R. Patel1, M. R. Borrelli1, K. Rustad1, B. Pridgen1, A. Momeni1, H. P. Lorenz1, S. Virk1, D. C. Wan1 1Stanford University,Palo Alto, CA, USA
Introduction: Bone grafting of alveolar clefts is routinely performed using cancellous bone harvested from the iliac crest. Graft site morbidity, however, is common, with many patients experiencing early post-operative pain. Conventional intraoperative use of local anesthetics such as Marcaine is often insufficient and requires additional opioid-based medications to achieve adequate postoperative analgesia. Marketed under the name Exparel®, liposomal bupivacaine has been demonstrated to provide significant improvement in post-operative pain for patients undergoing bunionectomy or hemorrhoidectomy, and this medication may similarly provide relief of donor site pain in patients requiring bone graft harvest. In this study we assessed the efficacy of a single dose of intraoperatively administered liposomal bupivacaine in children undergoing iliac crest bone graft harvest for repair of alveolar clefts.
Methods: 10 patients undergoing iliac crest bone graft from June 2017 to October 2017 were included in the study, which was performed under IRB approval. 5 patients underwent open iliac crest bone graft harvest, with administration of 0.25% Marcaine in Gelfoam at the hip donor site. The other 5 patients underwent open iliac crest bone graft harvest with direct infiltration of 1.3% liposomal bupivacaine around the osteotomy site. Post-operative measures included: patient-reported pain score, total narcotic use (in oral morphine equivalent) during hospitalization, length of stay, postoperative steps, as measured by a Fitbit Activity Tracker, and thigh numbness.
Results: There were no significant differences in age, weight, or distribution of clefts between the two groups. Patients receiving 0.25% Marcaine were discharged on average 1.4 ± 0.55 days after surgery and patients receiving Exparel discharged on average 1.2±0.45 days after surgery. However, differences were noted in average postoperative pain scores (4.25 ±2.15 vs. 2.50 ±1.51), oral morphine equivalents administered (7.08 ± 1.05 vs. 4.82 ± 1.55), and postoperative steps (498 ± 32 vs. 786 ± 157) for patients receiving 0.25% Marcaine vs. Exparel, respectively. Of note, two patients receiving liposomal bupivacaine did report transient thigh numbness lasting three days. No other complications were noted with these patients.
Conclusion: Liposomal bupivacaine may provide reliable and long-acting post-operative analgesia which contributes to a reduction in pain scores and need for additional narcotic administration. This is also reflected in improved post-operative activity, as measured by patient steps. Importantly, there are no recommendations for pediatric dosing of Exparel, and no studies exist in the literature describing use in this patient population. Nonetheless, safe use was observed in this study, highlighting the promise of this analgesic to improve postoperative pain management in children undergoing alveolar bone grafting.