Best Practices for Periarticular Infiltration With Liposomal Bupivacaine for the Management of Pain After Shoulder Surgery: Consensus Recommendation


Postsurgical pain, like that associated with major upper extremity surgery, can be significant and
usually require the use of opioid analgesics. However, opioids are associated with significant adverse
effects, including respiratory depression, which often drive the use of multimodal therapy with nonopioid analgesics, including local and regional analgesia techniques. However, use of older local anesthetics provides a limited duration of analgesia. An innovative formulation of liposomal bupivacaine (Exparel), which is approved for surgical site infiltration, can provide a longer duration of analgesia. Because optimal pain relief relies on the success of the surgical site infiltration technique, a group convened to address best practices for periarticular injection techniques for shoulder surgery. This article reviews the neuroanatomy of the shoulder, recommends optimal solutions (i.e., analgesic cocktails) and volume for injection, and provides a detailed description of the infiltration technique to develop the best approach to periarticular injection for major shoulder surgery. (Journal of Surgical Orthopaedic Advances 25(4):204–208, 2016) Key words: analgesia, liposomal bupivacaine, periarticular infiltration, postsurgical pain management, shoulder surgery

Girish P. Joshi, MBBS, MD, FFARCSI; Richard J. Hawkins, MD; Mark A. Frankle, MD; and Jeffrey S. Abrams, MD