BACKGROUND: Liposomal bupivacaine (LB) is a long-lasting local anesthetic agent that was developed for use in the surgical setting to help manage postoperative pain. The objective of this study was to evaluate the effect of LB on postoperative pain, function, and overall hospital course in patients with intracapsular hip fractures who were treated with hip hemiarthroplasty.
METHODS: This was a single-center, randomized prospective double-blinded study of 50 patients with an isolated intracapsular femoral neck fracture who were treated with hip hemiarthroplasty from 2018 to 2022. The study group consisted of 25 patients who were treated with intraoperative LB and bupivacaine hydrochloride injections, while the control group consisted of 25 patients who were treated with intraoperative bupivacaine hydrochloride injections only. Primary outcomes were a visual analog scale (VAS) score for pain, total morphine milligram equivalents (MME), delirium, and time to ambulation with physical therapy.
RESULTS: No significant differences between the study and control groups were found in any of the outcomes measured. Most notably, there were no differences in the average postoperative pain score (VAS, 2.26 versus 2.7; p = 0.34), total MME used postoperatively (11.73 versus 9.98 MME; p = 0.71), and postoperative day of discharge (4.00 versus 3.88 days; p = 0.82).
CONCLUSIONS: The results of our study suggest that use of LB is not associated with substantially improved postoperative pain or function or with a shorter hospital course following hip hemiarthroplasty for a femoral neck fracture. Given the higher cost of LB compared with standard postoperative pain modalities, it is worth questioning its use in the setting of geriatric hip fractures.
LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
This is a small (n=50) and relatively simple study, but it is useful in that it reflects common practice in the real world. That liposomal bupivacaine did not improve pain relief at 24 or 48 hours may be due to the relatively low level of pain in both groups at those time points -- only 2-3 out of 10. This is consistent with hip fracture repair being relatively less painful (once fixed) than many other surgeries. In the presence of ideal modern practice: rapid time to OR, and preop fascia iliaca block (even in the ED, as some places are now doing), it is likely that LB postop is even less helpful. The authors point out the cost of LB is on target. For this operation, at least, it does not seem justified in real-world practice.
Physician rater
I read the manuscript with interest on this clinically relevant topic. Liposomal bupivacaine is usually looked upon as an advantageous drug over the usual bupivacaine hydrochloride used in current practice. Interestingly, the authors could not demonstrate any benefit of the liposomal preparation use for postoperative pain after femoral arthroplasty/neck surgery. The results are intriguing, but it appears that the intervention and control group did not match the intervention technique and procedure. Although drug volume was matched, in the control group after capsule infiltration, the remaining bupivacaine was then used to inject the abductors and tensor fasciae latae. On the other hand, in the intervention group, the remaining drug was used for skin infiltration. It might have an impact on the result of the study.
, McMaster University