Abstract
The recent societal debate on opioid use in treating postoperative pain has sparked the development of long-acting, opioid-free analgesic alternatives, often using the amino-amide local anesthetic bupivacaine as active pharmaceutical ingredient. A potential application is musculoskeletal surgeries, as these interventions rank amongst the most painful overall. Current literature showed that bupivacaine induced dose-dependent myo-, chondro-, and neurotoxicity, as well as delayed osteogenesis and disturbed wound healing in vitro. These observations did not translate to animal and clinical research, where toxic phenomena were seldom reported. An exception was bupivacaine-induced chondrotoxicity, which can mainly occur during continuous joint infusion. To decrease opioid consumption and provide sustained pain relief following musculoskeletal surgery, new strategies incorporating high concentrations of bupivacaine in drug delivery carriers are currently being developed. Local toxicity of these high concentrations is an area of further research. This review appraises relevant in vitro, animal and clinical studies on musculoskeletal local toxicity of bupivacaine.
Highlights
Musculoskeletal surgeries rank amongst the most painful surgical interventions overall [1]
This review aims to assess (i) the in vitro, in vivo and clinical effects of bupivacaine on various musculoskeletal tissues, cell types and relevant environments and (ii) and the clinical translatability and real-world relevance of these effects
The local toxic effects of bupivacaine, when used as perioperative anesthetic, may have minimal impact compared to the extensive tissue damage and systemic response elicited by the surgery itself
Summary
Musculoskeletal surgeries rank amongst the most painful surgical interventions overall [1]. The use of local anesthetics (LAs) has the potential to accelerate postoperative recovery and reduce opioid consumption in musculoskeletal surgery. To this end, bupivacaine is especially popular as it displays the longest duration of action of all LAs. Bupivacaine Toxicity in Musculoskeletal Applications (up to 8 h) [7]. Examples of LA application in musculoskeletal surgery are local infiltration anesthesia (LIA) after total hip and total knee arthroplasty (THA and TKA, respectively) These local applications are associated with low rates of systemic toxicity and adverse effects, providing a favorable comparison with opioids [17,18,19,20].
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