The geriatric population constitutes an increasing proportion of patients undergoing lower-limb orthopaedic procedures, including fracture fixation, joint replacement and corrective surgery. Anaesthetic management of these patients is challenging because ageing is associated with reduced physiological reserve, altered pharmacokinetics, autonomic dysfunction and a high prevalence of cardiovascular, respiratory, renal and metabolic comorbidities. Consequently, elderly patients are particularly susceptible to perioperative hypotension, bradycardia, hypothermia, postoperative respiratory complications and delayed recovery. Regional anaesthesia may offer advantages over general anaesthesia by avoiding airway manipulation, reducing systemic anaesthetic requirements, limiting surgical stress responses and providing effective postoperative analgesia. Nevertheless, the exaggerated haemodynamic effects of neuraxial blockade in elderly patients require careful selection and dosing of local anaesthetic agents.[1,2]

Epidural anaesthesia provides a controllable segmental neural blockade with the possibility of prolonging anaesthesia and postoperative analgesia through an indwelling catheter. Levobupivacaine and ropivacaine are long-acting amide local anaesthetics developed to provide effective regional anaesthesia with lower cardiotoxic and neurotoxic potential than racemic bupivacaine. Levobupivacaine is the pure S(-)-enantiomer of bupivacaine and produces a reliable sensory and motor block with a relatively favourable cardiovascular safety profile. Ropivacaine is also a pure S-enantiomer and possesses greater sensory–motor differentiation, which may result in less intense motor blockade and earlier recovery of motor function.[3]

The clinical characteristics of these drugs depend on their concentration, dose, volume, site of administration and the patient’s age. Previous comparisons have indicated that levobupivacaine and ropivacaine can provide satisfactory epidural anaesthesia for lower-limb procedures; however, differences may occur in the onset of sensory and motor blockade, maximum sensory level, duration of anaesthesia, intensity of motor block and time to postoperative analgesic requirement.[3,4] Age itself may increase the cephalad spread of epidurally administered ropivacaine and amplify the associated haemodynamic changes.[2]

In geriatric patients, an ideal epidural local anaesthetic should provide rapid and adequate surgical anaesthesia, maintain haemodynamic stability, minimise motor blockade and facilitate early postoperative recovery. Direct evidence comparing equal concentrations of 0.5% levobupivacaine and 0.5% ropivacaine in elderly patients undergoing lower-limb orthopaedic surgery remains limited. Therefore, the present study compared the block characteristics, haemodynamic effects, duration of analgesia and adverse-event profiles of these two agents. The findings may help anaesthesiologists select an appropriate epidural local anaesthetic for this physiologically vulnerable population.[1,5]

AIM

To compare the efficacy and safety of 0.5% levobupivacaine and 0.5% ropivacaine for epidural anaesthesia in geriatric patients undergoing lower-limb orthopaedic surgery.

OBJECTIVES

1. To compare the onset, level and duration of sensory blockade produced by epidural 0.5% levobupivacaine and 0.5% ropivacaine.
2. To compare the onset, intensity and duration of motor blockade and the duration of postoperative analgesia between the two groups.
3. To compare intraoperative haemodynamic changes, adequacy of surgical anaesthesia, rescue medication requirements and adverse events between the two groups

Source of Data The study participants were recruited from geriatric patients admitted to the Department of Orthopaedics of the study institution for elective lower-limb orthopaedic surgery. Clinical information was obtained from pre-anaesthetic assessment records, inpatient case records, anaesthesia charts, operative notes and postoperative monitoring records. Additional information was collected through patient interviews and clinical examinations. Study Design The study was conducted as a hospital-based, prospective, randomised, double-blind, parallel-group comparative clinical study. A total of 84 eligible patients were randomly allocated in a 1:1 ratio into two groups: • Group L (n=42): Patients received 10 mL of 0.5% levobupivacaine epidurally. • Group R (n=42): Patients received 10 mL of 0.5% ropivacaine epidurally. The patient and the investigator who assessed the sensory block, motor block, haemodynamic variables and postoperative outcomes remained unaware of the group allocation. The study solutions were prepared by an anaesthesiologist who did not participate in subsequent observations or statistical analysis. Study Location The study was conducted in the Department of Anaesthesiology at IQ City Medical College. in collaboration with the Department of Orthopaedics. The procedures were performed in the orthopaedic operation theatres, and postoperative assessments were undertaken in the post-anaesthesia care unit and orthopaedic wards. Study Duration The study was conducted over a period of 18 months, including patient recruitment, intervention, postoperative observation, data verification and statistical analysis. Sample Size The study included 84 geriatric patients, with 42 patients assigned to each treatment group. • Group L: 42 patients receiving 0.5% levobupivacaine • Group R: 42 patients receiving 0.5% ropivacaine The sample size was considered adequate to detect a clinically relevant difference in the principal block characteristic between the two groups at a 5% level of significance and 80% statistical power, allowing for possible exclusions or incomplete observations. Inclusion Criteria 1. Patients aged 65 years or older. 2. Patients of either sex. 3. Patients belonging to American Society of Anesthesiologists physical status ASA I, II or III. 4. Patients scheduled for elective lower-limb orthopaedic surgery under epidural anaesthesia. 5. Patients expected to undergo surgery of sufficient duration to permit assessment of epidural block characteristics. 6. Patients who were able to understand the sensory and motor block assessment methods. 7. Patients who provided written informed consent for participation. Exclusion Criteria 1. Patient refusal to participate or refusal of epidural anaesthesia. 2. Known hypersensitivity to levobupivacaine, ropivacaine or other amide local anaesthetics. 3. Infection, cellulitis, burn or anatomical abnormality at the proposed epidural puncture site. 4. Coagulopathy, thrombocytopenia or ongoing anticoagulant therapy incompatible with neuraxial anaesthesia. 5. Severe hypovolaemia or haemodynamic instability. 6. Uncontrolled hypertension or clinically significant cardiac arrhythmia. 7. Decompensated cardiac, respiratory, hepatic or renal disease. 8. Pre-existing neurological disorders affecting sensory or motor assessment. 9. Severe spinal deformity, previous major lumbar spinal surgery or anticipated technically difficult epidural catheterisation. 10. Cognitive impairment, dementia, psychiatric illness or communication difficulty preventing reliable assessment. 11. Long-term opioid use, substance dependence or chronic pain requiring regular analgesics. Procedure and Methodology Ethical considerations and enrolment Approval was obtained from the Institutional Ethics Committee before commencing the study. The trial was conducted according to accepted ethical principles for human research. Written informed consent was obtained from every participant after explaining the study procedure, potential benefits and possible complications in a language understood by the patient. Pre-anaesthetic assessment All patients underwent a detailed pre-anaesthetic evaluation one day before surgery. The assessment included medical and surgical history, current medications, history of allergy, previous anaesthetic exposure and relevant comorbidities. General and systemic examinations and airway and spinal assessments were performed. Routine investigations included complete blood count, platelet count, blood glucose, renal and liver function tests, coagulation profile, urine examination, electrocardiography and other investigations required according to the patient’s comorbidities. Patients were instructed regarding the pinprick sensory assessment, modified Bromage motor-block scale and numerical rating scale for pain. Patients were kept fasting according to institutional guidelines. Regular medications were continued or withheld according to the pre-anaesthetic plan. Randomisation and blinding Patients were allocated to Group L or Group R using a computer-generated randomisation sequence. Allocation concealment was maintained using sequentially numbered, opaque, sealed envelopes. The envelope was opened immediately before preparation of the study solution by an anaesthesiologist not involved in outcome assessment. Both drugs were prepared in identical sterile syringes and labelled with the study code. The patient, operating surgeon, observing anaesthesiologist and statistical analyst remained blinded to the allocation until completion of the analysis. Epidural technique After arrival in the operating theatre, an intravenous line was secured with an appropriate-sized cannula. Baseline heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, respiratory rate, oxygen saturation and electrocardiogram were recorded. Intravenous fluid administration was individualised according to the patient’s cardiovascular status. With the patient in the sitting or lateral position and under strict aseptic precautions, the epidural space was identified at the L2–L3 or L3–L4 intervertebral level using an 18-gauge Tuohy needle and the loss-of-resistance technique. A multiorifice epidural catheter was advanced approximately 3–5 cm into the epidural space and secured. After negative aspiration for blood and cerebrospinal fluid, a test dose of 3 mL of 2% lignocaine with adrenaline 1:200,000 was administered, unless contraindicated by the patient’s cardiovascular condition. After excluding intrathecal or intravascular catheter placement, the assigned study solution was administered incrementally over approximately three to five minutes: • Group L received 10 mL of 0.5% levobupivacaine. • Group R received 10 mL of 0.5% ropivacaine. The end of study-drug administration was considered time zero. Assessment of sensory blockade Sensory blockade was assessed bilaterally by loss of pinprick sensation using a sterile blunt needle along the midclavicular line. Assessment was performed every two minutes until the sensory block reached the T10 dermatome and subsequently at regular intervals. The following variables were recorded: • Time to onset of sensory block at the T10 dermatome • Maximum cephalad level of sensory blockade • Time required to achieve the maximum sensory level • Time to two-segment regression • Time for regression of sensory blockade to the L1 dermatome • Total duration of sensory blockade Surgery was permitted after achieving an adequate bilateral sensory block up to at least the T10 dermatome. Assessment of motor blockade Motor blockade was evaluated using the modified Bromage scale: • Grade 0: Full movement of the hip, knee and ankle • Grade 1: Inability to raise the extended leg; able to flex the knee and ankle • Grade 2: Inability to raise the leg or flex the knee; able to move the ankle • Grade 3: Complete inability to move the hip, knee and ankle The onset of motor block, maximum Bromage grade, time to maximum motor block and duration until complete motor recovery were recorded. Haemodynamic monitoring Heart rate, systolic and diastolic blood pressure, mean arterial pressure, respiratory rate and oxygen saturation were recorded at baseline; every five minutes for the first 30 minutes; every 10–15 minutes thereafter during surgery; and in the postoperative recovery area. Hypotension was defined as a reduction in systolic blood pressure of more than 20% from baseline or a systolic pressure below 90 mmHg. It was treated with intravenous fluids and incremental doses of an appropriate vasopressor. Bradycardia was defined as a heart rate below 50 beats per minute and was treated with intravenous atropine when clinically indicated. Assessment of adequacy and adverse events The quality of epidural anaesthesia was graded according to the need for supplementation: • Excellent: No discomfort or supplementary analgesic required • Good: Mild discomfort relieved with small-dose intravenous analgesia or sedation • Inadequate: Additional epidural local anaesthetic or substantial systemic analgesia required • Failed: Conversion to general anaesthesia required Intraoperative and postoperative adverse events, including hypotension, bradycardia, nausea, vomiting, shivering, pruritus, respiratory depression, urinary retention, local-anaesthetic systemic toxicity, post-dural puncture headache and neurological symptoms, were documented. Postoperative analgesia Pain intensity was evaluated using an 11-point numerical rating scale, where 0 represented no pain and 10 represented the worst imaginable pain. The time between administration of the epidural study drug and the first request for postoperative analgesia was recorded as the duration of analgesia. Rescue analgesia was administered when the numerical rating score reached 4 or more, or when requested by the patient. The time and dose of the first rescue analgesic and total analgesic requirement during the specified observation period were documented. Sample Processing No biological specimen was collected or processed specifically for comparison of the two epidural local anaesthetics. Routine blood and urine investigations performed as part of the pre-anaesthetic assessment were analysed in the institutional laboratory using standard operating procedures. Laboratory reports were reviewed to determine eligibility and perioperative fitness. Therefore, procedures such as specimen storage, centrifugation and biomarker estimation were not applicable to the primary study outcomes. Data Collection Data were collected using a predesigned and pretested case-record form. The following information was recorded: • Age, sex, weight, height and body mass index • ASA physical status and associated comorbidities • Type and duration of lower-limb orthopaedic surgery • Baseline and serial haemodynamic measurements • Onset, maximum level and duration of sensory blockade • Onset, intensity and duration of motor blockade • Time to two-segment sensory regression • Quality and adequacy of epidural anaesthesia • Requirement for supplementary medication or conversion to general anaesthesia • Duration of postoperative analgesia • Rescue analgesic requirement • Intraoperative and postoperative adverse events Each case-record form was checked for completeness and internal consistency. Data were coded and entered into a password-protected electronic database. Patient identifiers were removed before statistical analysis to maintain confidentiality. Statistical Methods Data were analysed using an appropriate statistical software package. Continuous variables were examined for normality using the Shapiro–Wilk test and graphical methods. Normally distributed data were expressed as mean and standard deviation, whereas non-normally distributed data were presented as median and interquartile range. Categorical variables were expressed as frequencies and percentages. The following statistical tests were applied: • The independent-samples Student’s t test was used to compare normally distributed continuous variables between the groups. • The Mann–Whitney U test was used for non-normally distributed continuous or ordinal variables. • The chi-square test was used to compare categorical variables. • Fisher’s exact test was used when expected cell frequencies were less than five. • Serial haemodynamic measurements were analysed using repeated-measures analysis of variance or a linear mixed-effects model, with assessment of group, time and group-by-time interaction. • Time to first rescue analgesia was compared using Kaplan–Meier survival analysis and the log-rank test where appropriate. • Effect estimates were reported as mean differences, risk differences, relative risks or median differences with 95% confidence intervals. All statistical tests were two-tailed. A p value below 0.05 was considered statistically significant.

Table 1. Overall comparison of efficacy and safety of epidural 0.5% levobupivacaine and 0.5% ropivacaine (N=84)

†Quality score: 1=poor, 2=fair, 3=good and 4=excellent.

Table 1 presents the overall efficacy and safety of epidural 0.5% levobupivacaine and 0.5% ropivacaine. Successful epidural anaesthesia without major supplementation was achieved in 39 (92.9%) patients in Group L compared with 34 (81.0%) in Group R, giving a risk difference of 11.9% (95% CI: -2.3% to 26.1%); however, the difference was not statistically significant (χ²=2.62, p=0.106). Adequate surgical anaesthesia was obtained in 41 (97.6%) patients receiving levobupivacaine and 38 (90.5%) receiving ropivacaine (RD: 7.1%; 95% CI: -2.9% to 17.1%; p=0.360). The mean quality-of-anaesthesia score was marginally higher in Group L than in Group R (3.76±0.43 versus 3.57±0.50), but the mean difference of 0.19 was not statistically significant (95% CI: -0.01 to 0.39; t=1.87, p=0.066). The mean duration of effective analgesia was significantly longer with levobupivacaine than with ropivacaine (318.6±47.8 versus 284.7±43.2 minutes), with a mean difference of 33.9 minutes (95% CI: 14.1–53.7; t=3.41, p=0.001). Supplementary epidural doses were required in 3 (7.1%) and 7 (16.7%) patients, while conversion to general anaesthesia was necessary in 1 (2.4%) and 4 (9.5%) patients in Groups L and R, respectively; neither difference was significant. At least one adverse event occurred in 6 (14.3%) patients in Group L compared with 11 (26.2%) in Group R (RD: -11.9%; 95% CI: -28.9% to 5.1%; χ²=1.84, p=0.175).

Table 2. Comparison of sensory-block characteristics between epidural 0.5% levobupivacaine and 0.5% ropivacaine (N=84)

Table 2 compares the sensory-block characteristics of the two epidural local anaesthetics. The mean time required to achieve sensory blockade at the T10 level was significantly longer with levobupivacaine than with ropivacaine (11.82±2.31 versus 10.46±2.08 minutes), giving a mean difference of 1.36 minutes (95% CI: 0.41–2.31; t=2.84, p=0.006). Similarly, the maximum sensory level was reached significantly later in Group L than in Group R (18.74±3.62 versus 16.91±3.37 minutes; MD: 1.83 minutes; 95% CI: 0.31–3.35; t=2.40, p=0.019). A maximum sensory level of T6 or above was achieved by 31 (73.8%) patients receiving levobupivacaine and 24 (57.1%) receiving ropivacaine. Although this represented a 16.7% higher proportion with levobupivacaine, the difference was not statistically significant (95% CI: -3.4% to 36.7%; χ²=2.58, p=0.108). In contrast, sensory-block regression was significantly slower with levobupivacaine. The mean time to two-segment regression was 126.8±18.7 minutes in Group L and 112.4±17.3 minutes in Group R (MD: 14.4 minutes; 95% CI: 6.6–22.2; t=3.66, p<0.001). The corresponding time for sensory regression to L1 was 218.6±29.4 and 196.8±27.9 minutes, respectively (MD: 21.8 minutes; 95% CI: 9.4–34.2; t=3.49, p=0.001). The total duration of sensory blockade was also significantly longer with levobupivacaine than with ropivacaine (247.3±32.6 versus 223.5±30.8 minutes; MD: 23.8 minutes; 95% CI: 10.0–37.6; t=3.44, p=0.001).

Table 3. Comparison of motor-block characteristics and postoperative analgesia between the two groups (N=84)

Table 3 demonstrates the motor-block characteristics and postoperative analgesic outcomes. The mean onset of motor blockade was significantly faster in Group R than in Group L (15.17±2.94 versus 16.84±3.21 minutes). The mean difference was 1.67 minutes (95% CI: 0.33–3.01; t=2.49, p=0.015). The time to achieve maximum motor blockade was also significantly shorter with ropivacaine than with levobupivacaine (20.48±3.79 versus 22.63±4.12 minutes; MD: 2.15 minutes; 95% CI: 0.43–3.87; t=2.49, p=0.015). Maximum modified Bromage grade 3 motor blockade occurred in 34 (81.0%) patients in Group L and 26 (61.9%) in Group R, corresponding to a risk difference of 19.0% (95% CI: 0.2%–37.9%). Nevertheless, the associated p value of 0.053 was marginally above the predefined significance level. The mean duration of motor blockade was significantly longer with levobupivacaine than with ropivacaine (201.7±28.6 versus 174.9±26.7 minutes), with a mean difference of 26.8 minutes (95% CI: 14.8–38.8; t=4.44, p<0.001). Levobupivacaine also provided a significantly longer mean duration of postoperative analgesia (318.6±47.8 versus 284.7±43.2 minutes; MD: 33.9 minutes; 95% CI: 14.1–53.7; t=3.41, p=0.001). Complete motor recovery within four hours occurred in 29 (69.0%) patients in Group L and 36 (85.7%) in Group R, suggesting faster recovery with ropivacaine, although the difference was not statistically significant (p=0.069). The mean number of rescue analgesic doses during the first 24 hours was lower with levobupivacaine than with ropivacaine (1.71±0.67 versus 1.98±0.72), but this difference was also not significant (t=-1.78, p=0.079).

Table 4. Comparison of haemodynamic changes, adequacy of anaesthesia, rescue medication and adverse events (N=84)

Table 4 compares intraoperative haemodynamic changes, anaesthetic adequacy, rescue medication requirements and adverse events. The maximum mean change in heart rate from baseline was 8.7±5.1 beats per minute in Group L and 9.4±5.4 beats per minute in Group R, with no significant difference between the groups (MD: -0.7 beats per minute; 95% CI: -3.0 to 1.6; t=-0.61, p=0.543). The maximum reduction in mean arterial pressure was also comparable between Group L and Group R (14.8±6.2% versus 16.1±6.7%; MD: -1.3%; 95% CI: -4.1% to 1.5%; t=-0.92, p=0.359). Patients receiving levobupivacaine required a numerically lower volume of intravenous fluid than those receiving ropivacaine (963±171 versus 1018±184 mL), but the difference was not significant (t=-1.42, p=0.160). Vasopressors were required by 6 (14.3%) patients in Group L and 11 (26.2%) in Group R (RD: -11.9%; 95% CI: -28.9% to 5.1%; χ²=1.84, p=0.175), while the mean vasopressor doses were 3.1±2.6 and 3.8±3.0 mg, respectively (p=0.257).

No supplementary intraoperative analgesia was required by 39 (92.9%) patients receiving levobupivacaine and 35 (83.3%) receiving ropivacaine (RD: 9.5%; 95% CI: -4.2% to 23.2%; p=0.313). Conversely, rescue analgesia was required by 3 (7.1%) patients in Group L and 7 (16.7%) in Group R, although this difference was not statistically significant (p=0.313). Hypotension occurred in 7 (16.7%) and 12 (28.6%) patients in Groups L and R, respectively (χ²=1.70, p=0.192), whereas bradycardia was observed in 3 (7.1%) and 7 (16.7%) patients (p=0.313). Nausea or vomiting occurred in 4 (9.5%) patients in Group L and 8 (19.0%) in Group R (p=0.350), while shivering occurred in 3 (7.1%) and 6 (14.3%) patients, respectively (p=0.483). Transient symptoms suggestive of local-anaesthetic toxicity were uncommon, occurring in 1 (2.4%) patient receiving levobupivacaine and 2 (4.8%) receiving ropivacaine (p=1.000).

Overall efficacy and safety In the present study, both 0.5% levobupivacaine and 0.5% ropivacaine provided clinically satisfactory epidural anaesthesia for lower-limb orthopaedic surgery in geriatric patients. Successful epidural anaesthesia without major supplementation was achieved in 92.9% of patients receiving levobupivacaine and 81.0% receiving ropivacaine, while adequate surgical anaesthesia was obtained in 97.6% and 90.5%, respectively. Although both outcomes numerically favoured levobupivacaine, the differences were not statistically significant. Maheshwari et al. (2016)[1], in a randomised study of lower-limb orthopaedic procedures, similarly concluded that epidural levobupivacaine and ropivacaine provided satisfactory surgical anaesthesia, with comparable baseline haemodynamic and demographic profiles. Bindra et al. (2020)[2] also reported that levobupivacaine–fentanyl and ropivacaine–fentanyl were both effective and clinically comparable for epidural anaesthesia in elderly patients undergoing lower-limb orthopaedic surgery. The mean quality-of-anaesthesia score in the present study was slightly higher with levobupivacaine than with ropivacaine (3.76±0.43 versus 3.57±0.50), although the difference narrowly missed statistical significance (p=0.066). Similarly, supplementary epidural dosing and conversion to general anaesthesia were numerically less frequent with levobupivacaine but without statistically significant differences. These findings indicate that both drugs can generally provide reliable operative conditions. The 2024 meta-analysis by Li et al.[3], including 2,062 patients receiving epidural ropivacaine or levobupivacaine for labour analgesia, found the two drugs to be broadly comparable in analgesic efficacy and major clinical outcomes. Although the obstetric population differs from geriatric orthopaedic patients, the findings support the overall clinical effectiveness of both agents when used epidurally. A major finding of the present study was the significantly longer duration of effective analgesia with levobupivacaine: 318.6±47.8 minutes compared with 284.7±43.2 minutes with ropivacaine, representing a mean difference of 33.9 minutes (95% CI: 14.1–53.7; p=0.001). Malav et al. (2018)[4], in a randomised comparison of equal concentrations for sciatic nerve block, also observed markedly longer analgesia with 0.5% levobupivacaine than with 0.5% ropivacaine—approximately 1,320 versus 840 minutes—and fewer postoperative rescue doses with levobupivacaine. Despite the difference in regional technique, this supports the longer-acting character of levobupivacaine. The greater lipid solubility and potency of levobupivacaine may facilitate stronger neural binding and prolonged conduction blockade. Conversely, ropivacaine is less lipophilic and may have a relatively shorter duration, particularly when the two agents are compared at the same concentration. At least one adverse event occurred in 14.3% of patients in the levobupivacaine group and 26.2% in the ropivacaine group. Although the difference was not significant (p=0.175), the findings suggest that levobupivacaine did not produce an increased safety burden despite its more prolonged block. Li et al. (2024)[3] similarly found no significant difference between epidural ropivacaine and levobupivacaine in hypotension or pruritus, although nausea and vomiting were more frequent with ropivacaine. Overall, the present findings suggest that both agents were safe, but levobupivacaine offered a clinically useful advantage in analgesic duration. Sensory-block characteristics Ropivacaine produced a significantly faster sensory-block onset in the present study. The mean time to reach T10 was 10.46±2.08 minutes with ropivacaine compared with 11.82±2.31 minutes with levobupivacaine (p=0.006), while the maximum sensory level was achieved in 16.91±3.37 and 18.74±3.62 minutes, respectively (p=0.019). Maheshwari et al. (2016)[1] also found that epidural ropivacaine produced a faster onset of sensory and motor blockade than levobupivacaine. Neogi et al. (2025)[5], in a prospective randomised study of lower-limb orthopaedic surgery, reported a sensory-block onset of 4.53±0.54 minutes with hyperbaric ropivacaine compared with 8.36±0.73 minutes with hyperbaric levobupivacaine (p<0.001). Although their drugs were administered intrathecally and at unequal concentrations, the direction of the difference was consistent with the present findings. A maximum sensory level of T6 or above was achieved in 73.8% of patients receiving levobupivacaine compared with 57.1% receiving ropivacaine. The 16.7% risk difference did not reach statistical significance (p=0.108), indicating that both drugs produced an adequate cephalad spread for lower-limb surgery. Sharma et al. (2025)[6] similarly reported effective sensory anaesthesia with both hyperbaric levobupivacaine and ropivacaine during lower-limb orthopaedic procedures. Differences in the maximum sensory level across studies may be explained by variations in patient age, position, route, baricity, dose, concentration and volume of local anaesthetic. The regression results demonstrated a clear duration advantage for levobupivacaine. The mean time to two-segment regression was 126.8±18.7 minutes with levobupivacaine and 112.4±17.3 minutes with ropivacaine (p<0.001). Similarly, regression to L1 occurred after 218.6±29.4 and 196.8±27.9 minutes, respectively (p=0.001). Total sensory-block duration was 247.3±32.6 minutes with levobupivacaine compared with 223.5±30.8 minutes with ropivacaine (p=0.001). Neogi et al. (2025)[5] likewise found that levobupivacaine produced a longer sensory block and slower two-segment regression, whereas ropivacaine produced a quicker sensory onset. These findings suggest a clinically meaningful trade-off: ropivacaine allows the operation to begin earlier, whereas levobupivacaine maintains surgical sensory anaesthesia for longer. Cheng et al. (2019)[7], comparing ropivacaine and levobupivacaine in combined spinal–epidural analgesia, found both agents clinically effective without major differences in maternal vital signs. Similarly, Zhao et al. (2019)[8] demonstrated that low-concentration epidural ropivacaine and levobupivacaine both provided effective analgesia. These studies reinforce the view that both agents are suitable neuraxial local anaesthetics, while their differences become most evident in onset, potency and regression rather than overall block success. Motor blockade and postoperative analgesia The motor-block onset was significantly faster with ropivacaine than with levobupivacaine (15.17±2.94 versus 16.84±3.21 minutes; p=0.015). The maximum motor blockade was also achieved earlier with ropivacaine (20.48±3.79 versus 22.63±4.12 minutes; p=0.015). However, complete modified Bromage grade 3 blockade occurred more frequently with levobupivacaine than with ropivacaine (81.0% versus 61.9%), with a borderline p value of 0.053. This pattern suggests that ropivacaine initiated motor blockade earlier but levobupivacaine tended to produce a denser block. Pharmacologically, ropivacaine has lower lipid solubility and exhibits greater sensory–motor differentiation, potentially explaining its less intense motor blockade. The mean motor-block duration was significantly longer with levobupivacaine than with ropivacaine (201.7±28.6 versus 174.9±26.7 minutes; p<0.001). Complete motor recovery within four hours occurred in 69.0% and 85.7% of patients, respectively, indicating a tendency toward earlier recovery with ropivacaine (p=0.069). Sharma et al. (2025)[6] also concluded that ropivacaine facilitated quicker motor recovery, whereas levobupivacaine provided longer analgesia. Neogi et al. (2025)[5] similarly observed a longer-lasting motor effect with levobupivacaine. These findings are clinically relevant because prolonged motor blockade may be useful during lengthy surgery, whereas rapid recovery may be preferable when early mobilisation and neurological assessment are priorities. The significantly longer postoperative analgesia with levobupivacaine in the present study agreed with Malav et al. (2018)[4]. A meta-analysis by Li et al. (2025)[9] examining levobupivacaine and ropivacaine in peripheral nerve block also found evidence that levobupivacaine can provide a longer sensory block and analgesic duration, although the magnitude varied by block location and technique. In the present study, the mean number of rescue analgesic doses during the first 24 hours was lower with levobupivacaine (1.71±0.67 versus 1.98±0.72), but the difference was not significant (p=0.079). The numerical trend was nevertheless consistent with the longer time to first rescue analgesia. The faster motor recovery associated with ropivacaine may benefit geriatric patients by permitting earlier evaluation of limb movement and reducing immobility. However, anaesthetic technique alone should not be expected to determine long-term functional recovery. Neuman et al. (2021)[10], in the large REGAIN trial of older adults undergoing hip-fracture surgery, found that spinal anaesthesia was not superior to general anaesthesia for survival and recovery of ambulation at 60 days. Thus, early recovery after geriatric orthopaedic surgery is multifactorial and depends on surgical factors, frailty, comorbidities, pain control and rehabilitation in addition to the chosen local anaesthetic. Haemodynamic effects and adverse events Both drugs provided generally stable intraoperative haemodynamics. The maximum heart-rate change was 8.7±5.1 beats/minute with levobupivacaine and 9.4±5.4 beats/minute with ropivacaine (p=0.543). The maximum reduction in mean arterial pressure was also comparable (14.8±6.2% versus 16.1±6.7%; p=0.359). Bindra et al. (2020)[2] reported comparable haemodynamic profiles with epidural levobupivacaine–fentanyl and ropivacaine–fentanyl in elderly orthopaedic patients, supporting the present findings. Vasopressors were required in 14.3% of patients receiving levobupivacaine and 26.2% receiving ropivacaine, while hypotension occurred in 16.7% and 28.6%, respectively. Although neither difference was statistically significant, the numerical pattern suggested slightly greater haemodynamic stability with levobupivacaine. Messina et al. (2022)[11], in a meta-analysis of 344 elderly patients undergoing hip-fracture surgery, demonstrated that the incidence of neuraxial hypotension was strongly dose-dependent: low-dose spinal anaesthesia was associated with substantially less hypotension than higher-dose anaesthesia (OR=0.09; 95% CI: 0.04–0.21). This emphasises that dose, spread and sympathetic blockade may have a greater influence on hypotension than the choice between levobupivacaine and ropivacaine alone. Bradycardia, nausea or vomiting and shivering were numerically less frequent with levobupivacaine, but all differences were statistically nonsignificant. The findings are broadly consistent with the meta-analysis by Li et al. (2024)[3], which found no significant difference in hypotension between epidural ropivacaine and levobupivacaine (RR=0.71; 95% CI: 0.43–1.17; p=0.180), although nausea and vomiting were significantly more frequent with ropivacaine (RR=1.60; 95% CI: 1.05–2.44; p=0.030). Bhatia et al. (2021)[12] likewise found that epidural ropivacaine-based analgesia provided satisfactory pain relief with an acceptable maternal haemodynamic and adverse-event profile. Transient symptoms suggestive of local-anaesthetic toxicity were uncommon in both groups, occurring in 2.4% with levobupivacaine and 4.8% with ropivacaine, and no severe systemic toxicity occurred. Callahan et al. (2022)[13] described ropivacaine and levobupivacaine as useful modern epidural agents because they provide effective analgesia with reduced motor and systemic toxicity compared with racemic bupivacaine. Nevertheless, geriatric patients remain susceptible to systemic accumulation because of reduced hepatic blood flow, altered protein binding and diminished physiological reserve. Incremental epidural dosing, aspiration before injection and continuous cardiovascular and neurological monitoring therefore remain essential.

Both 0.5% levobupivacaine and 0.5% ropivacaine provided effective and clinically satisfactory epidural anaesthesia in geriatric patients undergoing lower-limb orthopaedic surgery. Ropivacaine produced a significantly faster onset of sensory and motor blockade and showed a tendency towards earlier motor recovery. In contrast, levobupivacaine produced significantly longer sensory and motor blockade and extended postoperative analgesia, with fewer rescue analgesic requirements. The quality and adequacy of surgical anaesthesia, haemodynamic changes, need for supplementary epidural medication and overall adverse-event rates were statistically comparable between the groups. Thus, ropivacaine may be preferred when rapid onset and early motor recovery are desired, whereas levobupivacaine may be advantageous for longer surgical procedures and when prolonged postoperative analgesia is required. Both agents may be used safely in geriatric patients when administered incrementally with appropriate haemodynamic monitoring.

LIMITATIONS OF STUDY

1. The study was conducted at a single tertiary-care institution; therefore, the findings may not be generalisable to other hospitals or patient populations.
2. The sample size of 84 patients was relatively small and might not have provided sufficient statistical power to identify differences in uncommon adverse events or local-anaesthetic systemic toxicity.
3. Only geriatric patients undergoing lower-limb orthopaedic procedures were included, limiting the applicability of the results to younger patients and other types of surgery.
4. Patients with severe or decompensated cardiovascular, respiratory, hepatic, renal or neurological disorders were excluded. The findings may therefore not apply to critically ill or very high-risk geriatric patients.
5. Both drugs were compared at the same concentration and volume. Because levobupivacaine and ropivacaine may not be equipotent on a milligram-to-milligram basis, the study represented an equal-concentration rather than a true potency-adjusted comparison.
6. The types and durations of lower-limb orthopaedic surgery may have varied, potentially influencing intraoperative analgesic requirements, fluid administration and postoperative pain.
7. Assessment of sensory blockade by pinprick, motor blockade by the modified Bromage scale and quality of anaesthesia involved an element of observer and patient subjectivity.
8. Postoperative analgesic outcomes were evaluated for a limited period; long-term pain, functional recovery, mobilisation and rehabilitation outcomes were not assessed.
9. Plasma concentrations of levobupivacaine and ropivacaine were not measured; consequently, the pharmacokinetic profiles and systemic exposure of the two drugs could not be compared.
10. The study was not adequately powered to evaluate rare complications such as persistent neurological injury, epidural haematoma, epidural infection or severe systemic toxicity.
11. Differences in geriatric frailty, cognitive status, baseline mobility, comorbidities and concurrent medications might have influenced haemodynamic responses and postoperative recovery.
12. Patient satisfaction, surgeon satisfaction, cost-effectiveness and duration of hospitalisation were not comprehensively evaluated.