Published online May 10, 2019. doi: 10.5313/wja.v8.i2.13
Peer-review started: October 31, 2018
First decision: November 8, 2018
Revised: March 7, 2019
Accepted: March 24, 2019
Article in press: March 25, 2019
Published online: May 10, 2019
Processing time: 189 Days and 17 Hours
Peripheral nerve block has provided excellent analgesia for total joint replacement procedures. However, its associated motor weakness is undesirable in enhanced recovery after surgery (ERAS) protocol. While Fascia iliaca compartment blocks (FIBs) have been shown to be satisfactory in pain control and minimize quadriceps weakness after total hip arthroplasty (THA), their value is still debatable. Prior studies have demonstrated the superiority of FIBs and femoral nerve blocks for pain control and ambulation following THA as compared to standard therapy of parenteral analgesics on postoperative day (POD) 2-3. However, there are few studies that investigate how this block affects the ambulation in POD 0 after THA, the time of ambulation that is recommended and considered beneficial under the new ERAS guidelines.
The use and popularity of ERAS protocols has led to the need for a common post-operative anesthetic plan following THA. We sought to examine the relationship between FIB and delayed ambulation after THA.
We collected perioperative data on 39 patients following THA, some with and without FIBs, and evaluated their ability to ambulate in the immediate post-operative period on POD 0 with a physical therapy team.
In this retrospective cohort study, the medical record and anesthetic records of patients undergoing THA with or without FIBs by a single physician throughout 2016 were reviewed. Patients that were evaluated by physical therapists promptly, within two hours, after arrival at the post-anesthesia care unit were identified. These patients were all evaluated for motor strength and if appropriate, were allowed to stand and ambulate. We additionally reviewed patient demographics as well as anesthetic agents administered intra-operatively in order to look for differences in anesthetic technique (i.e., spinal vs general anesthesia, adjuvant medications given, and type of local anesthetic.) that may affect the early ambulation.
We found that all but one patient in the FIB group were unable to ambulate within 2 h post-operative, mainly due to weakness, significantly lower than the patients without FIB. While pain control appeared to be adequate, the lack of ambulatory ability poised a problem with early ambulation as part of the ERAS protocol.
Out data indicated that there is significant correlation associated between the FIB and the delayed ambulation on POD 0 after THA. Despite the fact that the ERAS pathway of THA emphasized early ambulation during the immediate post-operative period and shorter stay in hospital, FIB appears to be interfering with this goal. Therefore, this post-operative pain control block should be excluded from the ERAS pathway of THA until further study.
This study is based on the retrospective reviewing of the data and some crucial information, such as degree of the motor weakness and Oxford Hip Score in both pre and post-operatively, are not available. Therefore, to objectively determine the efficacy of FIB for post-operative pain management and its role in the ERAS protocol, a prospective control study should be consideration. Going forward, the ideal pain management means for THA needs to be further examined in a way that can provide a common pathway for both pain control and early ambulation that satisfies the patients’ comfort as well as ERAS protocols.