Comparison of costoclavicular and paracoracoid approaches for infraclavicular perineural catheter placement in outpatient hand and wrist surgeries: a randomized controlled trial.

BACKGROUND

Continuous infraclavicular perineural catheters are widely used for ambulatory hand and wrist surgery, yet failure rates remain substantial. The costoclavicular (CC) approach may improve local anesthetic spread due to tighter clustering of the brachial plexus cords, but its clinical benefit during continuous infusion remains uncertain.

METHODS

In this prospective, randomized, double-blind superiority trial, adults undergoing ambulatory hand and wrist surgery were randomized (1:1) to receive an ultrasound-guided continuous infraclavicular catheter using either the CC or paracoracoid (PC) approach. All patients received a standardized infusion of 0.15% bupivacaine at 5 mL/hour for 48 hours. The primary outcome was successful sensory blockade in all four terminal nerve territories at 48 hours. Secondary outcomes included pain scores, opioid consumption, sleep quality, patient satisfaction, and complications. Analyses followed a modified intention-to-treat approach with complementary per-protocol analyses.

RESULTS

A total of 139 patients were included (69 CC, 70 PC). Successful sensory blockade at 48 hours occurred in 42.6% of the CC group and 47.8% of the PC group (adjusted risk difference -1.3%, 95% CI -17.5% to 15.0%). Per-protocol analyses were consistent. No clinically meaningful differences were observed in pain scores, opioid consumption, sleep quality, or patient satisfaction.

CONCLUSIONS

Under standardized low-rate infusion conditions, we found no evidence that the CC approach was superior to the PC approach for sensory blockade or analgesic effectiveness in ambulatory hand and wrist surgery. Technique selection may therefore be guided by operator preference and practical considerations.