A Clinical Pathway for Total Shoulder Arthroplasty - A Pilot Study

HSS Journal: Volume 10, Issue 2

Amanda K. Goon, BA

Hospital for Special Surgery

David M. Dines, MD
David M. Dines, MD

Attending Orthopaedic Surgeon, Hospital for Special Surgery
Professor, Weill Cornell Medical College
Chairman and Professor of Orthopedic Surgery, Albert Einstein College of Medicine at LIJ

Edward V. Craig, MD, MPH - Emeritus 5/15
Edward V. Craig, MD, MPH - Emeritus 5/15

Orthopedic Surgeon Emeritus, Hospital for Special Surgery

Michael A. Gordon, MD
Michael A. Gordon, MD

Attending Anesthesiologist, Hospital for Special Surgery
Assistant Clinical Professor in Anesthesiology, Weill Cornell Medical College

Enrique A. Goytizolo, MD

Hospital for Special Surgery

Yi Lin, MD, PhD

Hospital for Special Surgery

Emily Lin, PhD

The New York School of Regional Anesthesia (NYSORA), St. Luke's-Roosevelt Hospital Center

Jacques T. Ya Deau, MD, PhD

Associate Attending Anesthesiologist, Hospital for Special Surgery
Clinical Associate Professor of Anesthesiology, Weill Cornell Medical College




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


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


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.


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.


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.

Level of Evidence: Level of Evidence: Therapeutic study, level IV.

This article appears in HSS Journal: Volume 10, Issue 2.
View the full article at springerlink.com.

About the HSS Journal

HSS Journal, an academic peer-reviewed journal published three times a year, February, July and October. The Journal accepts and publishes peer reviewed articles from around the world that contribute to the advancement of the knowledge of musculoskeletal diseases and disorders.


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