Enhanced recovery after surgery in shoulder arthroplasty: a systematic review of perioperative outcomes

Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based perioperative care framework designed to reduce surgical stress, optimize physiological function, and accelerate post-operative recovery through standardized protocols. ERAS protocols have demonstrated clear benefits in hip and knee arthroplasty, yet their role in shoulder arthroplasty (SA) remains overlooked. The aim of this study is to assess the impact of ERAS protocols on perioperative outcomes in SA including pain control, opioid consumption, length of stay (LOS), and post-operative complications. 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 SA in which at least one ERAS-related perioperative intervention was compared with standard care and reported outcomes related to pain, opioid consumption, LOS, or complications. Study selection followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and qualitative synthesis was conducted in accordance with Synthesis Without Meta-analysis recommendations. 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-ISBs) provided superior pain relief over single-shot interscalene blocks 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. LOS was notably reduced with opioid-sparing regimens. Complication rates were generally low, with some studies reporting higher rates with C-ISB. This review found evidence that multimodal, opioid-sparing analgesia improves perioperative outcomes in SA. Techniques such as C-ISB, LB, and multimodal anaglesia minimize opioid use and reduce hospital stay without increasing complications. These findings support an evolving standard of care prioritizing patient safety and recovery while addressing opioid overuse.