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Multimodal Pain Management with Periarticular Infiltration of Liposomal Bupivacaine in Total Knee Arthroplasty

February 19, 2016

Contributors: John W Barrington, MD; Jeffrey Jai Cherian, DO; Michael A Mont, MD; Michael A Mont, MD

Multimodal pain management protocols aim to decrease opioid use, abuse, and their drug-related adverse events. These protocols have become increasing beneficial, as the old method of opioids only can lead to increased perioperative mortality, decreased ability to rehabilitate, and ambulation following total knee arthroplasty. Besides decreased opioid utilization, multimodal pain protocols can decrease hospital length of stay, lower costs, improve rehab, improve ambulation, and decrease morbidity. Specifically, the use of local periarticular injections have shown to improve pain, opioid use, adverse events, and length of stay in several systematic reviews. Liposomal bupivacaine is aqueous suspension of naturally occurring multivesicular liposomes containing bupivacaine. After injection of liposomal bupivacaine into soft tissue, bupivacaine is released from these multivesicular liposomes over a sustained period of time into the surrounding soft-tissues. In orthopaedic surgery, liposomal bupivacaine has been used in almost every subspecialty, and there has been a tremendous increase use in the field of hip and knee arthroplasty and, as such, is the focus of this presentation. Our preferred method, uses one vial of liposomal bupivacaine mixed with 30cc of .25% bupivacaine hydrochloride. When injecting, it is important to use equal small amounts into the entire soft tissue envelope. Then inject subcutaneous tissue and skin right before wound closure. Meticulous soft tissue injection is the key to successful outcomes with the use of this agent. Furthermore, one should make sure to use a small-bore needle for this to limit the use of large amounts. Our video and illustrations give surgeons a step-by-step approach on how to inject the entire soft tissue envelope in order to obtain optimal results in patients undergoing total knee arthroplasty. Our series of patients using this technique, demonstrated to have improved visual analog pain scores, opioid use, length of hospital stay, and costs compared to bupivacaine in patients undergoing total knee arthroplasty. Furthermore, recent evidence based outcomes studies have demonstrated concurrent findings. In conclusion, multimodal protocols are important for pain management. The addition of liposomal bupivacaine may further improve outcomes after total knee arthroplasty.

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