Pain management after total hip arthroplasty (HA) is achallenge with « fast track surgery » programs: how can we provide the best analgesia and make our patients walk quickly after surgery?

Different techniques are available today for analgesia after HA, with many studies being published.

HA can be performed in emergency (old polypathologic patients) or as a scheduled surgery. The surgical approach can be anterior or postero-lateral: no differences have been found today between those 2 techniques in terms of orthopedic outcomes. Pain management is different between primary HA and HA reintervention. We will not speak about anesthesia and about hip fracture here.

Pain management after HA is highly related to the possibility to prescribe an efficient multimodal analgesia:

- for patients who have no contra-indications to paracetamol, NSAID, nefopam…: what is the place for local infiltration (LA) or regional anesthesia (RA)?

- for older patients who can not receive NSAIDs and present a high risk of morphin side-effects = what are the different RA and LA techniques today?

RA techniques The innervation of the hip depends on the lumbar plexus (femoral and obturator nerves) for the anterior surface, and the sacral plexus (sciatic nerve) for the posterior surface.

Sciatic Nerve Block: The risk of injury to the sciatic nerve during hip surgery is known and relatively common (1 to 3%): the realization of a sciatic nerve block should not be systematic, but reserved for patients with a favorable benefit/risk ratio.

Femoral Nerve Block: The block of the femoral nerve can not provide the whole analgesia of the hip (only anterior). Old studies showed that femoral nerve block was only providing a better analgesia than placebo in the first 4 hours.³ Most of those studies were retrospective and using ‘blind’ puncture or neurostimulation. More recent studies found that femoral nerve block was not better that infiltration for the 24 first hours, and even had more side effects.² Moreover, the motor blockade associatyed is a limitation to early deambulation for patients after HA.⁸

Fascia Iliaca Comportment Block (FICB): FICB provides is an analgesic option for HA. The evidence supporting FICB is still not well established. A recent meta analysis showed that FICB could be used to reduce pain up to 24 h, total morphine consumption, and length of hospital stay (but no difference was found after 24 hours).⁵ Nevertheless, a similar meta analysis showed that this superiority was probably shorter and limited to the 12 first postoperative hours.⁶ However, when compared with spinal analgesia, a recent study showed that it was less effective for the morphine consumption of the first 24 hours⁴ and no difference was found between FICB and femoral nerve block in a meta analysis.⁷

Lumbar Posterior Block (LBP): LBP used to be considered as a gold standard for HA, but its risks of neurological and hemorragic complications still remind.⁹ In a recent meta-analysis about all pain techniques after HA (including RA techniques, infiltration, IV morphine and NSAID), the authours found no differences between all techniques for analgesia after HA from H12 to H24. The only interesting differences found were a positive difference for the first 12 hours for spinal anesthesia patients, and for lumbar plexus block for the first 48 hours.¹ But, a study showed that it was as efficient as a femoral block,⁸ which is definitely a less dangerous RA technique.

Obturator Nerve Block: Although some teams associate it with femoral nerve block and have good results, a recent study showed that the obturator nerve block alone did not provide a significant reduction in postoperative opioid consumption versus placebo,¹³ although it did not reduce the ability to deambulate for the patients.

Lateral Femoral Cutaneous Nerve Block: It seems to moderately reduce pain scores after THA,¹⁴ but those trials did not include a systematic good multimodal analgesia. An other study confirmed that when this multimodal analgesia was provided, there was no added analgesic effect of a LFCN-block when combined with paracetamol and ibuprofen after THA by the posterior approach.¹⁵

Quadratus Lumborum Block (QLB): It was recently discovered in cadaveric studies, that injecting from transmuscular QLB can spread to the lumbar plexus. A recent study suggests that transmuscular QLB provides similar analgesia to LPB following HA for the first 24 hours.¹⁶ Many studies are nowadays published, showing its efficiency.²⁰

Three techniques of QLB have been described: the QLB 3 (performed between the lumbar square and the psoas muscle next to L4) seems to be appropriate and successfull for HA analgesia by some teams.^{17 18} We must however remain cautious about this recent technique, which requires to be studied in order to find a place in the therapeutic strategy.¹⁹

Pericapsular Nerve Group (Peng) Block: This technique was described in 2018²⁰ and is actually an ulttrasound guided infiltration realised by the anesthesiologist (not the surgeon) before the surgery starts. It seems to be efficient but no comparative study has been published yet.

Infiltrations Surgical infiltration involves injecting a large volume of products around the acetabulum, joint capsule and into adjacent muscles. The results on postoperative analgesia and morphine consumption are contrasted. We speak here about periarticular infiltration (PAI) and not wound infiltration, which does not reduce morphine consumption compared with placebo.²²

Surgical infiltration has been of great interest since 2008 and the description of the technique by Kerr,²³ with 3 injections of a total volume of 50 to 70 ml.

Many authors have since taken over and modified the technique, and the literature is wide and disparate.

Some meta-analyzes found a significant decrease in early postoperative pain at rest and mobilization as well as a decrease in morphine consumption; but this effect is no longer found after 24 hours²⁴ and is not clinically important (a few miligrams of morphine only).

Some papers showed that periarticular Infiltration (PAI) seems to be almost as efficient as posterior lombar plexus block¹¹ and femoral nerve block.^{2 25}

However, other meta-analyzes found no difference in efficacy on postoperative pain between infiltration and balanced multimodal analgesia.¹²

Conclusion

• Compared to systemic analgesia alone, there is moderate–quality evidence that peripheral nerve blocks reduce postoperative pain.¹⁰

• Local infiltration is as efficient as some RA techniques and allows the patient to deambulate.

• Good systemic multimodal analgesia (when no contra indications) seems to be as efficient as RA ou infiltration for a primary hip surgery.

• RA should be used for patients with CI to systemic analgesics and with complicated surgeries.

References

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2. Kuchálik J, Magnuson A, Lundin A, Gupta A. Local infiltration analgesia or femoral nerve block for postoperative pain management in patients undergoing total hip arthroplasty. A randomized, double-blind study.). Scand J Pain 2017 Jul;16:223–230.

3. Fournier R, Van Gessel E, Gaggero G, Boccovi S, Forster A, Gamulin Z. Postoperative analgesia with «3-in-1» femoral nerve block after prosthetic hip surgery. Can J Anaesth 1998;45:34–8

4. Kearns R, Macfarlane A, Grant A, Puxty K, Harrison P, Shaw M, Anderson K, Kinsella J. A randomised, controlled, double blind, non-inferiority trial of ultrasound-guided fascia iliaca block vs. spinal morphine for analgesia after primary hip arthroplasty. Anaesthesia 2016 Dec;71(12):1431–1440.

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