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No effect of double nerve block of the lateral cutaneous nerve and subcostal nerves in total hip arthroplasty.

ABSTRACT: Background and purpose - The use of local infiltration anesthesia (LIA) has become one of the cornerstones of rapid recovery protocols in total knee arthroplasty patients during the past decade. In total hip arthroplasty (THR), however, the study results are more variable and LIA has therefore not yet been generally accepted. There is no consensus on which structure should be infiltrated and the cutaneous nerves are generally neglected. Hence, we hypothesized a pain-reducing effect of specifically blocking these nerves. Patients and methods - We performed a single-center randomized placebo-controlled trial in 162 subjects to evaluate the infiltration of the lateral cutaneous femoral and subcostal nerve with ropivacaine in patients undergoing total hip arthroplasty via a straight lateral approach. The primary endpoint was pain at rest after 24?hours. Patients were followed up to 6 weeks postoperatively. Results - After correction for multiple testing, no statistically significant differences in pain scores were found between the ropivacaine compared with the placebo group after surgery. In addition, no differences were observed in the use of escape pain medication, complications, and the length of hospital stay. Interpretation - We found no clinically meaningful differences in pain scores between placebo and ropivacaine patients in the postoperative period after THA performed via a straight lateral approach under spinal anesthesia and a multimodal pain regimen. Moreover, our primary endpoint, pain reduction after 24?hours, was not met. Further research should focus on the composition and volume of the LIA suspension, the optimal localization of the infiltration, and should be evaluated for every surgical approach separately.

SUBMITTER: Bron JL

PROVIDER: S-EPMC6055781 | biostudies-literature | 2018 Jun

REPOSITORIES: biostudies-literature

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No effect of double nerve block of the lateral cutaneous nerve and subcostal nerves in total hip arthroplasty.

Bron Johannes L JL Verhart Jeanette J Sierevelt Inger N IN De Vries Dirk D Kingma Hylke J HJ Rademakers Maarten V MV

Acta orthopaedica 20180301 3

Background and purpose - The use of local infiltration anesthesia (LIA) has become one of the cornerstones of rapid recovery protocols in total knee arthroplasty patients during the past decade. In total hip arthroplasty (THR), however, the study results are more variable and LIA has therefore not yet been generally accepted. There is no consensus on which structure should be infiltrated and the cutaneous nerves are generally neglected. Hence, we hypothesized a pain-reducing effect of specifical ...[more]

PMID: 29493328

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Project description:BackgroundSupercapsular Percutaneously Assisted total hip arthroplasty (SuperPATH approach) is a relatively new minimal invasive approach which has been associated with encouraging postoperative outcomes. The aim of this study is to compare the minimal invasive (MIS) SuperPATHapproach with the standard modified Hardinge approach at the base of muscle damage due to serum markers, functional results and other perioperative and postoperative data.Material and methodsForty eight (48) consecutive patients undergone primary total hip arthroplasty (THA) by the same surgeon (GD), were enrolled in our study. From this study population, the modified Hardinge approach was performed in 23 patients and the SuperPATH approach was performed in 25 patients. Soft tissue impairment was studied based on three representative markers, C-reactive-protein (CRP) and two enzymes, creatine kinase (CK) and lactate dehydrogenase (LDH). We measured these markers 10 min after surgery, on 1st and 2nd postoperative day. The levels of the perceived pain were evaluated according to the Visual Analog Scale/Numerical Rating Scale (VAS/NRS) score which was registered 6 h, 12 h, 1 day and 2 days postoperatively. The functional and clinical evaluation of the patients was achieved with Harris Hip Score (HHS), Charnley's Hip score, EuroQol (EQ-5D)-(EQ-100), Patient Health Questionnaire (PHQ-9) and neuropathic pain questionnaire (DN-4) 6 months and 1 year postoperatively. The rest of the collected data included patient's age, gender, body mass index (BMI), other comorbitities, the American Society of Anesthiologists score (ASA), Charlson Index score, the pre-operative diagnosis, implant positioning through radiographic evaluation, the type of anesthesia, the days of hospitalization, the operating time, incision length, blood loss and blood transfusion requirements and complication rates.ResultsSuperPATH approach was related with statistically considerable lower levels of CRP at 10 min (p = 0,001) and at 24 h (p = 0,047) postoperatively, as well as lower LDH levels in all time points postoperatively. It was also associated with shorter incision length (p < 0.001), longer operating time (p < 0.001), higher mean cup inclination p < 0.001, decreased postoperative pain levels the first 6 and 12 h (p < 0.001) and relatively better clinical and functional results 6 months after surgery, but not at 12 months.ConclusionOur study revealed some advantages in favor of the SuperPATH approach comparing with the standard modified Hardinge approach, mainly in terms of less muscle damage and less perceived pain postoperatively. More research is required in order to further elucidate its efficacy.

Project description:The ideal local anesthetic regime for femoral nerve block that balances analgesia with mobility after total knee arthroplasty (TKA) remains undefined.We compared two volumes and concentrations of a fixed dose of ropivacaine for continuous femoral nerve block after TKA to a single injection femoral nerve block with ropivacaine to determine (1) time to discharge readiness; (2) early pain scores and analgesic consumption; and (3) functional outcomes, including range of motion and WOMAC scores at the time of recovery.Ninety-nine patients were allocated to one of three continuous femoral nerve block groups for this randomized, placebo-controlled, double-blind trial: a high concentration group (ropivacaine 0.2% infusion), a low concentration group (ropivacaine 0.1% infusion), or a placebo infusion group (saline 0.9% infusion). Infusions were discontinued on postoperative Day (POD) 2. The primary outcome was time to discharge readiness. Secondary outcomes included opioid consumption, pain, and functional outcomes. Ninety-three patients completed the study protocol; the study was halted early because of unanticipated changes to pain protocols at the host institution, by which time only 61% of the required number of patients had been enrolled.With the numbers available, the mean time to discharge readiness was not different between groups (high concentration group, 62 hours [95% confidence interval [CI], 51-72 hours]; low concentration group, 73 hours [95% CI, 63-83 hours]; placebo infusion group 65 hours [95% CI, 56-75 hours]; p = 0.27). Patients in the low concentration group consumed significantly less morphine during the period of infusion (POD 1, high concentration group, 56 mg [95% CI, 42-70 mg]; low concentration group, 35 mg [95% CI, 27-43 mg]; placebo infusion group, 48 mg [95% CI, 38-59 mg], p = 0.02; POD 2, high concentration group, 50 mg [95% CI, 41-60 mg]; low concentration group, 33 mg [95% CI, 24-42 mg]; placebo infusion group, 39 mg [95% CI, 30-48 mg], p = 0.04); however, there were no important differences in pain scores or opioid-related side effects with the numbers available. Likewise, there were no important differences in functional outcomes between groups.Based on this study, which was terminated prematurely before the desired sample size could be achieved, we were unable to demonstrate that varying the concentration and volume of a fixed-dose ropivacaine infusion for continuous femoral nerve block influences time to discharge readiness when compared with a conventional single-injection femoral nerve block after TKA. A low concentration of ropivacaine infusion can reduce postoperative opioid consumption but without any important differences in pain scores, side effects, or functional outcomes. These pilot data may be used to inform the statistical power of future randomized trials.Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Dataset Information

No effect of double nerve block of the lateral cutaneous nerve and subcostal nerves in total hip arthroplasty.

Publications

No effect of double nerve block of the lateral cutaneous nerve and subcostal nerves in total hip arthroplasty.

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