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Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Werner, Mads


CiteScore 2018: 0.85

SCImago Journal Rank (SJR) 2018: 0.494
Source Normalized Impact per Paper (SNIP) 2018: 0.427

Online
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1877-8879
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Volume 16, Issue 1

Issues

Local infiltration analgesia or femoral nerve block for postoperative pain management in patients undergoing total hip arthroplasty. A randomized, double-blind study

Ján Kuchálik
  • Departments of Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Anders Magnuson
  • Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Anders Lundin
  • Department of Orthopedic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Anil Gupta
Published Online: 2017-07-01 | DOI: https://doi.org/10.1016/j.sjpain.2017.05.002

Abstract

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 24 h 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 30 ml of ropivacaine 7.5 mg/ml (225 mg) while Group LIA received a similar volume of saline. Spinal anaesthesia was then performed and bupivacaine heavy, 3–3.5 ml injected depending on patient characteristics. During surgery, patients in Group LIA received a mixture of 300 mg (150 ml) ropivacaine, ketorolac 30 mg (1 ml) and adrenaline 0.5 mg (0.5 ml) (total volume 151.5 ml) peri-articularly and subcutaneously while Group FNB received 151.5 ml 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 23 h, the LIA mixture consisting of 20 ml ropivacaine (7.5 mg/ml), ketorolac 30 mg (1 ml), adrenaline 0.1 mg (1 ml) (total volume 22 ml) 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 24 h (primary endpoint), mean difference 1.8 NRS units (95% CI 0.7–2.9) (P = 0.006), at rest after 4 h (P = 0.029) and on standing after 24 (P = 0.0003) and 48 h (P = 0.043). Rescue morphine consumption was also significantly lower in Group LIA during 0–24, mean difference 13.5 mg (95% CI, 6.1–20.9) (P = 0.002) postoperatively. Motor block was greater at 6 h (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 23 h postoperatively and needs to be furtherevaluated 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.

© 2017 Scandinavian Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Keywords: Total hip arthroplasty; Postoperative pain; Local infiltration analgesia; Femoral nerve block

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About the article

Department of Anesthesiology and Intensive Care, F:2:00, Karolinska University Hospital, Solna, Stockholm, Sweden. Tel.: +46 8 51770387.


Received: 2017-03-16

Revised: 2017-05-02

Accepted: 2017-05-03

Published Online: 2017-07-01

Published in Print: 2017-07-01


Author contribution: J Kuchálik: Design, patient recruitment, data control and writing the manuscript; A Magnuson: Design and statistical analysis, and writing the manuscript; A Lundin: Design and writing the manuscript; A Gupta: Design, data assessment, writing the manuscript.

Ethical issues: Informed written and verbal consent was required and obtained from each patient prior to inclusion. The study was approved by the Regional Ethic Board and the study protocol was registered in an international database prior to study start.

Conflict of interest: None declared.


Citation Information: Scandinavian Journal of Pain, Volume 16, Issue 1, Pages 223–230, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2017.05.002.

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