Addition of Liposomal Bupivacaine to Adductor Canal Block for Postoperative Pain Following TKA

Authors: Mikayla E. McGrath BS² , Kenneth J. Kress MD¹, Charles A. DeCook  MD¹, Jon E. Minter DO¹, Jeffrey P. Garrett MD¹, Mark E. Hamilton MD¹

¹Arthritis & Total Joint Specialists, Northside Hospita

²Force Therapeutics

Abstract

Background

Advances in Multi-Modal Analgesia and motor-sparing regional blocks   have revolutionized post-op analgesia for TKA, particularly as sameday discharge (SDD) becomes more prevalent.  At ASRA 2018, we presented a case report of the use of Liposomal   Bupivacaine (LB) for ACB and iPACK (LB-ACB/iPACK) for a complex TKA   revision in a patient on significant pre-op chronic narcotics1. (LB use for ACB is considered off-label at this time but is being done by many practioners2 .) He had marked pain relief extending 5-6 days. After successful adoption of LB-ACB/iPACK for TKR revisions, we   elected to trial it as a quality improvement for our primary TKRs.

Methods

From May through November 2019 medication consumption (narcotic and   non-narcotic), pain levels, pain satisfaction and patient data were collected  daily for POD 0-7 using our WBRP with 83% overall outcome form   compliance. This data, patient reported feedback and contemporary physical therapist  insights were used to analyze post-operative analgesia and function. After receiving baseline information on our standard MMAP 15ml   Bupivacaine 0.25% + iPACK - 20ml Bupivacaine 0.25% w epinephrine  (Protocol A), quality improvement changes to block formulation based on   clinical and patient feedback occurred over an 8-month period. Several iterations (Protocol B&C) were trialed until the final protocol of   10mL of LB to 5mL of 0.25% bupivacaine for ACB (Protocol D) maintained  decreased narcotic consumption and postoperative pain, with no adverse   clinical outcomes.

Results

Protocols A(N= 130) and D(N=132) were compared in final analysis.   No significant differences at baseline between groups.  Protocol D resulted in improved analgesia demonstrated by 44%   decrease in daily use of oxycodone 5mg pills POD 1-7 (1.05 to 0.59   pills/ day, p=<0.01), 43% decrease in total oxycodone 5mg pills over   POD 0-7 (7.48 to 4.25, p<0.01), and increase in patients taking 0   narcotic pills POD 0-7 (25% to 38%).  There was no difference in 12-week postoperative Knee Injury and   Osteoarthritis Outcome Score Jr. (p=0.39), Veterans Rand 12 Physical   (p=0.10) or Mental Component Scores (p=0.12).

Discussion & Conclusion

As Total Knee Arthroplasty moves to SDD, it will become even more   important and challenging to control pain post-discharge. In the  opioid crisis era, this needs to be done while decreasing reliance on   narcotics.  The addition of LB 10 ml to the ACB with our Standard MMAP  accomplished an even further reduction in post-op narcotic use with  43% reduction in narcotic use POD 1-7 and an increase from 25% to  38% who required ZERO narcotics POD 1-7.  With an already aggressive MMAP and low narcotic usage, the  addition of LB to ACB significantly decreased TKA postoperative narcotic usage POD 1-7.