Intraoperative Liposomal Bupivacaine vs. Bupivacaine for Total Hip Replacement Pain Management

Study Overview
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Brief Summary
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The purpose of this study is to compare two medications currently injected intra-operatively to help decrease pain after surgery in patients undergoing a primary total hip replacement (THR). The two medications are Exparel® (bupivacaine liposome injectable suspension) plus bupivacaine with epinephrine versus bupivacaine with epinephrine. This study is looking to see if one medication works better than the other in managing post-operative pain after THR. The study hypothesis is that Exparel® plus bupivacaine with epinephrine will demonstrate better pain management in THR patients post-operatively. Both medications are FDA-approved for post-operative analgesia.

Detailed Description
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All surgeries were performed by the same orthopaedic surgeon. Two groups, one receiving Exparel® (bupivacaine liposome injectable suspension) plus bupivacaine with epinephrine (LB group) and the other receiving bupivacaine with epinephrine (Control group), will be compared using post-operative pain scores, hospital length of stay, time to ambulation, falls, narcotic use, and narcotic-related adverse effects. Aside from hospital length of stay, all outcomes were recorded for up to 72 hours following surgery. An a priori power analysis was performed to calculate the total number of patients that needed to be enrolled to achieve a minimum 90% power, with the threshold of statistical significance set to 0.05. Based on a previous study reporting a mean oral opioid consumption of 57.04mg ± 25.6 at 24 hours post THR, a mean difference of 17.14mg was considered to be clinically significant. Thus, at least 26 patients were necessary in each group for an adequately powered assessment. The diagnosis for osteoarthritis was determined by patient history, physical examination, and imaging findings. Each patient received a thorough explanation of the protocol, and willing patients signed an informed consent form. All patients underwent a personal preoperative education program regarding pre, intra-, and post-procedural information including physical therapy, expectations, discharge goals, home therapy, and pain management. After written consent was collected, the form was sent to the hospital pharmacy for randomization. Envelopes were randomized, sealed, numbered, and given to the pharmacy staff, ultimately dispensing the envelopes to the nurse in the operating room in numerical order. The pharmacy documented the required information, selected medication, and drug accountability forms according to the contents of the envelopes. A nurse delivered study drugs to the operating room in a sealed, non-descriptive envelope. During the standard anterior approach procedure, an anesthesiologist administered fentanyl or hydromorphone as needed for analgesia. The local anesthetics were administered after reduction of the implants. Patients in the LB group received 20cc liposomal bupivacaine, 40cc 0.25% bupivacaine with epinephrine, and 20cc of normal saline. Each patient in the control group received 60cc of 0.25% bupivacaine with epinephrine. Using a 20-gauge spinal needle, the local anesthetics were injected using a deep tissue administration technique. Structures innervated by the femoral nerve, superior gluteal nerve, or lateral femoral cutaneous nerve were considered suitable for injection. Throughout administration, frequent aspirations were performed to check for blood and minimize the risk of intravascular injection. The patients, surgical team, and floor staff was blinded to the local anesthetic drugs given. During hospitalization, patients were observed, evaluated and treated according to postoperative protocols. Patients received opioids for pain management as needed, which was routinely documented by hospital staff. Opioids included fentanyl, hydromorphone, oxycodone, codeine, tramadol, morphine, and hydrocodone. All opioid dosages were converted into morphine equivalent dosages for analysis. Each patient began physical therapy within the first 24 hours postoperatively. Patients were discharged when they were able to begin self-care, their pain was controlled utilizing an oral regimen, and they were able to tolerate oral medication intake.

Official Title
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Post-surgical Pain Care Pathways During Enhanced Recovery Surgery Using Exparel (Bupivacaine Liposome Injectable Suspension) Plus Bupivacaine With Epinephrine Versus Bupivacaine.

Conditions
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Pain, Postoperative

Intervention / Treatment
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* Drug: Liposomal Bupivacaine
* Drug: 0.25% Bupivacaine with epinephrine
* Drug: Saline


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients scheduled to undergo primary unilateral total hip replacement Patients diagnosed with hip osteoarthritis Patients failed to improve with conservative measures Patients willing and able to sign informed consent Exclusion Criteria: Revision total hip replacement Bilateral total hip replacement Birmingham hip resurfacing Patients with hepatic/kidney disease Patients with a known allergy to bupivacaine or other local anesthetics

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 90 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Liposomal bupivacaine<br>Periarticular infiltration cocktail of 20cc of liposomal bupivacaine with 20cc of normal saline and 40cc of 0.25% bupivacaine with epinephrine | Drug: Liposomal Bupivacaine<br>* 266mg liposomal bupivacaine<br>* Other names: Exparel;Drug: 0.25% Bupivacaine with epinephrine<br>* 0.25% bupivacaine with epinephrine<br>* Other names: Marcaine;Drug: Saline<br>* Normal saline<br>* Other names: Saline solution;|
| Active Comparator: Bupivacaine with epinephrine<br>Periarticular infiltration cocktail of 60cc of 0.25% bupivacaine with epinephrine | Drug: 0.25% Bupivacaine with epinephrine<br>* 0.25% bupivacaine with epinephrine<br>* Other names: Marcaine;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Patient Morphine Equivalent Consumption | All opioid doses were administered to the patient at 12-hour intervals post-surgery. Doses were recorded till either of the following criteria was met, the patient was discharged or the 72-hour post-surgery timeframe ended. The doses were then collected and converted to OMEs, in milligrams. | 72 hours postoperation, divided into six 12-hour periods | 
| Change in Patient-reported Visual Analog Scale (VAS) Pain Intensity Score | Patient-reported VAS pain intensity score (0 = no pain, 10 = worst pain possible) will be collected. Mean VAS scores for the 72-hour period were calculated using the cohort's reported average pain scores at each 12-hour interval. | 72 hours post-operation, divided into six 12-hour periods | 
| Time to Ambulation More Than 20 Feet (in Hours) | The length of time (in hours) until the patient first ambulates more than 20 feet from the time of surgery will be recorded. | from time of surgery until patient first ambulates more than 20 feet or 72 hours post-surgery or patient discharge, whichever comes first | 
| Length of Stay (LOS, in Days) |  | From time of surgery until patient is discharged, an average of 1.5 days. | 
| Number of Patients That Experienced a Fall |  | 72 hours postoperation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Exparel, total hip replacement, bupivacaine