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Patient-Controlled Epidural Analgesia After Total Hip Arthroplasty: Ready for Prime Time?

Commentary on an article by Kethy M. Jules-Elysee, MD, et al.: “Patient-Controlled Epidural Analgesia or Multimodal Pain Regimen with Periarticular Injection After Total Hip Arthroplasty. A Randomized, Double-Blind, Placebo-Controlled Study”

Meding, John Brian MD*

doi: 10.2106/JBJS.O.00256
Commentary and Perspective

Center for Hip and Knee Surgery, Mooresville, Indiana

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It is axiomatic that adequate analgesia after total hip arthroplasty has both subjective and objective benefits. Patient satisfaction is improved when postoperative pain is controlled. Less discomfort leads to earlier ambulation and an enhanced level of participation in physical therapy. Yet, achieving sufficient pain control can be challenging, especially in elderly patients for whom the choice of analgesia, at least to some degree, is based on associated medical comorbidities. In this regard, regional analgesia may be favored over parenteral narcotics in order to mitigate potential narcotic-related side effects, improve patient satisfaction, and promote rapid rehabilitation and earlier hospital discharge1. However, although peripheral nerves are relatively resistant to damage from intraneural injection, mechanical compression may occur. The prevalence of prolonged paresthesia may be as high as 8% to 10%2. Because of this concern, spinal and epidural analgesia may be advantageous. But even these modalities do have potential and serious disadvantages, including systemic hypotension, urinary retention, and an unpredictable onset3.

Epidural analgesia may be administered by a physician-directed bolus, continuous infusion, patient-controlled epidural analgesia (PCEA), or a combination of any of the above. The study by Jules-Elysee et al. compared PCEA with a multimodal pain management program including periarticular injection (PAI). This Level-I investigation found that patients in the PAI group had more pain with ambulation and physical therapy and greater opioid consumption than the patients in the PCEA group. The ability to determine the precise efficacy of the PAI alone was limited, however, due to the concomitant use of oxycodone and a clonidine patch. In contradistinction, opioid-related symptoms, including nausea, vomiting, pruritus, dizziness, and headache, were higher in the PCEA group. Patient function and satisfaction were similar between the two groups.

Common side effects of epidural analgesia may also include urinary retention, orthostatic hypotension, and prolonged motor blockade including motor blockade of the nonoperative limb. More serious complications also include epidural abscess, back pain, and neck or back stiffness. It is very important to note that these problems were not specifically evaluated in this study. Furthermore, epidural analgesia limits the use of anticoagulation4 and has a much more unpredictable onset and regression3.

The authors are to be congratulated on performing this prospective and randomized study comparing these two modalities. PCEA is a well-established method used to control pain after major gynecological surgery and parturition. The use of PCEA after total hip arthroplasty may or may not become more common as surgeons and anesthesiologists search for the most predictable and reproducible modality for achieving pain relief with the least side effects. These side effects may have a potential and deleterious impact on patients and their progress after total hip arthroplasty. The arthroplasty surgeon should be quite familiar with the complications associated with PCEA, many of which were not reviewed in this study.

*The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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1. Pagnano MW, Hebl J, Horlocker T. Assuring a painless total hip arthroplasty: a multimodal approach emphasizing peripheral nerve blocks. J Arthroplasty. 2006 Jun;21(4)(Suppl 1):80-4.
2. Jeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral nerve blocks. Br J Anaesth. 2010 Dec;105(S1)(Suppl 1):i97-107.
3. Buckenmaier CC 3rd, Xenos JS, Nilsen SM. Lumbar plexus block with perineural catheter and sciatic nerve block for total hip arthroplasty. J Arthroplasty. 2002 Jun;17(4):499-502.
4. Scott DA, Beilby DS, McClymont C. Postoperative analgesia using epidural infusions of fentanyl with bupivacaine. A prospective analysis of 1,014 patients. Anesthesiology. 1995 Oct;83(4):727-37.
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