The AAHKS Clinical Research Award: Liposomal Bupivacaine and Periarticular Injection Are Not Superior to Single-Shot Intra-articular Injection for Pain Control in Total Knee Arthroplasty

A Network Meta-Analysis of Randomized Controlled Trials Assessing Intraoperative Anesthetic Therapies for Analgesic Efficacy and Morphine Consumption Following Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to compare intraoperative anesthetic therapies for total knee arthroplasty (TKA) regarding postoperative analgesic efficacy and morphine consumption by conducting a systematic literature search.

METHODS

Randomized controlled trials of TKA using various anesthetic therapies were identified from various databases from conception through December 31, 2021. A network meta-analysis of relevant literature was performed to investigate which treatment showed better outcomes. In total, 40 trials were included in this study.

RESULTS

Surface under the cumulative ranking curve showed local infiltration anesthesia (LIA) with saphenous nerve block (SNB) to produce the best pain relief on postoperative days (PODs) 1 and 2 and the best reduction of morphine consumption on PODs 1 and 3. However, femoral nerve block showed the largest effect on pain relief on POD 3, and liposomal bupivacaine showed the largest effect on reduction of morphine consumption on POD 2.

CONCLUSIONS

According to this network meta-analysis, surface under the cumulative ranking curve percentage showed that LIA with SNB provided the best analgesic effect after TKA. Furthermore, patients receiving LIA with SNB had the lowest consumption of morphine. Although femoral nerve block resulted in better pain relief on POD 3, LIA with SNB could be selected first when trying to reduce morphine consumption or increase early ambulation.

Analgesic Effects of Different Local Infiltration Anesthesia Techniques Combined with Femoral Nerve Block in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Clinical Trial

Objective

Pain after total knee arthroplasty (TKA) remains an unresolved problem. Femoral nerve block (FNB) could relieve pain; however, it alone is insufficient. The local infiltration anesthesia technique (LIA) has been suggested as a supplement to FNB. This study aimed to evaluate the analgesic effects of different LIA combined with FNB in TKA patients.

Methods

The femoral nerve was blocked with 0.375% ropivacaine 20mL, and all patients routinely received general anesthesia. The primary indicator was the proportion of patients who did not receive post-operative remedial analgesia. Seventy-eight patients were randomly assigned to PAI (periarticular injection combined with FNB), IAI (intra-articular injection combined with FNB), or control (FNB alone) groups. All patients underwent FNB under general anesthesia. The primary outcome was the proportion of patients who did not receive additional postoperative analgesia within the first 48 h after surgery.

Results

Compared with the PAI and control groups, the IAI group had a higher proportion (69.23%) of patients who did not receive remedial analgesia within 48 hours after surgery (P = 0.009; P = 0.009), a lower consumption of diclofenac sodium lidocaine (P = 0.021; P < 0.001), and an earlier time of walking with a walker (P < 0.001; P < 0.001). The time of first need for remedial analgesia postoperatively in IAI group was longer than the PAI group (P = 0.008) and IAI group has a shorter hospital stay than the control group (P = 0.008). The maximum NRS during the first 48 hours postoperatively and NRS 24 hours after surgery in the IAI group were lower than those in the control and PAI groups. The incidences of POD and PONV were similar among the three groups (P = 0.610; P = 0.264).

Conclusion

When combined with FNB, intra-articular injection offers a superior analgesic effect and favorable recovery compared to periarticular injection and separate application of FNB.

Periarticular Injection in Total Knee Arthroplasty

Optimal pain management after total knee arthroplasty (TKA) can expedite postoperative recovery, improve perioperative outcomes, and increase patient satisfaction. Periarticular injections (PAIs) have become increasingly used to improve pain management after TKA. Similar to peripheral nerve blocks, the use of intraoperative PAIs can lower pain scores and expedite discharge from the hospital. However, there is notable variability in the ingredients and administration techniques of PAIs. Currently, no standard of care exists for PAIs, especially in the setting of adjuvant peripheral nerve blocks. This study seeks to evaluate the ingredients, administration techniques, and outcomes of PAIs used during TKA.

The Effects of Liposomal Bupivacaine on Long-term Outcomes and Decreasing Immediate Postoperative Opioid Use Following One-level and Two-level Posterior Lumbar Fusions

STUDY DESIGN

This is a retrospective observational study.

OBJECTIVE

This study aims to determine the efficacy of liposomal bupivacaine in postoperative analgesia and long-term outcomes in patients undergoing one-level and two-level posterior lumbar fusion.

SUMMARY OF BACKGROUND DATA

Multiple studies have investigated the use of liposomal bupivacaine in spine surgery with varying results. The potential benefits of its use include decreasing postoperative opioid use, improved pain control, and a shorter hospital stay. Several studies have supported its use in spine surgery with others showing minimal to no benefit. No studies have investigated its possible impact on long-term outcomes.

MATERIALS AND METHODS

A total of 42 patients (22 one-level, 20 two-level) received liposomal bupivacaine injection just before surgical closure and were compared with a historical control group of 42 patients (27 one-level, 15 two-level) that did not receive liposomal bupivacaine. Daily opioid consumption was collected and converted to oral morphine equivalents. Length of stay and daily average pain scores using the visual analog scale were also recorded. In addition, SF-36 bodily pain and physical function outcome measures were collected preoperatively and at 6 months, 1 year and 2 years postoperatively.

RESULTS

The liposomal bupivacaine group was found to have a significantly lower total opioid consumption compared with the control group ( P =0.001). The liposomal bupivacaine group was also found to use significantly fewer opioids on the day of surgery compared with the control group ( P <0.0001). There was no significant difference shown in the average visual analog scale pain scores, length of stay, or long-term outcomes between the 2 groups.

CONCLUSIONS

The use of liposomal bupivacaine in one-level and two-level posterior lumbar fusions shows promise as an adjuvant for postoperative analgesia by decreasing postoperative opioid consumption. With the varying results demonstrated with the utilization of liposomal bupivacaine in spine surgery, further investigation is warranted, namely a larger prospective randomized control study.

LEVEL OF EVIDENCE

Level III.

Comparison of the Effect of Intra-Articular, Periarticular, and Combined Injection of Analgesic on Pain Following Total Knee Arthroplasty: A Double-Blinded Randomized Clinical Trial

The aim of this study was to compare the efficacy of 3 methods of intraoperative analgesic cocktail injection during total knee arthroplasty (TKA)—intra-articular (IA), periarticular (PA), and combined intra-articular and periarticular (IA+PA)—on controlling early postoperative pain.

The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis

BACKGROUND

Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine.

METHODS

The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI.

RESULTS

Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine.

CONCLUSION

Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.

Efficacy of Liposomal Bupivacaine and Bupivacaine Hydrochloride vs Bupivacaine Hydrochloride Alone as a Periarticular Anesthetic for Patients Undergoing Knee Replacement: A Randomized Clinical Trial

Question

Among patients undergoing knee replacement surgery, does liposomal bupivacaine and bupivacaine hydrochloride administered at the surgical site improve postoperative recovery at 72 hours and postoperative pain from 6 to 72 hours compared with bupivacaine hydrochloride alone?

Findings

In this randomized clinical trial of 533 patients undergoing knee replacement surgery, no difference in the coprimary outcomes of Quality of Recovery 40 score at 72 hours or pain visual analog scale score area under the curve from 6 to 72 hours was detected between patients receiving liposomal bupivacaine and bupivacaine hydrochloride and those receiving bupivacaine hydrochloride alone. In addition, liposomal bupivacaine was not found to be cost-effective.

Meaning

This study found that liposomal bupivacaine did not improve postoperative recovery or pain compared with bupivacaine hydrochloride alone among patients undergoing knee replacement surgery.

Importance

More than half of patients who undergo knee replacement surgery report substantial acute postoperative pain.

Objective

To evaluate the efficacy and cost-effectiveness of periarticular liposomal bupivacaine for recovery and pain management after knee replacement.

Design, Setting, and Participants

This multicenter, patient-blinded, pragmatic, randomized clinical superiority trial involved 533 participants at 11 institutions within the National Health Service in England. Adults undergoing primary unilateral knee replacement for symptomatic end-stage osteoarthritis were enrolled between March 29, 2018, and February 29, 2020, and followed up for 1 year after surgery. Follow-up was completed March 1, 2021. A per-protocol analysis for each coprimary outcome was performed in addition to the main intention-to-treat analysis.

Interventions

Two hundred sixty-six milligrams of liposomal bupivacaine admixed with 100 mg of bupivacaine hydrochloride compared with 100 mg of bupivacaine hydrochloride alone (control) administered by periarticular injection at the time of surgery.

Main Outcome and Measures

The coprimary outcomes were Quality of Recovery 40 (QoR-40) score at 72 hours and pain visual analog scale (VAS) score area under the curve (AUC) from 6 to 72 hours. Secondary outcomes included QoR-40 and mean pain VAS at days 0 (evening of surgery), 1, 2, and 3; cumulative opioid consumption for 72 hours; functional outcomes and quality of life at 6 weeks, 6 months, and 1 year; and cost-effectiveness for 1 year. Adverse events and serious adverse events up to 12 months after randomization were also assessed.

Results

Among the 533 participants included in the analysis, the mean (SD) age was 69.0 (9.7) years; 287 patients were women (53.8%) and 246 were men (46.2%). Baseline characteristics were balanced between study groups. There was no difference between the liposomal bupivacaine and control groups in QoR-40 score at 72 hours (adjusted mean difference, 0.54 [97.5% CI, −2.05 to 3.13]; P = .64) or the pain VAS score AUC at 6 to 72 hours (−21.5 [97.5% CI, −46.8 to 3.8]; P = .06). Analyses of pain VAS and QoR-40 scores demonstrated only 1 statistically significant difference, with the liposomal bupivacaine arm having lower pain scores the evening of surgery (adjusted difference −0.54 [97.5% CI, −1.07 to −0.02]; P = .02). No difference in cumulative opioid consumption and functional outcomes was detected. Liposomal bupivacaine was not cost-effective compared with the control treatment. No difference in adverse or serious adverse events was found between the liposomal bupivacaine and control groups.

Conclusions and Relevance

This study found no difference in postoperative recovery or pain associated with the use of periarticular liposomal bupivacaine compared with bupivacaine hydrochloride alone in patients who underwent knee replacement surgery.

Trial Registration

isrctn.com Identifier: ISRCTN54191675

Interscalene Brachial Plexus Block with Liposomal Bupivacaine versus Standard Bupivacaine with Perineural Dexamethasone: A Noninferiority Trial

BACKGROUND

The interscalene nerve block provides analgesia for shoulder surgery. To extend block duration, provide adequate analgesia, and minimize opioid consumption, the use of adjuvants such as dexamethasone as well as the application of perineural liposomal bupivacaine have been proposed. This randomized, double-blinded, noninferiority trial hypothesized that perineural liposomal bupivacaine is noninferior to standard bupivacaine with perineural dexamethasone in respect to average pain scores in the first 72 h after surgery.

METHODS

A total of 112 patients undergoing ambulatory shoulder surgery were randomized into two groups. The liposomal bupivacaine group received a 15-ml premixed admixture of 10 ml of 133 mg liposomal bupivacaine and 5 ml of 0.5% bupivacaine (n = 55), while the bupivacaine with dexamethasone group received an admixture of 15 ml of 0.5% standard bupivacaine with 4 mg dexamethasone (n = 56), respectively. The primary outcome was the average numerical rating scale pain scores at rest over 72 h. The mean difference between the two groups was compared against a noninferiority margin of 1.3. Secondary outcomes were analgesic block duration, motor and sensory resolution, opioid consumption, numerical rating scale pain scores at rest and movement on postoperative days 1 to 4 and again on postoperative day 7, patient satisfaction, readiness for postanesthesia care unit discharge, and adverse events.

RESULTS

A liposomal bupivacaine group average numerical rating scale pain score over 72 h was not inferior to the bupivacaine with dexamethasone group (mean [SD], 2.4 [1.9] vs. 3.4 [1.9]; mean difference [95% CI], -1.1 [-1.8, -0.4]; P < 0.001 for noninferiority). There was no significant difference in duration of analgesia between the groups (26 [20, 42] h vs. 27 [20, 39] h; P = 0.851). Motor and sensory resolutions were similar in both groups: 27 (21, 48) h versus 27 (19, 40) h (P = 0.436) and 27 [21, 44] h versus 31 (20, 42) h (P = 0.862), respectively. There was no difference in opioid consumption, readiness for postanesthesia care unit discharge, or adverse events.

CONCLUSIONS

Interscalene nerve blocks with perineural liposomal bupivacaine provided effective analgesia similar to the perineural standard bupivacaine with dexamethasone. The results show that bupivacaine with dexamethasone can be used interchangeably with liposomal bupivacaine for analgesia after shoulder surgery.

EDITOR’S PERSPECTIVE

Liposomal Bupivacaine Infiltration Versus Bupivacaine Hydrochloride for the Management of Unilateral Total Knee Arthroplasty in Geriatric Patients at a 287-Bed Community Hospital

Introduction: Geriatric patients receiving total knee arthroplasty (TKA) are found to have similar postoperative complications, functional scores, and perioperative mortality, as compared to younger patients. Conversely, geriatric patients often have longer lengths of stay. Periarticular injection (PAI) of liposomal bupivacaine (LB) as part of the multimodal pain management strategy is thought to improve recovery, however, mixed comparative efficacy data exists for its use in TKA.2-5. Methods: A retrospective, chart review was conducted at a 287-bed community teaching hospital. Orthopedic surgical patients who received an infiltration with liposomal bupivacaine versus bupivacaine HCl for unilateral TKA were compared. Patients identified in the electronic medical record by Diagnosis Related Group (DRG) 470-major joint replacement or reattachment of lower extremity without major complication or comorbidity codes were utilized. Patients who meet the following criteria were included: age 65 and older who underwent a TKA between 8/1/2018 to 7/31/2019 were discharged to home. Patients who have contraindications or hypersensitivity to bupivacaine formulations or a history of opioid dependence were excluded. The primary outcome is to identify whether patients who received an infiltration with liposomal bupivacaine had a lower total opioid consumption during their hospital stay. Results: A total of 114 patients who had a DRG 470 code and were above the age of 65 years were studied. There was no statistically significant difference in mean total opioid consumption (oral morphine equivalents) between the bupivacaine HCl (n = 25) and liposomal groups (n = 85) respectively, 93.76 versus 83.72 mg; P = .569. In addition, patients in both groups had similar lengths of hospital stay, 2.5 versus 3 days; P = .529 and mean pain scores until discharge 3.7 versus 4.34 on VAS; P = .305. Conclusion: The results of this drug utilization evaluation do not support a strong clinical advantage with local infiltration of liposomal bupivacaine over bupivacaine HCl in geriatric patients undergoing primary TKA surgery at this institution. There was not a statistically significant difference in mean total opioid consumption between the 2 groups. Additionally, the use of non-opioid analgesics, mean pain scores, and hospital lengths of stay were similar in both groups.

Liposomal Bupivacaine Versus Immediate-Release Bupivacaine for Postoperative Pain Control

BACKGROUND

Liposomal bupivacaine (LB) is increasingly being used for postoperative pain control, but there are conflicting efficacy data when compared with immediate-release bupivacaine (IRB).

OBJECTIVE

To evaluate the comparative efficacies of LB and IRB for postoperative pain control in order to assess the formulary status of LB at our institution.

METHODS

A single-center, retrospective, institutional review board-approved, noninferiority matched cohort study at a tertiary care academic medical center. Adult surgical patients admitted for >24 hours who received LB or IRB were included. The primary outcome was total opioid consumption within 24 hours postoperatively. Secondary outcomes included total opioid consumption within 72 hours postoperatively, nonopioid analgesic use within 24 and 72 hours postoperatively, time to rescue analgesic use, and postoperative length of stay (LOS).

RESULTS

A total of 326 patients were included in the matched cohort. Median 24-hour opioid consumption was significantly lower in the IRB group compared with the LB group (81 mg [30, 153] vs 103 mg [46, 241]; P = 0.01). Patients receiving IRB compared with LB also had a decrease in total opioid consumption 72 hours postoperatively (110 mg [45, 258] vs 165 mg [68, 402]; P = 0.005) and shorter postoperative LOS (2.8 days [1.7, 4] vs 3.3 days [2, 5.1]; P < 0.001). There was no difference in time to rescue analgesic use.

CONCLUSION AND RELEVANCE

Across a variety of surgical procedures, administration of IRB compared with LB was associated with a reduction in total opioid consumption within 24 and 72 hours postoperatively and shorter LOS in adult surgical patients.

Comparison of Periarticular Infiltration and Combination Delivery of Local Anesthetics for Reducing Pain and Opioid Consumption after Total Knee Arthroplasty

Surgical-site delivery of local anesthetics decreases pain and opioid consumption after total knee arthroplasty (TKA). The optimal route of administration is unknown. We compared local anesthetic delivery using periarticular soft-tissue infiltration to delivery using a combination of preimplantation immersion and intra-articular injection (combination treatment). The records of patients who underwent unilateral, cemented, primary TKA with spinal anesthesia and adductor canal blocks at a single Veterans Affairs Medical Center were retrospectively reviewed. Three subgroups were compared, including controls who did not receive additional local anesthetics, patients who received periarticular infiltration, and patients who received combination treatment. Mean daily pain scores and mean 24-hour opioid consumption on postoperative days (PODs) 0 and 1 were calculated, and analysis of variance was used to assess for significant differences. Factors that were associated with lower pain scores and opioid consumption were then identified using multivariate stepwise regression. There were 26 controls, 25 periarticular infiltration patients, and 39 combination patients. The periarticular infiltration cohort had significantly lower mean pain scores and opioid consumption than controls on POD 0, but not on POD 1. The combination cohort had significantly lower mean pain scores and opioid consumption than controls on PODs 0 and 1. There were no significant differences between the infiltration and combination groups on either day. Multivariate regression analysis showed that infiltration was associated with significantly decreased opioid consumption on both days and decreased pain on POD 0. Combination treatment was associated with significantly decreased pain and opioid consumption on both days. Both local anesthetic periarticular infiltration and combination treatment are associated with decreased pain and opioid consumption after TKA. The stronger effects of the combination treatment compared with periarticular infiltration on POD 1 suggests that combination delivery may have a longer duration of action.

Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty

ABSTRACT

The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.

Reduction of Opioid Use With Enhanced Recovery Program for Total Knee Arthroplasty

Background

Adequate pain control after total knee arthroplasty (TKA) is critically important to achieve early mobilization, shorten the length of hospital stay, and reduce postoperative complications. At Veterans Affairs North Texas Health Care System (VANTHCS) in Dallas, we implemented a multidisciplinary enhanced recovery after surgery (ERAS) protocol to deal with increasing length of stay and postoperative pain. We hypothesize that this protocol will reduce the overall opioid burden and decrease inpatient hospital length of stay in our TKA population.

Methods

A retrospective review of all TKAs performed by a single surgeon at VANTHCS from 2013 to 2018 was conducted. A postoperative ERAS protocol was implemented in 2016. We compared perioperative opioid use and LOS between cohorts before and after protocol implementation.

Results

Inpatient length of stay between cohorts was reduced from 66.8 hours for the standard of care (SOC) period to 22.3 hours in the ERAS cohort. Inpatient opioid use measured by total oral morphine equivalent doses averaged 169.5 mg and 66.7 mg for SOC and ERAS cohorts, respectively (P = .0001). Intraoperative use of opioids decreased from 57.4 mg in the SOC cohort to 10.5 mg in the ERAS cohort (P = .0001). Postanesthesia care unit (PACU) opioid use decreased from 13.6 mg (SOC) to 1.3 mg (ERAS) (P = .0002). There was no significant difference in complications between cohorts (P = .09).

Conclusions

Initiating a multidisciplinary ERAS protocol for TKA at VANTHCS significantly reduced inpatient length of stay and perioperative opioid use with no deleterious effects on complication rates. The ERAS protocol has major medical and financial implications for our unique VA population and the VA health care system.

The Efficacy of Liposomal Bupivacaine for Opioid and Pain Reduction: A Systematic Review of Randomized Clinical Trials

Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.

Comparison of Periarticular Injection and Intra-articular Injection for Pain Management After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

PURPOSE

Local infiltration analgesia, an essential component of multimodal analgesia after total knee arthroplasty (TKA), can be classified into periarticular injection (PAI) and intra-articular injection (IAI) as per administration techniques. Currently, there is no definite answer of the optimal choice between the two techniques. This meta-analysis aims to determine whether PAI provides superiority of pain relief and functional recovery than IAI after TKA.

DESIGN

Systematic review and meta-analysis.

METHODS

Comparative studies that compared PAI and IAI in patients after TKA were searched in the Embase, PubMed, MEDLINE, and the Cochrane Library databases. The primary outcomes were visual analog scale scores for pain and opioid consumption. The secondary outcomes were complications, function of recovery, and length of hospital stay.

FINDINGS

Four randomized controlled trials and two case-controlled studies with a total of 769 patients were enrolled. There were no significant differences in mean visual analog scale scores at postoperative day 0 (P = .17) and day 1 (P = .27), maximum visual analog scale scores at day 0 (P = .89) and day 1 (P = .82), total opioid consumption at day 1 (P = .96), opioid complications (P = .15), and length of hospital stay (P = .84) between PAI and IAI.

CONCLUSIONS

Based on the available evidence, PAI does not offer superior effects at pain control and discharge than IAI after TKA. However, owing to the limited sample size and heterogeneity of the included studies, further large well-designed randomized controlled trials are still needed to validate this conclusion.

REGISTRATION

The protocol has been registered in the PROSPERO international database under number CRD42020165138.

Narcotic-Free Perioperative Total Knee Arthroplasty: Does the Periarticular Injection Medication Make a Difference?

Multimodal pain management strategies are critical in total knee arthroplasty (TKA). There has recently been a shift toward opioid sparing protocols, yet most publications continue to use narcotics in the perioperative period. Periarticular injections are a popular adjunct but studies regarding the optimal medications have high variability making it difficult to choose the optimal medication. The purpose of this study is to validate a perioperative, opioid-free protocol and compare two different periarticular injections without the variability in previous reports. A multimodal pain protocol was instituted that administered no narcotic medications in the perioperative period. Over 2 years, primary TKA patients were informally randomized to receive liposomal bupivacaine (LB), or a cocktail of medications (CO). A total of 189 patients were included: 101 patients in group LB and 88 patients in group CO. Postoperative opioid consumption, length of stay, and inpatient distance ambulated were compared across the two injection groups. In morphine milligram equivalents, group LB consumed a mean of 20.36 mg of oxycodone versus 23.18 mg in group CO (p = 0.543). For tramadol, group LB consumed 27.24 mg versus 28.69 mg in group CO (p = 0.714). Mean hospital stay was 1.70 days for group LB and 1.72 days for group CO (p = 0.811). Distance ambulated was 528.4ft for group LB and 499.8ft for group CO (p = 0.477). In the LB group, 50% of patients required no oxycodone, and 12% of them took neither oxycodone nor tramadol for pain. In the CO group, 40% declined oxycodone and 10% declined both oxycodone and tramadol. We successfully treated all patients without narcotic medications in the perioperative period. Although we saw trends for improvements in group LB, these were small and not clinically meaningful. It appears that both injections were effective. There is a significant cost difference and medications should be chosen based on surgeon preference and institutional needs.

Clinical Effectiveness of Liposomal Bupivacaine Administered by Infiltration or Peripheral Nerve Block to Treat Postoperative Pain

The authors provide a comprehensive summary of all randomized, controlled trials (n = 76) involving the clinical administration of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, USA) to control postoperative pain that are currently published. When infiltrated surgically and compared with unencapsulated bupivacaine or ropivacaine, only 11% of trials (4 of 36) reported a clinically relevant and statistically significant improvement in the primary outcome favoring liposomal bupivacaine. Ninety-two percent of trials (11 of 12) suggested a peripheral nerve block with unencapsulated bupivacaine provides superior analgesia to infiltrated liposomal bupivacaine. Results were mixed for the 16 trials comparing liposomal and unencapsulated bupivacaine, both within peripheral nerve blocks. Overall, of the trials deemed at high risk for bias, 84% (16 of 19) reported statistically significant differences for their primary outcome measure(s) compared with only 14% (4 of 28) of those with a low risk of bias. The preponderance of evidence fails to support the routine use of liposomal bupivacaine over standard local anesthetics.

Which is the best analgesia treatment for total knee arthroplasty: Adductor canal block, periarticular infiltration, or liposomal bupivacaine? A network meta-analysis

STUDY OBJECTIVE

To review all randomized controlled trials (RCTs) comparing the analgesic efficacy of adductor canal block (ACB), periarticular infiltration (PAI), and any other mode of these treatments in analgesia, such as PAI with liposomal bupivacaine (LB), continuous adductor canal block (cACB) or ACB + PAI, after total knee arthroplasty (TKA).

DESIGN

Systematic review and network meta-analysis of RCTs.

PATIENTS

We searched PubMed, Embase, and the Cochrane database to detect all relevant RCTs on investigating the analgesic effects of ACB, PAI and LB for TKA published until April 2020.

INTERVENTIONS

Use of different analgesic methods of ACB, PAI, cACB, ACB + PAI and LB.

MEASUREMENTS

The primary endpoint was visual analog scale (VAS) score at rest and movement. The secondary endpoints were opioids consumption, length of hospitalization and knee range of motion (ROM). We used Cochrane risk of bias to assess the quality of evidence for outcomes.

RESULTS

Forty-two studies involving 3785 patients with 5 different methods containing ACB, PAI, ACB + PAI, continuous ACB (cACB), LB, were evaluated. According to surface under the cumulative ranking curve value, 24 h resting VAS score was the lowest the ACB + PAI (88.4%), followed by cACB (73.4%); Resting VAS score at 48 h and movement VAS score at 24 h and 48 h was the lowest in the cACB (99.9%, 92% and 100%). Total opioids consumption was the least in LB (81.4%) before cACB (60.8%). ROM was the largest in the ACB + PAI (84.1%) before cACB (78.8%).

CONCLUSION

Although all analgesic methods available were not evaluated, and further studies are needed to establish our results, the 24 h resting VAS score was lowest in ACB + PAI and 48 h resting and movement VAS score was lowest in cACB.

CLINICAL TRIAL REGISTRATION

PROSPERO (CRD 42020168102).

The Impact of Epinephrine in the Periarticular Injection Cocktail using Ropivacaine for Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind Comparison Study

BACKGROUND

Epinephrine is used in periarticular injection using ropivacaine to produce a synergistic effect when used with local anesthetic agents but the effect has not been proven yet. The purpose of this study is to evaluate how effective epinephrine is on postoperative clinical outcomes in primary total knee arthroplasty (TKA).

METHODS

One hundred sixteen cases (89 patients) who underwent primary TKA were randomized into 2 groups depending on whether epinephrine was mixed. Immediately after the operation, patient-controlled analgesia using fentanyl was initiated. The Numerical Rating Scale, the cumulative dose of fentanyl, active range of motion of the knee joint, and wound complications were evaluated postoperatively.

RESULTS

There were no significant differences in mean postoperative Numerical Rating Scale, cumulative dose of fentanyl, and active range of motion between the 2 groups. Neither skin necrosis nor wound dehiscence requiring operative management for skin care was required in either group.

CONCLUSION

The use of epinephrine in periarticular injection using ropivacaine after TKA did not have any effect on postoperative acute pain control and opioid usage.

THE LEVEL OF EVIDENCE

Therapeutic level I.

Surgeon-Performed High-Dose Bupivacaine Periarticular Injection With Intra-Articular Saphenous Nerve Block Is Not Inferior to Adductor Canal Block in Total Knee Arthroplasty

BACKGROUND

Periarticular injection or anesthesiologist-performed adductor canal block are commonly used for pain management after total knee arthroplasty. A surgeon-performed, intra-articular saphenous nerve block has been recently described. There is insufficient data comparing the efficacy and safety of these methods.

METHODS

This is a retrospective two-surgeon cohort study comparing short-term perioperative outcomes after primary total knee arthroplasty, in 50 consecutive patients with surgeon-performed high-dose periarticular injection and intra-articular saphenous nerve block (60 mL 0.5% bupivacaine, 30 mL saline, 30mg ketorolac) and 50 consecutive patients with anesthesiologist-performed adductor canal catheter (0.25% bupivacaine 6 mL/h infusion pump placed postoperatively with ultrasound guidance). Chart review assessed pain scores through POD #1, opioid use, length of stay, and short-term complications, including local anesthetic systemic toxicity. Statistical analysis was performed with two-tailed Student's T-test.

RESULTS

The high-dose periarticular injection cohort had significantly lower pain scores in the postanesthesia care unit (mean difference 1.4, P = .035), on arrival to the inpatient ward (mean difference 1.7, P = .013), and required less IV narcotics on the day of surgery (mean difference 6.5 MME, P = .0004). There was no significant difference in pain scores on POD #1, total opioid use, day of discharge, or short-term complications. There were no adverse events related to the high dose of bupivacaine.

CONCLUSION

Compared with postoperative adductor canal block catheter, an intraoperative high-dose periarticular block demonstrated lower pain scores and less IV narcotic use on the day of surgery. No difference was noted in pain scores on POD #1, time to discharge, or complications. There were no cardiovascular complications (local anesthetic systemic toxicity) despite the high dose of bupivacaine injected.

LEVEL OF EVIDENCE

III.

Efficacy of local infiltration anesthesia versus interscalene nerve blockade for total shoulder arthroplasty

Background

Optimal modalities for pain control in shoulder arthroplasty are not yet established. Although regional nerve blockade has been a well-accepted modality, complications and rebound pain have led some surgeons to seek other pain control modalities. Local injection of anesthetics has recently gained popularity in joint arthroplasty. The purpose of this study was to evaluate the effectiveness and complication rate of a low-cost local anesthetic injection mixture for use in total shoulder arthroplasty (TSA) compared with interscalene brachial plexus blockade.

Methods

A total of 314 patients underwent TSA and were administered general anesthesia with either a local injection mixture (local infiltration anesthesia [LIA], n = 161) or peripheral nerve block (PNB, n = 144). Patient charts were retrospectively reviewed for postoperative pain scores, 24-hour opioid consumption, and 90-day postoperative complications.

Results

Immediate postoperative pain scores were not significantly different between groups (P = .94). The LIA group demonstrated a trend toward lower pain scores at 24 hours postoperatively (P = .10). Opioid consumption during the first 24 hours following surgery was significantly reduced in the LIA group compared with the PNB group (P < .0001). There was a trend toward fewer postoperative nerve and cardiopulmonary complications in the LIA group than the PNB group (P = .22 and P = .40, respectively)

Conclusion

Periarticular local injection mixtures provide comparable pain control to regional nerve blocks while reducing opioid use and postoperative complications following TSA. Local injection of a multimodal anesthetic solution is a viable option for pain management in TSA.

Liposomal Bupivacaine Offers No Benefit Over Ropivacaine for Multimodal Periarticular Injection in Total Knee Arthroplasty

Local infiltration analgesia has become a mainstay of pain control for total knee arthroplasty. This study compared the efficacy and cost between periarticular injection cocktails containing liposomal bupivacaine vs ropivacaine. Two hundred forty-two primary total knee arthroplasties performed between September 2013 and January 2016 were retrospectively reviewed. All patients received similar pre-operative medications and a periarticular injection. The control group received 300 mg of ropivacaine, while the study group received liposomal bupivacaine. All patients received the same preoperative, intraoperative, and postoperative adjunct medications. Visual analog scale pain scores, narcotic requirements, distance walked, range of motion, length of stay, Knee Society Scores, and need for manipulation under anesthesia were recorded. Mean visual analog scale pain score 23 to 32 hours postoperatively, mean visual analog scale pain score during the entire hospitalization, and length of stay were lower in the ropivacaine group compared with the liposomal bupivacaine group. Knee range of motion was higher at 2 weeks in the ropivacaine group. There were no statistically significant differences in the other outcome measures. The cost of ropivacaine was considerably lower than the cost of liposomal bupivacaine. Bupivacaine added to liposomal bupivacaine addressed the delayed onset of this medication and gave an accurately matched comparison with the ropivacaine cocktail. All outcomes tested with liposomal bupivacaine were either equivalent or inferior to those with ropivacaine. When used as a component of a periarticular injection cocktail, liposomal bupivacaine offers no advantages over ropivacaine and has a considerably higher cost. [Orthopedics. 2020; 43(2):91-96.].

Efficacy of Adductor Canal Block With Liposomal Bupivacaine: A Randomized Prospective Clinical Trial

This study compared the postoperative analgesic efficacy of liposomal bupivacaine as a single-administration adductor canal block (ACB) vs periarticular injection (PAI) for pain control after total knee arthroplasty (TKA). From May 2016 to June 2017, a total of 70 unilateral TKA patients were randomized into 2 groups: PAI (extended-release bupivacaine 266 mg [20-mL vial] with 20 mL of 0.5% bupivacaine hydrochloride and normal saline to a total volume of 120 mL) and ACB (subsartorial saphenous nerve using extended-release bupivacaine 266 mg [20-mL vial]). All patents underwent spinal anesthesia with comprehensive preemptive and postoperative multi-modal pain protocol. All opioids administered were converted to morphine equivalents. Pain was recorded at 4 to 12 hours on the day of surgery, and on postoperative days 1, 2, and 3. Patients and investigators other than the surgeon and anesthesiologist were blinded to the study. The difference in pain scores between the PAI and ACB groups was not statistically significant during the first 12 hours (day 0) after surgery or on postoperative day 1 (5.31 vs 4.26, P=.091). However, on postoperative day 3, the mean pain score increased in the ACB group and decreased in the PAI group (4.8 vs 1.83, P=.037). There was no statistically significant difference between the 2 groups regarding the accumulative daily converted morphine equivalent consumption or total consumption. Although the PAI group demonstrated longer lasting pain relief than the ACB group for the duration of the study, other outcomes were similar between the 2 groups. [Orthopedics. 2020; 43(1):e47-e53.].

Evaluation of the Efficacy of Liposomal Bupivacaine in Total Joint Arthroplasty

BACKGROUND

Appropriate pain control is one of the cornerstones necessary to promote positive clinical outcomes. A new bupivacaine liposomal formulation was designed to extend its analgesic effect for up to 72-hours post-surgery, reportedly leading to significant opioid-sparing.

METHOD

Retrospective and prospective chart review conducted in a 178-bed academic institution between January 2013 to December 2013 and August 2014 to November 2014, in 115 patients that receive hip and knee arthroplasty. The primary outcome was the measurement of average daily pain score on post-operative days 1 and 2. Secondary outcomes included length of stay, overall opioid use post-surgery and pain control satisfaction using Press-Ganey® scores.

RESULTS

The average pain scores in the HCl group were 4.64 and 4.38 (Likert score: 0-10) for POD 1 and POD 2, compared to 4.72 POD 1 and 4.2 POD 2 in the liposome group (POD 1: p = 0.413; POD 2: p = 0.303). The difference in LOS for knee arthroplasty was statistically significant [HCl group: 1.94 days (± 0.66) versus liposome group: 2.27 days (±0.77) p-value = 0.038)] favoring the standard of care. For hip arthroplasty or bilateral knee arthroplasty the differences in LOS were not statistically significant (p = 0.052 and p = 0.484 respectively). 93% of the patients in the HCl group, pain was well controlled, versus 88.5% in the liposome group with similar oxycodone IR use among groups.

CONCLUSION

Liposome bupivacaine did not offer a notable benefit compared to the HCl formulation in our study.

The Efficacy of Liposomal Bupivacaine Over Traditional Local Anesthetics in Periarticular Infiltration and Regional Anesthesia During Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Since its Food and Drug Administration approval in 2011 as a local anesthetic for postsurgical analgesia, liposomal bupivacaine (LB) has been incorporated into the periarticular injection (PAI) of many knee surgeons. The slow release of this medication from vesicles should significantly extend the duration of its analgesic effect, but current evidence has not clearly demonstrated this benefit.

METHODS

We systematically searched electronic databases including PubMed, MEDLINE, Cochrane Library, EMBASE, ScienceDirect, and Scopus, as well as the Journal of Arthroplasty web page for relevant articles. All calculations were made using Review Manager 5.3.

RESULTS

We identified 42 studies that compared LB to an alternate analgesic modality. Seventeen of these studies were controlled trials that were included in meta-analysis. Significant differences were seen in pain scores with LB over a peripheral nerve block (mean difference = 0.45, P = .02) and LB over a traditional PAI (standard mean difference = -0.08, P = .004).

CONCLUSION

While LB may offer a statistically significant benefit over a traditional PAI, the increase in pain control may not be clinically significant and it does not appear to offer a benefit in reducing opioid consumption. However, there is no standardization among current studies, as they vary greatly in design, infiltration technique, and outcome measurement, which precludes any reliable summarization of their results. Future independent studies using a standardized protocol are needed to provide clear unbiased evidence.

The efficacy of liposomal bupivacaine compared with traditional peri-articular injection for pain control following total knee arthroplasty: an updated meta-analysis of randomized controlled trials

Background

The efficacy of postoperative pain management is an important factor that influences the final outcome of total knee arthroplasty (TKA). Whether liposomal bupivacaine offers better efficacy compared with traditional peri-articular injection after TKA remains inconclusive. We conduct this study to compare the true efficacy of liposomal bupivacaine (LB) with traditional peri-articular injection (TPAI) following TKA.

Materials and methods

Randomized controlled trials (RCTs) from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science were searched. Thirteen RCTs involving 1373 patients were finally included in our meta-analysis (LB = 691, TPAI = 682). The continuous and dichotomous outcome were collected in a standard form, and the data were analysed by using Review Manager 5.3 software. Finally, the results were presented in the forest plots.

Result

The pooled data demonstrated that the postoperative visual analogue score (VAS) in the LB group was not significantly different compared with that in the TPAI group at every time period after TKA. The liposomal bupivacaine group had significantly lower consumption of morphine equivalents 24 to 72 h postoperatively and reduced incidence of nausea and vomiting after TKA compared with the TPAI group. Finally, the length of hospital stay in the two groups was not significantly different.

Conclusion

Liposomal bupivacaine did not yield different results on the visual analogue scale compared with traditional peri-articular injection after total knee arthroplasty. However, liposomal bupivacaine was preferred in terms of lower consumption of morphine equivalents 24–72 h postoperatively and lower incidence of nausea and vomiting after total knee arthroplasty.

Improved pain control with adductor canal block using liposomal bupivacaine after total knee replacement: a retrospective cohort study

Background

Adductor canal blocks (ACBs), typically administered with a local anesthetic such as bupivacaine, help control perioperative pain after total knee arthroplasty. Recently, liposomal bupivacaine (LB) was introduced in an attempt to extend the duration of analgesia, used primarily in periarticular injections (PAIs). The purpose of this study was to compare pain control and early perioperative outcomes with ACB using LB vs standard bupivacaine (SB).

Methods

We retrospectively compared pain control in a group of 75 patients with ACB and PAI with SB to that of a cohort of 75 patients who received ACB and PAI with LB. The primary outcome measure was pain measured using the visual analog score. The secondary outcome measures were morphine equivalents of pain medication (ME), physical therapy distance ambulated, disposition status, and length of stay.

Results

There were no significant differences between the two cohorts for age, gender, body mass index, preoperative diagnosis, or American Society of Anesthesiologists. Visual analog scores were significantly lower in the LB group for postoperative day (POD) 0 (2.1 vs 2.8, P = .046), POD 1 (2.2 vs 3.3, P < .001), and POD 2 (2.1 vs 3.7, P = .001) than those in the SB group. The LB group consumed significantly fewer ME on the POD 0 (18.7 vs 25.2, P = .02) and POD 1 (23.4 vs 37.8, P = .003), as well as overall ME/day (24.6 vs 41.7, P < .001). The LB group walked more on POD 0 (261.6 vs 108.2, P < .001) and POD 1 (761.5 vs 372.0, P < .001).

Conclusions

We report improved outcomes across all measures for the LB group. There were no adverse events. This study supports the use of LB for ACBs in total knee arthroplasty.

Liposomal Bupivacaine Versus Standard Periarticular Injection in Total Knee Arthroplasty With Regional Anesthesia: A Prospective Randomized Controlled Trial

BACKGROUND

Liposomal bupivacaine (Exparel) is a long-acting local anesthetic preparation with demonstrated efficacy over placebo in reducing postoperative pain and opioid requirement. Limited comparative efficacy and cost-effectiveness data exist for its use in total knee arthroplasty (TKA) when used in a multimodal, opioid-sparing analgesic and anesthetic approach. We hypothesized that liposomal bupivacaine offers no clinical advantage over our standard of care but carries significant economic impact.

METHODS

This is a prospective, randomized, single-blinded, controlled trial comparing liposomal bupivacaine periarticular injection (PAI) to our current approach including conventional bupivacaine PAI, in the setting of regional anesthesia. All adult unilateral TKA patients of the collaborating surgeon were eligible to participate in the study. Patients were randomized 1:1 to either the liposomal bupivacaine protocol or the standard-of-care protocol. All patients received regional anesthesia and standard postoperative analgesia protocols. Patients and all postoperative healthcare providers were blinded to study arm assignment.

RESULTS

A total of 59 patients were enrolled per our a priori power calculation after 1 exclusion for randomization error. No significant demographic differences between the study arms were found. There was no statistically significant difference in the primary outcome of number of physical therapy (PT) sessions required to achieve home-going discharge goals (3.0 ± 1.2 vs 3.6 ± 1.3, P = .137), nor in the clinical secondary outcomes. A significant difference in medication charges was found.

CONCLUSION

Our study supports earlier literature suggesting no significant clinical benefit of using liposomal bupivacaine over standard of care in TKA and underscores cost-of-care concerns with this agent.

The efficacy of local liposomal bupivacaine infiltration on pain and recovery after Total Joint Arthroplasty: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Total Joint Arthroplasty (TJA) is gradually emerging as the treatment of choice for end-stage osteoarthritis. In the past, Perioperative liposomal bupivacaine treatment is still a controversial subject in TJA. Therefore, we write this systematic review and meta-analysis to evaluate the efficacy of liposomal bupivacaine on pain and recovery after TJA.

MATERIALS AND METHODS

Embase, Pubmed, and Cochrane Library were comprehensively searched. Randomized controlled trials (RCTs), cohort studies were included in our meta-analysis. Twelve studies that compared liposomal bupivacaine groups with placebo groups were included in our meta-analysis. The research was reported according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. RCTs were included in our meta-analysis.

RESULTS

Our study demonstrated that liposomal bupivacaine group was as effective as the placebo group in term of VAS score at 24 h (P = .09), 48 h (P = .97); Postoperative nausea (P = .72); and LOS (0.27). There was significant difference in terms of total morphine consumption at 24 h (P < .0001), 48 h (P = .0008).

CONCLUSION

Our meta-analysis demonstrated that liposomal bupivacaine has similar pain control and functional recovery after TJA which compared with the control group. However, we still need large sample size, high-quality studies to explore the relationship between complications and dose response to give the final conclusion.

Prospective Randomized Trial Comparing Femoral Nerve Block With Intraoperative Local Anesthetic Injection of Liposomal Bupivacaine in Total Knee Arthroplasty

BACKGROUND

Postoperative pain after total knee arthroplasty (TKA) may impact long-term results and incidence of complications. Femoral nerve block (FNB) provides excellent pain relief after TKA, although associated risks include weakness, delayed participation in therapy, and nerve injury. Liposomal bupivacaine (LB) is a potentially longer acting local anesthetic that may reduce postoperative pain.

METHODS

We performed a prospective, randomized, double-blind study of 373 TKA patients randomized to receive either an FNB (control group), or an intraoperative periarticular injection (PAI) with LB and a placebo saline FNB (experimental group). Patients were evaluated with visual analog scores for pain, range of motion, performance of straight leg raise (SLR), walking distance, and Short Form-12 up to 1 year postoperatively.

RESULTS

Twelve and 24 hours postoperatively, the control group had significantly lower pain scores (mean 3.24 vs 3.87; P = .02) and higher range of motion (84.54° vs 78°; P < .001). The patients receiving LB PAI were significantly more likely to perform a straight leg raise 12 hours postoperatively (73% vs 50%; P = .0003). Patients in the LB (experimental) group scored better in the physical function component of the Short Form-12 (-23 vs -27, P = .01) 3 months postoperatively.

CONCLUSION

While pain scores were slightly lower in the control group in the first 24 hours after TKA compared with LB PAI, the magnitude of the difference was small, and excellent pain relief was provided by both interventions. Use of LB PAI in TKA is a reasonable alternative to FNB, which avoids the additional weakness and other risk associated with FNB procedures.

Peripheral Nerve Blocks vs Periarticular Injections in Total Knee Arthroplasty

In patients undergoing surgery, optimal pain management is associated with improved perioperative outcomes, patient satisfaction with surgery, and a more rapid functional recovery. In recent years, the employment of multimodal pain management strategies has become increasingly widespread. In particular, there has been an explosion in the use of peripheral nerve blockade and periarticular injections in total knee arthroplasty. However, there is significant variability in the administration of either modality of anesthesia. As such, a critical evaluation of the current literature is warranted to elucidate the advantages and disadvantages of each technique with the ultimate goal of further refining current pain control strategies. In this symposium, we review each of these modalities and their association with pain management, narcotic consumption, length of hospital stay, and adverse events.

Adductor Canal Block Compared with Periarticular Bupivacaine Injection for Total Knee Arthroplasty: A Prospective Randomized Trial

BACKGROUND

In the last decade, the widespread use of regional anesthesia in total knee arthroplasty has led to improvements in pain control, more rapid functional recovery, and reductions in the length of the hospital stay. The aim of this study was to compare the efficacy of adductor canal blocks (ACB) and periarticular anesthetic injections (PAI), both with bupivacaine, for pain management in total knee arthroplasty.

METHODS

One hundred and fifty-five patients undergoing primary total knee arthroplasty under spinal anesthesia were randomized to 1 of 3 groups: ACB alone (15 mL of 0.5% bupivacaine), PAI alone (50 mL of 0.25% bupivacaine with epinephrine), and ACB+PAI. The primary outcome in this study was the visual analog scale (VAS) pain score in the immediate postoperative period. Secondary outcomes included postoperative opioid use, activity level during physical therapy, length of hospital stay, and knee range of motion.

RESULTS

The mean VAS pain score was significantly higher after use of ACB alone, compared with the score after use of ACB+PAI, on postoperative day 1 (POD1) (3.9 versus 3.0, p = 0.04) and POD3 (4.2 versus 2.0, p = 0.02). Total opioid consumption through POD3 was significantly higher when ACB alone had been used (131 morphine equivalents [ME]) compared with PAI alone (100 ME, p = 0.02) and ACB+PAI (98 ME, p = 0.02). Opioid consumption in the ACB-alone group was significantly higher than that in the ACB+PAI group on POD2 and POD3 and significantly higher than that in the PAI-alone group on POD2. There was no significant difference in opioid consumption between the patients treated with PAI alone and those who received ACB+PAI. The activity level during physical therapy on POD0 was significantly lower after use of ACB alone (26 steps) than after use of PAI alone (68 steps, p < 0.001) or ACB+PAI (65 steps, p < 0.001).

CONCLUSIONS

This randomized controlled clinical trial demonstrated significantly higher pain scores and opioid consumption after total knee arthroplasty done with an ACB and without PAI, suggesting that ACB alone is inferior for perioperative pain control. There were no significant differences between PAI alone and ACB+PAI with regard to pain or opioid consumption.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Effects of Body Mass Index on Pain Control With Liposomal Bupivacaine in Hip and Knee Arthroplasty

BACKGROUND

There is evidence to suggest that liposomal bupivacaine (LB) is an effective component of a multimodal pain regimen for total joint arthroplasty (TJA). Obesity has been associated with chronic pain following TJA. This study assessed whether early postoperative pain is affected by body mass index (BMI), and whether the standard LB dose has similar effects on obese vs nonobese patients.

METHODS

A retrospective analysis of 2629 primary TJA over a 12-month period was conducted, with LB used in half of this group. Patients were further classified as nonobese (BMI < 30) or obese (BMI ≥ 30). Pain scores and narcotic use were recorded. Independent-sample t-tests were used for continuous variables and chi-squared analyses for categorical variables. A multivariate regression analysis was performed.

RESULTS

Significantly less narcotic was required on postoperative days (POD) 0 and 1 in patients receiving LB compared to those who did not in both obese and nonobese patient groups. On POD 2, obese and nonobese patients had an increase in narcotic requirement, which was significant in obese patients. A regression analysis found that on POD 0 and POD 1, lack of LB use, obesity, and younger age were independently associated with increased narcotic use.

CONCLUSION

While narcotic requirement of obese and nonobese patients decreased on POD 0 and POD 1 with initiation of LB at our institution, all patients demonstrated increased narcotic requirement on POD 2 which was statistically and clinically significant in obese patients. Further studies are needed to determine the optimal pain regimen in the growing obese population undergoing TJA.

Effectiveness of liposome bupivacaine for postoperative pain control in total knee arthroplasty: A PRISMA-compliant meta-analysis of randomized controlled trials

BACKGROUND

Adequate pain control after total knee arthroplasty (TKA) enables quicker recovery and reduces readmissions and treatment costs. The aim of this study was to determine the effect of liposomal bupivacaine (LB) for postoperative pain control in patients prepared for TKA.

METHODS

We searched for the reports that evaluating the effect of liposomal bupivacaine for postoperative pain control in patients prepared for TKA between March 1983 and May 2017 in the electronic database Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, Web of Science, and Ovid. The main outcomes were visual analog scale (VAS) at 24, 48, and 72 hours. The secondary outcomes were total morphine consumption, the length of hospital stay, range of motion, and the occurrence of nausea.

RESULTS

Seven randomized controlled trials (RCTs) enrolling 825 patients, with 413 in the LB group and 412 in the control group, were included in this meta-analysis. Our results suggested that administration LB was associated with a reduction of VAS by 4.22 points at 72 hours after TKA (WMD = -4.22, 95% CI -7.47, -0.97, P = .011) on a 100-point VAS. What's more, LB can decrease the occurrence of nausea when compared with traditional bupivacaine by 18.3% (risk ratio  = 0.70, 95% confidence interval 0.55, 0.89, P = .003). LB was associated with an increase of the range of motion than traditional bupivacaine (P < .05). There was no significant difference between the VAS at 24, 48 hours, total morphine consumption and the length of hospital stay.

CONCLUSIONS

Administration with LB was associated with pain-relieving effects and reduces the morphine-related complications (nausea). Due the limited number of the included RCTs, large number and high quality RCTs are still need to identify the effects of LB for pain control after TKA.

Local Infiltration Analgesia With Liposomal Bupivacaine Improves Pain Scores and Reduces Opioid Use After Total Knee Arthroplasty: Results of a Randomized Controlled Trial

BACKGROUND

Local infiltration analgesia (LIA) with liposomal bupivacaine (LB) in patients undergoing total knee arthroplasty (TKA) has yielded mixed results. The PILLAR study, which was designed to minimize limitations associated with previous studies, compared the effects of LIA with or without LB on pain scores, opioid consumption, including proportion of opioid-free patients, time to first opioid rescue, and safety after primary unilateral TKA.

METHODS

Patients (N = 140) were randomized to LIA with LB 266 mg/20 mL (admixed with bupivacaine HCl 0.5%, 20 mL) or LIA with bupivacaine HCl 0.5%, 20 mL. Standardized infiltration techniques and a standardized multimodal pain management protocol were used. The coprimary efficacy endpoints were area under the curve (AUC) of visual analog scale pain intensity scores 12-48 hours (AUC_12-48) postsurgery and total opioid consumption 0-48 hours postsurgery.

RESULTS

Mean AUC_12-48 of visual analog scale pain intensity score was 180.8 with LB and 209.3 without LB (least squares [LS] mean treatment difference -26.88, P = .0381). LS mean total opioid consumption 0-48 hours postsurgery was 18.7 mg with and 84.9 mg without LB (LS ratio 0.220, P = .0048). Significant differences in favor of LB were observed for the percentage of opioid-free patients (P < .01) and time to first opioid rescue (P = .0230). Treatments were similarly well tolerated.

CONCLUSION

This study provides data on LIA with LB administered using optimal techniques specific to TKA. In this setting, LIA with LB significantly improved postsurgical pain, opioid consumption, and time to first opioid rescue, with more opioid-free patients and no unexpected safety concerns.

Improved Chondrotoxic Profile of Liposomal Bupivacaine Compared With Standard Bupivacaine After Intra-articular Infiltration in a Porcine Model

BACKGROUND

Increasingly, liposomal bupivacaine is being used with multimodal pain management strategies. In vitro investigations have shown decreased chondrotoxicity profiles for liposomal bupivacaine; however, there is no evidence regarding its in vivo effects. Hypothesis/Purpose: This study sought to investigate the in vivo chondrotoxicity of liposomal bupivacaine, hypothesizing that there would be increased chondrocyte viability after exposure to liposomal bupivacaine when compared with standard bupivacaine.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight juvenile, female Yorkshire cross piglets underwent a lateral stifle joint injection with either 1.3% liposomal bupivacaine or 0.5% bupivacaine. Injections were performed on one joint per animal with no injection to the contralateral knee, which served as the control. Chondrocyte viability was assessed 1 week after injection with a live-dead staining protocol and histologic examination.

RESULTS

Significant chondrocyte death was seen with the live-dead staining in the bupivacaine group (33% nonviable cells) in comparison with liposomal bupivacaine (6.2%) and control (5.8%) groups ( P < .01). However, histologic examination showed no differences in chondral surface integrity, fibrillation, and chondrocyte viability.

CONCLUSION

Liposomal bupivacaine was found to be safe for intra-articular injection in this animal model. Although bupivacaine demonstrated decreased chondrocyte viability on a cellular level, histologically there were no changes. This study highlights the dichotomy between fluorescent staining and histologic appearance of articular chondrocytes in short-term analyses of viability.

CLINICAL RELEVANCE

This study supports the peri-articular application of liposomal bupivacaine in the setting of preserved articular cartilage. A single injection of standard bupivacaine did not produce histologic changes in the articular cartilage.

Can Multimodal Pain Management in TKA Eliminate Patient-controlled Analgesia and Femoral Nerve Blocks?

BACKGROUND

TKA pain management protocols vary widely with no current consensus on a standardized pain management regimen. Multimodal TKA pain management protocols aim to address pain control, facilitate functional recovery, and maintain patient satisfaction.

QUESTIONS/PURPOSES

(1) Did changes to our pain management protocol, specifically adding liposomal bupivacaine, eliminating patient-controlled analgesia (PCA), and discontinuing femoral nerve blocks (FNBs), affect narcotic consumption after TKA? (2) Did these changes to our pain management protocols affect patient-reported pain scores? (3) Does the use of an immediate postoperative PCA affect rapid rehabilitation and functional recovery? (4) How did changes to our pain management regimen affect discharge disposition and pain-related Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores?

METHODS

We retrospectively analyzed an institutional arthroplasty database between September 2013 and September 2015 containing 1808 patients who underwent primary TKA. Departmental pain management protocols were compared in 6-month periods as the protocol changed. All patients received a multimodal pain management protocol including preoperative oral medications, spinal or general anesthesia, a short-acting intraoperative pericapsular injection, and continued postoperative oral narcotics for breakthrough pain. From September 2013 to April 2014, all patients received an intraoperative FNB and a PCA for the first 24 hours postoperatively (Cohort 1). From May 2014 to October 2014, a periarticular injection of liposomal bupivacaine was added to the protocol and FNBs were discontinued (Cohort 2). After April 2015, PCA was eliminated (Cohort 3). No other major changes were made to the TKA pain management pathways. Narcotic use, pain scores on 8-hour intervals, physical therapy milestones, and discharge disposition were compared.

RESULTS

Total narcotic use was the least in Cohort 3 (Cohort 3: 66 ± 54 morphine milligram equivalents versus Cohort 2: 82 ± 72 versus Cohort 1: 96 ± 62; p < 0.001). There was an increase in pain score immediately after surgery in Cohort 3 (4.0 ± 3.5 versus 1.2 ± 2.2 versus 1.2 ± 2.5, post hoc analysis of Cohort 2 versus 3: mean difference 2.6, 95% confidence interval [CI] 2.2-3.0; p < 0.001); however, it was not different for the remainder of the hospital stay. Patients who did not receive PCA reached functional milestones for both gait and stairs faster by postoperative day 1 (47% [328 of 698] versus 30% [158 of 527] versus 16% [93 of 583], p < 0.001; Cohort 3 versus 2: odds ratio 2.1, 95% CI 1.6-2.6; p < 0.001). Discharge to home occurred more frequently (84% [583 of 698] versus 78% [410 of 527] versus 72% [421 of 583], p = 0.010) in Cohort 3. There were no differences in pain-related HCAHPS scores across all cohorts.

CONCLUSIONS

Discontinuing PCAs and FNBs from our multimodal TKA pain management protocols and adding liposomal bupivacaine resulted in fewer narcotics consumed with no difference in pain control and faster functional recovery while maintaining high HCAHPS scores relating to pain.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A Prospective Randomized Study Comparing Bupivacaine Hydrochloride Versus Bupivacaine Liposome for Pain Management After Distal Radius Fracture Repair Surgery

PURPOSE

To compare pain experience and opioid use after distal radius fracture repair surgery performed with perioperative infiltration of the local anesthesia bupivacaine hydrochloride (Marcaine; Pfizer, New York, NY) or bupivacaine liposome (Exparel; Pacira, Parsippany, NJ).

METHODS

We conducted a prospective comparison of consecutive patients scheduled to undergo distal radius fracture repair surgery. Patients were randomized to either Marcaine or Exparel. Patients in the Marcaine group received 20 mL 0.5% bupivacaine without epinephrine into the incision and surgical site before incision. Patients in the Exparel group first received 10 mL 0.5% Marcaine with no epinephrine into the incision and surgical site before incision; then, upon completion of the surgery and wound closure, they also received 10 mL Exparel into the same site that had been preinjected with Marcaine. All operations were performed with the same surgical technique. Daily opioid pill consumption, pain levels, and any adverse reactions were recorded from postoperative days 0 to 5.

RESULTS

On the day of surgery, patients in the Exparel group reported significantly lower pain levels (3.9 vs 5.8) and consumed significantly fewer prescribed opioid pills (1.2 vs 2.0) compared with patients in the Marcaine group. However, there were no other significant differences between the Exparel and Marcaine groups on any subsequent days or in the total number of pills consumed at the end of the study period (7.5 vs 8.9 pills, respectively). No major adverse reactions were noted in either group.

CONCLUSIONS

Exparel use was found to result in decreased pain and opioid consumption only on the day of surgery and not thereafter.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Liposomal Bupivacaine Versus Continuous Popliteal Sciatic Nerve Block in Total Ankle Arthroplasty

BACKGROUND

Liposomal bupivacaine (LB) is widely used in joint arthroplasty, but there is little reported on the use of LB in foot and ankle surgery. Continuous popliteal sciatic nerve block (CPSNB) is more commonly used for major foot and ankle reconstructions. The purpose of this study was to compare use of intraoperative LB injection to CPSNB as a regional anesthetic for total ankle arthroplasty (TAA), with attention to postoperative pain scores, narcotic use, and complications.

METHODS

Retrospective review of TAA patients of 2 fellowship-trained orthopedic foot and ankle surgeons was performed. Patients received either preoperative single-shot popliteal sciatic nerve block with 0.2% ropivacaine followed by intraoperative injection of LB or preoperative CPSNB alone. Outcomes examined were visual analog scale (VAS) pain score at 8 hours, 24 hours, 1 week, and 3 weeks following surgery; need for opioid pain medication refill; physician office notification for pain issues or other adverse events; and complications within the first 90 days following surgery. Standard statistical analysis was performed, and P < .05 was considered significant. Seventy-five patients were identified who underwent TAA and met inclusion criteria. Forty-one received LB, and 34 received CPSNB.

RESULTS

No statistical difference was seen between groups with regard to complications, emergency department visits, readmissions, reoperations, VAS pain score at any time point, physician office contacts, and narcotic refills. Sixteen of 41 (39%) LB patients had narcotic refills, versus 12 of 34 (35%) CPSNB patients ( P = .81). Two of 41 (5%) LB patients had a complication postoperatively, versus 4 of 34 (12%) CPSNB patients. There were no complications specific to the anesthetic used in either group.

CONCLUSION

This is the first study evaluating the use of LB for total ankle arthroplasty. Liposomal bupivacaine was safe and effective as an option for regional anesthetic and postoperative pain control, with comparable results to CPSNB.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

QX-OH/Levobupivacaine: Fixed-dose combination to provide a long-acting postoperative pain of knee surgery in rodents

Although total knee arthroplasty (TKA) is a commonly performed procedure, anesthetic efficacy in post-surgical pain remains an issue. Exparel (45mM liposome bupivacaine), a relatively long-acting local anesthetic, has shown efficacy in blocking peripheral nerve or periarticular infiltration to achieve better post-TKA analgesia. In the present work, we tested whether a fixed-dose combination of QX-OH (35mM) and levobupivacaine (10mM) (QX-OH/LB) could confer longer-lasting pain relief and reduce periarticular tissue toxicity compared to liposome bupivacaine (45mM) after TKA operation. In the sciatic nerve block, the duration of sensory block by QX-OH/LB was 2-fold higher than by liposome bupivacaine (median [25th, 75th percentiles], 9.83 [9.33, 10.83] hours versus 4.83 [4.83, 5] hours; P=0.001). Liposome bupivacaine failed to improve post-surgical travel distance and speed (P=0.373) in rats 6h after TKA surgery (versus saline). Similar results were observed in operated mice treated with liposome bupivacaine. However, QX-OH/LB increased locomotor activities markedly both in rats and mice at 6h post-TKA (P<0.001). In addition, there was no difference in the inflammatory recruitment and articular structural damage among murine models-treated with QX-OH/LB, liposome bupivacaine and saline. In conclusion, we show that QX-OH/LB is a safe and long-lasting anesthetic than liposome bupivacaine in the post-TKA pain management in murine models.

Liposomal bupivacaine versus indwelling interscalene nerve block for postoperative pain control in shoulder arthroplasty: a prospective randomized controlled trial

BACKGROUND

Pain management strategies following shoulder arthroplasty vary significantly. Liposomal bupivacaine (LB) is an extended-release delivery of a phospholipid bilayer encapsulating bupivacaine that can result in drug delivery up to 72 hours. Prior studies in lower extremity surgery demonstrated efficacy of LB in comparison to a single-shot peripheral nerve block; however, no study has investigated LB in a total shoulder arthroplasty population. Therefore, this study compared LB vs. an indwelling interscalene nerve block (IINB).

METHODS

This is a prospective, randomized study of 83 consecutive shoulder arthroplasty patients; 36 patients received LB and a "bridge" of 30 mL of 0.5% bupivacaine, and 47 patients received an IINB. Postoperative visual analog scale pain levels, opiate consumption measured with oral morphine equivalents, length of hospital stay, and postoperative complications were recorded. Continuous variables were compared using an analysis of variance with significance set at P < .05.

RESULTS

Visual analog scale pain scores were statistically higher in the LB cohort immediately postoperatively in the postanesthesia care unit (7.25 vs. 1.91; P = .000) as well as for the remainder of postoperative day 0 (4.99 vs. 3.20; P = .005) but not for the remainder of admission. Opiate consumption was significantly higher among the LB cohort in the postanesthesia care unit (31.79 vs. 7.47; P = .000), on postoperative day 0 (32.64 vs. 15.04; P = .000), and for the total hospital admission (189.50 vs. 91.70, P = .000). Complication numbers and length of stay were not statistically different.

CONCLUSION

Use of an IINB provides superior pain management in the immediate postoperative setting as demonstrated by decreased narcotic medication consumption and lower subjective pain scores.

The Efficacy of Liposomal Bupivacaine Using Periarticular Injection in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Total knee arthroplasty (TKA) is gradually emerging as the treatment of choice for end-stage osteoarthritis. In the past, the method of liposomal bupivacaine by periarticular injection (PAI) showed better effects on pain reduction and opioid consumption after surgery. However, some recent studies have reported that liposomal bupivacaine by PAI did not improve pain control and functional recovery in patients undergoing TKA. Therefore, this meta-analysis was conducted to determine whether liposomal bupivacaine provides better pain relief and functional recovery after TKA.

METHODS

Web of Science, PubMed, Embase, and the Cochrane Library were comprehensively searched. Randomized controlled trials, controlled clinical trials, and cohort studies were included in our meta-analysis. Eleven studies that compared liposomal bupivacaine using the PAI technique with the conventional PAI method were included in our meta-analysis. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines and Cochrane Handbook were applied to assess the quality of the results published in all included studies to ensure that the results of our meta-analysis were reliable and veritable.

RESULTS

Our pooled data analysis demonstrated that liposomal bupivacaine was as effective as the control group in terms of visual analog scale score at 24 hours (P = .46), 48 hours (P = .43), 72 hours (P = .21), total amount of opioid consumption (P = .25), range of motion (P = .28), length of hospital stay (P = .53), postoperative nausea (P = .34), and ambulation distance (P = .07).

CONCLUSION

Compared with the conventional PAI method, liposomal bupivacaine shows similar pain control and functional recovery after TKA. Considering the cost for pain control, liposomal bupivacaine is not worthy of being recommended as a long-acting alternative analgesic agent using the PAI method.