Lumbar Plexus vs Quadratus Lumborum Block in Post-operative Pain Following Total Hip Replacement
Condition: Hip Osteoarthritis
MeSH terms: Osteoarthritis, Hip; Pain, Postoperative
Intervention: Lumbar plexus block; Quadratus lumborum type 3 block; Ropivacaine injection
Intervention description: Patient will be positioned in lateral decubitus position with side to be blocked facing upwards. Midline will be identified by palpating the spinous process. Intercristal line will be drawn connecting iliac crests. The point of needle insertion will be 4 cm lateral to the intersection of both lines. The transverse process will first contact with a finder needle. Subsequently an 18 gauge 10 cm insulated needle will be used and advanced until it contacted the transverse process. Needle will then be redirected cephalad or caudad and advanced 2 cm, until the quadriceps femoris twitch is obtained. Local anesthetic will then be injected after confirming a motor response between 0.3-0.5 milli amperes.; Patient will be placed in a lateral position with the side to be blocked facing up. A low frequency transducer will be used to identify three layers of abdominal musculature, probe will be then moved posteriorly till the transverse abdominus aponeurosis is visualized, the QL muscle is then identified by tracing the aponeurosis posteriorly. The transducer is then moved more posteriorly to visualize the shadow of transverse process and the origin of QL muscle. Psoas muscle is then identified lying anterior to the QL muscle. A 22 gauge 8 cm is inserted in plane posterior to the probe and advanced intramuscularly through the QL to interfacial plane between QL and psoas major and local anesthetic is deposited.; 0.5% ropivacaine 20 ml (100 mg) will be injected for both groups.
Intervention MeSH terms: Ropivacaine
Phase: Phase 4
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Lumbar plexus block vs Quadratus lumborum type 3 block
Masking: Double (Participant, Outcomes Assessor)
Masking description: The person who perform the block will be unblinded. The participants and the outcomes assessor will be blinded to the treatment allocations.
Enrollment: 46.0
Sex: All
Minimum age: 18 Years
Maximum age: 90 Years
Healthy volunteers: No
Keywords: lumbar plexus block; quadratus lumborum block; total hip arthroplasty

Summary:

      The Lumbar Plexus (LP) block is currently used as the standard-of-care regional anesthesia
      technique to provide postoperative pain management after primary hip replacement surgery at
      UPMC Shadyside Hospital. However, the LP technique is complex and can be associated with
      potentially serious side effects, including nerve injury, major bleeding, retroperitoneal
      hematoma, and intrathecal injection of local anesthetic. In rare instances the LP block can
      also lead to motor blockade, interfering with early ambulation. There are several case
      reports of Quadratus Lumborum inter-fascial block (QL3) giving equally adequate pain relief
      after total hip replacement surgery, and this QL3 block is performed routinely at this
      institution. The benefits to inter-fascial administration of local anesthetic include the
      avoidance of theoretical nerve injury, bleeding and intrathecal anesthetic administration
      associated with the direct interaction between the nerve and the nerve block needle. The
      purpose of this study is to show that QL3 block is non-inferior to the standard-of-care
      lumbar plexus block and should be used more regularly in hip replacement surgery. The study
      will be conducted as a prospective, randomized (1:1), double-blind, non-inferiority,
      active-comparator trial. The investigators plan to enroll 40 subjects, 20 in each treatment
      group. This study will prospectively investigate the efficacy of QL3 versus Classic LP block
      for post-operative pain management in subjects undergoing primary, unilateral hip replacement
      surgery and prospectively compare QL3 versus Classic LP block in time to mobilization and
      physical therapy response. Primary outcome measures include pain at rest and with movement at
      6, 12 and 24 hours after surgery. Secondary outcomes will be time for first request for pain
      medication, total pain medications (narcotics and non-narcotic analgesics) given in 24 hours
      and the time of participant's ability to walk 100 feet as recorded by a physical therapist.
    

Eligibility criteria:

        Inclusion Criteria:

          1. Patients 18-90 years old

          2. Primary unilateral total hip arthroplasty

          3. BMI 20 - 36

          4. Male and Female

          5. All races

        Exclusion Criteria:

          1. Patient refusal

          2. ASA class > or = 4

          3. Pregnancy

          4. Any condition precluding patient going home with in 24 hours of surgery

          5. Non-English speaking or inability to participate in the study

          6. Patients with coagulopathy or on therapeutic anticoagulation

          7. Chronic Steroid Use

          8. Narcotic Addiction