European Journal of Cardiovascular Medicine

Femoral neck fractures are one of the most common orthopaedic injuries, especially in old age . Hip fractures are life-threatening events with a high risk of morbidity and mortality, so appropriate treatment of such conditions is lifesaving, and surgical replacement whether total or hemi-arthroplasty is the cornerstone of treatment . Recent studies have shown that the one-year mortality rate after a surgically corrected hip fracture is about 21% compared to a 70% one-year mortality for untreated cases. Pain is one of the most burdensome postoperative symptoms and is experienced by all patients undergoing hip surgeries.[1,2,3]

Fascia iliaca block (FIB) shows important potential in pain control and the decrease in opioid consumption for surgery. It is easy and fast to be performed. FIB has become an increasingly significant option for hip arthroplasty. In addition, as a newer group of blocks, quadratus lumborum blocks (QLB) is conducted by injecting anesthetic through either anterolateral, posterior, or anterior/transmuscular relative to the quadratus lumborum muscle. Previous studies demonstrated the capability of QLB for postoperative pain relief of hip arthroplasty, as evidenced by the decrease in pain scores and opioid use.[5,6]

Various studies have demonstrated the positive effects of fascia iliaca block (FIB) in reducing pain resulting from hip fractures and reducing total opioid consumption .[7] There are 2 main approaches for the FIB: the supra-inguinal approach and the infra-inguinal approach. Although the infra-inguinal approach is easier and safer compared to the supra-inguinal approach, various studies have shown that its sensory block was inferior to the supra-inguinal approach [8]. In the era of fast-track protocols for total joint arthroplasties, there seems to be no ideal regimen for post-operative pain management. In this study, we aim to examine the efficacy of supra-inguinal FIB compared to anterior QLB in the management of postoperative pain in patients undergoing open hip surgeries.

This was a randomised prospective study conducted in Department of Anesthesia for a period of one year in 80 patients posted for hip surgeries done under subarachnoid block.

Inclusion criteria: male and female of age between 40-60 years scheduled for open hip surgeries with ASA status I-III.

Exclusion criteria: coagulopathy, infection at the injection site, allergy to local anesthetics, severe cardiopulmonary disease, neuropathies, opioid use for chronic analgesic therapy, contraindication to spinal anesthesia, and inability to comprehend the visual analog scale (VAS).

 After obtaining written informed consent from all subjects, patients were recruited to this study by our anaesthesia residents from our clinic. Sixty-eight patients were enrolled in this study.

pts are randomly assigned into two groups with online randomization program was used by a study assistant to generate a random sequence, and each code was enclosed in a sealed opaque envelope. Patients were allocated to either the FIB group or the QLB group. The patients and outcome assessors were blinded to the study group allocation

Patients were divided into 2 parallel study groups:

• Group (F): 40 Patients who received ultrasound- guided supra-inguinal fascia iliaca block S-FIB.
• Group (Q): 40 Patients who received ultrasound-guided anterior QLB.

Anterior quadratous lumborum or suprainguinal fascia iliaca block is applied under Ultrasound guidance . Measurements and outcomes is noted as follows.

1. VAS during seating the patient when applying the neuraxial block.
2. Postoperative pain assessment: Using the VAS score at rest during the immediate postoperative period (0 min), and at 30 min, 1, 2, 6, 12, and 24 hours. The assessment will be done by an independent anaesthesiologist who has no role in applying the block or intraoperative management of the patient.
3. All patients will receive paracetamol 15 mg kg–1 IV (500 mg or 1 gm) at an interval of 6 hours in the postoperative period.
4. If VAS > 4 at any time, then rescue analgesia in the form of Tramadol 50mgs IV will be given. If the pain persisted after 30 minutes the patient will be given another dose of tramadol. Time to rescue analgesic dose will be recorded.
5. The total dose of tramadol required in 24 hours will be documented.
6. Side effects of opioids such as nausea, vomiting, respiratory depression, and itching will be noted.
7. Postoperative nausea and vomiting (PONV) will be assessed using a 4-point numerical scale (0 = no PONV, 1 = mild nausea, 2 = severe nausea or vomiting once, and 3 = vomiting more than once).
8. Patient satisfaction will be evaluated and recorded 24 hours after surgery on a 7-point Likert scale (1 – extremely dissatisfied, 2 – very dissatisfied, 3 – dissatisfied, 4 – neither satisfied nor dissatisfied, 5 – satisfied, 6 – very satisfied, 7 – extremely satisfied).

Data will be collected, tabulated, and analysed using SPSS Statistics for Windows version 19. Numerical variables will be presented as mean (standard deviation) or median (IQR) as appropriate and compared using the t-test or Mann-Whitney test respectively. Any difference with a P-value < 0.05 will be considered statistically significant. Statistical analysis was done using descriptive statistics.

A total of 80 patients were enrolled in the study. Demographic data were similar between groups with 18 males and 22 females participating in the Q group with a mean age of 52.3 ± 6.1 and 19 males and 21 females participating in the F group with a mean age of 53.4 ± 4.2. ASA classification distribution between groups was non-significant 

Table-1: Demographic data among the 2 groups

Table-2: Time to first rescue analgesic dose, total morphine consumption, and VAS during patient positioning to receive spinal anaesthesia

The total morphine consumption in 24 hours was significantly lower in the group receiving supra-inguinal F with a mean consumption of morphine 5.8 ± 0.8 mg compared to 7.2 ± 1.91 mg and a P-value of 0.007

The VAS during positioning the patient showed a significant difference between the groups, 3.9 ± 2.6 in the supra-inguinal F compared to 5.3 ± 2.7 in the anterior Q group and a P-value of 0.008

Figure-1: Kaplan-Meier survival analysis for time to first rescue analgesia

Table-3: Overall patient satisfaction

Patients receiving F had better perioperative analgesia profiles overall, patient satisfaction showed no significant difference between groups.

Table-4: PONV scores among the studied patient groups

 Side effects including respiratory depression and itching were not reported in either group, and PONV scores were not significantly different between groups.

The results of our study revealed that both Group F and Q  show comparative postoperative analgesic profiles after hip surgeries. We found that patients who are in Group F had prolonged analgesia compared to the other group. They were more comfortable during positioning to receive spinal anaesthesia, and they received significantly smaller amounts of opioids in the postoperative period. Although patients receiving Group-F had better perioperative analgesia profiles overall, patient satisfaction showed no significant difference between groups. Our study is in coincidence with study of Sameh Refaat et al[9] concluded supra-inguinal Group-F provides prolonged postoperative analgesia compared to anterior Group-Q in patients undergoing hip surgery. It was associated with less pain during positioning in spinal anaesthesia and decreased total morphine consumption.

Many types of peripheral nerve blocks have been developed to minimize postoperative pain and maximize physical function for hip arthroplasty, such as FIB and QLB.[10,11] However, their comparison for pain control is unclear after hip arthroplasty. Our study comapared  with other studies undergoing hip surgeries, results revealed that compared to Group-Q, Grous-F was able to further reduce pain scores, first rescue analgesia, analgesic consumption was significant.

Our study contradicts the findings of Blackwell et al.[12], who found that posterior quadratus lumborum was superior to fascia iliaca block in hip arthroscopy, and that difference could derive from many factors. Their study was a retrospective study, which is an inferior level of evidence compared to randomized prospective studies. We found that some patients in the group assigned to the fascia iliaca block received femoral nerve block only, which makes the results questionable. Not all patients received the same form of postoperative opioids, some being converted to morphine equivalents, many patients received local infiltration of LA after the procedure, and the exact form of fascia iliaca block, whether supra- or infra-inguinal, was not mentioned.

Kukreja et al[13] reported that QLB provides effective analgesia after hip arthroplasty, whereas Aoyama et al[14] could not find consistent sensory blockade in the lumbar nerves after transmuscular QLB using the same procedure. Aoyama et al[14] compared continuous QLB and femoral nerve block, while our study compared Group Q and F using a single-shot technique.

Narcotic medications is widely used for the traditional pain management for orthopaedic surgery, but may result in some side effects on the gastrointestinal, respiratory, integumentary, genitourinary, and neurologic systems.[15,16] Multimodal pain management is extensively developed to improve postoperative pain control and reduce the adverse events. Especially, nerve block such as femoral nerve blocks, FIB, and lumbar plexus blocks showed important potential in improving multimodal pain management. Our meta-analysis aimed to find the ideal nerve block for hip arthroplasty and revealed the better pain relief of FIB than QLB.

 Our study has some limitations: during the postoperative period, assessment of the postoperative sensory block was not possible at certain dermatomal levels due to the presence of surgical dressing. The confounding effect of the spinal block impaired the assessment of intraoperative analgesia and early postoperative motor power.

Supra-inguinal Group-F provides prolonged postoperative analgesia compared to anterior Group Q in patients undergoing hip surgery. It is associated with less pain during positioning in spinal anaesthesia and decreased total morphine consumption.

1. Miyamoto RG, Kaplan KM, Levine BR, Egol KA, Zuckerman JD. Surgical management of hip fractures: an evidence- based review of the literature. I: femoral neck fractures. J Am Acad Orthop Surg 2008; 16: 596-607.
2. Chitnis SS, Tang R, Mariano ER. The role of regional analgesia in personalized postoperative pain management. Korean J Anesthesiol 2020; 73: 363-371.
3. Horn R, Kramer J. Postoperative Pain Control. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.
4. Chou R, Gordon DB, de Leon-Casasola OA, et al.. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council. J Pain 2016; 17: 131-157.
5. Desmet M, Balocco AL, Van Belleghem V. Fascia iliaca compartment blocks: Different techniques and review of the literature. Best Pract Res Clin Anaesthesiol. 2019;33:57–66.
6. Desmet M, Vermeylen K, Van Herreweghe I, et al. A longitudinal supra-inguinal fascia iliaca compartment block reduces morphine consumption after total hip arthroplasty. Reg Anesth Pain Med. 2017;42:327–33. 
7. Pepe J, Ausman C, Madhani NB. Ultrasound-guided Fascia Iliaca Compartment Block. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. A
8. Vermeylen K, Desmet M, Leunen I, et al. Supra-inguinal injection for fascia iliaca compartment block results in more consistent spread towards the lumbar plexus than an infra-inguinal injection: a volunteer study. Reg Anesth Pain Med 2019; rapm-2018-100092.
9. Refaat S, M Ali M, Elsherief IME, Mohamed MM. Ultrasound-guided fascia iliaca block versus quadratus lumborum block for perioperative analgesia in patients undergoing hip surgery. A randomised controlled trial. Anaesthesiol Intensive Ther. 2023;55(3):212-217.
10. Nielsen ND. Peripheral nerve blocks for analgesia after elective total hip arthroplasty. Acta Anaesthesiol Scand. 2020;64:829–30. 
11. Park HJ, Park KK, Park JY, Lee B, Choi YS, Kwon HM. Peripheral nerve block for pain management after total hip arthroplasty: a retrospective study with propensity score matching. J Clin Med. 2022;11:5456.
12. Blackwell RE, Kushelev M, Norton J, et al. A Comparative analysis of the quadratus lumborum block versus femoral nerve and fascia iliaca blocks in hip arthroscopy. Arthrosc Sports Med Rehabil 2020; 3: 7-13.
13. Kukreja P, Macbeth L, Sturdivant A, et al. Anterior quadratus lumborum block analgesia for total hip arthroplasty : a randomized, controlled study. Reg Anesth Pain Med. 2019.
14. Aoyama Y, Sakura S, Abe S, Tadenuma S, Saito Y. Continuous quadratus lumborum block and femoral nerve block for total hip arthroplasty: a randomized study. J Anesth. 2020;34(3):413–420.
15. Horlocker TT. Pain management in total joint arthroplasty: a historical review. Orthopedics. 2010;33(9 Suppl):14–9.
16. Wheeler M, Oderda GM, Ashburn MA, Lipman AG. Adverse events associated with postoperative opioid analgesia: a systematic review. J Pain. 2002;3:159–80