• Jacques T YaDeau, Michael A Gordon, Enrique A Goytizolo, Yi Lin, Kara G Fields, Amanda K Goon, Guilherme Holck, Timothy W Miu, Lawrence V Gulotta, David M Dines, and Edward V Craig.
• Departments of *Anesthesiology, and Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA; yadeauj@hss.edu.
• Pain Med. 2016 May 1; 17 (5): 940-60.

ObjectiveThis study investigated interscalene block for shoulder arthroplasty with various ropivacaine concentrations in the presence of clonidine, dexamethasone, and buprenorphine. The goal was prolonged analgesia with minimal motor blockade.DesignProspective, double-blind, randomized controlled trial.SettingUniversity-affiliated orthopedic hospital.MethodsPatients (20/group) received acetaminophen, ketorolac, pregabalin, opioids, and "Control"; interscalene block, 0.375% ropivacaine, intravenous additives (buprenorphine, clonidine, dexamethasone); "High Dose"; 0.375% ropivacaine, perineural additives; "Medium Dose"; 0.2% ropivacaine, perineural additives; and "Low Dose"; 0.1% ropivacaine, perineural additives.ResultsPain with movement at 24 hours was 4.9 ± 2.5 (mean ± standard deviation [SD]) (Control), 4.5 ± 3.0 (High Dose), 3.4 ± 1.8 (Medium Dose), 4.2 ± 2.4 (Low Dose). The difference between Medium Dose and Control was -1.5 (95% CI: -2.9, -0.1) (P = 0.040). Median time until need for opioids was 16.1 hours (Control) vs 23.7 hours (High Dose); hazard ratio 0.37 [95% CI: 0.17, 0.79]. High Dose had less pain with movement the morning after surgery, vs Control; 2.9 ± 2.5 vs 4.9 ± 2.7; P = 0.027. Pain with movement in the Post-Anesthesia Care Unit was higher in Low Dose, vs Control; 0.9 ± 1.4 vs 0 ± 0, P = 0.009. Low Dose had superior hand strength in the Post-Anesthesia Care Unit (mean ± SD of pre-operative strength: 44.0 ± 20.3%) compared to Control (27.5 ± 24.5%) (P = 0.031).ConclusionsFor maximum pain reduction, combining perineural additives with ropivacaine 0.375% or 0.2% is suggested. To minimize motor blockade, perineural additives can be combined with ropivacaine, 0.1%.© 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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