Postoperative Pain Treatment With Transmuscular Quadratus Lumborum Block and Fascia Iliaca Compartment Block in Patients Undergoing Total Hip Arthroplasty

A Randomized Controlled Trial

Qin Xia; Wenping Ding; Chao Lin; Jiayi Xia; Yahui Xu; Mengxing Jia


BMC Anesthesiol. 2021;21(188) 

In This Article


With the Chinese population becoming an aging society, elderly patients are often troubled by joint degeneration, osteoarthritis, and fracture.[1] Generally, total hip arthroplasty (THA) is the common method to treat severe hip diseases and reconstruct joint function; however, the incidence and degree of postoperative pain are closely related to postoperative cardio-cerebrovascular complications and early postoperative recovery quality.[2,3] A standardized, multimodal analgesic regimen is an essential and central element of ERAS pathways.[4] PROSPECT 2010 guidelines recommend various approaches, such as intravenous analgesia, epidural analgesia, local anesthetic infiltration techniques, and peripheral nerve block (PNB), that aim to minimize THA perioperative pain in elderly patients.[5] Nevertheless, there is no consensus on the optimal analgesic scheme for total hip arthroplasty. Postoperative pain management and minimization of opioid administration remain the primary perioperative challenges for elderly patients.[6]

Opioids are the primary means of postoperative intravenous analgesia.[7] However, opioid-related adverse effects, such as postoperative nausea and vomiting (PONV), respiratory depression, and impaired gastrointestinal function, may weaken postoperative recovery quality.[6] Among many opioid-sparing regional anesthesia technologies for patients undergoing THA, time-tested epidural anesthesia contributes to pain relief.[8] Nevertheless, epidural anesthesia use has become limited in elderly patients due to lumbar degenerative disease and the wide application of preoperative anticoagulants.[8] Currently, PNB is an essential part of perioperative multimodal analgesia, providing site-specific, rapid-onset analgesia and attracting increasing attention.[9]

Børglum[10] et al. first reported that the transmuscular quadratus lumborum block (T-QLB) was in 2013. Patients comparing T-QLB to lumbar plexus blocks for THA showed equivalent analgesia with similar opioid requirements and pain scores postoperatively in a retrospective cohort study.[11] Recently, a clinical study[12] showed that T-QLB could provide effective analgesia with opioid-sparing after THA. Similar results were demonstrated by Tulgar[13] et al. and Hockett[14] et al.

Fascial iliac compartment block (FICB) is an easier way to relieve patients' THA-related pain than the anterior approach of the lumbar plexus, especially in emergency surgery.[15] Theoretically, in addition to the femoral and lateral femoral cutaneous nerves, FICB is capable of blocking the obturator nerve. Hebbardet[16] et al. reported a 'longitudinal supra-inguinal approach' (S-FICB) to improve the spread of local anesthetic (LA) and the success of FICB. This is mainly because the femoral cutaneous nerve has an inconsistent course, with variable branching below the inguinal ligament.

It is challenging to meet patients' requirements by performing single-shot PNB in THA, with the innervation involved in THA being complex.[17] Previous studies[11,12,15,18] focused more on the application of single-shot PNB (such as lumbar plexus block, sacral plexus block, femoral nerve block, FICB, T-QLB) in total hip arthroplasty. These factors may increase the risk of local anesthetic overdose, high anesthetic concentration, nerve injury, and local anesthetic intoxication. The muscle and skin sensation involved in THA surgical incision is innervated by branches of superior cluneal nerves, the subcostal, iliohypogastric, ilioinguinal, femoral, obturator, sciatic, and lateral femoral cutaneous nerves.[12] A cadaver study[19] showed the spread of a dye around the subcostal nerve, iliohypogastric nerve, ilioinguinal nerve, genitofemoral nerve, and caudal spread to L2–L3 dermatomes by T-QLB. S-FICB can produce a more complete sensory block of the femoral, obturator, and lateral femoral cutaneous nerves.[17,18] We hypothesized that the combined application of T-QLB and FICB could optimize the effect of nerve block in the aspects of block range and degree, further reduce or eliminate the pain caused by noxious stimulation, and achieve a better analgesic effect.

The aim of the study was to compare the impact of T-QLB and T-QLB + FICB on postoperative sufentanil consumption, pain scores, joint range of motion, quality of recovery, and the incidence of postoperative complications in patients undergoing THA.