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Effective January 1, 2025: ASP+6% reimbursement for EXPAREL when billing with code J0666 across all outpatient surgical settings.

Reverse Total Shoulder Arthroplasty

This case study represents an individual clinician experience with and methodology for using EXPAREL.

Pacira BioSciences, Inc., recognizes that there are other methodologies for administering local anesthetics, as well as individual patient considerations, when selecting the dose for a specific procedure.

Please see Important Safety Information below and refer to the Full Prescribing Information.

Disclosure: Dr Routman is a paid consultant for Pacira BioSciences, Inc.

Background
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CASE INFORMATION
 
Physician Name
Howard D. Routman, DO
Affiliation
Director, Palm Beach Shoulder Service, Atlantis Orthopaedics, Palm Beach Gardens, FL
Surgical Case Performed
Reverse total shoulder arthroplasty
Inpatient or Outpatient Procedure
Inpatient
PATIENT CHARACTERISTICS
 
Gender
Male
Age
78 years
Patient History and Characteristics
Shoulder arthritis, with pain and loss of motion associated with rotator cuff tear
Pathology
Rotator cuff–deficient arthritis
PROCEDURAL DETAILS
 
Incision Size
8-cm deltopectoral incision
Preoperative Analgesics Used
Interscalene block with ropivacaine
IV acetaminophen
PO gabapentin
PO oxycodone
Intraoperative Analgesics Used
IV dexamethasone
10 mL of 0.25% bupivacaine HCl for short-term analgesia
70 mL of expanded EXPAREL for local tissue infiltration
Dose of EXPAREL and
Total Volume Used
80ml
IV=intravenous; PO=by mouth.

The recommended dose of EXPAREL for infiltration in adults is based on the size of the surgical site, the volume required to cover the area, and individual patient factors that may impact the safety of an amide local anesthetic. The maximum dose of EXPAREL should not exceed 266 mg. The recommended dose of EXPAREL for patients aged 6 to <17 years old is 4 mg/kg, up to a maximum of 266 mg. The recommended dose of EXPAREL in adults for interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal is 133 mg. The recommended dose of EXPAREL in adults for adductor canal block is 133 mg (10 mL) admixed with 50 mg (10 mL) of 0.5% bupivacaine HCl, for a total volume of 20 mL.

EXPAREL can be administered unexpanded (20 mL) or expanded to increase volume up to a total of 300 mL (final concentration of 0.89 mg/mL [ie, 1:14 dilution by volume]) with normal (0.9%) saline or lactated Ringer’s solution.

Bupivacaine HCl (which is approved for use in patients aged 12 and older) may be administered immediately before EXPAREL or admixed in the same syringe, as long as the ratio of the milligram dose of bupivacaine HCl to EXPAREL does not exceed 1:2. Admixing may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. The toxic effects of these drugs are additive and their administration should be used with caution, including monitoring for neurological and cardiovascular effects related to local anesthetic systemic toxicity. Other than with bupivacaine, EXPAREL should not be admixed with other drugs prior to administration

ASSESSED THE SIZE OF THE SURGICAL SITE AND DEPTH OF TISSUE, THEN PREPARED INJECTION MATERIALS ACCORDINGLY

In this procedure, Dr Routman determined that a total volume of 80 mL would be needed to cover the surgical site. He
expanded 20 mL of EXPAREL® (bupivacaine liposome injectable suspension) with 50 mL of normal saline and then admixed
10 mL of 0.25% bupivacaine HCl. Dr Routman added bupivacaine HCl to provide short-term local analgesia that overlapped
with the long-term local analgesia provided by EXPAREL.

injection

A greater total volume may be needed for patients with more muscle mass in the shoulder and/or larger incision sizes. The total volume can be increased to as much as 100 mL by expanding with additional normal saline.

DIVIDED INJECTATE INTO SYRINGES WITH NEEDLE GAUGES APPROPRIATE FOR INFILTRATION (20- TO 25-GAUGE) AND PLANNED WHICH AREAS TO INFILTRATE WITH EACH INJECTION

For this procedure, Dr Routman divided the injectate into four 20-mL syringes with 22-gauge needles. He then infiltrated as follows:

steps-img

Step #1

Dr Routman infiltrated 20 mL of expanded EXPAREL® (bupivacaine liposome injectable suspension) as a single injection over the rim of the glenoid, directed at the undersurface of the supraspinatus muscle belly in the area of the suprascapular nerve.

step1-img

FIGURE 1. Over the glenoid rim

Step #2

Dr Routman inserted the needle into and through the conjoined tendon, and infiltrated 20 mL of expanded EXPAREL as a single injection into the base of the coracoid process, as well as into the muscle and tendon, to ensure analgesic coverage of the upper portion of the brachial plexus.

step2-img

FIGURE 2. Base of coracoid process

injection

Avoid injection into neurovascular structures.

Step #3

Upon closing the deltopectoral interval, Dr Routman then infiltrated 20 mL of expanded EXPAREL along the length of the deltoid and pectoralis. He infiltrated 1 to 1.5 mL every 1 cm.

step3-img

FIGURE 3. Deltoid and pectoralis

injection

Before each injection, be sure to aspirate to minimize the risk of intravascular injection.

Step #4

Dr Routman infiltrated 20 mL of expanded EXPAREL along the length of the surgical incision into the subcutaneous tissues before closure. He infiltrated 1 to 1.5 mL every 1 cm.

step4-img

FIGURE 4. Subcutaneous tissues around incision

injection

Dr Routman has not found infiltration into the periosteum around the proximal humerus to be necessary.

PROPER TECHNIQUE IS CRUCIAL FOR ANALGESIC COVERAGE

Dr Routman infiltrated EXPAREL® (bupivacaine liposome injectable suspension) into all tissue layers using a moving needle technique. With a moving needle technique, the injections were spread in a fan-like pattern and occurred as the needle was withdrawn to maximize the coverage area. This technique was systematically and meticulously repeated at each injection site, with overlapping diffusion of EXPAREL to ensure there were no gaps in analgesic coverage.

technique

Reverse Total Shoulder ArthroplastyPerformed by: Dr Routman

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Important Notice

Indication

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information

  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
  • Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via nerve block were nausea, pyrexia, headache, and constipation.
  • Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia.
  • Do not admix lidocaine or other non-bupivacaine local anesthetics with EXPAREL. EXPAREL may be administered at least 20 minutes or more following local administration of lidocaine.
  • EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for nerve blocks, and/or pregnant patients.
  • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.

Warnings and Precautions Specific to EXPAREL

  • Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.
  • EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal block, or intravascular or intra-articular use.
  • The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

Warnings and Precautions for Bupivacaine-Containing Products

  • Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.
  • Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death.
  • Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.
  • Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.
  • Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

Please refer to full Prescribing Information.

SEE MORE

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

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