Multimodal Pain Strategies Including Liposomal Bupivacaine for Isolated Acetabular Fracture Surgery.

Abstract

The incidence of isolated acetabular fractures has been increasing, particularly in older adult patients. These fractures can be debilitating and may require prolonged immobilization and/or complex surgical reconstruction. Liposomal bupivacaine (LB) is a prolonged-release form of bupivacaine demonstrated to be effective in orthopaedic surgery. Defining a multimodal pain management plan, which incorporates optimized techniques for use of LB in acetabular surgery, may improve outcomes for patients. Two orthopaedic surgeons specializing in orthopaedic traumatology discussed best practices for infiltration of LB and recommendations for perioperative use of LB plus other anesthetics/analgesics for isolated acetabular fracture surgery. Consensus techniques for isolated posterior and anterior acetabular fractures were developed. LB (266 mg/20 mL) should be expanded with 50 mL of bupivacaine HCl 0.25% and saline to a total volume of 120 or 300 mL for the posterior or anterior techniques, respectively. A 3.5-inch spinal needle is inserted tangentially, infiltrating 1 mL/cm into the fracture site, periosteum, muscle fascia, subcutaneous tissue, and skin. Patients receive acetaminophen, celecoxib, gabapentin, and opioids before surgery, adjusting appropriately for patient comorbidities and potential drug-drug interactions. At the end of the surgery, before closure, LB is infiltrated and patients receive a dose of intravenous acetaminophen. Presurgical medications are continued after surgery for approximately 10-14 days, after which opioids are only considered to treat breakthrough pain. These recommendations can be used to optimize and streamline care for patients with isolated acetabular fractures and act as a foundation for additional clinical research. Therapeutic Level V.