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      Do liposomal bupivacaine infiltration and interscalene nerve block provide similar pain relief after total shoulder arthroplasty: a systematic review and meta-analysis

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          Abstract

          Objective

          Controversy still exists regarding the efficiency and safety of liposomal bupivacaine (LB) vs interscalene nerve block (INB) for pain management after total shoulder arthroplasty (TSA). The aim of the present meta-analysis was to perform a relatively credible and overall assessment to compare the efficiency and safety of LB-based infiltration vs INB for pain management after TSA.

          Methods

          The PubMed, Cochrane Library, Web of Science, and EMBASE were systematically searched. Only studies published up to March 2018 comparing LB vs INB for pain control after TSA were included. The primary outcome extracted from the studies was postoperative pain score at different periods. The secondary outcomes included total opioid consumption, length of hospital stay, and complications.

          Results

          Seven studies with 707 patients were included in this study. No statistically significant difference was observed between the LB and INB groups in pain scores at 8 hours, 12 hours, 24 hours, postoperative day (POD) 1, and POD 2. The two groups also showed comparable total opioid consumption at POD 0, POD 1, POD 2, and length of hospital stay. The LB group had a significantly higher pain score at 4 hours (standard mean difference =0.65, 95% CI=0.07 to 1.24, P=0.03) but a lower occurrence rate of complications than did the INB group (OR =0.51, 95% CI=0.28 to 0.91, P=0.02).

          Conclusion

          This meta-analysis revealed that INB provides excellent analgesic effects within 4 hours after TSA, while patients treated with LB infiltration experienced significantly less occurrence rate of complications after TSA. In general, both approaches provide similar overall pain relief and have similar opioid consumption after TSA, with no significant difference in the length of hospital stay. Nevertheless, more high-quality randomized controlled trails with long-term follow-up are still required to make the final conclusion.

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          Most cited references 28

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          Increasing incidence of shoulder arthroplasty in the United States.

          The number of total shoulder arthroplasties performed in the United States increased slightly between 1990 and 2000. However, the incidence of shoulder arthroplasty in recent years has not been well described. The purpose of the present study was to examine recent trends in shoulder hemiarthroplasty and total shoulder arthroplasty along with the common reasons for these surgical procedures in the United States. We modeled the incidence of shoulder arthroplasty from 1993 to 2008 with use of the Nationwide Inpatient Sample. On the basis of hemiarthroplasty and total shoulder arthroplasty cases that were identified with use of surgical procedure codes, we conducted a design-based analysis to calculate national estimates. While the annual number of hemiarthroplasties grew steadily, the number of total shoulder arthroplasties showed a discontinuous jump (p < 0.01) in 2004 and increased with a steeper linear slope (p < 0.01) since then. As a result, more total shoulder arthroplasties than hemiarthroplasties have been performed annually since 2006. Approximately 27,000 total shoulder arthroplasties and 20,000 hemiarthroplasties were performed in 2008. More than two-thirds of total shoulder arthroplasties were performed in adults with an age of sixty-five years or more. Osteoarthritis was the primary diagnosis for 43% of hemiarthroplasties and 77% of total shoulder arthroplasties in 2008, with fracture of the humerus as the next most common primary diagnosis leading to hemiarthroplasty. The number of shoulder arthroplasties, particularly total shoulder arthroplasties, is growing faster than ever. The use of reverse total arthroplasty, which was approved by the United States Food and Drug Administration in November 2003, may be part of the reason for the greater increase in the number of total shoulder arthroplasties. A long-term follow-up study is warranted to evaluate total shoulder arthroplasty in terms of patient outcomes, safety, and implant longevity.
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            Risk of bias versus quality assessment of randomised controlled trials: cross sectional study

            Objectives To evaluate the risk of bias tool, introduced by the Cochrane Collaboration for assessing the internal validity of randomised trials, for inter-rater agreement, concurrent validity compared with the Jadad scale and Schulz approach to allocation concealment, and the relation between risk of bias and effect estimates. Design Cross sectional study. Study sample 163 trials in children. Main outcome measures Inter-rater agreement between reviewers assessing trials using the risk of bias tool (weighted κ), time to apply the risk of bias tool compared with other approaches to quality assessment (paired t test), degree of correlation for overall risk compared with overall quality scores (Kendall’s τ statistic), and magnitude of effect estimates for studies classified as being at high, unclear, or low risk of bias (metaregression). Results Inter-rater agreement on individual domains of the risk of bias tool ranged from slight (κ=0.13) to substantial (κ=0.74). The mean time to complete the risk of bias tool was significantly longer than for the Jadad scale and Schulz approach, individually or combined (8.8 minutes (SD 2.2) per study v 2.0 (SD 0.8), P<0.001). There was low correlation between risk of bias overall compared with the Jadad scores (P=0.395) and Schulz approach (P=0.064). Effect sizes differed between studies assessed as being at high or unclear risk of bias (0.52) compared with those at low risk (0.23). Conclusions Inter-rater agreement varied across domains of the risk of bias tool. Generally, agreement was poorer for those items that required more judgment. There was low correlation between assessments of overall risk of bias and two common approaches to quality assessment: the Jadad scale and Schulz approach to allocation concealment. Overall risk of bias as assessed by the risk of bias tool differentiated effect estimates, with more conservative estimates for studies at low risk.
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              A randomized, double-blind, dose-ranging study comparing wound infiltration of DepoFoam bupivacaine, an extended-release liposomal bupivacaine, to bupivacaine HCl for postsurgical analgesia in total knee arthroplasty.

              DepoFoam bupivacaine is a novel liposomal formulation of bupivacaine designed to provide prolonged postsurgical analgesia. This dose-ranging study evaluated extent and duration of analgesia following administration of DepoFoam bupivacaine in patients undergoing total knee arthroplasty (TKA). Efficacy, safety, and pharmacokinetics of DepoFoam bupivacaine doses of 133, 266, 399, or 532 mg were compared with bupivacaine HCl (150 mg) with epinephrine given as single injections via wound infiltration in TKA patients (N=138). Primary efficacy measure was AUC of pain intensity scores assessed by numeric rating scale with activity (NRS-A) through Day 4 postsurgery. Other assessments included pain intensity at rest (NRS-R), postsurgical opioid consumption, and safety, among others. Mean AUC of NRS-A scores through Day 4 were 20.7, 19.5, 18.8, and 19.1 for the 133-mg, 266-mg, 399-mg, and 532-mg DepoFoam bupivacaine groups vs 20.4 for bupivacaine HCl. With DepoFoam bupivacaine 532-mg, differences in NRS-R scores reached statistical significance (P<0.05) vs bupivacaine HCl on Days 1 and 5 and mean AUC NRS-R scores were significantly lower through Days 2-5; a dose-response trend was demonstrated. Mean rating for blinded care provider's satisfaction with analgesia was significantly higher for DepoFoam bupivacaine 532 mg vs bupivacaine HCl (P ≤ 0.05). Other efficacy measures showed no statistically significant differences. Exposure to bupivacaine increased in a dose-related manner, as reflected by mean and maximum plasma bupivacaine concentrations, and AUC(0-∞). Treatment with DepoFoam bupivacaine 532 mg was associated with statistically significantly greater analgesia while patients were at rest after surgery compared with bupivacaine HCl. Copyright © 2011. Published by Elsevier B.V.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2018
                18 September 2018
                : 11
                : 1889-1900
                Affiliations
                Department of Articular Orthopaedics, The Third Affiliated Hospital of Soochow University, Changzhou 213003, Jiangsu, China, xiaoliangsuncz@ 123456163.com
                Author notes
                Correspondence: Xiaoliang Sun, Department of Articular Orthopaedics, The Third Affiliated Hospital of Soochow University, 185 Juqian Road, Changzhou 213003, Jiangsu, China, Tel +86 1 360 612 6656, Fax +86 0 519 6887 0000, Email xiaoliangsuncz@ 123456163.com
                [*]

                These authors contributed equally to this work

                Article
                jpr-11-1889
                10.2147/JPR.S177716
                6151095
                © 2018 Sun et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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