Pain Control and Functional Milestones in Total Knee Arthroplasty: Liposomal Bupivacaine versus Femoral Nerve Block

Abstract

Background Although pain management after total knee arthroplasty (TKA) affects rehabilitation, length of stay, and functional outcomes, pain management for patients undergoing TKA has yet to be standardized. Femoral nerve blocks (FNBs) are commonly used as an adjunct; however, these can result in transient quadriceps weakness and have been associated with in-hospital falls. Periarticular infiltration of liposomal bupivacaine has been recently introduced as a long-acting analgesic that can be administered without affecting motor function. Questions/purposes (1) Does periarticular liposomal bupivacaine compared with FNB result in improved pain control as measured by pain scores and narcotic consumption? (2) How do liposomal bupivacaine and FNB compare in terms of gait and stairclimbing milestones and the proportion of patients who experienced a fall in the hospital?Methods Between September 2013 and October 2014, a retrospective analysis was conducted involving 24 surgeons who performed a total of 1373 unilateral, primary TKAs. From September 2013 to April 2014, the routine approach to TKA pain management pathway consisted of preoperative administration of oral analgesics, intraoperative anesthesia (preferred spinal or general), an ultrasound-guided FNB, intraoperative analgesic cocktail injection, patient-controlled analgesia, and oral and IV narcotics for pain as needed. A total of 583 patients were included in this study group. Starting May 2014, FNBs were discouraged and there was department-wide adoption of liposomal bupivacaine. Liposomal bupivacaine became routinely used in all patients undergoing TKA with no other changes made to the multimodal analgesia protocol at that time, and 527 patients in this study group were compared with the FNB cohort. Chart review on a total of 1110 patients was conducted by a research assistant who was not participating in patient care. During the inpatient stay, pain scores during 8-hour intervals, narcotic use, and physical therapy milestones were compared. Results With the numbers available, we detected no clinically important difference in pain scores throughout the hospital stay; however, patients treated with liposomal bupivacaine consumed very slightly less narcotics overall (96 ± 62 versus 84 ± 73 eq mg of morphine; [95% confidence interval, 11-13 mg]; p = 0. Conclusions In the absence of strong data supporting FNB over liposomal bupivacaine, we have modified our TKA pain management protocols by adopting liposomal bupivacaine in lieu of FNBs, facilitating rapid rehabilitation while providing adequate pain control. Level of Evidence Level III, therapeutic study.

Comparison of periarticular anesthesia with liposomal bupivacaine with femoral nerve block for pain control after total knee arthroplasty

“…Only 1 study refers to the proper random sequence generation [24] and 6 studies were all referred to unknown risk of bias. [19–24,26] The study of Yu et al [25] is with high risk of bias for the random sequence generation. [25] The overall kappa value regarding the evaluation of risk of bias of included RCTs was 0.736, indicating an excellent degree of agreement between the 2 reviewers.…”

“…Five studies [19,21,23–25] with 1653 patients were used to carry out a meta-analysis on the VAS at 48 hours and final results revealed that there was no significant difference between VAS at 48 hours (MD = −4.16; 95% CI −8.76–0.43; P  = 0.076, Fig. 3A).…”

“…Only 3 studies [21,23,25] reported the VAS at 72 hours and pooled results indicated that PAI with LB has similar pain control at 72 hours (MD = −0.49; 95% CI −4.22–3.23; P  = 0.795, Fig. 4A).…”

Ketamine and bupivacaine attenuate post‑operative pain following total knee arthroplasty: A randomized clinical trial

“…Furthermore, ketamine has been reported to be more efficient when combined with bupivacaine and a femoral nerve block (19). Bupivacaine is recommended for treating post-operative pain management following TKA, as it induces fewer adverse effects and does not affect any motor function (4,20). Previously, Inanoglu et al (21) concluded that ketamine and bupivacaine (multimodal regimen) could effectively control the post-operative pain following tonsillectomy.…”

CORR Insights®: No Difference in Early Analgesia Between Liposomal Bupivacaine Injection and Intrathecal Morphine After TKA

“…Indeed, femoral nerve blockade has been the preferred strategy for pain management after TKA surgery in many centers around the world, and has been shown to be superior to morphine patient-controlled analgesia and equivalent to epidural pain management [4,22]. More recently, it was reported that PAI might be better than continuous femoral nerve block in terms of pain relief after TKA in retrospective [17,23] and prospective trials [12,19], and might even improve the time for discharge from the hospital [9]. One recent meta-analysis of 14 randomized controlled trials confirmed that femoral nerve block was not superior to PAI in terms of opioid consumption, pain scores (at rest or movement), ROM, muscle strength and length of stay [1].…”