Total Hip Arthroplasty 2019

Total hip arthroplasty-specific evidence

Data table: Paracetamol and NSAIDs/COX-2-selective inhibitors for pain management after THA

Arguments for…

• IV paracetamol was compared with placebo in two studies (Sinatra 2012; Takeda 2019), which showed lower pain intensity scores over the first 24 h and lower morphine consumption in the paracetamol groups.
• One study found no difference between IV and oral administration of paracetamol on postoperative pain outcomes (Westrich 2019).
• Paracetamol, anti-inflammatory drugs and placebo were recently compared in two studies (Camu 2017; Thybo 2019). When taken individually, both drugs improved postoperative pain outcomes, whereas parecoxib plus paracetamol did not improve pain scores over parecoxib alone in one study (Camu 2017), and paracetamol combined with ibuprofen did not result in a clinically relevant improvement over ibuprofen alone (Thybo 2019).
• Three studies showed analgesic benefit of NSAID administration vs placebo (Gombotz 2010; McQuay 2016; Moodie 2013).
  • Regular IV diclofenac and orphenadrine infusions after surgery and at 12 h reduced morphine PCA consumption postoperatively vs placebo (Gombotz 2010).
  • One study showed that a combination of oral dexketoprofen 25 mg with tramadol 75 mg was superior to both medications alone for postoperative pain control (McQuay 2016).
  • In a three-group study, ketorolac improved pain scores and morphine consumption compared with a novel protein kinase C-epsilon inhibitor and placebo (Moodie 2013).
• Three of four studies found benefits for postoperative pain with pre-incisional COX-2-selective inhibitor administration (Bao 2012; Renner 2012; Ittichaikulthol 2010; Peng 2018).
  • Two studies found that oral etoricoxib 2 h before surgery (Renner 2012), or IV parecoxib or oral celecoxib 1 h before surgery (Ittichaikulthol 2010) were associated with significantly lower postoperative pain scores and morphine consumption when compared with placebo.
  • These benefits were not found in another study with a 30-min pre-incisional IV parecoxib infusion (Peng 2018).
  • Another study directly compared 30-min pre- vs. 30-min post-incisional IV 40 mg parecoxib administration (Bao 2012) and found lower pain scores up to 6 h postoperatively and lower morphine consumption up to 24 h postoperatively with a pre-incisional protocol.
• A single study compared IV paracetamol with IV metamizole and found clinically insignificant reductions in morphine consumption and pain scores with metamizole (Oreskovic 2014), although pain scores in both groups were always lower than 40 mm on a VAS.

PROSPECT Recommendations

• The basic analgesic regimen should include the combination of paracetamol (Grade A) and an NSAID or a COX-2-selective inhibitor (Grade A) administered pre-operatively or intra-operatively and continued post-operatively.
  • The administration of paracetamol in combination with NSAID or COX-2-selective inhibitors is recommended unless contraindicated. Procedure-specific evidence suggests a limited impact of paracetamol when added to a regimen including COX-2-selective inhibitors or NSAIDs, but paracetamol is recommended as part of basic postoperative analgesia in general as side effects are minor.
  • There is insufficient evidence to determine whether pre-operative administration has an advantage over postoperative administration of COX-2-selective inhibitors.
  • There is no procedure-specific evidence to choose a specific NSAID or COX-2-selective inhibitor.

Total hip arthroplasty -specific evidence

Data table: Glucocorticoids for pain management after THA

Arguments for…

• Six studies showed a benefit for postoperative pain outcomes with glucocorticoid use (Backes 2013; Sculco 2016; Lunn 2013; Dissanayake 2018; Lei 2018; Lei 2017).
  • Peri-operative 125 mg methylprednisolone compared with placebo reduced 24-h pain scores (Lunn 2013).
  • A second study showed analgesic benefit from 20 mg prednisolone pre-operatively followed by two postoperative doses of IV hydrocortisone administered 8 h apart in patients with patient-controlled epidural analgesia, while pain scores did not differ (Sculco 2016).
  • One study (Backes 2013) demonstrated that 10 mg of peri-operative dexamethasone had a significant effect, reducing mean VAS pain scores by >20 mm, reducing opioid consumption in the first 24 h, with early ambulation and a shorter length of hospital stay. An additional dose of 10 mg dexamethasone at the postoperative 24-h mark showed continued effect, with lower morphine consumption on day two and a shorter length of stay when compared with a single dose.
  • The efficacy of dexamethasone was demonstrated on top of adequate basic analgesia (Dissanayake 2018; Lei 2018; Lei 2017) showing improved postoperative pain outcomes with 8 or 10 mg, a lower incidence of postoperative nausea and vomiting and a shorter length of stay.
• Three meta-analyses showed benefits from use of glucocorticoids on postoperative pain outcomes, time to discharge, and postoperative nausea and vomiting (Yang 2017; Li 2017; Fan 2018).
• No major adverse events were described in these studies, other than a small but significant increase in blood glucose concentration in diabetic patients when dexamethasone was used (Backes 2013; Dissanayake 2018). The occurrence of postoperative infection did not differ (Lei 2017; Yang 2017).

PROSPECT Recommendations

• A single intra-operative dose of dexamethasone 8–10 mg IV is recommended for its analgesic and anti-emetic effects (Grade A).

Total hip arthroplasty -specific evidence

Data table: Gabapentinoids for pain management after THA

Arguments for…

• One study showed effectiveness of pre-operative pregabalin 150 mg administration continued postoperatively when added to a basic analgesic regimen of celecoxib and morphine PCA (Clarke 2016).

Arguments against…

• One study found no analgesic benefit when gabapentin 600 mg was administered pre-operatively followed up by a regimen of 200 mg three times daily for 3 days postoperatively (Paul 2015).
• Another study investigated the combination of celecoxib and pregabalin (75 mg twice daily) for 2 weeks preceding and 3 weeks following surgery and found that patients in the treatment group experienced less acute pain on postoperative day one (Carmichael 2013). However, morphine consumption did not differ, and there were more side-effects in the pregabalin-celecoxib group.
• Three meta-analyses assessing the efficacy of gabapentin or pregabalin (Mao 2016; Han 2016; Li 2017) in total hip arthroplasty found morphine-sparing effects, but reported side-effects such as dizziness, and were inconsistent regarding pain reduction.

PROSPECT Recommendations

• Gabapentinoids are not recommended for postoperative pain management in total hip arthroplasty.
  • There is inconsistent evidence for single-dose administration.
  • There is procedure-specific evidence of pain reduction with multiple peri-operative doses of gabapentin or pregabalin, but this is not recommended as routine medication due to clinically relevant side-effects.

Total hip arthroplasty -specific evidence

Data table: Ketamine for pain management after THA

Arguments for…

• The efficacy of intra-operative ketamine vs. pregabalin was compared in a four-group study consisting of ketamine alone, pregabalin alone, a combination of pregabalin and ketamine or placebo (Martinez 2014). However, no basic analgesia was used. Both ketamine and pregabalin significantly reduced 48-h morphine consumption with no difference in pain scores and side-effects (nausea; pruritus; dizziness).

PROSPECT Recommendations

• Ketamine is not recommended for postoperative pain management in total hip arthroplasty due to limited procedure-specific evidence.

Total hip arthroplasty -specific evidence

Data table: Femoral nerve block for pain management after THA

Arguments for…

• In one study, single-shot femoral nerve block significantly improved pain scores and reduced analgesic consumption compared with no block with adequate basic analgesia, despite a high dropout rate (Kratz 2015).
• In another study, patients receiving a femoral nerve block met earlier post-anaesthesia care unit (PACU) discharge criteria, with lower pain scores and analgesic consumption, compared with no block (Wiesmann 2014).
• Continuous femoral nerve block was also compared with lumbar plexus block (Ilfeld 2011) and with epidural analgesia (Nishio 2014). Similar pain and analgesic requirements were reported.

Arguments against…

• When femoral nerve block was compared with fascia iliaca block, pain scores were higher in the femoral nerve block group (but only by 5 mm with both groups being <15 mm on the VAS) (Yu 2016).
• In one study, femoral nerve block proved inferior to local infiltration analgesia (LIA) for the first 24 postoperative hours on pain scores and morphine consumption, with significantly more motor blockade in femoral nerve block group (Kuchalik 2017).

PROSPECT Recommendations

• Femoral nerve block is not recommended for postoperative pain management in total hip arthroplasty due to side effects, despite procedure-specific evidence of analgesic benefit.
  • The femoral nerve block is associated with a significant incidence of muscle weakness (Auroy 2002; Kolaczko 2019).
  • The potential benefit of nerve blocks on postoperative pain should be balanced against the side-effects, such as delayed mobilisation, motor block or risk of falls.

Total hip arthroplasty -specific evidence

Data table: Fascia iliaca block for pain management after THA

Arguments for…

• One study showed clinically relevant significantly lower morphine consumption at 24 and 48 h with a fascia iliaca block compared with no block on top of multimodal basic analgesia (Desmet 2017).
• Fascia iliaca block was compared with other alternative regional techniques in four studies:
  • One study showed that morphine consumption was higher with fascia iliaca block when compared with 0.1 mg intrathecal morphine, with no difference in pain scores or side effects apart from 2 h shorter time to mobilisation in the fascia iliaca block group (Kearns 2016).
  • Another study found similar data between fascia iliaca block and psoas compartment block (Perry 2018).
  • When compared with LIA (Gasanova 2019; McGraw 2017), postoperative pain outcomes did not differ; however the fascia iliaca block group showed more muscle weakness at 6 h in one study (Gasanova 2019).
• Three meta-analyses, combining the existing data, all concluded that there were lower pain scores, lower morphine consumption and even shorter length of stay when fascia iliaca block was used, with no greater risk of falls (Zhang 2019; Cai 2019; Gao 2019).

Arguments against…

• One study used fascia iliaca block as rescue analgesia in PACU, reporting that it did not improve pain scores or morphine consumption vs. placebo (Shariat 2013).

PROSPECT Recommendations

• A single shot fascia iliaca block is recommended (Grade D) due to analgesic effects.
  • In meta-analyses no more falls were reported with fascia iliaca block (Cai 2019; Gao 2019), which is recommended as preferred nerve block when a nerve block is indicated for total hip arthroplasty.
  • The potential benefit of nerve blocks on postoperative pain should be balanced against the side-effects, such as delayed mobilisation, motor block or risk of falls.

Total hip arthroplasty -specific evidence

Data table: Lumbar plexus block for pain management after THA

Arguments for…

• An intra-operative, surgeon-delivered psoas compartment block performed during total hip arthroplasty prolonged the time to first request of rescue analgesia and reduced postoperative pain scores vs. no block (Green 2014).
• Continuous lumbar plexus block was compared with paravertebral block performed at L2 (Wardhan 2014). Morphine consumption during the first 24 h was higher in the paravertebral block group, but pain scores were similar.
• Ropivacaine 0.1% and 0.2% continuous lumbar plexus block have been compared, demonstrating similar pain outcomes and motor block intensity (Wilson 2014).

Arguments against…

• When compared with LIA (Fahs 2018; Johnson 2017), lumbar plexus block did not show any benefit on postoperative pain and opioid consumption. Local infiltration analgesia had lower pain scores at 3 h postoperatively in one study (Fahs 2018).
• When lumbar plexus block was compared with 0.1 mg intrathecal morphine, patients in the latter group required less intra-operative opioids, less rescue morphine and had lower pain scores in PACU (Fredrickson 2015). However, they needed more rescue morphine in the subsequent 24 h and experienced increased pruritus.

PROSPECT Recommendations

• Lumbar plexus block is not recommended for postoperative pain management in total hip arthroplasty due to side effects, despite procedure-specific evidence of analgesic benefit.
  • The lumbar plexus block is a deep block with potential risks (Auroy 2002).
  • The potential benefit of nerve blocks on postoperative pain should be balanced against the side-effects, such as delayed mobilisation, motor block or risk of falls.

Total hip arthroplasty -specific evidence

Data table: Lateral femoral cutaneous nerve block for pain management after THA

Arguments for…

• Lateral femoral cutaneous block was compared with placebo with adequate baseline multimodal analgesia in one study that showed that lateral femoral cutaneous block reduced movement-related pain (Thybo, Mathiesen 2016).

Arguments against…

• Lateral femoral cutaneous block was compared with placebo with adequate baseline multimodal analgesia in one study that did not show any difference in pain scores (Thybo, Schmidt 2016).
• A double nerve block of lateral femoral cutaneous block and subcostal nerves via infiltration had no effect on postoperative pain outcomes over placebo (Bron 2018).

PROSPECT Recommendations

• Lateral femoral cutaneous nerve block is not recommended due to limited procedure-specific evidence.

Total hip arthroplasty -specific evidence

Data table: Anterior quadratus lumborum block for pain management after THA

Arguments for…

• One study evaluated an anterior quadratus lumborum block compared with no block (Kukreja 2019). Patients in the treatment group showed lower morphine consumption and lower pain scores at 24 h, but not at other time-points.

PROSPECT Recommendations

• Anterior quadratus lumborum block is not recommended due to limited procedure-specific evidence.

Total hip arthroplasty -specific evidence

Data table: Local infiltration analgesia (single injection) for pain management after THA

Data table: Local infiltration analgesia infusions or repeated injections for pain management after THA

Arguments for…

• For the present review, single-injection LIA was directly compared with placebo or no injection in 15 randomised controlled trials (Lunn 2011; Dobie 2012; Andersen 2011; Hofstad 2015; den Hartog 2015; Zoric 2014; Hirasawa 2018; Titman 2018; Ban 2017; Busch 2010; Murphy 2012; Chen 2014; Villatte 2016; Liu 2011; Nakai 2013).
  • Of these, five placebo-controlled randomised controlled trials showed lower pain scores, opioid consumption or shorter length of stay (Titman 2018; Ban 2017; Murphy 2012; Chen 2014; Liu 2011).
  • When compared with no injection, one study showed significantly lower pain scores and morphine consumption, but basic analgesia was not used (Busch 2010). Another study reported a difference in pain scores, but this was not clinically meaningful (Villatte 2016).
  • Another seven randomised controlled trials in which LIA was combined with adequate basic analgesia failed to show improvements in pain control (Lunn 2011; Dobie 2012; Andersen 2011; Hofstad 2015; den Hartog 2015; Zoric 2014; Hirasawa 2018).
• In a meta-analysis, LIA resulted in significant benefits during the first 24 h in terms of less pain at rest and during movement, and a reduction in opioid consumption (Ma 2019).
• In a three-group study comparing a multi-drug LIA regimen, morphine PCA and epidural analgesia, patients with LIA reported reduced pain scores and morphine consumption compared with those receiving morphine PCA. No difference was observed when compared with epidural (Pandazi 2013).
• Three meta-analyses (Jiang 2013; Marques 2014; Wang 2017) indicated that multi-drug LIA had lower postoperative pain scores, lower opioid consumption and in one meta-analysis a shorter length of hospital stay (Marques 2014).
• Comparing LIA, peripheral nerve block and placebo in a network meta-analysis including 35 randomised controlled trials and 2296 patients, the LIA treatment group had lower postoperative pain scores and opioid consumption at 24 h vs. placebo, whereas peripheral nerve block failed to do the same (Jiménez-Almonte 2016). However, there was no difference between peripheral nerve block and LIA on these outcomes.
• Two studies compared LIA with intrathecal morphine 0.1 mg (Rikalainen-Salmi 2012; Kuchalik 2013).
  • One study found no differences in pain scores or postoperative nausea and vomiting (Rikalainen-Salmi 2012). Although patients in the LIA group required more rescue oxycodone, they mobilised better at 6 h after surgery as well as the following morning (Rikalainen-Salmi 2012).
  • The second study showed that intrathecal morphine was more effective in the first 24 h compared with multi-drug LIA, but patients in this group had higher morphine consumption after 24 h and experienced more postoperative nausea and vomiting and pruritus (Kuchalik 2013).
• When bupivacaine was compared with liposomal bupivacaine for LIA, there were similar pain outcomes (Perets 2018).

Arguments against…

• Two of five studies assessing multiple doses or continuous infusion of LIA compared with placebo found improved postoperative pain scores and morphine consumption at 48–72 h with a pericapsular infusion via a catheter (Aguirre 2012; Fusco 2018).
  • However, a systemic effect of local anaesthesia cannot be ruled out, and three studies with a similar design failed to show any benefit (Solovyova 2013; Specht 2011; Andersen 2015).
• When comparing a multimodal pain regimen containing LIA and patient-controlled epidural analgesia, pain scores during movement favoured the epidural group. However, for the primary outcome of readiness for hospital discharge, there was no difference (Jules-Elysee 2015).
• A meta-analysis of nine studies found no significant difference between LIA and epidural analgesia at 48–72 h after surgery for pain with movement, but less pain at 24 h in the epidural group (Yan 2016).

PROSPECT Recommendations

• Local infiltration analgesia is recommended (Grade D) due to analgesic effects.
  • The PROSPECT group emphasises that with modern surgical techniques and the correct implementation of basic analgesia and multimodal analgesia (paracetamol, NSAIDs and dexamethasone) the added value of local infiltration analgesia techniques still warrants further validation with well-conducted studies.
  • The PROSPECT group emphasises the considerable heterogeneity and variability of published LIA studies with regard to analgesic effect, technique, volume and dose of local anaesthetic used and the drug combinations used.
  • In addition, the studies are inconsistent with regard to the comparator groups (placebo vs. no injection vs. other analgesic technique) and single-shot or catheter techniques.
  • Also, in most studies of multi-drug LIA, there was no control for potential systemic effects of the additives in the mixtures.

Total hip arthroplasty -specific evidence

Data table: Epidural analgesia for pain management after THA

Arguments for…

• Epidural levobupivacaine with sufentanil adjuvant was compared with oral controlled-release oxycodone (Divella 2012).
  • Epidural analgesia provided better dynamic pain relief (mean VAS reduction from 3.0 to 1.7 on a 0–10 scale) and lower opioid consumption on day one postoperatively.
  • However, oral oxycodone was more effective on pain control at rest on postoperative days two and three.
  • The modest differences in pain reduce the impact of these results.
• Adjuvant epidural therapies were addressed in three studies (Banwait 2012; Gendy 2014; Erol 2014). The following had beneficial effects on postoperative pain outcomes: 8 mg epidural dexamethasone (Gendy 2014), 75 mg epidural magnesium (Banwait 2012) and epidural ketamine (Erol 2014); however, adequate basic analgesia was not used in these studies.

PROSPECT Recommendations

• Epidural analgesia is not recommended for postoperative pain management in total hip arthroplasty due to side effects, despite procedure-specific evidence of analgesic benefit.
  • Epidural analgesia is associated with well-recognised side-effects in lower limb surgery, such as limb weakness, bladder dysfunction and delayed mobilisation (Spreng 2010).

Total hip arthroplasty -specific evidence

Data Table: Spinal analgesia for pain management after THA

• Seven studies (Kearns 2016; Fredrickson 2015; Rikalainen-Salmi 2012; Kuchalik 2013; Damevski 2011; Wang 2014; Samir 2013) evaluated the effectiveness of adding intrathecal analgesia for postoperative pain after total hip arthroplasty.
• Comparison of intrathecal morphine with peripheral nerve block (Kearns 2016; Fredrickson 2015) or LIA (Rikalainen-Salmi 2012; Kuchalik 2013) is discussed in previous sections (Fascia iliaca block, Lumbar plexus block, Local infiltration analgesia).

Arguments for…

• Evaluating intrathecal morphine doses of 0.05 mg vs. 0.1 mg showed that patients receiving 0.1 mg had lower pain scores and a longer duration of analgesia (Damevski 2011) but use of basic analgesia was not reported. Similar postoperative nausea and vomiting frequency was found in both groups, but patients receiving the higher dose experienced pruritus more often.
• Intrathecal or IV magnesium lowered pain scores and 24-h morphine consumption vs. no adjuvants (Samir 2013).

Arguments against…

• Intrathecal ketorolac 2 mg showed no benefit on postoperative pain outcomes vs placebo (Wang 2014).

PROSPECT Recommendations

• If the patient has received spinal anaesthesia for the surgery, intrathecal morphine 0.1 mg could be considered (Grade D).
  • There was significant conflict amongst the PROSPECT members regarding the use of intrathecal morphine 0.1 mg, and a consensus could not be reached. If intrathecal morphine is used, the PROSPECT group reminds clinicians of the risks and benefits associated with its use.
  • In favour of intrathecal morphine is the documented analgesia it provides for at least 24 hours postoperatively and the limited adverse effects with small doses (≤0.1 mg morphine) (Bai 2020; Albrecht 2020).
  • However, pruritus and postoperative nausea and vomiting are associated with intrathecal morphine (Kuchálik 2013; Damevski 2011). It was thought that even if the incidence of these adverse events may be relatively lower with intrathecal morphine 0.1 mg, they may still delay ambulation and oral intake, and influence patient satisfaction (Kuchálik 2013; Damevski 2011).
  • Indeed, adequate multimodal analgesia with paracetamol, NSAIDs and dexamethasone, without intrathecal morphine, together with more recent surgical techniques, may be sufficient to provide patients with good pain relief (Andersen 2014; Coenders 2020; Fraser 2018).