Comparative effectiveness of liposomal bupivacaine versus standard bupivacaine alone for brachial plexus block in upper limb surgery: A meta-analysis

ABSTRACT

Single-injection brachial plexus block is widely used for postoperative analgesia in upper limb surgery, particularly shoulder arthroplasty, rotator cuff repair, and distal radius fixation. However, the finite duration of standard bupivacaine may be followed by rebound pain and opioid rescue requirements. Liposomal bupivacaine is an extended-release formulation designed to prolong local anesthetic exposure, but randomized trials comparing liposomal bupivacaine added to standard bupivacaine with standard bupivacaine alone have reported inconsistent results. PubMed/MEDLINE, Embase, Web of Science, Cochrane Library, and trial registries were searched from inception to May 2026. Randomized controlled trials (RCTs) enrolling adults undergoing upper limb surgery with interscalene or supraclavicular brachial plexus block were eligible if they compared perineural liposomal bupivacaine, generally combined with standard bupivacaine, with standard bupivacaine alone. The primary outcome was postoperative opioid consumption expressed as morphine milligram equivalents (MME). Secondary outcomes included early postoperative pain scores, quality of recovery, satisfaction, sensory or motor outcomes, and adverse events. Risk of bias was assessed using the Cochrane RoB 2 tool. Continuous outcomes were pooled as mean differences (MDs) using random-effects models. The search identified 51 records, of which eight RCTs published between 2017 and 2026 met the eligibility criteria (n = 684 analyzed patients). Six studies contributed to the opioid-consumption meta-analysis. Liposomal bupivacaine was associated with a statistically significant but modest reduction in postoperative opioid consumption (MD = −11.86 MME, 95% CI: −20.17 to −3.56; P = 0.005; I ² = 46.0%). Six studies contributed to the early pain meta-analysis that showed lower pain scores with liposomal bupivacaine by approximately one point on a 0–10 scale (MD = −1.03, 95% CI: −1.34 to −0.72; P < 0.001; I ² = 19.1%). Recovery and satisfaction outcomes favored liposomal bupivacaine in selected trials, whereas longer-term function and overall adverse-event profiles were generally similar between groups. For adult upper limb surgery performed with brachial plexus block, liposomal bupivacaine added to standard bupivacaine provides a small early analgesic and opioid-sparing advantage compared with standard bupivacaine alone. The average effect is statistically significant but modest, and routine use for all patients may not be justified. Selective use in patients at higher risk of rebound pain or opioid-related harm appears more appropriate pending larger pragmatic trials and cost-effectiveness analyses.

Categories: Anesthesiology, Regional Anesthesia, Orthopedic Surgery