Nonopioid Pain Management Is Effective in TSA Patients

By: Maureen Leahy

Select patients may benefit from multimodal pathway

An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing total shoulder arthroplasty (TSA), according to data presented Tuesday by Daniel Leas, MD.

“Overdoses are the leading cause of accidental death in our country, with opioids leading the way as the offending agent. For decades, we as surgeons have been comfortable with opioids as part of the routine operative course for our patients,” said Dr. Leas.

Recent studies utilizing multimodal protocols demonstrated a reduction in opioid consumption, but no previous investigation had eliminated opioids altogether. “As a study group, we felt a responsibility to ask the question of whether opioids were needed at all,” he explained.

The prospective, nonrandomized investigation involved 65 patients (mean age, 71 years) undergoing elective primary shoulder arthroplasty. Patients were given the choice of receiving routine opioid therapies (observation group, n = 30; 66.7 percent female) or a treatment protocol that excluded all opioid-based medications during the perioperative period (intervention group, n = 35; 58.5 percent female). Exclusion criteria were the following:

  • chronic opioid therapy
  • revision shoulder arthroplasty
  • liver or renal insufficiency
  • arthroplasty for fracture
  • sickle cell disease
  • inability to receive block
  • workers compensation

In addition, patients in the intervention arm of the study were excluded if they had creatinine clearance less than 30 mL/min or were allergic to NSAIDs.  

The researchers collected information on length of stay, perioperative patient-reported pain, and postoperative delirium, nausea, constipation, and falls. Patients were also asked to rate their satisfaction with their pain management. Pain levels at 24 hours postoperative or at time of discharge, whichever came first, were the primary outcome measures.

Pain management protocols

Most (60 percent) of the patients in the observation group received an anatomical TSA. Pain management involved the use of routine perioperative medications including fentanyl during surgery and regional anesthesia with interscalene nerve block or, if the patient declined or was not a candidate for regional anesthesia, local injection with liposomal bupivacaine. Routine postoperative medications included opioids, over the counter NSAIDs as needed, and any other modalities typically used by the treating surgeon.

Among the patients in the intervention group, 54.3 percent underwent reverse TSA. Preoperatively, patients received oral gabapentin and celecoxib (or meloxicam if the patient had a sulfa allergy) and an ultrasound-guided interscalene regional block, placed in standard fashion without the aid of opioid co-medication. Liposomal bupivacaine was injected into the periarticular soft tissues as an adjunct to the block. During the procedure, the patients received intravenous acetaminophen. Anesthetic modalities included, but were not limited to, regional block, propofol, IV lidocaine, rocuronium/vecuronium, and sevoflurane/desflurane.

Following surgery, patients in the intervention group received cryotherapy, 300 mg of gabapentin every 8 hours, and 15 mg of intravenous ketorolac tromethamine (Toradol) every 6 hours for four doses. Toradol was replaced with celecoxib (or meloxicam) for the remainder of the hospital stay. Patients with creatinine clearance between 30 and 60 mL/min received a half-dose of all NSAIDs; patients with creatinine clearance greater than 60 mL/min were eligible to receive full doses of NSAIDs. Opioids were approved for patients with poorly controlled pain only after use of all nonopioid modalities had been exhausted.

Intervention group patients were discharged with 14-day prescriptions for gabapentin and celecoxib (or meloxicam), and allowed to continue acetaminophen as needed. No opioid prescriptions were given at time of discharge or at follow-up.

No difference in pain control

No statistically significant differences in median visual analog scores between the intervention and observation groups were found at baseline (6 vs. 6.5, respectively; P = 0.544) or at 24 hours postoperative (2 vs. 3, respectively; P = 0.297). On average, patients in the intervention group reported lower median pain scores after discharge than patients in the observation group, although the differences were not always significant.

The researchers also noted no statistically significant differences in rates of nausea, delirium, or falls between the two groups. Symptoms of constipation occurred more frequently in the observation group than in the intervention group (67.9 percent vs. 37.5 percent, respectively; P = 0.0226).

“Our study firmly supports the idea that we should be exploring ways to eliminate opioids as ‘standard of care’ for pain in the medical community. Compared to patients receiving opioids, patients in the intervention arm of the study experienced extremely high rates of satisfaction, with no adverse outcomes/effects, and no risky leftover opioid pills,” Dr. Leas said.

He added, “As we shift away from opioid therapy, orthopaedic surgeons can expect to captain patient care teams to teach safe and effective alternatives for pain control. Patients respond well to the idea of preventing the side effect profile of opioids, particularly now that the lay media is reporting on the epidemic.”

Dr. Leas’s coauthors of “Opioid-Free Total Shoulder Arthroplasty” are Bryce Allen Van Doren, MA; Shadley C. Schiffern, MD; Patrick Michael Connor, MD; and Nady Hamid, MD.

Details of the authors’ disclosure as submitted to the Orthopaedic Disclosure Program can be found in the Final Program; the most current disclosure information may be accessed electronically at

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at


Caption: The results of this study found that perioperative pain management can be safely and effectively achieved without the use of opioids in properly selected TSA patients.  

Courtesy of Getty Images