Pain management in shoulder arthroplasty: a systematic review and network meta-analysis of randomized controlled trials.

Abstract Background Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Given the variety of pain management options available, the purpose of this investigation was to systematically review the literature for randomized controlled trials (RCTs) reporting on pain control after shoulder arthroplasty. We sought to determine which modalities are most effective in managing postoperative pain and reducing postoperative opioid use. Methods A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-II RCTs that compared interventions for postoperative pain control after TSA. Pain control measures included nerve blocks and nerve block adjuncts, local injections, patient-controlled analgesia, oral medications, or other modalities. The two primary outcome measures were pain level measured on a 0-10 visual analog scale (VAS) and opioid use. The risk of study bias and methodological quality was analyzed using the Cochrane Collaboration’s Risk of Bias 2 (RoB 2) tool. Network meta-analyses were performed for pain VAS at post-surgical timepoints and opioid use using a frequentist approach and random effects model, with heterogeneity quantified using the I2 statistic. Treatments were ranked using the P-score, and statistical significance was set at p Results The initial search yielded 2391 articles (695 duplicates, 1696 screened, 35 full-text review). Eighteen articles (1358 shoulders; 51% females; mean age range 65 to 73.7 years; four low risk, 12 some risk, and two high risk of bias studies) were included and analyzed. At 4 and 8 hours postoperatively, patients receiving local liposomal bupivacaine (LB) (p Conclusion ISBs are superior to local injection alone at managing pain after TSA. ssISBs are optimal for reducing early postoperative pain (