Combination Therapy with Continuous Three-in-One Femoral Nerve Block and Periarticular Multimodal Drug Infiltration after Total Hip Arthroplasty

A Comparative Evaluation of Combined Nerve Block Versus Periarticular Infiltration on Postoperative Pain Relief in Total Hip Arthroplasty

Introduction

To minimize the side effects of the central neuraxial blockade to obtain postoperative pain relief, there has been an increasing preference for targeting the peripheral structures in patients undergoing total hip arthroplasty (THA).

Patients and Methods

This prospective study was performed between September 2019 and September 2021 and involved 30 patients that were randomized to two groups. One group (n = 15) received combined nerve block (CNB) [obturator nerve, nerve to quadratus femoris, superior gluteal nerve, and femoral nerve], while another group (n = 15) received periarticular infiltrative analgesia (PIA). All the patients were given the same volume and composition of the drug cocktail (20 ml 0.5% ropivacaine, 1 ml (100 mcg) dexmedetomidine, and 29 ml normal saline).

Results

The patients in group CNB had a significantly lower visual analog score (VAS) at 6, 12, 18, 24, 30, 36, 42 and 48 h after surgery (p < 0.05). Patients in group CNB required fewer (p < 0.001) doses of the rescue analgesic (1.67 ± 0.90 doses) as compared to group PIA (3.53 ± 0.64 doses). Time to the first rescue analgesia was significantly longer (p = 0.01) in group CNB (6.71 ± 2.36 h) as compared to group PIA (4.80 ± 1.26 h). However, patients in group PIA had significantly faster sensory (p < 0.001) and motor recovery (p < 0.001) as compared to group CNB. It took significantly longer (p < 0.001) to administer the nerve block (16.87 ± 1.80 min) as compared to periarticular infiltration (6.53 ± 1.18 min). There were no complications in either group.

Conclusion

CNB registered significant superiority over PIA with respect to postoperative pain relief and time to rescue analgesia. However, the time taken to administer CNB was significantly higher and the patients in the PIA group had early recovery in sensory and motor modalities.

Level of Evidence

III (therapeutic).

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature

BACKGROUND

Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.

METHODS

A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.

RESULTS

Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).

CONCLUSIONS

Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.

RECOMMENDATION

PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis

BACKGROUND

For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient.

METHODS

We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients.

RESULTS

We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately.

CONCLUSIONS

We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.

Facilitators to the continuous abuse of tramadol among the youth: A qualitative study in Northern Ghana

STUDY AIM

Considering the alarming rate at which young people abuse tramadol, as evidenced by the numerous media reports on the subject, this qualitative study was conducted to explore the facilitators to the abuse of tramadol by young people.

DESIGN AND METHODS

A qualitative exploratory descriptive design was employed in conducting the study. A total of 18 participants were purposively sampled. Data for the study were collected through two focused group discussions and three in-depth-interviews. Thematic analysis was used to analyse the data.

RESULTS

The findings of the study revealed four main themes. These themes were initiating factors of abuse; desirable physical effects; desirable psychological effects; and undesirable effects. It was revealed that many young people initially get into tramadol abuse because of peer pressure, curiosity or post-traumatic addiction. However, they often continue the practice for various physical and psychological gratifications including euphoria, attentiveness, high energy levels, pain relief and improved sexual performance. The study also revealed some unpleasant side effects of tramadol abuse such as severe vomiting, loss of appetite, seizures, emotional aloofness and irritability. Many of the participants in this study also expressed willingness to quit tramadol abuse because of social discrimination and the enormous side effects that come with the abuse of the drug.

Comparison of Periarticular Local Infiltration Analgesia With Femoral Nerve Block for Total Knee Arthroplasty: a Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Total knee arthroplasty (TKA) is accompanied by moderate-to-severe postoperative pain. Postoperative pain will hamper functional recovery and lower patients' satisfaction with surgery. Recently, periarticular local infiltration analgesia (LIA) has been widely used in TKA. However, there is no definite answer as to the efficacy and safety of LIA compared with femoral nerve block (FNB).

METHOD

Randomized controlled trials about relevant studies were searched from PubMed (1996 to July 2017), Embase (1980 to July 2017), and Cochrane Library (CENTRAL, July 2017). Ten studies which compared LIA with FNB methods were included in our meta-analysis.

RESULTS

Ten studies containing 950 patients met the inclusion criteria. Our pooled data indicated that LIA was as effective as the FNB in terms of visual analog scale score for pain at 24 hours (P = .52), 48 hours (P = .36), and 72 hours (P = .27), and total morphine consumption (P = .27), range of motion (P = .45), knee society score (P = .51), complications (P = .81), and length of hospital stay (P = .75).

CONCLUSIONS

Our current meta-analysis results demonstrated that there were no differences in efficacy between the FNB and LIA method.