Update on Selective

Regional Analgesia for Hip

S u r ge ry Pat i en t s
Dario Bugada, MDa,*, Valentina Bellini, MD
b
, Luca F. Lorini, MD
a
,
Edward R. Mariano, MD, MASc,d

KEYWORDS
 Total hip replacement  Hip fracture  Femoral nerve block  Fascia iliaca block
 Lumbar plexus block  Local infiltration analgesia  Surgical outcome
 Postoperative analgesia

KEY POINTS
 A wide range of selective nerve blocks are available for hip surgery analgesia, reflecting
the complex innervation of the hip.
 The ideal block technique or combination for hip surgery is not yet defined; there is sup-
portive evidence for posterior lumbar plexus, femoral nerve, and fascia iliaca blocks.
 Alternative nerve and interfascial plane blocks may have a role in analgesia for patients
undergoing hip surgery but rigorous studies are lacking.
 Despite the type of block used, a strategy of multimodal analgesia in the perioperative
period is mandatory.

INTRODUCTION

The hip surgery patient population worldwide is quite diverse, from children with
congenital hip dysplasia, to younger athletic adults who undergo hip arthroscopy, to
frail elderly patients with multiple medical problems who suffer a mechanical fall.
This review focuses on adult hip surgery patients with a special emphasis on the ap-
plications of regional anesthesia and analgesia following hip fracture repair and total
hip arthroplasty (THA).

a
Emergency and Intensive Care Department, ASST Papa Giovanni XXIII, Piazza OMS, 1, Bergamo
24127, Italy; b Department of Anesthesia and Pain Therapy, Parma University Hospital, Via
Gramsci, 14, Parma 43126, Italy; c Department of Anesthesiology, Perioperative and Pain Medicine,
Stanford University School of Medicine, 3801 Miranda Avenue, MC 112A, Palo Alto, CA 94304,
USA; d Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health
Care System, 3801 Miranda Avenue, MC 112A, Palo Alto, CA 94304, USA
* Corresponding author. Emergency and Intensive Care Department, ASST Papa Giovanni XXIII,
Piazza OMS, 1, Bergamo 24127, Italy.
E-mail address: [email protected]

Anesthesiology Clin - (2018) -–-

https://doi.org/10.1016/j.anclin.2018.04.001 anesthesiology.theclinics.com
1932-2275/18/ª 2018 Elsevier Inc. All rights reserved.
2 Bugada et al

Hip fracture due to mechanical falls continues to occur at a significant rate despite
focused efforts on prevention.1 Most of these patients are elderly and frail with mul-
tiple comorbidities. In this vulnerable population, early and appropriate analgesic
treatment can have a strong positive influence on the trajectory of postoperative re-
covery.2 Total joint replacement, including THA, is projected to become among the
most common elective surgical procedures in the United States in the coming
decade.3 Effective pain management is an essential element of successful rehabili-
tation and enhanced recovery.4,5 In this context, appropriate application of regional
anesthesia and analgesia continues to play an important role in perioperative pain
management but must be carefully balanced with the expected occurrence of lower
limb motor block.6
Beyond the immediate postoperative period, regional anesthesia and analgesia
can have potentially beneficial effects on long-term outcomes, especially on persistent
postsurgical pain7 and functional rehabilitation.8 Continuous regional analgesia,
in particular, has been extensively studied in patients who undergo total joint replace-
ment surgery and may positively influence patient outcomes in other surgical
settings.9
New appraisals on hip anatomy and innervation, as well as the emergence of new
equipment and techniques, have increased the spectrum of possible regional anes-
thesia and analgesia options for anesthesiologists and pain physicians who care for
hip surgery patients. This review presents the latest information on this topic, with spe-
cial attention on anatomy, selective unilateral regional analgesic techniques, and
outcome data.

REVIEW OF HIP INNERVATION

Hip innervation is complex with contributions from many nerve components. Birn-
baum and colleagues10 reported that the femoral nerve (FN) innervates the anterolat-
eral capsule, and the obturator nerve (ON) innervates the anteromedial capsule.
Combined innervation of the anterior capsule was often observed. The posterior
and inferior parts of the hip joint capsule are innervated by the sacral plexus, consist-
ing of branches directly from the sciatic or superior gluteal nerves, or via the sciatic
nerve branch to the quadratus femoris muscle.
A histologic study of the hip joint capsule found nociceptive fibers to be pre-
dominantly present in the anterior and superolateral parts of the hip joint capsule.
Neural fibers found in the posterior and inferior parts were identified as mechano-
receptors.11 These findings support the assumption that the FNs and ONs may be
the primary mediators of nociceptive pain from the hip joint, thus narrowing the
focus of regional analgesic techniques.12 However, blockade of the sacral plexus
is necessary to provide surgical anesthesia, and the lateral femoral cutaneous
nerve (LFCN) is also important for postoperative analgesia because it innervates
the skin in the lateral part of the thigh, which is frequently involved in the surgical
incision (Fig. 1). Although neuraxial blocks, epidurals, and spinal techniques are
known to provide effective anesthesia and analgesia for hip surgery patients,
they are nonselective for unilateral surgery and may be associated with undesir-
able side effects.13

SELECTIVE REGIONAL ANALGESIC TECHNIQUES FOR HIP JOINT SURGERY

Lumbar Plexus Block
Lumbar plexus block (LPB) targets the FN, LFCN, and ON as they run within the psoas
major muscle. It is also known as the psoas compartment block. There are various
 Regional Analgesia for Hip Surgery Patients 3

Fig. 1. Innervation of the hip joint and skin dermatomes relevant for hip surgery. Innerva-
tion: (A) hip joint, anterior view; (B) hip joint, posterior or lateral view; (C) femur, medial
side. Skin innervation: (D) anterior view, (E) posterior view. LAT, lateral.

approaches to perform the LPB technique using both electrical stimulation and ultra-
sound guidance.14,15
Despite the introduction of newer approaches, the use of ultrasound for LPB in
adults has to date been unfortunately less helpful than in other peripheral blocks.16
The main reason is likely the depth of the plexus, resulting in reduced image resolution
and poor needle visualization. Nevertheless, the use of ultrasound imaging for pre-
puncture scanning17 or in conjunction with peripheral nerve stimulation may enhance
block performance by providing an indication of psoas muscle depth, position of the
kidney, and spread of injectate.18
The primary indication for LPB is postoperative analgesia after major hip surgery
such as arthroplasty. Single-injection LPB reduces pain ratings and postoperative
morphine requirements.19 Continuous LPB results in excellent pain relief during the
first 48 hours20 and decreases the time required to achieve discharge criteria.21
Compared with neuraxial blockade, LPB results in less hypotension and improved
analgesia in elderly patients undergoing hip fracture repair15 and is as effective as
epidural block for analgesia after THA, with less nausea, urinary retention, motor
block, and hypotension.
Despite proven efficacy, potential side effects and serious complications have tradi-
tionally limited the use of LPB. LPB is considered a deep block and is subject to all the
restrictions of neuraxial block in the anticoagulated patient.22,23 Further, neuraxial and
4 Bugada et al

bilateral spread can occur; the close proximity of the epidural and intrathecal spaces
may result in catheter misplacement.24
These concerns are based on the findings of a major multiinstitutional study of com-
plications after regional anesthesia that found 5 serious complications after 394 LPB
procedures,25 all either secondary to the occurrence of intrathecal or epidural block, or
intravascular local anesthetic administration. A more recent registry confirms that se-
vere complications are still possible despite all precautions related to the prevention of
neuraxial spread and intravascular injection.26 The reason for the migration of injectate
is not completely understood but it is thought that it relies on the diffusion along nerve
roots toward the neuraxis. Various attempts have been made to reduce this phenom-
enon but neuraxial spread of local anesthetic can still occur in up to 30% of cases. The
technique used for LPB,27 use of ultrasound, and the reduction in the volume of local
anesthetics do not seem to eliminate the problem.28 Recently, severe complications
have been associated with even the lowest possible volumes of injectate to obtain a
successful LPB; therefore, 100% prevention may not be possible even with new
ultrasound-guided approaches.26,28 Only limiting opening injection pressure (<15
psi)24 and lateral position29 seem to be protective but no large prospective studies
are available to support this claim. Hemodynamic monitoring, therefore, should be
continued for 45 minutes after block with regular assessment for contralateral spread
by sensory testing. Use of a test dose and/or radiological imaging may be warranted to
confirm catheter placement.30
In a randomized clinical trial (RCT) comparing continuous LPB to a proximally
inserted FN catheter technique (nearly identical to the fascia iliaca catheter) for sub-
jects undergoing THA, postoperative analgesia was equivalent between the 2
groups.31 Given these results and the comparison of procedure-related risks, the in-
dications for LPB seem to be shrinking.

Fascia Iliaca Block

The concept of fascia iliaca block (FIB) is to introduce high volumes of local anesthetic
underneath the fascia iliaca, assuming that the proximal diffusion of the injectate along
the psoas muscle will target FNs, LFCNs, and ONs during their course (the so-called
3-in-1 block).
Different techniques are available. The first to be described was the landmark-
based double-pop technique,32 a loss-of-resistance approach based on the pop felt
when the needle passes through both fascia lata and fascia iliaca.
Ultrasound-guided approaches have also been described. One early approach rec-
ommends the use of high frequency linear transducer with transverse orientation
placed below the inguinal ligament and lateral to the femoral artery. A more cranial ac-
cess point (above the inguinal ligament) has been described33 in the attempt to in-
crease proximal local anesthetic spread to the iliac fossa. The orientation of the
probe seems to influence block success with perpendicular orientation to the inguinal
ligament associated with greater incidence of successful LFCN block.34 Without ultra-
sound, the accuracy of the loss-of-resistance technique in positioning the needle in
the fascia iliaca compartment is 56%, with drug diffusion above the fascia in 14%
and intramuscular injection in 29% of patients.35 Ultrasound guidance increases the
frequency of FN block (FNB) and ON block (ONB).36
When compared with the FNB technique, FIB may have an inherent safety advan-
tage because the puncture site is further away from large vessels and the FN. FIB is
a valuable technique that can be used in the emergency department (ED) to treat
pain associated with hip fractures. RCTs have shown a statistically significant
improvement in maximum pain relief both at rest and at movement,37 with fewer
 Regional Analgesia for Hip Surgery Patients 5

adverse events compared with other analgesics.38 Furthermore, in a recent study on

ED patients with hip fracture, FIB provided immediate pain relief and allowed a larger
proportion of patients to reach a clinically meaningful decrease in pain without opioids
at 4 to 8 hours.39 FIB’s opioid-sparing effect and analgesic efficacy with fewer side ef-
fects have been consistently reported.40,41
Single-injection FIB techniques may provide effective analgesia for several hours or
even up to 2 days.42 When indicated (eg, when longer time is expected to pass be-
tween hospital admission and surgery), a catheter can be inserted to perform contin-
uous regional analgesia with potential benefits on patient outcomes, especially
cognitive impairment.43
FIB is also a valuable element of multimodal analgesia after THA. Despite some -con-
flicting results, FIB has generally been shown to be superior to placebo for postoper-
ative analgesia, irrespective of the type of hip surgery.44,45 In a recent RCT, a
high-dose longitudinal suprainguinal ultrasound-guided FIB resulted in a statistically
significant reduction in morphine consumption at 24 and 48 hours postoperatively
compared with intravenous analgesia alone, with decreased pain scores up to 24 hours
postoperatively.46 Continuous FIB maintained for the first 48 hours after surgery re-
duces pain intensity when compared with fentanyl intravenous patient-controlled anal-
gesia, with a lower incidence of postoperative nausea and vomiting, and pruritus.47
When managed appropriately (ie, pausing infusions hours before anticipated mobility),
continuous FIB may not impair ambulatory ability for postoperative THA patients.48
A recent meta-analysis comparing FNB and FIB indicates that both techniques mini-
mize opioid consumption in patients after THA.49 A study by Rashiq and colleagues50
compared multiple pain treatment options for subjects following hip fracture surgery,
with variable timing of block execution and type of injection (eg, single-injection, cath-
eter with continuous infusion, intermittent bolus). FIB was the most protective against
postoperative delirium. Further studies are required to confirm these results.

Femoral Nerve Block

FNB is a common peripheral nerve block procedure, carries a low risk of complica-
tions, and has multiple clinical applications for postoperative analgesia. All available
techniques are based on the relationship of FN to the vessels in the femoral triangle.
The FN is always lateral to the artery; identifying the femoral artery (either by palpation
or by ultrasound) is a helpful guide when locating the nerve. The nerve is easily iden-
tified by ultrasound (in between the fascia iliaca and iliacus muscle) and usually ap-
pears as a flat or teardrop-shaped hyperechoic structure. If using nerve stimulation,
needle-to-nerve proximity is indicated by eliciting quadriceps contraction with patellar
movement (the so-called dancing patella). Different approaches have been used for
ultrasound-guided FNB, typically with short-axis target imaging and either out-of-
plane or in-plane needle guidance.51
For patients presenting to the ED with acute hip pain from a proximal femoral frac-
ture, both nerve stimulator and ultrasound guidance result in successful blocks of
similar duration; however, ultrasound decreases block performance time.52 Providing
early FNB in this setting effectively controls pain during radiological examinations and
traction application.53 A recent review emphasizes FNB’s effectiveness versus opioids
and its higher safety profile in patients with hip fractures.54
FNB may also be useful when positioning patients for neuraxial anesthesia; when
compared with intravenous fentanyl, FNB reduces the need for additional analgesics
and decreases the time needed to perform spinal anesthesia.55
Single-injection FNB, although limited in duration, may offer some benefits during
postoperative recovery after hip surgery. When compared with placebo, FNB can
6 Bugada et al

extend the time from anesthetic emergence to the first request for analgesia.56 Ac-
cording to a study by Wiesmann and colleagues,57 subjects who received an FNB
for hip surgery demonstrated decreased systemic analgesic consumption up to
24 hours after surgery, improved pulmonary function, and faster achievement of post-
anesthesia care unit discharge criteria.
Continuous FNB provides extended postoperative analgesia after hip surgery.
When a catheter is properly placed next to the FN, effective analgesic duration is
longer, and the quality of analgesia is equivalent to that of a continuous LPB. A suc-
cessful FNB results in quadriceps weakness,58 which may impair early ambulatory
ability after lower extremity surgery.31 However, peripheral nerve blocks may not be
entirely to blame in terms of increased fall risk. Large-scale database studies and
RCTs have shown other factors (ie, obesity, age, higher comorbidity burden) to be
associated with postoperative falls and difficulty with ambulation after hip arthro-
plasty.48,59 For outpatient hip surgery (eg, arthroscopy), routine FNB may not be rec-
ommended due to this risk.60 Careful consideration of risks and benefits should
always be performed when evaluating potential candidates for peripheral nerve
blockade, and explicit instructions regarding safe care of the affected extremity should
be provided to the patient and caregivers.61

OTHER PERIPHERAL NERVE BLOCK TECHNIQUES

Obturator Nerve Block
The ON descends through psoas major and extends to the anterior thigh through the
obturator canal. The common ON runs between the pectineus and obturator externus
muscles immediately after the nerve emerges from the obturator canal. The articular
branch supplying the hip joint is derived from the common ON or its branches at
different levels in conjunction with the obturator canal.62
ONB can be performed by different techniques. Regardless of technique
used, the aim for successful analgesia of the hip joint should be the common
ON before bifurcation into anterior and posterior branches. When using nerve
stimulation alone, blind needle advancement toward intrapelvic components may
result in a higher rate of complications63 and articular branches to the hip joint
are not always blocked. Ultrasound-guided ONB below the inguinal ligament is
an easy technique to block anterior and posterior divisions64 but articular branches
to the hip may be inconsistently anesthetized. Recently, a cadaveric study has
demonstrated that injection of 15 mL within the muscular plane between the pecti-
neus and the external obturator muscle provides 100% block of the articular
branches.12
It remains unclear whether an ONB alone can significantly improve the management
of acute pain after hip surgery. An RCT demonstrating equivalent analgesia between
continuous FNB (essentially a fascia iliaca catheter technique) and continuous LPB31
argues against a clinically meaningful benefit of ONB. One RCT described the combi-
nation of ONB and LFCN blockade as an effective approach in controlling acute pain
after surgery for hip fracture.52 However, the available evidence is based on indirect
multicomparison analysis and should be carefully interpreted. The clinical relevance
of adding ONB to a standard FNB for analgesia in hip fracture or hip surgery, or
possible advantages of selective ONB compared with other plexus or peripheral nerve
blocks are unclear. As understanding of hip innervation increases and the expecta-
tions for postoperative ambulation after joint replacement change, combined with ad-
vances in ultrasound-guided techniques,65 there may yet be an indication for ONB in
this setting.
 Regional Analgesia for Hip Surgery Patients 7

Lateral Femoral Cutaneous Nerve Block

The LFCN is a sensory branch of the lumbar plexus. The LFCN divides into several
branches and provides superficial innervation over the anterolateral thigh. There is a
large variation in the area of sensory coverage among individuals because of the highly
variable course of the LFCN and its branches. Different anatomic variants have been
shown,66 which must be taken into account when this nerve block is performed, mak-
ing it challenging to perform an effective landmark-based block. Ultrasound guidance,
however, allows for more accurate needle insertion into the appropriate fascial plane.
The LFCN is typically visualized with ultrasound between the tensor fasciae latae and
the sartorius muscles, 1 to 2 cm medial and inferior to the anterior superior iliac spine,
as an oval hypoechoic small structure with a hyperechoic rim.67
LFCN block can be helpful for postoperative pain management in hip surgery pa-
tients but with limited effectiveness when performed alone. Thybo and colleagues68
demonstrated that ultrasound-guided LFCN block performed postoperatively in
THA subjects experiencing pain scores higher than 40 mm during hip flexion,
may reduce pain at mobilization by an average of 17 mm. However, they showed
a significant percentage of nonresponders (around 42%). The same investigators
performed an additional RCT in which an ultrasound-guided LFCN block was
administered at the end of THA, before the spinal block resolved. No differences
were reported in the following 24 hours in terms of opioid consumption, pain at
rest and movement, time to first mobilization, and degree of mobilization.69 The
limited effectiveness of LFCN block when performed alone may be due to the sur-
gical incision (at least in part) extending beyond the skin area innervated by LFCN.
In a group of 20 volunteers, more than half of incisions drawn according to a simu-
lated hip arthroplasty fell completely outside the area of anesthesia produced
by LFCN block. In these cases, an alternative approach may be the infiltration of
the skin performed by the surgeon because LFCN selectively innervates the skin
surface.70

Interfascial Plane Blocks: Quadratus Lumborum Block

The quadratus lumborum block (QLB) aims to block the anterior branches of thora-
coabdominal nerves and may extend to the upper branches of the lumbar plexus
and lateral cutaneous branches of the thoracoabdominal nerves with possible spread
of injectate to the paravertebral space. Multiple approaches are described in the liter-
ature: lateral, posterior, and anterior (transmuscular). Different approaches determine
different spread patterns of injectate with affected dermatomes ranging from thoracic
(T)6 to lumbar (L)2.71
QLB has mostly been described for abdominal surgery71 but has also recently been
applied for hip fracture patients. In patients with neck of femur fracture, QLB may
result in better pain control in the first 24 hours after surgery compared with FNB
with a lower use of opioids.72 La Colla and colleagues73 have described QLB with
block duration of about 30 hours, extending through T10 to L3 dermatomes, and
without associated muscle weakness. Analgesia lasting more than 24 hours has
been reported without association with hip flexor or quadriceps weakness in 2 other
patients receiving hip surgery with 0.5% ropivacaine.74 A continuous QLB with cath-
eter placement may represent an option for continuous regional analgesia. In a report,
0.2% ropivacaine was infused at 7 mL per hour to provide analgesia without motor
block in a single case of primary THA through posterior approach.75
However, not all QLB approaches are the same and motor weakness is possible,76
especially with deeper injection of local anesthetic anterior to the quadratus lumborum
8 Bugada et al

muscle. With deeper approaches, considerations related to regional anesthesia in the

anticoagulated patient are relevant.
There may be a role for QLB in multimodal pain management for hip surgery patients
due to its potential for analgesic effectiveness and preservation of muscle strength
with certain techniques, which makes it less likely to impair early functional rehabilita-
tion. More outcome data based on prospective studies are still needed, as well as bet-
ter understanding of the applications of the various QLB techniques. Safety issues
should be addressed because they may limit QLB application, especially in the anti-
coagulated patient.

LOCAL INFILTRATION ANALGESIA

Local infiltration analgesia (LIA) relies on the injection of local anesthetic (alone or in
combination with other analgesics) within the surgical field in multiple layers, providing
analgesia without any motor block. In contrast to LIA for total knee replacement, which
is strongly supported, the efficacy of LIA for analgesia after THA is not as widely
accepted.77,78 However, a recent RCT provides supportive evidence for the analgesic
effectiveness of LIA with liposomal bupivacaine after THA.79 Compared with intra-
thecal morphine and epidural analgesia, LIA was reported to have similar or improved
analgesic efficacy.80 In a recent meta-analysis, no difference was observed between
LIA and peripheral nerve blocks (LPB, FNB, FIB) in terms of cumulative opioid use and
pain scores at 24 hours after surgery. LIA had a greater probability of being ranked first
in efficacy for patient outcomes.81 This was confirmed by a recent study that showed
higher incidence of motor block for FNB, whereas lower morphine consumption and
better pain control at 24 hours were obtained with LIA; however, issues with study
design may limit generalizability of these results.82 In another recent RCT, the investi-
gators found a modest improvement with respect to analgesia in patients receiving
continuous LPB compared with those receiving LIA with ropivacaine.79 LIA for THA re-
quires systematic, extensive, and meticulous multilayer tissue injection before surgical
wound closure, encompassing both capsular and soft tissues.83 Injectate typically
contains local anesthetics, as well as other analgesic adjuncts.84

SUMMARY

Hip surgery is widely performed and regional anesthesia techniques offer many ben-
efits in terms of postoperative pain management and functional recovery. To date, no
single technique or combination of techniques has been shown to be superior in all hip
surgeries. Use of LPB, FNB, and FIB within the context of a multimodal regimen are all
fairly well supported by published evidence. Other techniques, such as ONB and
LFCN block, have limited applications when used alone. Newer regional analgesic ap-
proaches, such as QLB, still require rigorous comparative effectiveness studies
against established techniques. Regardless of which block technique is used, a multi-
modal approach must be used. To realize potential long-term outcome benefits, more
work is needed to advance postoperative regional analgesia tailored to the individual
patient, beyond the first 1 to 3 days after hip surgery.

REFERENCES

1. Bhimjiyani A, Neuburger J, Jones T, et al. The effect of social deprivation on hip

fracture incidence in England has not changed over 14 years: an analysis of the
English Hospital Episodes Statistics (2001-2015). Osteoporos Int 2018;29(1):
115–24.
 Regional Analgesia for Hip Surgery Patients 9

2. Centre NCG. The management of hip fracture in adults. London: National Clinical
Guideline Centre; 2011.
3. Maradit Kremers H, Larson DR, Crowson CS, et al. Prevalence of total hip and
knee replacement in the United States. J Bone Joint Surg Am 2015;97(17):
1386–97.
4. Andersen LO, Gaarn-Larsen L, Kristensen BB, et al. Subacute pain and function
after fast-track hip and knee arthroplasty. Anaesthesia 2009;64(5):508–13.
5. Kehlet H, Soballe K. Fast-track hip and knee replacement–what are the issues?
Acta Orthop 2010;81(3):271–2.
6. Shin JJ, McCrum CL, Mauro CS, et al. Pain management after hip arthroscopy:
systematic review of randomized controlled trials and cohort studies. Am J Sports
Med 2017. [Epub ahead of print].
7. Bugada D, Lavand’homme P, Ambrosoli AL, et al. Effect of preoperative inflam-
matory status and comorbidities on pain resolution and persistent postsurgical
pain after inguinal hernia repair. Mediators Inflamm 2016;2016:5830347.
8. Bugada D, Allegri M, Gemma M, et al. The effects of anaesthesia and analgesia
on long-term outcome after total knee replacement: a prospective, observational,
multicentre study. Eur J Anaesthesiol 2017;34(10):665–72.
9. Bugada D, Ghisi D, Mariano ER. Continuous regional anesthesia: a review of peri-
operative outcome benefits. Minerva Anestesiol 2017;83(10):1089–100.
10. Birnbaum K, Prescher A, Hessler S, et al. The sensory innervation of the hip joint–
an anatomical study. Surg Radiol Anat 1997;19(6):371–5.
11. Gerhardt M, Johnson K, Atkinson R, et al. Characterisation and classification of
the neural anatomy in the human hip joint. Hip Int 2012;22(1):75–81.
12. Nielsen TD, Moriggl B, Soballe K, et al. A cadaveric study of ultrasound-guided
subpectineal injectate spread around the obturator nerve and its hip articular
branches. Reg Anesth Pain Med 2017;42(3):357–61.
13. Rawal N. Current issues in postoperative pain management. Eur J Anaesthesiol
2016;33(3):160–71.
14. Awad IT, Duggan EM. Posterior lumbar plexus block: anatomy, approaches, and
techniques. Reg Anesth Pain Med 2005;30(2):143–9.
15. Nielsen MV, Bendtsen TF, Borglum J. Superiority of ultrasound guided Shamrock
lumbar plexus block. Minerva Anestesiol 2018;84(1):115–21.
16. Kirchmair L, Entner T, Kapral S, et al. Ultrasound guidance for the psoas compart-
ment block: an imaging study. Anesth Analg 2002;94(3):706–10 [Table of
contents].
17. Ilfeld BM, Loland VJ, Mariano ER. Prepuncture ultrasound imaging to predict
transverse process and lumbar plexus depth for psoas compartment block
and perineural catheter insertion: a prospective, observational study. Anesth An-
alg 2010;110(6):1725–8.
18. Karmakar MK, Li JW, Kwok WH, et al. Ultrasound-guided lumbar plexus block us-
ing a transverse scan through the lumbar intertransverse space: a prospective
case series. Reg Anesth Pain Med 2015;40(1):75–81.
19. Stevens RD, Van Gessel E, Flory N, et al. Lumbar plexus block reduces pain and
blood loss associated with total hip arthroplasty. Anesthesiology 2000;93(1):
115–21.
20. Capdevila X, Macaire P, Dadure C, et al. Continuous psoas compartment block
for postoperative analgesia after total hip arthroplasty: new landmarks, technical
guidelines, and clinical evaluation. Anesth Analg 2002;94(6):1606–13 [Table of
contents].
10 Bugada et al

21. Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory continuous femoral nerve blocks
decrease time to discharge readiness after tricompartment total knee arthro-
plasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology
2008;108(4):703–13.
22. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient
receiving antithrombotic or thrombolytic therapy: American Society of Regional
Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg
Anesth Pain Med 2010;35(1):64–101.
23. Dario Bugada MA, Zadra N, Antonio Braschi A, et al, RICALOR Group Investiga-
tors. Regional anesthesia and anticoagulant drugs: a survey of current Italian
practice. Eur J Pain Suppl 2011;5:335–43.
24. Gadsden JC, Lindenmuth DM, Hadzic A, et al. Lumbar plexus block using high-
pressure injection leads to contralateral and epidural spread. Anesthesiology
2008;109(4):683–8.
25. Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anes-
thesia in France: the SOS regional anesthesia hotline service. Anesthesiology
2002;97(5):1274–80.
26. Allegri M, Bugada D, Grossi P, et al. Italian Registry of Complications associated
with Regional Anesthesia (RICALOR). An incidence analysis from a prospective
clinical survey. Minerva Anestesiol 2016;82(4):392–402.
27. Mannion S, O’Callaghan S, Walsh M, et al. In with the new, out with the old? Com-
parison of two approaches for psoas compartment block. Anesth Analg 2005;
101(1):259–64 [Table of contents].
28. Sauter AR, Ullensvang K, Niemi G, et al. The Shamrock lumbar plexus block: a
dose-finding study. Eur J Anaesthesiol 2015;32(11):764–70.
29. Jankowski CJ, Hebl JR, Stuart MJ, et al. A comparison of psoas compartment
block and spinal and general anesthesia for outpatient knee arthroscopy. Anesth
Analg 2003;97(4):1003–9 [Table of contents].
30. Mannion S. Psoas compartment block. Continuing Education Anaesth Crit Care
Pain 2007;7:162–6.
31. Ilfeld BM, Mariano ER, Madison SJ, et al. Continuous femoral versus posterior
lumbar plexus nerve blocks for analgesia after hip arthroplasty: a randomized,
controlled study. Anesth Analg 2011;113(4):897–903.
32. Diwan S. Fascia iliaca block- an anatomical and technical description. Journal of
Anaesthesia and Critical Care Case Reports 2015;1(1):27–30.
33. Hebbard P, Ivanusic J, Sha S. Ultrasound-guided supra-inguinal fascia iliaca
block: a cadaveric evaluation of a novel approach. Anaesthesia 2011;66(4):
300–5.
34. Wang N, Li M, Wei Y, et al. A comparison of two approaches to ultrasound-guided
fascia iliaca compartment block for analgesia after total hip arthroplasty. Zhong-
hua Yi Xue Za Zhi 2015;95(28):2277–81 [in Chinese].
35. Liang-Jing Yuan JY, Xu Li, Qing-Guo Y. Clinical research on loss of resistance
technique in fascia iliaca compartment block. Biomed Res 2016;27(4):1082–6.
36. Dolan J, Williams A, Murney E, et al. Ultrasound guided fascia iliaca block: a
comparison with the loss of resistance technique. Reg Anesth Pain Med 2008;
33(6):526–31.
37. Foss NB, Kristensen BB, Bundgaard M, et al. Fascia iliaca compartment
blockade for acute pain control in hip fracture patients: a randomized,
placebo-controlled trial. Anesthesiology 2007;106(4):773–8.
 Regional Analgesia for Hip Surgery Patients 11

38. Godoy Monzon D, Vazquez J, Jauregui JR, et al. Pain treatment in post-traumatic
hip fracture in the elderly: regional block vs. systemic non-steroidal analgesics.
Int J Emerg Med 2010;3(4):321–5.
39. Groot L, Dijksman LM, Simons MP, et al. Single fascia iliaca compartment block is
safe and effective for emergency pain relief in hip-fracture patients. West J Emerg
Med 2015;16(7):1188–93.
40. Shelley BG, Haldane GJ. Pneumoretroperitoneum as a consequence of fascia
iliaca block. Reg Anesth Pain Med 2006;31(6):582–3.
41. Kassam AM, Gough AT, Davies J, et al. Can we reduce morphine use in elderly,
proximal femoral fracture patients using a fascia iliac block? Geriatr Nurs 2018;
39(1):84–7.
42. Levente BZ, Filip MN, Romaniuc N, et al. Efficacy and duration of ultrasound
guided fascia iliaca block for hip fracture performed in the emergency depart-
ments. Rom J Anaesth Intensive Care 2017;24(2):167–9.
43. Odor PM, Chis Ster I, Wilkinson I, et al. Effect of admission fascia iliaca compart-
ment blocks on post-operative abbreviated mental test scores in elderly fractured
neck of femur patients: a retrospective cohort study. BMC Anesthesiol 2017;
17(1):2.
44. Goitia Arrola L, Telletxea S, Martinez Bourio R, et al. Fascia iliaca compartment
block for analgesia following total hip replacement surgery. Rev Esp Anestesiol
Reanim 2009;56(6):343–8 [in Spanish].
45. Kumie FT, Gebremedhn EG, Tawuye HY. Efficacy of fascia iliaca compartment
nerve block as part of multimodal analgesia after surgery for femoral bone frac-
ture. World J Emerg Med 2015;6(2):142–6.
46. Desmet M, Vermeylen K, Van Herreweghe I, et al. A longitudinal supra-inguinal
fascia iliaca compartment block reduces morphine consumption after total hip ar-
throplasty. Reg Anesth Pain Med 2017;42(3):327–33.
47. Nie H, Yang YX, Wang Y, et al. Effects of continuous fascia iliaca compartment
blocks for postoperative analgesia in patients with hip fracture. Pain Res Manag
2015;20(4):210–2.
48. Mudumbai SC, Kim TE, Howard SK, et al. An ultrasound-guided fascia iliaca
catheter technique does not impair ambulatory ability within a clinical pathway
for total hip arthroplasty. Korean J Anesthesiol 2016;69(4):368–75.
49. Fei D, Ma LP, Yuan HP, et al. Comparison of femoral nerve block and fascia iliaca
block for pain management in total hip arthroplasty: a meta-analysis. Int J Surg
2017;46:11–3.
50. Rashiq S, Vandermeer B, Abou-Setta AM, et al. Efficacy of supplemental periph-
eral nerve blockade for hip fracture surgery: multiple treatment comparison. Can
J Anaesth 2013;60(3):230–43.
51. Ruiz A, Sala-Blanch X, Martinez-Ocon J, et al. Incidence of intraneural needle
insertion in ultrasound-guided femoral nerve block: a comparison between the
out-of-plane versus the in-plane approaches. Rev Esp Anestesiol Reanim 2014;
61(2):73–7.
52. Forouzan A, Masoumi K, Motamed H, et al. Nerve stimulator versus ultrasound-
guided femoral nerve block; a randomized clinical trial. Emerg (Tehran) 2017;
5(1):e54.
53. Somvanshi M, Tripathi A, Meena N. Femoral nerve block for acute pain relief in
fracture shaft femur in an emergency ward. Saudi J Anaesth 2015;9(4):439–41.
54. Riddell M, Ospina M, Holroyd-Leduc JM. Use of femoral nerve blocks to manage
hip fracture pain among older adults in the emergency department: a systematic
review. CJEM 2016;18(4):245–52.
12 Bugada et al

55. Hartmann FV, Novaes MR, de Carvalho MR. Femoral nerve block versus intrave-
nous fentanyl in adult patients with hip fractures - a systematic review. Braz J
Anesthesiol 2017;67(1):67–71.
56. Fournier R, Van Gessel E, Gaggero G, et al. Postoperative analgesia with "3-in-1"
femoral nerve block after prosthetic hip surgery. Can J Anaesth 1998;45(1):34–8.
57. Wiesmann T, Steinfeldt T, Wagner G, et al. Supplemental single shot femoral
nerve block for total hip arthroplasty: impact on early postoperative care, pain
management and lung function. Minerva Anestesiol 2014;80(1):48–57.
58. Charous MT, Madison SJ, Suresh PJ, et al. Continuous femoral nerve blocks:
varying local anesthetic delivery method (bolus versus basal) to minimize quad-
riceps motor block while maintaining sensory block. Anesthesiology 2011;115(4):
774–81.
59. Memtsoudis SG, Danninger T, Rasul R, et al. Inpatient falls after total knee arthro-
plasty: the role of anesthesia type and peripheral nerve blocks. Anesthesiology
2014;120(3):551–63.
60. Xing JG, Abdallah FW, Brull R, et al. Preoperative femoral nerve block for hip
arthroscopy: a randomized, triple-masked controlled trial. Am J Sports Med
2015;43(11):2680–7.
61. Memtsoudis SG, Poeran J, Cozowicz C, et al. The impact of peripheral nerve
blocks on perioperative outcome in hip and knee arthroplasty-a population-
based study. Pain 2016;157(10):2341–9.
62. Anagnostopoulou S, Kostopanagiotou G, Paraskeuopoulos T, et al. Anatomic var-
iations of the obturator nerve in the inguinal region: implications in conventional
and ultrasound regional anesthesia techniques. Reg Anesth Pain Med 2009;
34(1):33–9.
63. Obturator nerve block. Available at: https://www.nysora.com/obturator-nerve-
block. Accessed February 6, 2018.
64. Manassero A, Bossolasco M, Ugues S, et al. Ultrasound-guided obturator nerve
block: interfascial injection versus a neurostimulation-assisted technique. Reg
Anesth Pain Med 2012;37(1):67–71.
65. Yoshida T, Nakamoto T, Kamibayashi T. Ultrasound-guided obturator nerve block:
a focused review on anatomy and updated techniques. Biomed Res Int 2017;
2017:7023750.
66. Tomaszewski KA, Popieluszko P, Henry BM, et al. The surgical anatomy of the
lateral femoral cutaneous nerve in the inguinal region: a meta-analysis. Hernia
2016;20(5):649–57.
67. Hadzic A. Hadzic’s peripheral nerve blocks and anatomy for ultrasound-guided
regional anesthesia. 2nd edition. New York: McGraw-Hill; 2011.
68. Thybo KH, Mathiesen O, Dahl JB, et al. Lateral femoral cutaneous nerve block
after total hip arthroplasty: a randomised trial. Acta Anaesthesiol Scand 2016;
60(9):1297–305.
69. Thybo KH, Schmidt H, Hagi-Pedersen D. Effect of lateral femoral cutaneous
nerve-block on pain after total hip arthroplasty: a randomised, blinded,
placebo-controlled trial. BMC Anesthesiol 2016;16:21.
70. Davies A, Crossley A, Harper M, et al. Lateral cutaneous femoral nerve blockade-
limited skin incision coverage in hip arthroplasty. Anaesth Intensive Care 2014;
42(5):625–30.
71. Ueshima H, Otake H, Lin JA. Ultrasound-guided quadratus lumborum block: an
updated review of anatomy and techniques. Biomed Res Int 2017;2017:2752876.
72. Parras T, Blanco R. Randomised trial comparing the transversus abdominis plane
block posterior approach or quadratus lumborum block type I with femoral block
 Regional Analgesia for Hip Surgery Patients 13

for postoperative analgesia in femoral neck fracture, both ultrasound-guided. Rev

Esp Anestesiol Reanim 2016;63(3):141–8.
73. La Colla L, Uskova A, Ben-David B. Single-shot quadratus lumborum block for
postoperative analgesia after minimally invasive hip arthroplasty: a new alterna-
tive to continuous lumbar plexus block? Reg Anesth Pain Med 2017;42(1):125–6.
74. La Colla L, Ben-David B, Merman R. Quadratus lumborum block as an alternative
to lumbar plexus block for hip surgery: a report of 2 cases. A A Case Rep 2017;
8(1):4–6.
75. Hockett MM, Hembrador S, Lee A. Continuous quadratus lumborum block for
postoperative pain in total hip arthroplasty: a case report. A A Case Rep 2016;
7(6):129–31.
76. Wikner M. Unexpected motor weakness following quadratus lomborum block for
gynaecological laparoscopy. Anesthesia 2017;72(2):230–2.
77. Lunn TH, Husted H, Solgaard S, et al. Intraoperative local infiltration analgesia for
early analgesia after total hip arthroplasty: a randomized, double-blind, placebo-
controlled trial. Reg Anesth Pain Med 2011;36(5):424–9.
78. Andersen LO, Kehlet H. Analgesic efficacy of local infiltration analgesia in hip and
knee arthroplasty: a systematic review. Br J Anaesth 2014;113(3):360–74.
79. Johnson RL, Amundson AW, Abdel MP, et al. Continuous posterior lumbar plexus
nerve block versus periarticular injection with ropivacaine or liposomal bupiva-
caine for total hip arthroplasty: a three-arm randomized clinical trial. J Bone Joint
Surg Am 2017;99(21):1836–45.
80. Kuchalik J, Granath B, Ljunggren A, et al. Postoperative pain relief after total hip
arthroplasty: a randomized, double-blind comparison between intrathecal
morphine and local infiltration analgesia. Br J Anaesth 2013;111(5):793–9.
81. Jimenez-Almonte JH, Wyles CC, Wyles SP, et al. Is local infiltration analgesia su-
perior to peripheral nerve blockade for pain management after THA: a network
meta-analysis. Clin Orthop Relat Res 2016;474(2):495–516.
82. Kuchalik J, Magnuson A, Lundin A, et al. Local infiltration analgesia or femoral
nerve block for postoperative pain management in patients undergoing total
hip arthroplasty. A randomized, double-blind study. Scand J Pain 2017;16:
223–30.
83. Joshi GP, Cushner FD, Barrington JW, et al. Techniques for periarticular infiltration
with liposomal bupivacaine for the management of pain after hip and knee arthro-
plasty: a consensus recommendation. J Surg Orthop Adv 2015;24(1):27–35.
84. Ross JA, Greenwood AC, Sasser P 3rd, et al. Periarticular injections in knee and
hip arthroplasty: where and what to inject. J Arthroplasty 2017;32(9s):S77–80.