The Effectiveness of Periarticular Anesthetic Infiltration in Postoperative Analgesia of Total Hip Arthroplasty^*

Abstract

Objective

The present study aims to evaluate the effectiveness of the periarticular hip infiltration technique in the postoperative period of total hip arthroplasty.

Methods

This is a randomized double-blind controlled clinical trial in patients with femoral neck fractures or hip osteoarthritis submitted to a total hip arthroplasty at our institution. The periarticular infiltration technique consisted of the administration of an anesthetic (levobupivacaine) and a steroid (dexamethasone) agent in the nociceptor-rich tissues of the hip after orthopedic implants placement. The control group received an injection of 0.9% saline into the same tissues. Pain, range of motion, and use of opioid analgesic agents after 24 and 48hours of the procedure were evaluated, as well as the presence of adverse effects, time to resume walking, and total hospitalization time.

Results

The study evaluated 34 patients. The experimental group required fewer opioid agents between 24 and 48 hours. The reduction in pain scores was greater in the placebo group.

Conclusion

Periarticular anesthetic infiltration as a method of postoperative analgesia for total hip arthroplasty reduced the rates of opioid intake between 24 and 48hours. It provided no benefits regarding pain, mobility, length of stay, or complications.

Keywords
arthroplasty, replacement, hip; injections, intra-articular; analgesia; rehabilitation

Resumo

Objetivo

Este estudo tem como objetivo avaliar a eficácia da técnica de infiltração periarticular do quadril no pós-operatório de artroplastia total do quadril.

Métodos

Estudo clínico randomizado duplo-cego controlado. O estudo foi realizado nos pacientes com fratura de colo femoral ou osteoartrose de quadril, submetidos ao procedimento cirúrgico de artroplastia total do quadril em nossa instituição. A técnica de infiltração periarticular consistiu na aplicação da combinação de um anestésico (levobupivacaína) com um corticosteroide (dexametasona) nos tecidos ricos em nociceptores do quadril, após a colocação dos implantes ortopédicos. No grupo controle, foi realizada infiltração de soro fisiológico 0,9% nos mesmos tecidos. Após 24 e 48 horas do procedimento, foram avaliados os quesitos de dor, amplitude de movimentos, uso de analgésicos opióides, presença de efeitos adversos, período do início da deambulação e o tempo total de hospitalização.

Resultados

Trinta e quatro pacientes foram estatisticamente avaliados no estudo. Foi observada uma redução no consumo de opioides entre 24 e 48 h no grupo experimental. Uma redução maior da pontuação de dor foi observada no grupo placebo.

Conclusão

A infiltração periarticular anestésica como método de analgesia pós-operatória de artroplastia total do quadril, neste estudo, reduziu as taxas deconsumo de opioides

Palavras-chave
artroplastia de quadril; injeções intra-articulares; analgesia; reabilitação

Introduction

Total hip arthroplasty (THA) consists of the surgical treatment of patients with advanced coxarthrosis, chronic pain, significant functional limitation, and no improvement under conservative treatment.¹ Total hip arthroplasty improves pain, quality of life, and psychosocial features of these subjects.²

In addition, THA is the treatment of choice for displaced femoral neck fractures in patients over 60 years old who are active, healthy, and have a good life expectancy.³

Nevertheless, many patients present moderate-to-severe pain after the procedure, resulting in prolonged hospitalization and increased postoperative complications.⁴ An ideal postoperative THA analgesia regimen should preserve early knee and hip mobility, allow early physical therapy, accelerate recovery, shorten hospital stay, reduce the risk of postoperative complications, and increase patient satisfaction.⁵

Kerr and Kohan⁶ developed the local infiltration analgesia (LIA) technique in 2008. Local infiltration analgesia consists of the intraoperative intra-articular injection of a mixture of ropivacaine, ketorolac, and epinephrine for postoperative analgesia with lower rates of side effects or complications compared with other analgesic techniques.⁷,⁸,⁹,¹⁰,¹¹,¹²

However, many studies observed no significant difference between groups, and there is still controversy whether periarticular infiltration provides greater analgesia and early recovery after THA.¹³,¹⁴,¹⁵

The technical details of periarticular infiltration vary significantly among surgeons, with little standardization. Nociceptor location inthe hip determines the preferred infiltration site. The concentration of these receptors is higher at the labral base and the central round ligament (along with vascular structures). In addition, they occur diffusely, in moderate concentrations, at the joint capsule.¹⁶,¹⁷

There are many analgesia modalities for the postoperative period of THA, including epidural analgesia, opioid administration, and peripheral nerve blocks. Although widely used, each technique has local and systemic side effects: epidural analgesia may result in pruritus and spinal cord ischemia; opioids can cause nausea, emetic episodes, respiratory depression, and urinary retention; and peripheral blocks may lead to neurovascular injury. In addition, a greater intensity of joint pain on the date of surgery is a risk factor for chronic opioid use. Among THA patients,4.3% of those who had never used opioids before and 34.7% of those who used them continued to take them 6 months after surgery.¹⁸

Methodology

This is a primary, experimental, quantitative (analytical), randomized double-blind controlled clinical study in patients with femoral neck fracture or hip osteoarthrosis who underwent a total hip arthroplasty at our institution. This study used the non-probabilistic convenience sampling method. A software-based permuted randomization process assigned patients to their groups. The exclusion criteria were scheduled surgical reintervention procedures in a previously operated hip and impossibility to undergo spinal anesthesia. Selected patients underwent spinal anesthesia. The experimental group received a postoperative periarticular infiltration with levobupivacaine (0.75% concentration, 20 mL volume) and dexamethasone (4mg/mL, 2.5 mL vial, totaling 10mg) diluted in a saline solution (in a total volume of approximately 60mL). This solution was applied after implant placement in the remaining hip joint capsule (post-capsulorrhaphy), the external rotators (after suturing them), the periarticular gluteal musculature, and the periosteum adjacent to the implants. The control group (placebo) received an infiltration of the same volume of 0.9% saline solution in the same tissues (►Figure 1).

Fig. 1
Infiltration sites at the hip after prosthesis placement—joint capsule and external rotators (white arrows), periarticular gluteal muscles (yellow arrows), and periosteum adjacent to the femoral and acetabular implants (blue arrows).

Results

This study included 35 patients diagnosed with femoral neck fracture or hip osteoarthritis from October 2018 to December 2020 who underwent total hip arthroplasty. One patient developed hemodynamic complications and was excluded from the study because the assessment was not possible.

The evaluation included pain (visual analog scale [VAS]), hip range of motion, analgesic agent intake, length of hospitalization, ability to walk, and postoperative complications.

Data analysis used the statistical software Statistica version 7.0 (StatSoft, Tulsa, OK, USA). The established significance level was 5%.

The patients ages ranged from 44 to 82 years old, with a mean age of 64.15. There was no statistically significant difference between groups regarding age (p = 0.29).

There was no statistically significant difference between groups regarding surgical indication (p = 0.45). The main indication for both groups was coxarthrosis (►Table 1).

Table 1
Indication

	Group
Indication	Placebo	Experimental	Total
Coxarthrosis	11	13	24
%	64.71%	76.47%
Neck fracture	6	4	10
%	35.29%	23.53%
Total	17	17	34

The experimental group presented a significant change in opioids intake between 24 and 48hours. A significant number of patientsnolonger needed opioids after48hours (►Table 2).

Table 2
Opioids use by each group in 24 and 48hours

Placebo	48 hours			Experimental	48 hours
24 hours	No	Yes	Total	24 hours	No	Yes	Total
No	5	0	5	No	6	0	6
%	62.50%	0.00%		%	50.00%	0.00%
Yes	3	9	12	Yes	6	5	11
%	37.50%	100.00%		%	50.00%	100.00%
Total	8	9	17	Total	12	5	17
P	0.0248			P	0.041

The placebo group showed no significant change between the 24- and 48-hour period (►Table 3).

Table 3
Pain in each group at 24 and 48 hours

Group	Mean	n	Standard deviation	Minimum value	Maximum value
Placebo	-2.80	15	1.93	-6	1
Experimental	-1.35	17	1.22	-3	2
Total	-2.03	32	1.73	-6	2

There was a significant difference between the groups regarding pain (p = 0.033). The placebo group presented a greater reduction in pain scores when comparing patients at 24 and 48hours.

There was no significant difference between groups regarding range of motion, including flexion (p = 0.81), adduction (p = 0.84), abduction (p = 0.61), internal (p = 0.18) or external rotation (p = 0.54).

There was also no statistically significant difference between groups regarding time to resume walking (p = 0.68), length of hospitalization (p = 0.45), or postoperative complications (p = 0.24).

Discussion

There is little standardization regarding the therapeutic regimens for periarticular infiltration in the literature. Multiple studies have compared different drug combinations but with no precise definition of the ideal mixture. The analysis of the pharmacology of these agents should help the optimal choice and allow surgeons to use what they prefer.¹⁹

Infiltration in the soft tissues around the hip joint, including the joint capsule, direct and reflex heads of the rectus femoris, tensor fascia lata, and subcutaneous tissue, shows good results in postoperative analgesia.²⁰ The literature also describes infiltration in external rotators and gluteus, as well as the posterior capsule and gluteus medius attachment site, but with no satisfactory outcomes.²¹

In this study, although there was a higher temporal reduction (from 24–48hours) of pain scores in the placebo group (compared to the experimental group), opioid intake decreased significantly only in the experimental group between 24 and 48hours.

There were no differences in hip mobility between groups, including the range of motion in all analyzed planes. The length of hospitalization, early mobility (beginning to walk), or complication rates presented no significant differences.

Conclusion

Periarticular anesthetic infiltration as a method of postoperative analgesia for total hip arthroplasty reduced the rates of opioid intake from 24 to 48 hours. There were no benefits regarding pain, mobility, length of stay, or complications with this method.

• Financial Support
  There was no financial support from public, commercial, or non-profit sources.
• *
  Study developed at Getulio Vargas University Hospital (HUGV), Federal University of Amazonas (UFAM), Manaus, AM, Brazil.

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Publication Dates

• Publication in this collection
  11 Aug 2023
• Date of issue
  Mar-Apr 2023

History

• Received
  08 Sept 2021
• Accepted
  20 Jan 2022
• Published
  22 July 2022