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Trends of liposomal bupivacaine utilization in major lower extremity total joint arthroplasty in the USA: a population-based study
  1. Ottokar Stundner1,2,
  2. Elisabeth Hoerner1,
  3. Haoyan Zhong3,
  4. Jashvant Poeran4,
  5. Jiabin Liu3,
  6. Alex Illescas3 and
  7. Stavros G Memtsoudis2,3
  1. 1Department of Anesthesiology and Intensive Care, Medizinische Universität Innsbruck, Innsbruck, Austria
  2. 2Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
  3. 3Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
  4. 4Department of Orthopaedics/Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  1. Correspondence to Dr Ottokar Stundner, Department of Anesthesiology and Intensive Care, Medizinische Universität Innsbruck, Innsbruck, A-6020, Austria; otto.stundner{at}


Introduction Liposomal bupivacaine has been marketed for the achievement of long-acting local or regional anesthesia after major lower extremity total joint arthroplasty. However, it is comparatively expensive and controversy remains regarding its ability to decrease healthcare costs. With mounting evidence suggesting non-superiority in efficacy, compared with plain bupivacaine, we sought to investigate trends in liposomal bupivacaine use and identify changes in practice.

Methods We identified adult patients from the Premier Healthcare Database who underwent elective total joint arthroplasty between 2012 and 2021. Prevalence and trends of liposomal bupivacaine utilization were compared on the individual patient and hospital levels. Log-rank tests were performed to assess the influence of location, teaching status, or hospital size on time to hospital-level liposomal bupivacaine termination.

Results Among 103,165 total joint arthroplasty cases, liposomal bupivacaine use increased between 2012 and 2015 (from 0.4% to 22.8%) and decreased by approximately 1%–3% annually thereafter (15.7% in 2021). Liposomal bupivacaine was ever used in approximately 60% of hospitals. Hospital-level initiation of liposomal bupivacaine use peaked in 2014 and decreased thereafter (from 32.8% in 2013 to 4.3% in 2021), while termination rates increased (from 1.4% in 2014 to 9.9% in 2019). Non-teaching hospitals and those located in the South and West regions were more likely to retain liposomal bupivacaine longer than teaching or Midwest/Northeast hospitals, respectively (p=0.023 and p=0.014).

Discussion Liposomal bupivacaine use peaked around 2015 and has been declining thereafter on individual patient and hospital levels. How these trends correlate with health outcomes and expenditures would be a strategic target for future research.

  • Anesthesia, Local
  • Pain, Postoperative
  • Pharmacology
  • Economics

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  • Contributors OS is the guarantor for this work. OS, HZ, AI, and SGM developed the research protocol for this work. HZ and AI performed statistical analyses. OS, EH, JP, JL and SGM reviewed the statistical plan. OS, EH and SGM drafted the first manuscript. All authors reviewed the manuscript. All authors helped revise the manuscript.

  • Funding This work was supported solely by departmental sources.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.