to TSA.…”