Managing Donor Site Pain After Alveolar Bone Grafting: A Comparative Analysis of Liposomal Bupivacaine (Exparel), Bupivacaine-Soaked Gelfoam, and ON-Q Ropivacaine

Introduction: Traditionally, alveolar bone grafting (ABG) uses bone from the iliac crest for repair. Harvesting this graft has been associated with significant donor site pain. Local anesthetic is a useful adjunct to alleviate postoperative opioid requirements. This study compares the efficacy of liposomal bupivacaine (Exparel) to commonly used prolonged local anesthetics at our institution. Methods: Seventy-one patients undergoing open unilateral iliac crest bone harvest were included in this study. Thirty-seven patients received 1.3% liposomal bupivacaine injections to the donor site, 17 had 0.25% bupivacaine-soaked Gelfoam placed in the defect of the iliac crest, and 17 received ON-Q pump 0.2% ropivacaine infusion to the donor site. Intraoperative pain medications, breakthrough opioid utilization, and opioids prescribed at discharge were recorded. Results: Intraoperative pain medications and preincisional local anesthetic to the palate were comparable between cohorts. The ON-Q ropivacaine cohort received a greater dose of local anesthetic to the hip compared with the liposomal bupivacaine cohort. However, patients who received liposomal bupivacaine required significantly fewer opioids within the first 24 hours and throughout their hospitalization compared with both bupivacaine-soaked Gelfoam and ON-Q ropivacaine ( P <0.001). The frequency of opioids prescribed at discharge was significantly different between groups ( P= 0.002). Post hoc analysis revealed significantly fewer opioid prescriptions among patients who received liposomal bupivacaine compared with both cohorts. Conclusions: This study suggests that liposomal bupivacaine may have superior outcomes for postoperative pain control, leading to reduced opioid consumption when compared with alternative anesthetics in patients undergoing iliac crest harvest for ABG.