Efficacy and safety of different bupivacaine concentrations in periarticular infiltration combined with adductor canal block for bilateral total knee arthroplasty: a randomized controlled trial

Abstract Background Pain management for bilateral total knee arthroplasty (BTKA) often combines adductor canal block (ACB) with periarticular infiltration (PAI). However, concerns arise regarding local anesthetic toxicity. This study evaluated the efficacy and safety of different bupivacaine concentrations in simultaneous BTKA. Methods Patients undergoing simultaneous BTKA under spinal anesthesia were included in the study. They received ACB with 50 mg bupivacaine for each thigh. The patients were then randomized into two groups. Group A was administered a PAI of 100 mg bupivacaine per knee (totaling 300 mg bupivacaine for ACB and PAI). Group B received a PAI with 50 mg bupivacaine per knee (totaling 200 mg bupivacaine for ACB and PAI). Postoperative pain was assessed using a visual analog scale at 4-h intervals for 48 h after surgery. Plasma bupivacaine concentrations were measured at eight specified times. Postsurgery walking ability was also evaluated. Results Among the 57 participants analyzed, visual analog scale pain scores revealed no significant differences between the two groups. An interim analysis of plasma bupivacaine concentrations in both groups indicated no significant disparities. In group B, 93.1% managed to walk with assistance within 48 h, as opposed to group A’s 71.4% (P = 0.041). Conclusions Combining ACB with 100 mg bupivacaine and PAI with another 100 mg bupivacaine provided effective pain relief. This combination also had a better safety profile and led to more patients walking postsurgery than when combining ACB with 100 mg bupivacaine and PAI with 200 mg bupivacaine. Thus, ACB combined with PAI with a total dose of 200 mg bupivacaine appears suitable for simultaneous BTKA. Trial registration: ClinicalTrials.gov (NCT03249662).