Multimodal regional techniques for rapid ambulation after Total Hip Arthroplasty

Multimodal regional techniques for rapid ambulation after Total Hip Arthroplasty Mike Guzman Community East Surgery Center Introduction: There are multiple postoperative pain pathways for total hip arthroplasty (THA). Pain associated after THA may include medial groin, deep pelvic, proximal and distal incisional site. A single nerve block will not provide sustainable relief for this procedure. Presented are 5 patients from our outpatient surgery center for posterior THA that received multiple infiltration regional techniques for rapid ambulation and experienced significant pain reduction. Materials and Methods: As these case reports are devoid of patient identifiable information, it is exempt from IRB review requirements as per Community Hospital Network. Five patients ASA 2-3, BMI 30-48, age 49-70, had posterior THA in our outpatient surgery center. All patients received the following regional techniques. Local anesthetic included a mixture of liposomal bupivacaine 20 ml, bupivacaine 0.25% 30 ml, and normal saline 30 ml. Total local anesthetic dilution volume was 80 ml. Hypobaric spinals were placed preop at L4-5 with bupivacaine 0.25% 1.5-3 ml. Each patient was placed in an operative side up lateral position after spinal placement. The proximal femur was identified by ultrasound (1). Sterile placement of liposomal dilution 20 ml was infiltrated on the proximal femur shaft (2). Patients were positioned supine; liposomal dilution 20 ml was infiltrated medial, and beneath the external oblique (Table 1) and another liposomal dilution 20 ml was infiltrated in the plane between the psoas muscle and the superior pubic rami (Table 2). The lateral femoral cutaneous nerve was identified and liposomal dilution 10 ml was infiltrated both proximal and distal sites (Table 3). All patient's received propofol, rocuronium, endotracheal intubation and oxygen sevoflurane maintenance. Patients received ketorolac and IV acetaminophen before extubation. Results/Case Report Results: All patients had full motor, and easily performed physical therapy with pain scores of 0-1/10 within 3-4 hours of surgery end time. Supplemental opioids were minimal, usually oxycodone 5 mg q 6-8 hours.

Vitals were stable throughout the process. Patients were discharged after overnight observation from our outpatient center. Pain on discharge was remarkably 0-2/10. Discussion: Patients may have significant pain after THA. Pain receptors of the hip joint are primarily from sensory branches from the femoral and obturator nerves. Regional anesthesia blocks including lumbar plexus, fascia iliaca, femoral nerve, pericapsular infiltration, and lateral femoral cutaneous have been described for THA. Many of these techniques have known complications including motor block and hypotension. A single nerve block will not provide sustainable sensory relief for THA. Short acting spinal anesthesia was used for a smooth emergence after surgery. Multimodal regional techniques including genitofemoral for medial groin pain, pericapsular infiltration for deep pelvic pain, lateral femoral cutaneous fascia infiltration for incisional pain, and infiltration of the femur shaft allowed early ambulation and consistent low pain scores. Infiltrating local anesthetic in multiple areas of sensory innervation was motor sparing with significant reduction in opioids. References: Differential Diagnosis of Anterior Hip Pain – Nerve.” Dr Alison Grimaldi, 4 Aug. 2021, Dralisongrimaldi.com/blog/differential-diagnosis-of-anterior-hip-pain-nerve/. Accessed 20 Sept. 2022 “Lateral Femoral Cutaneous Nerve Anatomy, Function & Diagram | Body Maps.” Healthline, www.healthline.com/human-body-maps/lateral-femoral-cutaneous-nerve#1. Roriz, D., et al. “ESRA19-0294 Peng Block as an Analgesic Tool for Total Hip Arthroplasty: A Case Description.” Regional Anesthesia & Pain Medicine, vol. 44, no. Suppl 1, 1 Oct 2019, pp. A204-A205, rapm.bmj.com/content/44Suppl_1/A204.3, 10.1136/rapm-2019-ESRAABS2019.349. Disclosures: No