More Predictable Return of Motor Function with Mepivacaine Versus Bupivacaine Spinal Anesthetic in Total Hip and Total Knee Arthroplasty

Abstract

Background: Spinal anesthesia provides several benefits for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), but historically comes at the cost of slow and unpredictable return of lower-extremity motor function related to the use of long-acting local anesthetics. In this prospective, double-blinded, randomized clinical trial we sought to determine if an alternative local anesthetic, mepivacaine, would allow more consistent return of motor function compared with low-dose bupivacaine spinal anesthesia during primary THA and TKA. Methods: This trial was conducted at a single academic institution. Prior to trial initiation an internal pilot study determined that 154 patients were required to achieve 80% power. Patients were randomized in a 1:1 fashion with use of advanced computerized stratification based on procedure, age group, sex, and body mass index. Following the surgical procedure, motor function was assessed every 15 minutes in the nonoperative lower extremity according to the Bromage scale and discontinued once Bromage 0 was achieved (spontaneous movement at hip, knee, and ankle). Results: Return of lower-extremity function was more predictable in patients who received mepivacaine than in those who received low-dose bupivacaine. Among patients who received mepivacaine, 1% achieved motor function return beyond 5 hours compared with 11% of patients who received bupivacaine (p = 0.013). The mean time to return of lower-extremity motor function was 26 minutes quicker in patients who received mepivacaine (185 minutes; 95% confidence interval, 174 to 196 minutes) compared with low-dose bupivacaine (210 minutes; 95% confidence interval, 193 to 228 minutes) (p = 0.016). There were no significant differences in safety outcomes including pain scores, time to participation in physical therapy, incidence of orthostatic hypotension, urinary retention, or transient neurologic symptoms in patients receiving mepivacaine compared with low-dose bupivacaine. Conclusions: In patients undergoing primary THA and TKA, spinal anesthesia with mepivacaine allowed more consistent return of lower-extremity motor function compared with low-dose bupivacaine, without a concomitant increase in complications potentially associated with spinal anesthetics. This is particularly of value in an era of short-stay and outpatient surgical procedures. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Converting hip and knee arthroplasty cases to same-day surgery due to COVID-19

“…However, this is also in keeping with data identifying lower incidence of surgical site infection in SDS cohorts, although absolute risk was low across all cohorts. 38 …”

Mepivacaine Versus Bupivacaine in Adult Surgical Patients: A Meta-analysis, Trial Sequential Analysis of Randomized Controlled Trials

“…Finally, seven references were included in our meta-analysis. [23][24][25][26][27][28][29] The references screening process is shown in Figure 1.…”

“…All the included studies were RCTs comparing the analgesic effects of bupivacaine and mepivacaine directly. The seven trials [23][24][25][26][27][28][29] included 672 patients, of whom 309 received blocks using mepivacaine, and 363 received blocks with bupivacaine (199 using hyperbaric bupivacaine [HB], 164 using isobaric bupivacaine [IB]). The concentration of bupivacaine in the included studies ranged from 0.5% to 0.75%, whereas the concentration of mepivacaine ranged from 1.5% to 4%.…”

Postoperative outcomes of mepivacaine vs. bupivacaine in patients undergoing total joint arthroplasty with spinal anesthesia

“…Prior studies have cited an expected 284% increase in total hip arthroplasty (THA) and a 401% increase in total knee arthroplasty (TKA) by the year 2030 [ 1 ]. In patients undergoing TJA, the use of different anesthetic techniques has also been shown to influence a variety of surgical outcomes, such as length of stay, time to ambulation, distance of ambulation, home discharge rate, and readmission or emergency department (ED) return rate [ 2 , 3 ].…”

“…One study found those treated with mepivacaine had earlier ambulation, earlier return to motor function, and were more likely to have the same-day discharge compared to those treated with hyperbaric or isobaric bupivacaine [ 2 ]. Another study used a double-blind, randomized clinical trial to investigate the effects of mepivacaine and bupivacaine on a patient’s return to motor function following total hip and knee arthroplasty and found a mean time of 26 minutes sooner with mepivacaine [ 3 ]. Mepivacaine has not only been shown to shorten time to ambulation and length of stay, but also has a faster neurological recovery when compared to bupivacaine [ 11 ].…”