- Design
- Systematic review with PROSPECT procedure-specific recommendations
- Population
- 30 RCTs and 7 systematic reviews in total shoulder arthroplasty
- Primary outcome
- Postoperative pain scores and analgesic use
- Effect
- Benefit for paracetamol, NSAIDs, dexamethasone, interscalene block; conflicting for liposomal bupivacaine
This PROSPECT systematic review assessed 30 randomised trials and seven systematic reviews of analgesia after total shoulder arthroplasty.
Interventions that improved pain included paracetamol, NSAIDs, dexamethasone, interscalene brachial plexus block and, as an alternative, local infiltration analgesia. Evidence was conflicting for continuous interscalene catheters and for liposomal bupivacaine, whether used in the block or for infiltration. No surgical technique showed an analgesic advantage.
The resulting recommendation, unless contraindicated: paracetamol; an NSAID given perioperatively and continued afterwards; intravenous dexamethasone 8–10 mg; opioids for rescue; and a single-injection interscalene block with bupivacaine or ropivacaine — not liposomal bupivacaine. Where a block is contraindicated or expertise is lacking, local infiltration is reasonable. Plain long-acting local anaesthetics are also the cheaper choice, which matters in Indian practice.
- Give paracetamol and an NSAID perioperatively and continue them after surgery, unless contraindicated.
- Add intravenous dexamethasone 8–10 mg.
- Offer a single-injection interscalene block with plain bupivacaine or ropivacaine.
- Do not use liposomal bupivacaine for this operation on current evidence.
- Use local infiltration analgesia when an interscalene block is contraindicated or unavailable.
Why it matters
It removes the case for costly liposomal bupivacaine and catheters in a procedure where simple measures perform well.
Don't overread it
Continuous catheters were not shown to be ineffective — the evidence was conflicting.
The statistics, in plain English
PROSPECT recommendations weigh both the size of benefit and its consistency across trials; 'conflicting evidence' means some trials showed benefit and others did not, so no recommendation can be made.
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