Pain management after shoulder arthroplasty: a systematic review of randomized controlled trials

Abstract

ABSTRACT Introduction Patients who undergo total shoulder arthroplasty (TSA) may experience substantial postoperative pain, which may negatively impact patient satisfaction, lead to greater narcotic consumption, and impair early rehabilitation. The purpose of this study was to perform a systematic review of randomized controlled trials (RCTs) to evaluate the effect of analgesia methods on postoperative (1) pain, (2) opioid use, (3) length of stay (LOS), and (4) adverse events in patients undergoing TSA, reverse TSA, and hemiarthroplasty. Methods A systematic review was performed by querying PubMed, Web of Science, and Cochrane Controlled Register of Trials for studies on analgesic interventions following shoulder arthroplasty. Data pertaining to pain scores, narcotic requirements, LOS, and complications were extracted. Results Eight studies (67%) included continuous interscalene block (CISB) with an indwelling catheter, six studies (50%) included a single-injection interscalene block (ISB), five studies (42%) included local infiltration with liposomal bupivacaine, four studies (33%) included local infiltration with anesthetics other than liposomal bupivacaine, one study (8%) included brachial plexus blocks other than ISB. ISB provided better pain relief than local infiltration in the immediate postoperative period (0-8 hours) as seen in 5/7 (71.4%) studies, but pain levels became similar subsequently. CISB may be superior to single-injection ISB for pain control at the 24-hour time point. The lowest narcotic requirement was seen in the CISB groups postoperatively but was variable. No pain management modalities significantly impacted LOS. A greater number of adverse events were seen with CISB. Discussion Single-injection ISB and CISB appear to offer greater pain relief in the immediate postoperative period compared to local infiltration with liposomal bupivacaine or other anesthetics. CISB provided sustained pain relief at 24 hours compared to other modalities. Analgesic benefit of CISB should be considered in the context of greater cost and potential for more frequent adverse events. Level of Evidence Level I; Systematic Review