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Editorial Commentary: The Truth about Peripheral Nerve Blocks and Hip Arthroscopy
Editorial Commentary: The Truth about Peripheral Nerve Blocks and Hip Arthroscopy Alan L. Zhang, MD
Abstract: Peripheral nerve blocks targeting the fascia iliaca compartment have been used in attempts to improve postoperative pain after hip arthroscopy surgery. Recent level I evidence from randomized controlled trials have revealed injection of local anesthetic into the fascia iliaca compartment to be no better than sham injection for postoperative pain control, while contributing to decreased patient quadriceps strength and increased fall risk after surgery. The fascia iliaca compartment block is also inferior to local anesthetic injection at the surgery site for pain control. Results of these highlevel studies show that routine preoperative use of the fascia iliaca compartment block is not recommended for hip arthroscopy.
See related article on page 2608
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eripheral nerve block techniques have been shown to significantly reduce postoperative pain for shoulder and knee arthroscopy procedures.1,2 However, there have been limited research evaluating the effectiveness of peripheral nerve block techniques for the increasingly performed hip arthroscopy procedures.3,4 One potential target of local anesthetic blocks for hip arthroscopy is the fascia iliaca compartment, as it houses the femoral, lateral femoral cutaneous, and obturator nerves and has been shown to be safe and effective for hip fracture pain control.5 Although fascia iliaca compartment blocks (FICBs) are the most common peripheral nerve blocks performed for hip arthroscopy, recent level I evidence studies have brought into question the true effectiveness of this procedure. Our institution performed a randomized, double-blind, placebo-controlled trial comparing ultrasound-guided FICB with 40 mL of 0.2% ropivacaine versus sham block with 40 mL of 0.9% saline.6 Our results showed that for 78 patients (39 in each
University of California, San Francisco The author reports the following potential conflicts of interest or sources of funding: A.L.Z. reports personal fees from Stryker. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/19536/$36.00 https://doi.org/10.1016/j.arthro.2019.04.028
group), there was no difference in opioid requirements or pain scores in the postoperative recovery room or the first 24 hours after surgery. We did find that quadriceps strength was significantly decreased in the blocked group, and patients in the blocked group were 4 times more likely to suffer a postoperative fall than those in the sham group. These results were similar to another randomized controlled trial comparing ultrasoundguided FICB with local anesthetic injection at the portal tracks for hip arthroscopy pain control.7 In that level I study, the authors found local anesthetic injection to be superior to FICB for pain control after surgery, with significantly decreased patient pain scores and opioid requirements, and the trial was terminated before completion for patient safety. In addition to these previous trials, the study of Purcell, Brooks, Steelman, Christensen, Dickens, Kent, McCabe, and Anderson,8 “Ascia Iliaca Blockade With the Addition of Liposomal Bupivacaine Versus Plain Bupivacaine for Perioperative Pain Management During Hip Arthroscopy: A Double-Blinded Prospective Randomized Control Trial,” compares FICB with plain bupivacaine versus liposomal bupivacaine, which has been shown by previous studies to provide longer and greater local analgesia. The authors found no difference in postoperative pain control and opioid usage between patients treated with the liposomal formulation or plain bupivacaine. Because there was no control (sham) group compared with the 2 FICB groups, the study’s results do not reflect the true effectiveness of FICB
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 9 (September), 2019: pp 2617-2618
2617
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EDITORIAL COMMENTARY
blocks but only the effectiveness of different local anesthetics used for FICB relative to each other. Yet the results are very valuable, as they provide novel level I evidence for those interested in using liposomal formulations for local analgesia of the hip. Because the limited utility of fascia iliaca compartment blocks for hip arthroscopy may result from the intricate and complex innervation pattern of the hip, other avenues for mitigating postoperative pain after hip arthroscopy should be investigated. For example, pearls to improve surgical technique such as decreasing traction time, use of postless hip distraction, or even use of air arthrograms to help distraction are areas of focus.9,10 In a retrospective cohort analysis, our institution recently showed that the use of air arthrograms to aid joint distraction in hip arthroscopy decreased postoperative pain scores and opioid use in the recovery room.10 These methods need further validation with higher-level evidence, which is a goal of future research at many high-volume hip arthroscopy centers. Because level I evidence through randomized controlled trials is hard to come by in orthopaedics and anesthesia, the truth is clear regarding peripheral nerve blocks of the fascia iliaca compartment and hip arthroscopy. Multiple level I studies showing the ineffectiveness of this intervention in decreasing postoperative pain lead to the conclusion that routine preoperative use of the fascia iliaca compartment block is not recommended for hip arthroscopy.
References 1. Hussain N, Goldar G, Ragina N, Banfield L, Laffey JG, Abdallah FW. Suprascapular and interscalene nerve block for shoulder surgery: A systematic review and metaanalysis. Anesthesiology 2017;127:998-1013.
2. Xu J, Chen XM, Ma CK, Wang XR. Peripheral nerve blocks for postoperative pain after major knee surgery. Cochrane Database Syst Rev 2014;12:CD010937. 3. Sing DC, Feeley BT, Tay B, Vail TP, Zhang AL. Age-related trends in hip arthroscopy: A large cross-sectional analysis. Arthroscopy 2015;31:2307-2313.e2. 4. Zhang AL, Feeley BT. Editorial commentary: The rise of hip arthroscopy: Temporary trend or here to stay? Arthroscopy 2018;34:1831-1832. 5. Groot L, Dijksman LM, Simons MP, Zwartsenburg MM, Rebel JR. Single fascia iliaca compartment block is safe and effective for emergency pain relief in hip-fracture patients. West J Emerg Med 2015;16:1188-1193. 6. Behrends M, Yap EN, Zhang AL, Kolodzie K, Kinjo S, Harbell MW, Aleshi P. Preoperative fascia iliaca block does not improve analgesia after arthroscopic hip surgery, but causes quadriceps muscles weakness: A randomized, double-blind trial. Anesthesiology 2018;129:536-543. 7. Garner M, Alshameeri Z, Sardesai A, Khanduja V. Arthroscopy. A prospective randomized controlled trial comparing the efficacy of fascia iliaca compartment block versus local anesthetic infiltration after hip arthroscopic surgery. Arthroscopy 2017;33:125-132. Erratum. Arthroscopy 2018 Jan;34:348. 8. Purcell RL, Brooks DI, Steelman TJ, Christensen DL, Dickens JF, Kent ML, McCabe MP, Anderson TD. Ascia iliaca blockade with the addition of liposomal bupivacaine versus plain bupivacaine for perioperative pain management during hip arthroscopy: A double-blinded prospective randomized control trial. Arthroscopy 2019;35:2608-2616. 9. Mei-Dan O, Kraeutler MJ, Garabekyan T, Goodrich JA, Young DA. Hip Distraction without a perineal post: A prospective study of 1000 hip arthroscopy cases. Am J Sports Med 2018;46:632-641. 10. Hodax JD, Flores SE, Cheung EC, Zhang AL. Use of air arthrograms to aid in joint distraction during hip arthroscopic surgery decreases postoperative pain and opioid requirements. Orthop J Sports Med 2019;7: 2325967119837389.
Abstract: Peripheral nerve blocks targeting the fascia iliaca compartment have been used in attempts to improve postoperative pain after hip arthroscopy surgery. Recent level I evidence from randomized controlled trials have revealed injection of local anesthetic into the fascia iliaca compartment to be no better than sham injection for postoperative pain control, while contributing to decreased patient quadriceps strength and increased fall risk after surgery. The fascia iliaca compartment block is also inferior to local anesthetic injection at the surgery site for pain control. Results of these highlevel studies show that routine preoperative use of the fascia iliaca compartment block is not recommended for hip arthroscopy.
See related article on page 2608
P
eripheral nerve block techniques have been shown to significantly reduce postoperative pain for shoulder and knee arthroscopy procedures.1,2 However, there have been limited research evaluating the effectiveness of peripheral nerve block techniques for the increasingly performed hip arthroscopy procedures.3,4 One potential target of local anesthetic blocks for hip arthroscopy is the fascia iliaca compartment, as it houses the femoral, lateral femoral cutaneous, and obturator nerves and has been shown to be safe and effective for hip fracture pain control.5 Although fascia iliaca compartment blocks (FICBs) are the most common peripheral nerve blocks performed for hip arthroscopy, recent level I evidence studies have brought into question the true effectiveness of this procedure. Our institution performed a randomized, double-blind, placebo-controlled trial comparing ultrasound-guided FICB with 40 mL of 0.2% ropivacaine versus sham block with 40 mL of 0.9% saline.6 Our results showed that for 78 patients (39 in each
University of California, San Francisco The author reports the following potential conflicts of interest or sources of funding: A.L.Z. reports personal fees from Stryker. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/19536/$36.00 https://doi.org/10.1016/j.arthro.2019.04.028
group), there was no difference in opioid requirements or pain scores in the postoperative recovery room or the first 24 hours after surgery. We did find that quadriceps strength was significantly decreased in the blocked group, and patients in the blocked group were 4 times more likely to suffer a postoperative fall than those in the sham group. These results were similar to another randomized controlled trial comparing ultrasoundguided FICB with local anesthetic injection at the portal tracks for hip arthroscopy pain control.7 In that level I study, the authors found local anesthetic injection to be superior to FICB for pain control after surgery, with significantly decreased patient pain scores and opioid requirements, and the trial was terminated before completion for patient safety. In addition to these previous trials, the study of Purcell, Brooks, Steelman, Christensen, Dickens, Kent, McCabe, and Anderson,8 “Ascia Iliaca Blockade With the Addition of Liposomal Bupivacaine Versus Plain Bupivacaine for Perioperative Pain Management During Hip Arthroscopy: A Double-Blinded Prospective Randomized Control Trial,” compares FICB with plain bupivacaine versus liposomal bupivacaine, which has been shown by previous studies to provide longer and greater local analgesia. The authors found no difference in postoperative pain control and opioid usage between patients treated with the liposomal formulation or plain bupivacaine. Because there was no control (sham) group compared with the 2 FICB groups, the study’s results do not reflect the true effectiveness of FICB
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 9 (September), 2019: pp 2617-2618
2617
2618
EDITORIAL COMMENTARY
blocks but only the effectiveness of different local anesthetics used for FICB relative to each other. Yet the results are very valuable, as they provide novel level I evidence for those interested in using liposomal formulations for local analgesia of the hip. Because the limited utility of fascia iliaca compartment blocks for hip arthroscopy may result from the intricate and complex innervation pattern of the hip, other avenues for mitigating postoperative pain after hip arthroscopy should be investigated. For example, pearls to improve surgical technique such as decreasing traction time, use of postless hip distraction, or even use of air arthrograms to help distraction are areas of focus.9,10 In a retrospective cohort analysis, our institution recently showed that the use of air arthrograms to aid joint distraction in hip arthroscopy decreased postoperative pain scores and opioid use in the recovery room.10 These methods need further validation with higher-level evidence, which is a goal of future research at many high-volume hip arthroscopy centers. Because level I evidence through randomized controlled trials is hard to come by in orthopaedics and anesthesia, the truth is clear regarding peripheral nerve blocks of the fascia iliaca compartment and hip arthroscopy. Multiple level I studies showing the ineffectiveness of this intervention in decreasing postoperative pain lead to the conclusion that routine preoperative use of the fascia iliaca compartment block is not recommended for hip arthroscopy.
References 1. Hussain N, Goldar G, Ragina N, Banfield L, Laffey JG, Abdallah FW. Suprascapular and interscalene nerve block for shoulder surgery: A systematic review and metaanalysis. Anesthesiology 2017;127:998-1013.
2. Xu J, Chen XM, Ma CK, Wang XR. Peripheral nerve blocks for postoperative pain after major knee surgery. Cochrane Database Syst Rev 2014;12:CD010937. 3. Sing DC, Feeley BT, Tay B, Vail TP, Zhang AL. Age-related trends in hip arthroscopy: A large cross-sectional analysis. Arthroscopy 2015;31:2307-2313.e2. 4. Zhang AL, Feeley BT. Editorial commentary: The rise of hip arthroscopy: Temporary trend or here to stay? Arthroscopy 2018;34:1831-1832. 5. Groot L, Dijksman LM, Simons MP, Zwartsenburg MM, Rebel JR. Single fascia iliaca compartment block is safe and effective for emergency pain relief in hip-fracture patients. West J Emerg Med 2015;16:1188-1193. 6. Behrends M, Yap EN, Zhang AL, Kolodzie K, Kinjo S, Harbell MW, Aleshi P. Preoperative fascia iliaca block does not improve analgesia after arthroscopic hip surgery, but causes quadriceps muscles weakness: A randomized, double-blind trial. Anesthesiology 2018;129:536-543. 7. Garner M, Alshameeri Z, Sardesai A, Khanduja V. Arthroscopy. A prospective randomized controlled trial comparing the efficacy of fascia iliaca compartment block versus local anesthetic infiltration after hip arthroscopic surgery. Arthroscopy 2017;33:125-132. Erratum. Arthroscopy 2018 Jan;34:348. 8. Purcell RL, Brooks DI, Steelman TJ, Christensen DL, Dickens JF, Kent ML, McCabe MP, Anderson TD. Ascia iliaca blockade with the addition of liposomal bupivacaine versus plain bupivacaine for perioperative pain management during hip arthroscopy: A double-blinded prospective randomized control trial. Arthroscopy 2019;35:2608-2616. 9. Mei-Dan O, Kraeutler MJ, Garabekyan T, Goodrich JA, Young DA. Hip Distraction without a perineal post: A prospective study of 1000 hip arthroscopy cases. Am J Sports Med 2018;46:632-641. 10. Hodax JD, Flores SE, Cheung EC, Zhang AL. Use of air arthrograms to aid in joint distraction during hip arthroscopic surgery decreases postoperative pain and opioid requirements. Orthop J Sports Med 2019;7: 2325967119837389.