Postoperative pain following total hip arthroplasty has direct consequences for mobilization, length of stay, and long-term functional recovery. In a cohort of 411 hip fracture patients, Morrison et al. (2003) demonstrated that higher pain scores at rest were independently associated with longer hospital stays, missed or shortened physical therapy sessions, delayed ambulation past a bedside chair, and lower locomotion scores at six months. This evidence base has highlighted the value of regional and local anesthesia strategies for pain management after hip surgery that aim to reduce opioid reliance while preserving motor function and enabling early mobilization.
The PROSPECT guideline for total hip arthroplasty, synthesized from a review of 108 randomized trials and 21 meta-analyses, recommends a single-shot fascia iliaca block or local infiltration analgesia as first-line regional techniques, particularly when contraindications to basic systemic analgesics exist or when high postoperative pain is anticipated.
Although femoral nerve and lumbar plexus blocks are effective at reducing morphine consumption, they are no longer recommended because of their associated motor weakness and fall risk, while epidural analgesia is similarly discouraged—despite its analgesic efficacy—due to limb weakness, bladder dysfunction, and delayed mobilization. Intrathecal morphine 0.1 mg may be considered when spinal anesthesia is used, though the working group notes persistent disagreement among its members regarding its risk-benefit profile, given associations with pruritus, nausea, and delayed ambulation.
Local infiltration has accumulated substantial supportive evidence for being valuable to a targeted non-systemic approach for pain management. Researchers infiltrated ropivacaine, ketorolac, and adrenaline systematically around the surgical field with catheter-based re-injection at 15–20 hours in a case series of 325 hip and knee arthroplasty patients and found satisfactory pain control, independent mobility within 13–22 hours, and same-day-stay discharge in 71% of patients without serious complications related to the technique.
A 2015 systematic review found that local infiltration produced a statistically significant 24-hour morphine-sparing effect of 7.5 mg (95% CI 3.7–11.3) compared with placebo, though this was modest relative to intrathecal opioids (19.8 mg) and non-inferior in magnitude to lumbar plexus block (11.9 mg). However, reductions in pain scores did not reach statistical significance at any timepoint, and the overall quality of evidence was rated low across all intervention categories due to substantial heterogeneity and risk of bias.
Multimodal analgesia strategies also often include non-opioid systemic medication such as paracetamol, NSAIDs, or COX-2 inhibitors. Regional anesthesia in the form of a single-shot fascia iliaca block or local infiltration provides primary analgesia during and after hip surgery, with opioids reserved strictly for rescue, whereas techniques that offer deeper regional blockade also present motor and mobility risks.
References
- Anger, M., Valovska, T., Beloeil, H., Lirk, P., Joshi, G. P., Van de Velde, M., & Raeder, J. (2021). PROSPECT guideline for total hip arthroplasty: A systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia, 76(8), 1082–1097. https://doi.org/10.1111/anae.15498
- Karlsen, A. P. H., Geisler, A., Petersen, P. L., Mathiesen, O., & Dahl, J. B. (2015). Postoperative pain treatment after total hip arthroplasty: A systematic review. Pain, 156(1), 8–30. https://doi.org/10.1016/j.pain.0000000000000003
- Kerr, D. R., & Kohan, L. (2008). Local infiltration analgesia: A technique for the control of acute postoperative pain following knee and hip surgery: A case study of 325 patients. Acta Orthopaedica, 79(2), 174–183. https://doi.org/10.1080/17453670710014950
- Morrison, R. S., Magaziner, J., McLaughlin, M. A., Orosz, G., Silberzweig, S. B., Koval, K. J., & Siu, A. L. (2003). The impact of post-operative pain on outcomes following hip fracture. Pain, 103(3), 303–311. https://doi.org/10.1016/S0304-3959(02)00458-X
