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Analgesia after Hallux Valgus Osteotomy Posterior Tibial and Deep Peroneal Nerve Ankle Blocks with Bupivacaine Liposome Injectable Suspension+Bupivacaine HCl vs. Bupivacaine HCl vs. General Anesthesia Alone: A Randomized Clinical Trial

Boxstael SV, Jo Wierinckx, Vandepitte CF, Leunen I, Kuroda MM, Jalil H, Louage S, Meex I, Mesotten D, Hadzic A

Background: Many patients having hallux valgus osteotomy report sustained postoperative pain. We hypothesized that the addition of bupivacaine liposome injectable suspension to bupivacaine HCl in ankle blocks decreases postoperative pain and opioid consumption compared to bupivacaine HCl alone or to general anesthesia (GA).

Methods: After EC and FAGG approval, 40 subjects scheduled for corrective osteotomy received ultrasoundguided blocks of the posterior tibial and deep peroneal (ankle) nerves with a mixture of liposome bupivacaine 1.33% and bupivacaine HCl 0.5% (5 ml and 2.5 ml, respectively, per nerve; n=12), bupivacaine HCl 0.5% alone (7.5 ml per nerve; n=14), or GA alone (n=14). All received multimodal postsurgical analgesia and opioids for breakthrough pain. Pain scores and opioid consumption were assessed through the first postoperative week.

Results: The blocked groups had lower pain scores (GEE p=0.016) and shorter PACU stay than the GA group. Mean total opioid consumption exhibited stepwise differences from 9.6 MME (mg morphine equivalents) in the liposome bupivacaine mixture group, 26.8 MME in the bupivacaine HCl alone group, to 60.4 MME in the GA group. Compared to the bupivacaine HCl alone and GA groups, a greater proportion of subjects who received the liposome bupivacaine mixture were able to ambulate through Day 4 (GEE p=0.007). There were no neurological deficits.

Conclusion: Addition of liposome bupivacaine in ultrasound-guided ankle blocks prolongs analgesia and decreases opioid consumption compared to bupivacaine HCl alone and GA, and improves ambulation after hallux valgus surgery.