Singh Preet Mohinder, Borle Anuradha, Trikha Anjan, Michos Lia, Sinha Ashish, Goudra Basavana
Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India.
Drexel College of Medicine, Philadelphia, Pennsylvania.
J Arthroplasty. 2017 Feb;32(2):675-688.e1. doi: 10.1016/j.arth.2016.09.042. Epub 2016 Oct 8.
Over last 2 years, many trials have evaluated newly approved liposomal bupivacaine for periarticular infiltration in total knee arthroplasty (TKA) with mixed results. Our meta-analysis attempts to consolidate the results and make evidence-based conclusions.
Trails comparing periarticular infiltration of liposomal bupivacaine to conventional analgesic regimens for total knee arthroplasty published till June 2016 were searched in medical database. Comparisons were made for length of stay (LOS), postoperative pain scores, range of motion, and opioid consumption. Meta-regression was performed for LOS to evaluate various analgesic control subgroups.
Sixteen trials were included in the final analysis. Liposomal bupivacaine group showed a shorter LOS (reported in 13 subgroups) than control group by 0.17 ± 0.04 days (random effects, P < .001, I = 84.66%). Meta-regression for various types of control showed a predictability (R) of 73%, τ = 0.013 (random effects, P < .001, I = 45.16). Only femoral block subgroup attained statistically significant shorter LOS on splitting the control group. Numeric pain scores were lower for pooled control group and local anesthetic infiltration subgroup in immediate postoperative phase. Second postoperative day analgesia was statistically superior to overall clubbed controls and femoral block subgroup. Superiority and/or inferiority of liposomal bupivacaine could not be proven for opioid consumption and range of motion because of a small pooled sample size. Publication bias is likely for LOS (Egger test, X intercept = 2.42, P < .001).
Liposomal bupivacaine infiltration has questionable clinical advantage, as it marginally shortens patient's hospital stay especially in comparison with patients receiving analgesic femoral nerve block. Compared with conventional regimens, it can provide slightly superior yet sustained (till second postoperative day) perioperative analgesia. High heterogeneity suggests need for standardization of infiltration techniques for better predictability of results.
在过去两年中，许多试验评估了新批准的脂质体布比卡因用于全膝关节置换术（TKA）关节周围浸润的效果，结果不一。我们的荟萃分析旨在整合这些结果并得出基于证据的结论。
在医学数据库中检索截至2016年6月发表的比较脂质体布比卡因关节周围浸润与全膝关节置换术传统镇痛方案的试验。对住院时间（LOS）、术后疼痛评分、活动范围和阿片类药物消耗量进行了比较。对LOS进行了荟萃回归分析，以评估各种镇痛控制亚组。
最终分析纳入了16项试验。脂质体布比卡因组的住院时间（在13个亚组中有报告）比对照组短0.17±0.04天（随机效应，P<.001，I=84.66%）。对各种类型对照的荟萃回归显示预测性（R）为73%，τ=0.013（随机效应，P<.001，I=45.16）。在将对照组进行拆分时，只有股神经阻滞亚组的住院时间在统计学上显著缩短。术后即刻，合并对照组和局部麻醉浸润亚组的数字疼痛评分较低。术后第二天的镇痛在统计学上优于总体合并对照组和股神经阻滞亚组。由于合并样本量较小，脂质体布比卡因在阿片类药物消耗量和活动范围方面的优势和/或劣势无法得到证实。住院时间可能存在发表偏倚（Egger检验，X截距=2.42，P<.001）。
脂质体布比卡因浸润的临床优势存疑，因为它仅略微缩短了患者的住院时间，尤其是与接受镇痛性股神经阻滞的患者相比。与传统方案相比，它可以提供略优且持续（直至术后第二天）的围手术期镇痛。高度异质性表明需要对浸润技术进行标准化，以更好地预测结果。
