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A Clinical Pathway for Total Shoulder Arthroplasty—A Pilot Study

  • Original Article
  • Published:
HSS Journal ®

Abstract

Background

Appropriate pain management after total shoulder arthroplasty (TSA) facilitates rehabilitation and may improve clinical outcomes.

Questions/purposes

This prospective, observational study evaluated a multimodal analgesia clinical pathway for TSA.

Methods

Ten TSA patients received an interscalene nerve block (25 cm3 0.375% ropivacaine) with intraoperative general anesthesia. Postoperative analgesia included regularly scheduled non-opioid analgesics (meloxicam, acetaminophen, and pregabalin) and opioids on demand (oral oxycodone and intravenous patient-controlled hydromorphone). Patients were evaluated twice daily to assess pain, anterior deltoid strength, handgrip strength, and sensory function.

Results

The nerve block lasted an average of 18 h. Patients had minimal pain after surgery; 0 (median score on a 0–10 scale) in the Post-Anesthesia Care Unit (PACU) but increased on postoperative day (POD) 1 to 2.3 (0.0, 3.8; median (25%, 75%)) at rest and 3.8 (2.1, 6.1) with movement. Half of the patients activated the patient-controlled analgesia four or fewer times in the first 24 h after surgery. Operative anterior deltoid strength was 0 in the PACU but returned to 68% by POD 1. Operative hand strength was 0 (median) in the PACU, but the third quartile (75%) had normalized strength 49% of preoperative value.

Conclusions

Patients did well with this multimodal analgesic protocol. Pain scores were low, half of the patients used little or no intravenous opiate, and some patients had good handgrip strength. Future research can focus on increasing duration of analgesia from the nerve block, minimizing motor block, lowering pain scores, and avoiding intravenous opioids.

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Acknowledgment

This study was supported by the Department of Anesthesiology Research and Education Fund and approved by the Hospital for Special Surgery.

Disclosures

ᅟ

Conflict of Interest:

Amanda K. Goon, BA, Michael A. Gordon, MD, Enrique A. Goytizolo, MD, Yi Lin, MD, PhD, Emily Lin, MD, and Jacques T. YaDeau, MD have declared that they have no conflict of interest. David M. Dines, MD reports royalties from Biomet Inc., outside the work. Edward V. Craig, MD, MPH reports royalties from Biomet Inc., and patent with Biomet Inc., outside the work.

Human/Animal Rights:

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Informed Consent:

Informed consent was obtained from all patients for being included in the study.

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Disclosure forms provided by the authors are available with the online version of this article.

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Authors and Affiliations

  1. Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA

    Amanda K. Goon BA, David M. Dines MD, Edward V. Craig MD, MPH, Michael A. Gordon MD, Enrique A. Goytizolo MD, Yi Lin MD, PhD & Jacques T. YaDeau MD, PhD

  2. The New York School of Regional Anesthesia (NYSORA), St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY, 10025, USA

    Emily Lin MD

  3. Weill Cornell Medical College, New York, NY, 10065, USA

    David M. Dines MD, Edward V. Craig MD, MPH, Michael A. Gordon MD, Enrique A. Goytizolo MD, Yi Lin MD, PhD & Jacques T. YaDeau MD, PhD

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  1. Amanda K. Goon BA
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  2. David M. Dines MD
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  8. Jacques T. YaDeau MD, PhD
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Corresponding author

Correspondence to Jacques T. YaDeau MD, PhD.

Additional information

Work was performed at the Hospital for Special Surgery, New York, NY.

Level of Evidence: Therapeutic study, level IV

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Goon, A.K., Dines, D.M., Craig, E.V. et al. A Clinical Pathway for Total Shoulder Arthroplasty—A Pilot Study. HSS Jrnl 10, 100–106 (2014). https://doi.org/10.1007/s11420-014-9381-0

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  • DOI: https://doi.org/10.1007/s11420-014-9381-0

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