Good News: The Easier, More Efficient Technique for Pain Management Is Equivalent

Optimally managing pain is an important part of enhanced clinical recovery protocols. It is particularly important in primary arthroplasty because these procedures are common, have uniform techniques, and have outpatient and short-stay protocols that need to be facilitated. Perioperative and intraoperative interventions that reduce pain, such as preoperative peripheral nerve blocks and intraoperative periarticular local infiltration, the latter of which is widely used, are critical parts of these protocols and have been shown to be effective. There has been an interest in determining which protocols are best, as reflected in recent randomized studies, systematic literature reviews, editorials, and society-developed clinical practice guidelines1–4. This level of interest suggests that there is controversy regarding which perioperative pain management protocols best reduce postoperative pain and improve clinical outcomes—and where there is controversy, a well-designed randomized controlled trial is valuable. The randomized controlled trial by Li et al. adds to the literature by showing that intraoperative periarticular injections were not inferior to the preoperative block protocol used in the study in terms of opioid consumption on postoperative day (POD) 1. Similarly, there was no difference in most of the secondary outcomes, including opioid consumption on POD 2, Activity Measure for Post-Acute Care scores on PODs 1 to 3, the length of hospital stay, the home discharge rate, and PROMIS Pain, Global Mental Health, and Global Physical Health scores at 3 and 6 months and 1 year postoperatively. This study confirms the effectiveness of the periarticular injection, which is the most common clinically utilized protocol in current practice. The periarticular technique is widely available and takes little additional time, expense, or expertise. From the authors’ description, the fascial plane and peripheral nerve blocks were administered by a specialized, experienced team. The patient needed to be repositioned because a different position was required for each of the 2 blocks. It would be challenging to institute this preoperative block protocol without this type of team. This is especially an issue for wide adoption because of the shortage of anesthesia resources around the U.S. The fascial plane block and peripheral nerve block techniques are more likely than the periarticular injection techniques to be dependent on the skill and experience of the clinician performing the block or injection. This study is limited by its use of a selected sample of patients undergoing primary total hip arthroplasty. The results depend on the drugs and dosages studied. There is evidence to suggest that preoperative blocks decrease the incidence of complications such as deep venous thrombosis, urinary tract infection, and dislocation in the early postoperative period5, and these important outcomes were not assessed in the present study. It is reasonable to conclude that the 2 techniques provide equivalent early postoperative pain control and that this finding applies to most clinical practices. This is a welcome result because the surgeon-administered intraoperative cocktail is easier, is less expensive, and has a much less sophisticated method of drug delivery. The authors suggest that using both blocks and periarticular injections might further enhance the results over the use of each individually, and they state that it is their current practice to use both. This is a reasonable next hypothesis, but most surgeons will want to wait for a similarly rigorous study showing a significant, clinically relevant improvement in postoperative pain before adding preoperative fascial plane and peripheral nerve blocks to intraoperative periarticular injections to assist in multimodal pain management for their patients undergoing primary total hip arthroplasty.