Managing Pain in Shoulder Arthroplasty Patients

    Regional anesthesia – specifically, interscalene blocks – is considered to be an alternative to intravenous opioids to manage pain in patients undergoing primary shoulder arthroplasty.

    These blocks have generally done a good job of providing analgesia. [1-3] The problem, as described by Thomas W. Quin Throckmorton, MD, during a presentation at ICJR’s 7th Annual Shoulder Course, is that interscalene blocks are associated with some pretty serious side effects, including respiratory side effects similar to those associated with opioid use. [4-7]

    Dr. Throckmorton characterized his experience with using interscalene blocks in shoulder arthroplasty patients as “horrible,” citing a 13% rate of major complications, including respiratory depression and pneumonia, among 156 shoulder arthroplasty patients in 1 of his studies. [8]

    So, what is the alternative to something that is already supposed to be the alternative to opioids?

    The answer is evolving as surgeons investigate strategies to minimize pain and opioid use in shoulder procedures, Dr. Throckmorton said. For example, liposomal bupivacaine has been shown to provide pain relief equivalent to that of interscalene blocks in multiple studies, including research conducted by Dr. Throckmorton and his colleagues at Campbell Clinic Orthopaedics in Memphis, Tennessee. [8,9-13]

    Dr. Throckmorton’s study compared pain relief, narcotic use, complication rates, and cost in 214 patients undergoing shoulder arthroplasty who received 1 of the following:

    • Liposomal bupivacaine (n=58), which included liposomal bupivacaine plus 0.5% bupivacaine, ketorolac, and morphine
    • Indwelling interscalene blocks (n=156) that was left in place for 3 or 4 days

    Pain scores were equivalent between groups, and no differences were seen in narcotic use at 2, 6, and 12 weeks. As mentioned above, the rate of major complications was 13% for patients in the interscalene block group, compared with just 3.4% in the liposomal bupivacaine group. Cost was a factor: The liposomal bupivacaine mixture Dr. Throckmorton used in the study cost $304.40 per patient, compared with $1,472.42 for the interscalene block. [8]

    Another strategy that shoulder surgeons are adapting from the literature of other orthopaedic subspecialties is multimodal pain management, which has been shown to: [12,14-16]

    • Offer better pain control than individual pain medications
    • Minimize drug side effects
    • Allow for earlier postoperative mobilization
    • Facilitate earlier hospital discharge

    Dr. Throckmorton shared the multimodal pain management protocol he and his colleagues follow for shoulder arthroplasty and arthroscopy patients:


    • 10 mg oxycodone
    • 300 mg gabapentin
    • 1 gram acetaminophen intravenously


    • 20 mL liposomal bupivacaine
    • 40 mL 0.25% bupivacaine
    • 30 mg ketorolac (note: patients undergoing arthroscopy for rotator cuff tears do not receive ketorolac)


    • Oxycodone as rescue medication
    • Oral acetaminophen
    • Gabapentin

    Click the image above to watch Dr. Throckmorton’s presentation and learn more about pain management in shoulder arthroplasty patients.

    Disclosures: Dr. Throckmorton has no disclosures relevant to this article.


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