- Email: [email protected]
A comparison of the fascia iliaca block to the lumbar plexus block in providing analgesia following arthroscopic hip surgery: A randomized controlled clinical trial
Journal of Clinical Anesthesia 49 (2018) 26–29
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia journal homepage: www.elsevier.com/locate/jclinane
Original Contribution
A comparison of the fascia iliaca block to the lumbar plexus block in providing analgesia following arthroscopic hip surgery: A randomized controlled clinical trial☆
T
⁎
Ignacio Badiola, MDa, , Jiabin Liu, MD, PhDb, Stephanie Huang, MDb, John D. Kelly IV, MDc, Nabil Elkassabany, MD, MSCEa a b c
Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States Department of Orthopaedics, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
A R T I C LE I N FO
A B S T R A C T
Keywords: Regional anesthesia Fascia iliaca block Lumbar plexus block Postoperative pain Hip arthroscopic surgery
Study objective: This randomized controlled single blinded clinical trial compared the fascia iliaca block (FIB) and the lumbar plexus block (LPB) in patients with moderate to severe pain following hip arthroscopic surgery. Design: Single blinded randomized trial. Setting: Postoperative recovery area, postoperative days 0 and 1. Patients: Fifty patients undergoing hip arthroscopy were approached in the Post Anesthesia Care Unit (PACU) if they had moderate to severe pain (defined as > or equal 4/10 on the numeric rating scale). Twenty-five patients were allocated to the FIB and twenty-five patients to the LPB. Interventions: Fascia iliaca block or lumbar plexus block. Measurements: A blinded observer recorded pain scores just prior to the block, 15 min following the block (primary endpoint), and then every 15 min for 2 h (or until the patient was discharged). Total PACU time and opioid use were recorded. Pain scores and analgesic use on postoperative day (POD) 0, and POD 1 were recorded. At 24 h post block the Quality of Recovery 9 questionnaire was administered. Results: The mean pre-block pain scores were comparable between the two groups (P = 0.689). There was no difference in mean post block pain scores between the two groups at 15 min (P = 0.054). In the PACU patients who underwent a LPB consumed less opioids compared to FIB patients (P = 0.02), however no differences were noted between the two groups in PACU length of stay, or POD 0 or 1 opioid use. Conclusion: A fascia iliaca block is not inferior to a lumbar plexus block in reducing PACU pain scores in patients with moderate to severe pain following hip arthroscopic surgery and is a viable option to help manage postoperative pain following hip arthroscopic surgery.
1. Introduction Hip arthroscopic surgery is a commonly performed outpatient procedure utilized for treatment of a variety of pathology including acetabular labral tears, femoroacetabular impingement (from a variety of causes), bursa excisions, and psoas release [1,2]. Postoperative pain varies depending on many factors but can be moderate to severe [3,4] Regional anesthesia provides dense analgesia with the potential to decrease opioid related side effects (nausea/vomiting, sedation, respiratory depression) by decreasing reliance on opioid medications.
☆ ⁎
Postoperative pain tends to be most severe in the first 24 h [2] making it imperative to find an anesthetic technique that provides adequate analgesia to help improve patient comfort, decrease post anesthesia care unit (PACU) discharge times and reduce readmission for uncontrolled pain. Regional anesthesia is an enticing choice however, innervation to the hip joint is complex involving the femoral nerve (FN), obturator nerve (ON), and sciatic nerve (SN). The skin overlying the typical portal entry sites include innervation from the lateral femoral cutaneous nerve (LFCN). Due to this extensive innervation, an all-encompassing block would
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Corresponding author. E-mail addresses: [email protected] (I. Badiola), [email protected] (N. Elkassabany).
https://doi.org/10.1016/j.jclinane.2018.05.012 Received 20 February 2018; Received in revised form 4 May 2018; Accepted 18 May 2018 0952-8180/ © 2018 Published by Elsevier Inc.
Journal of Clinical Anesthesia 49 (2018) 26–29
I. Badiola et al.
0.25% Preservative Free bupivacaine with 1:200,000 epinephrine. The second group received a fascia iliaca block using 30 ml of 0.25% Preservative Free bupivacaine with 1:200,000 epinephrine. A total of 50 patients were randomized with 25 in the FIB group and 25 in the LPB group. The block was performed by an anesthesiologist trained in regional anesthesia and experienced in both types of blocks. All followup assessments were performed by a research assistant blinded to the randomization. The fascia iliaca block was performed with the patient in a supine position. The ipsilateral groin was prepped and cleaned with chlorhexidine. An ultrasound machine (Fujifilm Sonosite, Bothell, WA) with a linear transducer (C35, 8–3 MHz) covered with a sterile Tegaderm (3 M, St. Paul, MN) was used. The transducer was placed inferior to the inguinal ligament until the femoral artery was imaged. The probe was then moved laterally until the Sartorius muscle was seen. A skin wheal with 1% lidocaine was made and a Stimuplex 22 gauge 2-inch or 4-inch blunt tip needle (B. Braun Medical Inc., Bethlehem, PA) was inserted in plane. The needle was seen to pierce the fascia iliaca and 1–2 ml of 0.25% Preservative Free bupivacaine with 1:200,000 epinephrine was injected to confirm correct needle placement between the fascia iliaca and iliopsoas muscle. The injection was deemed adequate if local anesthetic was seen to separate these two layers in a lateral to medial direction as the local anesthetic was injected. The spread of local anesthetic was tracked under the fascia iliaca to confirm its spread to the femoral nerve as well. A total of 30 ml of 0.25% Preservative Free bupivacaine with 1:200,000 epinephrine was used. The lumbar plexus block was performed with the patient in a lateral position with the operative side facing up. An ultrasound machine (Fujifilm Sonosite, Bothell, WA) with a curved transducer (C35, 8–3 MHz)covered with a sterile Tegaderm (St. Paul, MN 55144) was utilized. With the ipsilateral hip and knee will be flexed to 90°, the anatomy for the LP block was localized using a modified transverse scan of the lumbar paravertebral area (PMTS). This technique is well described by Karmarkar et al. [9]. The target vertebral level was identified by locating the lumbosacral junction (the gap of L5-S1) using a paramedian sagittal scan and then counting cranially to locate both the lamina and the transverse process of L3–L5. The transducer was then placed 4 cm lateral to the midline at the L3–4 level and directed medially to insonate the intervertebral foramen through the lumbar intervertebral space. A skin wheal was then made at this site with 1% lidocaine and a 20 gauge 6-inch blunt tip needle (B. Braun Medical Inc., Bethlehem, PA) was introduced 4 cm lateral to the midline and just medial of the transducer after connecting it to a nerve stimulator set at 1.00 mA. The needle was slowly advanced under ultrasound guidance until engaged in the psoas compartment and a twitch elicited of the quadriceps at > 0.5 mA. 30 ml of 0.25% Preservative free bupivacaine with 1:200,000 epinephrine was injected slowly after negative aspiration. The fascia iliaca block was assessed by checking for decreased sensation to cold temperature (ice) along the distribution of the lateral femoral cutaneous nerve and femoral nerve and comparing this to sensation performed before the block and to sensation in the opposite lower extremity. The lumbar plexus block was assessed by checking for a decrease in sensation to cold temperature in the anterior lateral thigh and comparing it to sensation before the block and to sensation in the opposite lower extremity. After injection of local anesthetic and confirmation of a successful block, a blinded research assistant measured pain scores 15 min after the procedure and then every 15 min for 2 h (or until the patient was discharged). Intraoperative and PACU opioid/analgesic use was recorded. Total PACU time was also recorded. Patients were also followed on postoperative days (POD) 0, and 1 via phone contact. Prior to discharge they were provided with a pain diary to complete every 6 h after discharge until 24 h post block. Pain scores, analgesic use as well as adverse effects were recorded. At 24 h post block patients filled out a Quality of Recovery 9 questionnaire.
be best- if feasible. This block should be easy to perform, easy to learn, and have minimal adverse effects. The lumbar plexus block (LPB) is a compartment block which blocks the FN, ON, and LFCN making it an attractive choice. The fascia iliaca block (FIB) is also a compartment block. Various regional anesthetic techniques have been described for hip surgery including femoral nerve blocks, fascia iliaca block, lumbar plexus block, and paravertebral blocks [2]. However it is unknown which is best in providing analgesia following hip arthroscopic surgery. A study by YaDeau et al. [5] noted that the lumbar plexus block resulted in reduction in PACU resting pain after hip arthroscopy. In a study by Krych et al. [6] fascia iliaca block following hip arthroscopy was safe and effective. This study noted that patients that received the fascia iliaca blocks resulted in low opioid consumption and high patient satisfaction. A recent study noted that a lumbar plexus block administered in concert with general anesthesia provided clinically important and statistically significant post-operative pain relief when compared with general anesthesia alone or general anesthesia plus fascia iliaca block [7]. Our study sought to compare two compartment blocks with the potential to improve postoperative pain. We hypothesized that FIB would not be inferior to the LPB 15 min following the procedure as measured by pain intensity on the numeric rating scale. This has implications as the LPB is considered a technically challenging block with the potential for serious adverse effects including epidural spread (resulting in possible need for admission to the hospital) and visceral injury (i.e. structures in the retroperitoneum). The FIB is usually considered technically easier to perform with less risk of major adverse events [8]. Our goal was to show that both blocks decrease pain following hip arthroscopy and that the FIB is not inferior to the LPB. We also evaluated perioperative complications, PACU pain scores, PACU discharge times, postoperative days 0 and 1 analgesic use and pain scores, and patient satisfaction, all as secondary outcomes. 2. Methods This randomized, controlled, single blinded (assessment was blinded) trial was approved by the University of Pennsylvania's Institutional Review Board (IRB# 822547). It was registered at clinicaltrials.org (ID# NCT02882633). CONSORT guidelines were followed. Eligibility criteria included patients > 18 years of age undergoing a primary hip arthroscopy who were ASA physical status 1-III and English speaking. Exclusion criteria included chronic opioid use (use of any opioid daily or on most days of the week for > 3 months), diagnosed peripheral neuropathy in the surgical lower extremity, allergy to study medications, and a BMI > 35. All procedures were done at the University of Pennsylvania Presbyterian Medical Center or it's outpatient surgery facility. All patients were recruited between October 2015 and November 2016. Sample size was calculated by assuming an alpha of 0.05 and a power of 80. Using a median pain score after the block was performed of 5/10 on the VAS with the FIB, a 4/10 for the LPB (20–25% difference) and a standard deviation estimated between 1.35 and 2.34 resulted in 23 patients in the FIB group and 23 patients in the LPB group. Considering a 10% drop out during follow-up, 25 patients were recruited per group. A study physician approached the patient in the preoperative area and if patients elected to proceed with the study, informed consent was obtained preoperatively. The patient then underwent hip arthroscopic surgery under general anesthesia — which is the standard of care at our medical center. We did not make any stipulations as to how the general anesthetic was conducted. Patients were assessed on arrival to the PACU. Patients who had consented preoperatively and complained of pain greater than or equal to 4/10 on the NRS were randomized to either a lumbar plexus block or fascia iliaca block. Randomization was done using a random number generator to allocate patients into two groups. The first group received a lumbar plexus block using 30 ml of 27
Journal of Clinical Anesthesia 49 (2018) 26–29
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4. Discussion
Table 1 Baseline characteristics.
Sex (n) Male Female Body mass index (kg/m2) mean Age (mean ± SD) Femoral/acetabular osteoplasty (%) Peri-trochanteric space surgery (%)
Fascia illiaca block (n = 25)
Lumbar plexus block (n = 23)
P value
9 16 26.80 ± 4.52
7 16 29.89 ± 6.59
0.683
39.8 ± 11.40 23 (92)
38.83 ± 11.55 19 (82.6)
0.950 0.174
2 (4.2)
4 (8.3)
Although the number of hip arthroscopic surgical procedures is increasing, the best way to manage postoperative pain is not yet well defined [10]. Many, if not most, are being performed on an outpatient basis. It is essential to find a therapy, or therapies, that improves postoperative pain, decreases opioid reliance/use, improves PACU discharge times, and decreases the rate of hospital admission from poor pain management. Regional anesthesia is an enticing choice. However, due to the complexity of the innervation to the hip, various regional anesthetic techniques have been proposed, but not many have been compared. We chose to evaluate two of these blocks, specifically the two compartment blocks that have been described for use following hip arthroscopy. Our rationale was that these two blocks are compartment blocks and anesthetize multiple nerves compared to single nerve regional anesthetic blocks. They thus have the potential to provide better analgesia than single nerve blocks. Our primary hypothesis was that a postoperative fascia iliaca would not be inferior to a lumbar plexus block in providing analgesia in patients that arrive to the PACU in moderate to severe pain. Like most trials the rational for this trial did not form in a vacuum. Our institution favors FIB performed postoperatively following hip arthroscopy in patients who arrive to the PACU in moderate to severe pain. We have good anecdotal evidence that patients who arrive with severe pain subjectively feel better and have better pain scores before discharge following FIB. Our regional anesthesiologists also believe that that the FIB is easier to learn and perform than the LPB and have trained some of our non-regional anesthesiologists to perform FIB following hip surgery with good anecdotal success and no major adverse outcomes. Not all anesthesiologists involved in caring for patients undergoing hip arthroscopic surgery have been trained in regional anesthesia and a block that is considered easy to learn with minimal adverse effects is ideal. The fascia iliaca block is one such block. It has been used for hip surgery by anesthesiologists and by emergency room physicians as an easily learned analgesic technique to provide analgesia following acute hip fractures [8,11]. It has also been shown to be beneficial following hip arthroscopy [6]. Although the FIB can be done preoperatively, our institution typically performs these postoperatively for a few reasons. First, not all patients will require a block. Although the FIB has minimal reported adverse effects it is best to perform these blocks for patients that actually need it. Not all patients have moderate to severe pain on arrival to PACU. For example, in this study 11 out of the 61 patients preoperatively consented (18%) did not require a block as they had < 4/ 10 pain when they arrived to the PACU. Second, we believe that the use of irrigating fluid during arthroscopic surgery may wash away any local anesthetic placed in the fascia iliaca compartment before surgery reducing its postoperative efficacy. During arthroscopic hip surgery more than a liter of irrigation fluid may be extravasated into the soft tissues [12,13]. This fluid can theoretically extravasate into the plane between the psoas muscle and fascia
0.079
All data analysis was executed in STATA 14.2 statistical software (StataCorp LP, College Station, TX). Continuous variables were analyzed with the Student t-test and reported as mean and standard deviation for patient demographic information, or median and interquartile range for outcome variables. All categorical variables were analyzed with Chi-square test.
3. Results We screened 99 patients and excluded 49. Out of those 49 patients 14 did not meet inclusion criteria, 14 declined to participate, 11 had < 4/10 pain on arrival to PACU and 10 patients were excluded as our research assistant was performing other duties when those patients arrived in PACU. Our study cohort included 50 patients, with 25 patients receiving the FIB and 23 patients receiving the LPB post-operatively (see CONSORT diagram). Two patients in the lumbar plexus group were not included as one had epidural spread of local anesthetic leading to complete sensory and motor block in the bilateral lower extremities and the other did not have evidence of a successful block on postblock examination. Table 1 summarizes patient demographic information. The ages of patients were 39.8 ± 11.40 versus 38.83 ± 11.55 years in FIB and LPB group respectively (P = 0.950). Gender, body mass index, and ASA classification were not significantly different between these two groups. The pre-block pain scores were comparable between the FIB and LPB groups (5.8 versus 6.3, P = 0.689). There was no statistically significant difference in pain scores 15 min post block between the two groups 3.4 vs 2.9 P = 0.054). There was also no difference in change in pain scores 15 min postblock between the two groups. Total opioid use in the PACU was lower in the LPB group compared to the FIB group (Table 2). However, there were no differences in POD 0 or 1 opioid use. The length of PACU stay was 139.7 vs 165.0 min respectively (P = 0.419). Last, the quality of recovery as measured by QOR 40 questionnaire, were also comparable between the two study groups.
Table 2 Clinical outcomes. Fascia illiaca block
Pre-block pain Pain 15 min postblock Change in pain score (pre block and at 15 min PACU opioids (MED) (mg) POD 0 oxycodone meq POD 1 oxycodone meq Quality of recovery PACU length of stay (min)
Lumbar plexus block
Average
Interquartile range
Average
Interquartile range
P-value
5.84 3.4 1.72 20.80 14.46 25.63 15.91 139.72
2–9 0–6 0–8 5.62–33.75 3.75–30 10–47.5 11–18 90–219
6.30 2.87 3 16.98 13.43 21.55 14.52 165.04
4.5–8 2–4 1–3 5.81–22.5 5–20 13.13–33.5 14–17 113.5–183
0.689 0.054 0.098 0.020 0.075 0.763 0.320 0.419
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Journal of Clinical Anesthesia 49 (2018) 26–29
I. Badiola et al.
PACU compared to LPB patients. This study was not powered to detect if this was a true finding or a finding due to chance in a secondary end point. Future studies are needed to see if patients who undergo FIB require more opioids in PACU and if so do they report more adverse effects.
iliaca resulting in dilution and washing away of local anesthetic placed preoperatively. A case report of two patients undergoing a postoperative block following hip arthroscopy noted ultrasound evidence of fluid within the tissue plane between the fascia iliaca and iliopsoas muscle with distension of tissue and a hypoechoic signal (fluid) surrounding the femoral nerve before performing the block [14]. A systematic review of fluid extravasation following hip arthroscopy noted that in 40 asymptomatic patients, 100% had fluid extravasation into the thigh [15]. This in and of itself has the potential to render the FIB placed before surgery ineffective for postoperative analgesia. A recent study comparing a FIB to local anesthetic infiltration (LAI) of the portal tracts after hip arthroscopic surgery required early termination when it was noted that patients receiving the FIB were arriving to the PACU in significant pain [16]. Preliminary analysis revealed that FIB patients were having significantly more pain the first hour after surgery with mean pain scores of 3.4 vs 5.5 when compared to the LAI. It is important to note that the FIB were performed before surgery while the LAI were performed at the end of the surgical procedure. It is possible that washing away of local anesthetic from irrigation during surgery could have led to the higher pain scores in the FIB cohort. It is also worth noting that this study used a dilute concentration of 0.125% bupivacaine for the FIB. Our study used double (0.25%) the concentration in the FIB. Our study is in contrast to that of Wolff et al. who demonstrated that a lumbar plexus block was superior to a fascia iliaca block in providing postoperative analgesia after hip arthroscopic surgery [7]. However, the methodology of the studies is very different. Wolff et al. performed the fascia iliaca block preoperatively, which as described previously may have subjected this group to washout of local anesthetic with subsequent reduction in benefit compared to the lumbar plexus block. This study was also retrospective and thus subject to the known issues associated with these types of studies [17]. Our secondary outcomes did not show any difference between the two blocks in regards except for total PACU opioid use. There were no differences between the two groups on total home opioid use on POD 0 or 1. There was also no difference between the groups in regards to quality of recovery using the Quality of Recovery Questionnaire. This tool asks nine questions and assesses various domains of postoperative recovery [18]. We had one complication following a lumbar plexus block which resulted in epidural spread of local anesthesia leading to weakness and sensory deficits in the patient's bilateral lower extremities. This is a known complication of lumbar plexus blocks. The patient was admitted overnight for observation and was discharged the following day without sequela. No other complications were noted in any of the two groups. No postoperative falls were noted. However, this study was not powered to detect these extremely rare events. The results of our current study bring clinical implications that need future study. There are many reports of analgesic success following various regional anesthetic blocks following hip arthroscopic surgery, however comparisons of these blocks are lacking. To our knowledge, this study was the first to prospectively compare two compartment blocks for postoperative pain management in patients who underwent arthroscopic hip surgery. A study comparing both blocks in patients undergoing a femur fracture fixation or a total hip arthroplasty also noted no difference between both blocks in 24 h meperidine requirements or postoperative pain [19]. Although arthroscopic hip surgery is a wide encompassing term and can mean anything from simple debridement to extensive bony surgery, our study only blocked patients who had moderate to severe pain on arrival to the recovery room regardless of how extensive the surgery was. This study shows that FIB provides good post block analgesia with good patient satisfaction. It also shows that at home opioid consumption did not differ between the two groups. Interestingly, patients in the FIB group consumed more opioids in the
Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.jclinane.2018.05.012. References [1] Sardana V, Philippon MJ, de Sa D, et al. Revision hip arthroscopy indications and outcomes: a systematic review. Arthroscopy 2015;31(10):2047–55. http://dx.doi. org/10.1016/j.arthro.2015.03.039. [2] Yu HC, Al-Shehri M, Johnston KD, Endersby R, Baghirzada L. Anesthesia for hip arthroscopy: a narrative review. Can J Anaesth 2016;63(11):1277–90. http://dx. doi.org/10.1007/s12630-016-0718-7. [3] Ward JP, Albert DB, Altman R, Goldstein RY, Cuff G, Youm T. Are femoral nerve blocks effective for early postoperative pain management after hip arthroscopy? Arthroscopy 2012;28(8):1064–9. http://dx.doi.org/10.1016/j.arthro.2012.01.003. [4] Bech NH, Hulst AH, Spuijbroek JA, van Leuken LLA, Haverkamp D. Perioperative pain management in hip arthroscopy; what options are there? J Hip Preserv Surg 2016;3(3):181–9. http://dx.doi.org/10.1093/jhps/hnw015. [5] Yadeau JT, Tedore T, Goytizolo EA, et al. Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial. Anesth Analg 2012;115(4):968–72. http://dx.doi.org/10.1213/ANE.0b013e318265bacd. [6] Krych AJ, Baran S, Kuzma SA, Smith HM, Johnson RL, Levy BA. Utility of multimodal analgesia with fascia iliaca blockade for acute pain management following hip arthroscopy. Knee Surg Sports Traumatol Arthrosc 2014;22(4):843–7. http://dx. doi.org/10.1007/s00167-013-2665-y. [7] Wolff AB, Hogan GW, Capon JM, Napoli AM, Smith HJ, Gaspar PS. Pre-operative lumbar plexus block provides superior post-operative analgesia when compared with fascia iliaca block or general anesthesia alone in hip arthroscopy. J Hip Preserv Surg 2016:hnw021http://dx.doi.org/10.1093/jhps/hnw021. [8] Elkhodair S, Mortazavi J, Chester A, Pereira M. Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency department: a pilot study. Eur J Emerg Med 2011;18(6):340–3. http://dx.doi.org/ 10.1097/MEJ.0b013e32834533dd. [9] Karmakar MK, Li JW, Kwok WH, Hadzic A. Ultrasound-guided lumbar plexus block using a transverse scan through the lumbar intertransverse space: a prospective case series. Reg Anesth Pain Med 2015;40(1):75–81. http://dx.doi.org/10.1097/AAP. 0000000000000168. [10] Shin JJ, Mccrum CL, Mauro CS, Vyas D. Pain management after hip arthroscopy: systematic review of randomized controlled trials and cohort studies. Am J Sports Med 2017:363546517734518http://dx.doi.org/10.1177/0363546517734518. [11] Groot L, Dijksman LM, Simons MP, Zwartsenburg MMS, Rebel JR. Single fascia Iliaca compartment block is safe and effective for emergency pain relief in hipfracture patients. West J Emerg Med 2015;16(7):1188–93. http://dx.doi.org/10. 5811/westjem.2015.10.28270. [12] Stafford GH, Malviya A, Villar RN. Fluid extravasation during hip arthroscopy. Hip Int 2011;21(6):740–3. http://dx.doi.org/10.5301/HIP.2011.8845. [13] Hinzpeter J, Barrientos C, Barahona M, et al. Fluid extravasation related to hip arthroscopy: a prospective computed tomography-based study. Ortho J Sports Med 2015;3(3):2325967115573222http://dx.doi.org/10.1177/2325967115573222. [14] Davis JJ, Swenson JD, Kelly S, Abraham CL, Aoki SK. Anatomic changes in the inguinal region after hip arthroscopy: implications for femoral nerve block. J Clin Anesth 2012;24(7):590–2. http://dx.doi.org/10.1016/j.jclinane.2012.04.004. [15] Ekhtiari S, Haldane CE, de Sa D, Simunovic N, Ayeni OR. Fluid extravasation in hip arthroscopy: a systematic review. Arthroscopy 2017;33(4):873–80. http://dx.doi. org/10.1016/j.arthro.2016.11.009. [16] Garner M, Alsheemeri Z, Sardesai A, Khanduja V. A prospective randomized controlled trial comparing the efficacy of fascia iliaca compartment block versus local anesthetic infiltration after hip arthroscopic surgery. Arthroscopy 2017;33(1):125–32. http://dx.doi.org/10.1016/j.arthro.2016.10.010. [17] Vassar M, Holzmann M. The retrospective chart review: important methodological considerations. J Educ Eval Health Prof 2013;10:12. http://dx.doi.org/10.3352/ jeehp.2013.10.12. [18] Myles PS, Hunt JO, Nightingale CE, et al. Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults. Anesth Analg 1999;88(1):83–90. http://dx.doi.org/10.1213/00000539-19990100000016. [19] Abdelmawgoud A, Rashwan S. The analgesic efficacy of continuous fascia iliaca block vs. continuous psoas compartment block after hip surgery: a comparative study. Egypt J Anaesth 2012;28(3):183–7. http://dx.doi.org/10.1016/j.egja.2012. 02.007.
29
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia journal homepage: www.elsevier.com/locate/jclinane
Original Contribution
A comparison of the fascia iliaca block to the lumbar plexus block in providing analgesia following arthroscopic hip surgery: A randomized controlled clinical trial☆
T
⁎
Ignacio Badiola, MDa, , Jiabin Liu, MD, PhDb, Stephanie Huang, MDb, John D. Kelly IV, MDc, Nabil Elkassabany, MD, MSCEa a b c
Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States Department of Orthopaedics, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
A R T I C LE I N FO
A B S T R A C T
Keywords: Regional anesthesia Fascia iliaca block Lumbar plexus block Postoperative pain Hip arthroscopic surgery
Study objective: This randomized controlled single blinded clinical trial compared the fascia iliaca block (FIB) and the lumbar plexus block (LPB) in patients with moderate to severe pain following hip arthroscopic surgery. Design: Single blinded randomized trial. Setting: Postoperative recovery area, postoperative days 0 and 1. Patients: Fifty patients undergoing hip arthroscopy were approached in the Post Anesthesia Care Unit (PACU) if they had moderate to severe pain (defined as > or equal 4/10 on the numeric rating scale). Twenty-five patients were allocated to the FIB and twenty-five patients to the LPB. Interventions: Fascia iliaca block or lumbar plexus block. Measurements: A blinded observer recorded pain scores just prior to the block, 15 min following the block (primary endpoint), and then every 15 min for 2 h (or until the patient was discharged). Total PACU time and opioid use were recorded. Pain scores and analgesic use on postoperative day (POD) 0, and POD 1 were recorded. At 24 h post block the Quality of Recovery 9 questionnaire was administered. Results: The mean pre-block pain scores were comparable between the two groups (P = 0.689). There was no difference in mean post block pain scores between the two groups at 15 min (P = 0.054). In the PACU patients who underwent a LPB consumed less opioids compared to FIB patients (P = 0.02), however no differences were noted between the two groups in PACU length of stay, or POD 0 or 1 opioid use. Conclusion: A fascia iliaca block is not inferior to a lumbar plexus block in reducing PACU pain scores in patients with moderate to severe pain following hip arthroscopic surgery and is a viable option to help manage postoperative pain following hip arthroscopic surgery.
1. Introduction Hip arthroscopic surgery is a commonly performed outpatient procedure utilized for treatment of a variety of pathology including acetabular labral tears, femoroacetabular impingement (from a variety of causes), bursa excisions, and psoas release [1,2]. Postoperative pain varies depending on many factors but can be moderate to severe [3,4] Regional anesthesia provides dense analgesia with the potential to decrease opioid related side effects (nausea/vomiting, sedation, respiratory depression) by decreasing reliance on opioid medications.
☆ ⁎
Postoperative pain tends to be most severe in the first 24 h [2] making it imperative to find an anesthetic technique that provides adequate analgesia to help improve patient comfort, decrease post anesthesia care unit (PACU) discharge times and reduce readmission for uncontrolled pain. Regional anesthesia is an enticing choice however, innervation to the hip joint is complex involving the femoral nerve (FN), obturator nerve (ON), and sciatic nerve (SN). The skin overlying the typical portal entry sites include innervation from the lateral femoral cutaneous nerve (LFCN). Due to this extensive innervation, an all-encompassing block would
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Corresponding author. E-mail addresses: [email protected] (I. Badiola), [email protected] (N. Elkassabany).
https://doi.org/10.1016/j.jclinane.2018.05.012 Received 20 February 2018; Received in revised form 4 May 2018; Accepted 18 May 2018 0952-8180/ © 2018 Published by Elsevier Inc.
Journal of Clinical Anesthesia 49 (2018) 26–29
I. Badiola et al.
0.25% Preservative Free bupivacaine with 1:200,000 epinephrine. The second group received a fascia iliaca block using 30 ml of 0.25% Preservative Free bupivacaine with 1:200,000 epinephrine. A total of 50 patients were randomized with 25 in the FIB group and 25 in the LPB group. The block was performed by an anesthesiologist trained in regional anesthesia and experienced in both types of blocks. All followup assessments were performed by a research assistant blinded to the randomization. The fascia iliaca block was performed with the patient in a supine position. The ipsilateral groin was prepped and cleaned with chlorhexidine. An ultrasound machine (Fujifilm Sonosite, Bothell, WA) with a linear transducer (C35, 8–3 MHz) covered with a sterile Tegaderm (3 M, St. Paul, MN) was used. The transducer was placed inferior to the inguinal ligament until the femoral artery was imaged. The probe was then moved laterally until the Sartorius muscle was seen. A skin wheal with 1% lidocaine was made and a Stimuplex 22 gauge 2-inch or 4-inch blunt tip needle (B. Braun Medical Inc., Bethlehem, PA) was inserted in plane. The needle was seen to pierce the fascia iliaca and 1–2 ml of 0.25% Preservative Free bupivacaine with 1:200,000 epinephrine was injected to confirm correct needle placement between the fascia iliaca and iliopsoas muscle. The injection was deemed adequate if local anesthetic was seen to separate these two layers in a lateral to medial direction as the local anesthetic was injected. The spread of local anesthetic was tracked under the fascia iliaca to confirm its spread to the femoral nerve as well. A total of 30 ml of 0.25% Preservative Free bupivacaine with 1:200,000 epinephrine was used. The lumbar plexus block was performed with the patient in a lateral position with the operative side facing up. An ultrasound machine (Fujifilm Sonosite, Bothell, WA) with a curved transducer (C35, 8–3 MHz)covered with a sterile Tegaderm (St. Paul, MN 55144) was utilized. With the ipsilateral hip and knee will be flexed to 90°, the anatomy for the LP block was localized using a modified transverse scan of the lumbar paravertebral area (PMTS). This technique is well described by Karmarkar et al. [9]. The target vertebral level was identified by locating the lumbosacral junction (the gap of L5-S1) using a paramedian sagittal scan and then counting cranially to locate both the lamina and the transverse process of L3–L5. The transducer was then placed 4 cm lateral to the midline at the L3–4 level and directed medially to insonate the intervertebral foramen through the lumbar intervertebral space. A skin wheal was then made at this site with 1% lidocaine and a 20 gauge 6-inch blunt tip needle (B. Braun Medical Inc., Bethlehem, PA) was introduced 4 cm lateral to the midline and just medial of the transducer after connecting it to a nerve stimulator set at 1.00 mA. The needle was slowly advanced under ultrasound guidance until engaged in the psoas compartment and a twitch elicited of the quadriceps at > 0.5 mA. 30 ml of 0.25% Preservative free bupivacaine with 1:200,000 epinephrine was injected slowly after negative aspiration. The fascia iliaca block was assessed by checking for decreased sensation to cold temperature (ice) along the distribution of the lateral femoral cutaneous nerve and femoral nerve and comparing this to sensation performed before the block and to sensation in the opposite lower extremity. The lumbar plexus block was assessed by checking for a decrease in sensation to cold temperature in the anterior lateral thigh and comparing it to sensation before the block and to sensation in the opposite lower extremity. After injection of local anesthetic and confirmation of a successful block, a blinded research assistant measured pain scores 15 min after the procedure and then every 15 min for 2 h (or until the patient was discharged). Intraoperative and PACU opioid/analgesic use was recorded. Total PACU time was also recorded. Patients were also followed on postoperative days (POD) 0, and 1 via phone contact. Prior to discharge they were provided with a pain diary to complete every 6 h after discharge until 24 h post block. Pain scores, analgesic use as well as adverse effects were recorded. At 24 h post block patients filled out a Quality of Recovery 9 questionnaire.
be best- if feasible. This block should be easy to perform, easy to learn, and have minimal adverse effects. The lumbar plexus block (LPB) is a compartment block which blocks the FN, ON, and LFCN making it an attractive choice. The fascia iliaca block (FIB) is also a compartment block. Various regional anesthetic techniques have been described for hip surgery including femoral nerve blocks, fascia iliaca block, lumbar plexus block, and paravertebral blocks [2]. However it is unknown which is best in providing analgesia following hip arthroscopic surgery. A study by YaDeau et al. [5] noted that the lumbar plexus block resulted in reduction in PACU resting pain after hip arthroscopy. In a study by Krych et al. [6] fascia iliaca block following hip arthroscopy was safe and effective. This study noted that patients that received the fascia iliaca blocks resulted in low opioid consumption and high patient satisfaction. A recent study noted that a lumbar plexus block administered in concert with general anesthesia provided clinically important and statistically significant post-operative pain relief when compared with general anesthesia alone or general anesthesia plus fascia iliaca block [7]. Our study sought to compare two compartment blocks with the potential to improve postoperative pain. We hypothesized that FIB would not be inferior to the LPB 15 min following the procedure as measured by pain intensity on the numeric rating scale. This has implications as the LPB is considered a technically challenging block with the potential for serious adverse effects including epidural spread (resulting in possible need for admission to the hospital) and visceral injury (i.e. structures in the retroperitoneum). The FIB is usually considered technically easier to perform with less risk of major adverse events [8]. Our goal was to show that both blocks decrease pain following hip arthroscopy and that the FIB is not inferior to the LPB. We also evaluated perioperative complications, PACU pain scores, PACU discharge times, postoperative days 0 and 1 analgesic use and pain scores, and patient satisfaction, all as secondary outcomes. 2. Methods This randomized, controlled, single blinded (assessment was blinded) trial was approved by the University of Pennsylvania's Institutional Review Board (IRB# 822547). It was registered at clinicaltrials.org (ID# NCT02882633). CONSORT guidelines were followed. Eligibility criteria included patients > 18 years of age undergoing a primary hip arthroscopy who were ASA physical status 1-III and English speaking. Exclusion criteria included chronic opioid use (use of any opioid daily or on most days of the week for > 3 months), diagnosed peripheral neuropathy in the surgical lower extremity, allergy to study medications, and a BMI > 35. All procedures were done at the University of Pennsylvania Presbyterian Medical Center or it's outpatient surgery facility. All patients were recruited between October 2015 and November 2016. Sample size was calculated by assuming an alpha of 0.05 and a power of 80. Using a median pain score after the block was performed of 5/10 on the VAS with the FIB, a 4/10 for the LPB (20–25% difference) and a standard deviation estimated between 1.35 and 2.34 resulted in 23 patients in the FIB group and 23 patients in the LPB group. Considering a 10% drop out during follow-up, 25 patients were recruited per group. A study physician approached the patient in the preoperative area and if patients elected to proceed with the study, informed consent was obtained preoperatively. The patient then underwent hip arthroscopic surgery under general anesthesia — which is the standard of care at our medical center. We did not make any stipulations as to how the general anesthetic was conducted. Patients were assessed on arrival to the PACU. Patients who had consented preoperatively and complained of pain greater than or equal to 4/10 on the NRS were randomized to either a lumbar plexus block or fascia iliaca block. Randomization was done using a random number generator to allocate patients into two groups. The first group received a lumbar plexus block using 30 ml of 27
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4. Discussion
Table 1 Baseline characteristics.
Sex (n) Male Female Body mass index (kg/m2) mean Age (mean ± SD) Femoral/acetabular osteoplasty (%) Peri-trochanteric space surgery (%)
Fascia illiaca block (n = 25)
Lumbar plexus block (n = 23)
P value
9 16 26.80 ± 4.52
7 16 29.89 ± 6.59
0.683
39.8 ± 11.40 23 (92)
38.83 ± 11.55 19 (82.6)
0.950 0.174
2 (4.2)
4 (8.3)
Although the number of hip arthroscopic surgical procedures is increasing, the best way to manage postoperative pain is not yet well defined [10]. Many, if not most, are being performed on an outpatient basis. It is essential to find a therapy, or therapies, that improves postoperative pain, decreases opioid reliance/use, improves PACU discharge times, and decreases the rate of hospital admission from poor pain management. Regional anesthesia is an enticing choice. However, due to the complexity of the innervation to the hip, various regional anesthetic techniques have been proposed, but not many have been compared. We chose to evaluate two of these blocks, specifically the two compartment blocks that have been described for use following hip arthroscopy. Our rationale was that these two blocks are compartment blocks and anesthetize multiple nerves compared to single nerve regional anesthetic blocks. They thus have the potential to provide better analgesia than single nerve blocks. Our primary hypothesis was that a postoperative fascia iliaca would not be inferior to a lumbar plexus block in providing analgesia in patients that arrive to the PACU in moderate to severe pain. Like most trials the rational for this trial did not form in a vacuum. Our institution favors FIB performed postoperatively following hip arthroscopy in patients who arrive to the PACU in moderate to severe pain. We have good anecdotal evidence that patients who arrive with severe pain subjectively feel better and have better pain scores before discharge following FIB. Our regional anesthesiologists also believe that that the FIB is easier to learn and perform than the LPB and have trained some of our non-regional anesthesiologists to perform FIB following hip surgery with good anecdotal success and no major adverse outcomes. Not all anesthesiologists involved in caring for patients undergoing hip arthroscopic surgery have been trained in regional anesthesia and a block that is considered easy to learn with minimal adverse effects is ideal. The fascia iliaca block is one such block. It has been used for hip surgery by anesthesiologists and by emergency room physicians as an easily learned analgesic technique to provide analgesia following acute hip fractures [8,11]. It has also been shown to be beneficial following hip arthroscopy [6]. Although the FIB can be done preoperatively, our institution typically performs these postoperatively for a few reasons. First, not all patients will require a block. Although the FIB has minimal reported adverse effects it is best to perform these blocks for patients that actually need it. Not all patients have moderate to severe pain on arrival to PACU. For example, in this study 11 out of the 61 patients preoperatively consented (18%) did not require a block as they had < 4/ 10 pain when they arrived to the PACU. Second, we believe that the use of irrigating fluid during arthroscopic surgery may wash away any local anesthetic placed in the fascia iliaca compartment before surgery reducing its postoperative efficacy. During arthroscopic hip surgery more than a liter of irrigation fluid may be extravasated into the soft tissues [12,13]. This fluid can theoretically extravasate into the plane between the psoas muscle and fascia
0.079
All data analysis was executed in STATA 14.2 statistical software (StataCorp LP, College Station, TX). Continuous variables were analyzed with the Student t-test and reported as mean and standard deviation for patient demographic information, or median and interquartile range for outcome variables. All categorical variables were analyzed with Chi-square test.
3. Results We screened 99 patients and excluded 49. Out of those 49 patients 14 did not meet inclusion criteria, 14 declined to participate, 11 had < 4/10 pain on arrival to PACU and 10 patients were excluded as our research assistant was performing other duties when those patients arrived in PACU. Our study cohort included 50 patients, with 25 patients receiving the FIB and 23 patients receiving the LPB post-operatively (see CONSORT diagram). Two patients in the lumbar plexus group were not included as one had epidural spread of local anesthetic leading to complete sensory and motor block in the bilateral lower extremities and the other did not have evidence of a successful block on postblock examination. Table 1 summarizes patient demographic information. The ages of patients were 39.8 ± 11.40 versus 38.83 ± 11.55 years in FIB and LPB group respectively (P = 0.950). Gender, body mass index, and ASA classification were not significantly different between these two groups. The pre-block pain scores were comparable between the FIB and LPB groups (5.8 versus 6.3, P = 0.689). There was no statistically significant difference in pain scores 15 min post block between the two groups 3.4 vs 2.9 P = 0.054). There was also no difference in change in pain scores 15 min postblock between the two groups. Total opioid use in the PACU was lower in the LPB group compared to the FIB group (Table 2). However, there were no differences in POD 0 or 1 opioid use. The length of PACU stay was 139.7 vs 165.0 min respectively (P = 0.419). Last, the quality of recovery as measured by QOR 40 questionnaire, were also comparable between the two study groups.
Table 2 Clinical outcomes. Fascia illiaca block
Pre-block pain Pain 15 min postblock Change in pain score (pre block and at 15 min PACU opioids (MED) (mg) POD 0 oxycodone meq POD 1 oxycodone meq Quality of recovery PACU length of stay (min)
Lumbar plexus block
Average
Interquartile range
Average
Interquartile range
P-value
5.84 3.4 1.72 20.80 14.46 25.63 15.91 139.72
2–9 0–6 0–8 5.62–33.75 3.75–30 10–47.5 11–18 90–219
6.30 2.87 3 16.98 13.43 21.55 14.52 165.04
4.5–8 2–4 1–3 5.81–22.5 5–20 13.13–33.5 14–17 113.5–183
0.689 0.054 0.098 0.020 0.075 0.763 0.320 0.419
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PACU compared to LPB patients. This study was not powered to detect if this was a true finding or a finding due to chance in a secondary end point. Future studies are needed to see if patients who undergo FIB require more opioids in PACU and if so do they report more adverse effects.
iliaca resulting in dilution and washing away of local anesthetic placed preoperatively. A case report of two patients undergoing a postoperative block following hip arthroscopy noted ultrasound evidence of fluid within the tissue plane between the fascia iliaca and iliopsoas muscle with distension of tissue and a hypoechoic signal (fluid) surrounding the femoral nerve before performing the block [14]. A systematic review of fluid extravasation following hip arthroscopy noted that in 40 asymptomatic patients, 100% had fluid extravasation into the thigh [15]. This in and of itself has the potential to render the FIB placed before surgery ineffective for postoperative analgesia. A recent study comparing a FIB to local anesthetic infiltration (LAI) of the portal tracts after hip arthroscopic surgery required early termination when it was noted that patients receiving the FIB were arriving to the PACU in significant pain [16]. Preliminary analysis revealed that FIB patients were having significantly more pain the first hour after surgery with mean pain scores of 3.4 vs 5.5 when compared to the LAI. It is important to note that the FIB were performed before surgery while the LAI were performed at the end of the surgical procedure. It is possible that washing away of local anesthetic from irrigation during surgery could have led to the higher pain scores in the FIB cohort. It is also worth noting that this study used a dilute concentration of 0.125% bupivacaine for the FIB. Our study used double (0.25%) the concentration in the FIB. Our study is in contrast to that of Wolff et al. who demonstrated that a lumbar plexus block was superior to a fascia iliaca block in providing postoperative analgesia after hip arthroscopic surgery [7]. However, the methodology of the studies is very different. Wolff et al. performed the fascia iliaca block preoperatively, which as described previously may have subjected this group to washout of local anesthetic with subsequent reduction in benefit compared to the lumbar plexus block. This study was also retrospective and thus subject to the known issues associated with these types of studies [17]. Our secondary outcomes did not show any difference between the two blocks in regards except for total PACU opioid use. There were no differences between the two groups on total home opioid use on POD 0 or 1. There was also no difference between the groups in regards to quality of recovery using the Quality of Recovery Questionnaire. This tool asks nine questions and assesses various domains of postoperative recovery [18]. We had one complication following a lumbar plexus block which resulted in epidural spread of local anesthesia leading to weakness and sensory deficits in the patient's bilateral lower extremities. This is a known complication of lumbar plexus blocks. The patient was admitted overnight for observation and was discharged the following day without sequela. No other complications were noted in any of the two groups. No postoperative falls were noted. However, this study was not powered to detect these extremely rare events. The results of our current study bring clinical implications that need future study. There are many reports of analgesic success following various regional anesthetic blocks following hip arthroscopic surgery, however comparisons of these blocks are lacking. To our knowledge, this study was the first to prospectively compare two compartment blocks for postoperative pain management in patients who underwent arthroscopic hip surgery. A study comparing both blocks in patients undergoing a femur fracture fixation or a total hip arthroplasty also noted no difference between both blocks in 24 h meperidine requirements or postoperative pain [19]. Although arthroscopic hip surgery is a wide encompassing term and can mean anything from simple debridement to extensive bony surgery, our study only blocked patients who had moderate to severe pain on arrival to the recovery room regardless of how extensive the surgery was. This study shows that FIB provides good post block analgesia with good patient satisfaction. It also shows that at home opioid consumption did not differ between the two groups. Interestingly, patients in the FIB group consumed more opioids in the
Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.jclinane.2018.05.012. References [1] Sardana V, Philippon MJ, de Sa D, et al. Revision hip arthroscopy indications and outcomes: a systematic review. Arthroscopy 2015;31(10):2047–55. http://dx.doi. org/10.1016/j.arthro.2015.03.039. [2] Yu HC, Al-Shehri M, Johnston KD, Endersby R, Baghirzada L. Anesthesia for hip arthroscopy: a narrative review. Can J Anaesth 2016;63(11):1277–90. http://dx. doi.org/10.1007/s12630-016-0718-7. [3] Ward JP, Albert DB, Altman R, Goldstein RY, Cuff G, Youm T. Are femoral nerve blocks effective for early postoperative pain management after hip arthroscopy? Arthroscopy 2012;28(8):1064–9. http://dx.doi.org/10.1016/j.arthro.2012.01.003. [4] Bech NH, Hulst AH, Spuijbroek JA, van Leuken LLA, Haverkamp D. Perioperative pain management in hip arthroscopy; what options are there? J Hip Preserv Surg 2016;3(3):181–9. http://dx.doi.org/10.1093/jhps/hnw015. [5] Yadeau JT, Tedore T, Goytizolo EA, et al. Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial. Anesth Analg 2012;115(4):968–72. http://dx.doi.org/10.1213/ANE.0b013e318265bacd. [6] Krych AJ, Baran S, Kuzma SA, Smith HM, Johnson RL, Levy BA. Utility of multimodal analgesia with fascia iliaca blockade for acute pain management following hip arthroscopy. Knee Surg Sports Traumatol Arthrosc 2014;22(4):843–7. http://dx. doi.org/10.1007/s00167-013-2665-y. [7] Wolff AB, Hogan GW, Capon JM, Napoli AM, Smith HJ, Gaspar PS. Pre-operative lumbar plexus block provides superior post-operative analgesia when compared with fascia iliaca block or general anesthesia alone in hip arthroscopy. J Hip Preserv Surg 2016:hnw021http://dx.doi.org/10.1093/jhps/hnw021. [8] Elkhodair S, Mortazavi J, Chester A, Pereira M. Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency department: a pilot study. Eur J Emerg Med 2011;18(6):340–3. http://dx.doi.org/ 10.1097/MEJ.0b013e32834533dd. [9] Karmakar MK, Li JW, Kwok WH, Hadzic A. Ultrasound-guided lumbar plexus block using a transverse scan through the lumbar intertransverse space: a prospective case series. Reg Anesth Pain Med 2015;40(1):75–81. http://dx.doi.org/10.1097/AAP. 0000000000000168. [10] Shin JJ, Mccrum CL, Mauro CS, Vyas D. Pain management after hip arthroscopy: systematic review of randomized controlled trials and cohort studies. Am J Sports Med 2017:363546517734518http://dx.doi.org/10.1177/0363546517734518. [11] Groot L, Dijksman LM, Simons MP, Zwartsenburg MMS, Rebel JR. Single fascia Iliaca compartment block is safe and effective for emergency pain relief in hipfracture patients. West J Emerg Med 2015;16(7):1188–93. http://dx.doi.org/10. 5811/westjem.2015.10.28270. [12] Stafford GH, Malviya A, Villar RN. Fluid extravasation during hip arthroscopy. Hip Int 2011;21(6):740–3. http://dx.doi.org/10.5301/HIP.2011.8845. [13] Hinzpeter J, Barrientos C, Barahona M, et al. Fluid extravasation related to hip arthroscopy: a prospective computed tomography-based study. Ortho J Sports Med 2015;3(3):2325967115573222http://dx.doi.org/10.1177/2325967115573222. [14] Davis JJ, Swenson JD, Kelly S, Abraham CL, Aoki SK. Anatomic changes in the inguinal region after hip arthroscopy: implications for femoral nerve block. J Clin Anesth 2012;24(7):590–2. http://dx.doi.org/10.1016/j.jclinane.2012.04.004. [15] Ekhtiari S, Haldane CE, de Sa D, Simunovic N, Ayeni OR. Fluid extravasation in hip arthroscopy: a systematic review. Arthroscopy 2017;33(4):873–80. http://dx.doi. org/10.1016/j.arthro.2016.11.009. [16] Garner M, Alsheemeri Z, Sardesai A, Khanduja V. A prospective randomized controlled trial comparing the efficacy of fascia iliaca compartment block versus local anesthetic infiltration after hip arthroscopic surgery. Arthroscopy 2017;33(1):125–32. http://dx.doi.org/10.1016/j.arthro.2016.10.010. [17] Vassar M, Holzmann M. The retrospective chart review: important methodological considerations. J Educ Eval Health Prof 2013;10:12. http://dx.doi.org/10.3352/ jeehp.2013.10.12. [18] Myles PS, Hunt JO, Nightingale CE, et al. Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults. Anesth Analg 1999;88(1):83–90. http://dx.doi.org/10.1213/00000539-19990100000016. [19] Abdelmawgoud A, Rashwan S. The analgesic efficacy of continuous fascia iliaca block vs. continuous psoas compartment block after hip surgery: a comparative study. Egypt J Anaesth 2012;28(3):183–7. http://dx.doi.org/10.1016/j.egja.2012. 02.007.
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