Mepivacaine vs. bupivacaine in spinal anesthesia for total joint arthroplasty: a systematic review and meta-analysis

INTRODUCTION: Total hip and knee arthroplasties are among the most common surgeries worldwide. Advances in anesthesia and pain management have enabled fast-track pathways, with spinal anesthesia increasingly preferred over general anesthesia. Bupivacaine has been the traditional local anesthetic of choice; however, mepivacaine has gained attention due to its shorter recovery profile. We conducted a systematic review and meta-analysis comparing spinal mepivacaine versus bupivacaine in total joint arthroplasty. EVIDENCE ACQUISITION: We searched MEDLINE, Embase, Web of Science, and Cochrane databases for studies comparing spinal mepivacaine and bupivacaine in total joint arthroplasty. Statistical analyses were performed using R (version 4.2.2). Quality assessment and risk of bias were performed according to Cochrane recommendations. EVIDENCE SYNTHESIS: We included 13 studies comprising 4,167 adult patients, with 1,564 (37.5%) receiving spinal mepivacaine. Mepivacaine led to significantly faster motor function recovery (mean difference [MD] -30.70 min; 95% CI -44.71 to -16.70 min; P<0.01) and earlier ambulation (MD -51.60 min; 95% CI -96.50 to -6.70 min; P=0.02). It was also associated with shorter facility length of stay (LOS) (MD -4.36 hours; 95% CI -6.25 to -2.48 hours; P<0.01), though no difference was observed in post-anesthesia care unit LOS (MD -31.02 min; 95% CI -64.25 to 2.20 min; P=0.07). CONCLUSIONS: This meta-analysis suggests that mepivacaine spinal anesthesia for total joint arthroplasty may provide faster recovery and earlier home discharge. However, these findings should be interpreted with caution due to the potential risk of bias in most included studies.