Original Contributions
Postoperative analgesia after total hip arthroplasty: IV PCA with morphine, patient-controlled epidural analgesia, or continuous “3-in-1” block?: a prospective evaluation by our acute pain service in more than 1,300 patients

Presented in part at the Annual Meeting of the American Society of Anesthesiologists, San Francisco, CA, October 15–19, 1994.
https://doi.org/10.1016/S0952-8180(99)00092-6Get rights and content

Abstract

Study Objective: To assess the most appropriate postoperative analgesic technique after hip surgery.

Design: Prospective, nonrandomized study.

Setting: University hospital.

Patients: 1,338 ASA physical status I, II, and III patients scheduled for elective unilateral total hip arthroplasty (THA).

Interventions: During the first 48 postoperative hours, pain relief was provided by intravenous (IV) patient-controlled analgesia (PCA) with morphine (Group 1), continuous “3-in-1” block (Group 2), or patient-controlled epidural analgesia (PCEA) (Group 3).

Measurements and Main Results: During a 7.5-year period, pain scores, supplemental analgesia, satisfaction score, technical problems, and side effects were collected by our acute pain service. Postoperative pain relief was comparable in the three groups. More paracetamol was required in Group 2 (1.0 ± 1.2 g/48 h) and Group 3 (0.9 ± 1.3 g/48 h) than in Group 1 (0.5 ± 1.1 g/48 h) (p < 0.01). However, only 8% of patients in Group 2 and 12% of patients in Group 3 needed an opioid. A higher incidence of technical problems was noted in Group 3 (23.4%) than in Group 1 (2.3%) or Group 2 (5.5%) (p < 0.001). A lower incidence of side effects was observed in Group 2 (23.5%) when compared with Group 1 (58.8%) and Group 3 (71.9%) (p < 0.001). Satisfaction score was significantly higher in Group 2 than in the other two groups [80 ± 16 vs. 87 ± 14 vs. 81 ± 14 in Groups 1, 2, and 3 respectively (p = 0.003)].

Conclusion: After THA, IV PCA with morphine, continuous “3-in-1” block, and PCEA provided comparable pain relief. Because it induces the fewest technical problems and side effects, continuous “3-in-1” block is the preferred technique.

Introduction

Postoperative pain after total hip arthroplasty (THA) can be difficult to control. Severe in 50% of patients at rest, it is exacerbated on movement and by severe reflex spasms of the quadriceps muscle.1 When inadequately treated, this pain intensifies reflex responses that can cause serious complications, such as pulmonary or urinary problems, and thromboembolism.2 Moreover, it hinders early intense physical therapy, which is the most influential factor for good postoperative rehabilitation.3

Postoperative pain relief can be achieved by a variety of techniques, such as intravenous patient-controlled analgesia (IV PCA),3, 4 epidural analgesia with opioids and/or local anesthetics,4, 5, 6, 7 and lumbar plexus blockade.8 Which of these treatments is better suited to patients undergoing total hip arthroplasty has yet to be established.

At our institution, the Acute Pain Service (APS) has provided postoperative analgesia after THA either by IV PCA with morphine, patient-controlled epidural analgesia (PCEA), or continuous “3-in-1” block for over seven years. The present article analyzes this day-to-day clinical practice in more than 1,300 patients.

Section snippets

Materials and methods

With St. Luc Hospital Institutional approval, data from all ASA physical status I, II, and III patients scheduled for elective THA with general anesthesia (GA) were prospectively collected from January 1991 to June 1998. Patients with a contraindication to regional anesthesia (e.g., local infection, sepsis, coagulation abnormality) or to the use of nonsteroidal antiinflammatory drugs (e.g., gastric ulcers, allergy, renal insufficiency), preexisting neurologic deficit, diabetes, preoperative

Results

From January 1991 to June 1998, 1,400 patients were prospectively entered into this study. In 59 Group 2 patients (4.9%), no loss of temperature sense in the area innervated by the femoral nerve or the lateral cutaneous nerve of the thigh was noted in the recovery room. These patients were withdrawn from the study. In 3 (4.5%) Group 3 patients, absence of sensory level (catheter dislodged or misplaced) was observed. These patients also were withdrawn from the study, leaving 1,338 patients [132

Discussion

Postoperative pain after THA can be difficult to control. It is moderate in 40% and severe in 50% of patients at rest, and it is exacerbated on movement and by severe reflex spasms of the quadriceps muscles.1 When inadequately treated, it intensifies reflex responses that can cause serious complications, such as pulmonary or urinary problems, and thromboembolism.2 Moreover, it hinders early intense physical therapy, which is the most influential factor for good postoperative rehabilitation.3

Acknowledgements

The authors are grateful to F. Veyckemans, MD, for his criticism of the manuscript.

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