Liposomal bupivacaine in lower extremity arthroplasty: a comprehensive review

Background Postoperative pain management following lower extremity joint arthroplasty (TKA, THA, and ankle procedures) remains a significant clinical challenge, with approximately two-thirds of patients reporting moderate-to-severe pain within the first 24 h. Conventional local anesthetics, which have a short duration of action (6–8 h), frequently fail to provide prolonged analgesia, leading to opioid dependence and its associated risks. Liposomal bupivacaine (LB), a sustained-release formulation based on DepoFoam™ technology, provides analgesia for up to 72 h, thereby addressing this clinical gap. Methods This systematic review assesses the efficacy and safety of LB through an analysis of nine randomized controlled trials (RCTs; N = 828) sourced from PubMed, Web of Science, and the Cochrane Library (2010–2024). The inclusion criteria were restricted to RCTs comparing LB with conventional analgesics in adult arthroplasty patients, while excluding small case series and non-comparative studies. Results LB demonstrated superior outcomes, including a 35%–50% reduction in 24-hour opioid requirements (pooled relative risk [RR] = 0.62; 95% CI: 0.32–0.89; p = 0.008), reduced hospital length of stay (mean difference [MD] = −0.5 days; 95% CI: −0.7 to −0.3; p < 0.001), and enhanced early-phase analgesia (24-hour VAS: MD = −1.2 points; 95% CI: −1.5 to −0.9; p < 0.001). particularly when used with adductor canal block in TKA procedures. However, its cost-effectiveness varied by surgical procedure, and no significant difference in analgesia was observed beyond 72 h compared to controls. Conclusion LB provides clinically significant opioid-sparing effects and enhances postoperative recovery, though its cost-benefit profile requires careful assessment. Future studies should focus on formulation optimization, expanded clinical applications, and improved pharmacoeconomic approaches to establish its definitive role in enhanced recovery after surgery (ERAS) protocols.