Liposomal bupivacaine infiltration in dogs after TPLO / stifle surgery — MAYBE (weak evidence)

In dogs undergoing TPLO/stifle surgery, does local infiltration with liposomal bupivacaine reduce rescue-opioid need and pain scores vs systemic analgesia alone?

Shelf #188 · gate-verified and displayed under the developer's blinded-trial rule

MAYBE (weak evidence): The trials point in opposite directions, and the most on-question trial is null. In the one blinded, randomised, placebo-controlled trial in the exact TPLO population (Aldrich 2023; 15 dogs given liposomal bupivacaine wound infiltration and 17 given saline, all also receiving carprofen), there was no difference in treatment success, postoperative opioid consumption, Glasgow CMPS-SF pain scores or static bodyweight distribution over 48 hours (the treatment made no difference). Against that, an earlier masked, randomised, placebo-controlled pilot in a different stifle procedure (lateral retinacular suture; Lascelles 2016, 46 dogs) found a significant overall pain-score effect favouring liposomal bupivacaine (p = 0.0027) and more rescue-free successes at every window, and a randomised TPLO head-to-head against plain 0.5% bupivacaine (Reader 2020) found liposomal dogs were less likely to need rescue analgesia and received lower opioid amounts — but that trial has no placebo or systemic-only arm, so it cannot show the infiltration adds anything to systemic analgesia alone. Net: a benefit over systemic analgesia alone is unproven for TPLO and contradicted by the best-matched trial; a benefit over plain bupivacaine is suggested by one small trial. Drafted Nov 10, 2026 (VetMed build, topic #188); all figures from abstracts fetched and verified at drafting.

Aldrich 2023: liposomal bupivacaine vs saline after TPLO — no difference in rescue success, opioid use, pain scores or weight bearing (the treatment made no difference)

Blinded, randomized, placebo-controlled clinical prospective study (record's own abstract wording; indexed Randomized Controlled Trial, Veterinary)

Who: Dogs: client-owned dogs with confirmed unilateral cranial cruciate ligament insufficiency undergoing tibial plateau leveling osteotomy (TPLO) at a university hospital — 15 dogs received surgical wound infiltration with liposomal bupivacaine and 17 received an equivalent volume of saline placebo; all dogs also received carprofen 2.2 mg/kg subcutaneously every 12 h postoperatively, and rescue analgesia was provided if needed.

Result: There was no difference between treatment success (defined as not requiring rescue analgesia over the 48-h postoperative period), postoperative opioid consumption, Glasgow Composite Measure Short Form (CMPS-SF) pain scores, or static bodyweight distribution (%BWdist) to the operated limb in dogs that received surgical wound infiltration with liposomal bupivacaine compared with those receiving saline placebo, following TPLO (the treatment made no difference). There was also no linear correlation between CMPS-SF pain scores and %BWdist. The record concludes liposomal bupivacaine may not provide detectable analgesia during the first 48 h for dogs recovering from TPLO and receiving only postoperative carprofen.

Watch out: This is the only carded trial in the exact TPLO population with a placebo (systemic-analgesia-alone) comparison, and it is small (32 dogs), so a modest effect could be missed — but as carded it is a null, not a near-miss: no endpoint separated. Both groups received carprofen, so the comparison is infiltration added to systemic analgesia vs systemic analgesia alone, which is the question asked.

Aldrich LA, Upchurch DA, Roush JK. Blinded, randomized, placebo-controlled study of the efficacy of bupivacaine liposomal suspension using static bodyweight distribution and subjective pain scoring in dogs after tibial plateau leveling osteotomy surgery. Vet Surg. 2023;52(5):721-730. PMID: 37114870. Registry ID: none in the record. MeSH: Dogs · Animals · Postoperative Pain · Prospective Studies · Surgical Wound · Bupivacaine · Analgesics, Opioid · Anterior Cruciate Ligament Injuries · Osteotomy · Tibia · Dog Diseases

Reader 2020: liposomal vs plain 0.5% bupivacaine for TPLO — liposomal dogs less likely to need rescue analgesia and got less opioid

Randomized clinical trial vs plain bupivacaine (record's abstract wording; indexed Randomized Controlled Trial, Veterinary — blinding not established by the record)

Who: Dogs: client-owned dogs undergoing tibial plateau leveling osteotomy (TPLO) at a referral hospital — 33 dogs enrolled and 28 completed the study; dogs received liposome-encapsulated bupivacaine (LEB, 5.3 mg/kg) or 0.5% bupivacaine hydrochloride (0.5BH, 1.5 mg/kg) by periarticular soft tissue injection; all dogs received carprofen 2.2 mg/kg subcutaneously every 12 h from extubation, and methadone 0.1 mg/kg IV was given if the Colorado State University-Canine Acute Pain Scale score was ≥ 2 (scale 0 to 4).

Result: Dogs administered LEB were less likely to require rescue analgesia and received lower amounts of opioids than dogs administered 0.5BH. There were no significant intergroup differences in other measured variables (pain scores on the Colorado State University scale and Glasgow Composite Pain Scale-Short Form, pressure nociceptive thresholds at the stifle, times to first rescue analgesic, first walk and first meal). The record's abstract reports the rescue/opioid findings qualitatively, without group percentages or P values.

Watch out: The comparator is plain bupivacaine infiltration, not placebo or systemic analgesia alone — this trial cannot answer whether any infiltration beats systemic analgesia alone, and it sits awkwardly beside Aldrich 2023's placebo-controlled null. The record does not establish that pain assessors were blinded, so the design is carded as randomised only. Five of 33 enrolled dogs did not complete the study.

Reader RC, McCarthy RJ, Schultz KL, Volturo AR, Barton BA, O'Hara MJ, Abelson AL. Comparison of liposomal bupivacaine and 0.5% bupivacaine hydrochloride for control of postoperative pain in dogs undergoing tibial plateau leveling osteotomy. J Am Vet Med Assoc. 2020;256(9):1011-1019. PMID: 32301662. Registry ID: none in the record. MeSH: Anesthetics, Local · Animals · Bupivacaine · Colorado · Dog Diseases · Dogs · Osteotomy · Postoperative Pain · Stifle

Lascelles 2016: liposomal bupivacaine (AT-003) vs saline for stifle surgery — pain scores favoured AT-003 (p = 0.0027) with more rescue-free successes to 72 h

Masked, randomized, placebo-controlled, multi-center pilot field study (record's own abstract wording; indexed Randomized Controlled Trial)

Who: Dogs: dogs undergoing lateral retinacular suture placement for cranial cruciate insufficiency (a stifle procedure, not TPLO) at multiple centres — 46 dogs enrolled and evaluated, randomly assigned to surgical site infiltration with bupivacaine liposome injectable suspension (AT-003, 5.3 mg/kg) or an equivalent volume of saline, infiltrated prior to closure; Glasgow Composite Measure Pain Scale (CMPS-SF) was assessed before surgery and at 2, 4, 8, 12, 24, 30, 36, 48, 54, 60 and 72 h, with provision for rescue analgesia.

Result: For CMPS-SF scores there was a significant overall treatment effect (p = 0.0027) in favour of AT-003. There were significantly more successes (success/failure analysis based on the need for rescue analgesia) in the AT-003 group compared with placebo over each time period (p = 0.0001 for 0-24 h, p = 0.0349 for 0-48 h, and p = 0.0240 for 0-72 h). No significant adverse events were seen. The record concludes AT-003 provided measurable local analgesia over a 72-h period following stifle surgery infiltration.

Watch out: A pilot study in a different, less invasive stifle procedure (lateral retinacular suture, not TPLO), sponsored development work for the product (AT-003) — its positive result was not reproduced when the same comparison was run blinded in TPLO dogs (Aldrich 2023, carded above). Group sizes per arm are not stated in the abstract.

Lascelles BD, Rausch-Derra LC, Wofford JA, Huebner M. Pilot, randomized, placebo-controlled clinical field study to evaluate the effectiveness of bupivacaine liposome injectable suspension for the provision of post-surgical analgesia in dogs undergoing stifle surgery. BMC Vet Res. 2016;12(1):168. PMID: 27531019. Registry ID: none in the record. MeSH: Analgesia · Anesthetics, Local · Animals · Bupivacaine · Dog Diseases · Dogs · Female · Liposomes · Male · Postoperative Pain · Pilot Projects · Stifle

Synthesis: the placebo-controlled TPLO trial is null, the pilot stifle trial is positive, and the head-to-head only beats plain bupivacaine

Synthesis

Who: Synthesis of the cards above: Aldrich 2023 (blinded randomised placebo-controlled TPLO trial, 15 liposomal bupivacaine vs 17 saline dogs, all on carprofen); Reader 2020 (randomised TPLO trial, liposomal vs plain bupivacaine, 28 completers); Lascelles 2016 (masked randomised placebo-controlled pilot, 46 dogs, lateral retinacular suture stifle surgery).

Result: Read together, the evidence does not establish that adding liposomal bupivacaine infiltration to systemic analgesia reduces rescue-opioid need or pain scores after TPLO: the one trial that asked exactly that, blinded and placebo-controlled, found no difference on any endpoint (the treatment made no difference). The positive signals come from a pilot in a lesser stifle procedure and from a comparison against plain bupivacaine rather than against systemic analgesia alone. A clinician choosing the liposomal product over plain bupivacaine has one small randomised trial behind the choice; a clinician expecting it to spare opioids beyond a good systemic protocol after TPLO is ahead of the evidence — hence MAYBE (weak evidence).

Watch out: All three trials are small (28-46 dogs), all gave concurrent carprofen, and none was powered for uncommon harms; infiltration technique and dose (5.3 mg/kg in Reader and Lascelles) also differ from the saline-volume-matched TPLO trial. Do not generalise the null or the positives beyond stifle surgery.

Synthesis of Aldrich LA et al. PMID: 37114870; Reader RC et al. PMID: 32301662; Lascelles BD et al. PMID: 27531019. Registry IDs as on the individual cards.

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