Use of Liposomal Bupivacaine in Major Foot and Ankle Surgery

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1 Use of Liposomal Bupivacaine in Major Foot and Ankle Surgery Chris Adair MD, Bruce Cohen MD, Robert Anderson MD, W Hodges Davis MD, Carroll Jones MD, Kent Ellington MD

2 Disclosures: Chris Adair, MD: None Bruce E. Cohen, MD: Amniox, Arthrex, Inc., DJ Orthopaedics, Wright Medical Technology, Inc. Robert B. Anderson, MD: Amniox, Arthrex, Inc., DJ Orthopaedics, Wright Medical Technology, Inc. W. Hodges Davis, MD: Amniox, Arthrex, Inc., DJ Orthopaedics, Wright Medical Technology, Inc. Carroll P. Jones, MD: Amniox, Arthrex, Inc., Performance Orthotics, Wright Medical Technology, Inc. J. Kent Ellington, MD: Amniox, Arthrex, Inc., BME, Conventusortho, Pacira, Zimmer Authors received research grant from Pacira for this study

3 Introduction 40% of ambulatory foot and ankle surgery patients experience mod-severe pain at home Multimodal pain regimens including oral pain medications and regional anesthesia recommended

4 Liposomal Bupivacaine Extended-release liposomal bupivacainebased analgesics have been approved by the FDA for anesthetic injection Shown to provide extended pain relief and decrease opioid use phx.corporate-ir.net

5 Purpose What effect does surgeon applied liposomal bupivacaine have on post-operative pain in patients undergoing major ankle and hindfoot surgery?

6 Prospective Study: 28 pts Ankle arthrodesis, Tibiotalocalcaneal arthrodesis, Hindfoot arthrodesis, or Flatfoot procedure Popliteal block prior to surgery, GETA for procedure 20cc of liposomal bupivacaine mixed with 10cc of normal saline injected at the surgical site at conclusion of surgery Data Collection PACU - VAS pain scale, narcotic use, anti-emetic use, length of time in PACU Home - Oral narcotic use, VAS pain scales throughout the day, patient satisfaction with post surgical pain relief, complications (Day of surgery POD 3) First Post Op Visit - Patient satisfaction with post surgical pain relief and complications

7 *Greatest increase in VAS pain scores was seen from DOS to POD1 at 4:00 PM *Satisfaction with pain control was greatest on POD3 at midday (R= -0.68) Average Pain VAS 0 VAS PACU Admission VAS PACU Discharge VAS-DOS-4 hrs VAS-DOS-8 hrs VAS-DOS-12 hrs VAS-POD1-8:00 VAS-POD1-12:00 VAS-POD1-4:00 VAS-POD1-10:00 VAS-POD2-8:00 VAS-POD2-12:00 VAS-POD2-4:00 VAS-POD2-10:00 VAS-POD3-8:00 VAS-POD3-12:00 VAS-POD3-4:00 VAS-POD3-10:00

8 *Average morphine equivalents from DOS to POD3 was mg *Patients took the least amount of narcotic pain medications on DOS (28.83 mg) Average Morphine Equivalents by Day Individual Patient (n=14) Morphine Equivalents by Day DOS POD1 POD2 POD3 0 DOS POD1 POD2 POD3

9 On average, patients were very satisfied with pain management 64% rated their satisfaction as >4 (on a five-point scale) No postoperative wound complications, skin necrosis or persistent paresthesias

10 Summary Extended-release liposomal bupivacaine-based analgesics did not provide complete pain relief after the resolution of popliteal block Low pain scores without further rise in pain complaints after POD1 Lowest pain scores were seen on POD3 Application of liposomal bupivicaine was safe without an increase in complications, wound problems or adverse reactions

11 References Rawal, N. Hylander, J. Nydahl, P A. Olofsson, I. Gupta, A. Survey of postoperative analgesia following ambulatory surgery. Acta Anaesthesiologica Scandinavica. 41(8): , 1997 Sep. Clough TM. Sandher D. Bale RS. Laurence AS. The use of a local anesthetic foot block in patients undergoing outpatient bony forefoot surgery: a prospective randomized controlled trial. Journal of Foot & Ankle Surgery. 42(1):24-9, 2003 Jan-Feb. Hansen E. Eshelman MR. Cracchiolo A 3 rd. Popliteal fossa neural blockade as the sole anesthetic technique for outpatient foot and ankle surgery. Foot & Ankle International. 21(1):38-44, 2000 Jan. Provenzano DA. Viscusi ER. Adams SB Jr. Kerner MB. Torjman MC. Abidi NA. Safety and efficacy of the popliteal fossa nerve block when utilized for foot and ankle surgery. Foot & Ankle International. 23(5):394-9, 2002 May. Samuel R. Sloan A. Patel K. Aglan M. Zubairy A. The efficacy of combined popliteal and ankle blocks in forefoot surgery. Journal of Bone & Joint Surgery - American Volume. 90(7):1443-6, 2008 Jul. Golf M. Daniels SE. Onel E. A phase 3, randomized, placebo-controlled trial of DepoFoam bupivacaine (extended-release bupivacaine local analgesic) in bunionectomy. Advances in Therapy. 28(9):776-88, 2011 Sep. Bramlett K, Onel E, Viscusi ER, Jones K. A randomized, double-blind, dose-ranging study comparing wound infiltration of DepoFoam bupivacaine, an extended-release liposomal bupivacaine, to bupivacaine HCl for postsurgical analgesia in total knee arthroplasty. Knee Oct;19(5):530-6.

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