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This systematic review assessed the impact of Enhanced Recovery After Surgery (ERAS) protocols on perioperative outcomes in shoulder arthroplasty, including pain control, opioid consumption, length of stay, and postoperative complications. Analyzing 29 studies encompassing 141,042 patients, the review found that opioid-sparing and multimodal analgesic strategies, including continuous interscalene blocks (C-ISB) and liposomal bupivacaine (LB), reduced pain and opioid consumption, and shortened length of stay. While complication rates were generally low, some studies reported higher rates with C-ISB.
Multimodal, opioid-sparing analgesia, including C-ISB and liposomal bupivacaine, improves perioperative outcomes in shoulder arthroplasty by reducing pain, opioid use, and hospital stay.
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based perioperative care framework designed to reduce surgical stress, optimise physiological function, and accelerate postoperative recovery through standardised protocols. ERAS protocols have demonstrated clear benefits in hip and knee arthroplasty, yet their role in shoulder arthroplasty remains overlooked. AIM To assess the impact of ERAS protocols on perioperative outcomes in shoulder arthroplasty including pain control, opioid consumption, length of stay, and postoperative complications. METHODS A systematic search of PubMed, Embase, Medline, Cochrane Library, and Global Health was performed from inception to February 14, 2025. The search yielded 29 studies encompassing 141,042 patients. Eligible studies included adult patients undergoing shoulder arthroplasty in which at least one ERAS-related perioperative intervention was compared with standard care and reported outcomes related to pain, opioid consumption, length of stay, or complications. Study selection followed PRISMA guidelines, and qualitative synthesis was conducted in accordance with SWiM recommendations. RESULTS Opioid-free and multimodal analgesic strategies consistently reduced severity of pain and amount of opioid consumption, with opioid-free pathways additionally demonstrating effective pain control. Continuous interscalene blocks (C-ISB) provided superior pain relief over single-shot interscalene blocks (SS-ISB) within 24 hours. Liposomal bupivacaine (LB) showed significant pain reduction, although comparisons with other techniques were mixed. Opioid consumption was significantly lower in the LB, C-ISB, and multimodal groups. Length of stay was notably reduced with opioid-sparing regimens. Complication rates were generally low, with some studies reporting higher rates with C-ISB. CONCLUSION This review found evidence that multimodal, opioid-sparing analgesia improves perioperative outcomes in shoulder arthroplasty. Techniques such as C-ISB, LB and multi-modal anaglesia minimise opioid use, and reduce hospital stay without increasing complications. These findings support an evolving standard of care prioritising patient safety and recovery while addressing opioid overuse.
