A PROSPECT systematic review assessed 30 randomised trials and seven systematic reviews of analgesia after total shoulder arthroplasty, using the group's procedure-specific methodology.

Interventions that improved pain relief were paracetamol, NSAIDs, dexamethasone, and an interscalene brachial plexus block, with local infiltration analgesia as an alternative. Evidence for a continuous interscalene catheter and for liposomal bupivacaine was conflicting. No surgical technique showed an analgesic advantage.

The review recommends that, absent contraindications, the regimen include paracetamol, an NSAID given perioperatively and continued afterwards, intravenous dexamethasone 8 to 10 mg, and opioids only for rescue. For the block, it recommends a single injection of plain long-acting local anaesthetic such as bupivacaine or ropivacaine, not liposomal bupivacaine. Where a block is contraindicated or expertise is lacking, local infiltration is a reasonable substitute.

The value is simplicity: a regimen any unit can protocol, without expensive extended-release agents. Interscalene block carries a known risk of phrenic nerve palsy, so patients with limited respiratory reserve need individual assessment.

Give paracetamol and an NSAID perioperatively and continue them after surgery, unless contraindicated.
Add intravenous dexamethasone 8 to 10 mg, unless contraindicated.
Use a single-shot interscalene block with plain bupivacaine or ropivacaine.
Liposomal bupivacaine is not recommended for the block in this review.
If a block is unsuitable, use local infiltration analgesia; keep opioids for rescue.

Why it matters

Expensive extended-release agents and catheters were not shown to add to a simple, well-delivered regimen.

The statistics, in plain English

PROSPECT recommendations weigh both the trial evidence and the balance of benefit and harm; where trials conflict, as for catheters and liposomal bupivacaine, they do not recommend the intervention.