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Eppel B, Schneider MM, Gebhardt S, Balcarek P, Sobau C, Wawer Matos J, Zimmerer A. Pericapsular Nerve Group Block Leads to Small but Consistent Reductions in Pain Between 18 and 24 Hours Postoperatively in Hip Arthroscopy for Femoroacetabular Impingement Surgery: A Prospective, Randomized Controlled Clinical Trial. Arthroscopy 2024; 40:373-380. [PMID: 37355181 DOI: 10.1016/j.arthro.2023.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/29/2023] [Accepted: 06/01/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To investigate whether the use of a pericapsular nerve group (PENG) block would reduce perioperative pain after arthroscopic therapy for femoroacetabular impingement syndrome (FAIS) and to examine opioid requirements and occurrence of postoperative nausea and vomiting (PONV). METHODS Between May 2022 and October 2022, patients (N = 68) undergoing arthroscopic surgery for FAIS were randomly allocated into 2 groups. The first group received an ultrasound-guided PENG preoperatively with 20 mL of 0.375% ropivacaine and standardized postoperative oral medication. The second group received a sham block preoperatively with 20 mL of 0.9% saline and standardized postoperative oral medication. The primary end point was pain scores (visual analog score [VAS], 0-10) during the first 24 hours postoperatively. To quantify clinical significance of outcome achievement for the VAS pain score, the minimal clinically important difference (MCID) was calculated using the half standard deviation method. The incidence of PONV as well as opioid usage (converted to morphine equivalent) within the first 24 hours were secondary outcomes. RESULTS Randomization and permission were successfully obtained from 68 participants. From the fifteenth postoperative hour, the PENG group reported significantly less postoperative pain than the control group (24th postoperative hour: VAS pain PENG group 1.3 ± 0.9 [0-3]; 95% confidence interval {CI} 0.4-1.2 vs the VAS pain control group 2.4 ± 1.6 [0-5]; 95% CI 1.4-4.7; P = .009). The VAS pain score threshold for achieving the MCID at 24 hours postoperative was defined as a decrease of 1.1. 27 patients (79%) in the PENG group and 22 patients (65%) in the control group were able to achieve MCID (P = .009). Opioid dosage and postoperative nausea did not differ significantly between groups (P = .987 and P = .655, respectively). Concomitant complications such as falls, hematomas, or weakened muscles did not occur in either group. CONCLUSIONS According to this study, a PENG block minimally reduced pain after arthroscopic treatment for FAIS between the 18th and 24th postoperative hours. The PENG group achieved significantly more often the pain VAS MCID. However, there was no proof that the PENG group consumed fewer opioids than the control group. Overall, PONV was found at a low and comparable rate. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
| | - Marco M Schneider
- MVZ Praxisklinik Orthopädie Aachen, University of Aachen, Aachen, Germany; University Witten/Herdecke, Witten, Germany
| | - Sebastian Gebhardt
- Department of Orthopaedics, University Medicine Greifswald, Greifswald, Germany
| | | | | | | | - Alexander Zimmerer
- ARCUS Sportklinik, Pforzheim, Germany; Department of Orthopaedics, University Medicine Greifswald, Greifswald, Germany; Orthopädische Klinik Paulinenhilfe, Diakonie-Klinikum Stuttgart, Germany.
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Kim JY, Lee JS, Kim JY, Yoon EJ, Lee W, Lee S, Kim DH. Iliopsoas plane block does not improve pain after primary total hip arthroplasty in the presence of multimodal analgesia: a single institution randomized controlled trial. Reg Anesth Pain Med 2024:rapm-2023-105092. [PMID: 38286736 DOI: 10.1136/rapm-2023-105092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/17/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND The clinical analgesic efficacy of iliopsoas plane block remains a subject of discussion. This study aimed to assess the analgesic efficacy of iliopsoas plane block under general anesthesia using multimodal analgesia. METHODS Fifty-six adult patients who underwent elective primary hip arthroplasty were enrolled. Patients were randomized to receive either a single-shot iliopsoas plane block (10 mL 0.75% ropivacaine with 1:200 000 epinephrine) or a sham block (10 mL normal saline). All patients received general anesthesia, multimodal analgesia (preoperative buprenorphine patch, 5 µg/h), intraoperative intravenous dexamethasone (8 mg) and nefopam (20 mg), and round-the-clock acetaminophen and celecoxib. The primary outcome was the numeric rating scale pain score at rest 6 hour after surgery. RESULTS Iliopsoas plane block did not have a notable advantage over the sham block in terms of pain relief at rest, as assessed by the numeric rating scale score, 6 hour after total hip arthroplasty (iliopsoas plane block: median, 4.0; IQR, 2.0-5.8; sham: median, 5.5; IQR, 2.3-6.8; median difference, -1.0; 95% CI -2.0 to 0.0; p≥0.999). Linear mixed model analysis showed no differences in pain scores, opioid consumption, quadriceps strength, or quality of recovery between the groups. CONCLUSIONS Iliopsoas plane block did not improve postoperative analgesia following total hip arthroplasty under general anesthesia with a multimodal analgesic regimen. The blockade of sensory femoral branches supplying the anterior hip capsule using iliopsoas plane block may not yield additional benefits concerning patient outcomes in the aforementioned clinical context. TRIAL REGISTRATION NUMBER NCT05212038, https://clinicaltrials.gov/ct2/show/NCT05212038.
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Affiliation(s)
- Ji Yeong Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Seok Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Jang Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Wootaek Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seungyeon Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Do-Hyeong Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kim JY, Kim J, Kim DH, Han DW, Kim SH, Kim D, Chung S, Yu S, Lee UY, Park HJ. Anatomical and Radiological Assessments of Injectate Spread Stratified by the Volume of the Pericapsular Nerve Group Block. Anesth Analg 2023; 136:597-604. [PMID: 36727847 DOI: 10.1213/ane.0000000000006364] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The pericapsular nerve group (PENG) block was recently suggested as a regional technique for managing acute pain after hip surgery. However, few anatomical studies have confirmed the spread of injectate during the PENG block. This cadaver study aimed to analyze injectate spread to the target nerves during single-injection ultrasound-guided PENG block. METHODS Ultrasound-guided PENG block with 3 different injectate volumes (10, 20, or 30 mL) was performed in 18 cadavers. Injectate spread by the volume was first evaluated on computed tomography, followed by cadaver dissection. The spread of the dye over the pelvis and lower limb was evaluated. RESULTS The articular branches of the femoral nerve were stained nearly sufficiently with 20- and 30-mL specimens. The femoral nerve itself was stained simultaneously in six of 12 (50%) 20-mL specimens and 12 of 12 (100%) 30-mL specimens. The accessory obturator nerve was observed only in three (9%) of 36 specimens. The articular branches of the obturator nerve were rarely affected, regardless of injectate volume (1/12, 10 mL specimens; 2/12, 20 mL specimens; 1/12, 30 mL specimens; P > .999). Rather, the obturator nerve was affected. However, the obturator nerve was not stained consistently even with 30 mL of injectate (50%). CONCLUSIONS After combining the dissection and radiological findings, the single-injection ultrasound-guided PENG blocks with volumes of 10, 20, and 30 mL do not support motor sparing or selective anterior hip capsule innervation in a clinical setting. If early rehabilitation is needed, high-volume PENG block might not be the ideal option, and persisting pain after PENG block might be attributed in part to the lack of obturator nerve articular branches blockade.
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Affiliation(s)
- Ji Yeong Kim
- From the Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Jiyoung Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do-Hyeong Kim
- From the Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Dong Woo Han
- From the Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Sang Hyun Kim
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Donghyun Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Siwook Chung
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sanghyuck Yu
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - U-Young Lee
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hue Jung Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Widmeyer JR, Satalich J, Protzuk O, Hampton H, Torre M, Brusilovsky I, Vap A, O'Connell R. A Novel Approach to Improving Post-Operative Pain and Minimizing Opioid Consumption After a Hip Arthroscopy. Orthop Rev (Pavia) 2023; 15:74257. [PMID: 37091316 PMCID: PMC10115444 DOI: 10.52965/001c.74257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
Background There have been many different approaches to controlling pain in patients undergoing hip arthroscopy. These include medications, nerve blocks, and intra-articular injections among many others. We introduced a combination of a pre-operative pericapsular nerve group (PENG) block, and intra-operative pericapsular injection of BKK (bupivacaine, ketamine, and ketorolac). Methods Patients undergoing primary hip arthroscopy were identified. There were three patient cohorts based on type of anesthesia: general anesthesia only (GA), general anesthesia and a pericapsular Marcaine injection (GA/Marcaine), or GA with pre-operative PENG block and an intraoperative BKK pericapsular injection (GA+PENG/BKK). Data collected included post-operative pain scores in the PACU (Post-Anesthesia Care Unit), time spent in the PACU, inpatient opioid consumption (both PACU and inpatient), and outpatient opioid prescriptions filled. Results 20 patients received GA, 11 patients received GA/Marcaine, and 20 patients received GA+PENG/BKK. The GA+PENG/BKK group had average PACU pain score of 3.9 out of 10 compared to 7.7 in the GA group (p<.001) and 6.6 in the GA/Marcaine injection group (p=.048). The GA+PENG/BKK group had shorter mean PACU times than either other group (p<.001). The GA+PENG/BKK also consumed less opioids than the GA or GA/Marcaine groups in the PACU (p<.001), and in the total inpatient stay (p=.002, p=.003), as well as outpatient (p=.019, p=.040). Conclusion In patients undergoing a hip arthroscopy, performing a pre-operative PENG block and intra-operative BKK pericapsular injection will result in decreased postoperative pain, PACU time, and inpatient and outpatient opioids compared to general anesthesia only and general anesthesia with intracapsular Marcaine.
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Peripheral Nerve Block for Hip Arthroscopy Does Not Have any Clinical Advantage Compared With Local Anesthetic Regarding Pain Management: A Meta-analysis of Randomized Controlled Trials. Arthroscopy 2022; 38:2007-2017. [PMID: 34920002 DOI: 10.1016/j.arthro.2021.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the efficacy of peripheral nerve block on reduction in opioid consumption and pain control after hip arthroscopy. METHOD To identify studies evaluating the effects of peripheral nerve block on pain control and reduction in opioid consumption in hip arthroscopy, we searched all records in the PubMed, Embase, and Cochrane Library databases until May 2021. Studies with the following characteristics were considered eligible: 1) patients who underwent a hip arthroscopy (population); 2) patients who received peripheral nerve block (intervention); 3) patients who did not receive peripheral nerve block (comparator); 4) record of total opioid consumption as a primary outcome and pain level at 1, 3 to 6, and 24 hours after surgery, patient satisfaction, and incidence of nausea and vomiting as secondary outcomes (outcomes); and 5) randomized controlled trial (study design). Data were independently extracted by two reviewers and synthesized using a random or fixed-effects model, according to the heterogeneity. RESULTS Eight RCTs were finally included in the meta-analysis. There were no significant differences in postoperative opioid consumption at 24 hours (standardized mean difference [SMD] = -0.091, 95% confidence interval [CI] [-0.270, 0.089]) or in visual analog scale (VAS) score at 1 (SMD = 0.299, 95% CI [-0.758, 0.160]), 3 to 6 (SMD = -0.304, 95% CI [-0.655, 0.047]), and 24 (SMD = -0.230, 95% CI [-0.520, 0.060]) hours postoperatively between the peripheral nerve block and control groups. Moreover, no significant differences were observed in patient satisfaction (SMD < 0.001, 95% CI [-0.284, 0.284]) or the incidence of nausea and vomiting (SMD = 0.808, 95% CI [0.311, 2.104]) between the two groups. CONCLUSION Peripheral nerve block for hip arthroscopy has no clinical advantage regarding pain management after surgery when compared with the group that received the local infiltration of analgesics without peripheral nerve block. LEVEL OF EVIDENCE Level II, meta-analysis of level I and II randomized controlled trials (RCTs).
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Zimmerer A, Schneider MM, Sobau C, Miehlke W, Eichler F, Wawer Matos J. The Erector Spinae Plane Block in the Setting of Hip Arthroscopy: A Prospective Randomized Controlled Clinical Trial. Arthroscopy 2022; 38:65-71. [PMID: 34571187 DOI: 10.1016/j.arthro.2021.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate whether the use of an erector spinae plane block (ESPB) would reduce perioperative pain after arthroscopic therapy for femoroacetabular impingement syndrome (FAIS) and to examine the amount of additional opioids and postoperative nausea and vomiting (PONV). METHODS From October 2019 to October 2020, 68 patients undergoing arthroscopic therapy for FAIS were randomly allocated into 2 groups. The first group received an ultrasound-guided ESPB preoperatively with 30 mL of 0.375% ropivacaine and standard postoperative oral medication. The second group received a sham block preoperatively with 30 mL of 0.9% saline and standard postoperative oral medication. The primary endpoint was pain scores (numeric pain score out of 10) during the first 24 hours postoperatively. Secondary outcomes were opioid consumption during the first 24 hours (converted to morphine equivalents) and the incidence of PONV. Demographic and clinical characteristics were recorded for all patients. Categorial data were compared with chi-squared and Fisher's exact tests. Continuous data were compared with 2-sided t tests and Wilcoxon rank-sum tests. RESULTS Sixty-eight subjects consented and were successfully randomized. Reported postoperative pain was significantly lower in the ESPB group than in the control group during the first 24 hours. The opioid amount (P = .865) and postoperative nausea (P = .642) did not differ significantly between groups. No associated complications such as falls, hematomas, or muscular weakness occurred in either group. CONCLUSION This study demonstrates that ESPB significantly decreases pain in the first 24 hours after arthroscopic therapy for FAIS. However, there was no evidence of lower opioid consumption compared with the control group. Overall, a low and comparable rate of PONV was present. Therefore, the ESPB seems to complement a multimodal approach to perioperative pain management in hip arthroscopy. LEVEL OF EVIDENCE 1, randomized controlled trial.
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Affiliation(s)
- Alexander Zimmerer
- ARCUS Sportklinik Pforzheim, Pforzheim, Germany; Department of Orthopaedics, University Medicine Greifswald, Greifswald, Germany.
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Zheng J, Pan D, Zheng B, Ruan X. Preoperative pericapsular nerve group (PENG) block for total hip arthroplasty: a randomized, placebo-controlled trial. Reg Anesth Pain Med 2021; 47:155-160. [PMID: 34873023 DOI: 10.1136/rapm-2021-103228] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/20/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND We hypothesized that the addition of a preoperative pericapsular nerve group (PENG) block to intra-articular local anesthetic injection would improve analgesia after total hip arthroplasty. METHOD In this double-blinded trial, 71 patients scheduled for primary total hip arthroplasty were randomized to receive preoperative PENG block with 20 mL 0.5% ropivacaine (PENG group) or 20 mL saline (placebo group). All the patients received an intra-articular injection of 20 mL 0.5% ropivacaine by surgeon after the completion of the procedure. The primary outcome was the highest pain score reported in the recovery room. The secondary outcomes included quadriceps strength, pain scores, opioid use, and opioid-related side effects up to 48 hours after surgery. RESULTS Seventy patients were included in the final analysis. The highest visual analog scale in the recovery room showed significant intergroup difference (placebo: 5.2±3.1 vs PENG: 3.3±2.7, p<0.01) but the difference did not persist after discharge from the recovery room. The two groups' postoperative pain scores at rest were similar. A lower intraoperative morphine equivalent dose and lower postoperative vomiting were found in the PENG group. There were no differences in the other outcomes. CONCLUSION The addition of a preoperative PENG block to intra-articular injections of local anesthetic provides a limited benefit to postoperative analgesia in the recovery room with no discernible benefits thereafter. TRIAL REGISTRATION NUMBER NCT04480320.
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Affiliation(s)
- Jun Zheng
- The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Danyang Pan
- The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Bin Zheng
- The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Xiangcai Ruan
- Department of Anesthesiology and Pain Medicine, Sun Yat-sen University, Guangzhou, China
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Degen RM, McClure JA, Le B, Welk B, Marsh J. Persistent post-operative opioid use following hip arthroscopy is common and is associated with pre-operative opioid use and age. Knee Surg Sports Traumatol Arthrosc 2021; 29:2437-2445. [PMID: 33646372 DOI: 10.1007/s00167-021-06511-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/17/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Hip arthroscopy utilization continues to increase worldwide. Post-operative pain management is essential to allow appropriate rehabilitation. While multimodal analgesic protocols have been described, consensus agreement is lacking and opioid analgesia remains a mainstay of treatment. Unfortunately, the risk of persistent opioid use among opioid-naïve and non-naïve patients following hip arthroscopy remains unclear. Therefore, the purpose of this study was to identify rates of persistent post-operative opioid use, as well as to identify factors associated with persistent use. METHODS A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent hip arthroscopy between 2013 and 2018. Patients < 18 or > 60 years of age as well as those who had undergone prior hip arthroscopy were excluded. The primary exposure was whether patients had filled ≥ 2 opioid prescriptions within 1 year prior to their hip arthroscopy to define the opioid naïve and non-naïve populations. The primary outcome was persistent opioid use, defined as 2 + prescriptions filled between 9 and 15 months post-op. A regression analysis was performed to identify factors associated with persistent opioid usage. RESULTS Of the 1909 patients, 1525 (79.9%) were opioid-naïve, while 384 (20.1%) had a prior history of opioid use within 1 year of surgery. 224 patients (11.7%) demonstrated persistent opioid use, with ≥ 2 prescriptions filled between 9 and 15 months post-op. Of those, 42 (18.8%) cases were among opioid-naïve patients, while the remaining 182 (81.2%) were among non-naïve patients. The risk of persistent post-operative use was significantly higher in those with prior opioid use (OR 31.95, 95% CI 22.15-46.09; p < 0.0001). Regression analysis confirmed that pre-operative opioid use (OR 23.79, 95% CI 17.06-33.17; p < 0.0001) and older age (OR 1.04, 95% CI 1.02-1.05, p < 0.0001) were associated with increased risk of persistent post-operative opioid use. CONCLUSION Following hip arthroscopy, persistent opioid use is common. New persistent use was identified in 2.7% of opioid-naïve patients, compared with continued use in 47.4% of non-naïve patients. Pre-operative opioid use and older age were associated with the greater risk of persistent post-operative opioid use. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ryan M Degen
- Department of Surgery, Western University, London, ON, Canada.
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, N6A 3K7, Canada.
- Bone and Joint Institute, Western University, London, ON, Canada.
| | | | - Britney Le
- Institute for Clinical and Evaluative Sciences (ICES) Western, London, ON, Canada
| | - Blayne Welk
- Department of Surgery, Western University, London, ON, Canada
| | - Jacquelyn Marsh
- Department of Surgery, Western University, London, ON, Canada
- Bone and Joint Institute, Western University, London, ON, Canada
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON, Canada
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Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M, Raeder J. PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021; 76:1082-1097. [PMID: 34015859 DOI: 10.1111/anae.15498] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 12/11/2022]
Abstract
The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.
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Affiliation(s)
- M Anger
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - T Valovska
- Service d'Anesthésie Réanimation et Médecine Péri-opératoire, CHU Rennes, Université Rennes, Rennes, France
| | - H Beloeil
- Department of Anesthesiology, Henry Ford Health Systems, Wayne State School of Medicine, Detroit, MI, USA
| | - P Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - M Van de Velde
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Anaesthesiology, UZLeuven, Leuven, Belgium
| | - J Raeder
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.,Division of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
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Kolaczko JG, Knapik DM, Kroneberger E, Chadha A, Salata MJ. A comprehensive three-phase opiate sparing multimodal pain protocol for hip arthroscopy: a retrospective review. J Hip Preserv Surg 2020; 7:547-553. [PMID: 33948211 PMCID: PMC8081429 DOI: 10.1093/jhps/hnaa057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/04/2020] [Accepted: 11/01/2020] [Indexed: 01/29/2023] Open
Abstract
The aim of this study is to assess the efficacy of a three-phase, multimodal, perioperative pain protocol for primary hip arthroscopy based on pain scores, narcotic use, time to discharge, hospital admission and complications. A retrospective study of patients undergoing primary hip arthroscopy over a 48-month time period was conducted. Patients were separated into a multimodal group consisting of non-narcotic medication, local analgesia and a peripheral nerve block (PNB) versus patients receiving only a PNB. Differences in post-anesthesia care unit (PACU) visual analog scores, PACU time to discharge, PACU opioid consumption, hospital admission and complications between protocols were recorded and analyzed. There were 422 patients who underwent 484 surgeries, with 15 patients crossing over pain protocol groups for surgery on the contralateral hip. One hundred and ninety-six patients underwent 213 procedures in the multimodal group and 241 patients underwent 271 procedures in the PNB group. No differences in baseline characteristics were appreciated between groups. Mean time to discharge was significantly shorter in the multimodal group (137.4 ± 49.3 min versus 176.3 ± 6.5 min; P < 0.001) which also had less post-operative admissions (0 versus 9; P = 0.006) than the PNB group. In patients who crossed over protocol groups, a statistically shorter time to discharge was appreciated with the multimodal protocol compared with the PNB protocol (119.9 ± 32.1 min versus 187.9 ± 9.2; P = 0.012). The three-phase, multimodal pain protocol led to significantly faster discharge times and fewer hospital admissions when compared with isolated PNB in patients undergoing primary hip arthroscopy.
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Affiliation(s)
- Jensen G Kolaczko
- Department of Orthopaedic Surgery, University Hospitals Sports Medicine Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Hanna House 5043, Cleveland, OH 44106, USA
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, University Hospitals Sports Medicine Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Hanna House 5043, Cleveland, OH 44106, USA
| | - Elisabeth Kroneberger
- Case Western University School of Medicine, Health Education Campus, 9501 Euclid Ave, Cleveland, OH 44106, USA
| | - Amrita Chadha
- Department of Anesthesiology, CWRU School of Medicine, Pre-Admission Testing, University Hospitals Ahuja Medical Center, Beachwood, 3999 Richmond Rd, OH 44122, USA
| | - Michael J Salata
- Department of Orthopaedic Surgery, University Hospitals Sports Medicine Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Hanna House 5043, Cleveland, OH 44106, USA.,Department of Orthopaedic Surgery, Sports Medicine Institute, Joint Preservation and Cartilage Restoration Center University Hospitals Cleveland, Cleveland, OH, USA
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Villar R(R. Steer clear of honorary authorship. J Hip Preserv Surg 2019; 6:297-300. [PMID: 32015885 PMCID: PMC6990381 DOI: 10.1093/jhps/hnz064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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