A Comparative Evaluation of Quadratus Lumborum Block Versus Fascia Iliaca Nerve Block for Patients Undergoing Elective Total Hip Replacement Under Spinal Anaesthesia
Phase: NA
Conditions: Hip Replacement
Sponsor: The Adelaide and Meath Hospital, incorporating The National Children's Hospital

Study Protocol Cover Sheet 
 
Official Title: 
A Comparative Evaluation of Quadratus Lumborum Block Versus Fascia Iliaca Nerve 
Block for Patients Undergoing Elective Total Hip Replacement Under Spinal Anaesthesia 
NCT number: 
not yet known 
Unique Protocol ID: 
2017/1/01-2018-01 
Date of document: 
30/04/2018 
 
 
 
 
 
 
 
 
 
 
 
A COMPARATIVE EVALUATION OF QUADRATUS LUMBORUM BLOCK 
VERSUS FASCIA ILIACA NERVE BLOCK FOR PATIENTS UNDERGOING 
ELECTIVE TOTAL HIP REPLACEMENT UNDER SPINAL ANAESTHESIA 

 
INTRODUCTION 
Total hip replacement is a commonly performed surgical procedure with up to 4,500 
procedures performed annually in Ireland and up to 400,000 per year in the Unites States.1 
Most of the patients experience moderate to severe pain in the initial post-operative period.2 
Multimodal analgesia with peripheral nerve blockade is recommended as gold standard for 
management of lower limb joint replacements. The limitations with peripheral nerve blocks 
include limited duration of effect with single shot injections and associated motor block which 
can delay rehabilitation. 
Transmuscular Quadratus lumborum (TQL) block has been described recently as an effective 
option for post-operative analgesia in patients undergoing total hip replacements with single 
injection providing analgesia for up to 24 hours.3,4  We hypothesise that a single injection TQL 
block when compared to single injection fascia iliaca block (FIB) will provide better analgesia 
and less motor block in the initial 24 hour period.  
METHODS 
This prospective, randomised controlled trial will be conducted in patients undergoing total hip 
replacement surgeries under spinal anaesthesia. Ethical committee approval has been obtained 
from the Research Ethics Committee (REC) in Tallaght hospital and the study will be registered 
in Clinicaltrials.gov database.  All patients scheduled for elective total hip replacement surgery 
will be contacted up to 24 hours prior to the surgery by telephone. Information about the nature 
and purpose of the study will be provided to them by Anaesthetic trainees who are part of the 
study team. Informed written consent will be obtained from all consenting patients prior to 
participation in the study.  
Randomisation will be carried out by computer generated random numbers and allocation will 
be enclosed in sealed envelopes. Patients and Outcome assessors will be blinded to the study 
group. The following are the inclusion and exclusion criteria. 
Inclusion Criteria 
Patients undergoing elective total hip replacements under spinal anaesthesia 
ASA 1-3 
Age > 18 yrs. 

Written informed consent 
Exclusion Criteria 
Local infection 
Allergy to local anaesthetics 
Severe coagulopathy 
Primary Outcome Measure: 
24 hour morphine consumption between the two groups 
Secondary outcome 
Motor block assessed by the Modified Bromage Scale  
Numerical Rating Scale (NRS) score for pain  
Detailed description 
Consenting patients will be randomised to undergo either Transmuscular Quadratus Lumborum 
block (TQL)  or Fascia Iliaca Block (FIB).  
On arrival to the anesthesia induction room baseline monitoring (non-invasive blood pressure, 
pulse oximetry and 3 lead ECG) and intravenous access will be established. Patients in both 
groups will then be positioned sitting on a level trolley with feet resting on a foot rest. They 
will be given a pillow to hug and requested to maintain an arched back posture with an assistant 
holding the patient to aid positioning. No sedation will be given prior to or during 
administration of spinal anesthesia. 
Spinal anaesthesia will be performed under strict aseptic precautions (Chlorhexidine 0.5% for 
skin decontamination with anaesthetist performing the procedure scrubbed wearing sterile 
gown, cap and sterile gloves).  25G Whitacre needle will be used and 3.2ml 0.5% plain 
bupivacaine will be administered. 
Trasnmuscular Quadratus Lumborum Block (TQL): 
Following the administration of spinal anaesthetic, the patient will be positioned laterally with 
the operating side as the non dependant side. Skin decontamination of the block site will be 
done with 2% Chlorhexidine (Chloraprep 3 ml applicator, CareFusion Corporation, San Diego, 
CA 92130,USA).Under strict aseptic precautions (cap, mask,sterile gloves, sterile probe cover 

and sterile ultrasound gel), a 100 mm (Stimuplex® Ultra 360® 22 gauge insulated echogenic 
needle with 30° bevel and extension set) needle will be used to perform TQL block. A 
curvilinear low frequency probe (2-5 MHz) will be placed above the iliac crest and the 
following structures will be identified i) Transverse process ii) Erector spinae muscle iii) 
Quadratus lumborum muscle iv) Psoas major muscle. The needle will be advanced by in-plane 
technique and local anaesthetic will be deposited between psoas major and quadratus 
lumborum muscles. 20 ml of 0.25% bupivacaine will be administered under USG guidance 
following careful intermittent aspiration.  
Fascia Iliaca Block (FIB):  
Following the administration of spinal anaesthetic, the patient will be positioned supine. Skin 
decontamination of the block site will be done with 2% Chlorhexidine (Chloraprep 3 ml 
applicator, CareFusion Corporation, San Diego, CA 92130,USA).Under strict aseptic 
precautions (cap, mask, sterile gloves, sterile probe cover and sterile ultrasound gel), a 80 mm 
(Stimuplex® Ultra 360® 22 gauge insulated echogenic needle with 30° bevel and extension 
set) needle will be used to perform FIB. A linear high frequency probe (8-13 MHz) will be 
placed along the inguinal crease to identify the femoral artery, femoral nerve and Iliacus fascia. 
The needle will be advanced by in-plane technique and local anaesthetic will be deposited 
under the fascial iliaca. 20 ml of 0.25% bupivacaine will be administered under USG guidance 
following careful intermittent aspiration.  
All patients (unless contraindicated) will receive intra-operative intravenous medication viz: 
paracetamol 1gm, Parecoxib 40mg, tranexamic acid 1gm and antibiotics as per local guidelines. 
Perioperative sedation will be left to the discretion of the anaesthetist. 
Postoperatively:   
Following transfer to recovery unit, if patient reports pain score by numerical rating score  >3, 
morphine 2 mg increments will be given intravenously by the recovery staff. This will be 
repeated every 5 minutes till the pain score is <4. In patients needing more than 10 mg of 
morphine in the recovery, anaesthetist will be requested to review the patient. Post-operatively, 
in the absence of contraindications, all patients will be prescribed regular paracetamol 1g every 
6 hourly and celecoxib 200 mg, 12 hourly. Anti-emetics (ondansetron 4 mg, 8 hourly and 
Cyclizine 50 mg, 8 hourly) will be prescribed for all patients to be administered as required. 
All patients will receive morphine PCA in post-operative period. All patients will be reviewed 
at 6 hours and 24 hours to assess the pain scores and motor block. 

 
Statistics: 
A sample size of 46 patients (23 per group) is estimated based on 50% reduction in morphine 
consumption with power of 80% and alfa error of 0.05%. To allow for the drop outs, we aim 
to recruit 50 patients in total. 
 
 
 
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