Local infiltration analgesia or femoral nerve block for postoperative pain management in patients undergoing total hip arthroplasty. A randomized, double-blind study
Authors: Kuchálik Ján , Magnuson Anders , Lundin Anders , Gupta Anil 
Published: June 2017

Abstract

Background and aims
Several methods for pain management following total hip arthroplasty (THA) have been described but the best postoperative pain management technique remains uncertain. We compared surgeon applied local infiltration analgesia (LIA) with anaesthesiologist performed femoral nerve block (FNB) using ultrasound. The primary aim was to assess pain intensity 24 h after THA.

Methods
In this randomized, double-blind study, 56 patients (ASA I-III) undergoing THA consented to participate. In Group FNB, patients received an ultrasound-guided femoral nerve block using 30 ml of ropivacaine 7.5 mg/ml (225 mg) while Group LIA received a similar volume of saline. Spinal anaesthesia was then performed and bupivacaine heavy, 3–3.5 ml injected depending on patient characteristics. During surgery, patients in Group LIA received a mixture of 300 mg (150 ml) ropivacaine, ketorolac 30 mg (1 ml) and adrenaline 0.5 mg (0.5 ml) (total volume 151.5 ml) peri-articularly and subcutaneously while Group FNB received 151.5 ml of saline peri-articularly in a systematic way by the surgeon. A multi-hole catheter was placed with the tip placed intra-articularly at the end of surgery in both groups. After 23 h, the LIA mixture consisting of 20 ml ropivacaine (7.5 mg/ml), ketorolac 30 mg (1 ml), adrenaline 0.1 mg (1 ml) (total volume 22 ml) was injected in Group LIA and the same volume of saline in Group FNB. Postoperative pain, analgesic consumption (postoperative and post-discharge), side effects, home discharge, quality of life and hip function were recorded, the latter up to 6 months after surgery.

Results
Postoperative pain intensity was significantly lower in Group LIA compared to Group FNB during mobilization at 24 h (primary endpoint), mean difference 1.8 NRS units (95% CI 0.7–2.9) (P = 0.006), at rest after 4 h (P = 0.029) and on standing after 24 (P = 0.0003) and 48 h (P = 0.043). Rescue morphine consumption was also significantly lower in Group LIA during 0–24, mean difference 13.5 mg (95% CI, 6.1–20.9) (P = 0.002) postoperatively. Motor block was greater at 6 h (P = 0.029) postoperatively in Group FNB. Two patients (one in each group) had persistent post-surgical pain (NRS > 3) at 3 months (3.6%) but none at 6 month. No other differences were found between the groups.

Conclusion
Local infiltration analgesia significantly reduces pain intensity on standing and mobilization, and rescue analgesic consumption compared to femoral nerve block without causing significant side effects. The superior analgesia in the LIA group may result from the secondary injection at 23 h postoperatively and needs to be furtherevaluated in future studies. No differences were found in home discharge, quality of life and hip dysfunction between the groups.

Implication
Local infiltration analgesia is the preferred method for postoperative pain management following THA compared to single-shot femoral nerve block.
© 2017 Scandinavian Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.