Hip arthroscopy has emerged as a useful procedure in the diagnosis and treatment of hip pathology,1-8 experiencing a substantial rise in popularity in recent years, with the number of procedures growing by a factor of 18 from 1999 to 20099 and 25 from 2006 to 2013.10 Though hip arthroscopy is beneficial in many cases, marked postoperative pain has presented a substantial challenge, with patients requiring considerable doses of opiate-based medications in the post-anesthesia care unit (PACU).11,12 Increased narcotic use carries increased side effects, including postoperative nausea and vomiting,13 and poorly managed pain leads to increased unplanned admissions.14 Furthermore, patients with chronic hip pain and long-term opioid use may experience heightened and prolonged pain following the procedure, owing to medication tolerance and reduced opioid efficacy in this setting.15
Several pain control strategies have been employed in patients undergoing hip arthroscopy. General anesthesia16,17 and combined spinal epidural (CSE)18 are commonly used. However, such techniques rely heavily on opioids for postoperative pain control,11 and epidural anesthesia commonly requires adjunctive treatments (eg, neuromuscular blockade) to ensure muscle relaxation for joint distraction.19 One technique that has been employed recently is peripheral nerve block (PNB), which has been associated with a significant decrease in postoperative opioid use and nausea and vomiting.13,20 This method has proven successful in other fields of arthroscopy, including shoulder arthroscopy, in which it resulted in faster recovery, reduced opioid consumption,21 and demonstrated cost-effectiveness22 compared with general anesthesia and knee arthroscopy.23-26 As it is a relatively new field, little is known about the use of PNB in hip arthroscopy.
The goal of this systematic review was to comprehensively review the studies reporting on PNB in hip arthroscopy. We specifically focused on outcomes, including postoperative pain; analgesic use; nausea, vomiting, and antiemetic use; discharge time; inpatient admission; and patient satisfaction, as well as the complications associated with the use of PNB. Our knowledge of outcomes associated with PNB in hip arthroscopy is based on a few individual studies that have reported on small groups of patients using a variety of outcome measures and other findings. Furthermore, each of these studies commonly reflects the experience of an individual surgeon at a single institution and, when taken alone, may not be an accurate representation of the more general outcomes associated with PNB. A comprehensive review of such studies will provide surgeons, anesthesiologists, and patients with a better understanding of the anticipated outcomes of using PNB in hip arthroscopy. We hypothesize that the use of PNB in hip arthroscopy leads to improved outcomes and is associated with few complications.
MATERIALS AND METHODS
A systematic review of outcomes associated with PNB in hip arthroscopy was performed using the available English-language literature in accordance with the guidelines laid out by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included studies retrieved from the PubMed, Medline, Scopus, and Embase computerized literature databases. Searches were executed comprising all years from database inception through January 2015. Articles were retrieved by an electronic search of medical subject headings and keyword terms and their respective combinations (Table 1). The inclusion criteria for studies in this systematic review were studies that (1) were written in the English language and (2) reported explicit outcome data. The exclusion criteria were (1) review articles, meta-analyses, case reports, abstracts/conference papers, comments/letters, or technique articles without reported patient data and (2) basic research, biomechanics, or animal/cadaveric studies without reported patient data.
Table 1. Search Terms Entered to Identify English-Language Studies Through January 2015
Database | Search terms |
PubMed, Scopus | Keyword: (hip AND arthroscopy) AND (pain control OR pain management OR pain regimen OR nerve block OR spinal anesthesia OR regional anesthesia OR general anesthesia) |
Medline | MeSH (includes both MeSH terms and keywords): (Hip) AND (Arthroscopy) AND (“Pain Management” OR “Anesthesia, General” OR “Anesthesia” OR “Anesthesia, Inhalation”, OR “Balanced Anesthesia” OR “Anesthesia, Local” OR “Anesthesia, Spinal” OR “Anesthesia, Conduction” OR “Nerve Block”) |
Embase | MeSH (includes both MeSH terms and keywords): (Hip) AND (Arthroscopy) AND (“Pain Management” OR “General Anesthesia” OR “Anesthesia” OR “Inhalation Anesthesia”, OR “Balanced Anesthesia” OR “Local Anesthesia” OR “Spinal Anesthesia” OR “Regional Anesthesia” OR “Nerve Block”) |
The literature search strategy is outlined in the Figure. The initial title search yielded a subset of possible articles that were then further included or excluded on the basis of the contents of the article’s abstract, wherein articles were again selected on the basis of the aforementioned inclusion and exclusion criteria. Articles selected in both the title and abstract phases underwent full-text review, during which the full text of each qualifying article was reviewed. In addition, the reference sections from articles undergoing full-text review were scanned to identify any additional studies that had not been identified in the original literature search. Appropriate studies for final inclusion were then selected at this stage. The title, abstract, and full-text selection process were performed by 2 of the study authors (Dr. Steinhaus and Dr. Lynch), with any discrepancies being discussed and resolved by mutual agreement.
Continue to: For all 6 included studies...