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

Total Knee 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 Dysart is a paid consultant for Pacira BioSciences, Inc.

Background
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CASE INFORMATION
 
Physician Name
Stan Dysart, MD
Affiliation
Pinnacle Orthopaedics/Wellstar Health System
Surgical Case Performed
Total knee arthroplasty
Inpatient or Outpatient Procedure
Inpatient
PATIENT CHARACTERISTICS
 
Gender
Male
Age
81 years
Patient History
and Characteristics
Patient previously underwent a successful left TKA
Pathology
Patient has right knee osteoarthritis and is now undergoing a right TKA with an ERAS protocol
PROCEDURAL DETAILS
 
Incision Size
15 cm
Preoperative Analgesics Used
AC block—20 mL of 0.25% bupivacaine with epinephrine
Intraoperative Analgesics Used

TIVA general—150 to 200 mcg/kg/min propofol titrated based on surgical needs; 50 to 100 mcg fentanyl as needed

Periarticular injection with 20 mL EXPAREL and 50 mL 0.25% bupivacaine

Dose of EXPAREL and
Total Volume Used
120ml
AC=adductor canal; ERAS=enhanced recovery after surgery; TIVA=total intravenous anesthesia.

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 Dysart determined that a total volume of approximately 120 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 admixed this solution with 50 mL of 0.25% bupivacaine. Dr Dysart added bupivacaine to provide short-term local analgesia in the postanesthesia care unit that overlapped with the long-term local analgesia provided by EXPAREL.

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 Dysart divided the injectate evenly into six 20-mL syringes using a 21-gauge needle and infiltrated as follows:

cementation

INFILTRATED AFTER THE BONY CUTS WERE PERFORMED

After completing the bony cuts, Dr Dysart inserted a laminar spreader between the cut femur and tibia, exposing the posterior capsule of the knee. He then proceeded with infiltrating the injectate as follows:

Syringe #1

Medial and lateral infiltration of the posterior capsule

  • Medial infiltration of posterior capsule with approximately 10 needle sticks to create a field block
  • Lateral infiltration of posterior capsule with approximately 10 needle sticks
step1-img

FIGURE 1. Posterior capsule

injection

Before each injection, be sure to aspirate to minimize the risk of intravascular injection. Be sure not to inject too far laterally, and monitor the volume injected because of the proximity of the peroneal nerve.

Syringe #2

Medial and lateral infiltration of femoral periosteal/synovial tissues and of suprapatellar tissue with 20 needle sticks of 1 mL to 1.5 mL per injection

step2-img

FIGURE 2. Femoral periosteal/synovial and suprapatellar tissues

injection

Inject until a noticeable bubble forms. It is normal for there to be more dramatic swelling in this thick, fibrous layer than when soft tissue is infiltrated.

Syringe #3

Injection of fat pad, pes anserinus, MCL, and medial gutter, saturating the area

step3-img

FIGURE 3. Fat pad, pes anserinus, MCL, and medial gutter

Syringe #4

Medial and lateral infiltration of the circumferential periosteum of the tibia using 15 to 20 needle sticks

step4-img

FIGURE 4. Circumferential periosteum of tibia

Syringe #5

Injection of the synovial tissue beneath the quadriceps tendon and the retinacular tissue medially from the femur to the tibia

step5-img

FIGURE 5. Synovial tissue (quadriceps) and medial retinacular tissue (femur to tibia)

Syringe #6

Injection of the lateral gutter and the lateral retinacular tissue from the femur to the tibia. Residual volume is used in the subcutaneous tissue medially and laterally. There will likely be swelling of the tissue from fluid volume

step6-img

FIGURE 6. Lateral gutter and retinacular tissue (femur to tibia)

injection

When infiltrating, stay in the tissue to reduce the amount of extravasation.

PROPER TECHNIQUE IS CRUCIAL FOR ANALGESIC COVERAGE

When infiltrating EXPAREL® (bupivacaine liposome injectable suspension), Dr Dysart makes sure to infiltrate below the fascia, above the fascia, and into the subcutaneous tissue using a moving needle technique. With a moving needle technique, the injections are spread in a rapid and precise fan-like pattern to maximize the number of injection areas. The tissues are infiltrated as the needle is advanced and withdrawn to maximize the coverage area. This technique should be systematically and meticulously repeated with each subsequent injection site, and the next site should overlap with the prior infiltrated area to maximize effect.

technique

Total Knee Arthroplasty (TKA)Performed by: Dr Dysart

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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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