Rikshospitalet – Oslo University Hospital
Hip surgery involves different interventions, such as total hip replacement, hemiarthroplasty, or hip fracture surgery with metal plates or screws. Several of these procedures are associated with severe postoperative pain. Adequate pain therapy facilitates functional recovery and early mobilisation. For total hip arthroplasty a multimodal therapy including non-opioid analgesics, alpha-2 agonists, and regional anaesthesia techniques is recommended to improve postoperative analgesia.1 Peripheral nerve blocks have been shown to improve pain levels and reduce morphine consumption after hip surgery.2
Innervation to the hip joint comes from the lumbar plexus, formed by the divisions of the first four lumbar nerves (L1 – L4), and the sacral plexus arising from the lumbosacral trunk (L4- L5) and the sacral spinal nerves (S1 – S4). The hip capsule is innervated by proximal branches of the femoral nerve, obturator nerve, the accessory obturator nerve (all three from lumbar plexus), the nerve to quadratus femoris, and the sciatic nerve (both from sacral plexus).3
Centro-axial techniques provide anaesthesia and analgesia for all types of hip surgery. For elderly patients, spinal or epidural are often considered a safe alternative to general anaesthesia. However, in a recent multi-centre study, spinal anaesthesia was not superior to general anaesthesia with respect to survival and recovery of ambulation at 60 days in older adults undergoing hip-fracture surgery.4 For postoperative pain treatment epidural analgesia is no longer recommended for hip surgery since the adverse effects, like urinary retention and motor block, outweigh the benefits.1 The same reservations apply for the proximal block techniques of the lumbar plexus and the sacral plexus. A lumbar plexus block might still be considered in hip revision surgery and in patients where high postoperative pain level is anticipated.5
Femoral nerve blocks and fascia iliaca compartment blocks are frequently used for pain treatment after hip-fracture surgery and arthroplasty.6 7 Compared with a lumbar plexus block, analgesia or anaesthesia will be less complete with these distal block techniques. Yet, distal and superficial block techniques are associated with a lower risk for complications and adverse events. Inserting the needle in a remote distance to the femoral nerve, as done with the fascia iliaca compartment block, might further reduce the risk for nerve damage. Impaired motor function after femoral nerve blocks and fascia iliaca compartment blocks can delay mobilisation and increase the risk of falling after surgery.8
As an alternative to the conventional infra-inguinal fascia iliaca compartment block, supra-inguinal techniques have been described.9 By aiming for a proximal local anaesthetic spread below the fascia iliaca, the lateral cutaneous femoral nerve and the obturator nerve might be anaesthetised in addition to the femoral nerve. High injection volumes are needed to obtain a spread to all target nerves.10 Figure 1 illustrates anatomy and needle placement of a proximal supra-inguinal fascia iliaca block as described by Desmet and colleagues.9
Quadratus lumborum blocks are frequently used to provide analgesia after abdominal surgery. For a transmuscular quadratus lumborum technique a needle is placed between the quadratus lumborum muscle and the psoas muscle below the fascia transversalis (figure 2). As shown in several clinical studies, transmuscular quadratus lumborum blocks can also provide good analgesia after hip surgery.11 Impairment of motor function is less pronounced compared to a femoral nerve block. A spread to the lumbar plexus within the psoas muscle, however, cannot be excluded. Technically, a transmuscular quadratus lumborum blocks must be considered as more challenging compared with a femoral or fascia iliaca compartment block.
Pericapsular nerve group (PENG) blocks have been first described in 2018 (figure 3).12 The block technique aims to anaesthetise proximal branches of the anterior part of the hip capsula, as well as branches of the accessory obturator nerve. Clinical studies indicate that PENG blocks provide efficient postoperative analgesia comparable to a femoral nerve block.13Patients treated with PENG blockades have intact motor function. The posterior capsula of the hip joint is not covered by a PENG block. Hence, the technique might be combined with additional block techniques in the future to obtain more complete analgesia.14
Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M, et al. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2021;76(8):1082–97.
Guay J, Parker MJ, Griffiths R, Kopp SL. Peripheral Nerve Blocks for Hip Fractures: A Cochrane Review. Anesth Analg. 2017.
Tomlinson J, Ondruschka B, Prietzel T, Zwirner J, Hammer N. A systematic review and meta-analysis of the hip capsule innervation and its clinical implications. Sci Rep. 2021;11(1):5299.
Neuman MD, Feng R, Carson JL, Gaskins LJ, Dillane D, Sessler DI, et al. Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. N Engl J Med. 2021;385(22):2025–35.
Sauter AR, Ullensvang K, Niemi G, Lorentzen HT, Bendtsen TF, Borglum J, et al. The Shamrock lumbar plexus block: A dose-finding study. Eur J Anaesthesiol. 2015;32(11):764–70.
Steenberg J, Møller AM. Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation. Br J Anaesth. 2018;120(6):1368–80.
Unneby A, Svensson O, Gustafson Y, Olofsson B. Femoral nerve block in a representative sample of elderly people with hip fracture: a randomised controlled trial. Injury 2017;48(7):1542–9.
Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg. 2010;111(6):1552–4.
Desmet M, Vermeylen K, Van Herreweghe I, Carlier L, Soetens F, Lambrecht S, et al. A Longitudinal Supra-Inguinal Fascia Iliaca Compartment Block Reduces Morphine Consumption After Total Hip Arthroplasty. Reg Anesth Pain Med. 2017;42(3):327–33.
Kantakam P, Maikong N, Sinthubua A, Mahakkanukrauh P, Tran Q, Leurcharusmee P. Cadaveric investigation of the minimum effective volume for ultrasound-guided suprainguinal fascia iliaca block. Reg Anesth Pain Med. 2021;46(9):757–62.
Kishore Behera B, Misra S, Sarkar S, Mishra N. A systematic review and meta-analysis of efficacy of ultrasound-guided single-shot quadratus lumborum block for postoperative analgesia in adults following total hip arthroplasty. Pain Med. 2022.
Girón-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) Block for Hip Fracture. Reg Anesth Pain Med. 2018;43(8):859–63.
Lin DY, Brown B, Morrison C, Kroon HM, Jaarsma RL. Pericapsular nerve group block results in a longer analgesic effect and shorter time to discharge than femoral nerve block in patients after hip fracture surgery: a single-center double-blinded randomized trial. J Int Med Res. 2022;50(3):3000605221085073.
Ng TK, Peng P, Chan WS. Posterior hip pericapsular neurolysis (PHPN) for inoperable hip fracture: an adjunct to anterior hip pericapsular neurolysis. Reg Anesth Pain Med. 2021;46(12):1080–4.
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.