Editor’s note: “Literature Review” is a feature designed to provide you with brief summaries of recent articles of interest, particularly from sources that our readers might not normally consume. 

Discontinuation of Intraoperative Liposomal Bupivacaine in Primary THA Does Not Clinically Change Postoperative Pain, Opioid Consumption, or Objective Functional Status

Feng JE, Ikwauzom CP, Slover JD, et al. J Arthroplasty 2021 Jun;36(6): 2062-67. https://doi.org/10.1016/j.arth.2021.01.064.

Selection and summary by Anthony Machi, MD

Introduction: The literature regarding liposomal bupivacaine for periarticular infiltration for total joint replacement is conflicting. Recent studies demonstrated the limited benefits of liposomal bupivacaine when injected for periarticular infiltration against an active comparator. Usage remains controversial. Little data has been published to examine postoperative analgesia in total joint patients following discontinuation of liposomal bupivacaine from a clinical practice.

Methods: The authors performed a single center, retrospective cohort study in patients receiving a primary total hip arthroplasty (THA). Two cohorts were identified: those having surgery between January 1, 2019, and June 30, 2019, and those having surgery between July 1, 2019, and November 30, 2019, following an institutional discontinuation of liposomal bupivacaine from an opioid sparing perioperative protocol on July 1, 2019. No other changes were made to perioperative analgesia, intraoperative anesthesia, surgical approach, or implants. Outcomes included daily and total opioid consumption, 12-hour average verbal pain scores, and 24-hour functional status as assessed by the Activity Measure for Post-Acute Care (AM-PAC).

Results: 1577 patients were included in the study: 939 in the liposomal bupivacaine cohort and 638 in the non-liposomal bupivacaine cohort. There were no differences in daily or total opioid consumption or any of the measures or total score for the AM-PAC. There was a statistically significant, but clinically insignificant, difference in pain scores in favor of liposomal bupivacaine from 12-24 hours and from 36-48 hours. There was no difference at any other time point.

Key point: Discontinuation of liposomal bupivacaine for periarticular infiltration had no clinical impact on opioid consumption, pain scores or functional status when an opioid sparing multimodal analgesic regimen was used for patients undergoing primary THA.

Dexamethasone and Surgical-Site Infection

Corcoran TB, Myles PS, Forbes AB, et al. N Engl J Med 2021;384(18):1731-41. https://doi.org/10.1056/NEJMoa2028982

Selection and summary by Anthony Machi, MD

Introduction: Dexamethasone is administered perioperatively in approximately 50% of all patients undergoing general anesthesia for the prevention of postoperative nausea and vomiting, analgesia, and other indications. Due to its numerous effects on immune function, there has been concern that there could be an increased risk of postsurgical infection related to its use, particularly if a larger, analgesic dose is given.

Methods: In the Perioperative Administration of Dexamethasone and Infection (PaDDI) trial, the authors performed a multicenter, international, randomized, triple-blind, placebo-controlled prospective noninferiority trial of 8880 adult patients undergoing nonurgent, noncardiac surgery to examine if there was a risk of surgical site infection (SSI) within 30 days of surgery when dexamethasone 8 mg IV was administered as a one-time intraoperative dose.

Results: 8678 patients were included in the primary analysis. 8.1% (354 of 4350) of patients receiving dexamethasone and 9.1% (394 of 4328) of patients receiving placebo had an SSI. The results of patients who had diabetes in both groups were similar to the primary analysis. The findings were also similar across different subtypes of SSI and across different types of nonsurgical site infection that occurred in the 30 days after surgery.

Key point: A single intraoperative dose of dexamethasone 8 mg IV does not increase the risk of SSI up to 30 days after surgery when compared to placebo.

Liposomal Bupivacaine Infiltration in the Surgical Site for Analgesia after Rotator Cuff Repair: A Randomized, Double-Blinded, Placebo-Controlled Trial

Verdecchia, NM, Rodosky MW, Kentor M, Orebaugh SL. J Shoulder Elbow Surg 2021;30(5):986-93. https://doi.org/10.1016/j.jse.2020.10.035.  

Selection and summary by Anthony Machi, MD

Introduction: Patients undergoing major shoulder surgery often have moderate-severe postsurgical pain. There are conflicting and inconsistent outcomes in studies for postoperative analgesia when liposomal bupivacaine has been infiltrated into the surgical site for shoulder surgery. It is unclear if there is an added benefit to using liposomal bupivacaine for infiltration at the conclusion of surgery when a single injection interscalene nerve block is performed before surgery.

Methods: The authors performed a prospective randomized, double-blind placebo controlled trial comparing liposomal bupivacaine with saline injected into the subacromial space and arthroscopy portal sites. All patients also received a single injection interscalene brachial plexus block with either 0.5% ropivacaine or bupivacaine (subject to availability) for surgical anesthesia and sedation. The primary outcome was the pain score on postoperative day (POD) 1 following resolution of the single injection block. Secondary outcomes included opioid consumption on POD 1-3 and average pain scores on POD 1-3.

Results: 58 patients were randomized in the study with 26 analyzed in the liposomal bupivacaine group and 25 analyzed in the control group. There was no difference in the primary outcome of pain score on POD 1 (5.8 +/-3.2 vs 5.4 +/-2.6 p=0.66), no difference in opioid consumption at any time and no difference in average pain score except POD 3, which was not clinically significant.

Key point: Periarticular liposomal bupivacaine did not improve analgesia meaningfully or reduce opioid consumption in conjunction with a single injection interscalene block for rotator cuff repair.

Anthony Machi, MD, is an assistant professor in the department of Anesthesiology and Pain Management at the University of Texas (UT) Southwestern Medical Center in Dallas. Dr. Machi is also the program director for the fellowship in regional anesthesiology and acute pain medicine.