# Hospital Pharmacy - May 2017 - 371

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Jacob et al.
Table 4. Ambulation (Feet) and Range of Motion (Degrees) in Knee Patients (n = 244).
Parameter
Distance day 0
Distance day 1
Distance day 2
Distance day 3
Extension day 1
Extension day 2
Extension day 3
Flexion day 1
Flexion day 2
Flexion day 3

Study group (n = 133)

Control group (n = 111)

P value

76.96 (120.4)
398.7 (385.7)
343.6 (240.4)
344.5 (239.1)
4.55 (3.86)
1.7 (2.33)
1.29 (1.92)
88.73 (11.73)
92.02 (9.90)
93.16 (9.12)

22.5 (17.67)
313.1 (370.5)
334.2 (312.4)
307.1 (249.7)
4.60 (3.34)
2.18 (2.63)
1.51 (2.09)
90.94 (9.99)
95.80 (10.08)
96.85 (9.21)

.0533
.1019
.8099
.4325
.9112
.1539
.5709
.1360
.0056
.0323

Note. Physical therapists recorded distance ambulated, extension, and flexion for knee patients on day of surgery and subsequent postoperative days 1, 2,
and 3. The study group and control group were compared with respect to the mean ± standard deviation for these parameters. Statistical significance for
differences in the groups was set at a P value of <.05.

Table 5. Ambulation (Feet) in Hip Patients (n = 113).
Parameter

Study group
(n = 68)

Control group
(n = 45)

P value

Day 0
Day 1
Day 2
Day 3

36.75 (29.57)
366.0 (274.5)
335.3 (254.8)
305.4 (200.5)

15.00 (-)
345.9 (409)
237.8 (205.5)
232.5 (145.8)

.5104
.7932
.0409
1707

Note. Physical therapists recorded ambulation distance for hip patients
on day of surgery and subsequent postoperative days 1, 2, and 3. The
study group and control group were compared with respect to the mean
± standard deviation for distance ambulated. Statistical significance for
differences in the groups was set at a P value of <.05.

one-third of a day suggests limited potential for significantly
decreasing overall health care costs related to hospitalization; however, future studies may be warranted to better
characterize the potential cost implications.
The results of this study, in a larger number of patients,
are similar to prior retrospective studies of total knee replacement patients that demonstrated the potential for lower concurrent opioid use.31,32 However, prospective, randomized
studies have demonstrated no benefit of liposomal bupivacaine with respect to concurrent opioid use.28-30 With respect
to pain scores, a larger retrospective evaluation of greater
than 1000 joint arthroplasty patients receiving liposomal
bupivacaine found significantly lower average pain scores in
total knee replacement patients who received liposomal
bupivacaine.25 However, our study results are similar to what
prior prospective, randomized studies have shown in demonstrating no clinically relevant improvement in pain control.
The lack of analgesic benefit seen in overall average pain
scores may be explained by the higher concurrent use of opioids in the control group and the subjective nature of pain
assessments. Another unique aspect of this study is that
patients receiving liposomal bupivacaine were found to have
a significant delay of approximately 1.5 hours in requesting
a rescue pain medication. It is possible that a delay in the first

rescue pain medication can indicate some level of improved
pain control during the period of time immediately after the
surgery; however, the clinical significance of this is questionable given the fact that average pain scores were not different between groups during the first 24 hours after the
procedure. This study is important for the literature in that it
adds to the limited data regarding the effect of liposomal
bupivacaine on pain management in community hospital settings, as opposed to larger tertiary academic institutions.
Furthermore, the study included evaluation of physical therapy milestones such as ambulation and knee range of motion.
Ambulation as soon as possible after a surgery is an
important goal in physical therapy to minimize the hazards
of immobility that can include development of joint stiffness with pain, deep vein thrombosis, disuse muscle atrophy, and cardiopulmonary compromise. In a prospective,
randomized trial, Surdam and colleagues reported findings
suggesting that liposomal bupivacaine may be associated
with improved ambulation on the day immediately after
total knee replacement.30 Results from this study indicate no
significant differences in ambulation or range of motion
during the entire 72-hour postoperative period among knee
patients; however, there was a significant association
between use of liposomal bupivacaine and a reduction in
overall length of hospital stay indicating that patients receiving liposomal bupivacaine may achieve functional mobility
that supports an earlier discharge.
This study contradicts results from the very limited number of published studies examining use of liposomal bupivacaine during orthopedic hip procedures, which have reported
a statistically significant association with reduced opioid
analgesic use.26,27 Furthermore, in this study liposomal bupivacaine was not associated with any benefit with respect to
improved postoperative pain control. The difference in findings may be attributable to a larger sample size in this study
compared with previous evaluations. There is significant
variability in the surgical approaches and techniques used in
hip procedures compared with knee procedures; therefore,

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