Nerve block with liposomal bupivacaine yields fewer complications and similar pain relief when compared to an interscalene catheter for arthroscopic shoulder surgery: a randomized controlled trial

The Use of Liposomal Bupivacaine for Pain Control After Shoulder Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Liposomal bupivacaine (LB) is a relatively novel anesthetic agent used in the management of postoperative pain in patients who have undergone shoulder surgery.

PURPOSE

To explore the literature on LB in the setting of shoulder surgery and assess its efficacy and utility in managing postoperative pain.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 1.

METHODS

PubMed, Cochrane, and Google Scholar (pp 1-20) were searched for articles published up to November 2023. Inclusion criteria consisted of randomized controlled trials comparing anesthetic modalities using LB with other anesthetic modalities using alternative drugs in patients who underwent shoulder surgery. Complications, pain levels in the first 24 hours postoperatively, and opioid consumption intraoperatively and in the first, second, and third 24 hours postoperatively were assessed.

RESULTS

A total of 15 randomized controlled trials were included in the meta-analysis. In 4 studies comparing periarticular injections of LB (196 patients) with nerve blocks of other anesthetic agents (201 patients), there was no significant difference in pain levels (P = .74) and complication rates (P = .37); however, intraoperative opioid consumption was significantly greater in patients with periarticular injections of LB (P = .005). In 3 studies comparing single-injection LB nerve blocks (83 patients) with interscalene nerve block catheters (102 patients) and in 8 studies comparing single-injection LB nerve blocks (311 patients) with other nerve blocks (308 patients), single-injection LB nerve blocks demonstrated clinical superiority. Single-injection LB nerve blocks resulted in significantly lower pain levels and lower opioid consumption in the first, second, and third 24 hours postoperatively compared with other single-injection nerve blocks and both single-injection nerve blocks and interscalene catheters combined.

CONCLUSION

LB is a promising anesthetic component with efficacy in providing analgesia after shoulder surgery. Single-injection LB nerve blocks were found to be superior in reducing pain levels and opioid consumption compared with other anesthetic modalities.

Liposomal bupivacaine after arthroscopic rotator cuff repair moderately decreases early postoperative pain and demonstrates equivocal opioid consumption compared to traditional interscalene nerve blocks: A systematic review and meta-analysis of level 1 studies

BACKGROUND

Interscalene nerve blocks (ISNBs) reduce length of stay, postoperative pain, and opioid consumption following arthroscopic rotator cuff repair (ARCR). ISNBs with anesthetic agents like bupivacaine are associated with intense rebound pain, while liposomal bupivacaine (LB) can potentially extend pain relief up to 72 h and reduce opioid consumption. The purpose of this systematic review and meta-analysis is to compare the efficacy of LB versus traditional ISNB for postoperative pain management and opioid consumption following ARCR.

METHODS

A systematic review following PRISMA guidelines was performed from inception through March 2024. Randomized controlled trials comparing LB and traditional ISNB for postoperative pain management and opioid consumption following ARCR were included. The meta-analysis on each outcome measure was outlined in a forest plot detailing the standard mean difference (SMD) for continuous variables.

RESULTS

Data was extracted from 5 articles on 362 patients who underwent ARCR, 196 of whom received LB and 166 with a control non-LB ISNB. LB interventions had significantly lower pain scores than controls on postoperative day (POD) 1 and POD 2 (SMD -3.45, 95% CI [-5.20, -1.60]; P = 0.0003 and SMD -2.39, 95% CI [-4.01, -0.77]; P = 0.004, respectively). There was a significantly lower oral morphine equivalent dosage consumption in the LB cohort than controls on POD 0, POD 1, POD 2, and POD 3 (SMD -4.66; 95% CI, -7.95 to -1.36; p = 0.006; SMD -3.77; 95% CI, -5.69 to -1.85; p = 0.0001, SMD -3.34 95% CI [-5.13, -1.56]; p = 0.0002, and SMD -3.43; 95% CI, -5.74 to -1.12; p = 0.004, respectively).

DISCUSSION

LB moderately decreased pain scores 24-72 h postoperatively and reduced opioid consumption for up to 96 h following ARCR compared to a control ISNB cohort. However, the clinical difference in opioid usage may not translate to patient benefits or justify the increased cost.

LEVEL OF EVIDENCE

I.

Randomized clinical trial comparing mixed liposomal bupivacaine vs. continuous catheter for interscalene block during shoulder arthroplasty: a comparison of analgesia, patient experience, and cost

BACKGROUND

Continuous interscalene catheters extend analgesia beyond 24 hours but are resource-intensive, while the efficacy of liposomal bupivacaine for single-injection interscalene blocks (ISBs) remains uncertain. The purpose of this investigation was to examine the analgesic efficacy, quality of recovery, and treatment costs between interscalene nerve block using either an indwelling catheter or single shot block using liposomal bupivacaine, in patients undergoing shoulder arthroplasty.

METHODS

In this single-center, parallel, unblinded, randomized clinical trial, 83 patients undergoing primary shoulder arthroplasty were assigned to either a continuous interscalene catheter group (n = 44) or a single-injection liposomal bupivacaine ISB group (n = 39). The interscalene catheter group received a 15-20 mL bolus of 0.5% bupivacaine HCl followed by continuous infusion of 0.2% bupivacaine HCl at 8 mL/h for 69 hours. The single-injection interscalene group received 10 mL (133 mg) liposomal bupivacaine with 5 mL of 0.5% bupivacaine HCl. The primary outcome was pain at rest 24 hours postsurgery. Secondary outcomes included pain scores, opioid consumption, complications, quality of recovery, and a time-driven activity-based cost analysis through postoperative day (POD) 3.

RESULTS

There was no significant difference in median pain scores at 24 hours between the continuous interscalene catheter group and the single-injection liposomal bupivacaine group (1.0 [0.0, 2.0] vs. 1.0 [0.0, 3.0]; P = .433). Comparable analgesia was observed through postoperative POD 3, with no differences in opioid consumption or quality of recovery. No serious adverse events were reported; however, 16% of patients in the continuous catheter group experienced dislodgement or leakage. Liposomal bupivacaine was associated with a 28% reduction in costs compared to the continuous catheter approach.

CONCLUSION

Single-injection ISB with liposomal bupivacaine provides comparable analgesia to continuous interscalene catheters through postoperative POD 3 while offering better value in the perioperative management of shoulder arthroplasty patients.

Novel CO2-encapsulated Pluronic F127 hydrogel for the treatment of Achilles tendon injury

Nonsurgical treatment and surgical repairment of injured Achilles tendons seldom restore the wounded tendon to its original elasticity and stiffness. Therefore, we hypothesized that the surgically repaired Achilles tendon can achieve satisfactory regeneration by applying multi-drug encapsulated hydrogels. In this study, a novel bupivacaine-eluting carbon dioxide-encapsulated Pluronic F127 hydrogel (BC-hydrogel) was developed for the treatment of Achilles tendon injuries. The rheological properties of BC-hydrogel were measured. A high-performance liquid chromatography assay was used to assess the release characteristics of bupivacaine in both in vitro and in vivo settings. Furthermore, the effectiveness of BC-hydrogel in treating torn tendons was examined in a rat model, and histological analyses were conducted. Evidently, the degradable hydrogels continuously eluted bupivacaine for more than 14 days. The animal study results revealed that the BC-hydrogel improved the post-surgery mobility of the animals compared with pristine hydrogels. Histological assay results demonstrated a significant reaction to high vascular endothelial growth factor in the surrounding tissues and expression of collagen I within the repaired tendon. This demonstrates the potential of this novel BC-hydrogel as an effective treatment method for Achilles tendon injuries.