Key Points

  • Over one million hip and knee arthroplasties were performed in the United States in 2010 (http://www.cdc.gov/nchs/fastats/insurg.htm). Many can benefit from local analgesic wound infiltration.
  • Despite recent advances, 86% of patients report moderate to extreme pain following surgery.
  • Pain is the most common cause of hospital admissions after ambulatory surgery.
  • Multimodal strategies using two or more analgesic agents and including administration of local analgesics are recommended by surgical pain guidelines — eg, American Pain Society (APS), American Society of Anesthesiologists (ASA), American Society of PeriAnesthesia Nurses (ASPAN), Department of Defense (DOD).1-4, 9, 20
  • Since their clinical use was first demonstrated more than 120 years ago, local analgesics have provided an alternative to general anesthesia and an adjunct to better managing surgical pain that has proved beneficial for both patients and practitioners.10, 12, 13, 15, 19
  • Managing surgical pain with minimal use of opioids has been shown to accelerate patient recovery; reduce complications, hospital stays and readmissions; and improve overall patient outcomes.10, 12, 13, 15, 19
  • Wound infiltration with local analgesics has demonstrated benefits for reducing surgical pain and the use of opioids, minimizing expensive complications that cause patient harm and thereby shortening hospital stays and reducing readmissions.10, 12, 13, 18
  • The recent addition of a 72-hour liposome formulation of bupivacaine substantially and favorably alters the paradigm for evaluating and using surgical wound infiltration in joint arthroplasty to improve pain scores, significantly reducing the need for opioids and improving patient satisfaction.7
  • Always consider maximum dose and patient weight when infiltrating. Because amide-type local anesthetics such as bupivacaine are metabolized by the liver, they should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease are at a greater risk of developing toxic plasma concentrations.
  • Improving local analgesic administration techniques can improve surgical pain outcomes and benefit patients. This is the goal of the Best Infiltration Practices Working Group and its expert recommendations.
  • Infiltration techniques vary from procedure to procedure, requiring knowledge of each surgical site and its anatomy to produce optimal results.
  • It is important to remember that the total local analgesic volume required to adequately cover a wound and systemic local analgesic levels are dependent on an interplay between total dosage administered, any additives, and the relative vascularity of the specific surgical site of injection.18
  • Improved infiltration techniques for subcutaneous tissue and the placement of local analgesic into deeper myofascial tissues where neurons are dissected and pain foci often arise are important to maximize the effect and duration of analgesia.13

Technical Notes

  • Local analgesic should always be injected slowly into soft tissues of the surgical site with frequent aspiration to check for blood to minimize the risk of intravascular injection.
    • Aspirating while inserting the needle and injecting while withdrawing the needle further reduces risk.
  • Ideally use a 20-30 mL syringe with a 1.5-3 inch, 22-25 gauge needle.
    • The use of a blunt tip needle may enhance the surgeon’s ability to recognize the entry into, and exit from, the different fascial planes.
    • A 22-gauge needle is recommended since larger gauge needles allow more leakage of injectate into the wound. Choice of needle length depends on the anatomy being injected. This technique also avoids leaving large lakes of solution that swell tissues and increase pain.
  • In addition to generous administration to the dermis and subcutaneous areas of the surgical incision, special attention should be given to provide adequate local analgesic in the deep tissues where many myofascial nerve endings reside.
    • Awareness of what myofascial plane the infiltrating needle tip is in during infiltration is important. In open cases, the surgeon has the advantage of direct visualization to place the needle directly into the desired soft tissues and subfascial planes. When direct visualization is not possible, the location of the needle tip may best be appreciated by the sensation of a “pop” or “feel” as the needle passes through the different layers.

Recommended Injection Solutions

  • Injection solution includes bupivacaine liposomal injectable suspension (EXPAREL®) 20 mL and 0.25% bupivacaine with epinephrine 30 mL. Normal saline 10-20 mL may be added if extra volume is needed.

See full Prescribing Information at www.Exparel.com

Infiltration Technique Descriptions

THA Posterior Approach

Injection solution includes bupivacaine liposomal injectable suspension (EXPAREL) 20 mL and 0.25% bupivacaine with epinephrine 30 mL. Normal saline 10-20 mL may be added if extra volume is needed.


Step 1: Deep Injection
Infiltration TechniqueLocal Analgesic Volume
After the joint is prepared for implantation, inject 20 mL into the anterior
capsule and periosteum, the inferior capsule, the superior capsule and periosteum, the
psoas tendon sheath, the superior deep layer of abductors, and the
anterior femoral periosteum.
Note: Observe caution regarding the posterior injection due to the proximity
of the sciatic nerve.
20 mL
Step 2: Posterior Injection
Infiltration TechniqueLocal Analgesic Volume
Inject 10 mL into the short external rotators and posterior capsule (after repair), the abductors, the anterior femoral soft tissues, the periosteum of the trochanter and the vastus lateralis.

Note: Observe caution regarding the posterior injection due to the proximity of the sciatic nerve.
10 mL
Step 3: Superficial Injection
Infiltration TechniqueLocal Analgesic Volume
After insertion of the femoral prosthesis, inject the remaining 20 mL into the tensor layer, ilio-tibial band, gluteus maximus, subcutaneous layer and skin.

Note: For revisions:
  • Extend the deep injections, prior to stem placement but following placement
    of the acetabular cup:
    • more broadly superiorly in the region of the peri-acetabular periosteum
    • further along the femoral periosteum
    • into the vastus lateralis & deep quadriceps muscles
  • Extend the mid-layer injections, being careful to avoid the sciatic nerve:
    • into the gluteus maximus
    • into the interosseus membrane
  • Extend the superficial injections:
    • more broadly along the deep tissues & subcutaneous layers
20 mL

Figure 1. THA Posterior Approach