JBJS - 2026-06-16 - Journal Article
Incisional Infiltration of Liposomal Bupivacaine in Geriatric Hip Fracture Surgery: A Randomized Parallel-Group Trial.
Yu X, Yuan Y, Zhao S, Sun Z, Han F, Wang S, Zhang Z, Sun K, Duan F, Jia Y, Ma Y, Li T
Topics
Key Takeaway
Incisional liposomal bupivacaine infiltration failed to reduce the primary endpoint of resting VAS pain at 48 hours (median 0 both groups, p=0.143) in geriatric hip fracture arthroplasty, despite significant reductions in activity pain at 8, 24, and 48 hours and oral rescue opioid use (25 vs. 50 MME median).
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Summary
This single-center, participant- and assessor-blinded RCT tested whether incisional liposomal bupivacaine (LB) infiltration added to standardized multimodal analgesia improved resting VAS pain at 48 hours in geriatric patients undergoing hemiarthroplasty or THA for hip fracture. The primary endpoint did not differ (median VAS 0 both groups, p=0.143; Cohen d=-0.506), but LB significantly reduced activity pain at 8, 24, and 48 hours and halved median oral rescue opioid consumption (25 vs. 50 MME). Ambulation rates at 48 and 72 hours and time to discharge were equivalent between groups.
Key Limitation
The primary endpoint of resting VAS at 48 hours exhibited a floor effect (median 0 in both groups), rendering it insensitive to between-group differences and likely explaining the null result despite meaningful secondary outcome differences.
Original Abstract
BACKGROUND
Hip fracture volumes are rising with population aging, and inadequate analgesia following hip fracture surgery has been shown to impede early mobilization and recovery. Liposomal bupivacaine (LB) may extend analgesia, but previous orthopaedic trials have yielded mixed results. We therefore tested whether adding local incisional infiltration of LB to multimodal analgesia confers clinically relevant advantages in geriatric hip fracture surgery.
METHODS
This study was a single-center, prospective, randomized, participant and assessor-blinded, parallel-group exploratory trial in older adults undergoing hemiarthroplasty or total hip arthroplasty for a hip fracture. The intervention was local LB infiltration; the control was no local infiltration. The primary end point was resting pain measured on a visual analog scale (VAS, 0 to 10) at 48 hours postoperatively. Prespecified key secondary end points included early pain with activity, morphine milligram equivalents (MME) of the patient-controlled analgesia (PCA) infusion volume and of the total perioperative oral and intramuscular rescue counts, sleep quality measured on a numerical rating scale (NRS, 0 to 10), total sleep time, and nocturnal awakenings.
RESULTS
A total of 76 patients (median age, 77 years; 49 female) were included in the analysis. The primary end point did not differ between the groups (median 0 for both; p = 0.143; point estimate of between-group difference: Cohen d = -0.506, 95% confidence interval: -0.962, -0.048), whereas several secondary outcomes significantly favored LB, including resting pain at 24 hours; activity pain at 8, 24, and 48 hours; and oral rescue administrations (median and interquartile range: 25 [0, 50] versus 50 [25, 100] MME). The LB group had a higher NRS sleep quality score after surgery, with a longer total sleep duration on the operative night, than the control group; the number of awakenings was similar between the groups. Ambulation at 48 and 72 hours and the number of postoperative days to discharge did not differ between the groups.
CONCLUSIONS
In the context of a standardized multimodal analgesic pathway, local incisional infiltration of LB did not improve the prespecified primary end point of resting pain at 48 hours after geriatric hip fracture surgery. Overall, the current evidence does not support routine clinical use, and further investigation is warranted.
LEVEL OF EVIDENCE
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.