Efficacy of Fascia Iliaca Block Versus Intraoperative Nerve Infiltration During Anterior Hip Replacement Surgery
Condition: Pain, Postoperative
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      Surgical trauma causes nerve sensitization leading to amplification and prolongation of
      postoperative pain. In experimental studies, pre-injury neural blockade using local
      anesthetics has been shown to reduce post-injury sensitization of the central nervous system,
      while similar techniques applied after the injury had less or no effect (FILOS).
      Investigators have therefore designed this study to examine the timing of FICB
      (pre-operatively versus intra-operatively) on postoperative pain in patients undergoing
      anterior hip replacement surgery.
    

Detailed description: 
      Though still uncommonly used in the United States, the popularity of the anterior approach
      for total hip replacement is rapidly growing because of its clinical advantages.
      Rehabilitation is simplified and accelerated, dislocation risk is reduced, leg length is more
      accurately controlled, and incision is smaller than with traditional approaches (GOEBEL).
      Nevertheless, although pain is lessened, it is still considerable, and new techniques have
      been developed to improve postoperative pain control for this procedure.

      Surgical incision and tissue trauma result in postoperative pain. Regional pain blocks,
      especially when done under ultrasound guidance, have proven to be extremely effective at
      reducing postoperative pain and improving patient satisfaction. One such block, the fascia
      iliaca compartment block (FICB), has been shown to be effective in controlling pain
      associated with surgery involving the hip and femur.

      Although possible without ultrasound guidance, using this technique allows for identification
      of specific tissue planes and precise placement of medication near the nerves responsible for
      postoperative pain. Using ultrasound, the superficial fascial layer of the iliopsoas muscle
      is identified at the anterior edge of the ilium, and a needle is placed just beneath that
      fascia. A high volume of local anesthetic is then injected under ultrasound guidance,
      ensuring cephalad spread of medication, in an attempt to provide anesthesia of the lateral
      femoral cutaneous, femoral and obturator nerves.

      Unlike other approaches to hip replacement, anterior repair allows for direct visualization
      of the fascial layers described above. This allows for direct injection of local anesthetic
      beneath this fascia, potentially obviating the need for preoperatively performed, ultrasound
      guided, FICB. The primary differences in approach (ultrasound guided preop versus direct
      visualization intraop) is the timing of injection, and it is unclear if nerve block prior to
      or after tissue damage affects postoperative pain in these patients.

      Surgical trauma causes nerve sensitization leading to amplification and prolongation of
      postoperative pain. In experimental studies, pre-injury neural blockade using local
      anesthetics has been shown to reduce post-injury sensitization of the central nervous system,
      while similar techniques applied after the injury had less or no effect (FILOS).
      Investigators have therefore designed this study to examine the timing of FICB
      (pre-operatively versus intra-operatively) on postoperative pain in patients undergoing
      anterior hip replacement surgery.
    

Intervention name(s): Pre-operative Ultrasound FICB Group; Intra-operative FICB Group
Intervention type(s): Procedure; Procedure
Intervention description(s): Enrolled subjects will receive FICB with 50cc of 0.3% ropivacaine. Blocks will be performed under ultrasound guidance with an in-plane technique by a single study investigator in the preoperative area. Although possible without ultrasound guidance, using this technique allows for identification of specific tissue planes and precise placement of medication near the nerves responsible for postoperative pain. Using ultrasound, the superficial fascial layer of the iliopsoas muscle is identified at the anterior edge of the ilium, and a needle is placed just beneath that fascia. A high volume of local anesthetic is then injected under ultrasound guidance, ensuring cephalad spread of medication in an attempt to provide anesthesia of the lateral femoral cutaneous, femoral and obturator nerves.; Enrolled subjects will receive FICB with 50cc of 0.3% ropivacaine. Blocks will be performed intra-operatively under direct surgeon visualization, in the operating room. Unlike other approaches to hip replacement, anterior repair allows for direct visualization of the fascial layers described above. This allows for direct injection of local anesthetic beneath this fascia, potentially obviating the need for preoperatively performed, ultrasound guided, FICB.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: joint replacement; total hip replacement; regional pain block; ultrasound guidance; fascia iliaca compartment block