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The mornings after—periarticular liposomal bupivacaine infiltration does not improve analgesic outcomes beyond 24 hours following total knee arthroplasty: a systematic review and meta-analysis
  1. Nasir Hussain1,
  2. Richard Brull2,
  3. Brendan T Sheehy1,
  4. Michael Kushelev1,
  5. Michael K Essandoh1 and
  6. Faraj W Abdallah3
  1. 1 Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
  2. 2 Anesthesiology, Toronto Western Hospital, Toronto, Ontario, Canada
  3. 3 Anesthesiology and Pain Medicine, University of Toronto and University of Ottawa, Ottawa, Ontario, Canada
  1. Correspondence to Dr Faraj W Abdallah, Anesthesiology and Pain Medicine, University of Toronto and University of Ottawa, Ontario, Canada; mank_abda{at}


Periarticular local infiltration analgesia (LIA) is integral to multimodal analgesia following total knee arthroplasty (TKA); however, the duration of analgesia using traditional long-acting local anesthetics is often insufficient. LIA with slow-release liposomal bupivacaine may provide extended analgesia, but evidence of efficacy beyond the first 24 hours is conflicting. This meta-analysis compares the effects of periarticular liposomal and plain bupivacaine LIA on day 2 analgesic outcomes post-TKA. Trials comparing liposomal and plain bupivacaine LIA for TKA were sought. The two coprimary outcomes were (1) cumulative oral morphine equivalent consumption and (2) difference in area under the curve (AUC) of pooled rest pain scores on day 2 (24–48 hours) post-TKA. We also evaluated pain and analgesic consumption on day 3 (48–72 hours), functional recovery, length of hospital stay, patient satisfaction; and opioid-related side effects. Data were pooled using random-effects modeling. Seventeen trials (1836 patients) were analyzed. Comparing liposomal versus plain bupivacaine LIA for TKA failed to detect differences in morphine consumption and pain AUC on day 2 postoperatively, with mean differences of 0.54 mg (95% CI −5.09 to 6.18) and 0.08 cm/hour (95% CI −0.19 to 0.35), respectively (high-quality evidence). Secondary outcome analysis did not uncover any additional analgesic, functional or safety advantages to liposomal bupivacaine on postoperative day 2 or 3. Results indicate that liposomal and plain bupivacaine LIAs are not different for extended postoperative analgesic outcomes, including pain control, opioid consumption, as well as functional and safety outcomes on days 2 and 3 post-TKA. High-quality evidence does not support using liposomal bupivacaine LIA for TKA.

  • regional anesthesia
  • analgesia
  • pain
  • postoperative

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  • Correction notice This article has been corrected since it published Online First. The title has been corrected.

  • Contributors All authors provided equal contribution to warrant authorship.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests RB receives research time support from the Evelyn Bateman Cara Operations Endowed Chair in Ambulatory Anesthesia and Women’s Health, Women’s College Hospital, Toronto.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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