Local anaesthesia methods for analgesia after total hip replacement: Problems of anatomy, methodology and interpretation?

Johan Ræder

doi:10.1016/j.sjpain.2017.05.003

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Local anaesthesia methods for analgesia after total hip replacement: Problems of anatomy, methodology and interpretation?

Johan Ræder

Published/Copyright: July 1, 2017

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From the journal Scandinavian Journal of Pain Volume 16 Issue 1

In the present issue of the Scandinavian Journal of Pain, Ján Kuchalik and co-workers from Örebro and Stockholm report clinical results of comparing local infiltration analgesia (LIA) with femoral nerve block (FNB) for analgesia after total hip arthroplasty (THA) [1].

They found LIA to be favourable in terms of less immediate motor-block, less pain and less rescue opioid analgesics at some of the registrations during the first 48 h postoperatively. There were no differences between the groups in time to hospital discharge, post discharge function or pain after 3 months or 6 months. In another report from the same study, they also found lower levels of blood pro- and anti-inflammatory cytokines 4 h after the procedure with LIA, possibly flawed by mixing ketorolac only for the LIA mixture [2].

1 An increasingly frequent and often painful surgical procedure

Total hip replacement arthroplasty (THA) is one of the most frequently performed surgical procedures in the western world (http://ec.europa.eu/eurostat/statistics-explained/index.php/Surgical_operations_and_procedures_statistics).

With an ageing population, increased prevalence of osteoarthritis (arthrosis) and increased access to surgical service also in less affluent areas of the world, the number of patients for this procedure is expected to increase further. The post-operative pain after THA is often considered to be of intermediate intensity, and less severe than pain after total knee arthroplasty. Still, optimal pain control is always to be preferred, also important in these patients who need to be mobilized and have physiotherapy for best possible outcome.

2 Evidence based postoperative pain management?

The PROSPECT group on procedure specific and evidence based guidelines, recommends for postoperative analgesia after THA: spinal anaesthesia with an opioid added for the surgical procedure, followed by multimodal postoperative analgesia with paracetamol, NSAID or COX-II inhibitor and opioids on top as needed (www.postoppain.org). Epidural analgesia is only recommended for patients with high risk of cardio-pulmonary complications.

Still, the benefit of some sort of local anaesthetic (LA) administration is better than placebo in the THA post-operative setting in most studies. However, the best local analgesia protocol after THA is not fully settled, partly because the hip joint has a complex neural innervation from many sources, not readily available for a simple, accessible, straight forward single nerve block. Also, the real usefulness of LA on top of other simple, straightforward, optimal multimodal protocols is disputed [3, 4].

3 LIA superior to FNB?

Kuchalik and co-workers set out in this somewhat un-settled area, to compare the use of a single shot ropivacaine femoral nerve block with the LIA technique using single shot ropivacaine + ketorolac infiltration, repeated at 23 h by catheter injection, in a truly double blind design.

Local infiltration analgesia techniques reinforced eventually with topical NSAID is definitely effective, but the importance of LIA catheter and top-up doses is more controversial [3, 4]. Alternatively, posterior lumbar plexus block is efficient, but takes some expertise to do and is not without rare, but very serious complications [5].

The femoral nerve-block is easy to apply, but the analgesic effect is not regarded to be very strong for THA, in some studies not much better than placebo [6]. A more promising approach may be the fascia iliaca compartment block, where the inguinal nerves are blocked as well as the femoral nerve [7].

4 Limitations of the present study [1]

Kuchalik and co-workers openly and honestly discuss some of the limitations of their present study [1]. One is the problem of choosing analgesia at 24 h as their primary endpoint, just at the point of time when a maximal effect of the 23 h top-up dose of local analgesia and ketorolac in the LIA group is expected. This may not be representative for the overall analgesia throughout the first 24 h after surgery and not “just” in comparison with the single shot femoral method, applied with no adjuncts or top-ups right before start of surgery.

Further, it is also problematic that the size of study groups were only powered for pain measurement at 24 h which is the only strongly significant difference in the study, except for motor block at 6 h and the morphine consumption with a 13 mg difference during 24 h. The latter difference may be partly flawed by the two doses of ketorolac, only given in the LIA group.

Further, here are other issues that are important, e.g. study design and implications of the results for practical everyday clinical work. The authors make a compromise between the explanatory design; i.e. testing if the LIA technique per se is better than femoral nerve block, and the pragmatic design of testing each method on top of non-invasive multimodal analgesia methods. As for the explanatory part there is a problem with the ketorolac supplement to the LIA technique, as this will be absorbed and have systemic effect in addition to any local effect. Thus, it is “not fair” for the femoral nerve block to not receive ketorolac or another NSAID, as this would probably have improved the analgesia in that group. It is worth remembering that these potent NSAIDs can have serious negative effects on kidney functions of elderly patients with other risk factors of kidney function, also when administered locally around the joint and in the surgical wound area [8, 9, 10].

5 Multimodal analgesia well documented after hip replacement

A good, well documented method securing analgesia for THA includes paracetamol (start 2 g in the healthy adult less than 70 years of age, then 1 g twice a day for 4 days) + NSAID + a spinal opioid + wound infiltration with a local anaesthetic drug. In the present study the start dose of paracetamol was low, the NSAID was missing in one group, no spinal opioid was given and no wound infiltration given in one group. Thus we will not know if any of the methods tested in the study will add any extra analgesia on top of such very simple, common drugs and methods.

Still, the study of Kuchalik and co-workers is nicely done technically with 100% double-blinding, and appropriate methods of patient evaluation. It certainly rules out the single shot ropivacaine femoral nerve block without adjuvants as a favourable method, but still leaves some question as to the ideal LIA approach and how this will compare with an optimal, multimodal analgesic regimen.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.05.002.

Department of Anaesthesiology, Ullevaal, Oslo University Hospital and Faculty of Medicine, University of Oslo, Pb4950 Nydalen, 0224 Oslo, Norway.

Conflict of interest: None declared.

References

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Published Online: 2017-07-01

Published in Print: 2017-07-01

Articles in the same Issue

https://doi.org/10.1016/j.sjpain.2017.05.003