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A Longitudinal Supra-Inguinal Fascia Iliaca Compartment Block Reduces

Morphine Consumption After Total Hip Arthroplasty

Article  in  Regional anesthesia and pain medicine · January 2017

DOI: 10.1097/AAP.0000000000000543

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 REGIONAL ANESTHESIA AND ACUTE PAIN
ORIGINAL ARTICLE
A Longitudinal Supra-Inguinal Fascia Iliaca Compartment
Block Reduces Morphine Consumption After Total
Hip Arthroplasty
Matthias Desmet, MD,* Kris Vermeylen, MD,† Imré Van Herreweghe, MD,‡ Laurence Carlier, MD,‡
Filiep Soetens, MD,† Stijn Lambrecht, PharmD, PhD,§ Kathleen Croes, PharmD, PhD,§
Hans Pottel, PhD,|| and Marc Van de Velde, MD, PhD‡
Background and Objectives: The role of a fascia iliaca compartment
block (FICB) for postoperative analgesia after total hip arthroplasty (THA)
remains questionable. High-dose local anesthetics and a proximal injection
site may be essential for successful analgesia. High-dose local anesthetics
may pose a risk for local anesthetic systemic toxicity. We hypothesized that
a high-dose longitudinal supra-inguinal FICB is safe and decreases postop-
erative morphine consumption after anterior approach THA.
Methods: We conducted a prospective, double blind, randomized con-
trolled trial. Patients scheduled for THA were randomized to group FICB
(longitudinal supra-inguinal FICB with 40-mL ropivacaine 0.5%) or group C
(control, no block). Standard hypothesis tests (t test or Mann-Whitney U test,
χ2 test) were performed to analyze baseline characteristics and outcome
parameters. The primary end point of the study was total morphine (mg)
consumption at 24 hours postoperatively. Serial total and free ropivacaine
serum levels were determined in 10 patients.
Results: After obtaining ethical committee approval and written informed
consent, 88 patients were included. Mean (SD) morphine consumption at
24 hours postoperatively was reduced in group FICB compared to group
C: 10.25 (1.64) mg versus 19.0 (2.4) mg (P = 0.004). Using a mean dose
of 2.6-mg/kg ropivacaine (range, 2–3.4 mg/kg), none of the patients had total
or free ropivacaine levels above the maximum tolerated serum concentration.
Conclusions: We conclude that a high-dose longitudinal supra-
inguinal FICB reduces postoperative morphine requirements after anterior
approach THA.
Clinical Trials Registry: EU Clinical Trials Register. www.clinicaltrialsregister.
eu #2014-002122-12.
(Reg Anesth Pain Med 2017;42: 00–00)
P ostoperative pain after total hip arthroplasty (THA) is often
intense, and immediate postoperative opioid consumption
can be high.1 Unfortunately, opioid-related adverse effects may
From the *Department of Anaesthesia, AZ Groeninge, Kortrijk, Belgium;
†Department of Anaesthesia, AZ Turnhout, Turnhout, Belgium; ‡Department
Cardiovascular Sciences, KU Leuven, Department of Anesthesiology, UZ
Leuven, Leuven, Belgium; §Clinical Laboratory, AZ Groeninge, Kortrijk,
Belgium; and ||Department of Public Health and Primary Care, KU Leuven
Campus Kulak, Kortrijk, Belgium.
Accepted for publication October 5, 2016.
Address correspondence to: Matthias Desmet, MD, AZ Groeninge Hospital,
Loofstraat 43, 8500 Kortrijk, Belgium
(e‐mail: Matthias.Desmet@azgroeninge.be).
The Department of Anesthesiology of the University Hospitals Gasthuisberg,
University of Leuven, provided financial support for this work.
The authors declare no conflict of interest.
This work was presented in part at the 34th Annual ESRA congress
(Ljublijana 2015).
Drs. Matthias Desmet and Kris Vermeylen equally contributed to
this manuscript.
Copyright © 2017 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000543
Regional Anesthesia and Pain Medicine • Volume 42, Number 2, March-April 2017
Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
negatively affect postoperative outcome parameters such as early
mobilization.2 Regional anesthesia techniques reduce postopera-
tive opioid consumption and pain scores leading to higher patient
satisfaction and better outcomes.3
The hip joint is innervated by branches of the femoral nerve
(FN), obturator nerve (ON), and sciatic nerve (SN). The lateral
femoral cutaneous nerve (LFCN) should also be blocked if the
surgical incision extends to the lateral side of the thigh.4 The
FN, ON, and LFCN are all part of the lumbar plexus, implying
that blocking the lumbar plexus is an elegant way to provide post-
operative analgesia for THA. The fascia iliaca compartment block
(FICB) can be regarded as an anterior approach of the lumbar
plexus. A recent study failed to demonstrate the benefit of a “clas-
sic” transverse FICB at the level of the FN for postoperative anal-
gesia after THA.5 Hebbard et al described an ultrasound-guided
longitudinal supra-inguinal approach to the fascia iliaca compart-
ment for THA in which, at least theoretically, a cranial injection
could lead to a higher block success. This approach was success-
fully used in more than 150 patients according to the authors.6 To
our knowledge, there are no prospective randomized controlled
studies on the efficacy of this approach for THA.
The use of higher doses of local anesthetics (LA) increases
the risk of local anesthetic systemic toxicity (LAST). There is
no literature investigating the safety of high-dose LA in a FICB.
To assess the absorption of LA in a high-dose FICB, serial mea-
surements of arterial total and free ropivacaine serum levels can
be determined. We hypothesized that a high-dose longitudinal
supra-inguinal FICB decreases postoperative morphine consump-
tion after anterior approach THA without exceeding maximum
tolerable ropivacaine serum levels.
METHODS
After institutional ethical committee approval (AZG 2014037,
July 7, 2014) and governmental approval (EudraCT 2014-
002122-12), we obtained written informed consent and included
patients presenting for anterior approach THA in a 2-center,
double-blinded, randomized controlled study. The trial was regis-
tered with EU Clinical Trials Register (www.clinicaltrialsregister.
eu, #2014-002122-12).
Exclusion criteria were the following: inability or refusal to
sign informed consent, younger than 18 years, BMI greater than
35 kg/m2, intolerance to any of the drugs used in the study, a history
of hepatic or renal insufficiency, opioid dependency, coagulopathy,
and clinical evidence of peripheral neuropathies. Randomization
was done using a computer-generated random number table to allo-
cate patients to one of the 2 study groups. Group FICB received a
longitudinal supra-inguinal FICB with 40 mL of ropivacaine
0.5%. The control group (group C) received no block.
In the holding area, an investigator masked to group alloca-
tion performed a sensory assessment of the FN, ON, and LFCN,
1
Desmet et al Regional Anesthesia and Pain Medicine • Volume 42, Number 2, March-April 2017

using response to pinprick in the anterior, medial, and lateral as-
pects of the thigh. Motor function of the FN and ON was tested
using the method described by Neal.7 Briefly, to test FN motor
function, the investigator supported the knee under the popliteal
fossa, and the patient was asked to extend the knee against resis-
tance. To test motor function of the ON, the leg was abducted
and the patient was asked to adduct the leg toward the midline.
After induction of general anesthesia with propofol (2 mg/kg),
sufentanil (0.1–0.2 μg/kg) and cisatracurium (0.2 mg/kg), a sealed
envelope with group allocation was opened by a team member not
involved with data collection. In group FICB, an ultrasound-
guided longitudinal supra-inguinal FICB was performed. A linear
6- to 18-MHz ultrasound probe (HF Linear Array 8870; BK Ultra-
sound, Peabody, Massachusetts) was placed in the sagittal plane to
obtain an image of the anterior superior iliac spine. The fascia
iliaca and sartorius, iliopsoas, and oblique internal muscles were
identified by sliding the probe medially (Fig. 1A). After identify-
ing the “bow-tie sign” formed by the muscle fascias, an 80-mm
needle needle (22 G, Stimuplex Ultra 360; B. Braun Melsungen
AG, Germany) was introduced 1 cm cephalad to the inguinal lig-
ament (IL). Using an in-plane approach, the fascia iliaca was pen-
etrated and hydrodissected, separating the fascia iliaca from the
iliac muscle (Fig. 2A). In this created space, the needle was further
advanced in a cranial and slightly dorsal direction. As the deep
circumflex artery is superficial to the fascia iliaca, upward move-
ment of this artery upon injection, was used as a marker of
succesful penetration of the fascia iliaca (Fig. 2C). A total vol-
ume of 40 mL of ropivacaine 0.5% was injected. An injection
was considered succesful if spread of LA was observed cranial
to the point where the iliac muscle dives under the abdominal
muscles (Fig. 1D). If unsatisfying spread was obtained, the
injection was stopped and the needle was repositioned until ade-
quate spread was obtained. In the control group, no block was
performed. All blocks were performed by experienced anesthesi-
ologists otherwise not involved in the study.
We slightly modified the technique as described by
Hebbard et al. Hebbard et al introduce the needle 2 to 3 cm infe-
rior to the IL, whereas we penetrate the skin 1 to 2 cm superior to
the IL. With a more superior approach, the needle is more per-
pendicular to the fascia iliaca, increasing the tactile experience
of the “loss of resistance” once the fascia iliaca is pierced. The-
oretically, there is a risk of perforation of the abdominal cavity
and organs, but with the use of ultrasound, the abdominal content
can be visualized and perforation can be avoided.
Anesthesia was maintained with sevoflurane (1–1.5 mini-
mum alveolar concentration) in an oxygen/air admixture. To keep
heart rate and blood pressure within 20% of preoperative values,
bolus doses of 5-μg intravenous (IV) sufentanil were given. At
the end of surgery, all patients received 1 g of IV paracetamol
and 75 mg of IV diclofenac. In each center, a single surgeon
performed all THAs via an anterior approach.
For postoperative analgesia, patients received paracetamol
(1 g IV every 6 hours) and diclofenac (75 mg IV every 12 hours).
A patient-controlled IV analgesia system (PCIA) with morphine
sulphate (bolus only mode, bolus 1.5 mg, lockout 6 minutes, max-
imal dose 20 mg/4 hours) was started on arrival in the recovery
room. In case of insufficient analgesia, IV morphine was be ad-
ministered by the postanaesthesia recovery unit nurse or by the re-
sponsible physician. Nausea and vomiting were assessed and
treated with alizapride (50 mg IVevery 12 hours) and ondansetron
(4 mg IV every 12 hours). In the postanaesthesia recovery unit,
both cardiovascular (eg, arrhythmias, hypotension, hypertension,

FIGURE 1. Ultrasound images of a longitudinal supra-inguinal FICB. A, Ultrasound image with identification of relevant structures for FICB.
White arrows: fascia iliaca; *bow-tie sign. B, In-plane needle introduction with proximal end of the needle under the fascia iliaca. White
arrows: fascia iliaca; *needle. C, Start of injection of LA under the fascia iliaca; note the superficial position of the deep circumflex artery to the
fascia iliaca. White arrows: LA spreading under the fascia iliaca; *deep circumflex artery. D, Ultrasound image after injecion of 40 mL of LA
with adequate cranial spread of LA; *LA. ASIS, anterior superior iliac spine; IM, iliac muscle; IOM, internal oblique muscle; SM, sartorius muscle.

2 © 2017 American Society of Regional Anesthesia and Pain Medicine

Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 42, Number 2, March-April 2017
FIGURE 2. Consolidated Standards of Reporting Trials flow diagram of participant recruitment.
dyspnea, ST changes) and neurological signs (eg, dizzines,
perioral paresthesia, agitation, loss of consciousness, and con-
vulsions) of LAST were recorded.8
At 1, 6, and 24 hours postoperatively, an independent inves-
tigator evaluated the sensory block and motor block in the differ-
ent nerve territories in all patients. Pain scores at rest were
obtained at 1, 2, 4, 6, 12, 24, and 48 hours after surgery using a
visual analog scale for pain where 0 mm corresponds to no pain
and 100 mm to the worst pain imaginable.
Serum Ropivacaine Measurements
In 10 randomly selected patients receiving a FICB, we mea-
sured arterial free and total serum ropivacaine concentrations.
Blood samples were collected at 15, 30, 45, 60, 90, 120, and
180 minutes after completion of the FICB in a dry serum tube
without clotting activator (BD, New Jersey, USA). Samples were
centrifuged, and the serum was frozen at −20°C until assayed.
Total ropivacaine levels were determined using a validated
liquid chromatography mass spectrometry method. Briefly,
100 μL of serum was mixed with borate buffer (pH 8.8) and
ropivacaine-D7 (LGC Standards, Wesel, Germany) as internal
standard. The mixture was extracted with diethylether. After evap-
oration of the solvent phase, the residue was reconstituted in initial
mobile phase followed by injection on an XBridge C18 column
(Waters, Milford, Massachusetts). The mobile phase consisted
of a linear gradient mixture of water and methanol with 0.1%
formic acid. A triple quadrupole mass spectrometer (Quattro
Premier; Waters) was operated in positive ionization mode, and
a selective multiple reaction monitoring method was applied.
The limit of quantification was determined at 0.001 mg/L. A lin-
ear signal was obtained within a concentration range from 0.001
to 10 mg/L.
The proportion of unbound ropivacaine was determined by
equilibrium dialysis using rapid equilibrium dialysis RED devices
(ThermoScientific, Rockford, Illinois) with an 8-K molecular
weight cutoff.9 Sample and buffer chamber of the device were
© 2017 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Fascia Iliaca Compartment Block for THA
filled with 300 μL of patient serum and 500 μL of phosphate-
buffered saline (pH 7.4; Sigma-Aldrich, Saint Louis, Missouri) re-
spectively, according to the specifications of the manufacturer.
Equilibration was performed in an Eppendorf Thermomixer at
37°C with shaking at 300 rpm for 8 hours. After equilibration,
an aliquot of the buffer and serum compartment was assayed
for ropivacaine concentration as previously described. The
concentration of free ropivacaine was calculated as: [(Concen-
tration in Buffer Compartment) / (Concentration in Serum
Compartment)]  Total Concentration.
Statistical Analysis
The primary end point of the study was the total morphine
consumption (mg) at 24 hours postoperatively. Secondary out-
come parameters were the following: total morphine consump-
tion (mg) at 48 hours, block success defined as sensory and
motor block in the territories of the LFCN, FN, and ON, visual
analog scale for pain scores, signs and symptoms of LAST,
and ropivacaine serum levels.
We performed a sample size calculation where a 50% reduc-
tion of morphine use during the first 24 hours was considered clin-
ically relevant. Based on previous, unpublished data from our
institutions (mean [SD] of 20 [15] mg of morphine), 37 patients
per group were needed to reach 80% power with an α of 0.05,
using a 2-sided 2-sample t test. To correct for possible dropouts,
44 patients per group were included.
Data are presented as means (SD) in case of normally distrib-
uted data or medians [range] otherwise. Standard hypothesis tests
(2-sided t test or Mann-Whitney U test) were performed to analyze
baseline characteristics and outcome parameters. In case of multi-
ple testing, repeated -measures analysis of variance with post hoc
Tukey-Kramer correction was applied. Categorical data were
assessed using frequency tables and χ2 or Fisher exact test. A gen-
eral linearized model was developed to assess the effect of other
variables on morphine consumption. The primary hypothesis
was performed at 5% significance level.
3
Desmet et al Regional Anesthesia and Pain Medicine • Volume 42, Number 2, March-April 2017
TABLE 1. Baseline Characteristics per Group
Group C Group FICB P
Age, years 66.5 (12.4) 60.4 (10.8) 0.02
Sex, M/F 14/29 19/23 0.27
BMI 27.3 (4.5) 27.3 (4.0) 0.96
Peroperative sufentanil use, μg/kg 0.21 (0.06) 0.20 (0.06) 0.51
Values are presented as mean (SD) or proportions.
BMI indicates body mass index; F, female; M, male.
Statistical analysis was performed using Statistica version 12
(Statsoft Inc, Tulsa, Oklahoma).
RESULTS
From August 2014 until June 2015, 127 patients presented
for anterior approach THA, and 88 were included in the study.
Figure 2 presents the allocation process according to the Consol-
idated Standards of Reporting Trials (CONSORT). In 2 patients,
one in each study group, the PCIA pump was stopped during
the study period because of paravenous infusion of morphine.
One patient (group FICB) developed delirium leading to an unre-
liable assessment of primary and secondary outcome parameters.
Table 1 presents baseline characteristics of the patients.
In all patients of group FICB, a longitudinal supra-inguinal
FICB was performed. In 38% of the patients, the demarcation be-
tween fascia iliaca and underlying muscle was considered unclear
by the performing anesthesiologist. However, after injection of
2 mL of LA, only in 4 of 42 patients was needle repositioning nec-
essary to avoid a too superficial or intramuscular injection and to
obtain appropriate spread.
Mean (SD) morphine consumption at 24 hours postopera-
tively was significantly reduced in group FICB compared to group
C: 10.25 (1.64) mg versus 19.0 (2.4) mg (P = 0.004). At 48 hours,
there was also a significant reduction in morphine consumption
between group FICB and group C: 12.66 (2.4) mg and 22.88
(2.8) mg, respectively (P = 0.005) (Fig. 3). The generalized linear
model retained only group allocation (P = 0.005) and sex
(P = 0.04) as significant predictors of morphine consumption.
Pain scores at different time points are presented in Figure 4.
After Tukey-Kramer correction for multiple testing, there was a
statistically significant reduction in pain scores at 1, 2, 4, and
24 hours postoperatively (P = 0.0012, P = 0.0051, and
FIGURE 3. Morphine consumption (mg) at 24 hours (A) and at 48 hours (B) postoperatively. Individual patients (▲); mean (■); whiskers, 95%
confidence interval.
4 © 2017 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
P = 0.0357, respectively). There was no significant reduction in
pain scores at 6, 12, and 48 hours postoperatively.
No sensory deficits were discovered on preoperative exami-
nation of the patients. Three patients of group C and 2 patients
of group FICB had a mild preoperative motor deficit of the FN.
One patient of group C had a mild preoperative motor deficit of
the ON. Sensory and motor block characteristics for the different
nerve categories, at different time points, are presented in
Table 2. Sixty-nine percent of all patients in group FICB had both
a sensory and motor block of all 3 nerves.
Figure 5 presents the pattern of free arterial serum ropivacaine
levels over time for all patients. The mean (SD) peak arterial
serum levels (Cmax) were 1.25 (0.79–1.62) mg/L and 0.036
(0.004–0.07) mg/L for total and free serum levels, respectively.
Time to reach Cmax was 45 minutes after performance of the FICB
for both total and free serum levels of ropivacaine. None of the pa-
tients had symptoms of LAST during the time of the study.
In group C, 17 patients (20%) experienced at least one
episode of postoperative nausea and vomiting compared to
5 patients (6%) in group FICB (P = 0.006).
DISCUSSION
The present study demonstrates that a supra-inguinal longitu-
dinal FICB reduces morphine consumption after THA. On aver-
age, there is a reduction in morphine consumption of 46% after
24 hours and of 45% after 48 hours. Concomitantly, there was a
3-fold reduction of nausea and vomiting in group FICB compared
with group C. There was a reduction in pain scores in the first
4 hours postoperatively and at 24 hours postoperatively. The re-
duction in pain scores was the highest in the first postoperative
hour. In this study, the patients were able to control their analgesic
need with the use of a PCIA. Therefore, the reduction in pain
scores decreased with time as patients used the PCIA whenever
they required additional analgesia.
Our study is in contrast with the results of Shariat et al5 who
failed to demonstrate a reduction of morphine consumption or
pain intensity. Multiple mechanisms explain this difference. In
contrast to Shariat et al, we used a longitudinal supra-inguinal ap-
proach as opposed to a “transverse” approach. In a recent study,
the spread of LA after a transverse FICB was assessed using clin-
ical evaluation and magnetic resonance imaging. Although the FN
and LFCN were consistently blocked, there was no decrease in ad-
ductor strength indicating no block of the ON. Extension of LA
toward the ON was not observed on the magnetic resonance im-
ages.10 This is in line with the results of Shariat et al, where the
Regional Anesthesia and Pain Medicine • Volume 42, Number 2, March-April 2017 Fascia Iliaca Compartment Block for THA

FIGURE 4. Mean VAS for pain scores (mm) at different postoperative time points. Black bars, group FICB; gray bars, group C; *P < 0.05; §,
nonsignificant.

ON was only blocked in 25% of the patients, and only in 2 of
16 patients were all 3 nerves (LFCN, FN, ON) blocked.5 These
studies suggest that a transverse FICB is a suboptimal approach
of the lumbar plexus.
We used a longitudinal supra-inguinal FICB. This approach
leads to a more proximal deposition of LA. As such, we might ex-
pect a more consistent block of the targeted nerves, as they are to-
pographically more closely related in their proximal course.11 The
results of our study confirm our hypothesis: the ON was blocked
in 86% of the patients, and all 3 nerves were blocked in 67% of the
patients. We also used a higher volume of LA (40 mL vs 30 mL)
than Shariat et al used. As the FICB is a field block, volume is
essential for its success.
Finally, Shariat et al performed a FICB after surgery in pa-
tients who experienced pain scores higher than 30 mm despite ad-
ministration of PCIA with morphine; whereas in this study, the
FICB was performed before incision.
Local anesthetic systemic toxicity can occur owing to inad-
vertent intravascular injection or owing to rapid absorption of
LA. Ultrasound guidance can reduce the risk of intravascular in-
jection, but the high volumes of LA injected during FICB could
potentially lead to LAST due to absorption. Absorption of LA is
highly dependent on tissue vascularization; therefore, injection
site is an important predictor for LAST.12 Knudsen et al stud-
ied the maximum tolerated ropivacaine levels at which central
nervous system signs and changes in cardiac electrophysiology
and echocardiography in healthy adult volunteers occurred during
IV infusion of ropivacaine. The maximum tolerated plasma
concentrations in arterial blood were 4.3 mg/L for total and
0.56 mg/L for free fractions of ropivacaine.13 In our study, with
a mean dose of 2.6 mg/kg ropivacaine (range, 2–3.4 mg/kg), no
patient had a total or free ropivacaine concentration greater than
the maximum tolerated serum concentration, as determined by
Knudsen et al.13 Although reassuring, we are aware that with
only 10 patients studied, the safety of a longitudinal supra-
inguinal FICB with 40-mL ropivacaine 0.5% is not settled.
We acknowledge that our study has some limitations. First,
our study may be prone to bias. Although blinding of patients
was ensured by the randomization process and study protocol,
the characteristics of a FICB, with a unilateral sensory and motor
block, made it possible for patients to identify whether or not they
received an FICB. The assessment of the sensory and motor block
is, as all clinical assessments, prone to investigator bias. To mini-
mize bias, the same investigator, unaware of study randomization,
performed both the preoperative and postoperative assessments.
For practical reasons, we could not use objective measurements

TABLE 2. Sensory and Motor Block per Group for the Different Nerve Territories

Sensory Block
Femoral Nerve Obturator Nerve Lateral Femoral Cutaneous Nerve
Group FICB Group Control Group FICB Group Control Group FICB Group Control
1 hour postoperatively 39/42 (93%) 2/43 (4.7%) 32/42 (76%) 1/43 (2.3%) 40/42 (95%) 3/43 (7%)
6 hours postoperatively 34/42 (81%) 0/43 (0%) 26/42 (62%) 0/43 (0%) 38/42 (90%) 2/43 (4.7%)
24 hours postoperatively 16/42 (38%) 0/43 (0%) 10/42 (24%) 0/43 (0%) 21/42 (50%) 4/43 (9%)
Motor Block
Femoral Nerve Obturator Nerve Lateral Femoral Cutaneous Nerve
Group FICB Group Control Group FICB Group Control NA
1 hour postoperatively 37/42 (88%) 16/43 (37.2%) 36/42 (86%) 18/43 (41.9%) NA
6 hours postoperatively 31/42 (74%) 7/43 (16.3%) 30/42 (71%) 10/43 (23.3%) NA
24 hours postoperatively 8/42 (19%) 2/43 (4.7%) 13/42 (31%) 2/43 (4.7%) NA

© 2017 American Society of Regional Anesthesia and Pain Medicine 5

Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Desmet et al Regional Anesthesia and Pain Medicine • Volume 42, Number 2, March-April 2017
FIGURE 5. Mean total (A) and free (B) serum ropivacaine concentrations at different time points. (●) Mean values, (○) values for individual
patients.
of muscle strength and relied on a clinical assessment similar to
what others described in the literature.14
The assessment of ON block is difficult, as there is an incon-
sistent cutaneous distribution of the ON.15 We therefore relied on
evaluation of motor function. However, postoperative evaluation
of motor function is often difficult. Motor function can be
inhibited by postoperative pain causing early involuntary, antalgic
motor weakness or transient nerve palsy caused by improper
placement of surgical retractors or traction injury during surgery.
16
Indeed, 1 hour postoperatively, there was a high incidence of
motor block for both the ON and the FN in the control group. This
motor block regressed rapidly in contrast to the FICB group. As
such, one can argue that postoperatively reduced adductor and
quadriceps strength were not entirely caused by the FICB. None
of the patients experienced a fall during the study period. Al-
though falls after peripheral nerve block (PNB) have been de-
scribed, a recent meta-analysis including more than 1 million
patients demonstrates that the risk of falls is comparable in pa-
tients receiving a PNB compared to those who did not received
a PNB.17
Second, we did not investigate pain scores at mobilization.
Pain scores were collected on predetermined postoperative times.
Therefore, we anticipated that in many patients, data collection
would occur at night. To minimize patient inconvenience, we de-
cided not to test pain at mobilization.
Third, we did not attempt to evaluate length of stay, patient
satisfaction, or quality of recovery, all important outcome param-
eters to evaluate the efficacy of a patient-centered perioperative
care program. This is, as far as we know, the first study that inves-
tigates the effect of a longitudinal supra-inguinal FICB in THA
patients. With the disappointing results of other anterior ap-
proaches of the lumbar plexus in mind, we decided first to evalu-
ate the efficacy of this new approach. We therefore see this study
as a “proof of concept” of the ability of a longitudinal supra-
inguinal FICB to block the nerves of the lumbar plexus (FN, LFCN,
ON) and reduce morphine consumption and pain scores.
Finally, questions can be raised about the applicability of the
anesthetic and surgical protocol. The optimal anesthetic protocol
for THA remains a question of debate. Whereas some meta-
analysis demonstrated a benefit with the use of neuraxial tech-
niques, others could not.18,19 General anesthesia is still widely
used for THA. In a recent article, Memtsoudis et al20 demonstrated
6 © 2017 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
that in a sample of 124,993 patients, general anesthesia was used in
78%. This indicates that our study protocol, although not “progres-
sive,” does reflect clinical practice. We do acknowledge that a dif-
ferent anesthesia protocol could have led to different results. To
establish the role of a longitudinal supra-inguinal FICB in combina-
tion with spinal anesthesia or other analgesic protocols (eg, local in-
filtration analgesia), more research is needed. Furthermore, one can
argue if the observed reduction of pain scores and morphine con-
sumption justifies the use of a longitudinal supra-inguinal FICB.
The use of a multimodal analgesia protocol including paracetamol
and nonsteroidal anti-inflammatory drugs might have reduced the
effect of a FICB. However, for patients in which the use of a multi-
modal analgesia protocol is contraindicated, the FICB may be con-
sidered as a valuable alternative.
Our study was performed in patients with anterior approach
THA. This is an internervous and intermuscular approach acceler-
ating postsurgical recovery. In a recent meta-analysis, the anterior
approach led to a shorter length of stay, a higher likelihood of dis-
charge to home and less narcotic requirements postoperatively.21
However, only one study investigated short-term (48 hours) pain
scores and narcotic consumption between the anterior and poste-
rior approach for THA. As no difference was observed, we cur-
rently cannot conclude that anterior approach THA is less
painful in the immediate postoperative period.22 Whether or
not the results of our study are valid for other types of hip sur-
gery, for example, posterior approach THA, hip arthroscopy or
hip fracture surgery is a subject of further research.
CONCLUSIONS
A longitudinal supra-inguinal FICB for THA significantly
decreases morphine consumption at 24 and 48 hours. Maximum
tolerated ropivacaine levels were not exceeded using 40-mL
ropivacaine 0.5%. We conclude that the longitudinal supra-
inguinal FICB reduces analgesic requirements after THA.
ACKNOWLEDGMENTS
The authors thank Luk Verhelst, Jacobus Roos, Marc Reynvoet,
and Sabine Plasschaert for patient recruitment and care for
study patients.
 Regional Anesthesia and Pain Medicine • Volume 42, Number 2, March-April 2017
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