We reviewed eight high quality randomized clinical trials that represented the best available evidence to assess the effectiveness of fascia iliaca compartment, lumbar plexus nerve, and quadratus lumborum regional nerve blocks to reduce pain and/or opioid consumption following primary THA.[2-9] Although additional regional nerve blocks have been studied with randomized clinical trials following primary THA, the workgroup excluded these alternative regional nerve blocks because of limited evidence and lack of clinical relevance. For instance, the use of a femoral or sciatic nerve block is not as anatomically relevant compared to more widely used regional nerve blocks following primary THA. Additionally, the only comparison between types of regional nerve blocks was the single high quality randomized clinical trial comparing the fascia iliaca compartment and lumbar plexus nerve blocks to reduce pain and/or opioid consumption postoperatively following primary THA.[10] The same limitations encountered in the prior clinical practice guidelines prevented the use of meta-analysis due to the inconsistency in the reporting of outcomes and timepoints for reporting the outcomes.[11-14] Therefore, qualitative review of the available literature was used to develop the recommendations.
Among the regional nerve blocks evaluated for the clinical practice guidelines, five high quality studies investigated single-shot fascia iliaca compartment block, two high quality studies investigated single-shot lumbar plexus nerve block, and one high quality study investigated single-shot quadratus lumborum block.[2-9] Qualitative analysis of each regional nerve block consistently demonstrated an overwhelmingly significant response of a reduction in postoperative pain and opioid consumption for all three types of regional nerve blocks.[2-9] Although no significant difference was observed in adverse events between the regional nerve blocks and controls, the reporting was focused on adverse events related to opioid use (e.g., nausea/vomiting, pruritus, somnolence, and respiratory depression).[2-9] The lumbar plexus nerve and quadratus lumborum blocks are technically demanding procedures and are considered “deep blocks,” which have the same anticoagulation restrictions as neuraxial anesthesia.[15] In addition, lumbar plexus nerve and quadratus lumborum blocks require post-procedure monitoring because there is the possibility of bilateral spread due to placement in the epidural or intrathecal spaces.[15] In contrast, the fascia iliaca compartment block is a less technically demanding procedure without the same safety concerns, and is not considered a “deep block.”[15]
The workgroup downgraded the strength of the recommendations for fascia iliaca compartment, lumbar plexus nerve, and quadratus lumborum blocks based on the increased cost associated with the blocks, particularly in light of our advancements with effective multimodal analgesia of oral medications and peri-articular local anesthetic infiltration for THA. In addition, the lack of appropriate reporting of adverse events for lumbar plexus nerve and quadratus lumborum blocks were an additional concern cited for downgrading the strength of the recommendation for lumbar plexus nerve and quadratus lumborum blocks. Although the workgroup would advocate for reporting of adverse events specific to the nerve blocks, the relatively small sample sizes may not be large enough to accurately represent the frequency of these adverse events.
Among the clinically relevant regional nerve blocks for primary THA, only a single high quality randomized clinical trial offered a comparison between nerve blocks.[10] When comparing the fascia iliaca compartment and lumbar plexus nerve blocks, it demonstrated no significant difference in postoperative pain and opioid consumption.[10] Therefore, when a regional nerve block is used after primary THA, the workgroup would favor a fascia iliaca compartment block, as the increased risks and technical demands of a lumbar plexus nerve block do not come with any additional benefit.
- Bober K, Kadado A, Charters M, Ayoola A, North T. Pain Control After Total Hip Arthroplasty: A Randomized Controlled Trial Determining Efficacy of Fascia Iliaca Compartment Blocks in the Immediate Postoperative Period. The Journal of arthroplasty 35(6S): S241-S245, 2020 DOI: 10.1016/j.arth.2020.02.020.
- Bugada D, Bellini V, Lorini LF, Mariano ER. Update on Selective Regional Analgesia for Hip Surgery Patients. Anesthesiol Clin 36(3): 403-415, 2018 DOI: 10.1016/j.anclin.2018.04.001.
- Desmet M, Vermeylen K, Van Herreweghe I, Carlier L, Soetens F, Lambrecht S, Croes K, Pottel H, Van de Velde M. A Longitudinal Supra-Inguinal Fascia Iliaca Compartment Block Reduces Morphine Consumption After Total Hip Arthroplasty. Reg Anesth Pain Med 42(3): 327-333, 2017 DOI: 10.1097/AAP.0000000000000543.
- Fillingham YA, Hannon CP, Erens GA, Anesthesia A, Analgesia Clinical Practice Guideline W, Hamilton WG, Della Valle CJ. Acetaminophen in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. The Journal of arthroplasty 35(10): 2697-2699, 2020 DOI: 10.1016/j.arth.2020.05.030.
- Fillingham YA, Hannon CP, Roberts KC, Anesthesia A, Analgesia Clinical Practice Guideline W, Hamilton WG, Della Valle CJ. Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. The Journal of arthroplasty 35(10): 2704-2708, 2020 DOI: 10.1016/j.arth.2020.05.043.
- Green C, Byrne AM, O'Loughlin P, Molony D, Harmon D, Masterson E. Surgeon delivered psoas compartment block in total hip arthroplasty. The Journal of arthroplasty 29(2): 393-396, 2014 DOI: 10.1016/j.arth.2013.06.028.
- Hannon CP, Fillingham YA, Browne JA, Schemitsch EH, Anesthesia A, Analgesia Clinical Practice Guideline W, Buvanendran A, Hamilton WG, Della Valle CJ. Gabapentinoids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. The Journal of arthroplasty 35(10): 2700-2703, 2020 DOI: 10.1016/j.arth.2020.05.031.
- Hannon CP, Fillingham YA, Nam D, Courtney PM, Curtin BM, Vigdorchik JM, Buvanendran A, Hamilton WG, Della Valle CJ, Anesthesia A, Analgesia Clinical Practice Guideline W. Opioids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. The Journal of arthroplasty 35(10): 2709-2714, 2020 DOI: 10.1016/j.arth.2
- Hua X HY, Chen D, Xiao Y, Luo L. Efficacy and safety of ultrasound-guided fascia iliaca compartment block using dexmedetomidine combined with ropivacaine in aged patients undergoing hip replacement. International Journal of Clinical and Experimental Medicine 10(12): 16484-16491, 2017.
- Kukreja P, MacBeth L, Sturdivant A, Morgan CJ, Ghanem E, Kalagara H, Chan VWS. Anterior quadratus lumborum block analgesia for total hip arthroplasty: a randomized, controlled study. Reg Anesth Pain Med, 2019 DOI: 10.1136/rapm-2019- 100804.
- Liu X, Hu X, Li R, Zhang Y. Combination of post-fascia iliaca compartment block and dexmedetomidine in pain and inflammation control after total hip arthroplasty for elder patients: a randomized control study. J Orthop Surg Res 15(1): 42, 2020 DOI: 10.1186/s13018-020-1562-6.
- Perry CR, Jr., Fahs AM, Kurdziel MD, Koueiter DM, Fayne RJ, Verner JJ. Intraoperative Psoas Compartment Block vs Preoperative Fascia Iliaca Block for Pain Control After Direct Anterior Total Hip Arthroplasty: A Randomized Controlled Trial. The Journal of arthroplasty 33(6): 1770-1774, 2018 DOI: 10.1016/j.arth.2018.01.010.
- Stevens M, Harrison G, McGrail M. A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty. Anaesth Intensive Care 35(6): 949-952, 2007 DOI: 10.1177/0310057X0703500615.