Year : 2014 | Volume
| Issue : 3 | Page : 355-358
Hip hemiarthroplasty using major lower limb nerve blocks: A preliminary report of a case series
Ahmad Muhammad Taha, Mohammed Abd-Elfttah Ghoneim
Department of Anesthesia, Ain Shams University, Abbasia, Cairo, Egypt
Dr. Ahmad Muhammad Taha
ADK, Elsaif Tower, Electra St., Abu Dhabi, UAE
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||11-Jul-2014|
Background: Major lower limb nerve blocks are relatively safe techniques. However, their efficacy for hip hemiarthroplasty is unknown. The objective of this study was to determine the effectiveness of combined femoral, sciatic, obturator and lateral femoral cutaneous (LFC) nerve blocks in providing adequate anesthesia for hip hemiarthroplasty. Materials and Methods: A total of 20 patients with fracture neck femur; who underwent hip hemiarthroplasty, participated in this observational study. In the induction room, all patients received ultrasound-guided femoral, proximal obturator, LFC and parasacral sciatic nerve blocks in addition to local infiltration at the proximal site of the skin incision. Anesthesia was considered to be adequate only if the surgery was completed without any requirement for opioid administration. Results: All patients (100% [95% confidence interval, 86-100%]) had adequate anesthesia. Seventeen patients (85% [95% confidence interval, 63-96%] had mild discomfort during the reduction of the prosthetic femur head back into the hip socket; however, no supplementary analgesics were required. Conclusion: The combined femoral, sciatic, obturator and LFC nerve blocks in addition to local infiltration at the proximal site of skin incision could provide adequate anesthesia for hip hemiarthroplasty. Light sedation before reduction of the prosthetic femur head back into the hip socket is advisable.
Keywords: Anesthetics local, anesthetic techniques, bupivacaine, equipment, femoral, regional, ultrasound machines
|How to cite this article:|
Taha AM, Ghoneim MA. Hip hemiarthroplasty using major lower limb nerve blocks: A preliminary report of a case series. Saudi J Anaesth 2014;8:355-8
|How to cite this URL:|
Taha AM, Ghoneim MA. Hip hemiarthroplasty using major lower limb nerve blocks: A preliminary report of a case series. Saudi J Anaesth [serial online] 2014 [cited 2022 Jan 16];8:355-8. Available from: https://www.saudija.org/text.asp?2014/8/3/355/136432
| Introduction|| |
Fracture neck femur is the most common fracture in geriatric patients and is associated with a high mortality rate. It usually requires surgical femur head replacement (hip hemiarthroplasty) which if delayed, the mortality rate may further increase. ,, Many geriatric patients have numerous coexisting diseases and may not tolerate general or neuraxial anesthesia. ,, Peripheral nerve block of the lower limb is a safe technique.  Combined psoas compartment and sciatic nerve block can provide adequate anesthesia for hip surgeries ,, and may lower the mortality rate.  The femoral nerve block has lower incidence of complications compared with the posas compartment block;  however, its efficacy in hip hemiarthroplasty is unknown. The objective of this study was to determine the effectiveness of combined femoral, sciatic, obturator and lateral femoral cutaneous (LFC) nerve blocks in providing adequate anesthesia for hip hemiarthroplasty.
| Methods|| |
This observational study was approved by the Research Ethics Committee of Ain Shams University, Cairo, Egypt (Ethical Committee No. 1113/2012). After obtaining the patients' written informed consent, 20 patients formed the study group. All patients had pathological fracture neck femur and were scheduled for a hip hemiarthroplasty using the lateral hip approach.  Patients with high risk (American Society of Anesthesiologists physical status class III or more), known allergy to the used local anesthetics (LA), had an infection at the site of the needle insertion or had communication difficulties (hearing problems, cognitive dysfunction) were excluded.
In a well-equipped induction room; after application of routine monitoring and supplemental oxygen, all patients received midazolam 2 mg intravenously. Other hemodynamic monitors were placed when indicated. Fifty milliliters of LA mixture consisting of bupivacaine 0.25%, lidocaine 0.5% and epinephrine (1:200,000) were prepared. All blocks were performed by one experienced Anesthetist using an A6 ultrasound (US) machine (SonoScape, Shenzhen, China). Skin asepsis and sterile draping were performed and the US probes were sheathed.
The femoral, obturator and LFC nerve blocks were performed at the level of the inguinal crease using a linear probe (L745, 11.5-5 MHz) and 21G 5-cm needles (Locoplex, Vygon, Ecouen, France). For the femoral nerve block, the femoral artery and nerve were identified and then 13 mL of LA mixture was injected circumferentially perineural.  The LFC nerve was identified at the lateral border of sartorius muscle and 2 mL of LA mixture was injected close to the nerve  For the proximal obturator nerve block, 10 mL of LA mixture was injected interfascially between the pectineus and obturator externus muscles.  Patient was placed in Sim's position. The already performed femoral nerve block provided analgesia for the fracture site minimizing the patient discomfort during Sim's positioning. The sciatic nerve was then blocked at the parasacral area  using a curved probe (C351, 6-2 MHz) and a 20G 12-cm insulated needle. The sciatic nerve was identified deep and medial to the posterior border of ischium. After electrical confirmation, 25 mL of LA mixture was slowly injected. Complete inability to extend the knee, flex the foot (in the planter and dorsal directions), adduct the hip and recognize pinprick sensation at the lateral aspect of the thigh were considered as successful femoral, sciatic, obturator and LFC nerve blocks, respectively.  One femoral and one sciatic nerve blocks required supplementation. After successful blocks of all nerves were confirmed, the patient was positioned for surgery and 10-15 mL of lidocaine 0.5% with epinephrine was infiltrated beneath the proximal part of the skin incision.
Intraoperative pain was assessed using the visual analog scale (VAS); 0 = pain free and 10 = worst imaginable pain. A VAS up to 3 was considered as discomfort and was managed with midazolam injection. A VAS more than 3 was considered as pain. Patients who experienced pain (VAS > 3) at any time during the surgery were considered to have inadequate anesthesia and received opioid supplementation or general anesthesia. Patients who completed the surgery without any requirement for opioid administration (VAS ≤ 3 throughout the surgery) were considered to have adequate anesthesia. Adequacy of anesthesia, intraoperative pain with its causative surgical maneuver, opioid requirement and any complication were recorded. All patients were neurologically assessed before hospital discharge and also during the surgical visits for 3 weeks postoperatively. All measurements were assessed by an assistant.
Quantitative and qualitative variables were presented as mean (standard deviation) and frequency (% [95% confidence interval]), respectively. The 95% confidence interval was calculated using adjusted Wald method. 
| Results|| |
In the study, 20 patients participated [Table 1] and all patients (100% (86-100%)) were pain free (VAS = 0) throughout the surgery; except during the reduction of the prosthetic femur head back into the hip socket where 17 patients (85% (63-96%)) had discomfort (VAS ≤ 3). Anesthesia was considered to be adequate in all patients, as no opioids were required. Transient decrease of the mean blood pressure (more than 20% of its basal value) occurred in two patients (10% [2-31%]) and was treated with fluid infusion (no vasoconstrictors was needed). No other complications were recorded.
| Discussion|| |
The combined femoral, obturator, sciatic and LFC nerve blocks in addition to local skin infiltration at the site of skin incision provided a reliable anesthesia for hip hemiarthroplasty.
Fracture neck femur is the most common fracture in geriatric patients. ,, It is an intra-capsular fracture. The disruption of retinacular vessels markedly impairs its healing; therefore surgical femur head replacement (hip hemiarthroplasty) is usually required. Many geriatric patients have a deteriorated systems' functions; especially the cardiovascular functions and they may not tolerate the heomodynamic instability associated with general or neuraxial anesthesia. ,, Lower limb nerve blocks are relatively safe techniques.  They do not significantly impair the cardiac or respiratory functions (except with LA toxicity or epidural spread). Femoral nerve block was found to provide effective postoperative hip analgesia comparable to that of the psoas compartment block.  However; its ability to provide painless hip surgery is unknown.
An understanding of the surgical technique and regional anatomy is important to provide an effective nerve block anesthesia  when the lateral hip approach  is used, the skin and fasciae (illiotibial tract) are incised at the lateral aspects of the thigh, proximal and distal to the greater trochanter. The gluteus medius and minimus muscles are then split to expose the hip capsule which is incised to open the hip joint. Incomplete anesthesia of the joint, muscles or skin will result in a painful surgery.
The hip joint is supplied , by the femoral nerve (via its branch to the rectus femoris), the obturator nerve (via its hip branches) and sacral plexus (via the articular branches of nerve to quadrates femoris, superior gluteal and sciatic nerves). Fortunately, all these nerves can be blocked at the inguinal and parasacral regions. ,,, The femoral nerve block can block its branch to rectus femoris. A proximal block of the obturator nerve, between the pectineus and obturator externus muscles, can block its hip branch.  The parasacral sciatic nerve block can block the entire sacral plexus  Successful blocks of the above nerves anesthetize the entire lower limb (including all hip muscles) with exception of some skin areas and the iliopsoas muscle (innervated at the abdomen).  The skin area at the distal part of the incision is supplied by the LFC nerve,  which can be easily blocked sonographically.  However; the skin area at the proximal part is supplied by subcostal and illiohypogastric nerves, therefore, LFC nerve block, or even psoas compartment block, cannot anesthetize this skin area. , However, this was easily rectified with subcutaneous LA infiltration. The iliopsoas muscle is not dissected during the surgery; however, it is stretched during the distal traction of the femur to reduce the prosthetic femur head back into the hip socket. This may explain the associated discomfort. However, this maneuver takes a few seconds and could be managed by light sedation.
Psoas compartment block, when combined with the sciatic nerve block and skin infiltration, can provide a reliable anesthesia for hip surgery.  However risks related to psoas compartment block, unlike the femoral nerve block, are quite numerous and severe.  Epidural spread is the most frequent complication of psoas compartment block (up to 40%) and may cause significant hemodynamic instability in fragile patients. ,, Lumbar hematoma is not uncommon and may be a serious complication especially in patients with hip surgery receiving perioperative anticoagulant therapy.  In a case report,  hip hemiarthroplasty was performed under anterior lumber plexus block (3 in 1) and ketamine IV in addition to LA infiltration of unanesthetized tissues. In extremely risky patients, the hip hemiarthroplasty was performed using only LA infiltration in different surgical tissue plans. 
Regardless of the type of anesthesia, pre-operative evaluation of patient's coexisting diseases and optimization of these (as possible) is important. ,, Combination of nerve blocks requires large doses of LA, therefore risk of toxicity must be always considered. When available, the less toxic levorotatory enantiomers LA should be used. The current blocks still cause sympathectomy of the ipsilateral limb. Careful monitoring of the hemodynamics and other perioperative risks (excessive bleeding, cement related complications, deep venous thrombosis or pulmonary embolism) is essential. ,, No complications were recorded in the current study. However, high risk patients were not included and also the sample size was not sufficient to confirm safety of the technique. The current results may be also limited to the used approaches. Distal block approaches of the sciatic nerve do not block the sacral plexus. Similarly; distal block approaches of the obturator nerve may not block its hip branch; being the most proximal branch of the obturator nerve.  The accessory obturator nerve, if it exists, gives off its hip branches deep to the pectineus muscle.  The ability of proximal obturatoar nerve block technique to block this nerve is uncertain.
Despite conducting a nerve block anesthesia consuming more time compared with other alternatives, the ability to perform nerve blocks in the induction room optimizes the operating room time. The current nerve blocks could, theoretically, provide adequate anesthesia for surgical management of all types of hip fractures (including dynamic hip screw). However, during this surgery the traction applied on the contra-lateral unanesthetized limb necessitates the addition of continuous intraoperative sedation.
This is a small case series in relatively fit patients. Having established the adequacy of the describes technique to provide anesthesia for hip hemiarthroplasty, further randomized controlled trials to compare this technique with the standard spinal anesthesia (regarding the time required, complication and post-operative rehabilitation) are needed.
| Conclusion|| |
The combined femoral, sciatic, obturator and LFC nerve blocks in addition to local infiltration at the proximal site of skin incision could provide adequate anesthesia for hip hemiarthroplasty. Light sedation before reduction of the prosthetic femur head back into the hip socket is advisable.
| Acknowledgement|| |
I would like to express my sincere thanks to Dr Ahmed Desouki (lecturer of anatomy), Professor Dr Ahmed Kattab (professor of anesthesia), Dr Ahmed Abd Elmaksood (lecturer of anesthesia), Dr Manjusha Mohan and all the staff of anesthesia and orthopedic departments of Ain Shams University for their great support
| References|| |
|1.||Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, et al. Effect of early surgery after hip fracture on mortality and complications: Systematic review and meta-analysis. CMAJ 2010;182:1609-16. |
|2.||Mitchell ME. Regional anesthesia for hip surgery. Tech Reg Anesth Pain Manag 1999;3:94-106. |
|3.||Covert CR, Fox GS. Anesthesia for hip surgery in the elderly. Can J Anaesth 1989;36:311-9. |
|4.||Lim W, Kennedy N. Hemi-arthroplasty of the hip under triple nerve block. Anaesth Intensive Care 1994;22:722-3. |
|5.||Sher D, Biant LC. Subcapital fracture of the femoral neck in medically unwell patients: Technique for fixation using direct infiltration local anaesthetic rather than regional blockade. Injury 2007;38:1209-13. |
|6.||Al-Haddad MF, Coventry DM. Major nerve blocks of the lower limb. Br J Anesth CEPD Rev 2003;3:102-5. |
|7.||de Leeuw MA, Zuurmond WW, Perez RS. The psoas compartment block for hip surgery: The past, present, and future. Anesthesiol Res Pract 2011;2011:159541. |
|8.||De Tran QH, Clemente A, Finlayson RJ. A review of approaches and techniques for lower extremity nerve blocks. Can J Anaesth 2007;54:922-34. |
|9.||Eyrolle L, Zetlaoui P, Belbachir A, Rosencher N, Conseiller C. Regional anesthesia for femoral neck fracture surgery: Comparison of lumbar plexus block and spinal anesthesia. Br J Anaesth 1998;80:A383. |
|10.||Karaca S, Ayhan E, Kesmezacar H, Uysal O. Hip fracture mortality: Is it affected by anesthesia techniques? Anesthesiol Res Pract 2012;2012:708754. |
|11.||Capdevila X, Coimbra C, Choquet O. Approaches to the lumbar plexus: Success, risks, and outcome. Reg Anesth Pain Med 2005;30:150-62. |
|12.||Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg Br 1982;64:17-9. |
|13.||Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anesthesia. Br J Anaesth 2005;94:7-17. |
|14.||Fondi MA, Nava S, Posteraro CM, Vigorita I, Alessandri F, Dauri P. Peripheral nerve block: Lateral femoral cutaneous nerve (LFCN): In vivo anatomical study and ultrasound (us) imaging. Reg Anesth Pain Med 2008;33:101. |
|15.||Taha AM. Brief reports: Ultrasound-guided obturator nerve block: A proximal interfascial technique. Anesth Analg 2012;114:236-9. |
|16.||Taha AM. A simple and successful sonographic technique to identify the sciatic nerve in the parasacral area. Can J Anaesth 2012;59:263-7. |
|17.||Neal JM. Assessment of lower extremity nerve block: Reprise of the Four P′s acronym. Reg Anesth Pain Med 2002;27:618-20. |
|18.||Sauro J, Lewis J. Estimating completion rates from small samples using binomial confidence intervals: Comparisons and recommendations. Proceedings of the Human Factors and Ergonomics Society 49 th Annual Meeting. Orlando, FL: 2005. Available from: http://www.measuringusability.com/papers/sauro-lewisHFES.pdf [Last accessed on 2014 Apr 6]. |
|19.||Antonopoulou E, Papaioannou K, Stertsou E, Karamoulas B, Itsiopoulos I. Continuous psoas compartment block versus continuous femoral block in elderly patients with hip fractures. Eur J Anaesthesiol 2010;27:141. |
|20.||Moore KL, Dalley AF, Agur AM. Lower limb. In: More KL, Dalley AF, Agur AM, editors. Clinical Oriented Anatomy. 6 th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010. p. 509-669. |
|21.||Gray H. Anatomy of the Human Body. 20 th ed. Philadelphia, PA, USA: Lea & Fibiger; 1918. |
|22.||Akkaya T, Ozturk E, Comert A, Ates Y, Gumus H, Ozturk H, et al. Ultrasound-guided obturator nerve block: A sonoanatomic study of a new methodologic approach. Anesth Analg 2009;108:1037-41. |
|23.||Mansour NY. Reevaluating the sciatic nerve block: Another landmark for consideration. Reg Anesth 1993;18:322-3. |
|This article has been cited by|
||Paraespinhoso Sagital (PES): nova técnica no bloqueio transmuscular do quadrado lombar para analgesia em cirurgia de quadril - relato de quatro casos
| ||Ahmad S. Alabd, Moustafa A. Moustafa, Aly M.M. Ahmed |
| ||Brazilian Journal of Anesthesiology. 2020; 70(2): 178 |
|[Pubmed] | [DOI]|
||Paraspinous Sagittal Shift (PSSS): a novel approach for transmuscular quadratus lumborum block for hip surgery analgesia – four cases report
| ||Ahmad S. Alabd, Moustafa A. Moustafa, Aly M.M. Ahmed |
| ||Brazilian Journal of Anesthesiology (English Edition). 2020; 70(2): 178 |
|[Pubmed] | [DOI]|
||Sciatic obturator femoral technique versus spinal anaesthesia in patients undergoing surgery for fixation of open tibial fractures using Ilizarov external fixator. A randomised trial
| ||Hoda Shokri, Amr A. Kasem |
| ||BMC Anesthesiology. 2020; 20(1) |
|[Pubmed] | [DOI]|