SUPPLEMENT ARTICLE
Infiltration Techniques for Local Infiltration Analgesia With
Liposomal Bupivacaine in Extracapsular and Intracapsular
Hip Fracture Surgery: Expert Panel Opinion
Nirav H. Amin, MD,* Hank L. Hutchinson, MD,† and Anthony G. Sanzone, MD‡
Downloaded from https://journals.lww.com/jorthotrauma by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3SN2oLfdKwVecrWrvxy6Go6nxr0I9sKiL+EpvQZz10ok= on 04/05/2019
Background: Liposomal bupivacaine (LB) has demonstrated
efficacy in improving pain scores and reducing opioid consumption
across a variety of surgical settings, including orthopaedic surgery.
However, meticulous infiltration techniques combined with a multi-
modal approach are important to optimizing outcomes.
Methods: A panel of 4 orthopaedic surgeons and 3 anesthesiolo-
gists convened on April 1, 2017, to discuss current practices and
develop a consensus statement regarding local infiltration analgesia
with LB for extracapsular and intracapsular hip fracture surgery,
including LB infiltration techniques.
Results: Optimizing surgical outcomes with LB in hip fracture
surgery requires an understanding of the neuroanatomy of the
surgical site and the pharmacology of the drug. Meticulous
infiltration technique is critical to achieve optimal results with LB
given its viscosity and reduced diffusion compared with bupivacaine
HCl. For extracapsular procedures, a total injection volume of
120 mL is recommended, whereas intracapsular procedures typically
require a lower volume (;80 mL). In both cases, infiltration is best
achieved using a 22-gauge needle and applying a tracking and/or
fanning technique. To ensure optimal placement, LB should be in-
filtrated using multiple, small-volume (1- to 5-mL) injections spaced
at 1.0-cm intervals.
Accepted for publication May 7, 2018.
From the *Department is Orthopedic Surgery, Loma Linda University, Loma
Linda, CA; †Tallahassee Orthopedic Clinic, Tallahassee, FL; and ‡San
Diego Orthopaedic Trauma Fellowship Program, San Diego, CA.
N. H. Amin is a consultant and has received research funding from Pacira
Pharmaceuticals, Inc., Trice Medical, Smith & Nephew, and DePuy; he
has also received research support from Novadaq, Arthrex, Stryker, Zim-
mer Biomet, and IntelliSkin. H. L. Hutchinson is a consultant for Pacira
Pharmaceuticals, Inc., and Smith & Nephew. A. G. Sanzone is a consultant
for Johnson & Johnson, Mallinckrodt Pharmaceuticals, and Pacira Phar-
maceuticals, Inc., and has received research funding from Pacira Pharma-
ceuticals, Inc. Pacira Pharmaceuticals, Inc., funded the expert consensus
meeting and editorial support for development of this manuscript, which
was provided by Krystina Neuman, PhD, at C4 MedSolutions, LLC (Yard-
ley, PA), a CHC Group company.
Reprints: Nirav H. Amin, MD, Loma Linda University, 11406 Loma Linda
Dr, Room 213, Loma Linda, CA 92354 (e-mail: naminmd@gmail.com).
Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc.
This is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the work
provided it is properly cited. The work cannot be changed in any way or
used commercially without permission from the journal.
DOI: 10.1097/BOT.0000000000001227
J Orthop Trauma  Volume 32, Number 8 Supplement 2, August 2018
Conclusions: These consensus recommendations regarding LB
infiltration techniques can serve as a resource for designing clinical
studies to evaluate outcomes using periarticular infiltration of LB in
extracapsular and intracapsular hip fracture surgery as part of
a multimodal pain management approach.
Key Words: anesthesia, fracture, multimodal pain management,
opioids, periarticular infiltration, postsurgical pain
Level of Evidence: Level V.
(J Orthop Trauma 2018;32:S5–S10)
INTRODUCTION
The incidence of hip fracture in the United States is
increasing and is expected to exceed one million by 2050.1
Advanced age is one of several factors associated with an
increased risk,2 and in 2010, 273,000 individuals aged 65
years and older were admitted for hip fracture.3 Morbidity
and mortality rates after hip fractures are high.4,5 In elderly
patients, uncontrolled pain is associated with delirium,
depression, sleep disturbance, and cardiopulmonary dysfunc-
tion, which can aggravate pre-existing comorbities.5,6 Thus,
inadequate pain management can increase the potential for
postsurgical complications and compromise recovery.
Although effective postsurgical pain management is
fundamentally important and can increase patient satisfaction,
shorten hospital length of stay, and reduce costs,7 many pa-
tients who receive opioids experience respiratory, gastrointes-
tinal, genitourinary, or central nervous system adverse
events.8 The risk of opioid-related adverse events is approx-
imately 2-fold higher in patients aged 65 years and older and
is associated with a 3-fold increase in mortality, as well as
longer hospital stay, and higher rates of readmission and hos-
pital costs.8 Many patients will progress to long-term opioid
use after surgery,9 and the risk is increased in patients older
than 50 years.10 Approximately 30% of hip fracture patients
overall, and 3% of those who are opioid naive at the time of
surgery, receive opioids 6 months after surgery.11 Chronic
opioid users have a greater number of hospital admissions,
as well as 4 times higher total health care costs.12
Multimodal pain management combining different
types of medications, as well as nonpharmacologic interven-
tions, is recommended for treating postsurgical pain and may
decrease the need for opioid therapy.13 Pharmacologic
options for multimodal therapy include systemic therapies,
regional, or neuraxial anesthesia, and local, intra-articular,
or topical therapies.13 Multimodal postsurgical pain management
www.jorthotrauma.com | S5
Amin et al J Orthop Trauma  Volume 32, Number 8 Supplement 2, August 2018
approaches are strongly recommended for hip fracture surgery.14
As part of an enhanced recovery after surgery protocol, they
have improved outcomes such as ambulation, opioid consump-
tion, hospital length of stay, and postoperative complications
compared with usual care.15
Periarticular regional anesthesia techniques for hip and
knee surgery were developed to achieve analgesia without the
complications associated with other techniques such as
epidural analgesia, patient-controlled opioid analgesia, and
peripheral nerve block.16 Results of a meta-analysis of ran-
domized controlled trials show that addition of periarticular
regional anesthesia reduces pain and opioid consumption and
improves functional recovery, with lower rates of nausea and
vomiting, after total knee arthroplasty (TKA) and total hip
arthroplasty (THA).16 Demonstrated efficacy in the TKA
and THA settings suggests that this approach may have utility
in the hip fracture setting, although the data for hip fracture
surgery are far more limited. Results of a randomized con-
trolled trial demonstrate improved pain, reduced opioid usage,
and higher patient satisfaction in patients treated using a mul-
timodal approach incorporating periarticular regional anesthe-
sia compared with patients treated without the multimodal
approach.17
Liposomal bupivacaine [LB; EXPAREL (bupivacaine
liposome injectable suspension), Pacira Pharmaceuticals,
Inc., Parsippany, NJ] is a prolonged-release formulation of
bupivacaine HCl indicated for single-dose infiltration into
the surgical site to produce postsurgical analgesia.18 In stud-
ies in patients undergoing inguinal herniorrhaphy, TKA,
hemorrhoidectomy, or bunionectomy, LB demonstrated
dose-proportional plasma bupivacaine concentrations, rapid
absorption, bimodal kinetics, and prolonged release through
96 hours after single-dose administration.19 This pharmaco-
kinetic profile differs substantially from that of bupivacaine
HCl, which is characterized by a single peak, followed by
a rapid decline in plasma levels over the following 3–6
hours.19 Consistent with the pharmacokinetic profile of
LB, in clinical trials across a variety of surgical settings,
local infiltration analgesia (LIA) with LB has produced anal-
gesia for up to 72 hours.20
In the setting of THA, a retrospective cohort study
demonstrated improved pain control during the first 8 hours
postsurgery, reduced opioid consumption during the first 48
hours postsurgery, faster recovery, and shorter length of stay
in patients who received periarticular LB compared with
those who did not.21 Periarticular LB has also been demon-
strated to improve pain with less opioid consumption after
THA compared with LIA with bupivacaine HCl.22–25 Im-
provements have also been shown in the length of stay,23–25
although one study found no significant difference in pain
scores, opioid consumption, or length of stay between pa-
tients receiving periarticular LB or bupivacaine HCl.26 Re-
sults of a randomized trial show periarticular LB to be as
effective as continuous posterior lumbar plexus nerve block
with regard to improvements in pain and opioid use after
THA.27 Data regarding the use of LB in hip fracture surgery
are more limited. A retrospective chart review of 6 patients
who received fascia iliaca block with LB after hip fracture
reported extended postsurgical pain relief for all patients.28
S6 | www.jorthotrauma.com
In other surgical settings, it has been apparent that
outcomes with LIA with LB can vary from surgeon to
surgeon and study to study, likely reflecting differences in
study design and/or infiltration technique.29–33 Because LB is
more viscous than bupivacaine HCl, it does not diffuse
through tissues as quickly.34 Thus, meticulous infiltration,
which includes expanding the drug to an adequate volume,
multiple, small-volume injections throughout the layers of
incision using an adequately sized needle, and admixing with
bupivacaine HCl to achieve early analgesia, is critical to
achieve optimal results.30,32,33,35 Standardized protocols dic-
tating meticulous infiltration for periarticular LB32,35 can help
to optimize the results achieved.
As data are limited regarding the use of LB as part of
a multimodal pain management protocol in hip fracture
surgery, a group of 4 orthopaedic surgeons and 3 anesthesi-
ologists convened in April 2017 to discuss current practices
and develop a consensus statement related to the use of LB in
extracapsular and intracapsular hip fracture surgeries within
the context of a multimodal opioid-sparing pain management
approach. Discussion included multimodal pain management
protocols and LB infiltration techniques. This article reports
the panel’s recommendations on infiltration techniques for
LB, including anatomic/neuroanatomic considerations.
Local Infiltration Analgesia With Liposomal
Bupivacaine Infiltration Techniques
Neuroanatomic Considerations
Improving surgical outcomes and the standard of care
for hip fracture requires standardized procedures with a thor-
ough understanding of the neuroanatomy of the surgical site.
Highly innervated areas need to be identified and targeted for
infiltration. Most nerve roots of interest are in the L2 to L4
region of the lumbar plexus (Fig. 1).36 The anterior hip cap-
sule is mainly innervated by the articular branches of the
femoral and obturator nerves. Furthermore, the superior por-
tion of the anterior capsule is the most highly innervated and
should receive the most meticulous infiltration (Fig. 2A).37
The posterior hip capsule has less innervation compared with
the anterior capsule and is predominantly supplied by articu-
lar branches of the superior gluteal nerve, sciatic nerve, and
the nerve to the quadratus femoris muscle (Fig. 2B).37 The
highest degree of innervation of the hip labrum is found in the
anterosuperior aspect. On the right hip, mechanoreceptors and
free sensory nerve endings are concentrated within the region
around the acetabulum from the 10 o’clock to 2 o’clock posi-
tions. The periosteum and bursae of the greater trochanter are
innervated by a branch of the femoral nerve.38
Extracapsular Procedures
Panel recommendations regarding periarticular LB
infiltration techniques in extracapsular procedures are sum-
marized in Table 1. The recommended dose of LB is up to
266 mg (20 mL), depending on the size of the surgical site,
the volume required to cover the area, and individual patient
factors that may influence drug safety.18 When used for infil-
tration of extracapsular hip fractures, 20 mL of LB should be
mixed with 20 mL of 0.25% bupivacaine HCl and 80 mL of
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 32, Number 8 Supplement 2, August 2018
FIGURE 1. Lumbosacral plexus and major peripheral nerves of
the lower extremity.36 Reproduced by permission of Taylor and
Francis Group, LLC, a division of Informa plc.
saline to achieve an expansion volume of 120 mL. Panel rec-
ommendations regarding infiltration areas were scientifically
informed by the neuroanatomy of the hip joint (Fig. 2).37
The target(s) for LB infiltration will vary depending on the
surgical site; intertrochanteric and subtrochanteric fractures
are sufficiently different and would benefit from distinct infil-
tration coverage areas. The panel recommends infiltrating
around every fracture site, deep to and superficial to the frac-
ture, with special attention to the posterior greater trochanter,
where the highest concentration of nerve fibers resides. For
intertrochanteric fractures, injections should be focused on
the medial aspect to ensure that key targets are covered. Because
subtrochanteric hip fractures do not involve the obturator nerve,
infiltration in this region is less important to analgesic coverage.
The panel agreed that six 20-mL syringes with
a 22-gauge spinal needle, 3.5 inches in length, should be
used for infiltration, with 2 syringes for the nail entry site, 1.5
FIGURE 2. Innervation of the (A) anterior and
(B) posterior hip capsule.37 Ó 2013 Data Trace
Publishing Company. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
LB Infiltration: Extra-/Intracapsular Fracture
for the hip screw site, 1.5 for the fracture hematoma, and 1 for
the distal screws. If the distal screws are not placed, then the
additional syringe can be placed in the nail entry and/or screw
site. A total of 30 mL should be injected anteriorly into the
fracture hematoma using C-arm fluoroscopy, ensuring that the
needle remains no further medial than the medial femoral
cortex. Figure 3 shows the location of the nail entry and hip
screw sites. The nail entry site is proximal to the site of
infiltration, such that the needle should be directed distally.
The hip screw incision site is distal to the more proximal
screw placement site in the bone, and the needle should be
directed distally to cover the soft tissue and proximally where
the bone screw interface resides. The interlock screws are
directed perpendicular to the incision, as is the fracture hema-
toma. Several aspects of the technique are important to
achieve optimal coverage, including the use of a 22-gauge
or smaller needle, serial injections spaced 1 cm apart, and
www.jorthotrauma.com | S7
Amin et al J Orthop Trauma  Volume 32, Number 8 Supplement 2, August 2018

TABLE 1. Summary of Consensus Recommendations Regarding the Periarticular LB Infiltration Technique in Hip Fracture Surgery
Variable Extracapsular Procedures Intracapsular Procedures
Total injection volume, mL 120 80*
Admixing 20 mL of LB + 20 mL of 0.25% bupivacaine HCl + 20 mL of LB + 20 mL of 0.25% bupivacaine HCl +
80 mL of saline 40 mL of saline
Needle Spinal needle; 22 gauge, 3.5 inches Spinal needle; 22 gauge, 3.5 inches
Infiltration sites Nail entry, fracture site, hip screw, and distal screw At the fracture site and around the implant
 Around every fracture site, deep to and superficial to
the fracture
B Intertrochanteric fracture: focus on the medial

aspect
B Subtrochanteric fracture: infiltration around the

obturator nerve is less important

Insertion depth Determined based on the patient’s build (amount of fat
and muscle vs. bone), generally down to bone
Distance between injection sites Determined based on patient’s build (amount of fat and
muscle vs. bone), generally 1 cm
Distribution per injection site, mL 1–5
Technique Fanning or laying tracks along the surgical incision and
nail entry sites
Timing Deep tissues should be infiltrated before closing the
surgical incision, and superficial tissues should be
infiltrated subsequently
*Total volume will vary depending on wound size and surgical skill.
Determined based on patient’s build (amount of fat and
muscle vs. bone), generally down to bone
Determined based on patient’s build (amount of fat and
muscle vs. bone), generally 1 cm
1–5
Laying tracks around the implant
Capsule and labrum should be infiltrated before implant
placement

a tracking (along the surgical incision and surgical nail entry Intracapsular Procedures
sites) or fanning technique. Deep tissues should be infiltrated Panel recommendations regarding periarticular LB infil-
before closing the surgical incision, with subsequent infiltra- tration techniques in intracapsular procedures are shown in
tion of superficial tissues. Table 1. The surgical field is generally smaller for intracapsular

FIGURE 3. Locations of the nail entry and hip

screw sites.

S8 | www.jorthotrauma.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 32, Number 8 Supplement 2, August 2018
procedures compared with extracapsular procedures. Although
an expansion volume of 80 mL (20 mL of LB + 20 mL of
0.25% bupivacaine HCl + 40 mL of saline) is appropriate, the
total volume will vary depending on wound size and surgical
skill and can be diluted with saline to .80 mL for large
wounds. To ensure that incorrect amounts are not mixed and
that none of the admixture is lost, one panel member suggested
using six 20-mL syringes. Others suggested using two 20-mL
syringes, refilled multiple times, or a continuous flow container.
Injections of LB should be performed with a 22-gauge spinal
needle to spread the mixture throughout the tissue and the area
of trauma. Although the angle of injection can vary, it should
not be perpendicular to the joint, and infiltration into the joint
itself should be avoided. Tracking of LB is recommended,
particularly down to the femoral canal and at the fracture site,
to ensure adequate coverage. This can be accomplished by
inserting the needle down to the bone and injecting LB while
withdrawing. The panel agreed that epinephrine should be
excluded from the admixture because it would be an off-label
use, and there is insufficient evidence supporting its benefit.
DISCUSSION
A consensus was reached regarding extracapsular and
intracapsular LB infiltration techniques with respect to volume,
admixing with bupivacaine HCl, needle size and placement,
and injection spacing. Panel members agreed that special
consideration should be given to the neuroanatomy of the hip
to ensure adequate coverage of the highly innervated regions.37
This includes particular attention to the superior portion of the
anterior hip capsule and the posterior greater trochanter (ex-
tracapsular procedures) and the use of multiple small injections
using a 22-gauge needle or smaller, ideally using a tracking or
fanning approach.
As previous data suggest that differences in the infiltra-
tion technique may contribute to variable outcomes with LIA
with LB,29,31,32,35 use of a standardized, meticulous procedure
such as that described here has the potential to produce better
and more consistent results in hip fracture surgery. Tools that
standardize injections mechanically, such as spring-loaded,
repeater syringes and an admixture reservoir, could also be
beneficial in achieving further consistency with the injection
techniques. Such devices would require testing and evaluation
for functionality and applicability. It will be important to fol-
low up with clinical studies that can further evaluate the bene-
fits of the proposed techniques in hip fracture surgery.
In conclusion, the meticulous infiltration techniques for
periarticular LB described here may help optimize outcomes
achieved using LB as part of a comprehensive, multimodal
pain management protocol for patients undergoing intra-
capsular or extracapsular hip fracture surgery. This approach
is compatible with a variety of treatment options and may
help reduce opioid consumption and optimize patient out-
comes in this vulnerable patient population.
ACKNOWLEDGMENTS
Editorial support for development of this manuscript
was provided by Krystina Neuman, PhD, at C4 MedSolu-
tions, LLC (Yardley, PA), a CHC Group company.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
LB Infiltration: Extra-/Intracapsular Fracture
REFERENCES
1. Brown CA, Starr AZ, Nunley JA. Analysis of past secular trends of hip
fractures and predicted number in the future 2010–2050. J Orthop
Trauma. 2012;26:117–122.
2. Benetos IS, Babis GC, Zoubos AB, et al. Factors affecting the risk of hip
fractures. Injury. 2007;38:735–744.
3. Bollinger AJ, Butler PD, Nies MS, et al. Is scheduled intravenous acet-
aminophen effective in the pain management protocol of geriatric hip
fractures? Geriatr Orthop Surg Rehabil. 2015;6:202–208.
4. Dyer SM, Crotty M, Fairhall N, et al. A critical review of the long-term
disability outcomes following hip fracture. BMC Geriatr. 2016;16:158.
5. Abou-Setta AM, Beaupre LA, Rashiq S, et al. Comparative effectiveness
of pain management interventions for hip fracture: a systematic review.
Ann Intern Med. 2011;155:234–245.
6. Sanzone AG. Current challenges in pain management in hip fracture
patients. J Orthop Trauma. 2016;30(suppl 1):S1–S5.
7. Garimella V, Cellini C. Postoperative pain control. Clin Colon Rectal
Surg. 2013;26:191–196.
8. Kessler ER, Shah M, Gruschkus SK, et al. Cost and quality implications of
opioid-based postsurgical pain control using administrative claims data
from a large health system: opioid-related adverse events and their impact
on clinical and economic outcomes. Pharmacotherapy. 2013;33:383–391.
9. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use
after minor and major surgical procedures in US adults. JAMA Surg.
2017;152:e170504.
10. Sun EC, Darnall BD, Baker LC, et al. Incidence of and risk factors for
chronic opioid use among opioid-naive patients in the postoperative
period. JAMA Intern Med. 2016;176:1286–1293.
11. Lindestrand AG, Christiansen ML, Jantzen C, et al. Opioids in hip frac-
ture patients: an analysis of mortality and post hospital opioid use. Injury.
2015;46:1341–1345.
12. Leider HL, Dhaliwal J, Davis EJ, et al. Healthcare costs and nonadher-
ence among chronic opioid users. Am J Manag Care. 2011;17:32–40.
13. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of post-
operative pain: a clinical practice guideline from the American Pain
Society, the American Society of Regional Anesthesia and Pain Medi-
cine, and the American Society of Anesthesiologists’ Committee on
Regional Anesthesia, Executive Committee, and Administrative Council.
J Pain. 2016;17:131–157.
14. Roberts KC, Brox WT, Jevsevar DS, et al. Management of hip fractures
in the elderly. J Am Acad Orthop Surg. 2015;23:131–137.
15. Liu VX, Rosas E, Hwang J, et al. Enhanced recovery after surgery pro-
gram implementation in 2 surgical populations in an integrated health
care delivery system. JAMA Surg. 2017;152:e171032.
16. Jiang J, Teng Y, Fan Z, et al. The efficacy of periarticular multimodal
drug injection for postoperative pain management in total knee or hip
arthroplasty. J Arthroplasty. 2013;28:1882–1887.
17. Kang H, Ha YC, Kim JY, et al. Effectiveness of multimodal pain man-
agement after bipolar hemiarthroplasty for hip fracture: a randomized,
controlled study. J Bone Joint Surg Am. 2013;95:291–296.
18. EXPARELÒ (Bupivacaine Liposome Injectable Suspension). Full Pre-
scribing Information. San Diego, CA: Pacira Pharmaceuticals, Inc; 2016.
19. Hu D, Onel E, Singla N, et al. Pharmacokinetic profile of liposome
bupivacaine injection following a single administration at the surgical
site. Clin Drug Investig. 2013;33:109–115.
20. Bergese SD, Ramamoorthy S, Patou G, et al. Efficacy profile of liposome
bupivacaine, a novel formulation of bupivacaine for postsurgical analge-
sia. J Pain Res. 2012;5:107–116.
21. Yu SW, Szulc AL, Walton SL, et al. Liposomal bupivacaine as an
adjunct to postoperative pain control in total hip arthroplasty. J Arthro-
plasty. 2016;31:1510–1515.
22. Emerson RH, Barrington JW, Olugbode O, et al. Comparison of local
infiltration analgesia to bupivacaine wound infiltration as part of a multi-
modal pain program in total hip replacement. J Surg Orthop Adv. 2015;
24:235–241.
23. Asche CV, Ren J, Kim M, et al. Local infiltration for postsurgical analgesia
following total hip arthroplasty: a comparison of liposomal bupivacaine to
traditional bupivacaine. Curr Med Res Opin. 2017;33:1283–1290.
24. Domb BG, Gupta A, Hammarstedt JE, et al. The effect of liposomal
bupivacaine injection during total hip arthroplasty: a controlled cohort
study. BMC Musculoskelet Disord. 2014;15:310.
www.jorthotrauma.com | S9
Amin et al J Orthop Trauma  Volume 32, Number 8 Supplement 2, August 2018
25. Ma TT, Wang YH, Jiang YF, et al. Liposomal bupivacaine versus tra-
ditional bupivacaine for pain control after total hip arthroplasty: a meta-
analysis. Medicine (Baltimore). 2017;96:e7190.
26. Perets I, Walsh JP, Mu BH, et al. Intraoperative infiltration of liposomal
bupivacaine vs bupivacaine hydrochloride for pain management in pri-
mary total hip arthroplasty: a prospective randomized trial. J Arthro-
plasty. 2018;33:441–446.
27. Johnson RL, Amundson AW, Abdel MP, et al. Continuous posterior
lumbar plexus nerve block versus periarticular injection with ropivacaine
or liposomal bupivacaine for total hip arthroplasty: a three-arm random-
ized clinical trial. J Bone Joint Surg Am. 2017;99:1836–1845.
28. Belsh Y. Fascia iliaca block with liposomal bupivacaine for hip fractures
prior to surgery. Presented at: 41st Annual Regional Anesthesiology &
Acute Pain Medicine Meeting; March 31–April 2, 2016; New Orleans, LA.
29. Barrington JW, Olugbode O, Lovald S, et al. Liposomal bupivacaine:
a comparative study of more than 1000 total joint arthroplasty cases.
Orthop Clin North Am. 2015;46:469–477.
30. Joshi GP, Cushner FD, Barrington JW, et al. Techniques for periarticular
infiltration with liposomal bupivacaine for the management of pain after
hip and knee arthroplasty: a consensus recommendation. J Surg Orthop
Adv. 2015;24:27–35.
31. Khlopas A, Elmallah RK, Chughtai M, et al. The learning curve associ-
ated with the administration of intra-articular liposomal bupivacaine for
total knee arthroplasty: a pilot study. Surg Technol Int. 2017;30:314–320.
S10 | www.jorthotrauma.com
32. Mont MA, Beaver WB, Dysart SH, et al. Local infiltration analgesia with
liposomal bupivacaine improves pain scores and reduces opioid use after
total knee arthroplasty: results of a randomized controlled trial. J Arthro-
plasty. 2018;33:90–96.
33. Joshi GP, Hawkins RJ, Frankle MA, et al. Best practices for periarticular
infiltration with liposomal bupivacaine for the management of pain after
shoulder surgery: consensus recommendation. J Surg Orthop Adv. 2016;
25:204–208.
34. Scott WN. Insall & Scott Surgery of the Knee. 6th ed. Philadelphia, PA:
Elsevier; 2017.
35. Dysart S, Snyder MA, Mont MA. A randomized, multicenter, double-
blind study of local infiltration analgesia with liposomal bupivacaine for
postsurgical pain following total knee arthroplasty: rationale and design
of the PILLAR trial. Surg Technol Int. 2016;30:261–267.
36. Lennon RL, Horlocker TT. Mayo Clinic Analgesic Pathway: Peripheral
Nerve Blockade for Major Orthopedic Surgery. Boca Raton, FL: Mayo
Clinic Scientific Press. Taylor and Francis Group; 2006.
37. Simons MJ, Amin NH, Cushner FD, et al. Characterization of the neural
anatomy in the hip joint to optimize periarticular regional anesthesia in
total hip arthroplasty. J Surg Orthop Adv. 2015;24:221–224.
38. Genth B, Von During M, Von Engelhardt LV, et al. Analysis of the
sensory innervations of the greater trochanter for improving the treat-
ment of greater trochanteric pain syndrome. Clin Anat. 2012;25:
1080–1086.
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