Adjunct Analgesia Reduces Pain and Opioid Consumption After Hip Arthroscopy: A Systematic Review of Randomized Controlled Trials

Abstract

Background: Patients who undergo hip arthroscopy inevitably experience pain postoperatively; however, the efficacy and safety of adjunct analgesia to prevent or reduce pain are not well-understood. Purpose: To perform a comprehensive qualitative synthesis of available randomized controlled trials evaluating the effect of adjunct analgesia on postoperative (1) pain, (2) opioid use, and (3) length of stay (LOS) in patients undergoing hip arthroscopy. Study Design: Systematic review. Methods: PubMed, OVID/MEDLINE, and Cochrane Controlled Register of Trials were queried for studies pertaining to analgesia interventions for patients undergoing hip arthroscopy. Two authors independently assessed article bias and eligibility. Data pertaining to changes in pain scores, additional analgesia requirements, length of hospital stay, and complications were extracted and qualitatively reported. Network meta-analyses were constructed to depict mean pain, opioid use, and LOS among the 3 analgesia categories (blocks, local infiltration analgesia, and celecoxib). Results: Fourteen level 1 studies were included; 12 (85.7%) reported pain reductions in the immediate and perioperative period after hip arthroscopy. Of the 7 studies that assessed an intervention (2 celecoxib, 1 fascia iliaca block, 1 lumbar plexus block, 1 femoral nerve block, 1 intra-articular bupivacaine, 1 extracapsular bupivacaine) versus placebo, more than half reported that patients who received an intervention consumed significantly fewer opioids postoperatively than patients who received placebo (lowest P value = .0006). Of the same 7 studies, 2 reported significantly shortened LOS with interventions, while 4 reported no statistically significant difference in LOS and 1 did not report LOS as an outcome. Conclusion: The majority of studies concerning adjunct analgesia for patients undergoing hip arthroscopy suggest benefits in pain reduction early in the postoperative period. There is mild evidence that adjunct analgesia reduces postoperative opioid use and currently inconclusive evidence that it reduces length of hospital stay. Furthermore, it appears that local infiltration analgesia may provide the greatest benefits in reductions in pain and opioid consumption. We recommend the use of adjunct analgesia in appropriately selected patients undergoing hip arthroscopy without contraindication who are at a high risk of severe postoperative pain.

Editorial Commentary: Hip Preservation and Opioids

“…A systematic review and network meta-analysis of 14 level I evidence studies suggested that adjunct anesthesia (local anesthesia infiltration) significantly reduces postoperative pain and opioid consumption. 23 Although perioperative regional blockade may reduce pain after hip arthroscopy, there is a significant increase in fall risk. 24 Although not previously discretely analyzed and reported, patient education is likely a critical component of postoperative pain and expectation management.…”

Pain management practice patterns after hip arthroscopy: an international survey

“…The opioid epidemic in the United States is a well-recognized issue [ 29 ] and the potential risks of opioid use, in addition to the associated health care costs, should encourage surgeons to seek alternatives to postoperative pain management. The efficacy of non-opioid medications in this setting has been demonstrated in several studies [ 3 , 30 , 31 ] and the American Society of Anesthesiologists (ASA) and the American Pain Society (APS) emphatically recommend the use of non-opioid analgesia in the post-operative period, barring contraindications [ 32 , 33 ].…”

“…As it is largely performed in an outpatient setting [ 1 , 2 ], hip arthroscopy requires proper post-operative pain management. Adequate post-operative pain control is of utmost importance as it increases patient satisfaction, decreases opioid consumption and allows early ambulation and rehabilitation [ 3–5 ]. Moreover, inadequate post-operative pain control may lead to adverse physiologic effects, delayed recovery and increased risk of developing chronic pain associated with the procedure [ 6 , 7 ].…”

“…Several options for post-operative pain control have been described for hip arthroscopy including pre-emptive and post-operative systemic medications [ 3 , 11 ], intra-articular or peri-portal injection of local anesthetics [ 12 , 13 ] and peripheral nerve blocks, such as lumbar plexus block [ 14 ], fascia iliaca block [ 15 ] and femoral nerve block [ 16 ]. The diversity of modalities described may reflect a lack of consensus on an optimal approach to pain management after hip arthroscopy.…”

Fascia Iliaca Block for Postoperative Pain Control After Hip Arthroscopy: A Systematic Review of Randomized Controlled Trials

“…One manner by which surgeons have attempted to lessen perioperative pain is with the use of various adjunct analgesic modalities such as nerve blocks, intraoperative intra-articular or extracapsular anesthetic injections, and nonsteroidal anti-inflammatory drugs. 23 Regional nerve blocks have been accepted as a standard pain management practice for patients undergoing shoulder arthroscopy 33,34 and anterior cruciate ligament reconstruction. 12,29 However, the use of nerve blocks as a method of perioperative pain control for patients undergoing hip arthroscopy is more novel and may include a fascia iliaca block (FIB), 2,15,18 lumbar plexus block (LPB), 2,19 quadratus lumborum block, 20,26 or sciatic nerve block.…”