Preoperative Quadratus Lumborum Block Reduces Opioid Requirements in the Immediate Postoperative Period Following Hip Arthroscopy: A Randomized, Blinded Clinical Trial

Demographic and Socioeconomic Patient Data Are Rarely Included in Randomized Controlled Trials for Femoral Acetabular Impingement and Hip Arthroscopy: A Systematic Review

Purpose

To determine the rate of reporting for sociodemographic variables in randomized controlled trials (RCTs) investigating femoral acetabular impingement (FAI) and hip arthroscopy.

Methods

PubMed, Scopus, and Web of Science were queried for articles relating to FAI and hip arthroscopy. Articles included in final analysis were RCTs investigating operative management of FAI. Included RCTs were analyzed for reporting of age and sex or gender as well as the following sociodemographic variables: race, ethnicity, insurance status, income, housing status, work status, and education level in the results section or any section of the paper. Data was analyzed using χ2 and Fisher exact tests with significance defined as P < .05.

Results

Forty-eight RCTs were identified from 2011 to 2023. Age was reported in 48 of 48 (100%) of included papers; sex or gender was reported in 47 of 48 (97.9%). Reporting of sociodemographic variables in any section respectively was: race (7/48, 14.6%), ethnicity (4/48, 8.33%), insurance status (0/48, 0%), income (1/48, 2.08%), housing status (0/48, 0%), work status (3/48, 6.25%), and education (2/48, 4.17%). There was no significant difference for reporting demographic variables with respect to journal or year of publication (P = .666 and P = .761, respectively). Sociodemographic variables (9/48) were reported significantly less frequently than age and sex or gender (48/48) (P < .001).

Conclusions

This study found that sociodemographic variables in FAI and hip arthroscopy RCTs are reported with much lower frequency than age and sex or gender. These findings may demonstrate the need to include patient sociodemographic data in RCTs so that their results can be better generalized and applied to the appropriate patient population.

Level of Evidence

Level II, systematic review of level I and II evidence.

Transmuscular Quadratus Lumborum Block Does Not Provide Significant Benefit for Primary Hip Arthroscopy with Pericapsular Infiltration: A Randomized Control Trial

PURPOSE

To prospectively evaluate the effectiveness of the transmuscular quadratus lumborum block (TQLB) with pericapsular injection (PCI) versus PCI alone in patients undergoing hip arthroscopy for treatment of femoroacetabular impingement (FAI) in terms of perioperative pain control, as well as postoperative function in the postoperative anesthesia unit (PACU) setting.

METHODS

Patients undergoing hip arthroscopy for FAI were prospectively randomized to receive 30 mL of 0.5% bupivacaine in a TQLB (n = 52) with PCI versus PCI alone (n = 51). The PCI included 20 mL of 0.25% bupivacaine given by the surgeon. All analyzed patients received general anesthesia. The primary outcome was postoperative pain scores assessed via the numerical rating scale (NRS) at 30 minutes postoperatively and immediately prior to discharge. Secondary outcomes were opioid utilization, expressed as morphine milligram equivalents (MMEs), PACU recovery time, quadriceps strength (assessed after completion of PACU phase 1 criteria), and adverse events (nausea/vomiting).

RESULTS

Average age, body mass index, and preoperative pain assessment were not significantly different between groups. There were no differences in NRS pain scores preoperatively, 30 minutes postoperatively, or immediately prior to discharge between groups (P > .05). Intraoperative opioid consumption was significantly lower in the TQLB group (MME: 16.8 ± 7.9) compared to controls (MME 20.6 ± 8.0; P = .009). However, there was no difference in the total opioid consumption (P > .05). There was no significant difference in total PACU length of stay (minutes) between the treatment (133.0 ± 48) and control groups (123.5 ± 47; P > .05). Quadriceps weakness was not significantly different between groups (P = .2). There was no difference in the number of patients that experienced nausea or vomiting between the TQLB group and control group (13% vs 16%; P = .99). Neither group had any reported serious adverse events.

CONCLUSIONS

TQLB and PCI do not improve postoperative pain scores or total opioid consumption compared to PCI alone. TQLB may decrease the amount of intraoperative opiate usage.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Editorial Commentary: Hip Arthroscopy Pain Management With Surgeon-Administered Pericapusular Injection Is Fast, Safe, Inexpensive, and Effective

Regional pain management after hip arthroscopy is challenging. The hip capsule alone has a complex and highly variable innervation, including contributions from articular branches of the femoral, obturator, accessory obturator, accessory femoral, superior gluteal, accessory superior gluteal, inferior gluteal, sciatic, and posterior femoral cutaneous nerves, nerve to the quadratus femoris, as well as a direct supply from the lumbosacral plexus. Thus, it is unrealistic to expect a traditional peripheral nerve block, including blocks of the proximal lumbar plexus, femoral nerve, and fascia iliaca region to provide thorough hip analgesia without inducing quadriceps weakness that could result in a patient experiencing a fall during the postoperative period. In addition, newer, sensory-only blocks, such as quadratus lumborum or pericapsular nerve group blocks, have not been shown to be superior to simple pericapsular injection (PCI). Hip arthroscopy pain management using surgeon administered PCI is fast, safe, inexpensive, and effective. While not perfect, PCI is the best option among current choices.

Efficacy of regional anesthesia in hip preservation surgeries: a systematic review

The purpose of this study was to review the current literature on perioperative pain management in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation. A systematic review of the literature published from January 2000 to December 2022 was performed. Selection criteria included published randomized controlled trials, prospective reviews and retrospective reviews of all human subjects undergoing hip preservation surgery. Exclusion criteria included case reports, animal studies and studies not reporting perioperative pain control protocols. Thirty-four studies included hip arthroscopy in which peripheral nerve blocks were associated with a significant reduction in pain score (P = 0.037) compared with general anesthesia alone. However, no pain control modality was associated with a significant difference in postanesthesia care unit opioid use (P = 0.127) or length of stay (P = 0.251) compared with general anesthesia alone. Falls were the most common complication reported, accounting for 37% of all complications. Five studies included periacetabular osteotomy and surgical hip dislocation in which peripheral nerve blocks were associated with an 18% reduction in pain on postoperative Day 2, a 48% reduction in cumulative opioid use on postoperative Day 2 and a 40% reduction in hospital stay. Due to the low sample size of the periacetabular osteotomy and surgical hip dislocation studies, we were unable to determine the significant difference between the means. Due to significant between-study heterogeneity, additional studies with congruent outcome measures need to be conducted to determine the efficacy of regional anesthesia in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation.

Comparison of lateral quadratus lumborum and lumbar plexus blocks for postoperative analgesia following total hip arthroplasty: a randomized clinical trial

INTRODUCTION

Effective analgesia after total hip arthroplasty must minimize pain and optimize early ambulation. Lumbar plexus blocks (LPBs) provide analgesia but may cause motor weakness. Quadratus lumborum blocks (QLBs) may provide analgesia with preserved motor strength.

METHODS

This trial randomized subjects scheduled for elective hip arthroplasty to receive an LPB or lateral QLB for postoperative analgesia. The primary outcome was opioid consumption at 12-hour postoperative. Non-inferiority of lateral QLBs compared with LPBs was conducted using a one-sided two-sample t-test. Secondary outcomes included pain scores, cumulative opioid consumption, quadriceps strength, time to ambulation, and distance ambulated. Differences in pain scores and opioid consumption over time between groups were evaluated using a linear mixed model.

RESULTS

The trial consented and randomized 111 subjects and 103 completed the study: LPB (n=50) and lateral QLB (n=53). Mean (95% CI) cumulative opioid consumption (mg) at 12-hour postoperative was not found to be non-inferior in the lateral QLB (15.9 (12.7 to 19.2)) vs the LPB (12.7 (10.2 to 15.1)) group (p=0.625). Pain scores in postoperative anesthetic care unit (PACU) and 24-hour postoperative did not differ. The maximum distance ambulated did not differ, but lateral QLB patients were 2.4 times more likely to ambulate in the first 12 hours (p=0.024) and had significantly greater quadriceps strength in PACU (p<0.001).

DISCUSSION

Although we were unable to demonstrate non-inferiority for opioid consumption at 12-hour postoperative, strength and mobilization were improved in lateral QLB subjects.

TRIAL REGISTRATION NUMBER

NCT04402437.

Postoperative analgesic effectiveness of quadratus lumborum block: systematic review and meta-analysis for adult patients undergoing hip surgery

BACKGROUND

Quadratus lumborum block is a truncal block with several technique variations. It has been reported as providing effective analgesia for postoperative pain. The aim of this study is to determine the efficacy of the QL block in providing postoperative analgesia for hip surgery when compared with placebo or no block or other analgesic techniques.

METHODS

Randomized trials evaluating quadratus lumborum block benefits in elective hip surgery were sought. The primary outcome was the 24 h opioid requirement after surgery. Two independent reviewers selected the studies and extracted the data.

RESULTS

Thirteen randomized-controlled trials were included in this study. The included studies had significant heterogeneity regarding comparator groups; therefore, a limited quantitative analysis was undertaken for the comparison of QL block versus no block or placebo only. QL block reduced the opioid use by 15.78 (95% CI, 2.31 to 29.26) mg IME in the first postoperative 24 h compared with no block or placebo with no difference in static pain scores, pain grade was reduced by 2.95 (95% CI, 2.40 to 3.60) in the QL block group compared with placebo or no block in the first postoperative 24 h during movement.

CONCLUSIONS

Our meta-analysis indicates that QL block may be effective for analgesia in patients after hip surgery compared with placebo or no block. There is currently limited evidence comparing QL block with other analgesic techniques for hip surgery.

Editorial Commentary: Quadratus Lumborum Analgesia for Hip Arthroscopy: The New Kid on the (Nerve) Block

Quadratus lumborum (QL) nerve block is a new technique aimed to improve perioperative analgesia for patients undergoing hip arthroscopy. The QL block targets nerve roots from the lumbar plexus supplying the hip and is an alternative to the fascia iliaca compartment block, which has been shown to have variable effects on pain control while increasing motor weakness and postoperative fall risk. Although a recent Level I study showed decreased opioid consumption without increased motor weakness after QL block compared to sham block, another Level I study reported contrasting results with QL block demonstrating no improvement in pain control or opioid consumption compared to a multimodal pain regime after hip arthroscopy. These differing conclusions from high-level studies indicate further research is needed for QL block and that investigation of other potential nerve block options for hip arthroscopy patients, such as the PENG block, is warranted.

Efficacy of Quadratus Lumborum Block for Pain Control in Patients Undergoing Hip Surgeries: A Systematic Review and Meta-Analysis

BACKGROUND

Several studies have reported the use of anterior, posterior and lateral quadratus lumborum block (QLB) for pain control in hip surgeries. However, high-quality evidence is lacking. The current review aimed to summarize data on the efficacy of QLB for pain control in patients undergoing hip surgeries.

METHODS

PubMed, Embase, and Google Scholar databases were searched up to August 5, 2021 for randomized controlled trials (RCTs) or non-RCTs assessing the efficacy of QLB for any type of hip surgery.

RESULTS

Thirteen studies were included (nine RCTs and four non-RCTs). On pooled analysis, there was a statistically significant reduction of 24-h total opioid consumption in patients receiving QLB as compared to the control group (MD: -9.92, 95% CI: -16.35, -3.48 I 2 = 99% p = 0.003). We noted a statistically significant reduction of pain scores in the QLB group as compared to control group at 2-4 h (MD: -0.57, 95% CI: -0.98, -0.17 I 2 = 61% p = 0.005), 6-8 h (MD: -1.45, 95% CI: -2.09, -0.81 I 2 = 86% p < 0.00001), 12 h (MD: -1.12, 95% CI: -1.89, -0.34 I 2 = 93% p = 0.005), 24 h (MD: -0.71, 95% CI: -1.27, -0.15 I 2 = 89% p = 0.01) and 48 h (MD: -0.76, 95% CI: -1.37, -0.16 I 2 = 85% p = 0.01) after the procedure. There was a statistically significant reduction in the risk of nausea/vomiting (RR: 0.40, 95% CI: 0.18, 0.88 I 2 = 62% p = 0.02) in patients receiving QLB but no difference in the risk of pruritis (RR: 0.46, 95% CI: 0.17, 1.24 I 2 = 16% p = 0.13) and urinary retention (RR: 0.44, 95% CI: 0.19, 1.02 I 2 = 0% p = 0.06).

CONCLUSION

QLB as a part of a multimodal analgesic regimen reduces opioid consumption and pain scores in patients undergoing hip surgeries. The certainty of evidence based on GRADE was moderate. Despite the statistically significant results, the clinical relevance of the analgesic efficacy of QLB is debatable due to the small effect size.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021267861.