1. By: Joseph Westlake, SPT
SUNY at Buffalo - Doctor of Physical Therapy Program
Exparel: The local
anesthetic
A transition to advanced post-
operative pain management
and improved functional
outcomes after total joint
arthroplasty.

2. Traditional management includes...
Post-operative pain
control through:
1) Regional Nerve Blocks
- Brachial Plexus
- Femoral/Spinal
2) Systemic
- Opioids
- Epidural
3) Wound site
- Hypothermia
- Local block
- Anti-inflammatory

3. The problem is:
❖ Over-reliance of single-modal treatment
❖ Particularly Anesthetic Blocks and Opioids => Opioid
Related Adverse Effects (ORAE)
❖ Effects on CNS, GI motility, & general well-being
❖ Hampering functional mobility and therapy
participation

4. Switching lanes
❖ Recent shift in management to address these ORAE's -
10 year old data by Lombardi et al.
❖ Use of Peri- and intra-articular injections for TKA
❖ Significant reduction in: 1) rescue opioids 2) pt
confusion 3) blood loss 4) lower bleeding index

5. What is being replaced
❖ Instead of using peripheral nerve blocks, surgeons are
now transitioning to using Exparel
❖ Associated impacts from this include: improved motor
function of the target area, decreased risk of falls,
decreased occurrence of REBOUND pain, significant
decrease in opioid usage.

6. Multimodal regimens now...
❖ Are increasing effectiveness with time consideration of
all anesthetics being used.
❖ Exparel is an extended release anesthetic injected into
the peri- and intra-articular site, 60- 1cc locations.
❖ Continuous release for up to 72 hours, begins working 6
hours post-op. A bridge may be necessary.

8. What studies* are showing
❖ Decreased resting pain at 72
hours.
❖ Inc Amb distance by average of
16 feet post-op day 0
❖ Less assistance level for amb (2
therapist assist to Mod 1)
❖ Decreased LOS by 1/2 day
❖ Positive trends for improved
ROM at D/C. and less need for
manipulation long term.

9. Cost benefits for Hospitals
❖ Exparel - $299/cocktail
❖ Peripheral nerve block (Sciatic/Femoral) - $527.22/
block
❖ The extra costs are from anesthesia, ultrasound needed,
immobilizer, ball and tubing necessary.
❖ Total reductions in THA and TKA are $348 and $411
respectively. Multiply that by ~1200 joint replacements
performed at BI in 2014.

10. Outpatient surgeries
❖ Case studies with ankle replacements, bunionectomies,
ankle fractures/dislocations benefitted as well.
❖ Pt's report good satisfaction with pain levels,
particularly at 30 hours.
❖ For Out-pt procedures that allow WB, Exparel can
preserve motor strength greater than sciatic/ankle
blocks
❖ Total efficacy time: 6 vs 72hrs (Local vs Exparel)

11. Questions?

12. Bibliography
❖ Lombardi AV Jr., Berend KR, Mallory TH. Soft tissue and intra-articular injection of
bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty.
Clin Orthop Relat Res. 2004;(428):125-130
❖ Lombardi AV Jr. Recent advances in Incorporation of Local Analgesics in Postsurgical Pain
Pathways. AM J Orthop. 2014;43(10 suppl):S2-S5
❖ Springer, B. Transition from nerve blocks to periarticular injections and emerging techniques
in total joint arthroplasty. AM J Orthop. 2014;43(10 suppl):S6-S9
❖ Bergese SD, Ramamoorthy S, Patou G, Bramlett K. Efficacy profile of liposome bupivacaine,
a novel formulation of bupivacaine for post-surgical analgesia. J Pain Res. 2012;5:107-126.
❖ Herbst, S. Local infiltration of liposome bupivacaine in foot and ankle surgery: Case-based
Reviews. AM J Orthop. 2014;43(10 suppl):S10-S12
❖ Tayrose G, Newman D, Slover J, Jaffe F. Rapid mobilization decreases length of stay in joint
replacement patients. Bull Hosp Jt Dis (2013). 2013;71(3):222-226