Liposomal Bupivacaine Versus Standard Bupivacaine in the Adductor Canal for Total Knee Arthroplasty: A Randomized, Controlled Trial

Abstract

Peripheral nerve blocks are commonly used in total knee arthroplasty (TKA). Liposomal bupivacaine is an extended-release anesthetic medication that maintains efficacy upwards of 72 hours. This study compared single-shot liposomal bupivacaine (LB) with the standard single-shot bupivacaine (SB) in a preoperative adductor canal block in TKA patients. A double-blind randomized, controlled trial at a single institution was performed in patients undergoing TKA. A standard preoperative single-shot adductor canal nerve injection was performed in 31 patients using 266 mg of liposomal bupivacaine (20 mL), whereas 32 patients received a standard formulation of 0.5% bupivacaine hydrogen chloride (20 mL). The primary outcome measure was postoperative gait velocity. Secondary outcomes included knee range of motion, pain scores, patient satisfaction, knee extension strength, opioid consumption, length of stay, and adverse events. There were no differences in baseline measures between groups. Improved pain ratings with activity ( P =.009) were noted on postoperative day 1 with LB (mean, 4.4; SD, 2.0) compared with SB (mean, 5.9; SD, 2.6). Fewer opioids were used with LB compared with SB on postoperative day 1 (mean, 51.2 vs 66.1; P =.020) and on postoperative day 2 (mean, 39.5 vs 54.8; P =.016). No statistically significant differences in gait velocity, knee range of motion, knee extension strength, or patient satisfaction occurred. Peripheral nerve blockade with a single-shot adductor canal injection demonstrated improved pain scores with activity and diminished postoperative narcotic use when using LB compared with SB in TKA patients. There may be early postoperative advantages with LB as a single-shot injection in adductor canal blockade for patients undergoing TKA. [ Orthopedics . 2021;44(4):249–255.]

The postoperative analgesic efficacy of liposomal bupivacaine versus long-acting local anaesthetics for peripheral nerve and field blocks

“…Of the 1996 trials identified from the literature search, 27 met the inclusion criteria, 18–44 accounting for a total of 2122 patients. Figure 1 presents the PRISMA flow diagram showing the literature search results and Fig.…”

“…Eleven trials included patients undergoing orthopaedic surgery, 18,20,24,27–29,32,33,35,36,38 six others included patients undergoing breast or gynaecological surgery, 21,23,26,30,34,44 six trials included patients undergoing abdominal surgery 22,25,31,37,41,43 and four trials included patients who underwent other types of surgery 19,39,40,42 . Fifteen trials investigated the efficacy of liposomal bupivacaine on peripheral nerve blocks, 18–21,24,27–29,32,33,36,38–40,42 while 12 explored its efficacy on field blocks 22,23,25,26,30,31,34,35,37,41,43,44 . Nerve block were performed under ultrasound guidance in 19 trials 18,20,22–24,27–36,38,39,43,44 and following anatomic landmarks in four studies 19,21,25,42 ; in another four studies, 26,37,40,41 the surgeon performed the block under direct vision.…”

“…On the basis of 22 trials with a total of 1636 patients, 18,19,21–24,26–32,35–40,42–44 the pain score at rest at 24 postoperative hours was significantly reduced in patients receiving liposomal bupivacaine. For both types of block combined, the mean difference (95% CI) was -0.9 (-1.4 to -0.4), I 2 = 87%, P < 0.001.…”

“…2 summarises the risk of bias of the different trials. Seventeen authors were contacted 18,[21][22][23][24][26][27][28]30,31,34,35,[37][38][39][40]43 and five provided additional data. 18,21,23,26,27 Trial characteristics Table 1 presents the trial characteristics.…”

“…37 The peripheral nerve block was combined with a general anaesthesia in 23 studies [18][19][20][21][22][23][24][25][26][27][30][31][32][34][35][36][37][38][40][41][42][43][44] and with a spinal anaesthesia in two studies 29,33 ; the anaesthetic strategy was not specified in two trials. 28,39 Fourteen trials prescribed a multimodal analgesic regimen for the postoperative period. [20][21][22]24,29,32,33,[36][37][38][39][40][41]43 Finally, nine trials declared a conflict of interest.…”