Is There a Best Analgesic Technique for Hip Surgery?

INTRODUCTION

Anesthesia and analgesia for hip surgery present a great challenge, especially considering the patient demographic, namely the elderly with significant comorbidities such as cardiac disease, pulmonary disease, and renal insufficiency. All of these conditions can adversely affect surgical outcome. Therefore effective perioperative anesthesia and analgesia management is essential to decreasing morbidity and mortality and improving function recovery and long-term surgical outcome.

Hip surgery is traditionally performed under general anesthesia (GA) and/or spinal/epidural anesthesia (CSE). With emerging regional anesthesia approaches, there are several case reports of using psoas compartment block (PCB) to provide surgical anesthesia and analgesia for hip surgery. The choice of surgical anesthesia likely does not affect major surgical outcomes in elective hip surgery; however, neuraxial anesthesia technique might be associated with lower perioperative complications among traumatic hip surgical patients compared with GA. In 2019, the ICAROS (International Consensus on Anaesthesia-Related Outcomes after Surgery) group did a meta-analysis looking at hip arthroplasties, and, based on outcomes with a moderate to low evidence level, strongly recommended using neuraxial anesthesia over GA. There are also several ongoing prospective clinical trials investigating the types of anesthesia on outcomes after hip surgery, including the ongoing REGAIN (Regional Versus General Anesthesia for Promoting Independence After Hip Fracture) trial, a multicenter trial looking at spinal anesthesia versus GA in hip fractures. This study is looking to evaluate the association of anesthetic with functional recovery, but it is limited to only hip fractures and not other kinds of hip surgeries.

There are many techniques for postoperative analgesia management in hip surgical patients, including the lumbar plexus block (LPB)/PCB, the femoral nerve block (FNB)/fascia iliaca block (FIB)/“3-in-1” nerve block (3NB), high-volume local infiltration analgesia (LIA), and the pericapsular nerve group block (PENG).

Although all these approaches sound promising, it is important to define the peripheral nerve targets for anesthesia and analgesia. The analgesia for hip surgery can be covered, mostly, by targeting the lumbar plexus T12 to L4 nerves. With the articular branch that innervates the anteromedial capsule of the hip joint coming from the obturator nerve (ON), the classic FNB would not provide sufficient analgesia coverage to the entire hip. Similarly, branches of the sciatic nerve innervate the posteromedial capsule and thus would require analgesia coverage beyond the lumbar plexus.

EVIDENCE AND CONTROVERSIES