A Prospective, Randomized Trial Comparing Liposomal Bupivacaine vs Fascia Iliaca Compartment Block for Postoperative Pain Control in Total Hip Arthroplasty

The role for high volume local infiltration analgesia with liposomal bupivacaine in total hip arthroplasty: A scoping review

Introduction

Liposomal bupivacaine has been integrated into clinical practice within many surgical disciplines to reduce post-operative pain and opioid consumption. This novel agent has been utilized in this regard in many subdisciplines of orthopedic surgery. Total hip arthroplasty has significant opioid use post-operatively as compared to many other orthopedic disciplines.

Objectives

The purpose of the present investigation is to summarize the current use of liposomal bupivacaine after total hip arthroplasty and to shed light on the prospect of liposomal bupivacaine to reduce opioid use after total hip arthroplasty. A tertiary purpose is to identify future areas of adjunctive pain measures that can assist in the reduction of opioid use after total hip arthroplasty.

Methods

This IRB-exempt scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist strictly. The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. The full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by three authors until an agreement was reached.

Results

A total of 21 articles were included for qualitative description of the opioid epidemic, opioid overuse in total hip arthroplasty, and risk factors for opioid overuse in total hip arthroplasty. A total of 9 articles were included regarding the use of liposomal bupivacaine in total hip arthroplasty. Several risk factors have been identified for opioid overuse after total hip arthroplasty. These include younger age, an opioid risk tool score of > 7, a higher body mass index, chronic obstructive pulmonary disease, immunodeficiency syndromes, preexisting pain syndromes, peripheral vascular disease, anxiety and mood disorders, and substance abuse disorders. Liposomal bupivacaine reduces postoperative opioid use, patient-reported outcomes, length of stay, and time to ambulation, yet is more expensive than traditional bupivacaine.

Conclusions

Liposomal bupivacaine represents a useful adjunct for multimodal pain strategies in total hip arthroplasty with sufficient evidence to suggest that it may be useful in decreasing postoperative opioid use. The high costs of LB represent a barrier to institutional acceptance of LB into standardized multimodal pain strategies. Further efforts should be aimed toward better understanding the current state of integration of LB into academic and private practice settings, industry movements to decrease the cost, and the role other adjunctive measures may have in reducing post-operative opioid use.

Optimizing Rapid Recovery After Anterior Hip Arthroplasty Surgery: A Comparative Study of Fascia Iliaca Compartment Block and Local Infiltration Analgesia

BACKGROUND

Multimodal pain therapy combining analgesics, local infiltration analgesia (LIA) and peripheral nerve blocks, such as fascia iliaca compartment block (FICB), can improve postoperative pain, nausea and vomiting (PONV) and ambulation in patients undergoing total hip arthroplasty (THA). We hypothesized that addition of FICB would decrease opioid requirements and length of stay (LOS) but could create a motor block.

METHODS

This is a single center, prospective, blinded randomized controlled study of 152 patients undergoing elective THA via direct anterior approach from October 2019 till August 2021. Three patient groups were defined: patients receiving only spinal anesthesia (control group, n = 53); spinal anesthesia with LIA perioperatively (n = 50); and spinal anesthesia with FICB on the recovery unit (n = 49). Outcome measures consisted of postoperative pain scores, PONV, length of hospital stay, opioid requirements and mobility.

RESULTS

Overall pain scores were low for all patient groups, with a lower pain score for LIA in comparison to the control group until 4 hours postoperatively (P < .05). Length of hospital stay, postoperative pain, nausea and vomiting (PONV) scores and quadriceps muscle strength did not differ significantly between groups. The control group showed higher scores at 12 hours postoperatively in comparison to FICB regarding rehabilitation potential, use of walking aids and activities of daily living (P < .05), but all groups reached the same endpoint 48 hours postoperatively. The LIA and FICB groups required less opioids until 24 hours postoperatively.

CONCLUSION

LIA is a beneficial adjuvant therapy to spinal anesthesia in THA patients as it may decrease pain scores and the need for opioid consumption. Adjuvant FICB only provided lower opioid requirements.

Efficacy of liposomal bupivacaine in spine surgery: a systematic review

BACKGROUND CONTEXT

Spine surgery with posterior approaches may involve extensive manipulation of native structures, resulting in significant postoperative pain. Liposomal bupivacaine (LB) is an injectable analgesic that has demonstrated efficacy in decreasing postoperative pain and opioid requirements in patients across multiple surgical subspecialties.

PURPOSE

To consolidate and analyze the findings of retrospective cohort-matched studies and prospective randomized controlled trials investigating the use of LB in spine surgery.

STUDY DESIGN

A systematic review.

STUDY SAMPLE

Retrospective cohort-matched studies and randomized controlled trials (RCTs) investigating the efficacy of injected LB in spinal surgery compared with a control/no treatment group.

METHODS

MEDLINE, Cochrane controlled trials register, and Google Scholar were searched to identify all studies that examined the effect of LB use on outcomes in spine surgery. Our search identified 10 articles that independently evaluated the effect of LB on reduction of postoperative opioid use, pain scores, hospital length of stay, cost, and incidence of adverse effects. The principles of GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) were applied to assess the quality of evidence from each study.

RESULTS

Ten studies were analyzed (1,112 total patients). LB was associated with significantly lower millimolar morphine equivalents (MME) of postoperative opioids, especially in opiate-tolerant patients, visual analog scale (VAS) scores, area under the curve (AUC) of cumulative pain scores, numeric pain scale scores, and hospital length of stay (LOS), with comparable or lower odds of adverse effects relative to controls.

CONCLUSIONS

Low-quality evidence suggests that liposomal bupivacaine may safely decrease postoperative opioid requirements, pain scores, and length of stay in patients undergoing spine surgery, whereas moderate-quality evidence does not support its use at this time. Therefore, additional standardized well-powered prospective studies are necessary to more clearly assess the efficacy of LB in spine surgery.

Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis

BACKGROUND

For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient.

METHODS

We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients.

RESULTS

We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately.

CONCLUSIONS

We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.

The effect of fascia iliaca block on postoperative pain and analgesic consumption for patients undergoing primary total hip arthroplasty: a meta-analysis of randomized controlled trials

Background

The primary aim of this systematic review and meta-analysis was to compare postoperative pain, analgesic consumption, and complications after fascia iliaca block (FIB) versus control for patients undergoing primary total hip arthroplasty (THA). Second, we compared the outcomes of FIB versus placebo. Finally, we sought to evaluate pain and analgesic consumption after preoperative and postoperative FIB.

Methods

We performed a systematic literature search in MEDLINE, Embase, Scopus, Web of Science, Google Scholar, ClinicalTrials.gov, and CENTRAL through February 2021 to identify randomized controlled trials (RCTs) that evaluated the efficacy of FIB versus control for patients undergoing primary THA. All analyses were conducted on intent-to-treat data with a random-effects model.

Results

Twelve RCTs with a total of 815 patients were included. There was no difference in postoperative pain (P = 0.64), analgesic consumption (P = 0.14), or complication rate (P = 0.99) between FIB and control groups. Moreover, no difference in postoperative pain (P = 0.26), analgesic consumption (P = 0.06), or complication rate (P = 0.71) was found between FIB and placebo. Moreover, sensitivity analysis suggested that no significant difference in postoperative pain, analgesic consumption, or complication rate was present between FIB and control in studies that used preoperative and postoperative FIB.

Conclusion

FIB was not found to be superior to placebo or various anesthetic techniques for patients undergoing primary THA, as measured by postoperative pain, analgesic consumption, and complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02585-1.

Discontinuation of Intraoperative Liposomal Bupivacaine in Primary THA Does Not Clinically Change Postoperative Subjective Pain, Opioid Consumption, or Objective Functional Status

BACKGROUND

There is debate regarding the benefit of liposomal bupivacaine (LB) as part of a periarticular injection (PAI) in total hip arthroplasty (THA). Here, we evaluate the effect of discontinuing intraoperative LB PAI on immediate postoperative subjective pain, opioid consumption, and objective functional outcomes.

METHODS

On July 1, 2019, an institutional policy discontinued the use of intraoperative LB PAI. A consecutive cohort that received LB PAI and a subsequent cohort that did not were compared. All patients received the same opioid-sparing protocol. Nursing documented verbal rating scale pain scores were averaged per patient per 12-hour interval. Opiate administration events were converted into morphine milligram equivalences per patient per 24-hour interval. The validated Activity Measure for Postacute Care (AM-PAC) tool was used to evaluate functional outcomes.

RESULTS

Six hundred thirty eight primary THAs received LB followed by 939 that did not. In the non-LB THAs, BMI was higher (30.06 vs 29.43; P < .05). Besides marital status, the remaining baseline demographics were similar between the two cohorts (P > .05). The non-LB THA cohort demonstrated a marginal increase in verbal rating scale pain scores between 12 to 24 hours (4.42 ± 1.70 vs 4.20 ± 1.87; P < .05) and 36 to 48 hours (4.49 ± 1.72 vs 4.21 ± 1.83; P < .05). There was no difference in inpatient opioid administration up to 96 hours postoperatively (P > .05) or AM-PAC functional scores within the first 24 hours (P > .05).

CONCLUSION

A small statistical, but not clinically meaningful, difference was observed in subjective pain scores with LB PAI discontinuation. Opioid consumption and postoperative AM-PAC functional scores were unchanged after LB PAI discontinuation.

PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations

The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.

Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia

BACKGROUND

Liposomal bupivacaine is purported to extend analgesia of peripheral nerve blocks when administered perineurally. However, evidence of the clinical effectiveness of perineural liposomal bupivacaine is mixed. This meta-analysis seeks to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics.

METHODS

The authors identified randomized trials evaluating the effectiveness of peripheral nerve block analgesic that compared liposomal bupivacaine with nonliposomal local anesthetics. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-h rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. AUC pain scores were interpreted in light of a minimal clinically important difference of 2.0 cm · h.

RESULTS

Nine trials (619 patients) were analyzed. When all trials were pooled, AUC pain scores ± SD at 24 to 72 h were 7.6 ± 4.9 cm · h and 6.6 ± 4.6 cm · h for nonliposomal and liposomal bupivacaine, respectively. As such, perineural liposomal bupivacaine provided a clinically unimportant benefit by improving the AUC (95% CI) of 24- to 72-h pain scores by 1.0 cm · h (0.5 to 1.6; P = 0.003) compared with nonliposomal bupivacaine. Excluding an industry-sponsored trial rendered the difference between the groups nonsignificant (0.7 cm · h [-0.1 to 1.5]; P = 0.100). Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 h, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. No liposomal bupivacaine side effects were reported.

CONCLUSIONS

Perineural liposomal bupivacaine provided a statistically significant but clinically unimportant improvement in the AUC of postoperative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and functional outcomes. High-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks.

EDITOR’S PERSPECTIVE

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.

Pain intensity in total hip arthroplasty patients: how communication influences satisfaction

INTRODUCTION

An important global measure of health care quality is patient satisfaction. Patient satisfaction partially determines hospital reimbursement for procedures such as total hip arthroplasty (THA). Press Ganey (PG) survey responses assess patient satisfaction, and impact reimbursement. Current efforts to maximise repayment for THA include reducing postoperative pain. The "Pain Management" survey domain is considered a significant factor in patient ratings, but other studies have highlighted staff communication domains as determinants of satisfaction. Therefore, the purpose of this study is to compare PG survey responses to inpatient pain intensity.

METHODS

We queried the PG database for all patients who underwent a THA between November 2012 and January 2015. This yielded a total of 302 patients. Descriptive statistics were performed to analyse patient-level demographics. A multivariate regression model was constructed utilising pain intensity as the dependent variable.

RESULTS

Patients rating of "Communication with Doctors" (B = -25.534; p < 0.001) and "Communication about Medicines" (B = -31.49; p = < 0.001) domains were representative of patient pain intensity. No other factors demonstrated a significant relationship to pain intensity.

CONCLUSIONS

Patient satisfaction continues to be important in care quality. Surrogate markers, such as the PG survey, can guide institutions looking to improve care. Our study revealed scores for "Communication with Doctors" and "Communication about Medicines" best represented true pain intensity levels for THA recipients during the postoperative period. The "Pain Management" domain did not display a relationship to pain intensity. The current method of measuring patient satisfaction should be reassessed to better represent patient responses and outcomes.

Reduction of Postoperative Hip Arthroscopy Pain With an Ultrasound-Guided Fascia Iliaca Block: A Prospective Randomized Controlled Trial

BACKGROUND

Ultrasound-guided fascia iliaca blocks have been used for pain control after hip arthroscopy. There is little evidence regarding their effectiveness in comparison with other pain control modalities in patients who have undergone hip arthroscopy.

PURPOSE

To compare the efficacy of ultrasound-guided fascia iliac block with intra-articular ropivacaine in controlling pain after hip arthroscopy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Between 2015 and 2017, patients (N = 95) undergoing hip arthroscopy were randomly assigned to 2 groups. The first group received an ultrasound-guided fascia iliaca block with 50 to 60 mL of 0.35% ropivacaine. The second group received an intra-articular injection of 20 mL of 0.5% ropivacaine at the completion of the surgical case. Primary outcomes were postoperative pain scores in the recovery room; at postanesthesia care unit (PACU) discharge; and at 2 weeks, 6 weeks, and 3 months. Secondary outcomes included intraoperative and PACU narcotic usage (converted to morphine equivalent use) as well as readmission rates, PACU recovery time, and postoperative nausea and vomiting.

RESULTS

Postoperative pain across all points did not significantly differ between the groups. Intraoperative and PACU narcotics did not differ significantly between the groups. Readmission rates, PACU recovery time, and postoperative nausea and vomiting did not significantly differ between the groups. There were no associated complications in either group.

CONCLUSION

Ultrasound-guided fascia iliaca block for hip arthroscopy had no clinical advantage when compared with onetime intra-articular ropivacaine injection.

REGISTRATION

NCT02365961 (ClinicalTrials.gov identifier).

Differential Use of Narcotics in Total Hip Arthroplasty: A Comparative Matched Analysis Between Osteoarthritis and Femoral Neck Fracture

BACKGROUND

The United States is currently in an opioid epidemic as it consumes the majority of narcotic medications. The purpose of this investigation is to identify the incidence and risk factors for prolonged opioid usage following total hip arthroplasty (THA) due to hip fracture (Fx) or osteoarthritis (OA).

METHODS

The PearlDiver database was reviewed for patients undergoing THA from 2007 through the first quarter of 2017. Following a 3:1 match based on comorbidities and demographics, patients were divided into THA due to Fx (n = 1801) or OA (n = 5403). Preoperative and prolonged postoperative narcotic users were identified. Multivariate logistic regression analysis was performed to identify demographics, comorbidities, or diagnoses as risk factors for prolonged opioid use and preoperative and postoperative opioid use as risk factors for complications.

RESULTS

One thousand seven hundred ninety-four OA patients (33.2%) were prescribed narcotics preoperatively and 1655 patients (30.6%) were using narcotics postoperatively, while 418 Fx patients (23.2%) were prescribed narcotics preoperatively and 499 patients (27.7%) were using narcotics postoperatively. Diagnosis of Fx (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.28-1.72, P < .001) and preoperative narcotic use (OR 6.12, 95% CI 5.27-6.82, P < .001) were the most significant risk factors for prolonged postoperative narcotic use. Prolonged postoperative narcotic use was associated with increased infection, dislocation, and revision THA in both Fx and OA groups.

CONCLUSION

Diagnosis of femoral neck fracture and overall preoperative narcotic use were significant predictors of chronic postoperative opioid use. Patients with significant risk factors for opioid dependence should receive additional consultation and more prudent follow-up with regards to pain management.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Nanomedicine review: clinical developments in liposomal applications

Background

In recent years, disease treatment has evolved strategies that require increase in pharmaceutical agent’s efficacy and selectivity while decreasing their toxicity in normal tissues. These requirements have led to the development of nanoscale liposome systems for drug release. This review focuses on lipid features, pharmacological properties of liposomal formulations and the clinical studies of their application.

Main body

Several lipids are available, but their properties could affect pharmacological or clinical efficiency of drug formulations. Many liposomal formulations have been developed and are currently on the market. Proper selection of lipid is essential for the pharmacological effect to be improved. Most of the formulations use mainly zwitterionic, cationic or anionic lipids, PEG and/or cholesterol, which have different effects on stability, pharmacokinetics and delivery of the drug formulation. Clinical trials have shown that liposomes are pharmacologically and pharmacokinetically more efficient than drug-alone formulations in treating acute myeloid leukemia, hepatitis A, pain management, ovary, gastric breast and lung cancer, among others.

Conclusion

Liposomal formulations are less toxic than drugs alone and have better pharmacological parameters. Although they seem to be the first choice for drug delivery systems for various diseases, further research about dosage regimen regarding dose and time needs to be carried out.

Impact of liposomal bupivacaine on opioid use, hospital length of stay, discharge status, and hospitalization costs in patients undergoing total hip arthroplasty

Aims: Effective postsurgical analgesia hastens recovery, reduces hospital length of stay (LOS), and decreases hospitalization costs for total hip arthroplasty (THA). Improving these outcomes is critical for value-based surgical bundled payment programs such as the Medicare Comprehensive Care for Joint Replacement and similar programs for commercial insurance providers. This study compared clinical outcomes and hospitalization costs for patients undergoing THA with and without liposomal bupivacaine (LB).Materials and methods: This retrospective, comparative cohort study used data from the Premier Healthcare Database from the 10 hospitals with highest use of LB for THA from January 2011 through April 2017. A cohort undergoing THA with LB at those hospitals was compared with a propensity-score matched cohort at those hospitals who had THA without LB. Descriptive, univariate, and multivariable analyses compared post-surgical inpatient opioid consumption, hospital LOS, discharge status, same-hospital readmissions, and total hospitalization costs. Analyses were performed using the Pearson Chi-square test (categorical variables) and Wilcoxon or Student t-test (continuous variables).Results: For patients with Medicare (with LB, n = 3622; without LB, n = 3610) and commercial insurance (with LB, n = 2648; without LB, n = 2709), use of LB was associated with lower post-surgical inpatient opioid consumption (105 and 81 mg, respectively; p < 0.0001), a 0.7-day shorter LOS (p < 0.0001), a 1.6-1.7-fold increased likelihood of home discharge (p < 0.0001), and no increase in readmissions (p ≥ 0.103). Total hospitalization costs were $561 lower with LB in the Medicare population (p < 0.0001) and $41 higher with LB in the commercial population (p = 0.7697).Limitations: Hospitalization costs were estimated from the hospital chargemaster. Findings from these 10 hospitals may not represent other US hospitals.Conclusions: At select hospitals, THA with LB was associated with reduced post-surgical inpatient opioid consumption, shorter hospital LOS, increased likelihood of home discharge, and lower hospitalization costs. Post-surgical pain management with LB may help hospitals in value-based bundled payment programs.

Fascia Iliaca Blockade With the Addition of Liposomal Bupivacaine Versus Plain Bupivacaine for Perioperative Pain Management During Hip Arthroscopy: A Double-Blinded Prospective Randomized Control Trial

PURPOSE

To determine in a prospective, randomized fashion whether liposomal bupivacaine extends the effectiveness of decreased pain scores and reduces narcotic requirements following hip arthroscopy when used in addition to a fascia iliaca blockade with plain bupivacaine alone.

METHODS

Double-blinded prospective randomized controlled trial of participants undergoing hip arthroscopy. Randomized to receive a fascia iliaca blockade with 40 mL 0.25% plain bupivacaine (100 mg; control group) or 20 mL 0.5% plain bupivacaine (100 mg) plus 20 mL liposomal bupivacaine (266 mg; study group). The primary outcome was Defense and Veterans Pain Rating Scale (DVPRS) scores in the postanesthesia care unit and on postoperative days (POD) 1, 2, 3, and 14. Secondary outcomes included postoperative opioid consumption and subjective loss of anterior thigh sensation.

RESULTS

Seventy-four patients were enrolled, and 70 completed the study; 37 were randomized to the control group and 33 to the study group. There was no significant difference in postoperative DVPRS scores at any time point. There was no significant difference in total postoperative opioid use during any postoperative time points. While most patients reported anterior thigh numbness at discharge, significantly more patients in the study group reported anterior thigh numbness at POD2 (control, 19/37 numb vs study, 32/33 numb; P < .0001) and at POD3 (control, 8/37 numb vs study, 26/33 numb; P < .0001).

CONCLUSIONS

In this prospective evaluation comparing plain bupivacaine versus the liposomal formulation administered via a fascia iliaca blockade there were no significant differences in postoperative pain scores and narcotic pill usage. Given the highly significant findings of prolonged anterior thigh numbness out to POD3 in patients who received liposomal bupivacaine, this formulation did exhibit prolonged effects; however, it did not provide improved pain control when used in this surgical population, likely due to the innervation of the hip capsule from differential nerve plexi. Given the 6-fold increased cost of using the liposomal formulation, we are unable to recommend its use via a fascia iliaca blockade for hip arthroscopy.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Enhanced recovery after surgery (ERAS) in hip and knee replacement surgery: description of a multidisciplinary program to improve management of the patients undergoing major orthopedic surgery

PURPOSE

Enhanced recovery after surgery (ERAS) protocols aim to develop peri-operative multidisciplinary programs to shorten length of hospital stay (LOS) and reduce complications, readmissions and costs for patients undergoing major surgery. The aim of this study is to evaluate the effects of an ERAS pathway for total hip (THR) and knee (TKR) replacement surgery in terms of length of stay, incidence of complications and patient satisfaction.

METHODS

Patients scheduled for hip and knee replacement were included in the study. The main aspects of this program were preoperative education/physical therapy, rational choice of the anesthetic technique, optimization of multimodal analgesia, reduction of incidence of urinary retention and catheterization, active management of risk for blood loss and deep vein thrombosis, and early mobilization of the patients. All patients had 6 months predicted and planned follow-up appointments. Primary outcomes of the study were the mean LOS, readmission and complication rates. Secondary Outcomes were percentage of Knee Injury & Osteoarthritis Outcome Score (KOOS) and Hip disability and Osteoarthritis Outcome Score (HOOS) increase and patient's satisfaction.

RESULTS

We consecutively enrolled 207 patients who underwent total joint arthroplasty, 78 hip and 129 knee joint replacements. The mean length of stay (LOS) for patients of the two groups was 4.3 days for ASA 3-4 patients subjected to TKR and THR, in ASA 1-2 patients 3.6 days for TKR and 3.9 days for THR respectively. Postoperative satisfaction level was higher than 7 (very satisfied) in 94.4% of the cases. All patients were discharged home: 61.8% continued physical therapy in complete autonomy, 23.7% supported by a home-physiotherapist and only 14.5% needed the attendance to a physiotherapy center on a daily basis. The overall incidence of major complications was 3.4%.

CONCLUSIONS

The implementation of an ERAS program for hip and knee replacement surgery allows early patient's discharge and a quick return to independency in the daily activities.

LEVEL OF EVIDENCE

IV.

The efficacy of fascia iliaca compartment block for pain control after total hip arthroplasty: a meta-analysis

Purpose

Fascia iliaca compartment block (FICB) provides an analgesic option for total hip arthroplasty (THA) patients. The evidence supporting FICB is still not well established. The purpose of this meta-analysis was to assess FICB for pain control in THA patients.

Methods

PubMed, Embase, Cochrane Library, and Chinese Wanfang database were interrogated from their inceptions to December 15, 2018. We included randomized controlled studies reported as full text, those published as abstracts only, and unpublished data, if available. Data were independently extracted by two reviewers and synthesized using a random-effects model or fixed-effects model according to the heterogeneity.

Results

A total of eight RCTs were finally included for meta-analysis. Compared with placebo, FICB could significantly reduce VAS pain scores at 1–8 h (WMD = − 0.78, 95% CI [− 1.01, − 0.56], P = 0.000), 12 h (WMD = − 0.69, 95% CI [− 1.22, − 0.16], P = 0.011), and 24 h (WMD = − 0.46, 95% CI [− 0.89, − 0.02], P = 0.039). Compared with the control group, FICB could significantly decrease the occurrence of nausea and length of hospital stay (P < 0.05). There was no significant difference between the VAS pain score at 48 h and risk of fall between the FICB and the control groups (P > 0.05).

Conclusions

FICB could be used to effectively reduce pain intensity up to 24 h, total morphine consumption, and length of hospital stay in THA patients. Optimal strategies of FICB need to be studied in the future.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-1053-1) contains supplementary material, which is available to authorized users.

Opiate Pain Medication Consumption in Cigarette Smokers following Total Hip Arthroplasty

Purpose  The purpose of the present study was to assess perception of pain and pain management in smokers versus nonsmokers who received a total hip arthroplasty (THA).

Methods  Patients who underwent THA from 2010 to 2016 were propensity score matched 1:1 based on race, body mass index, age, and sex. This yielded 124 smokers and 124 nonsmokers. Pain intensity was quantified using area under the curve for visual analog scale pain scores. Opioid consumption was determined using a morphine milliequivalent (mEq) conversion algorithm. An independent samples t -test and Chi-square analysis was conducted to assess continuous and categorical variables respectively.

Results  Smokers experienced a nonsignificantly increased pain intensity (198.1 vs. 185.7; p  = 0.063). Smokers demonstrated significantly higher opioid consumption in both immediate postoperative (65.9 vs. 59.3 mEq; p  = 0.045) and 90 days postoperative periods (619.9 vs. 458.9 mEq; p  = 0.029).

Conclusion  Our study demonstrated a nonsignificantly increased pain intensity, and (in both the immediate and 90 days postoperative periods) a significantly higher opioid consumption following THA in patients who smoke cigarettes. This may be due to a relatively small effect size, warranting the need for larger prospective studies. Nevertheless, arthroplasty surgeons should encourage preoperative smoking cessation and alternative nonopioid analgesics to smoking patients receiving THA.

Level of Evidence  This is a level III, retrospective cohort study.

The Efficacy of Liposomal Bupivacaine in Lumbar Spine Surgery

Background

Postoperative pain management in spine surgery holds unique challenges. The purpose of this study is to determine if the local anesthetic liposomal bupivacaine (LB) reduces the total opioid requirement in the first 3 days following posterior lumbar decompression and fusion (PLDF) surgery for degenerative spondylosis.

Methods

Fifty patients underwent PLDF surgery in a prospective randomized control pilot trial between August 2015 and October 2016 and were equally allocated to either a treatment (LB) or a control (saline) group. Assessments included the 72-hour postoperative opioid requirement normalized to 1 morphine milligram equivalent (MME), visual analog scale (VAS), and hospital length of stay.

Results

LB did not significantly alter the 72-hour postoperative opioid requirement compared to saline (11.6 vs. 13.4 MME, P = .40). In a subgroup analysis, there was also no significant difference in opioid consumption among narcotic-naive patients with either LB or saline. Among narcotic tolerant patients, however, opioid consumption was higher with saline than LB (20.6 MME vs. 13.3 MME, P = .048). Additionally, pre- and postoperative VAS scores and hospital length of stay were not significantly different with either LB or saline.

Conclusions

In the setting of PLDF surgery, LB injections did not significantly reduce the consumption of opioids in the first 3 postoperative days, nor did the hospital length of stay or VAS pain scores, compared to saline. However, LB could be beneficial in reducing the consumption of opioids in narcotic-tolerant populations.

Level of Evidence

2.

Fascia iliaca blockade with the addition of liposomal bupivacaine vs. plain bupivacaine for perioperative pain management following hip arthroscopy

PURPOSE

A newer formulation of bupivacaine, encapsulated within carrier molecules, has garnered attention for its role in providing extended post-operative analgesia. The purpose was to evaluate the addition of liposomal bupivacaine to fascia iliaca blockade during hip arthroscopy.

METHODS

Retrospective cohort study of patients undergoing hip arthroscopy with a pre-operative fascia iliaca blockade with either liposomal bupivacaine (Group 1; 266mg + 20 cc 0.5% plain bupivacaine) or bupivacaine (Group 2; 40 cc 0.25% plain bupivacaine). All patients received standardized pre-operative oral pain medications. The primary outcome was the defense veteran pain rating scale (DVPRS). Secondary outcomes included duration of hospital admission, PACU opioid use, PACU pain scores, and duration of nerve blockade.

RESULTS

Thirty-eight males and 30 females, mean age of 33 years (range 14-56). There was no difference in pre-operative DVPRS between the groups (n.s.). There was no difference in post-operative DVPRS pain scores at POD0 (3.7 vs. 3.9, n.s.), POD1 (4.2 vs. 3.8, n.s.), POD2 (4.2 vs. 3.7, n.s.), POD3 (3.9 vs. 3.7, n.s.) or POD14 (2.2 vs. 2.4, n.s.). Group 1 trended towards longer mean total hospital admission time (872 vs. 822 min, n.s.), and greater mean morphine equivalents administered in the PACU (33 vs. 29 mg, n.s.). 68% of patients in group 1 reported continued anterior thigh numbness at POD3, compared to 34% in group 2 (p = 0.008).

CONCLUSIONS

Despite the advertised benefits of prolonged post-operative analgesia using liposomal bupivacaine, there were no significant differences in post-operative pain scores or PACU opioid consumption. Our results support that acceptable pain scores are successfully achieved at all time periods with the use of multimodal analgesia including fascia iliaca blockade despite the type of pain medication administered.

LEVEL OF EVIDENCE

III.

Patients With Major Depressive Disorder Experience Increased Perception of Pain and Opioid Consumption Following Total Joint Arthroplasty

BACKGROUND

Pain in the immediate postoperative period following total joint arthroplasty is influenced by various patient factors, including major depressive disorder (MDD). Therefore, this study aimed to compare the patient perception of pain and opioid consumption between patients with and without MDD who received either a total knee arthroplasty (TKA) or total hip arthroplasty (THA). Specifically, we compared (1) pain intensity, (2) lengths of stay, (3) opioid consumption, and (4) patient perception of pain control.

METHODS

We reviewed our institutional Press Ganey database to identify patients with a diagnosis of MDD who received a THA (n = 48) and TKA (n = 68) between 2012 and 2016. An independent samples t-test and chi-square analyses were conducted to assess continuous and categorical variables, respectively. Analysis of covariance assessed the effects of depression on postoperative pain intensity. Mixed-design analysis of variance assessed the difference in opioid consumption between groups.

RESULTS

Patients with MDD who received THA or TKA demonstrated a higher mean pain intensity score when compared to those without MDD; however, this was not statistically different (235.6 vs 207.7; P = .264 and 214.8 vs 185.1; P = .055, respectively). Patients with MDD who received THA or TKA consumed more opioids when compared to those without MDD (P = .048 and P = .038, respectively).

CONCLUSION

Patients with MDD undergoing total joint arthroplasty consume more opioids compared to their matched cohort during the immediate postoperative period. Identifying patient-specific factors, such as MDD, could help arthroplasty surgeons modulate patients' course of recovery. These findings warrant more cooperation between arthroplasty surgeons and primary care providers to optimize outcome.

Intraoperative Infiltration of Liposomal Bupivacaine vs Bupivacaine Hydrochloride for Pain Management in Primary Total Hip Arthroplasty: A Prospective Randomized Trial

BACKGROUND

Pain management after total hip arthroplasty is well studied. Nevertheless, there is no consensus regarding the "cocktail" to use in periarticular infiltration (PAI). Liposomal bupivacaine (LB) is a slow release local anesthetic that can be infiltrated during surgery. In this study, we compared LB to bupivacaine hydrochloride (HCL).

METHODS

Between September 2014 and March 2016, 181 patients were screened for this prospective randomized trial. A total of 107 patients were enrolled and studied. Patients were separated into LB and control groups. LB group (50) received PAI with LB and bupivacaine HCL with epinephrine and the control group (57) received PAI with bupivacaine HCL and epinephrine. Patient morphine equivalent consumption, pain score estimated on visual analog scale, time to first ambulation greater than 20 feet, time to discharge, drug-related side effects, and patient falls were documented. Data were collected up to 72 hours postoperation.

RESULTS

There was no significant difference in morphine equivalent consumption in any of the 12-hour time blocks, up to 72 hours. No patient falls were documented in either group. Time to first ambulation greater than 20 feet, ambulation same day as surgery, time to discharge, and drug-related side effects were not significantly different between groups.

CONLCUSION

Intraoperative PAI with LB did not result in significant differences in postoperative opioid consumption, pain scores, opioid-related side effects, time to first ambulation, and length of stay up to 72 hours following total hip arthroplasty compared to a control group.

Leading the Way to Solutions to the Opioid Epidemic: AOA Critical Issues

BACKGROUND

In the past 2 decades, overdoses and deaths from prescription opioids have reached epidemic proportions in the United States. The widespread use of opioids complicates management of the orthopaedic surgery patient in the acute and chronic settings. Orthopaedic surgeons are some of the top prescribers of opioids in the complex setting of chronic use, abuse, and diversion.

METHODS

The literature regarding the basic science of pharmacologic options for pain management (e.g., opioids and nonsteroidal anti-inflammatory drugs), the impact of strategies on bone and soft-tissue healing, and pain relief are summarized as they relate to the management of orthopaedic injuries and conditions. Additionally, a section on designing solutions to address the current opioid crisis is presented.

RESULTS

The mechanism of action of different classes of analgesic medications is discussed, as well as the basic scientific evidence regarding the impact of narcotic and nonnarcotic analgesic medications on bone-healing and on other organ systems. Differences between pain and nociception, various treatment strategies, and clinical comparisons of the effectiveness of various analgesics compared with opioids are summarized. Finally, options for addressing the opioid crisis, including the description of a large system-wide intervention to impact prescriber behavior at the point of care using health-information solutions, are presented.

CONCLUSIONS

Orthopaedic leaders, armed with information and strategies, can help lead the way to solutions to the opioid epidemic in their respective communities, institutions, and subspecialty societies. Through leadership and education, orthopaedic surgeons can help shape the solution for this critical public health issue.

Perioperative Pain Management in Hip and Knee Arthroplasty

Total hip and knee arthroplasty is associated with significant perioperative pain, which can adversely affect recovery by increasing risk of complications, length of stay, and cost. Historically, opioids were the mainstay of perioperative pain control. However, opioids are associated with significant downsides. Preemptive use of a multimodal pain management approach has become the standard of care to manage pain after hip and knee arthroplasty. Multimodal pain management uses oral medicines, peripheral nerve blocks, intra-articular injections, and other tools to reduce the need for opioids. Use of a multimodal approach promises to decrease complications, improve outcomes, and increase patient satisfaction after hip and knee arthroplasty.

Regional Anesthesia in Total Joint Arthroplasty: What Is the Evidence?

Total joint arthroplasty is one of the most common surgical procedures performed for end-stage osteoarthritis. The increasing demand for knee and hip arthroplasties along with the improvement in life expectancy has created a substantial medical and economic impact on the society. Effective planning of health care for these individuals is vital. The best method for providing anesthesia and analgesia for total joint arthroplasty has not been defined. Yet, emerging evidence suggests that the type of anesthesia can affect morbidity and mortality of patients undergoing these procedures.

Enhanced Recovery After Surgery in Laparoscopic Surgery

BACKGROUND

As part of an effort to maximize value in the perioperative setting, a paradigm shift is underway in the way that patients are cared for preoperatively, on the day of surgery, and postoperatively-a setting collectively known as the perioperative care. Enhanced Recovery After Surgery (ERAS^®) is an evidence-based, patient-centered team approach to delivering high-quality perioperative care to surgical patients.

METHODS

This review focuses on anesthesiologists, with their unique purview of perioperative setting, who are important drivers of change in the delivery of valuable perioperative care. ERAS care pathways begin in the preoperative setting by both preparing the patient for the psychological stress of surgery and optimizing the patient's medical and physiologic status so the body is ready for the physical demands of surgery.

RESULTS

Minimization of perioperative fasting is important to maintain volume status-decreasing reliance on intravenous fluid administration, and to reduce protein catabolism around the time of surgery. Intraoperative management in ERAS pathways relies on goal-directed fluid therapy and opioid-sparing multimodal analgesia. Postoperatively, early feeding and ambulation, as well as discontinuation of extraneous lines and catheters facilitate patients' functional recovery.

CONCLUSION

The laparoscopic approach to surgery, when possible, compliments ERAS techniques by reducing abdominal wall trauma and the resultant milieu of inflammatory, neurohumoral, and pain responses. Anesthesiologists driving change in the perioperative setting, in collaboration with surgeons and other disciplines, can improve value in healthcare and provide optimal outcomes that matter most to patients and healthcare providers alike.