Intra-articular cocktail offers clinical advantages over femoral nerve block for postoperative analgesia in patients undergoing arthroscopic hip surgery Sean Childs, MD; Sonia Pyne, MD; Kiritpaul Nandra, MD; Wajeeh Bakhsh, MD; S Atif Mustafa, BS; Amy LaLonde, MA; Derick Peterson, PhD; Brian Giordano, MD Investigation performed at the University of Rochester, Department of Orthopaedics and Rehabilitation, Rochester, NY USA
Disclosures Brian Giordano, MD Athrex: Consultant, Research Support, Royalties Sean Childs MD; Sonia Pyne MD; Kiritpaul Nandra MD; Wajeeh Bakhsh MD; S. Atif Mustafa BS; Amy LaLonde MA; Derick Peterson PhD Have no financial relationships to disclose 2
Background Regional anesthesia strategies have significant utility among patients undergoing arthroscopic hip surgery Preoperative femoral nerve blocks, while efficacious, have many potential pitfalls, including technical difficulty, intravascular injections, increased postoperative fall risk, and iatrogenic peripheral neuritis The purpose of this study was to compare clinical efficacy and complication rate between intra-articular blockade and femoral nerve block in patients undergoing arthroscopic hip surgery 3
Methods A consecutive series of patients undergoing elective arthroscopic hip surgery (11/2013 04/2015) by a singe surgeon were retrospectively reviewed Patients divided into 2 groups: Preoperative femoral nerve block for perioperative pain control Intra-operative, intra-articular cocktail injection Demographic data, perioperative pain scores, narcotic consumption, incidence of falls, and iatrogenic peripheral neuritis were collected for analysis. Postoperative data was collected at routine clinical visits (1 week, 3 weeks and 6 weeks postoperatively) 4
Femoral Block Technique 22 gauge, 5 cm blunt tip needle (B. Braun Plexufix) was advanced via a lateral approach with in-plane ultrasound guidance (Sonosite S-Nerve with linear transducer) towards the femoral nerve. A mixture of 0.5% bupivacaine with 1:200,000 epinephrine was administered over 1-3 minutes with needle manipulation as necessary to achieve circumferential spread of local anesthetic around the femoral nerve. Spread of local anesthetic deep to the fascia iliaca was confirmed with ultrasound visualization. 5
Intra-articular Block Technique 14 gauge spinal needle was inserted into the joint under direct visualization and the joint was aspirated of all residual fluid. An intra-articular cocktail injection, consisting of 300mg Ropivicaine with epinephrine, 30mg Toradol and 5mg Morphine (Astramorph, AVINza, Duramorph) was then administered Care taken to avoid extravasation of the injectate. 6
Results 193 patients (65/125 M/F, 105/88 Fem Block/IA Cocktail) No significant difference between groups with regards to age, sex, smoking status, history of chronic pain, worker s compensation, preoperative pain scores or intraoperative doses of narcotics No statistically significant differences between groups in patient reported pain scores at postoperative weeks 1, 3 and 6. Administration of an intra-articular block was associated with a significant reduction in the rate of postoperative falls and iatrogenic peripheral neuritis (P < 0.01) 7
Demographics Group 1, Fem Block (n=105) Group 2, IA Block (n=88) P Value Sex, n (Male) 38 27 0.42 Age, mean ± SD, y 33.4 ± 13.02 31.3 ± 14.05 0.29 Smoking Hx, n (Yes) 28 26 0.66 Workers Comp, n (Yes) 4 1 0.24 Hx Chronic Pain, n (Yes) 4 6 0.35 8
Outcomes Group 1, Fem Block Group 2, IA Block P Value Preoperative pain, mean ± SD Intraoperative Dilaudid, mean ± SD, mg 3.54 ± 2.69 3.69 ± 2.43 0.69 0.18 ± 0.33 0.22 ± 0.37 0.40 Pain on PACU Arrival 4.59 ± 2.85 6.16 ± 2.56 <0.01* Pain at Discharge 3.55 ± 2.26 4.28 ± 3.13 0.03* Pain at 1 week 3.05 ± 2.18 2.75 ± 2.16 0.34 Pain at 3 weeks 1.96 ± 2.13 1.82 ± 2.07 0.64 Pain at 6 weeks 1.70 ± 2.09 1.59 ± 1.95 0.70 Reported a fall, n 19 5 <0.01* Peripheral Neuritis, n 26 2 <0.01* 9
Conclusion Intra-articular cocktail administration provides comparable postoperative pain control to preoperative femoral nerve blocks in patients undergoing arthroscopic hip surgery Patients receiving intra-articular cocktail injections exhibited a significant reduction in the rate of postoperative falls and iatropgenic peripheral neuritis when compared to their femoral nerve block counterparts Intraoperative, intra-articular anesthetic injections provide effective postoperative pain control in patients undergoing arthroscopic hip surgery 10
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