Fascia iliaca compartment blocks (FIBs) have been used to provide postoperative analgesia after total hip arthroplasty (THA). However, evidence of their efficacy remains limited. While pain control appears to be satisfactory, quadriceps weakness may be an untoward consequence of the block. Prior studies have shown femoral nerve blocks and fascia iliaca blocks as being superior for pain control and ambulation following THA when compared to standard therapy of parenteral pain control. However, most studies allowed patients to ambulate on post-operative day (POD) 2-3, whereas new guidelines suggest ambulation on POD 0 is beneficial.

To determine the effect of FIB after THA in patients participating in an enhanced recovery after surgery (ERAS) program.

We conducted a retrospective analysis of patients undergoing THA with or without FICBs and their ability to ambulate on POD 0 in accordance with ERAS protocol. Perioperative data was collected on 39 patients who underwent THA. Demographic data, anesthesia data, and ambulatory outcomes were compared.

Twenty patients had FIBs placed at the conclusion of the procedure, while 19 did not receive a block. Of the 20 patients with FIB, only 1 patient was able to ambulate. Of the 19 patients without FIB blocks, 17 were able to ambulate. All patients worked with physical therapy 2 h after arriving in the post-anesthesia care unit on POD 0.

Our data suggests an association between FIB and delayed ambulation in the immediate post-operative period.

The frequency of total hip arthroplasty (THA) surgery is increasing, with the number of procedures performed in the United States being greater than 300000 annually. With such a high volume, many hospitals have implemented enhanced recovery after surgery (ERAS) protocols to help fast track these joint replacement patients, the goal being to reduce the stress response following surgery, promote early recovery, and lead to a decrease length of hospital stay without any increase in readmission rates. While the ERAS protocols still promote adequate pain control, the addition of early ambulation has resulted in changes to the anesthetic plans, to ensure that patients will be able to walk on the day of their surgery.

Adequate postoperative pain control is not only crucial for early ambulation; it is also associated with a decrease in length of hospital stay, and reductions in post-operative complications such as deep vein thrombus and pulmonary embolism[1]. The topic of what is the optimum analgesia regimen following THR is heavily debated and has yet to yield a universal consensus. With many options for pain control, including oral narcotics, local anesthetic infiltration, femoral nerve block, fascia iliaca block, patient- controlled analgesia, and intrathecal opioids, it is difficult to determine which is superior. Although it has been shown that opioids can adequately control pain, the unwanted side effects of nausea, vomiting, respiratory depression, pruritus, and urinary retention can be problematic. In addition, minimizing opioid consumption in this aging population who often have multiple co-morbidities is advantageous.

Intrathecal morphine (ITM) has fallen out of favor because of these unwanted side effects. When ITM was compared to local infiltration analgesia (LIA), it was shown that LIA provided superior analgesia effects within the first 24 h compared to ITM following total knee arthroplasty (TKA) and THA, and was associated with decreased rates of nausea, vomiting, and pruritus while having no effect of hospital length of stay[2]. While it is recognized that femoral nerve blocks (FNB) have been replaced by adductor canal blocks (ACB) for analgesia following TKA[3], there remains a lack of evidence for the best management of pain following THA. Although its effect is controversial, FIB has been utilized for procedures in hip, anterior thigh, and knee. In this block, LA is deposited in the compartment beneath the fascia iliaca ligament at the superficial fascial layer of the iliopsoas muscle near the anterior edge of the ilium. It creates a fluid- filled compartment which, in turn, spreads the LA cephalad beneath the fascia to reach the nerves of the lumbar plexus-the lateral femoral cutaneous, femoral, and obturator nerves. We hypothesized, that performing a FIB with dilute local anesthetic concentration might provide adequate analgesia, while minimizing the motor block. Thus, patients would have better pain control and allow ambulation in the immediate post-operative period in accordance with ERAS protocol. This retrospective review aims to access the patient’s ambulation ability immediately after THA by comparing ambulation in patients who received FICB with those who did not.

After approval by Institutional Review Board, we reviewed the anesthetic records (CompuRecord^®, Philips, MA) and medical records (Prism^®, GE Healthcare, United Kingdom) of all undergoing THA with or without FIBs with a single block anesthesiologist from July to December 2016. Patients were evaluated by a member of the physical therapy (PT) team approximately 2 h after admission to the post-anesthesia care unit (PACU). Motor strength was evaluated, and if deemed adequate, the patient was permitted to stand and then ambulate. In addition to patient demographics, we also examined the anesthetic agents administered intra-operatively, looking for differences in anesthetic techniques; spinal vs general anesthesia, type of local anesthetic, and adjuvant medications given.

All ultrasound-guided FIBs were performed by residents supervised by a single attending and using a standard technique. The femoral nerve and artery were identified on ultrasound and after moving laterally, a 22 gauge block needle was inserted below the junction of the lateral 1/3 and medial 2/3 of the inguinal ligament as described by a research[4]. Using an in-plane approach, 40 mL of 0.2% ropivicaine was injected beneath the fascia iliaca at the superficial fascial layer as showed in Figure 1

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Figure 1 Ultrasound image of fascia iliaca plane block. Image is permitted and modified from Dr. Ali Shariat. LA: Local anesthetic injected beneath the fascia iliaca ligament.

Perioperative data was collected on 39 patients who underwent THA. Demographic data appears in Table 1. The majority of patients received a single shot spinal as the primary anesthetic for their THA, with either isobaric bupivacaine (10-15 mg) or hyperbaric bupivacaine (12-15 mg). Twenty patients had FIBs placed at the conclusion of the procedure, while 19 did not receive a block. Of the 20 patients with FIB, only 1 patient was able to ambulate. Eighteen patients did not ambulate secondary to decreased muscle strength and sensation, while 1 patient was unable to walk due to severe nausea. Of the 19 patients without FIB blocks, 17 were able to ambulate. Two patients were not able to ambulate secondary to lethargy, but both were able to stand up with minimal assistance.

Although previous publications have promoted the use of FIB to provide excellent analgesia following THA as explained by Mudumbai et al[5], we observed that they were associated with delayed ambulation in the immediate postoperative period. While the FIB blocks the lateral femoral cutaneous nerve which is a sensory nerve, local anesthetic spread medially may result in direct block of the femoral nerve, causing quadriceps weakness and an inability to ambulate. Alternatively, there may be some retrograde spread of the local anesthetic into the lumbar plexus, which causes both weakness of quadriceps in addition to hip adductor weakness from obturator nerve involvement.

The concentration of local anesthetic used in FIB (0.2% ropivicaine) should not be enough to cause significant femoral motor blockade; however, the volume of 40cc may be a contributing factor.

Isobaric bupivacaine may be another contribution to prolonged muscle weakness and the prevention of immediate ambulation in the PACU. Our data indicate that this is not the case, since the ambulating and non- ambulating groups had similar spinal doses.

While FIB appears to delay ambulation, we also sought to determine if pain scores were improved in the block group. However, due to the retrospective nature of the study and lack of guidelines for documentation of pain scores, medications administered, and PACU length of stay; it was difficult to find consistent and reliable information. Further studies need to be done to address this issue in a standardized fashion.

With THA becoming a shorter stay, and in some cases an ambulatory procedure, it is important to develop ERAS protocols, which will provide excellent pain control, while still allowing prompt post-operative ambulation. Though FIB may provide post-operative analgesia, it appears to be preventing ambulation and should not be included in an ambulatory THA pathway until further studies examine this relationship.