Editorial Commentary: The Optimal Nerve Block for Hip Arthroscopy Is Undetermined

The optimal nerve block to help reduce pain after hip arthroscopy is undetermined. The fascia iliaca block was en vogue but may result in weakness, neuropathy, and equivocal pain outcomes. Other options include blocks to the femoral nerve, the lumbar plexus, the quadratus lumborum, and, more recently, the pericapsular nerve group block (PENG), in which ultrasound guidance allows injection under the iliopsoas muscle to affect the accessory obturator nerve and the articular branches of the femoral nerve. PENG block should not result in weakness, but weakness has been reported after PENG block for total hip arthroplasty, and falls could be a risk and a concern. The arthroplasty literature also suggests the PENG block adds little benefit to intra-articular injection beyond the recovery room and is comparable with a fascia iliac block. Perhaps the PENG block could show benefit in select cases such as for severe postoperative pain or in patients with anticipated pain control challenges. Until an ideal block for hip arthroscopy is determined, a patient tailored approach is indicated.     

Efficacy of Ultrasound-Guided Quadratus Lumborum Block for Postoperative Analgesia After Hip Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BackgroundUltrasound-guided quadratus lumborum (QL) block as a novel regional anesthetic technique was proposed in 2007 that can be applied in patients following hip arthroplasty. This study aimed to evaluate the efficacy of the QL block for pain control in patients undergoing hip arthroplasty.MethodsWe performed a comprehensive search of PubMed, Web of Science, Scopus, Cochrane Library, Embase databases, Google Scholar, and CNKI for randomized controlled trials up to December 2021. According to the inclusion and exclusion criteria established in advance, “QL block” and “hip arthroplasty” related MeSH terms and free-text words were used.ResultsOur meta-analysis included 11 randomized controlled trials involving a total of 830 patients between 2018 and 2021. The results indicated that compared to the non-QL block group, Visual Analog Scale (VAS) score at mobilization in the QL block group demonstrated statistical and clinical significance at all time points (12, 24, and 48 hours), but VAS score at rest failed to reach the MCID (minimal clinically important difference). Meanwhile, opioid consumption in the QL block group only demonstrated statistical and clinical significance at 48 hours postoperatively, but did not reach the MCID at 12 or 24 hours postoperatively. The QL block increased satisfaction scores. There was a statistically significant reduction in the incidence of postoperative nausea and vomiting, but no difference in the incidence of pruritus and urinary retention.ConclusionThe QL block significantly reduced postoperative VAS score at mobilization, and opioid consumption at 48 hours in patients after hip arthroplasty compared to no block, which reached the MCID. The QL block also decreased postoperative nausea and vomiting and increased satisfaction scores. Although these are promising results, the clinical relevance of the efficacy of the QL block remains to be further understood as larger studies are needed.     

The Efficacy and Safety of Regional Nerve Blocks in Total Knee Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundRegional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.MethodsWe searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks.ResultsCritical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective.ConclusionSingle shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control.     

Editorial Commentary: The Truth about Peripheral Nerve Blocks and Hip Arthroscopy

Peripheral nerve blocks targeting the fascia iliaca compartment have been used in attempts to improve postoperative pain after hip arthroscopy surgery. Recent level I evidence from randomized controlled trials have revealed injection of local anesthetic into the fascia iliaca compartment to be no better than sham injection for postoperative pain control, while contributing to decreased patient quadriceps strength and increased fall risk after surgery. The fascia iliaca compartment block is also inferior to local anesthetic injection at the surgery site for pain control. Results of these high-level studies show that routine preoperative use of the fascia iliaca compartment block is not recommended for hip arthroscopy.     

Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised,observer-masked,controlled trial

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0–10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0–3.7 [0–7]) vs. 5.5 (5.0–7.0 [2–8]) at 12 h; 3 (2.0–4.0 [0–7]) vs. 6 (5.0–6.0 [2–8]) at 24 h; and 2.0 (2.0–4.0 [0–5]) vs. 3.0 (2.0–4.7 [0–6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block.     

Evaluating the Effect of Intravenous Acetaminophen in Multimodal Analgesia After Total Hip Arthroplasty: A Randomized Controlled Trial

BackgroundPostoperative pain is a significant concern of patients before surgery. Multimodal pain management is an effective method of pain control after major orthopedic surgery. Acetaminophen is the most commonly used analgesic for the management of pain. It was hypothesized that 1000 mg of intravenous acetaminophen (IA) dosed every 6 hours would significantly reduce the postoperative pain score at rest and the opioid consumption volume in patients who would undergo total hip arthroplasty (THA) when compared to a control group.MethodsA single-center, prospective, open-label randomized control study was conducted. A total of 97 patients undergoing unilateral primary THA were divided into 2 groups: the study group (IA) (n = 45) and the control group (n = 52). The study group received administered IA after surgery, while the control group received only a standard pain control. Both groups received a preoperative femoral nerve block and postoperative intravenous fentanyl citrate. The primary outcome was the evaluation of the pain score at rest 24 hours after surgery. The pain score was measured using the Numerical Rating Scale. The primary outcome of this study was analyzed using generalized estimating equation.ResultsThe IA group had a significant improvement in Numerical Rating Scale score at rest 24 hours after THA compared to the control group (−0.91, 95% confidence interval −1.56 to −0.26, P = .006), suggesting a positive effect of IA usage for pain relief. The total fentanyl citrate consumption after surgery for 24 hours was significantly lower in the IA group than those of the control group (52.07 ± 7.64 vs 57.83 ± 12.44 mg, P < .001).ConclusionPostoperative administration of IA significantly reduced the postoperative pain score and opioid consumption volume after primary THA. IA was useful as one role of multimodal pain management after THA.Level of Evidence: Level 2.     

O bloqueio contínuo do quadrado lombar tipo 3 fornece analgesia pós‐operatória efetiva para cirurgia do quadril: relato de caso

Introduction

Hip surgery is a major surgery that causes severe postoperative pain. Although pain during rest is usually considerably reduced mobilization is important in terms of thromboembolic complications. The quadratus lumborum block is a regional analgesic technique that blocks T6‐L3 nerve branches. This block may provide adequate analgesia and reduce opioid consumption after hip surgery.

Anatomic changes in the inguinal region after hip arthroscopy: implications for femoral nerve block

Patients may experience significant pain after hip arthroscopy. Two patients who experienced severe pain after arthroscopic hip surgery, despite receiving multimodal pharmacologic therapy, are presented. In both cases, ultrasound-guided femoral nerve block provided excellent analgesia. However, during ultrasound, significant anatomic changes were noted in the inguinal region. In this report, we describe anatomic changes in the inguinal region that are visible with ultrasound after hip arthroscopy.     

Comparación del bloqueo del grupo de nervios pericapsulares (PENG) y la analgesia epidural después de una artroplastia total de cadera: análisis retrospectivo

Introduction and objectivesTotal hip arthroplasty (THA) is an increasingly common orthopedic pro-cedure, with moderate to severe postoperative pain. Pericapsular nerve group (PENG) block is a recent block that seems to provide adequate analgesia without significant motor blockade. The aim of this study is to retrospectively compare the analgesic efficacy and safety of PENG block with those of epidural analgesia, in patients undergoing THA.Material and methodsThis is a retrospective observational study of patients who underwent primary THA, submitted to epidural analgesia or single-shot ultrasound-guided PENG block, during a one-year period. Data regarding demographic characteristics, surgery and anesthesia techniques, pain scores, opioid consumption, complications and time to hospital discharge were retrieved from institutional records and compared between the 2 groups (epidural analgesia vs PENG block).ResultsNo significant difference was found regarding pain scores, opioid consumption, and mean time to hospital discharge between the 2 groups. Pain scores at rest (1.20 epidural vs 1.67 PENG) or with movement (3.95 epidural vs 3.72 PENG) were similar between groups. Total number of complications was higher in the epidural analgesia group (50% epidural vs 5% PENG). Paresthesia was reported in both groups. Motor block, sedation, nausea and catheter-related complications were only found in the epidural analgesia group.ConclusionsPENG block seems to be equivalent to epidural analgesia regarding quality of postop-erative analgesia for patients subject to primary THA, supporting routine use of this block in these patients. The low rate of reported complications limits conclusions on this topic.     

Editorial Commentary: Femoral Nerve Block: Don’t Kill the Motor Branch

Femoral nerve block is commonly used for pain control after knee surgery and helps to reduce the need for opioids in the early postoperative period. The potential disadvantage is blockage of the motor branch of the femoral nerve, resulting in quadriceps weakness and reduced strength by up to 50%. Adductor canal nerve block is a possible alternative resulting in less muscle weakness. The rationale behind adductor canal nerve block is blockage of the saphenous nerve and part of the obturator nerve, providing reliable and adequate pain relief.     

A comparison of pre‐operative nerve stimulator‐guided femoral nerve block and fascia iliaca compartment block in patients with a femoral neck fracture

We undertook a randomised, controlled trial to compare the analgesic efficacy and opioid sparing effect of nerve stimulator‐guided femoral nerve block with fascia iliaca compartment block in patients awaiting surgery for fractured neck of femur. Ten‐centimetre visual analogue pain scores were measured before and 2 h after the block and opioid consumption was recorded in the 12‐h period after the block. One hundred and ten patients were randomly assigned. Femoral nerve block provided superior pre‐operative analgesia for fractured neck of femur compared with fascia iliaca compartment block. The difference in the mean reduction of pain score after the block was 0.9 (95% CI 0–1.8); p = 0.047. Patients receiving a femoral nerve block required less morphine after the block than those receiving fascia iliaca compartment block (p = 0.041).     

超声引导髋关节囊周围神经阻滞在老年髋部骨折病人术前镇痛中的应用

目的初步探讨超声引导髋关节囊周围神经阻滞用于老年髋部骨折病人术前镇痛的效果。方法收集2019年3月至7月共22例拟在腰麻下行髋关节置换术的老年髋部骨折病人,均于腰麻前接受超声引导髋关节囊周围神经阻滞,记录神经阻滞操作所需时间,比较病人阻滞前、阻滞后5 min及翻身侧卧时的静息与运动状态下数字化疼痛量表(numeric rating pain scale,NRS)评分。结果超声引导髋关节囊周围神经阻滞操作用时为(19.9±2.6)s。22例病人阻滞前的静息、运动状态下NRS评分分别为(4.3±0.9)分、(7.3±0.8)分;阻滞后5 min时分别为(1.7±0.6)分、(2.8±0.6)分;翻身侧卧时分别为(1.6±0.5)分、(3.0±0.7)分。阻滞后5 min、翻身侧卧时的静息与运动状态下NRS评分均较阻滞前明显降低,差异均有统计学意义(P均<0.05)。结论本研究初步表明超声引导髋关节囊周围神经阻滞可有效用于老年髋部骨折病人的术前镇痛。     

Optimizing Rapid Recovery After Anterior Hip Arthroplasty Surgery: A Comparative Study of Fascia Iliaca Compartment Block and Local Infiltration Analgesia

BackgroundMultimodal pain therapy combining analgesics, local infiltration analgesia (LIA) and peripheral nerve blocks, such as fascia iliaca compartment block (FICB), can improve postoperative pain, nausea and vomiting (PONV) and ambulation in patients undergoing total hip arthroplasty (THA). We hypothesized that addition of FICB would decrease opioid requirements and length of stay (LOS) but could create a motor block.MethodsThis is a single center, prospective, blinded randomized controlled study of 152 patients undergoing elective THA via direct anterior approach from October 2019 till August 2021. Three patient groups were defined: patients receiving only spinal anesthesia (control group, n = 53); spinal anesthesia with LIA perioperatively (n = 50); and spinal anesthesia with FICB on the recovery unit (n = 49). Outcome measures consisted of postoperative pain scores, PONV, length of hospital stay, opioid requirements and mobility.ResultsOverall pain scores were low for all patient groups, with a lower pain score for LIA in comparison to the control group until 4 hours postoperatively (P < .05). Length of hospital stay, postoperative pain, nausea and vomiting (PONV) scores and quadriceps muscle strength did not differ significantly between groups. The control group showed higher scores at 12 hours postoperatively in comparison to FICB regarding rehabilitation potential, use of walking aids and activities of daily living (P < .05), but all groups reached the same endpoint 48 hours postoperatively. The LIA and FICB groups required less opioids until 24 hours postoperatively.ConclusionLIA is a beneficial adjuvant therapy to spinal anesthesia in THA patients as it may decrease pain scores and the need for opioid consumption. Adjuvant FICB only provided lower opioid requirements.     

Is Continuous Adductor Canal Block Better Than Continuous Femoral Nerve Block After Total Knee Arthroplasty? Effect on Ambulation Ability,Early Functional Recovery and Pain Control: A Randomized Controlled Trial

Total knee arthroplasty is associated with intense, early post-operative pain. Femoral nerve block is known to provide optimal pain relief but reduces the strength of the quadriceps muscle and associated with the risk of falling. Adductor canal block is almost pure sensory blockade with minimal effect on quadriceps muscle strength. We prospectively randomized 100 patients in two groups' continuous adductor and femoral block group. Ambulation ability (Timed up go, 10-m walk, 30 s chair test), time to active SLR, quadsticks, staircase competency, ambulation distance was significantly better (P value < 0.001) in adductor canal group whereas pain scores, opioid consumption showed no significant difference. Adductor canal block provided better ambulation and early functional recovery but without superior analgesia than femoral nerve block post TKA. Level of evidence: Level III, therapeutic study.     

Use of continuous passive motion device after arthroscopic hip surgery decreases post-operative pain: A randomized controlled trial

BackgroundWe sought to determine whether continuous passive motion (CPM) usage improves outcomes following arthroscopic hip surgery involving acetabular labral repair. Our hypothesis is that CPM usage reduces pain and pain medication use and improves quality of life in individuals who undergo hip arthroscopy.MethodsWe created a randomized controlled trial consisting of 54 patients who underwent arthroscopic acetabular labral repair. Patients were randomized to two groups, one with CPM use post-operatively and one without. Primary outcomes measured were pain level, patient satisfaction, and quality of life. Parameters used to measure these outcomes were self-reported pain scores on Likert scale, frequency of analgesic medication use, and self-reported scores on Hip Outcome Score Activity of Daily Living (HOS ADL). These parameters were compared between the two randomized groups using t-test for statistical analysis.ResultsThere was no statistical difference between the treatment and control groups in terms of patient characteristics. There was no statistical difference between the two groups in terms of HOS ADL scores, although the patients in the control group demonstrated a trend toward higher HOS ADL scores. The patients in the CPM group had a statistically significant decrease in pain levels after surgery compared to patients in the control group. The total morphine equivalent dose consumed in the first two post-operative weeks was higher in the control group compared to the CPM group, although this difference was not statistically significant.ConclusionsUse of CPM resulted in lower pain level scores in patients after hip arthroscopy. Although there is no statistical difference in quality of life or quantity of analgesics consumed post-operatively, patients who used CPM tended to have lower HOS ADL scores (which is desirable) and less consumption of pain medication. A study with a larger sample of patients might elucidate more differences between the two groups.Level of EvidenceII, therapeutic.     

Combination Lower Extremity Nerve Blocks and Their Effect on Postoperative Pain and Opioid Consumption: A Systematic Review

The purpose of this study was to perform a systematic review of the literature examining postoperative outcomes following single site and combined peripheral nerve blocks (PNBs), including (1) sciatic and femoral nerve, (2) popliteal and saphenous nerve, and (3) popliteal and ankle nerve, during elective foot and ankle surgery. We hypothesized that combination blocks would decrease postoperative narcotic consumption and afford more effective postoperative pain control as compared to general anesthesia, spinal anesthesia, or single site PNBs. A review of the literature was performed according to the PRISMA guidelines. Medline, EMBASE, and the Cochrane Library were searched from January 2009 to October 2019. We identified studies by using synonyms for “foot,” “ankle” “pain management,” “opioid,” and “nerve block.” Included articles explicitly focused on elective foot and ankle procedures performed under general anesthesia, spinal anesthesia, PNB, or with some combination of these techniques. PNB techniques included femoral, adductor canal, sciatic, popliteal, saphenous, and ankle blocks, as well as blocks that combined multiple anatomic sites. Outcomes measured included postoperative narcotic consumption as well as patient-reported efficacy of pain control. Twenty-eight studies encompassing 6703 patients were included. Of the included studies, 57% were randomized controlled trials, 18% were prospective comparison studies, and 25% were retrospective comparison studies. Postoperative opioid consumption and postoperative pain levels were reduced over the first 24 to 48 hours with the use of combined PNBs when compared with single site PNBs, both when used as primary anesthesia or when used in concert with general anesthesia either alone or combined with systemic/local anesthesia in the first 24 to 48 hours following surgery. Studies demonstrated higher reported patient satisfaction of postoperative pain control in patients who received combined PNB. Nine of 14 (64%) studies reported no neurologic related complications with an overall reported rate among all studies ranging from 0% to 41%. Our study identified substantial improvement in postoperative pain levels, postoperative opioid consumption, and patient satisfaction in patients receiving PNB when compared with patients who did not receive PNB. Published data also demonstrated that combination PNB are more effective than single-site PNB for all data points. Notably, the addition of a femoral nerve block to a popliteal nerve block during use of a thigh tourniquet, as well as addition of either saphenous or ankle blockade to popliteal nerve block during use of calf tourniquet, may increase overall block effectiveness. Serious complications including neurologic damage following PNB administration are rare but do exist.