Pain management after total shoulder arthroplasty: a systematic review and procedure‐specific postoperative pain management ( PROSPECT ) recommendations

Summary Introduction Total shoulder arthroplasty is associated with moderate‐to‐severe postoperative pain. The aim of this systematic review was to assess the available literature and provide PROSPECT (PROcedure SPECific Postoperative Pain ManagemenT) recommendations for optimal pain management after total shoulder arthroplasty. Methods A systematic review utilising PROSPECT methodology was performed. Randomised controlled trials and systematic reviews published in the English language that assessed postoperative pain using analgesic, anaesthetic and surgical interventions were identified from databases. Results Of the 1809 articles identified, 30 randomised controlled trials and seven systematic reviews/meta‐analyses met our inclusion criteria. Interventions that improved postoperative pain relief included: paracetamol and non‐steroidal anti‐inflammatory drugs; dexamethasone; interscalene brachial plexus block and, as an alternative, local infiltration analgesia. Conflicting evidence was found for continuous interscalene brachial plexus block (catheter) or liposomal bupivacaine for interscalene block or local infiltration analgesia. No evidence was found for a specific surgical technique. Discussion In the absence of contraindication, the analgesic regimen should include: paracetamol; a non‐steroidal anti‐inflammatory drug administered peri‐operatively and continued postoperatively; intravenous dexamethasone (8–10 mg); and postoperative opioids for rescue analgesia. As a regional technique, an interscalene brachial plexus block with a single‐bolus injection of long‐acting local anaesthetic (bupivacaine or ropivacaine), but not liposomal bupivacaine, should be provided. In case of contraindications or absence of expertise, local infiltration analgesia is a reasonable alternative. Further studies are required to investigate the analgesic benefit of a continuous infusion for the interscalene brachial plexus block.