No Difference in Early Analgesia Between Liposomal Bupivacaine Injection and Intrathecal Morphine After TKA

• Published in: Clinical orthopaedics and related research 2017-01, Vol.475 (1), p.94-105
• Main Authors: Barrington, John W., Emerson, Roger H., Lovald, Scott T., Lombardi, Adolph V., Berend, Keith R.
• Format: Article
• Language: English
• Subjects: Aged; Analgesia, Patient-Controlled - methods; Analgesics, Opioid - administration & dosage; Analgesics, Opioid - therapeutic use; Anesthetics, Local - administration & dosage; Anesthetics, Local - therapeutic use; Arthroplasty, Replacement, Knee - adverse effects; Bupivacaine - administration & dosage; Bupivacaine - therapeutic use; Conservative Orthopedics; Double-Blind Method; Female; Humans; Injections, Spinal; Liposomes; Male; Medicine; Medicine & Public Health; Middle Aged; Morphine - administration & dosage; Morphine - therapeutic use; Orthopedics; Pain Measurement; Pain, Postoperative - drug therapy; Sports Medicine; Surgery; Surgical Orthopedics; Symposium: 2016 Knee Society Proceedings; Treatment Outcome
• ISSN: 0009-921X; 1528-1132
• DOI: 10.1007/s11999-016-4931-z

Background Opioid analgesics have been a standard modality for postoperative pain management after total knee arthroplasty (TKA) but are also associated with increased risk of nausea, pruritus, vomiting, respiratory depression, prolonged ileus, and cognitive dysfunction. There is still a need for a method of anesthesia that can deliver effective long-term postoperative pain relief without incurring the high cost and health burden of opioids and nerve blocks. Questions/purposes (1) Is liposomal bupivacaine-based periarticular injection (PAI) more effective than morphine-based spinal anesthesia or ropivacaine-based PAI in controlling postoperative pain after TKA? (2) Do patients treated with liposomal bupivacaine-based PAI experience fewer opioid-related adverse events compared with patients treated with morphine-based spinal anesthesia or ropivacaine-based PAI in controlling postoperative pain after TKA? Methods This multicenter, blind trial randomized 119 patients undergoing TKA with spinal anesthesia to receive spinal anesthesia plus periarticular injection with liposomal bupivacaine (40 patients), spinal anesthesia with bupivacaine plus intrathecal morphine (41 patients) but no liposomal bupivacaine injection, or spinal anesthesia with bupivacaine (38 patients) and no liposomal bupivacaine injection. The two groups that did not receive periarticular liposomal bupivacaine did receive periarticular injection with ropivacaine, and all three groups had ketorolac (30 mg) plus epinephrine (1:1000) in the periarticular injections. Patients in all three groups received identical perioperative multimodal analgesic and antiemetic drugs. All patients were analyzed in the group to which they were randomized and no patients were lost to followup. The primary study endpoints were visual analog score (VAS) for pain and narcotic use during postoperative day 1. Secondary endpoints included side effects associated with narcotic administration during the hospital stay. Results Mean VAS pain in the liposomal bupivacaine PAI group was lower than that for the ropivacaine PAI group at 6 hours (1.8 ± 2.1 versus 3.3 ± 2.3, p = 0.005, mean difference: 1.5, 95% confidence interval [CI], 0.5–2.5) and 12 hours (1.5 ± 2.0 versus 3.3 ± 2.4, p < 0.001, mean difference: 1.8, 95% CI, 0.8–2.8) after surgery. The morphine spinal group had lower pain compared with the liposomal bupivacaine PAI group at 6 hours (0.9 ± 1.8 versus 1.8 ± 2.1, p = 0.035, mean difference: 1.0, 95% CI, 0.1–1.8), b