Periarticular Ropivacaine Cocktail Is Equivalent to Liposomal Bupivacaine Cocktail in Bilateral Total Knee Arthroplasty

Optimal timing for the second surgery in staged bilateral total knee arthroplasty: a patient-determined interval approach

PURPOSE

The decision to perform a second surgery in staged bilateral total knee arthroplasty (BTKA) remains undetermined. While previous studies have investigated the timing of the second surgery, they have not reached a consensus on the optimal interval and lack self-controlled comparisons between the first and second surgeries to minimize bias. This study aimed to address these gaps by evaluating postoperative outcomes across patient-determined intervals and conducting internal comparisons between sequential surgeries to optimize the timing of the second procedure in staged BTKA.

METHODS

We retrospectively reviewed 528 patients (1,056 knees) who underwent staged BTKA between January 1, 2015, and December 31, 2019. Considering the different intervals, all patients were divided into 3 groups using 3 different cut-off points: group A (≤ 180 days), group B (> 180 days and ≤ 365 days), and group C (> 365 days). Comparison was done among the 3 groups for the second arthroplasties (A2 vs. B2 vs. C2). In each group, comparison was conducted between two surgeries (A1 vs. A2, B1 vs. B2, and C1 vs. C2, respectively).All data were retrieved retrospectively.This study utilized the propensity score matching (PSM)was performed to minimize confounding factors when comparing outcomes among groups.The matching variables included age, sex, BMI, height, comorbidities (hypertension, diabetes, coronary heart disease, chronic obstructive pulmonary disease, liver cirrhosis, and smoking status), ASA score (American Society of Anesthesiologists classification), and surgeon (C.X.W. or G.D.). Patients with same Kellgren-Lawrence (K-L) grades (grade 4)were included during the initial screening to ensure homogeneity in osteoarthritis severity. We evaluated demographics and clinical outcomes, major complications, and hospital adverse events.

RESULTS

There were no statistically significant differences in any of the clinical outcomes, major complications, and hospital adverse events among the 3 groups (A2 vs. B2 vs. C2)( all P > 0.05). When C1 and C2 were compared, LOS (12.23 ± 3.41 vs 10.12 ± 2.76, P < 0.0001), drainage volume (115.62 ± 45.67 vs 101.26 ± 49.28, P = 0.003), additional morphine analgesics consumption (131.52 ± 259.11 vs 69.78 ± 159.89, P = 0.016), and the rate of hospital adverse events (58.33% vs 46.15%, P = 0.026) were significantly better in group C2.

CONCLUSION

The time frame of staged BTKAs has no influence on postoperative outcomes when the intervals are determined by patients. However, prolonging the interval between the surgeries may be beneficial for a faster recovery after the second knee arthroplasty. Benefits such as reduced intraoperative blood loss, lower postoperative analgesic use, and shorter hospital stays are especially evident when the interval exceeds one year, showing statistically significant differences. Therefore, if patients are willing to wait, we recommend scheduling the second surgery at least one year after the first.

TRIAL REGISTRATION NUMBER

ZE2020-139-01, for retrospectively registered trials.

LEVEL OF EVIDENCE

Retrospective cohort study, LEVEL III.

One Size Does Not Fit All: Women Experience More Pain Than Men After Total Knee Arthroplasty

BACKGROUND

Multimodal pain regimens are universally applied to all patients, despite known differences in pain and responses to medication between patients of different sexes, ethnicities, and races. The purpose of this study was to understand the influence of patient sex on postoperative total knee arthroplasty pain perception as well as the efficacy of perioperative pregabalin for pain control.

METHODS

Visual analog Scales (VASs) and Knee Injury and Osteoarthritis Outcome Junior (KOOS Jr.) scores were prospectively collected for 150 patients (64 men and 86 women). Mean pain scores, delta pain scores, time to achieve minimal clinically important differences, influence of pregabalin, and opioid consumption were recorded at baseline, day of surgery, 24 hours, 48 hours, and 72 hours postoperatively, as well as postoperatively weeks 1, 2, 6, 12, and 26, and compared between women and men cohorts. This study was registered on ClinicalTrials.gov (NCT04471233).

RESULTS

The VAS pain scores for women were higher than for men at all study time points (P < 0.05). The change in VAS walking and mean KOOS Jr. scores from baseline to final follow-up at 26 weeks were not significantly different between cohorts. Both cohorts achieved VAS minimal clinically important difference by 2 weeks postoperatively. No significant differences in opioid consumption between men and women were noted during the study time periods. Women were also noted to have significantly higher raw KOOS Jr. scores than men at all-time points, except for at 26 weeks postoperatively. Interim analysis revealed no significant influence of pregabalin on VAS scores, so this arm of the study was discontinued.

CONCLUSIONS

Patient sex plays a role in perceived postoperative total knee arthroplasty pain, as women reported higher pain scores than men. We recommend not overly relying on standardized protocols, but rather instituting patient-specific pain management strategies.

Custom Periarticular Injection Cocktail Preparations Are Associated With a Major Financial Burden in Total Joint Arthroplasty

BACKGROUND

Periarticular injections (PAIs) are an important component in modern multimodal pain management protocols for total joint arthroplasty. There is a wide variety of formulas reported in the literature, from simple bupivacaine to surgeon-specific "cocktails" that include up to seven different components. Due to the broad lack of standardization in PAI formulations, this study aimed to evaluate the cost savings associated with our institution's transition to a standardized approach while ensuring no adverse impact on inpatient pain outcomes.

METHODS

We identified 16 unique PAI formulations used by 20 arthroplasty surgeons at a single institution, each prepared by the institution's pharmacy and nursing staff. Costs associated with the PAI formulations included the cost of each medication comprising the "cocktail" and the labor cost associated with their preparation. These costs were compared to the in-operating room preparation of bupivacaine injections. An evaluation of the potential cost savings was extrapolated based on our annual total joint volume.

RESULTS

The average surgeon-specific formulation costs $10.33 for ingredients alone, which is 435% higher than a bupivacaine injection and leads to an annual ingredient cost of $22,496.17 for PAIs. The preparation of these cocktails required a total labor cost of $93,600 annually. Taken together, the elimination of custom cocktails and the adoption of isolated bupivacaine translated into institutional savings of $116,096.17 per year. Inpatient pain scores were not significantly different between bupivacaine-only and surgeon-specific PAI formulations.

CONCLUSIONS

Surgeon-specific PAI formulations impose a large, somewhat hidden expense on hospital systems through the cost of sourcing medications and, in particular, the labor cost of preparing each unique combination. As bupivacaine-only PAI achieves satisfactory clinical outcomes for joint arthroplasty patients, the elimination of custom cocktails is of major benefit from a value-based care perspective.

Effect of ultrasound-guided nerve blocks on anesthesia and pulmonary function in patients undergoing distal radius fracture surgery

This study aimed to assess the impact of ultrasound (US)-guided nerve blocks (NBs) on anesthesia and their protective effect on pulmonary function (PF) in patients undergoing distal radius fracture (DRF) surgery. A total of 122 patients undergoing DRF surgery between April 2020 and June 2023 were included. According to the type of peripheral NB technique, these patients were randomized into a control group (CG; n = 60) receiving brachial plexus block (BPB) using blinded techniques, and an observation group (OG; n = 62) receiving US-guided supraclavicular BPB. Anesthetic effects, BPB-related indexes, adverse events, PF parameters (forced expiratory volume in 1 second, forced vital capacity, peak expiratory flow), and serum biochemical indexes (interleukin [IL]-6/10) were compared. The OG showed a relatively higher proportion of good anesthetic effects, shorter onset and completion times of block, and longer block duration compared to the CG, with a lower AE rate. Despite reductions in PF parameters and IL-10 levels after intervention, the OG maintained higher values than the CG. IL-6 levels increased significantly in the OG but remained lower than in the CG. In conclusion, US-guided NBs demonstrated significant anesthetic efficacy and apparently reduced anesthesia adverse events while also exerting a protective effect on PF in DRF surgery patients.

A Novel Patient Selection Tool Is Highly Efficacious at Identifying Candidates for Outpatient Surgery When Applied to a Nonselected Cohort of Patients in a Community Hospital

BACKGROUND

There is a paucity of validated selection tools to assess which patients can safely and predictably undergo same-day or 23-hour discharge in a community hospital. The purpose of this study was to assess the ability of our patient selection too to identify patients who are candidates for outpatient total joint arthroplasty (TJA) in a community hospital.

METHODS

A retrospective review of 223 consecutive (unselected) primary TJAs was performed. The patient selection tool was retrospectively applied to this cohort to determine eligibility for outpatient arthroplasty. Utilizing length of stay and discharge disposition, we identified the proportion of patients discharged home within 23 hours.

RESULTS

We found that 179 (80.1%) patients met eligibility criteria for short-stay TJA. Of the 223 patients in this study, 215 (96.4%) patients were discharged home; 17 (7.9%) were on the day of surgery, and 190 (88.3%) within 23 hours. Of the 179 eligible patients for short-stay discharge, 155 (86.6%) patients were discharged home within 23 hours. Overall, the sensitivity of the patient selection tool was 79%, the specificity was 92%, the positive predictive value was 87% and the negative predictive value was 96%.

CONCLUSION

In this study, we found that more than 80% of patients undergoing TJA in a community hospital are eligible for short-stay arthroplasty with this selection tool. We found that this selection tool is safe and effective at predicting short-stay discharge. Further studies are needed to better ascertain the direct effects of these specific demographic traits on their effects on short-stay protocols.

Periarticular infiltration used in total joint replacements: an update and review article

Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.

Ropivacaine-Epinephrine-Clonidine-Ketorolac Cocktail as a Local Anesthetic for Lumbar Decompression Surgery: A Single Institutional Experience

OBJECTIVE

The goal of this study is to discuss our initial experience with a multimodal opioid-sparing cocktail containing ropivacaine, epinephrine, clonidine, and ketorolac (RECK) in the postoperative management of lumbar decompression surgeries.

METHODS

Patients were either administered no local anesthetic at the incision site or were administered a weight-based amount of RECK into the paraspinal musculature and subdermal space surrounding the operative site once the fascia was closed. We performed a retrospective chart review of all patients 18 years of age or older undergoing lumbar laminectomy and lumbar diskectomy surgeries between December 2019 and April 2021. Outcomes including total opioid use, measured as morphine milligram equivalent, length of stay, and postoperative visual analog scores for pain, were collected. Relationships between variables were analyzed with Student's t-test, chi-square tests, and Fisher exact tests.

RESULTS

A total of 121 patients undergoing 52 lumbar laminectomy and 69 lumbar diskectomy surgeries were identified. For lumbar laminectomy, patients who were administered RECK had decreased opioid use in the postoperative period (11.47 ± 12.32 vs. 78.51 ± 106.10 morphine milligram equivalents, P = 0.019). For patients undergoing lumbar diskectomies, RECK administration led to a shorter length of stay (0.17 ± 0.51 vs. 0.79 ± 1.45 days, P = 0.019) and a lower 2-hour postoperative pain score (3.69 ± 2.56 vs. 5.41 ± 2.28, P = 0.006).

CONCLUSIONS

The RECK cocktail has potential to be an effective therapeutic option for the postoperative management of lumbar decompression surgeries.

Effects of Adding Morphine to Periarticular Infiltration Analgesia Combined with Single Dose Epidural Morphine in Total Knee Arthroplasty: A Randomized Controlled Study

OBJECTIVE

Morphine plays an important role in postoperative analgesia after total knee arthroplasty (TKA). However, there are limited data that investigate the administration ways of morphine. To evaluate the efficacy and safety of adding morphine to periarticular infiltration analgesia (PIA) combined with single-dose epidural morphine for the patients undergoing TKA.

METHODS

In total, 120 patients with knee osteoarthritis who underwent the primary TKA from April 2021 and March 2022 were randomized into three groups (a cocktail containing morphine with single-dose epidural morphine [Group A]; a cocktail containing morphine [Group B]; and a cocktail free of morphine [Group C]). The three groups were compared based on the Visual Analog Score at rest and during motion, requirement of tramadol, functional recovery including quadriceps strength and range of motion, and adverse events including nausea and vomiting and local and systemic adverse events. The repetitive measure analysis of variance and chi-square test among three groups were used to analyze the results.

RESULTS

Analgesia strategy in Group A (0.4 ± 0.8, and 0.9 ± 1.0 points, respectively) significantly reduced rest pain at 6 and 12 h after surgery relative to Group B (1.6 ± 1.2, and 2.2 ± 1.4 points, respectively) (p < 0.001), and the analgesic effect of Group B was stronger than that of Group C (2.1 ± 0.9, and 2.6 ± 0.9 points, respectively) (p < 0.05). Rest pain at 24 h after surgery was significantly lower in Group A (2.5 ± 0.8 points) and B (1.9 ± 1.0 points) than in Group C (2.5 ± 0.8) (p < 0.05). Within 24 h after surgery, the requirements for tramadol in Group A (0.25 g) and Group B (0.35 g) were significantly lower than those in Group C (0.75 g) (p < 0.05). Within 4 days of surgery, the quadriceps strength in the three groups increased gradually, and no statistical significance was noted among the three groups (p > 0.05). From the second day to the fourth day after surgery, although the three groups showed no statistical difference in the range of motion, the result of Group C was inferior to that of the other two groups. There were no significant differences in the incidence of postoperative nausea and vomiting and metoclopramide consumption among the three groups (p > 0.05).

CONCLUSION

PIA combined with single-dose epidural morphine effectively reduces early postoperative pain and tramadol requirement as well as few complications, which can become a safe and effective measure to improve postoperative pain after TKA.

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.

Clinical effect of ultrasound-guided nerve block and dexmedetomidine anesthesia on lower extremity operative fracture reduction

BACKGROUND

Lower extremity fractures are mainly treated by surgical reduction, but this operation is often affected by the patient’s level of agitation and the type of anesthesia used. The main treatment for lower-extremity fractures is operative reduction. However, operations can often be affected by both agitation and the degree of anesthesia. Therefore, it is of great importance to develop an effective anesthesia program to effectively ensure the progress of surgery.

AIM

To discuss the effect of ultrasound-guided nerve block combined with dexmedetomidine anesthesia in lower extremity fracture surgery.

METHODS

A total of 120 hospital patients with lower extremity fractures were selected for this retrospective study and divided into an observation group (n = 60) and a control group (n = 60) according to the anesthesia scheme; the control group received ultrasound-guided nerve block; the observation group was treated with dextromethomidine on the basis of the control group, and the mean arterial pressure, heart rate (HR), and blood oxygen saturation were observed in the two groups.

RESULTS

The mean arterial pressure of T1, T2 and T3 in the observation group were 94.40 ± 7.10, 90.84 ± 7.21 and 91.03 ± 6.84 mmHg, significantly higher than that of the control group (P < 0.05). The observation group’s HR at T1 was 76.60 ± 7.52 times/min, significantly lower than that of the control group (P < 0.05); The observation group’s HR at T2 and T3 was 75.40 ± 8.03 times/min and 76.64 ± 7.11 times/min, significantly higher than that of the control group (P < 0.05). The observation group’s visual analog score at 2 h, 6 h and 12 h after operation was 3.55 ± 0.87, 2.84 ± 0.65 and 2.05 ± 0.40. the recovery time was 15.51 ± 4.21 min, significantly lower than that of the control group (P < 0.05). Six hours post-anesthesia, epinephrine and norepinephrine in the observation group were 81. 10 ± 21.19 pg/mL and 510. 20 ± 98.27 pg/mL, significantly lower than that of the control group (P < 0.05), and the mini-mental state exam score of the observation group was 25. 51 ± 1.15, significantly higher than that in the control group (P < 0.05).

CONCLUSION

Ultrasound-guided nerve block combined with dexmedetomidine has a good anesthetic effect in the operation of lower limb fractures and has little effect on the hemodynamics of patients.

Reducing Narcotic Usage With 0.5% Bupivacaine Periarticular Injections in Total Knee Arthroplasty

BACKGROUND

Periarticular injections (PAIs) and adductor canal blocks (ACBs) are widely accepted pain management strategies for total knee arthroplasty (TKA); however, the optimal anesthetic concentration to provide adequate pain relief while avoiding toxicity remains controversial. The purpose of this study is to evaluate the efficacy of different anesthetic concentrations for PAI alone and in combination with ACB.

METHODS

This retrospective cohort study of patients undergoing primary TKAs between January 2019 and November 2020 included 3 groups: 0.25% PAI (50 cc of 0.25% bupivacaine PAI diluted with 50 cc of saline and ketorolac), 0.5% PAI (50 cc of 0.5% bupivacaine with 50 cc of saline and ketorolac), and PAI + ACB (ultrasound-guided preoperative anesthesiologist-administered ACB and 0.25% PAI).

RESULTS

In total, 368 TKAs were analyzed (123 0.25%, 132 0.5%, and 113 PAI + ACB). Total overall hospital narcotic usage in oral morphine equivalents (OME) was significantly lower for the 0.5% group (120.09 vs 165.26 and 175.75) compared to the 0.25% and PAI + ACB groups, respectively (P < .0001). Cumulative OME for the first 3 shifts was also lower for 0.5% (68.7 vs 83.7 and 76.4) compared to the 0.25% and PAI + ACB groups, respectively (P = .030). Total postoperative narcotics in OME were significantly lower for 0.5% (617.9 vs 825.2 and 1047.6) than 0.25% and PAI + ACB, respectively (P = .0003). Number of prescriptions within 6 weeks postoperatively were also significantly lower for 0.5% (1.7) than 0.25% (2.1) and PAI + ACB (2.4) (P = .0003).

CONCLUSION

Patients receiving 0.5% PAI had lower narcotic usage compared to 0.25% PAI or PAI + ACB. ACB may be eliminated without compromising pain control if the dose of local anesthetic in the PAI is sufficiently high.

Different Concentrations of Ropivacaine under Ultrasound Guidance on Quadratus Lumbar Muscle Nerve Block in Elderly Patients with Hip Replacement

Objective

To compare the effect of ropivacaine in different concentrations under ultrasound guidance on lumbar muscle nerve blocking in elderly patients undergoing hip replacement surgery.

Methods

60 elderly patients underwent hip replacement in our hospital over a period of April to December of 2019 were equally randomized into control and observation groups, with 30 each. Patients in the control group and observation group received 0.5% and 0.25% ropivacaine to block psoas muscle nerve, respectively. The anesthetic effect of ropivacaine at different concentrations was evaluated by time of sensory block onset and recovery and time of motor block onset and regression, blood pressure, heart rate, visual analogy scale, and postoperative nerve blocking degree.

Results

The onset time of sensory and motor block in the observation group was dramatically higher than that in the control group (P < 0.05), while the recovery time of sensory and motor was significantly shorter than that of the control group (P < 0.05). The heart rate in the observation group was notably lower than that in the control group, while the average blood pressure was remarkably higher (P < 0.05). After surgery, the degree of nerve block in the observation group was much lower compared with the control group (P < 0.05), while no marked difference in the visual analogue scale in the control group before and after surgical intervention was observed (P > 0.05).

Conclusion

The 0.25% ropivacaine method has distinctive advantages over 0.50% ropivacaine psoas nerve anesthesia in hip replacement surgery in elderly patients.

An Update on Multimodal Pain Management After Total Joint Arthroplasty

➤

Multimodal analgesia has become the standard of care for total joint arthroplasty as it provides superior analgesia with fewer side effects than opioid-only protocols.

➤

Systemic medications, including nonsteroidal anti-inflammatory drugs, acetaminophen, corticosteroids, and gabapentinoids, and local anesthetics via local infiltration analgesia and peripheral nerve blocks, are the foundation of multimodal analgesia in total joint arthroplasty.

➤

Ideally, multimodal analgesia should begin preoperatively and continue throughout the perioperative period and beyond discharge.

➤

There is insufficient evidence to support the routine use of intravenous acetaminophen or liposomal bupivacaine as part of multimodal analgesia protocols.

Implementation and results of an enhanced recovery (fast-track) program in total knee replacement patients at a French university hospital

INTRODUCTION

In total knee replacement (TKR) surgeries, "fast-track" or enhanced recovery after surgery (ERAS) programs are being developed, but their impact on care pathway quality and safety has not been fully explored in the French literature. The present study aimed to compare results in TKR between fast-track and conventional pathways, addressing the following questions: (1) Are 90-day rates of complications, readmission and surgical revision higher with fast-track? (2) Is mean length of stay (LoS) shorter with fast-track? (3) Are postoperative pain and clinical results improved by fast-track? And, (4) are patients and care staff satisfied with these new programs?

HYPOTHESIS

Implementing fast-track for TKR in a university hospital center is beneficial for the patient and does not impair the quality and safety of care.

PATIENTS AND METHOD

A case-control study was performed using a retrospective analysis of prospectively collected data. A fast-track program was implemented for TKR by modifying the care pathway. This involved instituting a therapeutic education consultation, optimizing blood sparing, modifying surgical practices, and hastening early mobilization thus actively involving patients in their own management. Between January 2017 and January 2019, 216 patients with a mean age of 69.23±7.80years and mean BMI of 30.15±4.79kg/m² were included in the fast-track group, with 335 matched patients included in the conventional group.

RESULTS

At 90days, there were no significant inter-group differences in rates of infection (fast-track=1.39%, conventional=0.90%; p=0.34), readmission (fast-track=3.24%, conventional=3.58%; p=0.49), or surgical revision (fast-track=2.78%, conventional=2.69%; p=0.298). The visual analog scale (VAS) pain rating was 1.56±1.36 in the fast-track group versus 5±2.41 in the conventional group; p<0.001. LoS was 3.17±1.59days in fast-track versus 7.25±1.85days in the conventional group; p<0.001. Ninety-five percent of patients and 96% of care staff were satisfied with the fast-track program.

DISCUSSION

Fast-track implementation ensured quality and safety of care; it did not increase the rate of complications in primary TKR. Mean length of stay was drastically reduced. Both patients and care staff were very satisfied with these new procedures.

LEVEL OF EVIDENCE

III; case-control study.

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.

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.

The mornings after-periarticular liposomal bupivacaine infiltration does not improve analgesic outcomes beyond 24 hours following total knee arthroplasty: a systematic review and meta-analysis

Periarticular local infiltration analgesia (LIA) is integral to multimodal analgesia following total knee arthroplasty (TKA); however, the duration of analgesia using traditional long-acting local anesthetics is often insufficient. LIA with slow-release liposomal bupivacaine may provide extended analgesia, but evidence of efficacy beyond the first 24 hours is conflicting. This meta-analysis compares the effects of periarticular liposomal and plain bupivacaine LIA on day 2 analgesic outcomes post-TKA. Trials comparing liposomal and plain bupivacaine LIA for TKA were sought. The two coprimary outcomes were (1) cumulative oral morphine equivalent consumption and (2) difference in area under the curve (AUC) of pooled rest pain scores on day 2 (24-48 hours) post-TKA. We also evaluated pain and analgesic consumption on day 3 (48-72 hours), functional recovery, length of hospital stay, patient satisfaction; and opioid-related side effects. Data were pooled using random-effects modeling. Seventeen trials (1836 patients) were analyzed. Comparing liposomal versus plain bupivacaine LIA for TKA failed to detect differences in morphine consumption and pain AUC on day 2 postoperatively, with mean differences of 0.54 mg (95% CI -5.09 to 6.18) and 0.08 cm/hour (95% CI -0.19 to 0.35), respectively (high-quality evidence). Secondary outcome analysis did not uncover any additional analgesic, functional or safety advantages to liposomal bupivacaine on postoperative day 2 or 3. Results indicate that liposomal and plain bupivacaine LIAs are not different for extended postoperative analgesic outcomes, including pain control, opioid consumption, as well as functional and safety outcomes on days 2 and 3 post-TKA. High-quality evidence does not support using liposomal bupivacaine LIA for TKA.

Future in regional anesthesia: new techniques and technological advancements

Regional anesthesia has a very interesting long history, initially preferred over general anesthesia because of safety concerns, then for a period general anesthesia became safer and was preferred. The use of innovative technologies such as ultrasound technology has made the blocks safer and successful by directly visualizing targeted nerves and the location of local anesthetics. With the wide use of ultrasound in the regional anesthesia field success rate of peripheral nerve blocks increased and novel blocks techniques developed. Moreover, new extended-release local anesthetic agents have begun to be promising time-efficient and longer duration of analgesia with a single injection. In this article, we attempt to summarize some of the novel block techniques, pharmacological agents, and new technologies in the field of regional anesthesia.

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.

Advances of Nano-Structured Extended-Release Local Anesthetics

Extended-release local anesthetics (LAs) have drawn increasing attention with their promising role in improving analgesia and reducing adverse events of LAs. Nano-structured carriers such as liposomes and polymersomes optimally meet the demands of/for extended-release, and have been utilized in drug delivery over decades and showed satisfactory results with extended-release. Based on mature technology of liposomes, EXPAREL, the first approved liposomal LA loaded with bupivacaine, has seen its success in an extended-release form. At the same time, polymersomes has advances over liposomes with complementary profiles, which inspires the emergence of hybrid carriers. This article summarized the recent research successes on nano-structured extended-release LAs, of which liposomal and polymeric are mainstream systems. Furthermore, with continual optimization, drug delivery systems carry properties beyond simple transportation, such as specificity and responsiveness. In the near future, we may achieve targeted delivery and controlled-release properties to satisfy various analgesic requirements.

Recent research and development of local anesthetic-loaded microspheres

This review introduces the recent research and development in local anesthetic-loaded microsphere, as efficient microspheres formulation, the efficient microspheres: optimum preparation method, high loading efficiency, and ideal release rate.

Effectiveness of local anesthetic injection in geriatric patients following operative management of proximal and diaphyseal femur fracture

INTRODUCTION

Geriatric fracture patients are at risk for poorly controlled pain and side effects of opioid medications. The arthroplasty literature has demonstrated that infiltration of long-acting local anesthetic or anesthetic cocktails improves pain control and reduces post-operative opioid use resulting in better postoperative mobility without the deleterious effects of narcotics. Despite having a higher risk for adverse events, there is limited data among geriatric trauma patients. The aim this study was to evaluate whether local anesthetic infiltration (LAI) into the soft tissues surrounding the surgical field reduces narcotic use or pain scores in patients undergoing surgical management of proximal and diaphyseal femur fractures.

MATERIALS AND METHODS

A retrospective review was performed of patients age >65 undergoing operative intervention for proximal and diaphyseal femur fracture. The electronic record was utilized to determine if local anesthetic was injected into the surgical wound, the amount of narcotics administered over 48 h in four-hour intervals, and to obtain visual analog scale (VAS) pain scores associated with patients post-operative course in four-hour intervals. The amount of narcotics was converted to morphine milligram equivalents (MME).

RESULTS

Among 477 patients with femur fracture, 358 did not receive LAI and 119 patients received LAI. Baseline demographics, fracture types, and surgical procedure were equivalent between the groups. In the first 28 h following surgery, compared with those who did not receive LAI, those who did required significantly less opioid (57.8 MME versus 94.3 MME, p = 0.034) and despite decreased narcotics, had equal pain scores (mean difference 0.37, p = 0.22). There was no difference in rates of post-operative complications.

CONCLUSION

LAI is associated with a reduction in opioid consumption in geriatric fracture patients with equivalent pain scores. Optimizing pain control is a critical issue in caring for geriatric fracture patients since both under-treated pain and opioid medications are implicated in postoperative delirium, complications, and ability to mobilize early. More research is needed to identify effective ways to optimize pain management in this at-risk patient population.

Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway

BACKGROUND

Opioid therapy has been a cornerstone of perioperative pain control for decades in the United States, despite our increased understanding of the morbidity and mortality linked to opioids. The purpose of this study is to explore the safety, efficacy, and feasibility of an entirely opioid-free perioperative pathway in patients undergoing elective shoulder arthroplasty.

METHODS

Thirty-five patients undergoing elective total shoulder arthroplasty with a mean age of 71 (range, 50-87) years elected into a comprehensive opioid-free, multimodal pain management protocol. Opioid use was completely eliminated for all points in the perioperative period including during regional and general anesthesia. Data were collected regarding patient-reported pain, opioid consumption in the perioperative period, postoperative delirium, nausea, constipation, and falls.

RESULTS

Pain level at the primary outcome point of 24 hours or discharge was rated at 2.5 on the numeric rating scale. Stable, low pain scores were demonstrated at all time points postoperatively. Low rates of nausea, falls, and constipation were reported. Only 1 patient required "rescue" opioid medications during the in-patient stay, and an additional patient was given a low-dose opioid prescription at the 2-week postoperative appointment.

CONCLUSIONS

An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. This study is the first such study to present a surgical protocol entirely free of opioids at all portions of the patient care pathway.

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.

Timing of periarticular injection has no effect on postoperative pain and functional recovery in simultaneous bilateral total knee arthroplasty: a prospective randomized, double-blinded trial

BACKGROUND

Given no consensus on optimal timeframe of periarticular multimodal drug injection (PMDI) in knee osteoarthritis patients undergoing total knee arthroplasty (TKA), this study was aimed to compare the postoperative pain and the functional recovery in patients who underwent simultaneous bilateral TKA (SBTKA) and received PMDI at the different intraoperative time points.

METHODS

This prospective, randomized, double-blinded controlled trial study included 48 patients who underwent SBTKA and received PMDI mixture, either before prosthetic implantation (late PMDI), or just after knee arthrotomy (early PMDI). Each subject's knees were randomly selected to different PMDI administration time points. The outcome parameters were postoperative pain assessed by using a visual analog scale (VAS), the maximal angle of knee flexion, and quadriceps function from day 1 to 6 weeks after surgery.

RESULTS

Late PMDI revealed slightly higher VAS at 6 and 12 h after the operation than early PMDI administration. Afterward, the VAS tended to be lower in the late than early PMDI administration until the end of the study, but without statistical significance. The time difference between early and late PMDI had no effect on postoperative VAS, while older age resulted in significantly less pain. No statistical differences between the two groups in all other outcome parameters were observed.

CONCLUSIONS

Postoperative pain reduction and functional recovery of SBTKA with early and late PMDI administration were not significantly different. The time interval of PMDI between knees did not confound the comparison of postoperative pain and functional recovery in SBTKA.

TRIAL REGISTRATION

The protocol of this study was retrospectively registered in the Thai Clinical Trials Registry database No. TCTR20170617001 on 16 June 2017.

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.