A Clinical Pathway for Total Shoulder Arthroplasty-A Pilot Study

Amanda K. Goon, David M. Dines, Edward V. Craig, Michael A. Gordon, Enrique A. Goytizolo, Yi Lin, Emily Lin, Jacques T. YaDeau

Research output: Contribution to journalArticlepeer-review

15 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)100-106
Number of pages7
JournalHSS Journal
Issue number2
StatePublished - Jul 2014

Bibliographical note

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


  • clinical pathway
  • interscalene nerve block
  • multimodal analgesia
  • non-opioid analgesics
  • postoperative pain
  • total shoulder arthroplasty


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