title: A clinical pathway for total shoulder arthroplasty-a pilot study.
abstract: BACKGROUND
  Appropriate pain management after total shoulder arthroplasty (TSA) facilitates rehabilitation and may improve clinical outcomes.
  
  
  OBJECTIVE
  This prospective, observational study evaluated a multimodal analgesia clinical pathway for TSA.
  
  
  METHODS
  Ten TSA patients received an interscalene nerve block (25 cm(3) 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.
authors: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.
authors: Amanda K
authors: AK
authors: Goon
authors: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ; Weill Cornell Medical College, New York, NY 10065 USA.
authors: David M
authors: DM
authors: Dines
authors: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ; Weill Cornell Medical College, New York, NY 10065 USA.
authors: Edward V
authors: EV
authors: Craig
authors: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ; Weill Cornell Medical College, New York, NY 10065 USA.
authors: Michael A
authors: MA
authors: Gordon
authors: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ; Weill Cornell Medical College, New York, NY 10065 USA.
authors: Enrique A
authors: EA
authors: Goytizolo
authors: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ; Weill Cornell Medical College, New York, NY 10065 USA.
authors: Yi
authors: Y
authors: Lin
authors: The New York School of Regional Anesthesia (NYSORA), St. Luke's-Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025 USA.
authors: Emily
authors: E
authors: Lin
authors: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ; Weill Cornell Medical College, New York, NY 10065 USA.
authors: Jacques T
authors: JT
authors: YaDeau
keywords: clinical pathway; interscalene nerve block; multimodal analgesia; non-opioid analgesics; postoperative pain; total shoulder arthroplasty