Advances in Managing Postop Pain and Improving Outcomes

    Liposomal bupivacaine may be a game-changer in controlling postsurgical pain in patients undergoing knee, hip, foot and ankle, and orthopaedic trauma surgery.

    Orthopaedic surgical procedures are associated with varying degrees of postsurgical pain that can be a challenge for the health care team to manage.

    Fortunately, advances in periopoperative pain management have given surgeons new tools and techniques to better control postsurgical pain, improve outcomes, and even reduce costs.

    Faculty at the recent symposium, “Advancing Orthopaedic Postsurgical Pain Management & Multimodal Care Pathways: Improving Clinical & Economic Outcomes,” shared their experience with one such advance: the use of bupivacaine liposome injectable suspension (EXPAREL®; Pacira Pharmaceuticals, Parsippany, New Jersey) for long-acting postsurgical pain control via infiltration in the wound site during surgery.

    Presentations from the symposium are now available online.

    The Evolution in the Use of Local Analgesics in Management of Total Joint Arthroplasty – Adolph V. Lombardi, Jr., MD, FACS

    Adolph V. Lombardi, Jr., MD, FACS, the moderator of the symposium, believes liposomal bupivacaine is a “game changer” for orthopaedic pain management.


    Using liposomal bupivacaine puts pain control back into the hands of the orthopaedic surgeon, he said, and provides significant benefits for the patient. Many of Dr. Lombardi’s patients go home the same day as hip or knee arthroplasty, thanks in large part to an anesthesia, pain control, and blood loss management protocol that includes:

    • Short-acting spinal (hip patients)
    • Adductor canal block (knee patients)
    • General anesthesia
    • Tranexamic acid
    • Pericapsular injectable cocktail with liposomal bupivacaine
    • IV acetaminophen
    • IV steroid dexamethasone
    • Celecoxib

    Dr. Lombardi and his partners in Joint Implant Surgeons, Inc., of New Albany, Ohio, began operating at a same-day surgical center in June 2013. Since then, they have performed 760 hip and knee arthroplasties at the surgical center, with 92% of those patients going home the same day as surgery. Those who stayed overnight did so mostly for convenience, travel distance, or later OR time. Patient satisfaction is at 98%.

    These patients have good pain control, Dr. Lombardi said, and can bear weight and ambulate quicker than those who have a femoral nerve block. And they have less need for rescue opioids.

    DISCLOSURES: Dr. Lombardi is a paid consultant for Biomet and Pacira.

    Transition of Femoral Nerve Blocks to the Use of Peri-articular Injections Emerging Techniques in the Management of Orthopaedic Surgery – Bryan D. Springer, MD

    Bryan D. Springer, MD, has been in practice for 9 years, and he said in that short time there have been several revolutionary advances in hip and knee surgery including:

    • Highly cross-linked polyethylene
    • Tranexamic acid
    • Rapid recovery protocols
    • Multimodal pain management

    The latter is especially important, Dr. Springer said, as it helps to alleviate one of the biggest fears patients have about arthroplasty by allowing the surgeon to address pain at different levels, making patients more comfortable following arthroplasty.

    Dr. Springer echoed Dr. Lombardi’s list of benefits to the patient, and added that he has also noted important cost savings when using liposomal bupivacaine as part of a multimodal analgesia protocol compared to peripheral nerve blocks.

    In fact, Dr. Springer has replaced peripheral nerve blocks with the use of periarticular injections for his hip and knee arthroplasty patients. This significantly reduces the risk of falls, allows for early mobilization, and reduces rebound pain and many of the sequelae of peripheral nerve blocks, such as neurogenic pain and paresthesias.

    Dr. Springer also reviewed best infiltration practices as determined by a group of high-volume users of liposomal bupivacaine at a meeting in Vail, Colorado, earlier this year. The group has recommended:

    • Standardized dosing. The standard dose should be 20 mL of liposomal bupivacaine with 30 mL of 0.25% Marcaine with epinephrine. The surgeon may add 10 to 20 mL of normal saline if more volume is needed.
    • Drug compatibility. Liposomal bupivacaine has demonstrated no significant interaction with epinephrine, corticosteroids, antibiotics, tranexamic acid, NSAIDs (Toradol), opioids, and Marcaine (up to a 2:1 ratio). It also does not interact with stainless steel, titanium, polypropylene, and silicone
    • Injection technique for hip and knee cases. With a 22-gauge needle, the surgeon should use a moving needle technique to ensure liposomal bupivacaine is deposited in multiple areas around the surgical site, avoiding vascular areas.
      • Total knee arthroplasty injection sites: posterior capsule (20 mL), periosteum (10 mL), and arthrotomy and subcutaneous skin (20 mL)
      • Total hip arthroplasty injection sites: anterior capsule (20 mL), posterior rotators/abductors (20 mL), and subcutaneous tissue/fascia/skin (20 mL)

    DISCLOSURES: Dr. Springer is a paid consultant for ConvaTec, Pacira, Polaris, and Stryker.

    Emerging Data in the Use of Liposomal Bupivacaine: Comparative Review of 2,000 Patients – John W. Barrington, MD

    John W. Barrington, MD, and his colleagues from the Texas Joint Replacement Center in Plano, Texas, have embraced the concept of multimodal analgesia for their joint replacement patients and have added surgical wound infiltration with liposomal bupivacaine to their regimen. Dr. Barrington explained their process for introducing a new product in their practice:

    • Study data from all phases of the development process or from the FDA approval
    • Initiate a pilot study, in which they review results and compare them with prior results
    • Introduce the product on a large scale, which includes ongoing review of outcome data
    • Participate in large case-control studies and randomized controlled trials

    After two successful pilot studies with liposomal bupivacaine, they changed their perioperative pain management protocol to incorporate the drug.

    At the 2014 Annual Meeting of the American Academy of Orthopaedic Surgeons, Dr. Barrington and his partner, Roger Emerson, MD, presented groundbreaking data in which they compared pain control in 1,000 consecutive total joint arthroplasty patients who received local infiltration with liposomal bupivacaine with 1,000 consecutive patients who did not receive liposomal bupivacaine.

    The primary outcome measure was mean VAS score and percentage of VAS scores at 0. Dr. Barrington said patients in the liposomal bupivacaine group did significantly better in both primary outcomes.

    The secondary outcomes measures included complications (mortality, infection, hemorrhage/hematoma, missed PT because of nausea and vomiting, falls, DVT, cardiopulmonary event, transfusion, and readmission), length of stay, Press Ganey overall satisfaction, and cost. Patients experienced fewer falls, shorter length of stay, and increased satisfaction, with no increase in infection, hemorrhage/hematoma, or adverse cardiopulmonary events.

    Importantly, Dr. Barrington and his colleagues realized a $1,246 per patient cost savings with the use of liposomal bupivacaine.

    DISCLOSURES: Dr. Barrington is a paid consultant for Angiotech, Biomet, Medtronic, Orthosensor, and Pacira.

    The Use of Liposomal Bupivacaine in Foot and Ankle Surgery – Steven A. Herbst, MD

    Steven A. Herbst, MD, from Central Indiana Orthopedics Center, Anderson, Indiana, noted that his foot and ankle surgery patients have unique needs from an anesthesia standpoint, with the type of block dictated by the complexity of the procedure:

    • Sciatic/saphenous block for ankle procedures, more extensive hindfoot/midfoot/forefoot procedures, and arthroscopy
    • Ankle block for simple, less-painful, and soft tissue procedures
    • Local, digital, or field block for isolated Morton’s neuromas, hammertoes, and ganglions

    The issue, Dr. Herbst said, is that indwelling catheters are costly, put the patient at risk for complications, and are a nuisance – but they provide good pain control. Ankle blocks provide pain control for only about 6 hours, but in most cases, an indwelling catheter would be “overkill,” Dr. Herbst said, and would limit ambulation.

    Liposomal bupivacaine, he said, provides the long-acting pain control he wants for his patients without the impaired mobilization of an indwelling catheter.

    Dr. Herbst mixes 20 mL of liposomal bupivacaine with 20 mL of 0.25% Marcaine. He injects 10 mL into the anterior and posterior capsule and 30 mL into the peri-ankle area. He emphasized the importance of following the protocol to achieve consistent results; success with the drug is very technique-dependent, he said.

    DISCLOSURES: Dr. Herbst is a paid consultant for Accumed LLC, Pacira, and Zimmer.

    The Use of Liposomal Bupivacaine in Orthopaedic Trauma – Hank L. Hutchinson, MD

    Hank L. Hutchinson, MD, from the Tallahassee Orthopedic Clinic in Tallahassee, Florida, is an orthopaedic trauma surgeon, and he said liposomal bupivacaine has a made a big difference in his ability to provide pain control for a variety of patients.

    Dr. Hutchinson shared a number of cases, including the case of a 63-year-old female with history of bisphosphanate use and prior subtrochanteric fracture. The fracture was treated in 2011 with a cephalomedullary nail, but was referred to Dr. Hutchinson for management of fracture nonunion.

    When Dr. Hutchinson rounds on patients who have surgery to repair a subtrochanteric fracture, they are usually asleep from the opioids they have taken to control their pain.

    With this patient, however, he infiltrated the site with liposomal bupivacaine, and when he saw her 30 hours after surgery, she was able to flex her knee and lift her leg off the bed. That is typical of his patients who receive liposomal bupivacaine, he said, who are usually sitting up soon after surgery, interacting with their families, reading, and eating.

    Based on his patient experience, Dr. Hutchinson believes liposomal bupivacaine has utility in the hospital setting for controlling postsurgical pain in orthopaedic trauma patients.

    DISCLOSURES: Dr. Hutchinson is a paid consultant for Pacira.