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


This study was approved by the Affiliated Hospital of Xuzhou Medical University's ethics committee. This manuscript adheres to the applicable CONSORT guidelines. This study was a single-center, prospective, single-blind, randomized controlled trial. Fifty-four elderly patients scheduled for elective total hip arthroplasty in the Affiliated Hospital of Xuzhou Medical University from November 2019 to August 2020 provided written informed consent.

Study Participants

The inclusion criteria were as follows: patients who (1) underwent primary unilateral THA; (2) aged 65–80 years old; and (3) American Society of Anesthesiologists' (ASA) physical status II-III. The exclusion criteria were as follows: (1) severe abnormal coagulation function; (2) puncture site infection; (3) morbid obesity (BMI > 35 kg/m2); (4) unable to cooperate with researchers for any reason; (5) allergy to local anesthetics; and (6) chronic pain, long-term use of analgesics or other psychotropic drugs. Patients who violated the scheduled postoperative analgesia program, were transferred to the ICU after surgery, and had a failed block were also excluded from the analysis.

Randomization and Blinding

An anesthesia assistant (not involved in the study) generated random numbers with a 1:1 ratio for group Q or group QF using a computerized random-number generator. The randomization sequence was put into sealed opaque envelopes and drawn up by an experienced anesthetist who performed the block and anesthesia induction. An investigator assessing the block quality was blinded to the group allocation. A resident anesthetist blinded to the randomization was responsible for the collection of intraoperative data. Another investigator who was independent of the group allocation collected postoperative data. Finally, a statistician masked the entire process and performed the statistical analysis.

Study Procedures

After entering the anesthesia preparation room, subjects were monitored with electrocardiography, invasive arterial blood pressure, and pulse oximetry. The blocks were performed on the side of surgery with a 22G/100-mm Stimuplex block needle (Braun, Ogaki, Japan) using an ultrasound machine (diagnostic ultrasound system, model Wisonic Navi s, Shenzhen Wisonic Medical Technology Co., Ltd., China). An experienced anesthesiologist performed all block procedures before anesthesia induction.

In group Q, T-QLB was performed in the lateral position, and the surgical side was nondependent, with lower extremity flexion.[20] The skin was sterilized twice with chlorhexidine. The low-frequency curvilinear ultrasonographic probe was placed transversely cranially to the iliac crest and at the posterior axillary line level and then moved to the dorsal side (Figure 1). After the probe visualizes the 'Shamrock sign,' composed of the quadratus lumborum muscle (QLM), psoas major (PM), and erector spinal muscles.[21] Infiltrating the skin with 2 ml of 2% lidocaine. Using an in-plane approach, a 22G/100-mm Stimuplex block needle was inserted on the posterior corner of the convex probe. When the correct needle position was achieved via repeated negative aspiration tests and hydro-separation, a total of 40 mL of 0.375% ropivacaine was injected incrementally between the QLM and PM.

Figure 1.

A: Posture and injection approach of transmuscular quadratus lumborum block; B: Ultrasound image of transmuscular quadratus lumborum block. Solid arrow indicates needle trajectory and injection point between QLM (quadratus lumborum muscle) and PM (psoas major muscles); dashed line indicates the spread of the LA (local anesthetic); blue:local anesthetic; ESM: erector spinae muscle; TP: transverse process

In group QF, FICB was administered in the supine position with the technique used by Hebbard and colleagues.[16] Initially, the low-frequency curvilinear ultrasonographic probe was placed at the inguinal ligament crease to identify the femoral artery and sartorius muscle by short-axis scanning and then move the probe cranially to the anterior superior iliac spine level. Rotating the probe 90 to 120° counterclockwise, the external oblique muscle, internal oblique muscle, transverse abdominal muscle aponeurosis, PM, and iliac fascia covering the iliac muscle were visualized; the latter was the final probe position (Figure 2). After skin infiltration with 2 ml of 2% lidocaine, a 22G/100-mm Stimuplex block needle was advanced in an in-plane technique to the point that the fascia iliaca was penetrated and hydro-separation. Once tip position security was confirmed, 20 ml of 0.375% ropivacaine was injected incrementally into the surface of the iliacus muscle. After that, the patient switched to a lateral position, and QLB was performed. The specific procedure was the same as that in group Q, and 20 ml of 0.375% ropivacaine was injected.

Figure 2.

A: Posture and injection approach of fascia iliaca compartment block; B: Ultrasound image of fascia iliaca compartment block. Solid arrow indicates needle trajectory and injection point between fascia iliaca and iliac muscle (IM); dashed line indicates the spread of the LA (local anesthetic); blue:local anesthetic; ASIS, anterior superior iliac spine; PM, psoas major muscles

Thirty minutes after performing the block, the block effect was evaluated by a masked investigator with pin-prick sensation in each dermatomal distribution of the obturator nerve, lateral femoral cutaneous nerve, and femoral nerve. Pain to pin-prick was graded according to a 3-point scale: 0 = pain disappearance (no sensation of pain), 1 = hypoesthesia (decreased sensation of pain compared to the opposite side), 2 = normal sensation.[22] If the three branches of the innervated area were less than or equal to 1 point, it was considered block effective. Patients with a score of 2 were considered block failure and then excluded from the study.


All subjects received standardized general anesthesia as follows: induction with midazolam 0.05 mg/kg, etomidate 0.3 mg/kg, sufentanil 0.5 μg/kg, and cis-atracurium 0.15 mg/kg; insertion of the laryngeal mask airway (LMA). Adjust respiratory parameters to maintain 35–40 mmHg of PetCO2 (partial pressure of end-tidal carbon dioxide). Then, anesthesia was maintained with propofol 3 mg/(kg·h) and remifentanil 0.3 μg/(kg·min), and the infusion rate of propofol was adjusted to keep the bispectral index (BIS) within 40–60. If the mean arterial pressure (MAP) increased by more than 20% compared with baseline, a 0.5 μg/kg supplemental dose of remifentanil was provided, and increasing the infusion rate of remifentanil by 0.05 μg/(kg·min), and nicardipine or esmolol was administered as appropriate. After completion of the surgery, patients were transferred to the postanesthesia care unit (PACU) and received intravenous tropisetron 4 mg and paracetamol 1 g. When the patient was fully awake and meets the extubation principle, remove the LMA.

Postoperative Pain Management

Postoperative multimodal analgesia included oral nonsteroidal anti-inflammatory drugs, patient-controlled intravenous analgesia (PCIA), and rescue analgesia. The patient received oral paracetamol 1 g regularly at 6 h intervals. The PCIA pump was composed of sufentanil 100 μg + tropisetron 8 mg, diluted with normal saline to 100 ml, programmed to deliver 2 ml per dose with a lock-time of 15 min, without a background infusion. Pain was assessed using the numerical rating scale (NRS) from 0 to 10 (0 = no pain, 10 = most severe pain). The subjects were trained before the operation, and the PCIA pump was used when the patient reported NRS > 3. Nonetheless, if the pain could not be relieved by PCIA, tramadol 25 mg i.v. was prescribed as rescue analgesia.

Outcome Measurements

Outcome assessment was conducted by investigator members trained before the study and independent of the group allocation. The primary outcome was cumulative sufentanil consumption via PCIA in the first 24 h postoperatively. The secondary outcomes including (1)sufentanil consumption at 6 h intervals (0–6, 6–12, 12–18, and 18–24 h) after surgery (μg), (2)the pain scores both at rest (supine position) and during movement (defined as lifting 15° on the affected limb in supine position) were assessed with NRS at 2, 6, 12, 18, and 24 h postoperatively(NRS 0–10/10),(3)time to the first analgesic requirement (time from the completion of the block to the first PCIA opioid bolus) (min), (4) quality of recovery-15 (Qor-15 scale) scores[23] at 24 h and 48 h after surgery, (5) the maximal flexion and abduction range of movement (ROM) of the hip joint at 12, 24, 48 and 72 h postoperatively(°), (6) number of people requiring rescue analgesia, and (7) incidence of nausea and vomiting (yes/no).

Statistical Analysis

The sample size was calculated based on our preliminary study. Our preliminary experience with T-QLB showed that the cumulative sufentanil consumption was 46.4 ± 17.5 μg (mean ± standard deviation SD) in the first 24 h postoperatively. The cumulative sufentanil consumption was reduced by roughly one-third when patients were receiving T-QLB combined with FICB. Thus, we supposed that sufentanil consumption in the first 24 h would be reduced by a third in group QF in this study. The sample size calculated by PASS 15.0 software (NCSS, LLC, Kaysville, USA) was 24 individuals per group (with α = 0.05, power = 0.8). Considering the loss-to-follow-up rate of approximately 10%, we enrolled 54 subjects.

Data were analyzed using SPSS statistical software 25.0 (SPSS for Windows, ver. 25.0). The Kolmogorov–Smirnov test was used to evaluate the normal distribution of data. Continuous data are presented as the mean and SD or median and interquartile range. Standard hypothesis tests (2-sided t-test or Mann–Whitney U test) were performed to analyze baseline characteristics and outcome parameters. Categorical data are presented as n (%) and were analyzed by using chi-square tests or Fisher's exact test. Kaplan–Meier curves and log-rank tests were performed to analyze the time-to-event data. The repeated measurement data (such as sufentanil consumption at 0–6, 6–12, 12–18, and 18–24 h after surgery, pain score during rest and movement at 2, 6, 12, 18, 24 h after surgery, and other repeated measurement data involved in this study) were compared using a linear mixed-effects model (LMM).[24] The linear mixed-effects model was performed using the lmerTest package in R software (R version 3.6.1). The group, time (modeled as a categorical variable) and group-by-time interaction were fixed effects, and the random effect was a random intercept for subjects.