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Local infiltration analgesia or femoral nerve block for postoperative pain management in patients undergoing total hip arthroplasty: A randomized, double-blind study
Örebro University, School of Medical Sciences. Departments of Anesthesiology and Intensive Care.
School of Medical Sciences, Örebro University, Örebro, Sweden. (Clinical Epidemiology and Biostatistics)
Department of Orthopedic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.
2017 (English)In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 16, p. 223-230Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND AIMS: Several methods for pain management following total hip arthroplasty (THA) have been described but the best postoperative pain management technique remains uncertain. We compared surgeon applied local infiltration analgesia (LIA) with anaesthesiologist performed femoral nerve block (FNB) using ultrasound. The primary aim was to assess pain intensity 24h after THA.

METHODS: In this randomized, double-blind study, 56 patients (ASA I-III) undergoing THA consented to participate. In Group FNB, patients received an ultrasound-guided femoral nerve block using 30ml of ropivacaine 7.5mg/ml (225mg) while Group LIA received a similar volume of saline. Spinal anaesthesia was then performed and bupivacaine heavy, 3-3.5ml injected depending on patient characteristics. During surgery, patients in Group LIA received a mixture of 300mg (150ml) ropivacaine, ketorolac 30mg (1ml) and adrenaline 0.5mg (0.5ml) (total volume 151.5ml) peri-articularly and subcutaneously while Group FNB received 151.5ml of saline peri-articularly in a systematic way by the surgeon. A multi-hole catheter was placed with the tip placed intra-articularly at the end of surgery in both groups. After 23h, the LIA mixture consisting of 20ml ropivacaine (7.5mg/ml), ketorolac 30mg (1ml), adrenaline 0.1mg (1ml) (total volume 22ml) was injected in Group LIA and the same volume of saline in Group FNB. Postoperative pain, analgesic consumption (postoperative and post-discharge), side effects, home discharge, quality of life and hip function were recorded, the latter up to 6 months after surgery.

RESULTS: Postoperative pain intensity was significantly lower in Group LIA compared to Group FNB during mobilization at 24h (primary endpoint), mean difference 1.8 NRS units (95% CI 0.7-2.9) (P=0.006), at rest after 4h (P=0.029) and on standing after 24 (P=0.0003) and 48h (P=0.043). Rescue morphine consumption was also significantly lower in Group LIA during 0-24, mean difference 13.5mg (95% CI, 6.1-20.9) (P=0.002) postoperatively. Motor block was greater at 6h (P=0.029) postoperatively in Group FNB. Two patients (one in each group) had persistent post-surgical pain (NRS>3) at 3 months (3.6%) but none at 6 month. No other differences were found between the groups.

CONCLUSION: Local infiltration analgesia significantly reduces pain intensity on standing and mobilization, and rescue analgesic consumption compared to femoral nerve block without causing significant side effects. The superior analgesia in the LIA group may result from the secondary injection at 23h postoperatively and needs to be further evaluated in future studies. No differences were found in home discharge, quality of life and hip dysfunction between the groups.

IMPLICATION: Local infiltration analgesia is the preferred method for postoperative pain management following THA compared to single-shot femoral nerve block.

Place, publisher, year, edition, pages
Walter de Gruyter, 2017. Vol. 16, p. 223-230
Keywords [en]
Total hip arthroplasty; Postoperative pain; Local infiltration analgesia; Femoral nerve block
National Category
Anesthesiology and Intensive Care Neurology
Identifiers
URN: urn:nbn:se:oru:diva-61186DOI: 10.1016/j.sjpain.2017.05.002ISI: 000419850300041PubMedID: 28850408Scopus ID: 2-s2.0-85020070292OAI: oai:DiVA.org:oru-61186DiVA, id: diva2:1145835
Available from: 2017-09-29 Created: 2017-09-29 Last updated: 2018-09-18Bibliographically approved
In thesis
1. Postoperative pain, inflammation and functional recovery after total hip arthroplasty: Prospective, randomized, clinical studies
Open this publication in new window or tab >>Postoperative pain, inflammation and functional recovery after total hip arthroplasty: Prospective, randomized, clinical studies
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Total hip arthroplasty (THA) is performed in patients with osteoarthritis of the hip joint. Pain following THA is often moderate but no gold stand-ard exists for pain management. Good postoperative pain management may lead to a better quality of life and hip function. In study I, we inves-tigated whether intrathecal morphine (ITM) or local infiltration analgesia (LIA) is better for pain management. Eighty patients were randomized to one of two groups, ITM or LIA in this randomized double-blind study. Lower pain intensity was recorded early after surgery (< 8 h) in ITM group but subsequently (> 24 h), analgesic consumption, pain intensity on mo-bilization, and side-effects were lower in patients receiving LIA. In study II, in a randomized, double blind study, we compared LIA with femoral nerve block (FNB) for pain management following THA in 56 patients. We found that LIA significantly reduces pain intensity on standing and mobilization at 24 -48 h, as well as rescue analgesic consumption (0 – 24 h) compared to FNB without causing significant side effects. In study III, the same patients were included as in study II to determine the role of inflammation on postoperative pain by analyzing a battery of cytokines in the plasma before and at fixed time points after surgery. We found that LIA has a modest but short-lasting effect (≈4 h) on postoperative inflam-mation, specifically IL-6. This is likely to be due to local infiltration of ketorolac and/or local anesthetics.

Study IV was a long-term follow-up of patients included in study I. We found no differences in quality of life or hip function up to 6 months after surgery when comparing LIA with ITM. Additionally, the incidence of persistent post-surgical pain and postoperative complications was similar between the groups and LIA had no long-term negative effects.

In conclusion, LIA is a good alternative to intrathecal morphine or fem-oral nerve block in patients undergoing THA. The analgesic effect may be due to anti-inflammatory effect of ketorolac injected locally or local anes-thetics. No negative long-term effects of LIA were found. The technique is efficacious, simple to apply and offers a good alternative to intrathecal morphine or femoral nerve block without negative effects during THA.

Place, publisher, year, edition, pages
Örebro: Örebro University, 2017. p. 92
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 166
Keywords
Total hip arthroplasty, local infiltration analgesia, intrathecal morphine, femoral nerve block, postoperative pain, spinal anesthesia
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-58066 (URN)978-91-7529-210-6 (ISBN)
Public defence
2017-10-27, Örebro universitet, Campus USÖ, hörsal C3, Södra Grev Rosengatan 32, Örebro, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2017-06-16 Created: 2017-06-16 Last updated: 2017-09-29Bibliographically approved

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