Elective primary shoulder replacement surgery is most commonly performed under a general anaesthetic. In recent years pain control post-surgery for patients has changed greatly. Pain control is important to aid recovery and additional options are discussed with patients pre-operatively and choices made about supplementary pain blocking procedures and post-operative analgesia (pain killers). In addition to general anaesthesia, anaesthetists as routine now offer supplementary local anaesthetic interventions. Firstly a nerve block is an injection of anaesthetic into the nerves that supply the shoulder joint. The second option is local anaesthetic infiltration where a large volume of anaesthetic is injected it into the tissues around the operation site. It is considered that such adjunct pre-emptive analgesic methods allow shoulder replacement patients to wake up pain free and get up and out of bed almost immediately post-operatively which can aid earlier discharge from hospital and less peri-operative morbidity. Regional anaesthesia via inter-scalene nerve blocks under ultrasound guidance is now common practice in orthopaedic shoulder units for patients undergoing such surgery if there is no contraindication. These can be utilised instead or on top of general anaesthesia and do not benefit from augmentation with other nerve blocks or local anaesthetic infiltration. This review seeks to determine the most clinically effective and cost-effective approach to anaesthesia for total shoulder replacement surgery.