WEBVTT - Ankle Fx Dr. Munz Full Surgical video and 
Interview

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My name is John Munz, I'm 
Orthopedic Trauma surgeon here at

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McGovern medical school, I am
here with a part of UT Health.

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So, I first got started, actually from 
other colleagues in other disciplines

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in the plastic surgery in general 
surgery divisions and after hearing

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their successes with the product 
I was interested in trying this.

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And I first started out in trauma, in 
patients that I previously would have

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blocked with our anesthesia team, 
but now I'm able to do something 

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myself as part of a multimodal 
pathway. 

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Initially I would describe my 
EXPAREL experiences initially one 

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of intrigue, in that when I first 
started using the medication, I was 

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very excited about the potential
72-hour illusion of medication.

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I think it's been a learning endeavor
and that trying to hone my technique 

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of the actual infiltration. So, I'm very
pleased with the experience 

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and the journey, but for sure they're 
still learning to do. 

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The biggest change is how you use 
EXPAREL, in regard to your 

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anesthesia team. In that, if you just 
rely upon blocks and regional 

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anesthesia, how to incorporate 
EXPAREL with those other pathways. 

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What has changed and I my practice 
is I would use EXPAREL and not 

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expand it and still use a popliteal 
block, but now I started using it on 

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its own with bupivacaine and then 
now not rely upon the block. 

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Another change of my practice is 
previously our anesthesia partners 

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would use the On-Q pumps and 
send patients home with that. 

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I found now that I can just use 
EXPAREL, and it completely 

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obviates the need for On-Q pump. 

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So I think the biggest issue in regard to
learning how to use EXPAREL is the technique. 

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It's not just the medication that you 
can sprinkle into a wound I think the 

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actual administration technique of how
you infiltrate the tissues is very important. 

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In regards to how you do that, unlike 
plain bupivacaine, EXPAREL does 

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not diffuse to the tissues, so where 
are you place that medication that's 

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where it stays, so this takes many 
more injections. 

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So, in regard to volumes, I tend to 
use 20 cc's of EXPAREL and then 

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depending upon the size of the 
wound and depth and the structures 

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I'm targeting I will expand that, 
usually with .25% bupivacaine. 

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In regards to the structures that are 
targeted, I like to in fracture 

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surgery, infiltrate the periosteum if I 
can, the surrounding 

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musculotendinous units and then 
subcutaneous tissues and skin

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as I close the wound.

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This particular patient was a 36 
year-old female and initially 

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presented at 9 days prior with an 
ankle fracture dislocation,

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she was initially placed into an external
fixator and once the soft tissues were 

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optimized, she was brought back for 
a delayed open reduction internal 

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fixation of her right tirailleur ankle 
fracture dislocation. 

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For procedural details, the initial part 
of the procedure was a

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prone posterolateral 15 cm approach. 

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This was followed by a supine 7 cm 
medial approach for the medial component. 

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During this particular operation, 35 
mL of medication was infiltrated. 

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This was 20 mL of EXPAREL 
expanded with 15 mL of .25% 

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bupivacaine, for total of 35 mL using two
20 cc syringes and two 23-gauge needles. 

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After the completion of the open 
reduction internal fixation of the 

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postural malleolar and lateral 
malleolar components through this 

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posterolateral wound, the medication was
infiltrated using a moving needle technique. 

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This is particularly important to use 
this technique to spread the 

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medication in a fan like pattern to 
make sure you have a maximal 

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coverage area. 

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I tend to start a deep to superficial in 
a clockwise or counterclockwise

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fashion to make sure that you 
infiltrate the deeper layers, 

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more intermediate layers and finally
the more superficial layers, 

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covering all important structures 
as you're infiltrating. 

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I tend to use 1 to 2 mL of medication 
every 1 to 1.5 cm in the deeper 

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layers including the periosteum, the 
muscular layers and the dermal 

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layers followed by of the 
subcutaneous layers. 

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The important part here is to use the 
moving needle technique to make 

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sure that you cover all particular aspects
of your wound for maximal pain control. 

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After completion of this the 
infiltration at the posterior lateral 

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wound, this wound was closed, the 
patient was then repositioned,

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re-prepped and draped and a supine 
a medial approach was performed. 

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After completing fixation of the 
medial malleolus component,

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the medial incision 7 cm was then 
infiltrated in a similar technique 

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using a moving needle technique 
with 15 mL of expanded medication 

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in this systematic fashion.

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The biggest barrier at my current 
institution is the interaction with anesthesia. 

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I think just engaging them and 
having certain patient populations 

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populations that you typically would 
not block and using EXPAREL in those

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and being coordinated in our efforts. 
I look at a success with EXPAREL 

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and that any of these multimodal 
pathways, is if we can give less 

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narcotic medication, less opioids or 
a lower dose and less quantity,

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I think that's a win. 

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I think we have an obligation as 
physicians to try to minimize our use 

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of opioids and what I found is that 
I'm prescribing less,

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I'm prescribing smaller doses 
and less quantity. 

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When I first heard that one in 14 or 
up to 7% of patients who are 

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exposed to opioids go on to long-term
addiction that was an eye-opener. 

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And I think just that fact and knowing 
the number of surgeries I do every 

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year and thinking of potentially how 
many patients I exposed to this, 

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that's what caused me concern.