Practical Considerations for Liposomal Bupivacaine Use in Orthopaedic Surgery

Abstract

» Opioid-related dependence remains a major concern following surgery in the United States, driving increased interest in non-opioid, multimodal pain control strategies within orthopaedic surgery.

» Liposomal bupivacaine is an extended-release anesthetic approved for specific nerve blocks and offers the potential to prolong analgesia without the need for post-operative catheters.

» Liposomal bupivacaine is currently approved for use in interscalene brachial plexus blocks, sciatic nerve blocks in the popliteal fossa, and adductor canal blocks.

» Despite mixed clinical trial results compared to unencapsulated bupivacaine, liposomal formulations may provide clinical and economic advantages in selected orthopaedic settings.

Introduction

Approximately 6% to 40% of patients undergoing surgery in the United States experience prolonged opioid use at up to 1 year postoperatively^1–4. Many studies have attempted to identify risk factors for such a dependence, and others have tried to understand individual patient needs depending on their specific surgery to prevent overprescribing and optimize the number dispensed (over 90% of patients keep unused opioid pills rather than disposing them)⁵. But virtually all studies express regret at the need to include opioids in pain regimens at all as the ideal perioperative protocol would eliminate them completely.

There is a shift toward opioid-free recovery, with a recognition that carefully designed multimodal protocols can effectively control pain in even the most invasive procedures, including orthopaedic surgery. For example, in isolation, nonsteroidal anti-inflammatory drugs often lack the potency needed after surgery, but can play a critical role in combination with a wide variety of similarly safe options. But the multimodal options rely on effective pain control in the immediate perioperative period by regional anesthesia. Peripheral nerve blocks rely on locally administered compounds like bupivacaine, which provide sensory analgesia while ideally preserving motor function. While neuraxial techniques such as epidural analgesia have historically been used in some surgical contexts, they are now uncommon in orthopaedic procedures and were therefore not the focus of this review. The sensory blockade, however, is limited by the half-life of the anesthetic when administered as a “single shot”, an effect which can be prolonged through either continuous administration or new formulations involving liposomal encapsulation for extended release (Exparel [Pacira Pharmaceuticals]). According to the Food and Drug Administration, liposomal bupivacaine is approved for interscalene, popliteal sciatic, and adductor canal blocks, but not for femoral nerve blocks, which remain excluded because of the lack of supporting data in this indication. These both involve trade-offs. While the innovation to develop liposomal bupivacaine has led to a somewhat higher up-front cost, continuous administration through catheters involves not only equipment costs but also the cost of complications and provider time to troubleshoot them. In addition, single-shot peripheral nerve blocks have proven high efficacy with a favorable safety profile, and the burden is on these newer entrants to demonstrate safety, efficacy, and value for patients in the marketplace.

Orthopaedic surgery presents an ideal setting to test the above as many procedures require regional anesthesia while also being high-volume, relatively standardizable, electively scheduled, and often performed in patients medically optimized preoperatively. Many also occur in outpatient settings where postoperative pain control is particularly crucial. In addition, the above procedures represent a large payor expense nationally, some of which have come under political and payor scrutiny for reimbursement⁶. Recognizing this, as well as the frequency of concomitant opioid prescription postoperatively, Congress recently passed the Non-Opioids Prevent Addiction In the Nation (NOPAIN) Act. While this legislation does not validate the clinical or economic superiority of any individual agent, it does create reimbursement pathways that may facilitate broader adoption of nonopioid analgesics in outpatient surgery. Specifically, a J-code (J3304) now exists for liposomal bupivacaine, allowing for separate payment in hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs). However, in inpatient settings, liposomal bupivacaine remains bundled into the fixed DRG payment, limiting any direct reimbursement benefit for hospitals under those conditions. This bill provides separate Medicare reimbursement for nonopioid treatments administered in ambulatory or hospital-based outpatient settings, potentially changing the incentive structure and implementation barriers for multimodal regimens and regional anesthesia. The purpose of this review is to discuss the role within orthopaedic surgery for which liposomal bupivacaine may possess clinical and economic value and to project how changing political and market conditions may affect this value. Unlike previous reviews that focus on a single joint or delivery approach, we aim to provide an integrated assessment of clinical effectiveness, economic impact, and evolving policy incentives.

Evidence

A wide range of high-quality, randomized controlled trials (RCTs) have been published over the past 5 to 8 years directly comparing liposomal bupivacaine with unencapsulated bupivacaine for regional anesthesia, whether as a single shot or a continuous infusion catheter. Other studies have also examined its use in surgeon-administered periarticular blocks. These studies typically examine primary outcomes such as pain scores within the first 24 to 72 hours after surgery, the number of opioid pills consumed, and complications. Some also examine secondary outcomes such as ability to ambulate, length of stay, and patient satisfaction. Systematic reviews and meta-analyses of this literature have helped not only in quantifying efficacy and safety but also in evaluating risk of bias and industry sponsorship of trials. In addition, given the heterogeneity of many trials incorporated into the meta-analyses, a select number of lower-quality (level 3 or 4) studies may hold value as well. The summary of systematic reviews and meta-analyses examining liposomal bupivacaine is shown in Table I.

TABLE I.

Summary of Systematic Reviews and Meta-analyses Examining Liposomal Bupivacaine

Study	Type	Studies (Patients)	Findings
Shoulder surgery
Fares et al., AJSM, accepted 20247	Meta-analysis	15 RCTs (1,201 patients, arthroplasty and rotator cuff repair)	Lower pain and opioid consumption versus continuous catheters and other single-shot blocks, no difference for PAI
Li et al., JOSR, 20248	Meta-analysis	12 RCTs (1,537 patients, shoulder arthroplasty)	No benefit
Li et al., JSES, 20229	Meta-analysis	11 RCTs (846 patients, arthroplasty and rotator cuff repair)	No benefit
Alaqaili et al., MLTJ, 202410	Meta-analysis	7 RCTs (442 patients, rotator cuff repair)	Significantly decreased opioid use and pain, but not clinically meaningful
Total hip and knee arthroplasty
Chen et al., JOSR, 202311	Meta-analysis	16 RCTs (1,629 patients)	Superior opioid consumption at 24-48 hours, otherwise no difference
Hannon et al., JOA, 202212	Meta-Analysis	60 studies	No benefit
Liu et al., Orthopaedic Surgery, 201913	Meta-analysis	11 RCTs (2,908 patients)	Superior opioid consumption and functional recovery, shorter length of stay
Zhao et al. Medicine, 201914	Meta-analysis	7 RCTs, 5 retrospective studies	Superior opioid consumption, otherwise no difference
ACL reconstruction
Vij et al., Orthopedic Reviews, 202215	Systematic review	4 RCTs (226 patients)	Better pain and fewer opioids, better sleep, fewer physician calls

PAI = periarticular injection, and RCT = randomized controlled trial.

Shoulder Surgery

Within shoulder surgery, evidence is mixed to positive regarding liposomal bupivacaine, depending on the comparison treatment. To date, the largest meta-analysis of 15 RCTs for shoulder arthroplasty and rotator cuff repair is in press and found that single-shot liposomal bupivacaine was superior to unencapsulated anesthetic, whether administered through a continuous interscalene catheter or as a single-shot brachial plexus (interscalene) block. This meta-analysis included both shoulder arthroplasty and rotator cuff repair procedures, contributing to some procedural heterogeneity in the pooled results⁷. Periarticular injections of liposomal bupivacaine, however, demonstrated no benefit. Another recent meta-analysis of 12 RCTs for shoulder arthroplasty specifically found less-convincing results for liposomal bupivacaine compared with traditional single-shot and continuous interscalene blocks, whereas a 2022 meta-analysis of 11 RCTs for shoulder arthroplasty and rotator cuff repair found liposomal bupivacaine to be similar to other treatment modalities^8,9. Randomized and nonrandomized studies have also demonstrated superior pain scores and lower opioid use for liposomal bupivacaine versus bupivacaine or ropivacaine continuous catheters and even single-shot regimens for shoulder arthroplasty^16–18. Several shoulder arthroplasty studies have also demonstrated lower cost with liposomal bupivacaine relative to continuous catheters, with noninferior pain scores and fewer major complications^19,20. Studies examining rotator cuff repairs have specifically shown benefits from liposomal bupivacaine compared with both catheters and single-shot regimens, with improved pain scores and satisfaction (with or without dexamethasone), although this continues to be somewhat controversial when subjected to meta-analysis^10,21,22.

Hip and Knee Arthroplasty

Nearly 3 million total hip and knee arthroplasties (THA, TKA) are performed in the United States each year, typically with regional anesthesia for postoperative pain control²³. Evidence is similarly mixed to positive for liposomal bupivacaine. A meta-analysis of 11 trials and over 2,900 patients showed reduced total morphine consumption and superior functional recovery with shorter length of stay for patients who received liposomal bupivacaine versus femoral nerve block after TKA¹³. Another meta-analysis of 12 studies of TKA/THA patients showed lower opioid consumption for patients undergoing a periarticular injection (PAI) with liposomal bupivacaine versus traditional bupivacaine, although with similar pain levels, outcome scores, and length of stay¹⁴. A more recent meta-analysis of 16 RCTs showed that liposomal bupivacaine for an intraoperative PAI reduced morphine equivalent consumption at 24 to 48 hours compared with traditional bupivacaine, but otherwise observed no significant differences across all other outcome measures¹¹. A meta-analysis of 60 RCTs involving THA/TKA patients showed that adding ketorolac or corticosteroid to the intraoperative PAI provides additional benefit, but observed no benefit with liposomal bupivacaine or the addition of morphine¹². Although not a meta-analysis of RCTs, perhaps the highest-quality single study of liposomal bupivacaine is a recent RCT of 533 patients which observed no benefit when incorporated as a periarticular injection²⁴.

ACL Reconstruction

Less literature exists regarding liposomal bupivacaine administration in patients undergoing anterior cruciate ligament reconstruction. A recent systematic review of 4 RCTs showed mixed to positive results, with some studies showing better pain management and lower opioid consumption with liposomal bupivacaine¹⁵. Better sleep and fewer calls to the physician postoperatively were also observed, with all other outcomes at least equivocal. However, a meta-analysis of these studies was not performed.

Summary of Meta-analyses and Systematic Reviews

Across anatomic sites and delivery methods, the evidence regarding liposomal bupivacaine remains mixed. Most benefit has been demonstrated in comparisons against continuous catheters, particularly in shoulder surgery, where LB appears to offer equivalent or superior pain control and reduced complication rates. When compared with single-shot unencapsulated anesthetics, results are more variable, with some meta-analyses showing improved outcomes and others reporting no significant difference. A 2024 pharmacodynamic study by Zadrazil et al. also demonstrated the prolonged action of LB relative to bupivacaine hydrochloride in a randomized crossover design, helping to explain its clinical potential despite inconsistent superiority in pain scores across trials.

Liposomal Bupivacaine vs. Continuous Catheters: A Cost Analysis

A variety of studies provide evidence in support of liposomal bupivacaine over continuous catheters, both for pain control, complications, and cost. No dedicated meta-analyses, however, have yet been published for orthopaedic surgery. Within shoulder surgery, a 2017 study showed liposomal bupivacaine to have a lower cost ($289 vs. $1,559) and 4 times fewer major complications than interscalene catheters, with no difference in opioid consumption after discharge²⁰. In addition, liposomal bupivacaine has been shown to have lower cost ($1,115 vs. $1878) and noninferior pain scores compared with interscalene continuous catheters, whereas a similar study showed lower pain scores and higher rates of opioid-free regimens^16,25. A RCT by Krupp et al. showed lower medication costs with a mixture of liposomal/standard bupivacaine versus a ropivacaine continuous catheter ($190.17 vs. $357.12) while also observing better pain control and reduced narcotic consumption with shorter administration time as well²⁶. Notably, for the above studies, the wide variability in reported cost points to the discrepancies in equipment cost for catheters, the variety of adjuncts included in mixtures with liposomal bupivacaine, and the year of the studies. This highlights the difficulty in comparing cost across studies because of this variability, but more standardization in both equipment and administration is not necessarily imminent as more is learned about liposomal bupivacaine administration at both the system and provider level.

Within hip and knee arthroplasty, a variety of studies have compared liposomal bupivacaine with continuous catheter pumps. An older 2016 study showed superior opioid consumption for liposomal bupivacaine versus continuous catheters, whereas another 2016 study showed superior pain control and ambulation, with the additional benefits of shorter length of stay and a hospital cost per patient on average $455 lower^27,28. A 2022 study similarly observed cost savings of $95 per patient ($155,800 total) with no difference in complications, whereas a 2021 study observed a 22% complication rate for continuous catheters compared with zero complications for liposomal bupivacaine, a finding they proposed balanced out a somewhat better pain control observed for catheters in their cohort^29,30. Importantly, some emerging evidence shows the superiority of continuous catheters compared with single shot when both use traditional (unencapsulated) anesthetic, as seen in a recent 2023 meta-analysis of 10 RCTs comprising 828 TKA patients receiving adductor canal blocks³¹. However, a similar 2022 meta-analysis of 11 RCTs (with a substantial overlap in included studies) showed no significant difference between the 2 protocols³². If a consensus does eventually emerge showing a clinical benefit for continuous catheters over single-shot unencapsulated anesthetic, there may be less need for direct comparisons of liposomal bupivacaine with single-shot traditional bupivacaine or ropivacaine blocks although this clearly still remains premature.

When comparing the cost of encapsulated bupivacaine with that of single-shot bupivacaine or ropivacaine injections, however, the cost difference becomes more substantial. A recent study involving TKA patients undergoing a PAI observed a cost difference of $300.66 for liposomal bupivacaine compared with $16.83 for a single-shot bupivacaine regimen³³. An older study found a cost difference for single-shot regimens, with liposomal bupivacaine 7.1 times more costly than a modified Ranawat regimen incorporating ropivacaine ($285 vs $40)³⁴. In some contexts, however, performing injections with only half the maximum recommended dose (266 mg) and making up the difference with standard bupivacaine may be appropriate, leading to a lower encapsulated bupivacaine raw material cost on a per-patient basis ($180.35)²⁵. However, it is important to note that in a randomized trial of 533 patients, Hamilton et al.²⁴ found no clinical benefit and no cost-effectiveness of liposomal bupivacaine compared with standard bupivacaine using commonly accepted willingness-to-pay thresholds based on QALYs. This finding highlights the variability in economic outcomes depending on the comparator and the assumptions underlying cost modeling. These half-dose encapsulated bupivacaine regimens seem to be more prevalent in upper extremity surgery, while lower extremity arthroplasty typically involves full doses. Overall, Hyland et al. note that the cost of liposomal bupivacaine is approximately $270 to $390 per 266 mg dose, similar to costs published in other subspecialties^33,35.

Clinical and Economic Considerations

While encapsulated anesthetic currently has a higher up-front cost, taken together, evidence is building in support of liposomal bupivacaine as a more cost-effective alternative to continuous infusion catheters, with lower complication rates for patients as well as equivalent to superior pain control, opioid consumption, and activity level postoperatively. As high-volume orthopaedic procedures increasingly transition to value-based care models in which a single reimbursement covers all expenses for the entire 30- or 90-day episode of care, regional anesthesia protocols that minimize complications and provider time in dealing with catheter issues will become increasingly important. As highlighted by recent studies, much of the economic argument for LB hinges on the procedural and logistical costs of continuous catheter placement—particularly in shoulder surgery—which may vary by institution and should be interpreted accordingly.

Overall, the economic case for liposomal bupivacaine over continuous catheters is straightforward. The 2021 study by Kenny et al. involving 333 shoulder arthroplasty patients discussed above offers the most detailed comparison²⁵. In it, the authors note that their liposomal bupivacaine regimen costs $762.93 less than the continuous catheter although they use only half of the maximum dose. If they had used the maximum 266 mg dose often used in TKA instead of a half dose combined with 10cc 0.5% bupivacaine ($54.18), this cost difference would narrow to $636.76 per patient in favor of liposomal bupivacaine. Notably, this difference includes not only the cost of catheter raw materials but also a $476 higher procedure cost for catheter placement ($869 vs $1,345) and physician follow-up for the catheters (2 days, $484). Notably, their cost for 2 days of 0.2% ropivacaine (1500cc) to run through the catheter was $259.84, which was similar to the raw medication costs in the liposomal bupivacaine half-dose group ($234.53) and not dramatically different from the $270-$390 range cited above for a single shot of maximum dose liposomal bupivacaine. A more dramatic difference in raw material costs favoring liposomal bupivacaine was observed by Krupp et al. ($190.17 vs $357.12, a difference of $166.95)²⁶. Even in the absence of any complications, when considering equipment, procedure billing, and physician follow-up costs, based on the above, a maximum-dose liposomal bupivacaine regimen would represent a cost saving of at least $636.76 per patient. Based on the savings noted above, demonstrating clinical equivalence to continuous catheters (whether by pain scores, opioid consumption, or both) may be enough to justify the acceptance of liposomal bupivacaine by health systems or payors who desire to decrease cost. We acknowledge that several of the cost comparisons presented rely on assumptions about procedural billing, follow-up intensity, and complication rates, which may not apply uniformly across institutions. As such, these results should be interpreted as context-specific and not as generalizable proof of economic dominance.

The complications related to the regional anesthesia protocol must also be considered in the value analysis. The most serious of these is pulmonary compromise, for which readmissions cost on average $6,849³⁶. Although exact rates vary by study and population, a recent analysis reported a readmission rate of approximately 1.5% after interscalene catheter use because of pulmonary-related complications, including respiratory distress and delayed discharge. In theory, pulmonary risk should be similar between liposomal bupivacaine and in-dwelling catheters given the extended release time of the former, so less severe adverse events like superficial infection, catheter migration, or mechanical problems should also be considered. A recent 2024 study by Lee et al. reported a high rate of minor complications with in-dwelling catheters in patients undergoing arthroscopic rotator cuff repair, including 48% reporting erythema and bruising at the catheter site and a 24% rate of catheter or pump problems³⁷. These include a 12% rate of catheter removal (half of which was for leakage) and a 12% rate of pump malfunction. Their group compared single-shot standard ropivacaine versus a catheter administering ropivacaine, notably finding worse pain control and rebound pain in the single-shot group meeting the minimal clinically important difference (MCID), and while they do not comment on the costs of dealing with the above minor complications, they do note the time and manpower spent on patient education and troubleshooting postoperatively. Liposomal bupivacaine itself is not without risks, particularly the inability to titrate down the effects of the block, unlike continuous catheters in which the infusion can simply be stopped. While extended lower extremity motor blockade, phrenic nerve paralysis, and Horner’s syndrome are all possible with liposomal bupivacaine, clinical incidence has been relatively infrequent and any measured decreases in function often still fall within a clinically normal range³⁸. However, it is important to note that the cited study excluded patients with any underlying pulmonary disease—precisely the population at greatest risk of clinically significant diaphragm dysfunction—thereby limiting the generalizability of its findings.

Logistics and patient flow considerations play a role in the economic analysis as well. A study by Thompson et al. in shoulder arthroplasty patients compared delivery of unencapsulated anesthetic as a single-shot versus continuous perineural administration and found that continuous delivery resulted in significantly higher barriers to discharge and a significantly longer mean length of stay (2.3 vs 2.6 days) although contrasting results were noted in a similar 2017 study by Chalmers et al. (2.5 vs 2.2 days)^39,40. The authors in both studies discuss rebound pain, which is noted in the literature at approximately 20 hours postadministration of single-shot ropivacaine, a time when the latter study notes that many discharge decisions are being made, factors that can delay discharge by as much as a day. Depending on the care setting (hospital vs ASC), this extra day can cost thousands of dollars, and further work is needed to determine whether encapsulated bupivacaine can mitigate this risk. Within TKA, a population-based study found that those receiving liposomal bupivacaine had lower total hospitalization costs on average, for both Medicare ($616) and commercial insurance ($775), and these patients were more likely to be discharged home and had a length of stay 0.6 days shorter although this is controversial^41,42. Studies examining arthroplasty in the inpatient setting like those above (i.e. inpatient stays of 2 or more days), however, might have decreasing relevance given the recent transition to ambulatory settings. There is a need for more work to quantify any role liposomal bupivacaine may play in helping patients successfully complete same-day discharge.

Finally, phone calls associated with regional anesthesia must be considered, and a 2020 study by Hutchins et al. found them to be significantly more frequent with patients undergoing a single-shot unencapsulated versus encapsulated regimen (5.6% vs 3.2%) and rates with continuous catheters are likely much higher⁴⁰. The challenge in setting up the infrastructure for managing continuous catheters was detailed by Faraoni et al. in 2023, who emphasized that daily phone calls were almost mandatory and that the actual call lengths were “vastly underestimated” before starting the program⁴³. This occurred despite substantial predischarge verbal and written instructions for patients, and these phone calls frequently involved questions outside the scope of regional anesthesia (i.e. questions related to the surgery itself). The cost comparison between single-shot liposomal bupivacaine and continuous infusion catheters is summarized in Table II.

TABLE II.

Cost Comparison Between Single-shot Liposomal Bupivacaine and Continuous Infusion Catheters

	Liposomal Bupivacaine	Continuous Catheter (0.2% Ropivacaine)
Medication cost	$376 (266 mg) or $228 (133 mg)	$260 (2 days/1500 cc)
Equipment cost	$12	$31
Physician procedure cost	$869	$1,345
Physician follow-up	N/A	$484
Phone call management	N/A	Difficult to estimate
Additional length of stay	N/A	Difficult to estimate

Considering the above discussion, even conservative estimates of $500 to $1,000 cost savings per patient for single-shot liposomal bupivacaine versus continuous infusion catheters approximate the magnitude of per-patient cost savings cited during early bundled payment transitions in select orthopaedic episodes of care⁶. However, it is important to note that for procedures billed under inpatient DRG bundles—such as THA/TKA—individual medication costs are not itemized, and thus, these savings would not directly influence cost competition. Nevertheless, in outpatient or ambulatory settings where itemized tracking is more applicable, liposomal bupivacaine may still yield meaningful cost reductions, particularly when accounting for potential decreases in length of stay and reduced postdischarge resource utilization.

Policy Implications

Both the American Academy of Orthopaedic Surgeons (AAOS) and the American Association of Hip and Knee Surgeons have proposed clinical practice guidelines (CPG) and appropriate use criteria related to perioperative pain management, including regional anesthesia, but none have yet offered guidance regarding encapsulated anesthetics. Other subspecialty societies for foot and ankle, sports, shoulder and elbow, and others generally rely on the guidance of the AAOS, but the latter's guidelines are often updated only every 5 to 7 years. The AAOS CPG for Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery (released in July 2021) does not mention liposomal bupivacaine, and the AAKHS CPG (released in February 2022) also does not mention it specifically, despite the large amount of studies and interest in its use^44,45.

The above value calculations could also substantially change if ongoing legislation regarding opioid reduction incentives continues to progress. In December 2022, as part of the Consolidated Appropriations Act of 2023, Congress signed the NOPAIN Act into law. This legislation was created to provide separate Medicare reimbursement at an average sales price of +6% for qualifying nonopioid perioperative treatments used in both ASCs and HOPDs⁴⁶. As stipulated by the legislation, nonopioids qualifying for separate reimbursement must “have demonstrated the ability to reduce or avoid intraoperative or postoperative opioid use or the quantity of opioids prescribed in a clinical trial or through data published in a peer-reviewed journal.” Liposomal bupivacaine is one of only 6 nonopioid medications qualifying for separate Medicare reimbursement, as documented in the CMS Proposed Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment System Rule for 2025, which was issued on July 10, 2024. CMS released more details in that preliminary rule regarding separate payment rates in the HOPD and ASC settings, including $1.46 per billing unit for liposomal bupivacaine. For billing units in milligram dosage, this would result in a $194.18 reimbursement for the 133 mg vial and a $388.36 reimbursement for the 266 mg vial, which would cover 85% and 103% of the cost noted above, respectively. This coverage substantially narrows the cost difference between encapsulated and unencapsulated bupivacaine for Medicare patients in HOPD and ambulatory settings, and private or commercial insurers are likely to follow suit as the patients they cover begin to demand it.

Conclusion

Increased attention to opioid dependence, a renewed focus on cost, and the continuous migration to ambulatory settings all require an evolution in perioperative care after orthopaedic surgery. In particular, a more sophisticated approach to pain control and opioid minimization is necessary. Policymakers are now beginning to understand this reality, with emerging legislation incentivizing the necessary perioperative evolution. While data remain mixed to positive overall with liposomal bupivacaine use in perioperative regional anesthesia for some common orthopaedic procedures, a clear economic case exists for its value over continuous infusion catheters after accounting for equipment, postprocedure monitoring requirements, and management of any catheter-associated complications after patient discharge. This value stands in contrast to common narratives contending liposomal bupivacaine to be more costly, which often narrowly consider raw medication costs alone. As surgeons bear more responsibility for the entire episode-of-care cost, understanding the full implications of each regional anesthesia option will become increasingly necessary.