Use of Liposomal Bupivacaine in Major Ankle and Hindfoot Surgery
Authors: Adair Chris R. , Cohen Bruce , Anderson Robert B. , Davis W. Hodges , Jones Carroll P. , Ellington J. Kent 
Published: October 2016

Category: Ankle Introduction/Purpose: Nearly 40% of patients undergoing ambulatory orthopedic surgery experience moderate-to-severe pain at home in spite of analgesic medication.As a result, a multimodal approach consisting of oral opioid agents and regional analgesics are recommended.Regional anesthesia is considered the primary anesthetic modality and adjunct to post-operative pain control following foot and ankle surgery, however it is not without potential complication.An ideal analgesic would provide long-term pain relief without resulting in a transiently weak or insensate limb. Extended-release liposomal bupivacaine-based analgesics as been approved by the FDA for anesthetic injection and have been shown to provide extended pain relief and decrease opioid use after bunionectomy, compared with placebo. This prospective study has been designed to evaluate the effect of surgeon applied liposomal bupivacaine on post-operative pain in patients undergoing major ankle and hindfoot surgery. Methods: 28 patients who were scheduled to undergo ankle arthrodesis, a tibiotalocalcaneal arthrodesis, hindfoot arthrodesis including, or a flatfoot procedure were enrolled prospectively. Prior to surgerypatients received a single shot popliteal block and at the conclusion of the case received 20cc of liposomal bupivacaine mixed with 10cc of normal saline injected at the surgical site. VAS pain scale at PACU admission and discharge, narcotic use, anti-emetic use, length of time in PACU and any complications were documented. A take home questionnaire documenting oral narcotic use, VAS pain scales at different intervals throughout the day, patient satisfaction with post surgical pain relief, as well as any complications for the day of surgery up to post op day 3 was completed. Patient satisfaction with post surgical pain relief and complications were also recorded at the patient’s first post- operative visit. Results: 28 total patients were enrolled ( Average age 55.6, Range 20-80). Post operatively 18/28 patients (64%) rated their satisfaction as >4 (on a five-point scale). Greatest increase in VAS pain scores was seen from DOS to POD1 at 4:00 PM. Satisfaction with pain control was most strongly associated on POD3 at midday with a negative correlation (R= -0.68). Patients took the least amount of pain medications on DOS (28.83 mg) with an average total morphine equivalents consumed from DOS to POD3 of 236.68 mg. There were no complications associated with application of liposomal bupivacaine, this included postoperative wound complications, skin necrosis and persistent paresthesias. Conclusion: Extended-release liposomal bupivacaine-based analgesics when utilizedduring major ankle or hindfoot surgery did not provide complete pain relief as demonstrated by the sharp rise in pain scores seen after the resolution of the analgesic effect of the popliteal block. However it seemed that the effect of liposomal bupivacaine did contribute to lower pain scores at the conclusion of the period of efficacy, as there was no further rise in pain complaints after POD1 and lowest pain scores were seen on POD3. Application of liposomal bupivacaine appears to be safe without an increase in complications, wound problems or adverse reactions.