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Multimodal Pain Management With Periarticular Infiltration of Liposomal Bupivacaine in Total Hip Arthroplasty

February 19, 2016

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

The goal of multimodal pain management protocols is to decrease opioid use and abuse and their drug-related adverse events. These protocols have become increasing beneficial because previous pain management method of opioids alone may lead to increased perioperative mortality, decreased rehabilitation potential, and decreased ambulation. In addition to decreased opioid use, multimodal pain management protocols may decrease hospital length of stay, decrease costs, improve rehabilitation, improve ambulation, and decrease morbidity. Specifically, several systematic reviews have reported that local periarticular injections improve pain, decrease opioid use, decrease adverse events, and decrease hospital length of stay. Liposomal bupivacaine is an aqueous suspension of naturally occurring multivesicular liposomes that contain bupivacaine. After liposomal bupivacaine is injected into soft tissue, bupivacaine is released from these multivesicular liposomes into the surrounding soft tissues over a sustained period of time. In orthopaedic surgery, liposomal bupivacaine has been used in almost every subspecialty, and the tremendous increased use of liposomal bupivacaine in the field of hip and knee arthroplasty is the focus of this video. Our preferred method involves the use of one vial of liposomal bupivacaine mixed with 30 cc of 0.25% bupivacaine hydrochloride. Surgeons should inject equal, small amounts into the entire soft-tissue envelope. Injection into the subcutaneous tissue and skin should be performed immediately before wound closure. Meticulous soft-tissue injection is the key to successful outcomes with the use of liposomal bupivacaine. In addition, surgeons should use a small-bore needle to limit the injection of large amounts of liposomal bupivacaine. This video, which includes illustrations, describes a step-by-step approach on how to inject the entire soft-tissue envelope to achieve optimal results. Our series of patients in whom this technique was used had improved visual analog pain scores, decreased opioid use, decreased hospital length of stay, decreased costs, and fewer postoperative falls compared with patients treated with bupivacaine who underwent total hip arthroplasty. Recent evidence-based outcomes studies have reported similar findings. In conclusion, multimodal protocols are important for pain management. The use of liposomal bupivacaine may further improve outcomes after total hip arthroplasty.

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