Pain Management Following Total Hip Arthroplasty
Condition: Postoperative Pain Intensity; Rescue Pain Requirements
MeSH terms: Pain, Postoperative; Pain
Study type: Interventional
Phase: Phase 3

Summary: 
      Total hip arthroplasty (THA) is a common and standardized procedure. Postoperative mortality
      after hip joint replacement is low but some complications remain, including chronic
      post-surgical pain (1), hip dislocation (2), infection (3), and deep vein thrombosis (4).
      Strategies that have been identified to reduce morbidity and mortality include: posterior
      surgical approach, mechanical and pharmacological prophylaxis of deep vein thrombosis, and
      the use of spinal anesthesia (5). One of the important factors for patient satisfaction with
      lower limb arthroplasty is good postoperative pain management (6). Poorly managed
      postoperative pain can lead to chronic post-surgical pain and therefore aggressive
      postoperative pain management is important (7). Several different methods have been used to
      treat postoperative pain following THA. Recently, local infiltration analgesia (LIA) using a
      combination of large volume local anesthetics (LA) and non-steroidal anti-inflammatory agents
      (NSAID) injected systematically peri-articularly has been used for pain management with
      variable success (8). We found that better analgesia could be achieved when using LIA
      compared to intrathecal morphine during the first few days postoperatively (9,10).

      Ultrasound techniques are commonly used for peripheral nerve blocks and have been shown to
      reduce pain intensity and may be considered by many to be a standard of care. Specifically,
      the 3-in-1 block has been commonly used because of its ease of application and good pain
      management following total hip arthroplasty. The present study aims to compare postoperative
      pain intensity following local infiltration analgesia with a standardised 3-in-1 block for
      total hip arthroplasty.
    

Detailed description: 
      Sixty ASA I-II patients undergoing THA would be randomised to one of two groups in a
      double-blind study:

      Group LIA: A total of 151.5 ml of a combination of 0.2% ropivacaine (150 ml), 30 mg ketorolac
      (1 ml) and 0.5 mg (0.5 ml) adrenaline was administered systematically peri-articularly during
      THA and 30 ml of normal saline for ultrasound-guided 3-in-1 block Group Femoral block:
      Received 30 ml of ropivacaine 0,75% for ultrasound-guided 3-in-1 block and a total of 151.5
      ml of normal saline peri-articularly.

      All patients would receive spinal anaesthesia with 0.5% heavy bupivacaine for surgery

      Postoperatively, the following parameters would be measured:

        1. Pain intensity at fixed time intervals during 0-7 days and thereafter at weekly
           intervals for 1 month

        2. Rescue morphine consumption during 0-4, 4-24 and 24-48 h

        3. Side effects and complications

        4. Home readiness and length of hospital stay

        5. Chronic pain intensity measured after 3 and 6 months using the Brief Pain Inventory

        6. Plasma Cytokine concentration at fixed intervals

        7. Motor block using Bromage scale

        8. EQ5D and HOOS questionnaires
    

Intervention name(s): ropivacaine + ketorolac + adrenaline
Intervention type(s): Drug
Intervention description(s): A combination of drugs injected locally for postoperative pain management
Intervention MeSH terms: Ketorolac; Epinephrine; Racepinephrine; Ropivacaine; Epinephryl borate
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: postoperative pain; morphine; total hip arthroplasty; femoral nerve block